DHS OIG FY 2009 Annual Report

Helping Families. Supporting Communities. Empowering Individuals.

November 2009


To Governor Pat Quinn and Members of the Illinois General Assembly:


In accordance with the Illinois Department of Human Services Act (20 ILCS 1305) and the Adults with Disabilities Domestic Abuse Intervention Act (20 ILCS 2435), I am pleased to submit the Fiscal Year (FY) 2009 report of the Office of the Inspector General (OIG) in the Department of Human Services (DHS), entitled Abuse and Neglect of Adults with Disabilities.

This annual report provides an overview of how OIG works to prevent abuse or neglect of adults who have a mental illness or developmental disability and who live at home and/or who receive services from a DHS-operated facility or a community agency program licensed, certified or funded by DHS. This report covers the wide range of OIG's activities and services, which are aimed at preventing, reporting, investigating, and responding effectively to allegations of abuse and neglect of these vulnerable individuals.

One accomplishment this year that is not covered in this report is Public Act 96-0407. This act was passed unanimously this spring but signed on August 13, 2009, after the end of FY 2009. The act revised OIG's statute to make it easier to read and to apply lessons learned from OIG's twenty years of experience. The act made these significant changes, which will be reflected in next year's annual report.

  • Physical abuse is no longer defined as a physical injury; thus, inappropriate contact that causes harm is clearly included. 
  • Physical abuse is now, like neglect, by an employee, facility or community agency. It now also includes an employee directing someone else to injure an individual.
  • Mental abuse is likewise no longer defined as an "injury"; thus, it avoids the difficulty of having to prove a mental injury. 
  • As it already does in private homes, OIG may now investigate financial exploitation of adults with disabilities in facilities and community settings. 
  • Neglect now includes placing an individual at substantial risk, even if he or she is not actually injured as a result. 
  • For neglect to be called "egregious," it now must either have a serious outcome or show "a gross failure" or "calloused indifference" on the part of the employee. 
  • Appropriate health care services are now specifically exempted from abuse or neglect. 
  • The law now clearly prohibits retaliation against an employee who reports an allegation of abuse or neglect. 
  • Employees of facilities and community agencies now have a clearly stated duty to cooperate during OIG's investigations and Written Response Compliance Reviews, and they are also required to testify at Health Care Worker Registry hearings.
  • OIG may now subpoena documents and witnesses to testify in any subsequent hearing, not just during the investigation. 
  • One of two appeal processes for actions taken was discontinued, since it duplicated existing employment appeal processes for facility employees and since DHS had no legal way to enforce an order involving a community agency employee. 
  • No name will be sent to the Health Care Worker Registry until after resolution of all administrative appeals that have been filed. 
  • OIG's practice of including investigative timeliness information in its annual report was written into law. 
  • The requirement for a program audit of OIG by the Illinois Auditor General now matches the one for OIG in the Department of Children and Family Services, which is "as deemed warranted by the Auditor General."

These statutory changes and the overview contained in this annual report depict how OIG is committed to providing quality investigations, working to prevent abuse/neglect, and assisting service providers in their work to improve the lives of the people in Illinois who have disabilities. Thank you for the opportunity to make a positive difference in their lives.


Sincerely,

William M. Davis

Inspector General



Executive Summary

During Fiscal Year 2009 (FY09), OIG accomplished the following:

  • Conducted all eighteen site visits to facilities and made 58 recommendations, down from 120 in FY08 and 114 in FY07, largely due to many fewer repeat recommendations, and made five recommendations to the DHS divisions;
  • Trained a combined total of 1,134 participants in 68 trainings OIG conducted;
  • Approved 143 community agencies' applications for authorization to investigate, and assigned primary responsibility on 136 investigations to 45 of those agencies;
  • Received, recorded and, if warranted, referred 1,483 complaints that did not meet the definition of a reportable allegation, which is up from 1,279 in FY08;
  • Received 2,748 allegations of abuse or neglect - 3% more than last year and 17% more than three years ago - with community agencies accounting for most of the increase;
  • Noted continued improvement in timeliness of reporting by community agencies and facilities: only 11.8% were self-reported late, compared to 15.8% in FY08 and in FY07;
  • More evenly balanced caseloads across bureaus, dropping the variance over 60%;
  • Referred 124 victims of domestic abuse/neglect/exploitation for development of a service plan, fewer than the 193 referred in FY08, but more than the 119 referred in FY07;
  • Completed 2,866 investigations into abuse/neglect allegations - 4% more than last year and 23% more than three years ago - with no increase in staff;
  • Completed those 2,866 investigations in an average of 37.7 days - 8% faster than last year and 26% faster than three years ago - far shorter than the required 60 days;
  • Sent out 843 investigative reports with administrative recommendations, requiring the facility or community agency to identify corrective actions - this total of 843 reports with recommendations is a 70% increase over the past four years;
  • Conducted 194 Compliance Reviews (a 20% random sample of the approved Written Responses OIG received), verifying the facility/agency took the corrective actions;
  • Referred to the Health Care Worker Registry 64 names of persons substantiated to have committed physical abuse, sexual abuse, or egregious neglect (less than the 73 names referred in FY08 but close to the 67 referred in FY07);
  • Closed 2,853 investigations - 4% more than last year and 29% more than three years ago - substantiating abuse or neglect in 13.2% of the cases; and
  • Substantiated neglect in two of 144 death reports closed during FY09.

Table of Contents

Chapter I: OIG works proactively to prevent abuse and neglect

  1. Unannounced Site Visits to Facilities 
  2. Quality Care Board 
  3. Proactive Summaries

Chapter II: OIG provides training on reporting and investigating

  1. OIG Investigator Training
  2. Training of Facility/Agency Staff
  3. Investigative Protocol for Community Agencies
  4. Investigative Protocol for DHS Facilities

Chapter III: OIG handles allegations of abuse or neglect

  1. Non-Reportable Complaints
  2. Timeliness of Initial Reporting
  3. Allegations of Abuse or Neglect
  4. Referrals to Law Enforcement

Chapter IV: OIG investigates allegations of abuse or neglect

  1. Investigative Caseloads
  2. Case Reviews
  3. Timeliness of OIG Investigations
  4. Reconsiderations
  5. Case Closures

Chapter V: OIG acts to prevent recurrence of abuse or neglect

  1. Emergency Domestic Interventions
  2. Service Plans
  3. Registry Referrals
  4. Clinical Recommendations
  5. Written Responses
  6. Implementation Status Reports
  7. Compliance Reviews

Chapter I: OIG works proactively to prevent abuse and neglect.

A. Unannounced Facility Site Visits

FY09 Authority

OIG is authorized by State statute to conduct an unannounced site visit annually to each of the department's psychiatric hospitals and developmental centers (20 ILCS 1305/1-17(f)). The statute does not clearly specify a purpose for these unannounced site visits; however, the implied intent is to identify issues that might lead to abuse or neglect. OIG then recommends the facilities address those issues, thereby preventing abuse or neglect.

Therefore, OIG site visits focus on systemic issues that have a potential for allowing abuse or neglect to occur. The site visitors make recommendations to the facility in a written report, sending a copy of that report to departmental management. In addition, OIG follows up on recommendations made during the previous year's site visit, to examine the actions that the facility has taken to address those recommendations.

An OIG Directive (BCE 02-003) describes the process. Each spring, the OIG site visitors meet to develop a list of issues to review during the coming fiscal year's site visits, along with a plan on how to review them. A tentative schedule for conducting those site visits is developed, with a requirement that each facility's site visit not be done in the same month as in the past two years. Documents may be requested in advance from several facilities at a time, so the actual site visit date remains unannounced.

FY09 Actions

The OIG site visitors met May 8, 2008, to choose issues to review during the FY09 site visits. Prior to the meeting, the site visitors reviewed completed investigations and survey findings, talked with field investigators and management, and discussed issues that had been raised in the department's internal coordination and proactive committees.

The FY08 site visits had made an unusually large number of recommendations; some were repeated from the prior year. The FY09 site visits followed up on each of the recommendations. If a facility had no recommendations in the issue area, OIG did not include that issue in the FY09 site visit at that facility.

The site visitors then chose new issues to review at all facilities during the FY09 site visits. These additional issues were as follows:

  • Timely and thorough completion of habilitation/treatment plans and communication of those to staff;
  • Requirement for cardiopulmonary resuscitation (CPR) training for security personnel;
  • Internal quality assurance review processes on medical charts and documentation of actions taken as a result, if any;
  • Implementation of a new "OIG Investigative Protocol for DHS Facilities," which mandates communicating requirements to staff who act as administrator on duty (AOD); and
  • Procedures for return of employees from paid administrative leave after an investigation of alleged abuse/neglect.

FY09 Impact

Each FY09 site visit was conducted by a team of two OIG staff: a compliance reviewer and a registered nurse. The dates of the FY09 site visits were as follows:

  • Alton MHC,  July 15-16, 2008
  • Chester MHC,  September 9-10, 2008
  • Chicago-Read MHC,  February 3-4, 2009
  • Choate DC,  October 22-23, 2008
  • Choate MHC,  October 21-22, 2008
  • Elgin MHC,  January 21-22, 2009
  • Fox DC,  December 8, 2008
  • Howe DC,  March 17-19, 2009
  • Jacksonville DC,  January 13-14, 2009
  • Kiley DC,  September 16-17, 2008
  • Ludeman DC,  October 16-17, 2008
  • Mabley DC,  August 27-28, 2008
  • Madden MHC,  March 30-31, 2009
  • McFarland MHC,  February 17-18, 2009
  • Murray DC,  November 12-13, 2008
  • Shapiro DC,  July 22, 2008
  • Singer MHC,  November 6-7, 2008
  • Tinley Park MHC,  August 4-6, 2008

OIG's annual site visit report, produced at the conclusion of all the FY09 site visits, summarized the site visit findings, identified "repeat" recommendations, and provided recommendations to the two DHS divisions over the mental health (MH) facilities and the Developmental Disabilities (DD) facilities, where warranted. The issues reviewed, including any recommendations to the divisions, are listed below.

Repeat FY08 issues

The summary of the FY08 recommendations followed up on in FY09, along with any new FY09 recommendations to the divisions, are given below.

  • Repeat recommendations - OIG found that the facilities had sufficiently addressed 101 of the 120 recommendations. Four of the remaining nineteen were repeated for the third year, another was repeated a fourth year. All but two facilities had repeats.
    OIG recommended that the divisions continue to ensure that all facilities promptly and appropriately address the findings and recommendations in OIG site visit reports.
  • Emergency response drills - These drills test a facility's ability to respond quickly and adequately to an emergency, which might prevent neglect. During FY07, OIG made 33 recommendations regarding these drills and, during FY08, OIG made 29. During FY09, OIG made eighteen recommendations - most commonly that the facility keep better documentation that it had addressed suggestions its staff made during the drills.
    OIG recommended that the divisions ensure that the facilities maintain adequate documentation of drill actions, follow-up and review.
  • Non-Reportable response - Complaints OIG receives that do not meet the definitions of abuse or neglect are called "Non-Reportables." OIG refers these back to the facility to investigate the complaint, review the findings, take any needed action to address the complaint, and maintain a central file with documentation of these steps. Although OIG had looked into this process in FY08, about half the facilities had recommendations on this issue in FY09: for example, inadequate investigation, no central committee review, limited description of actions, and insufficient documentation of those steps in the file.
    OIG recommended that the divisions ensure that, for each OIG non-reportable incident, all facilities maintain a file that includes documentation of the internal investigation, findings, committee review, and any actions taken.
  • Training on reporting - OIG has frequently reviewed each facility's training of staff on reporting abuse/neglect in the past. Where a recommendation had been made, OIG reviewed it again in FY09. One facility still did not provide documentation that the policy was given to the staff or that all the staff was trained. At another facility, OIG found that only two of eight contractual workers and only two of 43 volunteers had been trained. The most recent Illinois Auditor General's audit report also noted inadequate documentation of Rule 50 training at each facility.
    OIG recommended that the divisions continue with plans to require biennial training of all facility staff in abuse/neglect reporting and to document that training.
New FY09 issues

The new issues reviewed during the FY09 site visits also resulted in findings, one of which triggered a fifth recommendation to the program divisions.

  • Investigative protocol - In FY08, OIG had developed an investigative protocol and began a calendar year authorization process for facilities, similar to the fiscal year process for community agencies. Timely distribution of the Protocol to relevant staff and training of staff acting as administrator on duty (AOD) in its expectations were cited as problems at only two facilities. OIG made no recommendations to the divisions on this issue.
  • CPR training - For FY09, OIG's site visits reviewed if the facility's security personnel, whether full-time or contractual employees, were required to have cardiopulmonary resuscitation (CPR) training. OIG found it was an issue at only one facility. OIG made no recommendations to the divisions on this issue.
  • Habilitation/treatment planning - In FY09, OIG looked into how the facility ensures the timeliness, clarity, and thoroughness of habilitation/treatment planning. Although a few minor problems were found at five facilities, most often in getting monthly reviews done in a timely manner, the planning process appears to be working well at all facilities. OIG made no recommendations to the divisions on this issue.
  • Chart reviews - OIG also looked into how the facility audits the entire medical charts of individuals, finding a wide range of practices. Four facilities had exemplary audit tools, but three facilities had inadequate processes in place.
    OIG recommended that the divisions consider requiring the facilities to ensure that quality assurance programs include consistent medical chart audits to ensure performance improvement.
  • Administrative leave - OIG found that employees on paid administrative leave pending an abuse/neglect investigation were typically returned to work reasonably quickly after the facility received the OIG investigative report. Few delays were found: at one facility, an employee was returned to work more than ten weeks after receiving the final OIG report; and at another facility, two employees in an unsubstantiated case were returned to work more than seventeen days later. OIG made no recommendations to the divisions on this issue.

In total, in FY09, OIG made 58 recommendations to the facilities, down from 120 in FY08 and 114 in FY07. In FY09, OIG also made five recommendations to the divisions; OIG had also made five in FY08 and had made eight recommendations in FY07. OIG greatly appreciates the divisions' involvement in the exit conferences and in supporting the facilities' actions to address the recommendations.

FY09 Example

An individual alleged in June 2008 that an employee had called him vulgar names and spoken to him in a way that made him feel bad. He could not recall who he told that day, but another staff member later recalled him telling her three days later. The staff member notified Security but did not write a progress note; she claimed that the security officer said she did not need to. Two days later, the staff member followed up with Security again, reaching a different security officer, who reported it to OIG. The staff member still did not write a progress note.

OIG conducted its FY09 unannounced site visit to the facility three months later. Among the issues reviewed was an earlier recommendation regarding progress notes. In response, the facility had started re-training staff and setting up a process to audit progress notes.

In January 2009, another individual in that living unit alleged verbal abuse by an employee. The staff member to whom he made the allegation immediately notified Security - the same staff member and same security officer as in the prior case - who this time immediately called OIG. Also this time, the staff member immediately wrote a detailed two-page progress note.

