DHS OIG FY 2010 Annual Report

Helping Families. Supporting Communities. Empowering Individuals.

November 2010

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) 2010 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 describes the activities and services OIG provides to prevent and investigate abuse and neglect of individuals with disabilities who reside in private homes, in DHS-operated facilities, or in programs operated by local community agencies and licensed, certified or funded by DHS for mental health or developmental disability services. The report provides statistics on OIG's work during FY2010, comparing it to prior fiscal years, and describes the range of OIG's findings and recommendations.

The report also reflects the changes that you made to the DHS Act in Public Act 96-407, approved on August 13, 2009, and to the administrative Rule 50 (59 Ill. Admin. Code, Chapter I, Part 50), approved on March 25, 2010. The report identifies where and how these statutory and regulatory changes have improved the services that OIG provides the citizens of Illinois.

Significant among these changes were expanded definitions of abuse and neglect, including the addition of financial exploitation. The expected resulting increase in allegations has compounded a long-term trend to more allegations each year - in FY2010, OIG received 24% more allegations than just four years ago.

Thank you for your continued commitment to the proper care and treatment of individuals who are facing mental and physical challenges and may experience abuse or neglect. I submit this FY2010 annual report to show how OIG is fulfilling its role in implementing that commitment.

Sincerely,

William M. Davis

Inspector General


Contents

Executive Summary

Chapter I: Preventing Abuse/Neglect.

  1. Quality Care Board.
  2. Unannounced Site Visits.
  3. FY2010 census and staffing ratios.
  4. Reporting Policies.
  5. FY2010 initial report timeliness.
  6. Training.
  7. Investigative Protocols.
  8. Non-Reportable Complaints.

Chapter II. Reporting Abuse/Neglect.

  1. Physical abuse.
  2. Sexual abuse.
  3. Mental abuse.
  4. Financial exploitation.
  5. Neglect.
  6. FY2010 Reporting.

Chapter III. Investigating Abuse/Neglect.

  1. Conducting Investigations.
  2. Investigative Timeliness.
  3. Case Closures.

Chapter IV. Preventing Abuse/Neglect.

  1. Domestic Abuse Intervention.
  2. Health Care Worker Registry.
  3. Recommendations.
  4. Written Responses.

Executive Summary

During FY2010, the Office of the Inspector General (OIG) accomplished the following.

  • Implemented Public Act 96-407, which enables OIG's investigative authority in State facilities and community agencies providing mental health or developmental disability services, and promulgated a revised Rule 50. The new statute and rule update and expand definitions and make other changes to improve the reporting and investigating of abuse and neglect.
  • Presented 70 training sessions on reporting or investigating abuse or neglect, with a total of 1,242 participants.
  • Conducted an unannounced site visit to every department facility providing mental health or developmental disability services, making 47 recommendations to prevent abuse or neglect.
  • Referred 1,225 complaints that were outside OIG jurisdiction to the appropriate entity, as well as recording an additional 357 calls that needed no referral.
  • Received 3,184 abuse/neglect allegations - 16% more than during FY2009, 19% more than during FY2008, and 24% more than during FY2007. Compared to FY2007, OIG received:
    • 12% more allegations at facilities,
    • 44% more allegations at community agencies, and
    • 10% more allegations in domestic settings.
  • Completed 2,840 investigations - one percent fewer than in FY2009, but four percent more than in FY2008 and fourteen percent more than in FY2007. During FY2010, OIG completed those investigations in an average of 40 days per case, compared to the goal of 60 days.
  • Closed 2,870 investigations - four percent fewer than in FY2009, but five percent more than FY2008 and eight percent more than FY2007. In FY2010, OIG substantiated abuse or neglect in 350 cases, plus five deaths. Domestic cases accounted for 96 of the 355 and facility/agency cases for the other 259.
  • Reviewed reports of 143 deaths of individuals in department facilities or in community agencies providing mental health or developmental disability services. OIG finished reviews on 92 of these deaths plus another 51 that were reported prior to FY2010, substantiating neglect in four of them.
  • Referred to the Registry 68 employees of facilities or community agencies for substantiated physical abuse, sexual abuse, or egregious neglect. The Health Care Worker Registry is maintained by the Illinois Department of Public Health.


Chapter I: Preventing Abuse/Neglect

A. Quality Care Board

The OIG Quality Care Board was initially authorized in 1992 by Public Act 87-1158. Its purpose was to "monitor and oversee the operations, policies, and procedures" of OIG. The Board was empowered to provide consultation on OIG practices, to review regulations, to advise on training, and to recommend policies to improve intergovernmental relations.

The law provides for the Board to have seven members, appointed by the governor with consent of the State Senate. The members must be qualified by professional knowledge or experience in law, investigatory techniques, or the care of people who have mental illness or developmental disabilities. At least two members must either have a disability or have a child with a disability.

During most of FY2010, the Board had only four members: Rita Ann Burke (Makanda), chair; Thane A. Dykstra (Joliet); Nathaniel Gibson (Springfield); and Brian Neal Rubin (Buffalo Grove). OIG has requested re-appointment and nominated additional members to fill vacancies, but final approval was not received by the end of June 2010.

The Board meets once per quarter. During FY2010, the Board met July 21 and October 21, 2009, and January 21 and May 6, 2010. As specified in the law, members are not paid but may be reimbursed for expenses, such as travel. As a convenience and cost saving measure, however, most meetings are held by conference call.

B. Unannounced Site Visits

The Office of the Inspector General (OIG) is statutorily mandated by the Department of Human Services Act (20 ILCS 1305/1-17) to conduct annual unannounced site visits to the DHS facilities providing developmental disability or mental health services. The site visits are part of the statutory mission of OIG to prevent abuse and neglect.

The site visits thus seek to cover a wide range of activities, initiatives, and potential problem areas related to abuse and neglect. Each year, unique issues are identified for site visits. These issues are reviewed with the goal of providing actionable feedback that will allow the facilities to take steps to prevent abuse and neglect in the future.

FY2010 improvement

OIG has rarely had a problem at facilities getting copies of records or being allowed into a living unit during a site visit, but Public Act 96-407 added these site visits to the section on duty to cooperate (1-17(i)). That is, OIG now has statutory authority to access any unit or get copies of any record for the purpose of conducting an annual unannounced site visit at a facility.

FY2010 schedule

In FY2010, each OIG site visit was conducted by a team of two OIG staff, one of whom is a registered nurse. In advance of a planning meeting for the FY2010 site visits, the team members reviewed past site visit reports, issues raised in investigations, and abuse/neglect issues identified during surveys. The team then met on May 20, 2009, and selected six new issues beyond the follow-up on recommendations from FY2009 and prior site visits.

The site visit team also planned the dates of OIG's FY2010 unannounced site visits, ensuring that no facility would be visited in a month that the site visit had been conducted at that facility in the prior three fiscal years. OIG's FY2010 site visits were as follows:

  •  Alton MHC on December 1-2, 2009
  •  Chester MHC on January 13-14, 2010
  •  Chicago-Read MHC on December 17-18, 2009
  •  Choate DC on July 13-14, 2009
  •  Choate MHC on July 14-15, 2009
  •  Elgin MHC on August 4-5, 2009
  •  Fox DC on October 7-8, 2009
  •  Jacksonville DC on September 1-2, 2009
  •  Kiley DC on November 17-18, 2009
  •  Ludeman DC on July 1-2, 2009
  •  Mabley DC on October 13-14, 2009
  •  Madden MHC on September 29-30, 2009
  •  McFarland MHC on August 11-12, 2009
  •  Murray DC on February 3-4, 2010
  •  Shapiro DC on November 5-6, 2009
  •  Singer MHC on March 16-17, 2010
  •  Tinley Park MHC on January 20-21, 2010

Process

OIG batched preliminary request for documents (e.g., relevant policies) to three facilities at a time, so that no facility was forewarned about the date of the site visit. Receiving these documents ahead of time reduces travel for OIG staff and any interruption caused at the facility.

Each site visit began with an entrance conference, where the site visitors introduced themselves, provided an explanation of the site visit plan, and identified the administrative staff to be interviewed. The OIG site visit team reviewed relevant documentation and interviewed administrative personnel, as well as staff on the units, to discuss the issues.

Each site visit then ended with an exit conference, where the overall findings of the site visit were presented. A formal report of the findings was provided to the facility within sixty working days of the site visit. The facility was asked to send OIG a copy of any written plan the facility might develop to address the report's recommendations.

Issues and Overall Recommendations

Repeat recommendations:

During the FY2009 unannounced site visits to the facilities, OIG made a total of 58 recommendations aimed at preventing abuse and neglect.

For FY2010, OIG reviewed all 58 recommendations made during the FY2009 site visits, looking at the actions the facility took and the outcomes of those actions.

OIG found that the facilities had completed adequate corrective action on 48 of the 58 recommendations, and OIG made only ten repeat recommendations. Eleven of the seventeen facilities had no repeat recommendations.

OIG recommended that the divisions continue to ensure that all facilities appropriately and promptly address recommendations in OIG site visit reports, especially those that are repeated.

Emergency response drills:

Events requiring an emergency response increase the possibility for abuse or neglect by staff, so drills are a way to ensure the continuing adequacy of a facility's emergency response.

For FY2010, OIG reviewed the facility's documentation of emergency response drills and issues raised in those drills.

OIG found that, despite improvement, this issue has continued to be the one with the most recommendations. Conducting drills per facility policy and completing the review documentation remain the problem areas.

OIG recommended that the divisions ensure that the facilities maintain adequate documentation of emergency medical drills, actions, follow-up and review.

Infectious diseases:

Neglect is a failure to provide adequate medical care, personal care or maintenance that results in harm. Thus, preventing common infectious diseases as well as identifying and treating them when they occur would prevent neglect.

For FY2010, OIG reviewed each facility's process for preventing and for responding to outbreaks of serious or common infectious diseases.

OIG found that all facilities had adequate policies and systems in place for preventing, identifying, monitoring, controlling, and reporting infectious disease processes. Further, each had a database used to identify trends/patterns and areas needing improvement.

OIG made no overall recommendation regarding this issue.

Medication errors:

Errors can occur at many steps: ordering, filling, dosing, or administration. Indeed, the vast majority of errors are caught before the medication even reaches the individual. DHS has a policy ("program directive") that establishes how medication errors are to be reported and reviewed, allowing each facility to catch and learn from all medication errors.

For FY2010, OIG reviewed how each facility reports, reviews and acts to prevent recurrence of medication errors.

OIG found that every facility had a policy and system in place to monitor medication errors, although some facilities' policies did not conform to the DHS policy, most often by not using the approved DHS form.

OIG recommended that the divisions ensure the facilities adopt Program Directive 02.06.02.030 for documenting medication errors and revise facility policies whenever the directive is revised.

Outdated medications:

Delays caused by finding outdated medications or equipment when responding to an emergency - or administering those outdated medications - might lead to reportable physical or mental deterioration and are against DHS policy.

For FY2010, OIG reviewed how the facility ensures that medications and equipment used in emergencies is kept up to date and how outdated medications are handled.

OIG found that all but three facilities had specific policies/protocols in place for regularly monitoring and maintaining the emergency equipment, for ensuring that medications are checked on a monthly basis for expiration dates, and for documenting these activities.

OIG recommended that these three facilities develop such policies and procedures but made no overall recommendation to the divisions regarding this issue.

Staffing levels:

Implementing adequate staff-to-individual ratios on every unit, including maintaining those ratios during staff absences (e.g., breaks, 1:1s, and off-unit escorts) can be a complicated process, but it can prevent abuse and neglect.

For FY2010, OIG reviewed how each facility schedules staffing levels and how it maintains these levels during 15-minute breaks, lunch/dinner time, and monitoring/escorting responsibilities.

OIG found that, with two exceptions, the facilities had plans in place for maintaining adequate staffing levels. The people who do the scheduling at the facilities were very knowledgeable about maintaining acceptable ratios and what to do when unplanned situations arose. At two facilities, staffing levels routinely dropped below minimum whenever employees went on breaks or an emergency or off-site transport occurred.

OIG recommended that these two facilities revise their procedures regarding breaks and off-unit responsibilities so the minimums in their staffing plans are maintained. OIG made no overall recommendation to the divisions regarding this issue.

Administrative reassignment:

State law requires that accused employees be removed from having contact with involved individuals whenever credible evidence of alleged abuse is found. DHS policy allows administrative reassignment, rather than paid administrative leave, but actual practice appeared to vary among facilities.

For FY2010, OIG reviewed the facility's practices on reassignment: local policies implementing the DHS policy; any collective bargaining unit agreements restricting its use; the tasks assigned to staff on reassignment; documentation of its use; the tracking of staff on reassignment; and the return of staff from reassignment.

OIG found concerns in seven of the facilities, including a lack of documenting new work location, duties, and/or notification to the receiving supervisor.

OIG recommended that the divisions ensure that all facilities have a local policy that fully implements the DHS policy and documents the use of administrative reassignment, the employee's reassigned work location and duties, and notification to the receiving work location.

Peer aggression / staff involvement:

Rule 50 requires reporting to OIG injuries inflicted by a another person receiving services ("peer") only when abuse or neglect is alleged or suspected. DHS policy requires a review for such staff involvement and for possible root causes. Direct or indirect staff involvement is physical abuse; staff inattention allowing it to occur is neglect.

For FY2010, OIG reviewed how each facility has implemented the review requirement and how it documented facility review for possible staff involvement.

OIG found that all facilities had standing committees to promptly review peer to peer aggression incidents, usually as part of the review of all injuries. All but five facilities had forms to document pertinent information and show that the incidents were reviewed for possible staff involvement.

OIG made no recommendations to the divisions regarding this issue.

Conclusion

In all, OIG made 47 site visit recommendations in FY2010, down from 58 in FY2009 and 114 in FY2008. Further, only ten of the 47 were repeat recommendations from last year. OIG additionally made six recommendations to the Division of Mental Health and the Division of Developmental Disabilities, up from five in FY2009 but down from eight in FY2008.

Howe Developmental Center

Due to the pending closure of this facility, OIG developed a unique set of issues to examine during the site visit at Howe DC. In addition, rather than conducting just one site visit, OIG conducted an initial entrance conference and then numerous "drop-in" visits from February through May 2010. For the FY2010 site visit to Howe DC, OIG looked at how the facility was:

  • Continuing to do quality assurance audits on charts of remaining individuals;
  • Ensuring emergency medications were kept up-to-date and handling any outdated and unneeded medications;
  • Reviewing incidents of peer-to-peer injury for possible abuse or neglect by staff;
  • Handling transition education - of the guardian on the overall process, of the guardian about options for new homes, and of the individual about moving;
  • Monitoring the transition process for each individual and what forms or other monitoring tools the facility used; and
  • Receiving, identifying and forwarding documents arriving at the facility after an individual has moved to another home.

OIG found that the processes were working well and made no findings or recommendations from these visits. Still, OIG decided to include issues related to transition education during all site visits during the coming fiscal year.

C. FY2010 census and staffing ratios

By law, OIG's annual report must include census and staffing ratios at the facilities. Below are tables showing the following for each type of facility for FY2010.

Table 1a: Census and Staffing Ratios, DHS Psychiatric Hospitals, June 30, 2010

DHS Facility Undup. count  Person-days Inpatient census Direct care staff Direct care to patient ratio
Alton MHC 316 43,289 120 164.5 1.37
Chester MHC 469 86,639 233 316.0 1.36
Chicago-Read MHC 1,550 45,881 107 176.0 1.64
Choate MHC 306 39,022 58 89.6 1.55
Elgin MHC 1,467 138,572 379 475.8 1.26
Madden MHC 2,894 44,845 115 181.0 1.57
McFarland MHC 680 40,852 116 130.0 1.12
Singer MHC 766 26,225 67 92.6 1.38
Tinley Park MHC 1,789 22,483 62 105.7 1.70
MH facility totals 10,237 487,808 1,257 1,731.2 1.38

Table 1b: Census and Staffing Ratios, DHS Developmental Centers, June 30, 2010

DHS Facility Undup. count Person-days Inpatient census Direct care staff Direct care to patient ratio
Choate DC 182 41,778 154 219.5 1.43
Fox DC 133 46,148 123 167.6 1.36
Howe DC 266 64,631 0 0 -
Jacksonville DC 226 75,195 207 275.5 1.33
Kiley DC 235 140,897 225 346.4 1.54
Ludeman DC 435 79,393 416 602.5 1.45
Mabley DC 95 32,206 91 114.9 1.26
Murray DC 310 107,192 293 398.6 1.36
Shapiro DC 603 197,097 577 977.0 1.69
DD facility totals 2,485 784,537 2,086 3,102.0 1.49


D. Reporting Policies

In FY2006, OIG began a review of abuse/neglect reporting policies at community agencies that had not reported any allegations since at least January 2002, when Rule 50 was last revised. OIG found that only six of the agencies had local reporting policies that had the correct Rule 50 definitions, time frames for reporting, prohibition of screening, and requirements for securing the scene and preserving evidence. OIG recommended changes to address the deficiencies.

However, OIG also began a review of all community agencies' reporting policies, focusing on the definitions, timeframes for reporting, prohibition of screening out allegations, and securing the scene of an alleged incident. OIG worked with the agencies to ensure that these definitions and requirements were included, and those that did not have a local policy were asked to create one. By August 2008, all agencies had abuse/neglect reporting policies that were fully compliant.

FY2010 improvement

Previously, a DHS policy required facilities to have a local policy detailing procedures for reporting allegations and deaths; the community agencies were required to have one by the annual contract with DHS. Rule 50.20(d) now mandates that all community agencies and facilities have a local policy detailing procedures for reporting allegations and deaths.

With the significant changes in the statute and Rule 50, local reporting policies would need to be revised. As a result, OIG has begun another review of all community agency and facility abuse/neglect reporting policies. On April 9, 2010, the community agencies were asked to submit their revised policies; the facilities' policies will be reviewed during the FY2011 site visits.

OIG's review of these updated policies is focusing on accuracy and completeness of the following statutory requirements:

  • Current definitions of physical abuse, sexual abuse, mental abuse, financial exploitation, neglect and egregious neglect;
  • Requirement for initial training in Rule 50 upon hiring and biennially thereafter for all employees, including contractors and volunteers; and
  • The prohibition of retaliation against an employee for reporting an allegation, since retaliation is a violation of subsection k(3) the act.

E. FY2010 initial report timeliness

Since the speed of getting allegations reported to OIG is sometimes critical to a successful investigation, Rule 50.20(a) retains the previous time requirements for reporting: four hours for any allegation of abuse or neglect; and 24 hours for deaths absent any allegation of abuse or neglect. In addition, the statute declares an employee's willful failure to report timely to be a Class A misdemeanor.

OIG monitors new intakes for timeliness in allegations reported to OIG by staff of the community agency or facility where the alleged abuse/neglect occurred; this is called a "self-report" (does not apply to domestic cases). If an allegation is reported late, the database will flag the intake as late reporting. Then, the field investigator will investigate as to why it was late. If it was late, the final investigative report will mention the late reporting, and the Written Response will list it as needing corrective action.

Each month, OIG sends the DHS program divisions two reports - one of reporting by community agencies and the other of reporting by facilities. The reports show the number of "self-reports" that were reported to OIG late and the percentage late. For each late intake, the reports also shows the number of days it was late. The table shows this information for the past six fiscal years.

Table 2: Late Reporting by Program and Disability Type, FY2005 through FY2010

Fiscal Year Total Self* Reports Late from DD agencies Late from MH agencies Late from DD facilities Late from MH facilities Total late Percent late
FY2005 1,419 18 14 24 31 257 18.1
FY2006 1,514 186 24 35 16 261 17.2
FY2007 1,603 174 27 24 29 254 15.8
FY2008 1,642 185 32 18 24 259 15.8
FY2009 1,909 172 17 16 20 225 11.8
FY2010 2,033 163 15 33 21 232 11.4

*Reported to OIG by the facility or community agency staff.


The table shows that, despite the increase of allegations reported by the community agencies and facilities, OIG has seen a fairly steady decrease in the percentage of late reports. OIG continues to work to encourage timely reporting of allegations. One way OIG has done this is through providing and conducting training.