No evidence could be found to support the first allegation. However, the second allegation was substantiated, partly due to the detailed progress note at the time.

B. Quality Care Board

FY09 Authority

The Quality Care Board was authorized by Public Act 87-1158, which was passed in 1992. The statutory responsibility given to the Board is to "monitor and oversee the operations, policies, and procedures" of OIG, to ensure that abuse/neglect investigations are prompt and thorough (20 ILCS 1305/1-17(i)). The Board is to meet quarterly.

The law provides that the Board shall have seven members, appointed by the Governor with advice and consent of the State Senate. The Board members are to be qualified by professional knowledge or experience in the areas of law, investigatory techniques, or the care and treatment of individuals with mental illness or developmental disabilities. At least two of the members must either have a disability or have a child with a disability. Board members are unpaid, but may be reimbursed for travel and other expenses.

FY09 Actions

The Board had one vacancy during FY09. The six Board members were: Rita Burke (Chair), Brian Rubin, Nate Gibson, Thane Dykstra, Maria Esther Lopez, and Keith Kemp. The group includes three service providers and three parents of individuals who receive services. As specified in the statute, the Board met quarterly during FY09: August 21, 2008; October 22, 2008; January 22, 2009; and April 23, 2009.

FY09 Impact

During the meetings, the Board was given presentations by OIG staff on programs and projects, such as the unannounced site visits and recent legislation. The Board discussed a variety of issues, such as proposed DHS facility closures, backlogs in DHS approval of Written Responses, and OIG's handling of agency-conducted investigations. The Board reviewed OIG policies, legislative proposals, and the Auditor General's FY07-FY08 program audit of OIG.

FY09 Example

During its meeting on January 22, 2009, the Board members discussed the audit report's recommendation that OIG include serious injuries in its database.

OIG pointed out that the audit report failed to distinguish injuries alleged or suspected to have resulted from abuse/neglect by staff from injuries that were not. Without an allegation or suspicion, OIG has no authority to investigate and records any such injury as "non-reportable." However, any injury that is alleged or suspected to be the result of abuse/neglect by staff is recorded in the database and investigated by OIG. This approach to reporting of injuries to OIG met the expectations of the Board.

One example of such a case during FY09 was a bad injury that required five staples to close. The individual got the injury on her head when her wheelchair tipped over in an agency van. Since a wheelchair must be secured when a van moves, there was a suspicion of neglect by staff. Thus, the agency reported the injury to OIG.

OIG found that an employee had helped the individual into the van but then drove away without properly attaching any of the safety straps or hooks. OIG substantiated neglect by that employee, and the agency re-trained her in the use of the safety equipment.

C. Proactive Summaries

FY09 Authority

OIG's primary statutory role is reactive: investigating and recommending administrative action be taken to protect the alleged victim. Yet, the statute also envisions a proactive role for OIG: e.g., recommending action to prevent recurrence or to eliminate problems that may later result in abuse or neglect (20 ILCS 1305/1-17(c)). A proactive approach that OIG uses is conducting semi-annual statistical summaries that look at patterns and trends in reported allegations and recommending issues to consider in preventing abuse and neglect from occurring.

FY09 Actions

OIG again produced two semi-annual proactive summaries: November 20, 2008, covering the latter half of FY08; and March 25, 2009, covering the first half of FY09. These proactive summaries were discussed in the department's internal Proactive Committee, which considers ways to address those issues.

OIG's semi-annual proactive summaries include a look at the rate of allegations relative to the size of the facilities. OIG uses data provided by DHS and presents them here as required by statute (please note that some columns do not total exactly due to rounding error).

Table 1a: Census and Staffing Ratios for DHS Psychiatric Hospitals, June 30, 2009

Facility Person-days (on-books) Census on June 30, 2009  Direct care staff (full time equivalents) Direct care staff to patient ratio
Alton MHC 44,014 122 165 1.35
Chester MHC 97,320 255 336 1.32
Chicago-Read MHC 46,453 122 184 1.51
Choate MHC 20,922 48 99 2.07
Elgin MHC 136,593 375 492 1.31
Madden MHC 46,451 135 182 1.35
McFarland MHC 40,858 108 134 1.25
Singer MHC 25,569 66 91 1.38
Tinley Park MHC 23,253 66 107 1.62
MH facility totals 481,433 1,297 1,790 1.38
Table 1b:

Census and Staffing Ratios for DHS Developmental Centers, June 30, 2009

Facility Person-days (on-books) Census on June 30, 2009 Direct care staff (full-time equivalents) Direct care to patient ratio
Choate DC 63,063 165 232 1.40
Fox DC 48,060 124 150 1.21
Howe DC 109,036 262 510 1.95
Jacksonville DC 77,423 203 276 1.36
Kiley DC 79,374 210 296 1.41
Ludeman DC 135,342 372 472 1.27
Mabley DC 31,478 84 118 1.41
Murray DC 110,807 290 398 1.37
Shapiro DC 196,659 521 812 1.56
DD facility totals 851,242 2,231 3,264 1.46

FY09 Impact

In November 2008, OIG completed its semi-annual prevention summary covering the latter half of FY08. The following are some examples of recommendations in these summaries.

DHS Facilities

  • Since the most frequent time periods for alleged incidents are during evenings (6:00-10:00 pm), facilities should continue to focus prevention efforts on that time period.
  • At DD facilities, particular problem times were generally right after dinner (6:00-7:00 pm), right before bed (8:00-9:00 pm), and right after day programming (3:00-4:00 pm).
  • The two facilities having the most allegations self-reported late (Jacksonville DC and Chester MHC) should focus on training their staff to report allegations more timely.
  • Facilities should review internal personnel procedures to return employees from administrative leave promptly and/or pursue administrative action, as appropriate, after receipt of the OIG investigative report.

Community Agencies

  • DD agencies may need to focus on Mondays as days on which alleged incidents commonly occur.
  • MH agencies should be encouraged to continue reporting allegations, since they report significantly fewer allegations than either MH facilities or DD agencies.
  • The community agencies should continue to focus on timely self-reporting, since they are improving but continue to report a substantial number of allegations late.
  • The divisions should continue to work to obtain, approve, and forward approved Written Responses to OIG in a timely manner, to ensure that prompt actions are taken to prevent abuse/neglect.

In March 2009, OIG completed the semi-annual prevention summary covering the first half of FY09. Examples of recommendations in this summary were the following.

DHS Facilities

  • MH facilities should consider why more incidents are allegedly occurring on Sundays, especially in contrast to the continued low number of alleged incidents on Saturdays.
  • DD facilities should look into possible reasons for the significant rise in allegations reportedly occurring during the morning hours (6:00-10:00 am).
  • Singer MHC, Jacksonville DC, and Mabley DC should review the initial sources of allegations to see if any underlying issues caused the significant increases seen in allegation rates per bed.
  • The facilities and the divisions should redouble joint efforts to ensure that OIG receives approved "Written Responses" in a timely manner.

Community agencies

  • The drop in allegations from MH community agencies is largely due to a drop at residential programs, most notably CILAs. The MH Division and the Bureau of Accreditation, Licensure, and Certification may want to ensure that their reviews conducted at these programs include verifying that all staff and volunteers are receiving biennial training in OIG Rule 50.
  • The community agencies should continue to focus on timely self-reporting, since they are improving but continue to report a substantial number of allegations late.
  • The nine agencies that have made the effort to get authorized to conduct investigations in spite of no self-reported allegations should be encouraged to continue applying for authorization each year.
  • The divisions should continue to remind agencies to submit implementation status reports to OIG when required.

The department's Proactive Committee continues to meet regularly to review the semi-annual prevention summaries and other reports, seeking ways to address the recommendations and improve services

FY09 Example

Despite the requirement for biennial training in reporting abuse and neglect, late reporting continues to be a problem from community agencies. In previous prevention summaries and in the two distributed this fiscal year, OIG has identified a need to ensure the community agencies report timely. This case is an example of the problem.

A CILA's night shift employee was suspected of having moved the home's van while on duty, even though agency policy prohibits night shift employees from going outside the home. So, an employee was asked to document the odometer reading at the end of the evening shift one day. At the time, the CILA had five residents, some with behavioral intervention plans for physical or verbal aggression, delusional behavior, anxious or agitated behavior, and/or self-abuse.

In the morning, the van's odometer had sixteen additional miles on it. The residents were all asleep, except for one who has a program plan requiring that he not be left alone at any time. None of the residents appeared to have any injuries, but the potential for emotional distress or maladaptive behavior was high.

The residential supervisor was notified that morning, and he referred it to an internal health and safety committee, of which he is a member. Not until four days later did he report the allegation to OIG, and the night shift employee was not taken out of patient care until the following evening.

When interviewed by OIG, the night shift employee admitted that she had left the CILA to go to a fast food restaurant in a nearby town and that she had been gone for about 45 minutes. OIG substantiated neglect, and her employment was terminated.

It is not known how many times that employee may have left the CILA residents unattended in the five days between the morning the additional miles were found and the evening she was taken out of direct care. However, the agency should have reported it to OIG immediately and taken action to prevent recurrence. OIG cited the agency's failure to report, and the residential supervisor and the other members of the committee were re-trained on Rule 50.


Chapter II: OIG provides training on reporting and investigating.

A. OIG Investigator Training

FY09 Authority

OIG's statute contains two training mandates. One mandate, located in 20 ILCS 1305/1-17(e), addresses training of employees of DHS facilities and community agencies on reporting and investigating abuse and neglect. That training mandate is discussed below in Section B: Training of Facility/Agency Staff.

The authorizing statute also states that OIG is to establish a comprehensive training program to ensure that each of its investigators receives initial and ongoing training in investigative skills and communication with individuals receiving services (20 ILCS 1305/1-17(j)). OIG has established this training program through OIG Directive ADM 01-002, which describes initial and continuing education (CE) requirements for its staff.

FY09 Actions

In February 2009, OIG revised its Training Directive (ADM 01-002) to reflect changes in expectations. Among the most substantial revisions were an increase in the trainings required of supervisors, who now must have training in team building, conflict resolution, time management and labor relations. Further, all OIG staff must take a class in sexual harassment, one in HIV/AIDS, and the annual State employee ethics training.

However, the revised directive also clarified the list of additional trainings required for OIG investigators. Requirements for classes in patient safety and infection control are now required of all OIG staff, and the organization of classes on conducting investigations into deaths and medical issues was changed.

Continuing education is still required of all OIG staff holding investigative credentials. These staff must have a minimum of five courses every year, at least one of which must be in each of three categories: investigative skills, computer skills, and personal/professional growth. The remaining two may be from any of the three categories.

OIG provides some internal training to investigators to meet these continuing education requirements. In FY09, OIG provided an on-line training course on "Credible Evidence" and an in-person class on "Testifying in Hearings."

FY09 Impact

Some of the continuing education received by OIG investigators had an immediate impact in improving OIG. Trainings in investigative skills, interpersonal communications, and computer skills enable OIG investigators to do better and more efficient investigations.

FY09 Example

OIG's new "Testifying in Hearings" training became especially helpful within four months. OIG had substantiated an allegation by an individual that she had been choked and pushed backwards by an employee. While the employee denied it, another employee on duty said that she had witnessed the physical abuse. The individual and witness were consistent in their accounts, and the individual had slight red marks on her neck.

The accused employee filed an appeal to stop OIG from referring her to the IDPH Health Care Worker Registry. She denied the alleged abusive actions, and she showed letters from the individual that were very complimentary of her. OIG did not ask the individual to testify, since the staff witness was coming.

However, when the hearing was held, the staff witness failed to appear. OIG's investigator had to be asked to testify to what these two had said. The OIG investigator, however, was well trained and did a good job testifying what the two had told him. He had also brought the individual's and the employee's signed statements and photographs of the injuries.

The administrative law judge agreed with the referral, recommending that the appeal be denied. OIG referred the identity of the accused employee to the Health Care Worker Registry, and the agency terminated her employment.

B. Training of Facility/Agency Staff

FY09 Authority

State statute gives OIG authority to establish and conduct periodic training on preventing and reporting abuse and neglect for DHS employees and for employees of the community agencies (20 ILCS 1305/1-17(e)). This training mandate is met in three ways.

First, OIG has provided - and periodically updates - a standard training presentation on the administrative rule's definitions and reporting requirements for abuse and neglect allegations. OIG emailed this training to all facilities and community agencies within its investigative jurisdiction and has included it in the department's on-line library of training courses, making it available electronically to all department employees.

Second, OIG has worked with the Division of Developmental Disabilities and the Division of Mental Health to ensure that the annual contracts with community agencies ("Community Service Provider Agreements") require training at least every two years in identifying and reporting abuse and neglect, as delineated in Rule 50 (Illinois Administrative Code, Part I, Chapter 59, Rule 50).

Third, OIG has conducted local trainings on Rule 50 and in investigative skills for designated employees of facilities and community agencies. By training administrators, trainers and investigators at facilities and agencies, OIG can maximize its limited training resources.

FY09 Actions

Beginning in FY09, OIG combined two half-day courses into one full day course. The first was an overview of Rule 50, covering the following: its definitions, such as abuse, neglect, and substantiated; the requirements for reporting, such as the time frames for allegations and deaths; the basic requirements for initial response to incidents; the reconsideration and appeals processes; and reporting to the Health Care Worker Registry. The second, entitled "First Responder," repeated the definitions but focused on the basic requirements for initial response to incidents. Since the two courses had significant overlap, they were combined beginning with the start of FY09.

The combined course is still called "OIG Rule 50," and it is the basic course on reporting and responding to allegations. This course is open to anyone, but it is required for any employee of a community agency or facility who is designated by the agency or facility to function as its OIG liaison or as an investigator.

OIG's second course is "Basic Investigative Skills" (BIS). This two-day investigative skills course covers incident scene preservation, evidence collection, injury assessments, investigative planning, statement-taking, conducting interviews, and report writing. BIS is required for any agency/facility employee seeking authorization as an investigator, and only those employees (or an agency's primary authorized representative) may attend this course. The prerequisite is OIG Rule 50 within two years.

The third course OIG offers is "Investigative Skills Refresher." This one-day course can be taken as a refresher for both of the other two courses, but it must be taken within two years of the most recent investigative skills course (either BIS or Refresher).

FY09 Impact

During FY09, OIG conducted 68 trainings with a combined total of 1,134 participants:

  • 583 participated in 27 OIG-conducted Rule 50 classes;
  • 190 participated in 15 Basic Investigative Skills classes; and
  • 361 participated in 26 Investigative Skills Refresher classes.

In December 2008, OIG sent a brief computer-based training module on investigative report-writing to all agencies with approved investigative protocols. This training is a reminder of the requirements for report-writing, which are covered in OIG's investigative skills classes.

OIG also gave five presentations on Rule 51 (domestic abuse, neglect and exploitation of adults with disabilities) to local Independent Living Centers groups around the state and three to local law enforcement.

Further, OIG continues to coordinate with other reporting lines in Illinois. During FY09, OIG gave two presentations on reporting to employees of the Child Abuse Hotline of the Department of Children and Family Services.

FY09 Example

Training serves to raise participants' awareness of abuse and neglect and to remind them of the importance of reporting to OIG and other appropriate entities. A neglect allegation that OIG substantiated during FY09 illustrates how increased awareness leads to appropriate reporting.

About a week after attending an OIG Rule 50 Training, an employee arrived at work and found no staff member present. Since a few of the eight individuals in the CILA had serious behavioral issues, she recognized the situation as suspicious for neglect as defined in Rule 50, and she reported it immediately.

The investigation found that the evening shift employee was scheduled to be off at midnight, but the night shift employee did not arrive. The evening shift employee stated that, after unsuccessfully trying for over an hour to reach his supervisor, he left to attend to some personal commitments. The night shift employee never did arrive, claiming later that he did not know that he was scheduled to work.

The employee who had attended OIG Rule 50 training arrived for work in the morning and found the individuals apparently all asleep. However, there was sugar and flour all over the kitchen and the house was a mess, indicating that at least one individual had been up during the night. All eight individuals in the home required 24 hour supervision - for example due to histories of severe seizures, property destruction, physical aggression, or wandering off - so the employee recognized there may be harm, and she immediately reported it as an allegation of neglect.

OIG substantiated neglect by the evening shift employee, since his actions could reasonably have resulted in serious mental deterioration or physical harm to several individuals in the home. OIG recommended that the agency also review the night shift employee's failure to report to work. In response, the agency discharged the evening shift employee and gave the night shift employee a written reprimand.

C. Investigative Protocol for Community Agencies

FY09 Authority

Rule 50.40(a) gives OIG the authority to assign investigations to a community agency "with OIG's investigative protocol," if the investigation is an allegation of mental injury or neglect without a serious injury. OIG has standardized an "OIG Investigative Protocol for Community Agencies" and requires community agencies to adopt the protocol and apply for authorization every fiscal year. This process is described in OIG Directive BCE 03-006.

Only if OIG has reviewed the application and approved the agency for the fiscal year will the agency be allowed to conduct investigations. Part of the application process requires that the agency identify individual employees that have been trained directly in investigative skills by OIG within the past two years. OIG then reviews those individual employees and their job titles to ensure there is no readily apparent conflict of interest. Again, this approval process is for one fiscal year only; the agency must reapply the following year.

Investigative assignment, however, is on a case-by-case basis. Even if OIG approves the application and authorizes the designated employees to be investigators, OIG must assign the particular investigation to the community agency before it is authorized to begin. While a community agency must take immediate action to protect the individuals from harm or danger, it must also request approval from OIG before conducting an investigation.

FY09 Actions

To be ready for the fiscal year, the annual process for approving investigative protocols at community agencies actually begins prior to the start of the fiscal year. On May 13, 2008, OIG e-mailed all the community service providers a copy of the current Agency Investigative Protocol, the application form, and a letter announcing the start of the application process. Most agencies that would eventually apply responded within a few weeks. By the start of FY09, a total of 80 agencies had applied and been approved by OIG for the fiscal year.

Eventually, OIG received and approved 143 community agencies' applications during FY09. This total is slightly lower than the prior two fiscal years, but higher than FY06. The most common reasons that agencies gave for not applying were: limited resources, too small an agency to have enough allegations to make it reasonable, and the desire for independent investigations by an outside entity.

These 143 agency applications identified a combined total of 710 employees who could be assigned to conduct investigations. The agencies provided each employee's position title and job functions and certified that the employee had no conflict of interest in investigating. OIG reviewed the identified employees and authorized them - unless the employee had a prior violation of Rule 50, had an apparent conflict of interest, or did not have current OIG training.

FY09 Impact

Rule 50 allows OIG to assign only mental abuse or neglect investigations to community agencies and only to those that have approved protocols. During FY09, OIG assigned a total of 136 investigations to 45 of the 143 agencies. OIG investigations also rely on initial investigative work - i.e., securing the scene, preservation of evidence, and even interviews - by authorized investigators at the agencies in many more cases. Since OIG cannot be present immediately when every allegation is made, these investigators are an invaluable assistance to timely and effective OIG investigations.

OIG remains involved when an agency is assigned to conduct an investigation. An OIG investigator is chosen to monitor the investigation. The monitoring investigator sends the agency investigator an Investigative Plan to help identify investigative steps and to organize those steps to address the elements of the alleged offense. He/she is also available during the course of the investigation to answer questions and provide guidance.

The monitoring investigator is also responsible for doing the first-level review of the agency investigator's draft investigative report. At that point, OIG may accept the investigative report or decide to take over the investigation. If accepting the investigative report, OIG may still make changes to it or add formal recommendations to the agency based on the findings.

FY09 Example

When she arrived to work, an employee of a community agency reported that she smelled a foul odor. So, she went to check on an individual who had a serious bacterial infection that required her to be monitored closely by staff, especially when using the bathroom. She allegedly found the individual alone in her bedroom and covered in feces, so she immediately reported the prior shift staff for neglect.

OIG assigned the investigation to the agency. The investigation found that, when this employee went to check on the individual, the prior shift staff told her not to open the bedroom door. When she did open it, the individual and the mattress, which was on the floor, were covered in feces, some of it dried. She questioned the two prior shift staff, who stated that the individual had a bowel movement only about twenty minutes before.

One of these two staff members, the one in charge of making breakfast and passing medications, said she had told the other staff member several times to clean the individual. This second staff member said that, since the individual had the bacterial infection, she just told her to stay in her room until all the other individuals had used the bathroom. Both staff claimed they were not aware that the individual had often smeared feces before.

The agency investigation substantiated neglect only by the second staff member. OIG accepted the investigation but added a recommendation that the agency develop a procedure designating one staff person as responsible for diaper-changing.

In the Written Response, the agency stated that they had fired the staff member who had been substantiated for neglect. The agency also sent a copy of its policy, which requires all staff on duty to be responsible for changing individuals' diapers as needed and to document all diaper changes on a specific form.

D. Investigative Protocol for DHS Facilities

FY09 Authority

Since Rule 50.40(a) specifically includes facilities along with community agencies in being allowed to assist in investigations, OIG established a comparable protocol and approval process in FY08. The "OIG Investigative Protocol for DHS Facilities" contains the same requirements for an "OIG Liaison" and investigators, the same expectations for handling of allegations and for investigative steps, and the same annual application process as in the community agency version, although it runs on calendar year.

The facility protocol, however, excludes assigning any investigations to the facilities: authorized facility investigators may only conduct initial investigative steps. In addition, the facility protocol includes requirements for investigating "non-reportable" complaints - those that OIG receives but determines do not meet the definitions of abuse or neglect even if occurring as alleged.

FY09 Actions

While OIG's approval of agency investigative protocols is based on fiscal year, the process for approving DHS facility investigative protocols follows the calendar year. The 2009 facility investigative protocol approval process thus began December 29, 2008, when OIG sent a copy of the DHS Facility Investigative Protocol and an application form to all DHS facilities that primarily provide mental health or developmental disability services.

All the facilities replied promptly, and OIG approved all eighteen facility protocol applications for calendar year 2009. The facilities identified as investigators a combined total of 124 employees who were trained by OIG in investigative skills. OIG reviewed each of those employees' position title, job duties, and training; OIG also checked for any substantiated findings of abuse/neglect. OIG was then able to authorize all 124 employees as investigators.

FY09 Impact

The DHS facilities serve a larger number of individuals in one location than do most community agency programs. Therefore, facilities have more allegations than most community agencies. The facilities also have more incidents that, while not reportable to OIG, need to be investigated for other reasons. Therefore, although the facilities may not be assigned any investigations, each OIG-authorized facility investigator typically conducts initial investigative steps on more allegations and has more internal investigations to handle.

OIG thus relies on these trained investigators to handle many initial interviews and to gather and preserve relevant evidence in a timely and appropriate manner. By providing the protocol and investigative training, OIG ensures that facility staff will appropriately handle evidence, not contaminate it, and will not delay in notifying law enforcement authorities when warranted.

FY09 Example

An individual received a wrong dosage of a medication, but she appeared to be unharmed by it. The medication error was thus not reportable to OIG, and the facility began an investigation as required by OIG's Facility Investigative Protocol.

The facility investigator found that a new pharmacy had provided the medication; it was labeled differently and the dropper was too large, requiring the licensed practical nurse (LPN) to use a syringe. She poured the medication into a cup, drew the medication into a syringe, put the remaining amount back in the bottle, and had a second LPN and a registered nurse (RN) verify the amount in the syringe. She then administered the medication and charted it.

The second LPN on duty told the facility investigator that, sometime later, she received a call from the pharmacist, who wanted to ensure staff understood the bottle labeling correctly. During the call, she said, she realized that they had probably given the incorrect amount. So, she went to talk to the RN who was just coming on duty. This RN noticed that the chart said the individual had been given her prescribed 2.5 mg but the bottle was missing 2.5 cc, which is about twenty times as much as prescribed and was potentially fatal.

The LPN said that the RN told her to report the error to the doctor but also to add water to the bottle to make up for the difference. A third LPN alleged that the second LPN told her to add water to the medication bottle and to change the chart to cover up the medication error, although she did neither. Hearing this, the facility investigator called OIG, and an allegation of neglect was taken.

The investigation found that the doctor arrived to examine the individual four hours after the medication was given. By that time, the doctor noted, the medication would have passed out of the individual's body, and he found no signs of any problems - although the overdose might have caused brain damage and was potentially fatal.

OIG re-interviewed several employees to verify accounts and to continue the investigation. Although it could not be proven who wanted to cover up the error by adding water and changing the chart, OIG substantiated neglect by the two initial LPNs based on the great risk of serious harm. The facility gave the two LPNs 15-day suspensions without pay and re-trained them in medication administration procedures.


Chapter III: OIG handles allegations of abuse, neglect, and exploitation.

A. Non-Reportable Complaints

FY09 Authority

Administrative Rule 50.20(b) mandates that OIG's 24-hour hotline number (1-800-368-1463) be posted in facility and community agency program locations throughout the state. These postings result in OIG not only receiving more allegations, but also receiving many complaints that do not meet the definitions in Rule 50: for example, complaints about limitations on an individual's freedom to use a telephone or to smoke cigarettes. In such cases, OIG refers it back to the agency or facility to be handled as a human rights complaint.

The statute specifically restricts OIG from investigating in any program licensed by another State agency and Rule 50.30(c) requires that any such complaints be referred to the "appropriate agency or unit of government." OIG thus refers any complaint involving nursing homes, private hospitals, and intermediate care facilities to the Illinois Department of Public Health, which licenses those programs. OIG refers complaints about individuals younger than 18 years old to the Department of Children and Family Services and domestic calls about individuals older than 50 years old to the Department on Aging. OIG often directly transfers the caller to the appropriate hotline. OIG's goal is to ensure that any issues are addressed before they have a chance to escalate into an abusive or neglectful situation.

OIG has long had internal directives on referrals of these "non-reportable" complaints (OIG Directives INV 02-013 and ADAP 02-006). During FY07, at the recommendation of the Illinois Auditor General, OIG developed a process for saving these "non-reportables" in the OIG incident database. Although identified as non-reportables, they are listed along with allegations on later intakes involving any of the same persons.

Since calls about domestic situations often have limited information, it is only after going out to investigate that OIG finds the problems are under the investigative jurisdiction of another entity, such as the Department on Aging. When this happens, OIG immediately refers the complaint to that entity and re-classifies the complaint as a non-reportable.

FY09 Actions

In the middle of FY08, OIG began recording all non-reportables in its database. During that fiscal year, OIG received and recorded a total of 1,279 complaints that were non-reportable initially, not counting 95 allegations that were determined after some initial investigation to not meet the requirements of Rule 51 (domestic allegations only). During FY09, OIG received and recorded 1,483 non-reportable complaints, similarly not counting 85 complaints later determined to not meet the requirements of Rule 51.

FY09 Impact

As noted above, when non-reportables are received, OIG does more than just record them in the database. Where appropriate, the issues are referred out to the appropriate unit of government, such as a local law enforcement or public health entity, or are referred directly back to the facility or community agency for resolution. During FY09, the 1,483 complaints were referred as shown in Table 2 below.


Table 2:
Referrals for Non-Reportable Complaints Received in FY09

Referral Location NonReportable Rule 50 complaint (Agency/Facility) NonReportable Rule 51 complaint (Domestic)
Local community agency or facility 779 92
Illinois Department of Public Health 19 13
Department of Children & Family Services 17 7
Local lawenforcement authority 8 15
DHS Division of Rehabilitation Services 0 8
Illinois Department on Aging 0 7
DHS Division of Developmental Disabilities 2 5
DHS-BALC* 6 0
DHS Division of Mental Health 1 4
Office of the Executive Inspector General 1 1
Illinois State Police 2 0
Other 3 3
None needed 192 296
Totals 1030 453

* DHS Bureau of Accreditation, Licensure and Certification.


Approximately three-fourths (76%) of the non-reportable Rule 50 complaints were referred to an agency or facility that was already providing mental health or developmental disability services to the individual. Illinois' Department of Public Health and the Department Children and Family Services received just under two percent. Nineteen percent of the Rule 50 non-reportables needed no referral.

By far, the largest referral source for Rule 51 (domestic) non-reportable complaints was also local community agencies that could provide needed services (20% of the referrals). Local law enforcement authorities were the second most common referral location (3% of referrals). Since many of the Rule 51 complaints received were about situations that the police or other entities were already aware of - and often had already resolved - nearly two-thirds of these non-reportable complaints needed no referral.

A growing number of non-reportable complaints are of this type: situations already reported to the appropriate entity but which were also being reported to OIG. Such duplicative reporting would run contrary to the intent of OIG's statute, which prohibits OIG from conducting any investigation that would be redundant to another agency's investigation. Thus, OIG is unable to conduct any investigation, to develop any evidence to aid in the referral, or to take any direct action to address the situation.

FY09 Example

An individual receiving outpatient mental health services told the community agency he had loaned an employee $2,500. He complained that, although she had started sending him payments on the loan, her checks had bounced. The agency noted that this employee had resigned since that time.

The agency reported this to OIG. However, financial exploitation is not abuse or neglect as defined in Rule 50, so OIG had no jurisdiction to investigate. OIG explained this to the agency and strongly advised referring the individual to the local police, who would be able to investigate it as a criminal complaint. The individual did not want to file a criminal complaint, but the agency was able to get the money back for him.

With the passage of the new law, OIG now has authority to investigate financial exploitation. Complaints such as this one will no longer simply be referred to another entity; OIG will be able to investigate and to refer the evidence directly to law enforcement, when appropriate.