F. Training

OIG has always been committed to training as a primary means to prevent abuse/neglect and to ensure reporting, investigating, and taking action when it is alleged to have occurred. The statute has mandated both basic training of facility and community agency staff and specialized investigative training of OIG staff.

FY2010 improvement

Previously, OIG had worked with the department to require Rule 50 training of all facility and community agency staff, including subcontractors and volunteers, at least once every two years. For community agencies, this biennial training requirement was included in the annual contracts the department has with these agencies.

However, Rule 50 now includes this biennial mandate. That is, the facilities and community agencies must train all employees - again, including subcontractors and volunteers - in Rule 50 upon hire and then at least every two years.

FY2010 Training

Following promulgation of the new Rule 50 in March 2010, OIG distributed to the community agencies a pre-packaged training that covered definitions of the types of abuse and neglect and discussed what is appropriate as a first response to allegations and incidents. By pre-packaging the training, OIG ensured that the definitions and proper response would not be changed. OIG has received positive reviews on this training.

OIG also revised its handbook entitled, "Reporting of Abuse and Neglect of Adults with Disabilities." This reporting handbook, which is set up in a question-and-answer format, is available on-line at http://www.dhs.state.il.us/page.aspx?item=10687

However, OIG also continues to conduct a more thorough Rule 50 course and two investigative skills courses: Basic Investigative Skills, and Investigative Skills Refresher. OIG updated all three of these during FY2010, to address changes in the statute and rule.

The first OIG-conducted course, "OIG Rule 50," is the most commonly attended. It covers the definitions, reporting requirements, and initial response expectations in Rule 50. OIG encourages each community agency to send its administrators, including its executive director and designated OIG liaison, to attend this one-day class. During FY2010, OIG conducted 31 Rule 50 classes with a total of 752 attendees.

The second course, "Basic Investigative Skills," is a two-day course concentrating on all aspects of conducting an investigation, with a special emphasis on allegations involving persons with developmental disabilities or mental illness. During FY2010, OIG conducted fourteen Basic Investigative Skills classes with a total of 161 attendees.

The third course, "Investigative Skills Refresher," is a one-day refresher for individuals who have completed the first two courses within the past two years. It reviews the definitions and emphasizes the key points in conducting an investigation. During FY2010, OIG conducted 25 Investigative Skills Refresher classes with a total of 329 attendees.

Successful completion of one of the two investigative skills courses within two years of the start of the fiscal year is required for anyone who wishes to be designated as an investigator on the agency's annual protocol authorization application to OIG.

G. Investigative Protocols

Rule 50 mandates that facilities and community agencies take some initial steps in response to allegations that are made. Most importantly, they are to ensure the health and safety of involved individuals and staff, including ordering medical examinations when applicable. They are also to secure the scene and preserve evidence. If the allegation is of abuse, the facility or community agency must also remove the accused staff from having contact with any individuals pending the outcome of the investigation.

Beyond these initial steps, the facility or community agency may take no other investigative steps without the permission of OIG or a criminal investigating entity. The facility or community agency may take administrative actions it deems necessary, but it must request permission from OIG before conducting its own investigation.

OIG may assign the full investigation to a community agency only if the agency has been through the investigative authorization process. This process is an effective way to obtain commitments by the agency or facility to investigate objectively, avoid any appearance of a conflict of interest, and to designate specific employees as investigators.

The facility or community agency must first adopt OIG's Investigative Protocol - there is one for facilities and one for community agencies - and then apply to OIG. The application must include the names and job functions of the persons designated to be OIG Liaison and investigators, including an assurance these persons have no conflict of interest conducting investigations.

To approve a designated person as an investigator, OIG reviews his or her position title and job functions. OIG also checks that the employee has attended OIG-conducted investigative skills training within the past two years and has no substantiated cases against him/her.

Once OIG has reviewed and approved a facility or community agency application, the designated investigators have additional responsibilities in every allegation. Specifically, unless otherwise directed by OIG, a designated investigator must do the following: secure the scene and all possible evidence; identify and separate possible witnesses; conduct initial interviews of persons involved; and photograph the scene, evidence, and any injuries. Again, no further investigative steps may be done until allowed by OIG or the investigating agency.

OIG may then assign the full investigation to the community agency - but only in allegations of mental abuse, financial exploitation valued under $300, or neglect that is not alleged to be egregious. When an investigation is assigned to a community agency, however, OIG remains involved: an OIG investigator is assigned to monitor and assist the investigation. This monitoring investigator sends an investigative plan to follow, remains available to provide guidance, and is responsible for the first-level review of the final investigative report.

Renewal of an approved agency or facility investigative protocol is not automatic. An application must be submitted each year: Community agency authorizations are for a fiscal year; facility authorizations are for a calendar year. OIG considers the performance of the agency or facility when determining whether to renew the authorization.

FY2010 community agency investigative authorizations

In May 2009, just prior to FY2010, OIG distributed an email to all 365 community agencies providing services within OIG's investigative jurisdiction. The email included a letter from the Inspector General providing an overview of the annual authorization process and links to three websites: the investigative protocol; the annual application form; and the OIG training calendar.

A total of 117 community agencies applied and were authorized by OIG for FY2010. A total of 362 agency employees were designated and approved as investigators.

CY2010 DHS-operated facility investigative authorizations

In December 2009, just prior to calendar year 2010, OIG distributed an email to the eighteen State-operated mental health or developmental disability facilities. By January 1, 2010, OIG had authorized all eighteen facilities. Each had a designated liaison with OIG; as few as two and as many as fifteen employees were designated and approved as facility investigators.

H. Non-Reportable Complaints

The OIG Hotline receives some calls about incidents or complaints that do not meet the abuse or neglect definitions or other reporting requirements in Rule 50 or Rule 51. The Hotline investigator explains why it is not reportable to OIG and, unless the caller can be immediately referred to the correct entity, completes "Non-Reportable" entry into the main OIG database. By including these "Non-Reportables" in the database, they can be listed if reportable allegations are received on the same person.

Referrals

Many of these "Non-Reportables" do not require any follow-up, such as a crime that has already been handled by the local police. Other examples are a complaint of domestic abuse after the person has moved out of Illinois and a notification of a natural death more than 14 days after leaving a service provider.

Other calls do need to be referred to the most appropriate entity, since OIG does not have any jurisdiction over complaints that are outside the statute and rules. OIG may make the referral itself or instruct the caller on where and how to refer it. Table 3 below shows the referral locations for Non-Reportables received during this fiscal year.

Table 3: Referrals of Non-Reportable Complaints Received in FY2010

Referral Location

Facility/Agency

Complaint

Domestic

Complaint 

Local community agency or facility  896  90
Illinois Department of Public Health  29  16
Department of Children and Family Services  15  11
Local law enforcement authority  17  39
Department on Aging  1  20
DHS Division of Rehabilitation Services  3  18
DHS - BALC *  10  1
DHS Division of Developmental Disabilities  9  5
DHS Division of Mental Health  4  8
Illinois State Police  6  3
Other  9  15
None needed  147 210
Totals 1146 436

*DHS Bureau of Accreditation, Licensure, and Certification


Most often, Non-Reportables are calls by a community agency or facility, self-reporting an issue or incident that is not reportable. Thus, OIG just notifies the caller to handle it internally and to call OIG back if any indication of abuse or neglect is found. During FY2010, OIG referred back to a facility or community agency over 75% of complaints at those locations.

In domestic allegations as well, a community agency may already be providing services and would be in the best position to determine what additional services may be needed. During FY2010, OIG referred to a local community agency just over 20% of complaints about domestic settings.

However, 210 calls - nearly half of the 436 domestic Non-Reportables during FY2010 - needed no referral at all. The reasons are varied, but the two most common were the following.

  • In 141 of the calls, the alleged victim had already taken steps to seek help for the problem, such as changing caregivers, showing that he/she was not impaired as required by OIG's domestic abuse statute.
  • In 53 of the calls, the alleged victim's situation had already been resolved, such as moving to a different residence or getting a different guardian.

These two reasons together accounted for 194 (92%) of the 210 domestic Non-Reportables that OIG did not refer during FY2010. The remaining sixteen were for issues such as it is a duplicate of an earlier report or the individual is under 18 years of age.


Chapter II: Reporting Abuse/Neglect

The new statute kept the basic requirements for reporting to OIG, including a 24-hour hotline, the four-hour time frame for reporting, and prohibitions on screening or delaying of allegations. Willful failure to report an allegation remains a Class A misdemeanor.

The statute also kept the requirement for reporting of deaths within 24 hours even if it occurred up to fourteen days after discharge or transfer elsewhere. If abuse or neglect is suspected, the death must be reported to OIG within four hours and OIG will do a full investigation.

OIG's statute had not contained definitions of the various types of abuse and neglect. Rather, it relied on the definitions in the Illinois Department of Public Health's statute (210 ILCS 30/3), where OIG's enabling legislation was also previously located. The new statute took definitions from the previous Rule 50 and put them into law, clarifying or expanding it as needed.

A. Physical Abuse

FY2010 improvement

The previous statute and rule had defined physical abuse as a "physical injury" inflicted on an individual by other than accidental means. In order to substantiate physical abuse under this definition, OIG had to prove that the individual was harmed physically. If, for example, the employee's alleged action did not result in a visible injury or if the allegation was made long after the incident, it might be difficult to prove physical harm.

The new statute now defines physical abuse as physical contact that causes bodily harm. Bodily harm is defined in Rule 50 as a "physical injury, damage or impairment..., or a physical contact of an insulting or provoking nature with an individual." That is, the abuse may involve only indirect physical contact by the employee; that is, an employee may use or throw an object. Similarly, the statutory definition of physical abuse now includes an employee directing someone else to injure an individual.

FY2010 case example

OIG received an allegation that an employee had sprayed water from a bottle into an individual's face several times during a meal and force-fed her. The investigation found that the individual had been talking during the mealtime, repeating a name over and over. The employee apparently got frustrated and sprayed the individual in the face with a bottle of water used to clean the tables.

When the individual did not stop, the employee sprayed her several more times, even after being confronted. The investigation also found that the employee then put too much on the individual's fork, so some of the food fell out of her mouth.

The employee made no direct physical contact, and the individual was not physically injured. However, spraying the individual in the face met the definitions of physical abuse and bodily harm: physical contact that is insulting or provoking. OIG substantiated physical abuse by the employee and referred her name to the Registry. She was fired by the community agency.