B. Timeliness of Initial Reporting

FY09 Authority

The statute mandates that each employee or contractual worker report to OIG any allegation of abuse or neglect within four hours after initially discovering it, whether by witnessing it or hearing of it. Rule 50(a)(2) repeats this requirement. Since OIG has a 24-hour hotline, OIG can identify instances where a "required reporter" failed to do so. If the investigation finds evidence of failing to report, OIG typically cites the person in the final investigative report.

OIG has also identified apparent systemic problems at a facility or community agency. When found, such problems are referred to the respective program division for correction. Further, the Illinois Auditor General, during an audit in FY08, recommended that OIG continue to work with both the facilities and the community agencies to ensure allegations are reported timely.

FY09 Actions

To ensure reporting of allegations of abuse or neglect, OIG worked with the DHS Division of Mental Health and Division of Developmental Disabilities to ensure that training in Rule 50 is a biennial requirement for all facility and community agency staff.

OIG also set a strategic objective to work with the community agencies to ensure the policies adequately covered four basic requirements on reporting, one of which is the time requirements for reporting allegations and deaths to OIG. The last of the policies was approved in July 2008, not long after the start of FY09.

Since the new statute revises the definitions of most types of abuse, adds financial exploitation as a type of abuse, broadens the definition of neglect, and makes procedural changes, Rule 50 will need to be revised. Once that is complete, the agencies and facilities will likely be asked again to revise and submit their policies on reporting abuse and neglect.

When an agency/facility representative reports an allegation or death to the OIG Hotline (this is called a "self-report," since the agency/facility itself reported it), the database still calculates if the self-report met the time requirement. If not, the database automatically flags the intake form as a late report. The investigation will include determining if and why it had been reported late. If the allegation was reported late, OIG cites the late reporting in the investigative report and recommends that the agency/facility take action to address the late reporting.

OIG continues to send the program divisions a monthly listing of allegations and deaths reported late, so the divisions can follow up with the agencies and facilities. This listing shows how many cases were reported late and how late each case was reported.

FY09 Impact

By taking these proactive steps, OIG has improved the timeliness of initial reporting another four percent over last year. During FY08, sixteen percent of the self-reports (259 of 1,642) were reported late; during FY09, only twelve percent were reported late (225 of 1,909).

DD facilities continue to have the fewest late self-reports: only 4.7% were reported late in FY09. MH agencies, despite having the greatest percentage increase in reporting, had the greatest drop in percentage of self-reports late.

The table below shows the breakout by location and disability type over the past five fiscal years. The table shows that, while the number of self-reports continues to climb, the number that are late has been falling. Actions taken by agencies and facilities to correct systemic and employee performance causes for late reporting are being increasingly effective.

Table 3: Late Reporting by Program and Disability Type, FY05 through FY09

Fiscal Year Total Reports Late from DD Agencies Late from DD Facilities Late from MH Agencies Late from MH Facilities Total Late Percent Late
FY05 1,419 18 14 24 31 257 18.1
FY06 1,514 186 24 35 16 261 17.2
FY07 1,603 174 27 24 29 254 15.8
FY08 1,642 185 32 18 24 259 15.8
FY09 1,909 172 17 16 20 225 11.8


FY09 Example

Timely reporting has been an issue in community agency cases. Here is an example of a community agency case where timeliness was important to substantiating the case.

When he arrived at an agency's day program, an individual alleged that a CILA employee had dumped hot tea on him. He had a fist-sized burn on his shoulder, so he was sent to the hospital for treatment. The day program reported the allegation immediately, and so an OIG investigator was able to go to the hospital and take photos of the burn and begin interviews right away. The accused employee denied the allegation. However, the individual was consistent in his account, two other individuals remembered seeing it happen, and the photos documented the injury. OIG substantiated the allegation, and the employee was discharged.

Timely reporting is also important in facility cases as well.

A supervisor noticed serious discrepancies in one nurse's entries in the blood sugar level record of an individual who has diabetes. The facility immediately called OIG. The testing machine retains readings, but the particular machine was traded in for an updated model shortly after the investigation began. Since the allegation had been reported timely, the old machine was kept and many readings could be compared to the nurse's entries. At least one entry was falsified - the nurse had written 140 when the machine showed 469 (the nurse did not notify a physician, which is required whenever a reading is over 400). Also, at least seven other readings were not written down at all, and four written entries had no corresponding reading on the machine. Timely reporting further helped undermine the accused nurse's excuses for these errors. OIG substantiated neglect, and the nurse was discharged.

C. Allegations of Abuse and Neglect

FY09 Authority

OIG's statutory mission of investigating allegations relies on the reporting of abuse/neglect allegations, so the statutes require OIG to maintain a reporting hotline (20 ILCS 1305/1-17(a) and 20 ILCS 2435/30). OIG is also to include in its annual report an analysis of trends in the numbers of allegations reported and their disposition for the most recent three-year time period (20 ILCS 1305/1-17(l)).

Administrative Rule 50 contains details of reporting of allegations and of deaths, including the mandate that OIG "be available 24 hours a day to assess reports of allegations of abuse, neglect or death and provide any technical assistance with making the report" (Rule 50.30(a)).

By statute and rule, facilities and community agencies are prohibited from withholding, screening or delaying allegations or reports. While employees may report to their supervisors "according to the community agency's or facility's procedures" (Rule 50.20(a)(1)), the report may not be withheld or delayed beyond the mandated time frames.

FY09 Actions

During FY09, OIG received a total of 2,748 allegations, an increase of three percent over FY08. The increase was uneven across settings, however: allegations rose seven percent at facilities, increased four percent at community agencies, and fell four percent in domestic settings. For the third year in a row, allegations at community agencies accounted for the largest proportion of total allegations.

The biggest changes were in neglect allegations at facilities (up 24%) and at community agencies (up 12%) and in abuse allegations in domestic settings (down 8%). Allegations received by OIG during FY09 are shown in the table below.

 Table 4: Summary of Allegations Received by OIG in FY09

Location  Abuse allegations Neglect allegations Total Allegations
DHS-operated facilities 733 122 855
Community agencies 945 334 1,279
Domestic settings 298* 316 614
Total 1,976 772 2,748

 * includes 53 allegations of financial exploitation, which has been statutorily reportable to OIG only in domestic settings.


Overall, allegations OIG receives have been rising steadily over the past three fiscal years, increasing seven percent over that time period. However, the increase has primarily been in allegations at community agency programs. That is, in FY07, OIG received 2,562 allegations - 866 at facilities, 1,044 at community agencies and 652 in domestic settings - and thus, while allegations at community agencies have risen 22.5% over the time period, allegations at facilities dropped 1.3% and domestic allegations dropped 5.8%.

Facilities with significant decreases over those three fiscal years are: Choate DC (down 56%), Howe DC (down 52%), Elgin MHC (down 36%), and Kiley DC (down 34%). Facilities experiencing significant increases over those three fiscal years are: McFarland MHC (up 98%), Singer MHC (up 95%), Chester MHC (up 47%), and Murray DC (up 45%). These changes are largely due to particular individuals reporting much more or much less.

However, over the past six fiscal years, allegations OIG received have increased 68%. During FY04, OIG received 1,634 allegations, 657 at facilities, 525 at community agencies, and 452 in domestic settings. Therefore, during FY09, OIG received 30% more allegations at facilities, 36% more allegations in domestic settings, and 144% more allegations at community agencies compared to six years ago. OIG has received no increase in budgeted headcount during these fiscal years.

Tables 5a through 5c show more detailed counts by specific allegation type and program location; deaths reported to OIG during FY09 are also included. Those tables list the facilities individually, but, at the nine public psychiatric hospitals, the "forensic" residential units - those for individuals who are committed by a criminal court order or who have aggressive behaviors - are listed separately from the "civil" (not forensic) residential units; please note that Chester MHC is an entirely forensic facility. The allegations and deaths reported at community agencies are grouped into residential and non-residential programs.


Table 5a: Allegations and Deaths Received in FY09 - Mental Health Services Only

Location  Physical abuse allegations Sexual abuse allegations   Mental abuse allegations Neglect allegations  Total allegations received Deaths
Alton (civil) 11 2 3 0 16 0
Alton (forensic) 23 8 27 4 62 0
Chester (forensic) 153 5 30 13 201 0
Chicago-Read 7 4 9 4 24 0
Choate MH 19 1 5 4 29 0
Elgin (civil) 6 0 4 3 13 0
Elgin (forensic) 7 4 8 11 30 3
Madden 11 6 7 7 31 2
McFarland (civil) 15 4 7 5 31 2
McFarland (forensic) 5 1 2 0 8 0
Singer 21 9 7 13 50 1
Tinley Park 3 0 2 4 9 0
Facility totals 281 44 111 68 504 12
Agency Residential 15 11 15 7 48 13
Agency Non-residential 8 14 14 7 43 6
Agency totals 23 25 29 14 91 19
Rule 50 MH totals 304 69 140 82 595 31


Table 5b: Allegations and Deaths Received in FY09 - Developmental Services Only

Location Physical abuse allegations Sexual abuse allegations Mental abuse allegations Neglect allegations Total allegations received Deaths
Choate DC* 30 1 9 4 44 1
Fox 2 0 3 5 10 1
Howe 28 0 8 10 46 8
Jacksonville 73 1 20 12 106 5
Kiley 17 1 2 10 30 2
Ludeman 28 0 1 5 34 0
Mabley 10 0 2 3 15 1
Murray 18 0 4 3 25 4
Shapiro 37 0 2 2 41 4
Facility totals 243 3 51 54 351 26
Agency Residential 398 33 137 243 811 88
Agency Non-residential 199 18 83 77 377 5
Agency totals 597 51 220 320 1188 93
Rule 50 DD totals 840 54 271 374 1539 119

* Includes three physical abuse allegations and two mental abuse allegations on the DD forensic unit.


Table 5c: Allegations and Deaths Received in FY09 - Domestic Settings Only

Disability Type Physical abuse allegations Sexual abuse allegations Mental abuse allegations Neglect allegations Financial exploitation allegations Total allegations received
Developmental 153 16 15 162 27 373
Physical 35 3 2 114 14 168
Mentalhealth 16 4 1 40 12 73
Rule 51 totals  204 23 18 316 53 614


FY09 Impact

In addition to looking at the total number of abuse or neglect allegations reported about each facility, OIG also compares the rate of allegations received about facilities based on facility size. That is, in order to appropriately compare facilities on allegations received, OIG must calculate a rate that takes into consideration that the facilities vary greatly in the number of individuals who receive services in those facilities.

To calculate a rate, OIG uses a count of individuals that DHS provides. This count includes all individuals who are still on the facility's books as having a bed during the fiscal year, although they may be on a visit to home or to a potential community placement during part of the time. The resulting count, called "on-books bed days" (which was shown in Table 1), is divided into the number of allegations received by OIG about that facility, and then multiplied by 1000 to give a reporting rate.

These reporting rates for the facilities in FY09 are given in Tables 6a and 6b below. As with Tables 5a and 5b, the counts of allegations from forensic and non-forensic units in these tables are shown separately. However, the facility averages shown at the bottom of each table are for whole facilities; that is, they combine a facility's forensic and non-forensic units where the facility has both types.


Table 6a: Reporting Rates from DHS MH Facilities, FY09

Facility Allegations Received Rate of Allegations
Alton (civil) 16 2.39
Alton (forensic) 62 1.67
Chester (forensic) 201 2.07
Chicago-Read 24 0.52
Choate MH 29 1.38
Elgin (civil) 13 0.46
Elgin (forensic) 30 0.28
Madden 31 0.67
McFarland (civil) 29 1.03
McFarland (forensic) 10 0.86
Singer 50 1.95
Tinley Park 9 0.38
Facility averages 56 1.05


Table 6b: Reporting Rates from DHS DD Facilities, FY09

Facility Allegations Received Rate of Allegations
Choate DC (civil) 39 0.70
Choate DC (forensic) 5 0.67
Fox 10 0.21
Howe 46 0.42
Jacksonville 106 1.37
Kiley 30 0.38
Ludeman 34 0.25
Mabley 15 0.48
Murray 25 0.22
Shapiro 41 0.21
Facility average 39 0.41


Overall, the rates of abuse/neglect allegations are low, no more than about two allegations per thousand patient-days and less than one per thousand patient-days at most of the facilities. Three facilities stand out as having the highest rates: Alton MHC's civil unit, Chester MHC, and Jacksonville DC. Each of these facilities has individuals who make multiple allegations. At Alton MHC, three individuals accounted for 50% of the FY09 allegations; at Chester MHC, three individuals accounted for 13%; at Jacksonville DC, three individuals account for nearly 40%. Many of these allegations are vague, making it difficult to investigate and to substantiate.

FY09 Example

An individual alleged that she and other individuals were pushed and yelled at by a particular employee, but she did not provide any dates or names of other victims. The OIG investigator interviewed many people and reviewed nineteen months of progress notes, injury reports, and other documents for multiple individuals. This extensive investigation found enough evidence to substantiate both mental and physical abuse by the accused employee. The employee was then discharged from employment.

OIG also found that the community agency knew about the allegations earlier. However, instead of reporting these, the agency had conducted an unauthorized abuse investigation using an unapproved investigator. The agency then decided the allegations were unfounded and had not reported them to OIG and had allowed the abusive employee to continue to work with the individuals. OIG substantiated neglect by the agency and made multiple recommendations for training all staff in Rule 50 and for other actions to ensure that allegations are reported and investigated properly. Further, when the agency then applied to OIG for authorization to investigate cases, OIG denied the application.

D. Referrals to Law Enforcement

FY09 Authority

OIG is statutorily responsible for only administrative investigations, so OIG is authorized to report any allegations of criminal conduct to the appropriate law enforcement entity. OIG must make such reports to law enforcement within 24 hours of finding credible evidence that a crime may have occurred (20 ILCS 1305/1-17(b) and Rule 50.30(e)). The FY07-08 program audit by the Illinois Auditor General found that, although the current version of the reporting form was not always used, OIG had reported allegations as required and on time.

Reporting credible evidence of crimes to the appropriate law enforcement entity is also authorized by statute on domestic abuse, neglect, and exploitation (20 ILCS 2435/25(g)) and its companion rule (Rule 51.50(f)), although neither designate a time frame for reporting. This statute, however, envisions OIG investigators and local law enforcement working more integrally in particular situations, to "encourage and support the efforts of law enforcement officers to provide immediate, effective assistance and protection for adults with disabilities who are abused, neglected, or exploited" (20 ILCS 2435/10(c-5)).

FY09 Actions

OIG and the Illinois State Police (ISP) have worked hard over the past several years to improve coordination. During FY08, OIG had taken ISP's standard reporting form and created an electronic version that allows OIG investigators to print the form directly from the OIG database. Since it draws most of the information from the database, the form takes less time to complete, is always clearly legible, and has fewer errors. This form is used for reporting to local law enforcement entities, as well as to ISP.

Unfortunately, the electronic version was not consistently utilized due to slow network speed, an incorrect address for an ISP office, and simple lack of familiarity; thus, the wrong form was sometimes used, which resulted in the audit report's recommendation. OIG addressed these issues during FY09, distributing a formal reminder to all staff, along with copies of the directive and form.

OIG works closely with law enforcement, both to support and to augment efforts at assisting adults who have disabilities and are allegedly being abused, neglected or exploited. Since OIG has statutory authority to gather evidence of such mistreatment, OIG is sometimes indirectly involved in criminal investigation and prosecution.

FY09 Impact

During FY09, OIG reported 41 allegations to the Division of Internal Investigation (DII) of the Illinois State Police and sixteen cases to local law enforcement. In all instances, OIG reported the allegation to law enforcement within 24 hours of determining that there was credible evidence of criminal conduct.

The Illinois State Police accepted fifteen of the 41 cases that OIG developed credible evidence and reported to it. Local law enforcement entities accepted fourteen of the sixteen cases that OIG developed credible evidence and reported to them. When the State Police accept a case, OIG stops investigating until the State Police have finished, so that parallel investigations are not being conducted. OIG coordinates with local law enforcement but does not stop pending the outcome. If criminal prosecution results from either a State Police or a local law enforcement investigation, OIG still pursues an administrative investigation.

As noted, OIG's domestic investigators work closely with law enforcement authorities. So, these cases almost always involve notification to the local law enforcement entity with primary jurisdiction. Often, by working together, OIG and local law enforcement can best address both the alleged victim and the accused perpetrator.

FY09 Examples

OIG's Rule 50 investigators refer criminal allegations at facilities or agency programs to the appropriate law enforcement authority. Here is an example at a DHS facility.

OIG received an allegation that an employee had repeatedly kicked and punched an individual. However, she had no visible injuries and had a history of making up allegations so that employees she did not like would get reassigned elsewhere. Thus, OIG initially did not have any credible evidence. However, during interviews, another employee corroborated the allegation. OIG took the evidence to the Illinois State Police, since it might be a criminal act. The employee was arrested and charged with a felony; the court case is still pending.

OIG's domestic abuse investigators often work with local law enforcement agencies to resolve problems for adults with disabilities who are being mistreated at home. Here is an example.

OIG received an allegation that an individual receiving mental health services claimed that her husband had been having sex with their adult daughter, who has a developmental disability. The man was reportedly also the payee on both his wife's and his daughter's disability checks and had been spending the money on himself instead. An OIG investigator went to the family home, but the mother declined to be interviewed. The daughter, however, stated that her father had been having sex with her since she was twelve years old and that, whenever she refused to have sex with him, he hit her. The father admitted to having had sex with her - but only since she turned sixteen and claimed that it was because he loved her so much. He denied ever physically abusing her. OIG wanted to remove the daughter from the home, but she refused. Still, OIG notified the local police of the evidence, and the father repeated his admission to the reporting officer. The county State's Attorney, however, declined prosecution.


Chapter IV: OIG investigates abuse, neglect and exploitation.

A. Investigative Caseloads

FY09 Authority

Investigating allegations of abuse/neglect - and, in domestic settings, of exploitation as well - is OIG's primary mission (20 ILCS 1305/1-17(a) and 20 ILCS 2435/5, 20). Efficient and timely investigation requires prompt initial case assignment, thorough investigative plans, and effective caseload management. The FY07-FY08 program audit by the Illinois Auditor General noted an improvement in OIG's caseload balance.

FY09 Actions

The number of allegations naturally varies over time, so OIG continually monitors the distribution of open investigations and takes action to improve caseload balance. Monthly case listings, as well as informal discussions, ensure that imbalances are dealt with promptly and effectively. Further, areas that border another investigative bureau may be routinely assigned to the other bureau during times of peak intakes; for example, the Metro Bureau's cases in northern Cook County are often handled by the North Bureau.

During the course of the fiscal year, 152 OIG investigations were assigned to field investigators who were not in the OIG investigative bureau with primary jurisdiction. While this number is small relative to the total number of OIG investigations, it is enough to balance caseloads.

FY09 Impact

The table below compares, for FY07 through FY08, the average number of cases assigned to all field investigators in each investigative bureau during the fiscal year and their average caseloads on the last day of the fiscal year.


Table 7: Average Annual Cases Assigned and Average Caseloads on June 30

Bureau FY07 Assigned FY07 Caseload FY08 Assigned FY08 Caseload FY09 Assigned FY09 Caseload
North 63.2 13.2 86.8 16.0 105.3 10.0
Metro 98.5 27.8 95.8 18.0 105.5 12.5
Central 89.3 15.0 122.3 15.3 133.0 14.3
South 95.7 16.0 65.8 8.5 95.8 12.0
Domestic 159.0 34.3 136.8 30.0 136.0 5.0


The table shows caseloads have become much more consistent across bureaus. The average caseload in the Metro Bureau at the end of FY07 was more than twice as high as the North Bureau, yet they were only slightly different at the end of FY09. Notice also that the average number of cases assigned during the fiscal year was more even between those two bureaus.

FY09 Example

On July 22, 2008, OIG received an allegation that an employee injured an individual by throwing a drinking glass at her. Although in the jurisdiction of OIG's Metro Bureau, the case was assigned to an investigator in OIG's North Bureau due to availability and proximity.

The investigation found that the individual had returned to the CILA in a bad mood and refused to complete assigned tasks. When confronted by the employee, the individual became very angry: she called the employee names and threw water in the employee's face. In response, the employee picked up the glass and threw it at the individual - it shattered on the individual's head - and pushed the table over to grab the individual's arm. Another individual ran to the CILA next door to get help. When a staff member from that CILA arrived, the accused employee was very upset and swearing; the back door was open, and the injured individual was outside, walking away. She was brought back, examined by a nurse, and taken by ambulance to a hospital, where she received three staples to close the head laceration.

The employee was fired, and the agency conducted an in-service training for all the other employees on dealing with negative behavior by individuals.

B. Case Reviews

FY09 Authority

When an investigation into alleged abuse/neglect at a facility or community agency is done, the authorizing statute provides for a formal internal OIG review of the preliminary report (20 ILCS 1305/1-17(b-5)). This review process is expanded upon in Rule 50.60(a) and is further detailed in OIG Directive INV 02-020 (for OIG-conducted investigations) and in OIG Directive INV 02-021 (for agency-conducted investigations).

For OIG's investigations in domestic settings, such case reviews are not specifically mentioned in the statute or rule. However, OIG follows the similar process for these cases, which is formalized in OIG Directive ADAP 02-010.

FY09 Actions

The OIG directives require the relevant bureau chief review to all investigative case reports. Three of the five investigative bureaus have an "Investigative Team Leader" (ITL), who functions as a lead investigator and a first-line supervisor. The ITL reviews the report and case file to determine whether the investigator has properly followed the investigative plan, interviewed all pertinent witnesses, and obtained the appropriate documents. The ITL may return the case file to the investigator (or to the monitoring investigator, if the case was investigated by an agency) for any correction or additional investigation. If a bureau has no ITL, the bureau chief handles these functions.

Upon approval, the ITL forwards it on to the investigative bureau chief for review. For cases that are not substantiated, the bureau chief acts as the Inspector General's designee and approves the case report, signing the cover letter. Of course, the bureau chief may instead return the case file to the investigator for correction or further investigation.

If an allegation of abuse or neglect is substantiated, the draft investigative report is reviewed by the Deputy Inspector General, who may send the draft report back for clarification, correction, or follow-up investigation. In order to ensure timely case completion, the OIG directives require that each of these levels of review takes no more than seven working days.

In addition to these "case reviews," the Deputy Inspector General conducts a "quarterly review" of a small sample of unfounded or unsubstantiated investigative case reports. The goal of this review, among other objectives, is to ensure that the four investigative bureaus are consistent in the investigative approach and findings. The case files are pulled and reviewed by a team consisting of the Deputy Inspector General and either an investigative bureau chief or investigative team leader.

FY09 Impact

Case reviews -

Initial examination of case review time for the latter half of FY09 shows that these reviews add on average only 2.4 working days to each case and, on a majority of cases, they add only one working day or less. OIG has found that effective reviews are essential and do not significantly increase the time required to complete investigations.

The one exception to this timeliness of reviews is the nineteen cases requiring a clinical review by one of OIG's registered nurses. In the first half of FY09, OIG hired an additional registered nurse on contract. During the latter half of FY09, clinical reviews averaged fifteen working days, but the reviews of nine of these nineteen cases were completed that same day.

Quarterly reviews -

During FY09, four Deputy Inspector General Quarterly Reviews were conducted, each addressing one type of allegation: Sexual abuse in the first quarter (completed September 28, 2008);  Mental injury in the second quarter (completed December 31, 2008); Neglect in the third quarter (completed March 19, 2009); and Physical abuse in the fourth quarter (completed June 28, 2009).

The reviews looked at sampled cases from every bureau, ranging from three to four from each bureau; however, all sexual abuse allegations were reviewed, as OIG receives proportionately fewer of that type.

The Deputy Inspector General's quarterly reviews during FY09 again found no substantial issues of interpretation or consistency across bureaus. They also looked at recommendations made in the reports, finding that these were usually clearly stated and appropriately addressed any problems identified during the investigation.

The four quarterly reviews identified several practices that could have been more uniform and highlighted some effective ways of approaching particular kinds of interviews and evidence-gathering, and OIG took steps to address these. OIG views the quarterly reviews as a useful tool in ensuring its effectiveness and internal consistency.

FY09 Example

A male employee allegedly had inappropriate relationships with three female individuals. The investigation revealed that he had taken each of the three women on unauthorized weekend outings, but the employee and all three individuals denied any sexual relationship. However, one believed she was in a romantic relationship, and she kissed the employee during one outing. Despite these apparent feelings and his supervisor's direction to stop the outings, the employee took a second individual on an unauthorized outing, which upset the first individual, since she believed she had an exclusive relationship with him.

The OIG investigative manager reviewed the initial draft report and asked the investigator to verify the employee had been directed to stop the outings - showing he knew that what he was doing was wrong - and to determine if the employee had reported the kiss by the first individual, which would have allowed the clinical treatment staff to deal with her issues before it led to other inappropriate behaviors.

The continued investigation verified that the employee had understood the supervisor's directions and knew that what he was doing was wrong. It also determined that he had failed to report the individual's inappropriate behavior. Since his failure to report her inappropriate behavior and his continuing the outings had led to her emotional distress, OIG substantiated neglect. The employee was discharged by the agency.

C. Timeliness of OIG Investigations

FY09 Authority

While neither statute has a specific timeframe for completing investigations, Rule 50.60(a)(1) includes the long-standing internal expectation that an OIG investigation is to be completed "within 60 days from assignment unless there are extenuating circumstances such as the unavailability of witnesses or official documents."

The FY07-FY08 program audit of OIG by the Illinois Auditor General noted that OIG had improved, decreasing its overall average from 53 days/case in FY06 to 44 days/case in FY08. OIG responded that it would strive to continue this improvement.

FY09 Actions

OIG has taken several steps to improve in timeliness of investigations, including the following:

  • Balanced caseloads to prevent backlogs with individual investigators or bureaus;
  • Improved case reviews, to reduce time an investigative report spends in review;
  • Continued allowing Intake investigators to draft a final investigative report whenever receiving an allegation that an individual made but then immediately recanted (requires the facility obtain an independent interview of the individual and supporting evidence);
  • Filled vacancies as quickly as possible when an investigator resigned or took an extended leave of absence;
  • Encouraged investigative supervisors to take a more active role in monitoring caseloads;
  • In August 2008, hired a short-term graduate intern to handle duties that an OIG investigator had been handling, freeing him to conduct investigations; and
  • Starting in March 2009, made the OIG training coordinators available to write up a few completed and unfounded allegations each month.

FY09 Impact

As a result of OIG's ongoing efforts, the average time to complete an OIG investigation has continued to drop despite the persistent rise in allegations and a decrease in available staff and resources. During FY09 and for the first time in many years, OIG reduced the average time to complete its investigations to less than forty days per investigation: 37.7 days.

The table below shows the average time to completion for all OIG investigations over the past four fiscal years.


Table 8: Average Time to Completion for All OIG Investigations by Fiscal Year

Investigations FY06 FY07 FY08 FY09
Number completed 2,333 2,494 2,744 2,866
Average total days * 50.8 44.3 40.8 37.7
Average OIG days * 47.7 42.6 39.1 36.6

*Average total days includes delays due to pending Illinois State Police investigations, while average OIG days omits that time.


Since the Illinois State Police request that OIG suspends its investigation until the State Police's criminal investigation is completed, the table above shows the total average days to completion and the average days to completion omitting that suspended investigative time. The decreasing difference between the two averages shows that the timeliness of State Police investigations has improved as well.

Although the overall average time dropped, average time to completion for OIG's Rule 50 investigations was relatively flat this past year, increasing to 44.5 days per case in FY09 from 44.2 days per case in FY08. The largest single factor in the increase was the completion of several cases that had been open for a long time pending a clinical review. OIG had hired a new clinical coordinator to fill a vacant position in FY08, and then in early FY09, OIG obtained a temporary contractual nurse investigator. These two employees completed older cases first, causing the slight rise in the overall average time to completion.

On the other hand, the average time to completion for OIG's Rule 51 investigations during FY09 dropped to 13.2 days per case from 31.9 days per case in FY08. OIG attributes this decrease to several factors, including the following:

  • Fewer Rule 51 allegations received than last year,
  • Completed training of a new domestic investigator who filled a long-vacant position,
  • Reassignment to domestic investigations of an investigator who had been doing inventory management, and
  • Expedited review of cases in which the alleged victim refused to consent to OIG conducting an investigation.

OIG is continuing its efforts to improve overall timeliness of investigations despite the persistent rise in allegations received and the fiscal constraints facing the State. OIG will strive to improve its timeliness as prompt investigation may speed actions to correct problems and to prevent the recurrence of abuse or neglect.

FY09 Example

On November 6, 2008, OIG received an allegation that, the day before, an employee had physically abused one individual and verbally abused another. An OIG investigator was assigned the case that day.

The agency did not have an approved protocol, so the OIG investigator responded and interviewed all the involved persons the next day. A signed statement was obtained from the accused employee, who admitted to pushing the one individual into a cabinet and yelling at the other individual, upsetting her.

The OIG investigator submitted a draft case report on November 12, only two working days after the interviews. Supervisory review was completed the same day; review and approval from the Inspector General designee were received on November 18. The case file was compiled and reviewed, and the case report and all notification letters were printed out on November 19 and mailed the following morning.

OIG completed this substantiated investigation only eight working days after receiving it, even without relying on initial investigative steps by the agency. The agency fired the employee on November 25, just nineteen days after the allegation was received.