B. Sexual Abuse

FY2010 improvement

The new definition of sexual abuse appears to be minimally changed from the prior definition. However, sexual abuse is now broadened to include "intimate physical contact, sexual behavior or intimate behavior" of a sexual nature.

Therefore, physical contact that is sexual in nature is included even if the employee claims there was no sexual intent. Conversely, behavior that is sexual in nature is included even if the employee claims there was no physical contact.

FY2010 case example

OIG received an allegation that an agency employee had sent sexually explicit text messages and a lewd picture to an individual's cell phone. The individual was upset by them but said that she didn't want to get the employee in trouble. The director of the individual's residential program asked her for her cell phone and took it to the local police.

The local police got transcripts of the text messages from the cell phone. The employee, who worked at another agency's day program where the individual received services, had sent several sexually explicit text messages and a lewd picture of himself. He had also invited the individual to his home to spend the night. There was evidence that she had sent him sexually explicit texts in response and had sent a lewd picture of herself.

The investigation could find no evidence that the individual ever went to his home or that there had been any physical contact. However, the employee's behavior was sexual in nature. Therefore, since it had occurred after the new statute was signed, OIG was able to substantiate sexual abuse by the employee.

The employee resigned from employment by the agency. Referral to the Health Care Worker Registry is pending an appeal hearing.

C. Mental Abuse

FY2010 improvement

Like physical abuse, the definition of mental abuse had previously been "mental injury" and is now "mental abuse." This change merely clarifies that a mental injury need not be proven to substantiate mental abuse.

The new definition underscores this intent by changing the start of the definition. The old definition's "Harm caused by an act or omission..." has been replaced with "The use of demeaning, intimidating, and threatening words, signs or gestures...."

The new statutory definition also incorporates the prior Rule 50's phrase: "or could have caused emotional distress or maladaptive behavior." This provision has allowed OIG to substantiate mental abuse even if the individual's mental condition limits any response.

FY2010 case example

During an interview on another allegation, an individual mentioned that an employee yells and curses at the individuals in the CILA. OIG began a separate investigation.

The other individuals who resided in the CILA gave conflicting accounts. Some complained of being upset by particular words, while others denied hearing any yelling or cursing addressing individuals at all. Complicating the case was the issue of credibility, as some of the individuals had a diagnosis or documented history of falsifying injuries, lying, sociopathic behaviors, or psychosis.

However, three other employees who had worked with the accused employee admitted that they had also heard her curse, use vulgar terms, and yell at two of the individuals. The supervisor denied having heard any of this, but the agency's executive director recalled that she and the supervisor had talked to the accused employee about her use of language with the individuals several weeks before the allegation was made.

The accused admitted only using such language when she got hurt, such as being burned on the stove. She denied yelling or cursing at the individuals.

The use of vulgar terms and cursing at the individuals was determined to be mental "abuse," since those words did - and reasonably would have - caused them emotional distress. OIG substantiated mental abuse, and the agency fired the accused employee and disciplined the three employees who had known about the behavior yet had not reported it.

D. Financial Exploitation

FY2010 improvement

OIG has had statutory authority to investigate financial exploitation in domestic settings since 2001, but not in facilities or community settings. The new law rectified this oversight. The law and Rule 50 now include financial exploitation, which is defined as: "Taking unjust advantage of an individual's assets, property, or financial resources through deception, intimidation or conversion [i.e., theft] for the employee's facility's or agency's own advantage or benefit." Rule 50 requires OIG to conduct the investigation if the value is over $300.

FY2010 case example

An anonymous caller reported to OIG that a house manager of a CILA had taken $300 out of an individual's in-house account and had not paid it back. Since the allegation was made after the statute was signed on August 13, 2009, OIG had jurisdiction for alleged financial exploitation. Thus, OIG took the allegation.

Although she was the only agency employee who had been authorized by the individual's guardian to sign for withdrawals from his account, the house manager claimed that a former employee had responsibility for the account. The house manager admitted that she had once taken $50 from an in-house account to buy the individual a new swing, but she claimed that she had replaced it with a personal check for $50. A copy of that personal check shows that it was returned to her for insufficient funds.

The former employee stated that she found a discrepancy of $300 between the account books and the bank account when she was resigning from the job at the community agency. Since she knew the house manager was the only one who had authority to sign for the individual, she confronted the house manager about both the $50 shortage in the in-house account and the $300 shortage in the bank account. She recalled that the house manager explained the $50 but denied knowing anything about the $300.

OIG obtained withdrawal slips for $100 and $200 from the time period, and they had the house manager's signature on them. The house manager said that she may have signed them, but that the former employee would have gotten the money. The former employee denied having seen the withdrawal slips or having gotten them money.

Further investigation found that the house manager had personal financial difficulties, had recently asked to borrow money from other employees, and admitted to taking money from other individual's in-house accounts to return later. The investigation found no evidence that would question the former employee's credibility.

OIG substantiated financial exploitation by the house manager and recommended that the agency revise its internal procedures to limit a staff's abilities to take money from individual's bank and in-house accounts. The agency terminated the employee and revised its procedures.

E. Neglect

FY2010 improvement

Another significant change in the new law is the expansion of neglect to include an act or omission that places an individual's health or safety "at substantial risk." The prior definition of neglect required that the individual be injured before OIG was permitted to substantiate the allegation. Now, even if the individual is "lucky" enough not to be injured by the act or omission of the employee, agency or facility, OIG may still substantiate neglect.

The previous Rule 50 required the act or omission to be a "substantive" failure before the neglect could be determined to be "egregious." The new law clarifies this standard by replacing it with the following: "a gross failure" or "a callous indifference" to the individual's health, safety or medical needs. This failure, however, must still result in death or serious deterioration before the neglect may be determined to be "egregious."

FY2010 case example

An agency reported that one of the individuals was found by a neighbor in the street, yet the staff were unaware the individual was gone. The individual has profound mental retardation and has often eaten inappropriate objects, so he requires same room supervision.

The investigation found that the employee who usually monitors this individual was assigned to help in a different CILA, and the supervisor asked a second employee to handle her duties. This second employee claimed not to recall this conversation, even though the investigation found that the two other staff who were on the CILA that shift did remember it.

So, this second employee did her own typical duties, instead of monitoring the individual. Thus, she was accused of neglect.

After dinner, one of the other employees on the shift left to take two other individuals for a walk, and she asked the accused employee to set the alarm. However, the alarm was not set when the neighbor rang the front doorbell, escorting the individual back to the CILA. The neighbor reported that she had found the individual standing in the middle of the road, blocking traffic.

Since the individual was in imminent danger by standing in the road and not being monitored to keep him from eating inappropriate objects, OIG substantiated neglect. Because of the new law, OIG could substantiate neglect even though the individual did not sustain any injuries nor suffer any physical or mental deterioration. The agency then discharged the accused employee.

F. FY2010 Reporting

During FY2010, OIG received a total of 3,184 allegations of abuse or neglect. The counts by type and location are shown in the table below. Tables 5a through 5c on the following pages show a more detailed breakout by allegation type and location.

Table 4: Summary of Allegations Received by OIG in FY2010

Location Abuse allegations Neglect allegations Total allegations
DHS-operated facilities  819 148  967
Community agencies 1,058 442 1,500
Domestic settings  350 367  717
Total 2,227 957 3,184

Facilities

During FY2010, OIG received 819 allegations of abuse at the DHS facilities, including three allegations of financial exploitation. OIG also received 148 allegations of neglect at facilities. The ratio of abuse to neglect has steadily fallen over the past three years, as overall, neglect allegations have increased faster than abuse allegations, driven recently by the changes in definitions.

These changes in definitions - notably, adding financial exploitation to abuse and significant risk without harm to neglect - have driven a recent increase in all allegations. Compared to allegations in FY2007, OIG received 3.8% fewer allegations of abuse at facilities in FY2009 but 7.5% more in FY2010. Similarly, neglect allegations at facilities during FY2009 were up 17% from FY2007; but those during FY2010 were up 42%. Overall, allegations at the facilities in FY2010 were up 13% over last year, even excluding financial exploitation allegations.

As fewer individuals are served in facilities, allegations at facilities have constituted a progressively smaller portion of total allegations. Since FY2007, the facilities' on-books patient-days have decreased 12.7%, and the percentage of allegations that are from facilities have decreased 10.1%.

Community agencies

During FY2010, OIG received 1,058 allegations of abuse and 442 allegations of neglect at the community agencies. Thirty of the 1,058 abuse allegations were of financial exploitation, newly reportable to OIG.

Allegations at community agencies have increased substantially over the past few years, due most significantly to the change in definitions. At community agencies, allegations of abuse have risen 12% over last year and 37% since FY2007, while allegations of neglect have risen 32% over last year and 64% since FY2007.

The ratio of abuse allegations to neglect allegations at the community agencies has remained relatively stable and significantly lower than at the facilities. During FY2007 through FY2010, at the community agencies, OIG received about three allegations for every neglect allegation (high of 3.1 in FY2008 and low of 2.4 in FY2010). As noted above, during FY2007 through FY2010, at the facilities, the ratio has dropped substantially (the actual drop has been from a high of 7.3 in FY2007 to a low of 5.5 in FY2010).

Since no type of allegation has decreased over the four years, the reason for a difference in ratios appears to be due to abuse allegations at the facilities rising more slowly than any other type of allegation. In FY2007, for the first time, OIG received more abuse allegations about community agencies than about facilities (772 to 762). In FY2010, OIG received 7.5% more abuse allegations at facilities but 37% more at community agencies, almost five times as fast. Meanwhile, neglect allegations rose 42% at the facilities and 63% at the community agencies.

Allegations of abuse/neglect at the community agencies have been rising faster than in other settings over the past several years. In FY2005, allegations at community agencies accounted for one-third (33%) of all allegations OIG received. By FY2007, they accounted for two-fifths (41%), and in FY2010, they account for nearly one-half (47%). These changes underscore the growing number of individuals receiving services by the community agencies.

Domestic

As noted earlier in this report, OIG's jurisdiction in domestic settings began in FY2001 and is limited to individuals between the ages of 18 and 59 who have a physical or mental disability that prevents them from seeking help on their own. Thus, OIG receives only a fraction of all complaints of abuse, neglect, or financial exploitation in domestic settings.