D. Reconsiderations

FY09 Authority

The statute governing OIG investigations at facilities and community agencies allows for requests for reconsideration or clarification for investigative reports, although any such request must be based on information not already in the report (20 ILCS 1305/1-17(b-5)). The process for requesting and handling a reconsideration is further delineated in Rule 50.60(b) and in OIG Directive INV 02-031.

The statute and administrative rule governing OIG's investigations in domestic settings do not provide for reconsiderations or clarifications.

FY09 Actions

Each year, OIG typically receives relatively few requests for reconsideration or clarification of the findings. Further, many of these reconsiderations do not meet the regulatory requirements for a reconsideration: they must be in writing, must be submitted to OIG within fifteen working days, and must contain new information not in the case report that could change the outcome. Requests for simple clarification do not require new information.

OIG received only 84 requests for reconsideration in FY07, only 106 requests in FY08, and only 107 requests in FY09. These 107 requests addressed 85 cases, or only four percent of the total of 2,091 Rule 50 investigations that OIG completed.

FY09 Impact

Of these 107 reconsideration requests received in FY09, OIG granted 27 and denied 80 as not meeting the requirements in the rule. The 27 granted requests addressed 24 cases and resulted in a new finding in ten cases, a modified but same overall finding in six cases, and no change to the finding in eight cases. Thus, OIG issued an amended report in 16 of the 24 cases in FY09.

For comparison, of the 84 requests for reconsideration that were received in FY07, OIG granted sixteen reconsiderations and issued an amended report in thirteen of those sixteen cases. Of the 106 requests received in FY08, OIG granted 34 reconsiderations and issued an amended report in 32 of those 34 cases.

FY09 Example

OIG investigated an allegation of physical abuse, substantiating that the employee had yelled at an individual, slapped her on the leg, and pulled her up from a chair by the wrists. The OIG investigation had identified a staff witness to the abuse. The employee was fired by the community agency.

The accused employee filed a reconsideration, alleging that the staff witness had previously threatened to get her fired. She listed names of other staff who she claimed had witnessed conflicts between the staff witness and her. OIG granted the reconsideration, as it was filed timely and included new information.

OIG conducted a follow-up investigation, including interviewing the named staff and the supervisor about the relationship between the two employees. All those interviewed stated that the two appeared not to like each other, and one interviewee recalled an argument between them. However, they all stated that the two worked okay together, and none remembered hearing any threats by either of them.

OIG issued an amended case report that included the alleged threat and the findings from the follow-up investigation. The case remained substantiated physical abuse.

E. Case Closures

FY09 Authority

Both statutes governing OIG's investigations refer to "substantiated" cases, and Rule 50.10 and Rule 51.20 define "substantiated" as a preponderance of the evidence - that is, more than half of the evidence gathered in the investigation supports the allegation.

Neither statute subdivides findings for cases that are not substantiated. However, Rule 50 does make a distinction; in practice, OIG applies that distinction to Rule 51 cases as well. "Unsubstantiated" cases are those in which the investigation found some credible evidence but less than a preponderance. "Unfounded" cases are those cases where the investigation found no credible evidence to support the allegation at all. "Unfounded" does not mean that the alleged abuse or neglect did not occur, only that no evidence was found to support an allegation or suspicion that it had occurred.

FY09 Actions

During FY09, OIG closed a total of 2,997 cases: 934 at facilities, 1,433 at community agencies, and 630 in domestic settings. Of the total, 2,853 (95%) were allegations, 144 (5%) were deaths.

The 2,997 closed cases is an increase of six percent over FY08, when OIG closed 2,842 cases, 101 of them death reports. This FY09 total is 12% higher than two years ago, 29% higher than three years ago, and 53% higher than six years ago - yet OIG has not received any increase in funding or staffing.

However, the increases in cases have been uneven. The number of deaths has remained a small fraction of the total, but the number of allegations OIG has closed has been steadily increasing. Further, that increase has been largely in allegations at community agencies. During FY09, OIG closed almost 60% more allegations at community agencies than just three years ago and more than twice the number of six years ago.

OIG closed more allegations about the DHS facilities as well, but it is a much smaller increase. During FY09, OIG closed 903 allegations at facilities, compared to 883 in FY06. Even that is uneven. Of the 903 allegations that OIG closed, 526 were at MH facilities, which is a 30% increase over three years ago; the 377 closed at DD facilities is a 21% decrease over the same time period.

Tables 9a through 9c show the number of cases OIG closed in FY09 by location and finding. As with Tables 5a through 5c, the "forensic" residential units at facilities are separated from the "civil" (non-forensic) residential units.


Table 9a: Cases Closed by OIG in FY09, Mental Health Services Only

Location Abuse substan- tiated Neglect substan- tiated Other issue only Not substan- tiated Allegation findings totals Closed death cases
Alton (civil) 2 0 4 14 20 0
Alton (forensic) 3 0 4 61 68 0
Chester (forensic) 1 3 19 173 196 0
Chicago-Read 0 0 10 19 29 4
Choate MH 1 0 1 32 34 2
Elgin (civil) 0 0 4 12 16 4
Elgin (forensic) 0 0 6 21 27 2
Madden 0 0 6 31 37 0
McFarland (civil) 1 0 7 28 36 1
McFarland (forensic) 0 0 0 5 5 0
Singer 0 1 3 42 46 1
Tinley Park 0 0 2 10 12 2
Facility subtotals 8 4 66 448 526 16
Agency Residential 6 2 22 30 60 12
Agency NonResidential 5 3 12 17 37 1
Agency subtotals 11 5 34 47 97 13
Rule 50 MH Totals  19 9 100 495 623 29


Table 9b: Cases Closed by OIG in FY09, Developmental Disability Services

Location Abuse substan- tiated Neglect substan- tiated Other issue only Not substan- tiated Allegation findings totals Closed death cases*
Choate DC 1 1 3 41 46 1
Fox 1 2 1 2 6 3
Howe 2 3 17 40 62 7
Jacksonville 5 3 8 92 108 6
Kiley 0 2 11 21 34 3
Ludeman 0 0 5 28 33 0
Mabley 1 1 1 14 17 0
Murray 1 0 9 12 22 1
Shapiro 1 1 4 43 49 7
Facility subtotals 12 13 59 293 377 28
Agency Residential 80 33 300 446 869 80
Agency Non-residential 54 25 129 189 397 7
Agency subtotals 134 68 429 635 1266 87
Rule 50 DD Totals 146 81 488 928 1643 115

* Includes two agency deaths substantiated as neglect.


Table 9c: Cases Closed by OIG in FY09, Domestic Settings

Disability Type Abuse substan- tiated Neglect substan- tiated Exploitation substan- tiated Refused consent Not substan- tiated Findings totals
Developmental 59 39 2 53 232 385
Physical 5 8 2 47 106 168
Mental 5 3 1 28 40 77
Rule 51 totals  69 50 5 128 378 630


FY09 Impact

As the tables above show, a majority of Rule 50 allegations of abuse or neglect closed during FY09 were not substantiated. Most of these allegations are closed as not substantiated because no evidence could be found to support the alleged incident occurred. During FY09, only 253 of the Rule 50 allegations (11%) and two of the deaths (1%) were substantiated as abuse or neglect.

Substantiation rates for Rule 51 investigations (domestic settings) are typically higher but still no more than one-fourth of the cases. This is partly due to the fact that Rule 51 grants the alleged victim the right to refuse consent to OIG's investigation. Again during FY09, OIG closed a substantial number of the domestic allegations because the alleged victim refused to consent to OIG doing an investigation: 128 of 630 closed cases, or 20% of all domestic investigations closed during FY09.

Table 10 compares substantiation rates by location and by fiscal year for the past five fiscal years. Although the definitions of abuse and neglect are different for Rule 50 (facility and community agency) cases than for Rule 51 (domestic) cases, overall rates are calculated for comparison purposes.


Table 10: Substantiation Rates by Location and Fiscal Year

Location FY04 FY05 FY06 FY07 FY08 FY09
DHS facilities 7.2% 4.5% 6.3% 5.9% 5.9% 4.1%
Community agencies 19.1% 18.4% 17.5% 16.2% 16.4% 16.0%
Domestic settings 15.0% 21.9% 19.9% 19.3% 26.2% 19.7%
Overall 12.9% 13.5% 14.4% 14.0% 15.9% 13.1%


The table above shows that OIG's rate of substantiation has fluctuated over the past six years, but the overall rate has remained around 14%. The substantiation rate at facilities was highest in FY04, but the rate at facilities in FY05 is similar to the rate in FY09. The substantiation rate for investigations at DD facilities has been consistently higher than at MH facilities, largely due to the differences between the inpatient populations.

As many more allegations are being reported in community settings, the number substantiated has dropped slightly. In the past six years, substantiation rates were highest in FY04 and FY05 and lowest in FY07 and FY09. However, the actual number of substantiated cases at community agencies has increased from 138 in FY04 to 218 in FY09.

Substantiated allegations in domestic settings in FY09 were significantly lower than in FY08. However, FY08 was unusually high, and the FY09's substantiation rate is similar to the percentage in the four previous fiscal years.

FY09 Example

An agency reported that one of its employees had pushed an individual in a wheelchair out of a van while the wheelchair lift was still on the ground. OIG investigated and found that the employee had received extensive training in how to operate the wheelchair lift. However, before pushing the wheelchair out, she had failed to ensure the lift was raised. Realizing this too late, she tried to hold onto the individual but was not able to keep her from falling.

The individual fell three feet, face first onto the metal grate of the lift. She broke her neck, her nose, and three teeth, which then had to be extracted. She needed stitches for several cuts to her face and neck, and she now requires a feeding tube.

The employee's failure resulted in a substantiated neglect case that was determined to be egregious due to the serious and life-threatening injuries. She was fired, and OIG referred her name to the Health Care Worker Registry.

OIG also recommended that agency policy require two staff be present - one outside and one inside - when using the wheelchair lift. Since the nurse and case manager present at the time of the fall immediately sat the individual back up in her chair despite the possible broken neck, OIG also recommended that staff be retrained in responding to medical emergencies.


Chapter V: OIG acts to prevent recurrence of abuse and neglect.

A. Emergency Domestic Intervention

FY09 Authority

The Adults with Disabilities Domestic Abuse Intervention Act that authorized OIG to conduct investigations of abuse, neglect, and exploitation in domestic settings (20 ILCS 2435) states that that the law "shall be liberally construed… to prevent, reduce, and eliminate abuse, neglect, and exploitation of adults with disabilities" (Section 10(a)). The law further states that, if OIG "determines that there is a clear and substantial risk of death or great bodily harm, it shall immediately secure or provide emergency protective services for purposes of preventing further abuse, neglect, or exploitation, and for safeguarding the welfare of the person" (Section 35(a)). OIG is to work with local entities to resolve the problems.

The statue entitles an individual to refuse consent for services - even for any investigation - but OIG is to refer evidence of crimes to appropriate law enforcement, to find emergency housing if needed, to obtain relevant financial records, and to go to court and take guardianship from a guardian who is abusing, neglecting, or exploiting an individual with disabilities. OIG's responsibility includes addressing the immediate situation.

FY09 Actions

The most common emergency interventions that OIG takes are for immediate protection from further harm. Preventing further harm is a primary goal of the statute.

Removing the individual from the harmful environment and finding a safe and healthy place for him or her to live, along with obtaining needed medical treatment, are often the first steps to protection. During FY09, emergency placement was the most frequent action OIG took. Out of the 124 substantiated cases, OIG sought emergency placement in 32 instances.

OIG addressed guardianship in eighteen cases. While the statute allows OIG to go to court to take guardianship, in eight of those cases, OIG found another relative who was concerned and willing to take guardianship of the individual. In the remaining ten cases, OIG went to court to get the Office of State Guardian named the guardian. Sometimes, the guardianship is only temporary, until the development of a full service plan that identifies a permanent residence.

Infrequently, OIG may need to assist the individual in obtaining an order of protection against the alleged perpetrator. While emergency placements usually resolve the problem, OIG helped pursue an order of protection in three cases during FY09. As with other emergency interventions, the primary goal is immediate protection from further harm.

FY09 Impact

While the number of substantiated cases has decreased from last year, OIG has needed to take more emergency interventions (see Table 11 below, which compares the prior four fiscal years). OIG has utilized fewer orders of protection but has increasingly pursued a change in guardianship as the only way to prevent recurrence of abuse/neglect/exploitation in the specific situations encountered. Still, only a small percentage of OIG's Rule 51 cases each fiscal year require any emergency interventions.


Table 11: Emergency Interventions by Fiscal Year

Intervention FY05 FY06 FY07 FY08 FY09
Orders of Protection 8 8 4 3 3
Emergency Placement 26 33 29 25 32
Guardianship Pursued 11 16 18 14 18
-- Guardianship by OIG 3 3 6 6 10


The table shows the number of cases where OIG pursued a change in guardianship, typically to a different family member. The number of cases where OIG was also the entity that was given guardianship is a subset of that.

FY09 Example

OIG received a report that an individual with disabilities was being neglected by her father. Just a month earlier, OIG had investigated the case, finding that the individual appeared thin but reportedly ate regularly. OIG also had found that, because the father failed to get his daughter a photo ID, services provided through the department's Division of Rehabilitation Services (DRS) had been cancelled. In that case, OIG instructed the father to get a photo ID and referred the individual again to DRS.

After several weeks had gone by and this individual was still not coming to DRS services, OIG received the new allegation. OIG again went out, but no one answered the door. OIG returned two days later and found the individual being placed into an ambulance. She was taken to the hospital, where she was described as being seriously malnourished with deep bed sores on her back, she was very dirty with excrement, and her left eye was extremely infected; that eye eventually had to be surgically removed.

OIG made sure that the hospital began all necessary treatment, and OIG then went to the local police department to report the severe lack of care of the individual as a possible criminal act. OIG contacted the local community agency which, along with the hospital, found an alternative place for the individual to live.

In light of the father's persistent refusal to take her to needed services and a physician's report that she was unable to make her own decisions, OIG went to court to have a new guardian named. The court granted guardianship to the Office of State Guardian.

B. Service Plans

FY09 Authority

The statute on investigations of abuse, neglect, and exploitation in domestic settings (20 ILCS 2435) states that, when OIG substantiates a case, OIG is to refer the individual to the appropriate division in the Department of Human Services for development of a service plan. The plan, which is to be developed in consultation with the individual, is to identify and meet needs, thereby preventing recurrences of the problems. Again, the statue entitles each individual to refuse consent for a service plan or for any particular services.

FY09 Actions

OIG substantiated 124 allegations in domestic settings in FY09, referring each one to a DHS division for development of a service plan. This number of referrals is a 36% decrease from the large jump in FY08, but more referrals were made in FY09 than in the prior fiscal years.