Allegations OIG received about abuse/neglect in domestic settings have also increased over the past few years, although not steadily and much less dramatically. Decreases in FY2006 and again in FY2008-FY2009 have been offset by larger increases in other years. During FY2005, OIG received 531 allegations in domestic settings. During FY2007, OIG received 652 allegations; during FY2010, OIG received 717 allegations. Still, the overall increase averages to 7% per year, compared to an overall average increase of 21.5% per year in abuse/neglect allegations at community agencies.

Every year, OIG receives more allegations of domestic neglect than of domestic abuse and relatively few of financial exploitation. In domestic settings, neglect allegations have risen faster than abuse allegations, but financial exploitation allegations have risen even faster. From FY2005 through FY2010, domestic abuse allegations have increased 23%; the number received during FY2010 is two percent lower than the number received in FY2008. Allegations of domestic neglect, on the other hand, increased 35% from FY2005 through FY2010, and they rose 15% just since FY2008. Meanwhile, allegations of financial exploitation have increased 60% since FY2008, and they nearly doubled from FY2005 through FY2010 (43 to 85).

The tables below show the allegations and deaths that OIG received during FY2010 by type of allegation and program location.

Table 5a: Allegations and Deaths Received in FY2010, Mental Health Services Only

Location Allegations Deaths
Physical abuse Sexual abuse Mental abuse Financial exploit'n Neglect Total alleg.s Initial reports
Facilities
Alton MHC  (civil) *   8  3  13  0  1  25  0
Alton (forensic) *  25 13  26  0  5  69  0
Chester MHC 141 19  42  0  9 211  2
ChicagoRead MHC  12  3  11  0 10  36  0
Choate MHC  17  1 5  0  5  28  2
Elgin MHC (civil)   6  2  12  0 11  31  0
Elgin (forensic)  15 10  14  0 11  50  0
Madden MHC  16  1  12  0 10  39  0
McFarland MHC (civil)  15  8  10  0  4  37  0
McFarland (forensic)   8  0   2  0  1  11  1
Singer MHC  16  5   5  1  5  32  0
Tinley Park MHC   2  3 4  0  3  12  2
Facility subtotals 281 68 156  1 75 581  7
Community agencies
Residential sites  10 11  25  3 11  60 27
Non-Residential   8  8  11  9  7  43  2
Agency subtotals  18 19  36 12 18 103 29
Rule 50 MH totals 299 87 192 13 93 684 36

* Civil units are for individuals who are not committed to the facility by the judicial system, while Forensic units are for individuals who are court-committed or who have aggressive behaviors.


Table 5b: Allegations and Deaths Received in FY2010, Developmental Services Only

Location Allegations Deaths
Physical abuse Sexual abuse Mental abuse Financial exploit'n Neglect Total alleg.s Initial reports
Facilities
Choate DC  49  0  11  1  12  73 2
Fox DC   1  0   1  0   5   7 5
Howe DC  18  1   3  0  19  41 3
Jacksonville DC  69  0  23  1   8 101 3
Kiley DC  10  0   7  0   9  26 0
Ludeman DC  36  2   2  0   6  46 1
Mabley DC   7  0   0  0   3  10 0
Murray DC  20  0   5  0   8  33 3
Shapiro DC  35  0  11  0   3  49 4
Facility subtotals 245  3  63  2  73 386 21
Community agencies
Residential sites 447 31 202 16 311 1007 79
Non-Residential 182 22  71  2 113  390  0
Agency subtotals 629 53 273 18 424 1397 79
Rule 50 DD totals 874 56 336 20 497 1783 100


Table 5c:
Allegations Received in FY2010, Domestic Settings Only

Disability Type Physical abuse Sexual abuse Mental abuse Financial exploit'n Neglect Total alleg.s
Developmental disability 153 23 11 38 184 409
Mental health  26  2  1 23  58 110
Physical disability  38  4  7 24 125 198
Rule 51 totals 217 29 19 85 367 717


Chapter III: Investigating Abuse/Neglect

A. Conducting Investigations

The new law did not change how OIG conducts investigations, but it clarified some definitions and improved OIG's effectiveness in investigating and in referring findings to other entities for review and other actions.

These improvements have affected OIG's related statutory responsibilities as well. For example, the statute and the rule strengthened OIG's authority to gain admittance to facility and agency program sites, to conduct interviews of involved staff, and to review relevant documents. This improved access also applies to conducting facility site visits and to reviewing implementation of corrective actions.

As with its investigative findings, OIG is prohibited from releasing any personally identifiable health information to other entities, except as provided in the Health Insurance Portability and Accountability Act of 1996.

FY2010 improvements

The law added "on-site or off-site" to the definition of an "individual" - the alleged victim in OIG's cases. Alleged abuse or neglect that occurs away from the facility or agency's program site is now more clearly something that OIG investigates.

The law changed the definition of "employee" - the accused person in Rule 50 cases - to clarify that OIG may investigate these allegations even after the employee resigns but only for actions done while an employee.

The law requires employees to cooperate with OIG investigations. Failure to cooperate with an OIG investigation or compliance review is a violation of the law. No person is allowed to obstruct or interfere with an OIG investigation.

The law directs the Illinois Auditor General to change its biennial program audit of OIG to one that is done on an "as needed" basis, determined by the Auditor General. This wording matches the wording of the Auditor General's audit of the Office of the Inspector General in the Department of Children and Family Services (DCFS).

The rule clarifies that OIG investigation reports remain confidential, and if one is unsubstantiated or unfounded, it cannot be released to anyone. On the other hand, if OIG substantiates abuse or neglect by an employee in a licensed profession (for example, nurse, physician, social worker, or therapist), the rule now clearly allows OIG to send a copy to the Department of Financial and Professional Regulation for review and follow-up investigation.

OIG is in the process of creating new inter-agency agreements with other State investigative agencies to reflect the improvements in the statute and the rule. As the number of allegations reported to OIG continues to increase, such improvements in OIG's investigative authority and coordination with other entities become critically important for timely and effective investigation of all allegations.

B. Investigative Timeliness

Rule 50 states that investigative case reports are to be submitted within 60 working days from assignment, unless extenuating circumstances prevent it. One such circumstance preventing completion within 60 days is the time required to get death certificates or medical records on deceased individuals.

A more common circumstance is an ongoing criminal investigation. When the Illinois State Police (ISP) accepts an allegation for criminal investigation, OIG is prohibited from beginning its administrative investigation. If the criminal investigation results in a referral for prosecution, OIG is often prohibited from beginning until the State's Attorney makes a prosecutorial decision.

Thus, OIG counts total time and OIG time separately (see Table 6). Although investigations took longer in FY2010 than in FY2009, OIG has still completed its Rule 50 and Rule 51 investigations 18% faster over the past five fiscal years, while completing 26% more investigations. Looking only at Rule 50 investigations, OIG slightly improved this fiscal year, dropping to 44.2 days per case compared to 44.5 days per case during FY2009.

Table 6: Average Time to Completion for All OIG Investigations, by Fiscal Year

Investigations FY2006 FY2007 FY2008 FY2009 FY2010
Number completed 2,333 2,494 2,744 2,866 2,840
Average total days* 50.8 44.3 40.8 37.7 39.9
Average OIG days* 47.7 42.6 39.1 36.6 38.0

*Average total days includes all time from initial report until case closure; while average OIG days omits time for delays necessitated by pending Illinois State Police investigations.


One part of the length of time required for investigation is the time needed for supervisory and management review of draft investigative case reports. OIG has recently focused on trying to reduce the time needed for these case reviews without sacrificing improved quality.

C. Case Closures

The new law and rule did not change the basic findings in OIG cases. "Substantiated" cases still require a simple preponderance of the evidence - that the allegation is more likely true than not. "Unfounded" cases have no evidence supporting the allegation. "Unsubstantiated" cases may have some evidence supporting the allegation but not a preponderance.

FY2010 improvement

The new law still allows OIG to identify "aggravating" and "mitigating" circumstances, although the definitions of these were clarified. "Aggravating" circumstances increase the culpability of the accused, but do not increase the severity of the act or omission. "Mitigating" circumstances may lessen the culpability of the accused and may be considered when determining the administrative action to take, but do not alter the substantiation. That is, neither aggravating or mitigating circumstances change the basic finding of the case.

FY2010 case closures

The findings in abuse/neglect allegations and in death cases OIG closed during FY2010 are presented in the three tables that follow, one each for mental health services, developmental disability services, and domestic settings. The column entitled "Other issue only" shows cases in which OIG did not substantiate abuse/neglect but did make an administrative recommendation to the community agency or facility.

Table 7a: Cases Closed in FY2010, Mental Health Services Only

Location  Allegations Deaths
Abuse substan-tiated Neglect substan- tiated Other issue only Not substan-tiated Alleg. findings totals Closed cases
Facilities
Alton MHC (civil) * 0 0  1  23  24  0
Alton (forensic) * 1 0  3  51  55  0
Chester MHC (forensic) 1 1  7 208 217  2
Chicago-Read MHC 0 0  3  21  24  1
Choate MHC 1 1  1  16  19  3
Elgin MHC (civil) 1 0  7  16  24  0
Elgin (forensic) 1 2 11  40  54  0
Madden MHC 0 0  2  20  22  2
McFarland MHC (civil) 3 0  2  32  37  1
McFarland (forensic) 1 0  0  12  13  1
Singer MHC 1 0  2  31  34  0
Tinley Park MHC 0 1  7   3  11  1
Facility subtotals 9 5 42 399 455 11
Community agencies
Residential sites 6 0  9  30  45 24
Non- Residential 6 0  5  24  35  7
Agency subtotals 12 0 14  54  80 31
Rule 50 MH Totals 21 5 56 453 535 42

* Civil units are for individuals who are not committed to the facility by the judicial system, while Forensic units are for individuals who are court-committed or who have aggressive behaviors.


Table 7b: Cases Closed in FY2010, Developmental Services Only

Location Allegations Deaths
Abuse substan- tiated Neglect substan- tiated Other issue only Not substan- tiated Alleg. findings total Closed cases
Facilities
Choate DC   4  4  5 53  66 1
Fox DC   1  0  7  1  9 2
Howe DC   0  7 10 31  48 5
Jacksonville DC   2  2  7 79  90 2
Kiley DC   0  2 11 10  23 0
Ludeman DC   1  1  9 29  40 0
Mabley DC   1  2  1  2  6 1
Murray DC   1  0  8 16  25 5
Shapiro DC   1  0  2 26  29 4
Facility totals  11 18  60 247  336 20
Community agencies
Residential sites  76 59 241 490  866  79
Non- Residential  44 20  87 200  351  2
Agency totals 120 79 328 690 1217  81
Rule 50 DD Totals 131 97 388 937 1553   101*

*OIG substantiated neglect in three deaths in agency residences and one death at Howe DC.


Table 7c: Cases Closed in FY2010, Domestic Settings Only

Disability type Abuse substan- tiated Neglect substan- tiated Exploitation substan- tiated Refused consent Not substan-tiated Findings totals
Developmental disability 33 41 3  85 197 359
Mental health  2  5 0  38  55 100
Physical disability  4  7 1  72  96 180
Rule 51 Totals 39 53 4 195 348 639


The statute governing OIG's investigations in domestic settings allows an alleged victim to refuse consent for the investigation. That is, in the 195 domestic cases above, the alleged victim did not consent to OIG conducting an investigation into the alleged abuse or neglect.

Trends in investigative findings

As the statute and rule governing OIG's investigations in facilities and community agencies has expanded in its understanding of what constitutes abuse and neglect, allegations reported have increased. At the same time, the rate of substantiations has fluctuated and has recently been trending downward only slightly in community agency cases and more significantly in domestic cases (see Table 8).

Table 8: Substantiation Rates by Location and Fiscal Year, FY2005 through FY2010

Location FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
DHS facilities  7.2%  4.5%  6.3%  5.9%  5.9%  4.1%  5.0%
Community agencies 19.1% 18.4% 17.5% 16.2% 16.4% 16.0% 15.3%
Domestic settings 15.0% 21.9% 19.9% 19.3% 26.2% 19.7% 13.0%
Overall total 12.9% 13.5% 14.4% 14.0% 15.9% 13.1% 11.7%


OIG sees the decrease in rate of substantiation as a simple artifact of the ever-increasing number of allegations received. That is, as the number of allegations has risen, more of them have been allegations that are simply not true.

Reconsiderations

During FY2010, OIG received 151 requests to reconsider the findings of an OIG investigation under Rule 50, although these requests were of the findings of 123 investigations. OIG received requests for reconsideration of just about half of all substantiated cases.

Of these 151 requests, OIG granted 45 (covering 40 cases); the remaining 106 requests were denied because they provided no new information. Of the 40 cases with granted reconsiderations, OIG revised 25 case reports but changed the findings in only five cases. The reconsideration process continues to show that OIG investigative findings are largely accurate and that OIG is responsive to new information that can change the finding.


Chapter IV: Stopping Abuse/Neglect

OIG's statutory mission goes beyond investigating. As noted at the outset of this report, OIG has been given responsibilities to act to prevent abuse and neglect from occurring. Further, the statutes require that OIG act to help stop abuse and neglect when it is happening. This role is evident in emergency interventions in domestic abuse/neglect, in clinical recommendations to change and respond to situations, and in administrative recommendations to eliminate problems that may lead to abuse/neglect, and in tracking and ensuring compliance with actions taken in response to those recommendations.

The new statute strengthened OIG's role in making recommendations beyond the findings. That is, OIG is now more clearly empowered to make administrative recommendations to the facility or community agency, identifying issues that need to have actions taken to prevent the occurrence or recurrence of abuse or neglect.

A. Domestic Abuse Intervention

Since the new statute addresses OIG's Rule 50 cases, it did not affect OIG's Rule 51 (domestic abuse/neglect) cases. OIG continues to have separate statutory authority to take immediate actions to intervene in domestic situations where abuse, neglect, or financial exploitation are being substantiated or will be substantiated (20 ILCS 2435/).

The three primary interventions described in the statute are: Emergency placement, or a move to a different residence immediately; Order of protection, secured through a local law enforcement agency and a court hearing; and Guardianship, whether by OIG or by another entity.

FY2010 emergency interventions

The most common type of emergency intervention is the removal of the individual from a situation where there is risk of injury or death. Upon investigating an allegation, OIG may find an individual in a serious, life-threatening medical condition, which requires emergency transport to a hospital or other medical facility.

When the individual's immediate medical condition is not life-threatening but OIG finds an imminent risk of serious injury or death, OIG may ask the individual if he/she would like to move. If the individual agrees, OIG may facilitate his/her move to a different residence on an emergency basis. This may be done after some initial investigation into the situation reveals significant risks not immediately known.

OIG may instead find that the problem is the alleged perpetrator, not the individual's home. Infrequently, the individual may want help in pursuing an Order of Protection against the alleged perpetrator, and OIG can help get that. More often, the alleged perpetrator is the individual's guardian, and OIG needs to help get the guardianship changed. OIG tries to find another family member to assume guardianship. If that fails, OIG will use its statutory authority to go to court and get the Illinois Guardianship and Advocacy Commission's Office of State Guardian to take over guardianship of the individual.

Table 9 below shows the break-out of emergency interventions during FY2010 and the prior five fiscal years. There is variation from year to year, but no long-term trends are apparent.

Table 9: Emergency Interventions by Fiscal Year, FY2005 through FY2010

Intervention FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Emergency placement 26 33 29 25 32 24
Orders of protection  8  8  4  3  3  6
Guardianship pursued 11 16 18 14 18 17
- Guardianship by OIG*  3  3  6  6 10  7

*A subset of all cases where guardianship is pursued.


FY2010 case examples

Emergency placement - Imminent risk

An individual with severe developmental disabilities was also reportedly aggressive, having left several holes in the walls. His parents admitted that they thus often locked him in his room and gave him more than the prescribed amount of his medications, so they could keep him calmer. The room had torn out electrical outlets and dried feces on the wall. The family stated that they were afraid of the individual and admitted they were unable to care for him. OIG had the victim taken to the hospital for an evaluation and, after discharge, placed in a residence operated by a community agency. OIG substantiated the case.

Emergency placement

A woman was the paid caregiver and Social Security payee for her son, who has profound developmental disabilities. She was also allegedly addicted to drugs and used her son's money to support her habit. She had not paid the rent, so they had been evicted from their apartment and were temporarily living with her daughter at the time of the allegation. However, the daughter made her mother leave because of continuing drug addiction and said she was unable to care for her brother long-term. OIG substantiated the case, helped the sister start guardianship proceedings and become his payee, and worked with a local agency to find a placement for him. He got moved the next day.

Guardianship

A new DHS-paid caregiver noted that an individual with developmental delay had a bloody stool. The individual's husband said not to worry about it, since it had been like that for a year and a half. The caregiver, however, took her to the hospital, where she was found to have a cancerous tumor in her colon. Further, the individual had other physical problems, yet the unemployed husband had refused to buy needed medical supplies with her benefit check, spending the money on himself instead. Thus, OIG substantiated neglect and financial exploitation. The individual also exhibited behaviors consistent with sexual exploitation. When the physician determined the victim to not be competent, OIG started guardianship proceedings, and the Office of State Guardian agreed to be the victim's guardian.

Order of Protection

An individual with cerebral palsy and mild developmental delay reported that he had been beaten, choked, and given a black eye by his sister's boyfriend. He said that he feared for his life, yet his sister did nothing. The police arrested the boyfriend, and OIG substantiated physical abuse by him. However, OIG also found that the individual's home had no working toilet or stove, and his schoolteacher said he had poor hygiene, especially untreated dental problems. The individual's father said he was unable to afford dental care or dental insurance, but he could not explain what he did with the individual's Social Security benefits. The individual also reported that he was left alone much of the day, that he was not given dinner until 10:30 pm, and that he was afraid of living there. The individual's father and sister gave contradictory accounts about his care. Thus, OIG substantiated neglect by the individual's father and sister, started guardianship proceedings, and got him a placement in a community agency's residential program. When the father lied to the school, saying that the States Attorney had said he could talk to the individual at any time, OIG secured an order of protection, restricting the father's contact with the individual.

FY2010 service plan referrals

When OIG substantiates a domestic case, the statute requires that OIG refer the individual to the appropriate DHS program division to develop a plan for providing needed services. Individuals referred may already be receiving services provided by DHS either directly or through a community agency. Table 10 shows the program division to which OIG referred individuals in substantiated cases during FY2010 and the five prior fiscal years.

Table 10: Service Plan Referrals by Fiscal Year, FY2005 through FY2010

DHS Division FY2005 FY2006 FY2007 FY2008 FY2009 FY2010
Developmental Disabilities  83  61  76 107  96 67
Rehabilitation Services  29  42  35  74  23 22
Mental Health   6   7   8  12   5  7
Totals 119 110 119 193 124 96


B. Health Care Worker Registry

The Illinois Department of Public Health maintains Illinois' Health Care Worker Registry (formerly "Nurse Aide Registry"), which is a listing of health care workers in Illinois. The Registry also contains adverse findings against these people. Since January 1, 2002, OIG has been required to tell the Registry the identity of any person substantiated to have committed physical abuse, sexual abuse or egregious neglect.

FY2010 improvement

The statute retains the mandate for OIG to refer identities to the Health Care Worker Registry, thereby identifying these people as not permitted to work in any health care setting in Illinois.

The statute also retains the appeal process for someone to keep his or her name from being referred, and it clarifies that this is the purpose of that appeal process. However, the statute also makes three substantive changes to the process. First, it allows OIG to subpoena documents and witnesses at an appeal hearing. Second, it mandates testimony by witnesses named in the investigation. Third, it grants the person the right to file a lawsuit, if he or she disagrees with the decision of the appeal hearing officer.

The new law also removes a separate appeal of actions taken by the agency or facility in response to the OIG finding. This old appeal process did not prevent referral to the Registry. However, the new law made it clear that OIG may not refer a person to the Registry until all related pending personnel action is concluded.

FY2010 Registry referrals

During FY2010, OIG made 68 referrals to the Registry, although two of these 68 were for the same person (two different substantiated cases). While the total number of referrals has varied only slightly over time, DD community agency employees have constituted an increasingly large majority of names referred: 90% in FY2010, compared to 66% in FY2007. Table 11 below shows the breakout by disability type and location over the past four years.