The largest percentage of OIG's substantiated cases of abuse, neglect, or exploitation in domestic settings every year involves individuals who have developmental disabilities. Thus, each year, most substantiated cases result in a service plan referral to the department's Division of Developmental Disabilities. The table below compares OIG's FY09 referrals for service plan development by division with the prior four fiscal years.


Table 12: Service Plan Referrals by Fiscal Year

DHS Division FY05 FY06 FY07 FY08 FY09
Developmental Disabilities 83 61 76 107 96
Rehabilitation Services 29 42 35 74 23
Mental Health 6 7 8 12 5
Totals 119 110 119 193 124


FY09 Impact

Some individuals have never been connected to any services through the department prior to the OIG investigation. However, the great majority were receiving some DHS-funded services already, typically through a contractual arrangement with a service provider or a caregiver. The referral for service plan development, usually results in improved or additional services to the individual. This referral for better or expanded services enables OIG to ensure that the statutory goals of protecting from harm and providing for services are met.

FY09 Example

OIG received a call reporting a woman slapping an individual with disabilities in a store. The woman, who turned out to be a paid caregiver to the individual, denied the allegation. However, OIG found a second witness to the slapping, which both witnesses described as being forceful. OIG found that the woman also worked part-time for a community agency program that provided care to other individuals with developmental disabilities.

OIG referred the substantiated case of abuse to the department's Division of Developmental Disabilities for a service plan. The division worked with the local pre-admission screening (PAS) agency on the case. The PAS agency noted that the accused woman resigned as the individual's caregiver, and they had hired a new caregiver for the individual. OIG also notified the community agency that employed the woman part-time, so that agency could review her interactions with individuals in that program.

C. Registry Referrals

FY09 Authority

When OIG substantiates physical abuse, sexual abuse or neglect that is egregious at a department facility or community agency, the statute (20 ILCS 1305/1-17(g-5)) authorizes OIG to report the identity of the employee(s) to the Health Care Worker Registry operated by the Illinois Department of Public Health. The Registry then lists the substantiated finding, making it illegal for those employee(s) to work in any health care setting in Illinois. The statute allows for appeals processes, which are further described in Rule 50.80 and 50.90. There is no comparable Registry reporting for OIG investigations in domestic settings.

A separate statute that governs administrative hearings (20 ILCS 1705/7.3) authorizes OIG to substantiate physical abuse yet not contest an appeal that the particular physical abuse was not severe enough to report to the Registry. Such "stipulations" are done only with the involvement of the department's attorneys and must be agreed to by the administrative law judge and the DHS Secretary.

FY09 Actions

During FY09, OIG referred 64 names to the Registry; one employee was referred for more than one case. Eight of these had been employed by a facility; 56 were employed by a community agency. Direct care staff - i.e., those whose primary job involves working in direct contact with individuals receiving services - accounted for all but six of those referrals.

Most Registry referrals are for substantiated physical abuse. During FY09, a total of 52 referrals - 80% of all referrals - were for substantiated physical abuse; substantiated sexual abuse accounted for nine (14%), and substantiated egregious neglect accounted for four (6%). The percentages of referral by type of substantiation have remained relatively stable over the past four fiscal years.

During FY09, a total of 40 appeals were filed by persons wanting to keep their names from being referred to the Registry. Thirteen additional appeals were pending from the previous fiscal year, for a total of 53 appeals pending during FY09.

The outcome was determined in 30 of those appeals. Of those 30 appeals:

  • In eight, OIG stipulated no contest to the appeal, and the employee was not referred;
  • In seven, the employee won the appeal and was not referred;
  • In ten, the employee lost the appeal and was referred;
  • In three, the appeal was dismissed and the employee was referred; and
  • In two, the employee withdrew the appeal and so was referred.

At the end of FY09, the outcomes of 23 appeals were still undecided. One of these appeals is by an employee cited in two cases, so outcomes were still pending on 24 cases.

Once on the Registry, a person may request removal once every twelve months. During FY09, seven requests for removal from the Registry were filed, and two were pending from the previous fiscal years. Five of the nine requests were still pending at the end of FY09. Only two of the remaining four requests resulted in removal from the Registry.

FY09 Impact

The table below shows the counts and percent of names that OIG has referred to the Registry during the past three fiscal years.


Table 13: Names Referred to the Registry by Disability and Location, FY07-FY09

Location Disability type FY07 Count FY07 Percent FY08 Count FY08 Percent FY09 Count FY09 Percent
Facilities DD 13 20% 9 12% 8 13%
Facilities MH 2 3% 5 7% 0 0%
Agencies DD 44 66% 56 77% 50 78%
Agencies MH 7 11% 3 4% 6 9%
Totals DD 57 86% 65 89% 58 91%
Totals MH 9 14% 8 11% 6 9%


The above table shows that employees of community agencies continue to constitute the largest - and a growing - percentage of names referred. During FY07, names of agency employees accounted for 77% of all names referred; during FY09, they accounted for 87% of all names referred. Likewise, employees of DD programs constitute the largest percent and a growing percentage, rising from 86% in FY07 to 91% in FY09. In actual counts, however, the number of referrals is slightly lower in FY09 in most program types.

FY09 Example

OIG received an allegation that an individual had broken his leg helping an employee move a new dishwasher into the employee's home. The employee had allegedly taken several individuals to a local store, purchased a dishwasher, and asked the individuals to carry the dishwasher into his house. While carrying it, the individual fell, dropping it on his leg.

The employee allegedly told the individuals to say that the injured individual had slipped and fallen in the CILA. The individual repeated that lie at the emergency room, so the doctor treated him for a sprained ankle. Seven days later, however, the individual told his sister what had really happened. The next day, the agency took him to an orthopedic specialist, and he was found to have a fractured right femur and extensive ligament damage.

OIG substantiated neglect by the employee. Since the use of the individuals for his personal benefit caused the serious injury and since his lie resulted in an extensive delay in treating the injury, OIG determined the neglect was egregious and referred the employee's name to the Health Care Worker Registry. The employee was also fired from his job as a CILA supervisor.

D. Clinical Recommendations

FY09 Authority

Since facilities and community agencies provide mental health or developmental disability services, many OIG investigations involve medical issues, such as healthcare management, medication administration, monitoring/treatment, and behavioral intervention. In addition, when a death occurs at a facility or community agency (or within two weeks of discharge or transfer elsewhere), Rule 50.20(a)(2) and Rule 50.20(a)(3) require it be reported to OIG, whether an allegation of abuse or neglect has been made or not.

In conducting its investigations, therefore, OIG examines the medical issues involved, looking for problems or concerns that may have contributed to the situation. When evidence of such is found, OIG makes clinical recommendations to eliminate those problems and prevent recurrence (20 ILCS 1305/1-17(c)).

FY09 Actions

During most of the past several fiscal years, OIG has had two registered nurses ("clinical coordinators") who are also trained investigators. During FY08, following the resignation of one of the two, OIG realized that even two clinical coordinators were not sufficient for handling the number of deaths and cases with clinical issues being received.

In response, OIG did two things. First, when renewing a contract with a registered nurse who is a member of the team that conducts unannounced site visits, OIG amended the contract to include assistance with death reviews and additional consultation in investigations, as needed. This change began at the start of FY09.

Second, in October 2008, OIG hired another registered nurse on contract to participate in investigating allegations, complete death cases, and conduct consultations and reviews. This contractual clinical coordinator received OIG's investigative skills training and, after a period of on-the-job training, began handling a full clinical coordinator caseload.

OIG greatly appreciates the support it received from DHS to be able to continue these two contractual positions.

FY09 Impact

Deaths -

During FY09, OIG completed reviews on 145 deaths of individuals either within a mental health (MH) or developmental disability (DD) program or shortly after discharge or transfer to a local hospital. Of the 145 deaths, 101 had been receiving services in a community agency program, 88 in DD agencies and 13 in MH agencies. The remaining 44 deaths occurred in a DHS facility or within fourteen days of deflection from admission, discharge from the facility, or transfer to a local hospital.

The most common causes of death were: cardiac disease, respiratory infections (particularly, pneumonia), aspiration (choking), complications from sepsis (systemic infections), seizures, and renal (kidney) failure. The official manner of death in the vast majority was "natural," and the average age of death was 56 years (notably, 59 in DD programs, 44 in MH programs).

Abuse or neglect was suspected in very few deaths. However, OIG did substantiate neglect in two deaths, both of which occurred within DD community agency programs.

In the first case, the on-duty direct care staff thought an individual was on a home visit, so they did not check on him for seven hours. Finally, one of them noticed him lying on the floor next to his bed. CPR was initiated, but the local paramedics and the coroner confirmed that the individual had been dead for a few hours already. OIG cited failure of the staff to follow the agency's policy on taking attendance and conducting bed checks.

The second death case with substantiated neglect involved an individual with severe medical problems requiring multiple hospitalizations. The hospital finally discharged her to the CILA and arranged for home health care visits by a registered nurse (RN) with an outside entity. Since this RN was employed by another entity, the community agency never asked the RN's schedule and never checked up on her. The individual developed additional problems that the RN failed to identify. When the individual was finally admitted, she was so sick that she died one week later. OIG cited the agency for failure to follow up to ensure adequate home care and also filed a complaint on the RN with the Illinois Department of Professional and Financial Regulation.

OIG made several recommendations in other death cases, with a goal of eliminating problems identified. The need for retraining - in cardiopulmonary resuscitation (CPR), in medication administration, in medication error reporting, and in pertinent policies (like DHS policies at facilities) - was the most common. Other recommendations were to develop policies or a system for monitoring individuals at high risk for choking.

Abuse/Neglect -

The clinical coordinators were also involved in 89 of OIG's abuse/neglect investigations in FY09, resulting in many other recommendations to prevent recurrence.

Examples of clinical recommendations during FY09 addressing staff training include:

  • Conduct basic training on monitoring for abnormal observations, seizures, and injuries;
  • Mandate and track annual retraining in cardiopulmonary resuscitation (CPR);
  • Provide training in progress note documentation and the use of assistive equipment;
  • Ensure mandatory annual retraining in medication administration and use of the forms;
  • Provide adequate training for contractual nurses; and
  • Obtain a physical or occupational therapy consultation for individuals at risk of fractures.

Examples of FY09 recommendations regarding ongoing care include:

  • Mandate that all staff read and review each individual's treatment/habilitation plan;
  • Ensure monthly reviews compare orders and records so correct dosages are given;
  • Review and monitor dietary orders; and
  • Begin discharge planning early in the hospitalization and ensure continuity of care.

Examples of FY09 recommendations involving nursing practices include:

  • Ensure that Licensed Practical Nurses do not perform Registered Nurse duties;
  • Mandate that Registered Nurses perform annual nursing assessments;
  • Mandate that nursing assessments document diagnoses, medications, and allergies;
  • Clarify the medication administration policy, including adding how to report errors;
  • Develop a written procedure for quality assurance on medication administration; and
  • Designate staff to handle pre- and post-hospitalization documentation.

Examples of FY09 recommendations regarding medical emergencies include:

  • Develop a policy and procedure for monitoring emergency medical equipment;
  • Conduct annual medical emergency drills;
  • Review documentation of drills and medical emergencies to highlight issues; and
  • Maintain documentation of corrective actions taken as a result of those reviews.

A review for patterns and trends revealed that the five most common clinical issues in cases during FY09 were as follows:

  • Failure of staff to follow Rule 116 on medication administration in community settings;
  • Failure of staff to follow established CPR or First Aid training;
  • Lack of clear direction by nurses regarding individuals who were ill, needing special monitoring, or returning from the hospital;
  • Failure of medical staff to follow up with individuals needing special care - or a lack of documentation that the follow-up was done; and
  • Failure of the staff who were accompanying an individual to see a consulting physician to either have or know the individual's medical history.

Clinical coordinator involvement in investigations also helped substantiate two abuse allegations and 29 neglect allegations. For example, a registered nurse allegedly reinserted an unsterilized gastrostomy tube in direct violation of facility policy and then, with the cooperation of two other registered nurses, had destroyed or falsified official documents and lied about the incident to the physician and nursing supervisor. OIG substantiated the allegation of neglect.

In another example, a dentist and the nurse assisting him allegedly failed to provide adequate care after extracting seven teeth from an individual. OIG found that, immediately after the procedure, they made her walk down two flights of stairs, even though she complained of being lightheaded, and then did not monitor her. OIG substantiated the allegation of neglect.

A third case, which had multiple clinical findings, is detailed below.

FY09 Example

An individual was allegedly not receiving all of his prescribed medications. The investigation found a delay in giving him some prescribed medications and determined that this was due to multiple issues. First, a Licensed Practical Nurse (LPN) assigned to give him his medications was not trained in Rule 116, "Medication Administration in Community Settings," and did not know to review the Medication Administration Record. Thus, the LPN did not know all of his prescribed medications and so had not obtained some of them in a timely manner. That delay resulted in worsening of the individual's medical condition, so OIG substantiated neglect by the LPN and by the agency.

OIG also recommended that the agency retrain all direct care staff on Rule 116, that it specify who is responsible for completion of weekly and bi-monthly medications audits, that it ensure that all prescriptions are promptly filled and delivered to the correct home, and that it develop and implement procedures for disposal of unused medications. The agency followed all these recommendations.

E. Written Responses

FY09 Authority

The statute authorizing OIG's investigations at facilities and community agencies providing mental health or developmental disability services (20 ILCS 1305/1-17(c)) allows OIG to cite issues beyond whether an allegation itself is substantiated or not. OIG may identify any other problem needing administrative action.

The statute requires the facility or agency to then submit a "written response" detailing the "…actions that the agency or facility will take or has taken to protect the resident or patient from abuse or neglect, prevent reoccurrences, and eliminate problems identified and shall include implementation and completion dates for all such action" (20 ILCS 1305/1-17(c)). This requirement is repeated in Rule 50.60(a)(5) and (c)(1).

When sending out a completed investigative case report that cites an issue and makes a recommendation, OIG includes a blank Written Response form. The facility or agency must complete the Written Response form - this is required by Rule 50.60(a)(6) - and return it to the appropriate DHS division. That division then reviews and approves it as the designee of the DHS Secretary, as approval by the Secretary is required for all Written Responses (20 ILCS 1305/1-17(c)).

Written Responses apply only to Rule 50 cases. The statute authorizing OIG's investigations in domestic settings (20 ILCS 2435/) does not provide for such a process, and therefore, neither does Rule 51.

FY09 Actions

Number required -

During FY09, OIG sent out 843 investigative reports with recommendations, either substantiated as abuse/neglect or citing other administrative issues. On each case, OIG included an initial Written Response form that lists OIG's finding and recommendation(s) and has columns for the agency/facility to identify the actions it will take, the date of implementation for each of those actions, and the person responsible for implementation.

OIG is requiring Written Responses in a growing number of investigations, requiring them in:

  • 495 cases during FY06, 24% more than in FY05;
  • 671 cases during FY07, a jump of 36% over FY06;
  • 722 cases during FY08, an 8% increase over FY07; and
  • 843 cases during FY09, another 17% increase over FY08.