Table 11: Registry Referrals by Disability and Location, FY2007 through FY2010

Location FY2007 FY2008 FY2009 FY2010
 Disab. Count Percent Count Percent Count Percent Count Percent
Facilities
 DD 13 20  9 12  8 13  3  4
 MH  2  3  5  7  0  0  0  0
Agencies
 DD 44 66 56 77 50 78 61 90
 MH 7 11 3  4 6  9 4  6
Totals
 DD 57 86 65 89 58 91 64 94
 MH 9 14  8 11 6  9  4  6


Most referred persons are direct care staff - that is, employees who are not clinically licensed and whose primary job is helping individuals directly. In FY2010, these staff accounted for 96% of community agency employees referred and 100% of facility employees referred.

Most referred persons are for substantiated physical abuse. Of the 68 referrals this fiscal year, 59 were for physical abuse, while eight were for sexual abuse and only one for egregious neglect. This pattern is consistent with prior years.

Referral appeals

Sixty appeals were either filed in FY2010 or had been filed before and yet remained undecided. Of these 60 filings, 35 were finalized during the fiscal year. In thirteen instances, the employee was referred to the Registry: in two appeals, the employee withdrew the appeal; three appeals were dismissed for procedural reasons; and in eight appeals, the decision was to refer the employee. In the remaining 22 instances, the employee was not referred to the Registry: four of these were stipulations agreed to prior to the hearing; in eighteen appeals, the decision was to not refer the employee to the Registry.

Removal appeals

After being referred to the Registry, the statute allows a person to appeal to have the finding removed from the Registry, although the person may file only one such appeal each year. A total of eleven such appeals were filed either in FY2010 or remained unresolved from FY2009. Of these eleven appeals, four remained open at the end of FY2010. The seven decided resulted in three removed and four not removed.

C. Recommendations

Since the original statute creating the position of the Inspector General, the legislative intent has always been clear: to go beyond simply proving or disproving allegations. As noted above, in domestic cases (Rule 51), OIG has the statutory authority for taking emergency interventions to stop ongoing abuse/neglect and to prevent recurrence.

In cases at facilities and community agencies (Rule 50), however, OIG has the statutory authority for making recommendations. That is, OIG may identify related issues that appear to have led to the incident, or might lead to other incidents, and may then make recommendations to prevent recurrence. Prevention has always been a focus of OIG's investigations.

FY2010 improvement

The new statute for Rule 50 investigations underscores this focus. It specifically authorizes OIG to take actions to prevent abuse or neglect from happening, now including termination of a community agency's licensing, funding or certification (1-17(r)), and to conduct facility site visits for the purpose of making recommendations on system issues to prevent abuse and neglect.

For Rule 50 investigations, the law authorizes OIG to make recommendations that go beyond the case finding - i.e., whether the allegation is substantiated or not - to "require action by the facility, agency, or department to correct a systemic issue, problem or deficiency identified in the investigation" (1-17(b)).

In these instances, OIG makes recommendations to the facility or community agency in the investigative case report and puts those on a form requiring a response (see Written Responses, below). Some of those recommendations address clinical issues.

FY2010 clinical recommendations

OIG has registered nurses who are trained investigators and function as "clinical coordinators." The clinical coordinators review all deaths reported to OIG, which includes all deaths occurring within a facility or community agency program or within fourteen days of deflection, transfer, or discharge. They also assist in investigations that have clinical issues, may take primary responsibility for the investigation, and review draft investigative case reports when requested. OIG currently has three clinical coordinators, plus a fourth who helps with consults and death reviews.

Death Cases

During FY2010, OIG completed reviews on 143 deaths of individuals: 112 individuals had been receiving services from a community agency, and 31 individuals from a DHS facility.

The major causes of death were cardiac diseases, respiratory failure (including pneumonia), cancer, aspiration (i.e., choking), and sepsis (i.e., systemic infection). In 113 of the 142 deaths, the death certificate listed the manner of death as natural, ten were accidental, five were suicides, and one was by homicide; the rest were undetermined or unknown.

Deaths in agencies

Of the 112 deaths of individuals who had been receiving services in a community agency program, 81 had been receiving DD services and 31 had been receiving MH services. Abuse or neglect by staff was rarely alleged in these deaths, but OIG substantiated neglect in three of them. These three are described below:

  • An individual died from peritonitis due to diverticulitis about a week after returning from a hospital ER for stomach pains. The OIG investigation found that a licensed practical nurse (LPN): had discontinued the medications ordered by the ER physician; had failed to conduct any physical exam despite the individual continuing to suffer from nausea and vomiting; had never instructed the staff on the ER instructions; and had not informed the supervising nurse of the individual's ongoing problems. OIG substantiated neglect and determined it was egregious, since it was directly related to the cause of death. The OIG investigation also found that this LPN had been completing annual nursing assessments without physically examining the individual and without any review or involvement of the supervising nurse. Instead, the LPN had falsified these assessments and related documents and his supervising nurse ignored complaints about him presented by the direct care staff. OIG substantiated neglect by the supervising nurse, determined it was egregious, and referred the case to another agency for a licensing investigation into the nursing practices.
  • An individual was known to leave her residence and day program without telling staff and without proper clothing. About a week before her death, she was disoriented and had fallen at home, so she was admitted to a hospital for a couple days for observation and her medication was adjusted. Three days before her death, she fell and sustained a closed head injury. On the day of her death, about lunch time, she went to smoke a cigarette, and when the staff came to transport her back home, they could not find her. A search was conducted, and the local police were contacted. That night, the individual's body was found in a pond outside the agency's building. The cause of death was an accidental drowning. OIG substantiated neglect for failure to provide adequate supervision and monitoring for the individual and for failure to monitor the smoking area next to the pond. OIG also recommended that the agency take immediate action to address these issues.
  • The last of the three was included in the FY2009 OIG Annual Report but was reopened following a reconsideration. In this case, the individual had multiple serious medical problems and developed fluid in her abdomen. After a hospitalization for this condition, the agency contracted for home health care by a registered nurse. However, the agency never asked for the nurse's schedule and never checked on her. The nurse failed to adequately assess the individual, who eventually was re-hospitalized and died a week later.
Deaths in facilities

During FY2010, OIG completed 31 deaths of individuals either within a facility or within 14 days of deflection, transfer, or discharge. Again, abuse/neglect was rarely alleged in these deaths, but OIG did substantiate neglect in one death, as described below.

  • An individual who had a known history of stuffing food into his mouth began choking while eating lunch. The staff performed the Heimlich maneuver several times and called a medical emergency. He became unconscious, so the staff started CPR (cardiopulmonary resuscitation). The paramedics arrived but were unsuccessful in resuscitating him, and the cause of death was accidental asphyxiation due to a food bolus. However, upon investigation, OIG found that the medical staff had not gotten the necessary medical emergency equipment in a timely manner, because it was locked in a cabinet with a faded padlock on it. OIG also found that the medical staff had not followed standard CPR guidelines; that is, the individual's airway was never completely cleared. OIG substantiated neglect and recommended that the facility: ensure emergency medical equipment is readily available throughout the facility; develop a policy or procedure for the storage and use of emergency medical equipment; and conduct retraining on CPR for all staff.

In other death cases, OIG made recommendations to prevent or eliminate problems identified. The most common was to provide retraining, especially in medication administration, reporting medication errors, dietary monitoring, and medical emergencies and CPR. OIG also recommended better monitoring of individuals at a high risk for falls and choking.

Abuse and Neglect

During FY2010, OIG substantiated five cases of neglect involving clinical issues and involved the clinical coordinator in the OIG investigation. Four of these were at community agency programs and the fifth was at a facility. The five cases are as follows:

  • An agency's registered nurse failed to follow multiple physician's orders over several months for fecal occult blood testing to be done on an individual. When the test was finally done, the individual was diagnosed with colon cancer with lymph node involvement, and the individual required extensive surgery and chemotherapy. The oncologist stated that the ordered testing would have found it earlier, greatly improving the individual's chances of survival. OIG substantiated neglect and determined it to be egregious.
  • A physician ordered that an individual with decubitus ulcers not wear a diaper while in the home but be re-positioned and toileted every two hours. The agency assigned only one employee to work, even though it was obvious that one person could not provide the required hygiene and still monitor the other individuals. For several hours, the individual did not get the required hygiene, so OIG substantiated neglect for placing the individual at substantial risk of her physical condition deteriorating. OIG recommended that the agency review its staffing plan.
  • An individual who had vomited earlier was apparently not properly cleaned, as he was found later with dried emesis on his skin, which had caused dermatitis. Several staff were aware of the problem, but did not notify anyone. Upon being notified, the agency's registered nurse did not promptly evaluate the individual or get a timely evaluation by a physician. OIG substantiated neglect.
  • An individual who had an abdominal ostomy developed serious skin problem due to a lack of care for the ostomy site. The OIG investigation found that the staff were not aware of proper care of an ostomy site due to the lack of adequate policies and relevant training. OIG substantiated neglect and recommended the agency develop policies on ostomy care and train its direct care staff.
  • An individual who used a wheelchair for mobility was at high risk for decubitus ulcers, because he had quadriplegia. However, such ulcers are preventable with adequate care. The most recent annual physical exam showed that he already had developed Stage II decubitus ulcers, and the physician had written orders to provide treatment for them. The nursing staff failed to: document the prescribed treatment; conduct a nursing assessment on skin care with a comprehensive plan of care; monitor, provide, and document hygiene treatment and position changes. Although the individual's death was due to pancreatic cancer, OIG substantiated neglect by the agency for failure to provide adequate medical care and maintenance for the individual's condition. OIG also recommended that the agency conduct nursing assessments on skin care, document the plan of care, and address the failure of direct care staff to document hygiene treatments and position changes.
Common problems

During FY2010, the six most common clinical failures cited in OIG investigation reports were all in community agencies. They were:

  • Failure to follow Rule 116 on medication administration procedures, with adverse events;
  • Failure to report medication errors and immediate follow up with the physician;
  • Failure to follow Rule 115 standards for adequate documentation;
  • Failure to perform CPR when necessary;
  • Failure of nursing to provide clear instructions on special monitoring of individuals; and
  • Failure to document and follow-up on medical consultations and specialized care.
 Patterns in clinical recommendations

During FY2010, the clinical coordinators made many recommendations to community agencies and facilities aimed at preventing recurrence of abuse/neglect by eliminating underlying problems. Four areas that had multiple recommendations, along with examples of such recommendations, are as follows.