In four years, OIG closed 34% more cases but made recommendations in 70% cases.


Cases at community agencies providing developmental disability (DD) services account for most of the required Written Responses: 631 of the 843 Written Responses in FY09. These programs also have seen the largest percentage increase, rising 24% over last year, while cases at community agencies providing mental health (MH) services rose only 6%.

In Written Responses, OIG does not specify the type of administrative action or the particular level of disciplinary action against employees. Instead, the agency or facility is required to complete the Written Response and send it to the appropriate program division within DHS, since it is the statutory responsibility of the department to oversee the specific actions taken to eliminate the problems identified.

Timeliness of submission -

OIG tracks and records Written Responses to ensure that they are completed and returned for DHS approval. The agency or facility has 30 calendar days from the date of the investigative report to submit a Written Response to the division for approval, and OIG then gives the division an additional 30 days to review and approve it.

Previously, OIG had problems with receiving approved Written Responses from the divisions in a timely manner, but more were received timely in FY09. Overall, the number of approved Written Responses received timely rose 15% over FY08. The greatest increase was by the program division office overseeing DD community agencies: OIG received 71% timely during FY09, when it received only 28% timely during FY08.

In comparison, approved Written Responses in FY09 were received timely in 76% of cases at MH community agencies, 63% of cases at MH facilities, and 51% of cases at DD facilities. OIG is committed to continuing to work with the agencies, facilities, and the DHS program divisions to continue to improve these numbers.

FY09 Impact

OIG may make multiple recommendations on a single Written Response, and each of those recommendations may result in multiple actions taken. So, the numbers of Written Responses, of issues cited, and of actions taken are different: during FY09, the 843 Written Responses cited 1,518 issues, resulting in 1,995 actions. The table below provides information about the issues cited over the past three fiscal years.


Table 14: Issues Cited in Approved Written Responses Received, by Fiscal Year

Issues FY07 Count FY07 Percent FY08 Count FY08 Percent FY09 Count FY09 Percent
Substantiations 187 23.5% 244 24.7% 329 21.7%
Late reporting to OIG 68 8.5% 175 17.7% 305 20.0%
Nursing practices 47 5.9% 28 2.8% 200 13.1%
Investigative error 35 4.4% 78 7.9% 127 8.4%
Treatment plan change 49 6.2% 47 4.8% 115 7.6%
Inappropriate interaction 57 7.2% 63 6.4% 99 6.5%
Failure to report 196 24.6% 98 10.0% 98 6.5%
Monitoring/staffing 29 3.6% 49 5.0% 68 4.5%
All other issues 128 16.1% 204 20.7% 177 11.7%
Total issues 796 100% 986 100% 1,518 100%


During the past two fiscal years, substantiated abuse or neglect was the most commonly cited issue on an approved Written Response, and in FY07, it was second only by a slight amount. Neglect accounted for 120 (36%) of FY09's 329 substantiations in approved Written Responses; while mental abuse accounted for 106 (32%), physical abuse accounted for 89 (27%), and sexual abuse for 14 (4%).

Among the other administrative issues cited in Written Responses approved in FY09, the most common was late reporting to OIG (305). Failure to report, which was the most common in FY07 accounted for only 6.5% (98) cases.

The next two most common issues in FY09 approved Written Responses were nursing practices (200) and investigative errors (127). The category of nursing practices includes clinical errors, failure in clinical documentation, and inadequate nursing policies. The category of investigative errors includes failure to get a medical exam after an allegation that alleged injury, failure to obtain photos in those cases, inadequate progress notes, errors in interviewing, and errors in obtaining investigative documentation.

The agencies and facilities took a total of 1,995 actions to address the issues that OIG had cited in FY09 approved Written Responses. The most common action taken was retraining of the specific employee or of a group of employees (783 such actions), termination of the accused employee's employment (289 actions), and policy/procedural change (213 actions).

While the actions taken by agencies and facilities in response to OIG recommendations are listed on the Written Response and thus are reviewed and approved by the divisions, OIG still receives and records those actions. By recording the actions taken in response to the findings, OIG can identify appropriate steps to prevent recurrence and to eliminate the problems cited in the investigative report.

FY09 Example

An individual started flipping tables over and throwing chairs. Two employees attempted to restrain him and, during the process, the individual threw an empty box at one of them, hitting him on the chest. That employee picked up the box and threw it back at him, hitting him on the shoulder and head. The staff present at the time reported the allegation and, since the agency had an approved investigative protocol, the agency began getting interviews.

However, the staff present did not report a separate allegation that the second employee had, in his attempt to restrain the individual, thrown him to the floor, causing him to fall into a pile of wooden crates. The investigators discovered the second allegation and reported it to OIG, but the agency's internal Human Rights Committee then determined that it was not substantiated, although this committee did not write a formal investigative report.

When OIG arrived to investigate, the first employee had been fired and the second employee was back to work. OIG conducted additional investigation, arriving at the same conclusion as the agency investigators. However, OIG made multiple other recommendations, which the agency then addressed in its Written Response.

First, OIG recommended the agency amend the individual's behavior plan to identify appropriate intervention techniques to use when he becomes physically aggressive. The agency responded that the plan was revised to follow the Nonviolent Crisis Intervention approach of the Crisis Prevention Institute (CPI).

Second, OIG recommended that the agency address the staff failure to report the separate abuse allegation. The agency responded that four staff had been given a formal counseling and one, the workshop manager, was given an oral reprimand. In addition, all five employees were re-trained in the reporting procedures for abuse and neglect.

Third, OIG recommended that the agency amend its Human Rights Committee policy to specify that it would not conduct an investigation of any allegation that was being investigated by OIG. The agency responded that it had amended the policy to state that specifically.

OIG's recommendations, including those for administrative action against accused employees, are aimed at preventing recurrence of problems identified by the investigation. Citing multiple issues with multiple resulting actions will increase the probability of preventing recurrence.

F. Implementation Status Reports

FY09 Authority

Once the relevant DHS division has approved a Written Response, it sends the approved form back to OIG. If any actions listed on the form are not already completed, the facility or community agency is required to send "…an implementation report to the Inspector General on the status of the corrective action implemented" (20 ILCS 1305/1-17(c)). That section mandates that the facility or agency send an implementation status report every sixty days until the planned corrective action is completed. OIG is authorized to review any implementation plan that takes more than 120 days.

FY09 Actions

When an approved Written Response is received from the DHS division, OIG enters the following into its database: date of approval, type of issues OIG identified, and actions that the agency/facility planned to take for each issue. If an action has already been taken, OIG also enters the dates of implementation.

If an action that the agency or facility planned to take is not yet implemented, OIG designates that action as incomplete. The agency or facility is then expected to send in implementation status reports every sixty days until completion; when these are received, the date is logged into the database. Any implementation status report left outstanding is identified, and a letter is sent to the authorized representative requesting one. If no implementation status report is received after 120 days, the case is added to the Written Response Compliance Review process discussed in section G below.

FY09 Impact

During FY09, OIG sent letters to 39 agencies or facilities identifying overdue Written Response implementation status reports. These letters listed a total of 63 cases, since some agencies had more than one case with an overdue Written Response implementation status.

The most common issue with delayed implementation status was late reporting to OIG. The typical corrective action for this issue is retraining, and it often involves a group of employees. Completing the retraining appears to be the cause of the delay in implementation. That is, the training is scheduled but may not be completed before the Written Response gets submitted and approved, and the agency/facility forgets to send an implementation status within 60 days. Sometimes, the corrective action does not get completed until after OIG sends the letter identifying the overdue Written Response implementation.

FY09 Example

OIG received a report that an individual was found with linear red scratches on his arm, neck, and lower back. Although he had small bruises from an altercation with another individual the prior week, the investigation determined that the scratches had occurred when an employee with long fingernails had accidentally scratched him during routine care. OIG thus did not substantiate abuse but recommended that the agency address long fingernails in its dress code policy for employees.

On the Written Response, the agency stated that it would add this issue to the dress code within two months; the DHS division approved this planned action. However, three months later, the agency had still not sent to OIG either documentation of the implemented action or an updated implementation status report. So, OIG sent the agency a request for implementation status.

Four weeks later, the agency sent in a copy of a newly revised policy requiring that fingernails be short enough that no harm can be done to anyone else. OIG cannot be certain that the policy was not already being revised; however, the policy's revision date was well after the date of OIG's letter requesting implementation status.

G. Compliance Reviews

FY09 Authority

The statute gives OIG an additional role regarding Written Responses approved by the DHS program divisions, in that it authorizes OIG to "monitor compliance through a random review of completed corrective actions" (20 ILCS 1305/1-17(c)). The statute authorizes OIG to assess compliance through any means, including site visits, phone calls or document reviews.

The process that OIG follows for these Written Response Compliance Reviews is detailed in OIG Directive BCE 03-005. The process involves requesting documentation of actions taken, doing site visits, conducting interviews in person or on the phone, and reviewing facility policies, procedures, training materials, habilitation/treatment plans, and other documents to verify that the actions listed in the Written Response were fully implemented.

FY09 Actions

The OIG directive calls for selecting cases randomly from Written Responses approved by the divisions, after allowing time for mailing. Thus, for example, cases that the divisions approve during May would be received during May and June, the random selection is done in late June, and OIG reviews the selected cases during July. Thus, OIG's FY09 Compliance Reviewers selected from Written Responses approved by the DHS program divisions during the time period of May 1, 2008, through April 30, 2009.

OIG received 982 Written Responses approved by the divisions during that time period; thus, the random sample for OIG's FY09 Compliance Reviews comprised 194 randomly selected approved Written Responses: 166 from community agencies and 28 from facilities.

The table below shows the break-out by location and disability type for cases chosen for a Written Response Compliance Review during FY09.


Table 15: Written Response Compliance Reviews, FY09

Program location DD programs MH programs Totals
DHS Facilities 15 13 28
Community Agencies 158 8 166
Totals 173 21 194


Compliance Reviews on these 194 Written Responses reviewed documentation to ensure all identified actions were taken. Typically, OIG needed to send follow-up requests, either by letter or phone call, to get additional documentation of the actions. OIG also conducted on-site visits on 33 of the Written Responses (26 of the 166 from agencies and seven of the 28 from facilities), including face-to-face and follow-up phone interviews as needed. OIG did only phone interviews of people in an additional 31 Written Responses (30 of the 166 from agencies and one of the 28 from facilities).

Nearly all agencies and facilities were found to have implemented all actions listed on the approved Written Response. Infrequently, due to the time required for disciplinary actions or policy revisions, implementation was delayed. However, OIG followed up on these few cases and, eventually, was able to send out an "in-compliance" letter on all 194 Written Responses, indicating that the actions were taken as approved.

FY09 Impact

Issues -

The most frequent issue in these 194 Written Responses was a failure to report the alleged incident or death to OIG within the required timeframe (four hours for allegations, 24 hours for deaths absent an allegation). OIG cited late reporting in 53 Written Responses (48 at agencies and five at facilities) and cited a failure to report in another 21 (eighteen at agencies and three at facilities). In all, OIG had cited reporting delays in 38% of all Written Responses chosen for Compliance Reviews.

Substantiated abuse/neglect was the second most common issue cited. Substantiations cited in the 166 Written Responses at agencies were mental injury (25), non-egregious neglect (19), and physical abuse (15). Substantiations cited in the 28 Written Responses at facilities were non-egregious neglect (5), physical abuse (4), and mental injury (1). Other frequent issues OIG cited in Written Responses were habilitation or treatment plan issues (30) and clinical errors by medical or treatment staff (23).

Actions -

Corrective actions listed in these 194 Written Responses are grouped in Table 16. As noted above, the totals for actions taken are larger than the totals for issues cited, since the facility or community agency may take multiple actions in response to each cited issue in the Written Response.

The table below shows that the most frequent corrective actions taken involved training, either retraining of the involved employee or group training. The next most common corrective actions involved discharge or resignation of the accused employee(s) and other discipline of the employee(s), followed by revisions of habilitation/treatment plans or of local policies/procedures. Actions taken were generally similar across locations. However, discharge or written reprimand of an employee was relatively more common at the community agencies; resignation or suspension of the employee was relatively more common at the facilities.


Table 16: Most Frequent Actions in Written Responses in FY09 Compliance Reviews

Corrective action Community agencies DHS facilities Totals
Retraining of employee(s) 64 13 77
Group training of staff 51 8 59
Discharge of employee(s) 46 4 50
Resignation of employee(s) 23 5 28
Habilitation/treatment changes 24 3 27
Procedural change 20 3 23
Suspension of employee(s) 13 7 20
Counseling of employee(s) 14 5 19
Written reprimand of employee(s) 16 0 16


In the cases of retraining and group training for the issue of late reporting, the Compliance Reviewers interviewed some or all of the staff to ensure that the training was completed and to confirm staff knowledge of abuse/neglect reporting. Typically, this interview was conducted in person at the agency or facility.

Where the interview process found problems, the Compliance Reviewers either reviewed the material with staff interviewed or recommended that the agency/facility retrain the employees in abuse/neglect reporting and, later, OIG re-interviewed those employees. OIG also reminded those agencies/facilities to supplement their internal training with the OIG Rule 50 Training Module, which was distributed to all agencies and facilities in August 2007. Several agencies and facilities were provided with another copy of the OIG Rule 50 Training Module.

FY09 Example

An individual alleged that an employee scratched her face and threw an empty soda can at her. The investigation found that the individual had first hit the employee in the face and grabbed the employee by the hair, pulling some of it out and refusing to let go. While trying to get free, the employee accidentally scratched the individual's face. However, the individual then threw the can at the employee, who picked it up and threw it back at the individual, hitting her on the arm. The individual alleged injury, but the employee did not report the allegation. When the individual was examined later, no injuries could be seen.

OIG substantiated abuse by the employee for throwing the can, but not for scratching the individual's face, as that was accidental. OIG also cited the mitigating factor of the individual's aggression and recommended that the agency review how much supervision she needs. Further, OIG cited the employee's failure to report the allegation promptly.

In its Written Response, the agency stated that they would discipline the employee, counsel her on how to handle conflict and behavior concerns of individuals, and retrain her in OIG Rule 50. The Written Response was submitted in January 2009 and approved by the DHS division in February.

This case was among those chosen randomly for the Compliance Review the following month. OIG received documentation of actions taken and then interviewed the employee about the requirements in Rule 50. However, when asked the time frames for reporting, the employee guessed "24 hours." When asked how she would handle an allegation from an individual with a history of making false allegations, she said she would "walk away." Neither answer is correct.

The OIG Compliance Reviewer, therefore, sent a pre-packaged OIG Rule 50 training module, which the agency used to re-train the employee and all other staff. When OIG re-interviewed the employee later, she was able to accurately answer all questions.