Continuity of care - In the area of ensuring that habilitation and treatment is consistent across programs and after transfer to a new residence, OIG recommended that the facility/agency:

  • Ensure all staff are familiar with each individual's service/treatment/habilitation plan;
  • Ensure dietary orders and food allergies are listed in the medical record and posted in the kitchen or designated place;
  • Conduct monthly comparisons of physician orders and medication administration records to ensure correct medication doses;
  • Ensure follow-up with pre- and post-hospitalizations with appropriate documentation;
  • Develop early discharge planning with hospitalizations; and
  • Mandate timely adherence for medical management in community agencies.

Direct care staff training - In the area of ensuring that staff are adequately trained to provide required habilitation and treatment, OIG recommended that the facility/agency:

  • Conduct basic training on monitoring vital signs, observations, injuries, falls and seizures;
  • Mandate and monitor annual training for progress notes documentation and medication administration, especially in community settings per Rule 116;
  • Ensure documentation, such as the Medication Administration Record, is legible and is done according to CILA Rule 115 standards; and
  • Ensure that the direct care staff accurately record seizure activity and notify the nursing staff in a timely manner.

Nursing practices - In the area of proper nursing practices and clinical management, OIG recommended that the facility/agency:

  • Mandate that only registered nurses (RN) perform initial and annual nursing assessments;
  • Ensure that licensed practical nurses (LPN) do not perform RN duties and mandate that an RN review LPNs' documentation monthly;
  • Ensure nursing assessments have current diagnoses, medications, and all food and medication allergies;
  • Ensure medical management coordination and Medication Administration Records are reviewed monthly by an RN;
  • Develop a written procedure on monitoring quality assurance of medication administration;
  • Review the medication administration policy and provide staff with instructions on how to report medication errors;
  • Mandate nursing staff document hospitalizations and follow-up clinic appointments;
  • Ensure that telephone calls/messages on medications and medical issues are documented by nursing staff; and
  • Conduct annual training for part-time and contractual nurses.

Medical emergencies - In the area of preparing for and responding to medical emergencies, OIG recommended that the facility/agency:

  • Mandate and monitor annual retraining for cardiopulmonary resuscitation (CPR);
  • Conduct annual medical emergency drills;
  • Review documentation of drills and of actual medical emergencies to address areas for improvement;
  • Mandate posting of the CILA's address for availability when calling 911 on medical emergencies;
  • Develop policies and procedures for monitoring emergency medical equipment; and
  • Conduct annual maintenance checks on emergency medical equipment, and ensure replacements and repairs are done timely.

OIG's clinical coordinators provide consultation and expert opinions regarding medical care, treatment, and habilitation issues in OIG's investigations and make recommendations as warranted to identify and prevent abuse and neglect of individuals with disabilities.

D. Written Responses

The requirement for a written response is unchanged. Whenever OIG substantiates abuse/neglect or makes a recommendation regarding other administrative issues during an investigation, the facility or agency is required to provide a response in writing. This "Written Response" must indicate the actions that will be taken or is planning to be taken to protect the individual from future occurrences of abuse/neglect and eliminate the problem(s) identified during the investigation.

OIG will recommend that the facility or agency take action to address identified issues, but it is the responsibility of the facility or agency to develop detailed actions to address those issues and the responsibility of the DHS program division to review and approve those actions. The facility or agency has 30 calendar days from the date the investigative report is received to submit a Written Response to the appropriate program division in DHS. The program division then reviews and approves the Written Response listing the proposed actions, sending the approved Written Response to OIG.

FY2010 improvement

An entirely new section of Rule 50 (Section 50.80) describes the process of requiring, submitting, approving, and reviewing Written Responses, as well as the requirements for OIG's Compliance Reviews, which are described below. Section 50.80 specifically requires that the Written Response the facility or agency initially submits be signed by the authorized representative.

FY2010 issues

In a reversal of a recent trend, OIG made findings/recommendations in fewer cases than last year, so fewer Written Responses were due. During FY2009, OIG had required Written Responses in 843 cases, up eight percent from FY2008's 722 cases. During FY2010, OIG required Written Responses in 739 cases, down twelve percent from FY2009, although still higher than FY2008. The decrease was nearly identical across settings, except for mental health agencies, which had 34% fewer than the previous year.

Those Written Responses also identified fewer issues. A total of 1,180 issues were cited during FY2010. Table 12 below compares the number of issues cited across the past four fiscal years. Although lower than during FY2009, OIG cited more issues during FY2010 than any prior year.

Table 12: Issues Cited in Approved Written Responses Received, FY2007 through FY2010

WR Issues FY2007 FY2008 FY2009 FY2010
Count Percent Count Percent Count Percent Count Percent
Substantiations 187 23.5 244 24.7 329 21.7 282 24.0
Late reporting  68  8.5 175 17.7 305 20.0 190 16.0
Nursing practices  47  5.9  28  2.8 200 13.1 189 16.0
Investigative error  35  4.4  78  7.9 127  8.4  62  5.0
Service plan  49  6.2  47  4.8 115  7.6  74  6.0
Inappr. Interaction  57  7.2  63  6.4  99  6.5  92  8.0
Failure to report 196 24.6  98 10.0  98  6.5  69  6.0
Monitoring/staffing  29  3.6  49  5.0  68  4.5  48  4.0
All other issues 128 16.1 204 20.7 177 11.7 174 15.0
Total issues 796 100 986 100 1518 100 1180 100

This table shows that the drop in issues cited was less in substantiations than in other issues. During FY2010, substantiations still accounted for 24% of the issues cited.

Late reporting was cited 190 times, and failure to report 69 times. These are both lower than last year, reflecting that the timeliness of initial reporting has been improving.

Nursing practices were cited as issues 189 times, habilitation or treatment plan concerns were cited 74 times, and monitoring or staffing problems were cited 48 times. These issues include failures in clinical documentation and inadequate nursing or staffing practices.

Investigative errors after an allegation is made, such as failure to obtain a medical examination or take a photograph of an injury site, are decreasing. OIG attributes the decrease to its mandated biennial investigative training required of facility and agency investigators.

FY2010 timeliness

Despite fewer Written Responses with fewer issues, more of the approved Written Responses that OIG received during FY2010 were late. The statute expects the agencies and facilities to submit Written Responses to the program division within 30 days of the case completion date. OIG then gives the division another 30 days to review and approve the Written Response.

For several years, over half of all approved Written Responses had been later than those 60 days. Then, 69% of approved Written Responses received during FY2009 were timely. During FY2010, this fell slightly to 66% on time. The Division of Developmental Disabilities did significantly worse in FY2010 - approved agency Written Responses dropped from 71% to 67% timely, approved facility Written Responses dropped from 51% to 38% timely. Conversely, the Division of Mental Health did significantly better in FY2010 - approved agency Written Responses increased from 76% to 89% timely, approved facility Written Responses increased from 63% to 90% timely.

Across all four settings, the timeliness of DHS program division review is better than two years ago. During FY2008, only 41% of all approved Written Responses were received within 60 days from the date that OIG completed the case report.

OIG continues to send the divisions a monthly listing of Written Responses that have not been received as approved. This listing has been helpful in identifying and resolving problems.

FY2010 actions taken

OIG may identify multiple issues in a single case, and each issue may require multiple actions. So, more actions are taken than issues are cited, and more issues are cited than cases with findings or recommendations. During FY2010, the facilities and agencies took 1,541 actions to address the 1,180 issues identified in the 739 cases closed and requiring a Written Response. This is in contrast to FY2009, when facilities and agencies took 1,995 actions to address the 1,518 issues identified in the 843 cases closed and requiring a Written Response.

OIG categorizes the actions taken into 22 types. The most common action taken continues to be retraining of the involved employee or employees (365); related to this is general retraining, which may involve a single unit, a job function, a range of job titles, or the entire staff of the facility or agency (total of 199).

Following training is disciplinary action against employees: discharge (208); suspension (71), written reprimand (114); and oral reprimand (16). Ten employees had been fired for other reasons, 37 were reassigned, and 57 resigned in lieu of disciplinary action. Counseling (86), increased supervision (24), and performance evaluation objectives (3) were other actions taken against employees.

Policy or procedural revisions were made 177 times, modifications were made to habilitation or treatment plans 61 times, administrative changes were made 39 times, and repairs/upgrades to buildings and other structures were the primary action thirteen times.

FY2010 implementation status reports

As noted, OIG investigations continue to cite administrative issues, resulting in significant actions by the facilities and agencies to prevent recurrence and to eliminate problems. While the DHS program divisions are required to review and approve those actions, the statute gives OIG the responsibility to ensure that those actions are implemented. OIG does this two ways.

One way is that the agency or facility must list on the Written Response the date that all actions were implemented. If all actions were not implemented by the time the Written Response was approved, the agency or facility must send an implementation status report to OIG every 60 days until every listed action is implemented.

FY2010 Compliance Reviews

The other way that OIG ensures that the actions are implemented are through getting actual documentation proving the implementation. These "Compliance Reviews" are discussed in a new section of Rule 50 dedicated to Written Responses (50.80). OIG conducts Compliance Reviews on two types of Written Responses. First, each month, OIG selects a random sample of all approved Written Responses received during the prior month - Rule 50 requires a minimum of 10%; OIG chooses 20%. Second, each month, OIG adds to that sample every approved Written Response that has been approved for longer than 120 days, but the actions listed on it have not yet been implemented.

For FY2010 Compliance Reviews, OIG randomly selected 153 (20%) of the 766 required Written Responses approved from May 1, 2009 through April 30, 2010, and then added the remaining 26 unselected Written Responses that were over 120 days. Table 13 below shows the break-out of all 179 Compliance Reviews by disability type and location.

Table 13: FY2010 Compliance Reviews on Approved Written Responses

Location DD Programs MH Programs Totals
DHS facilities  20 23  43
Community agencies 129  7 136
Totals 149 30 179


OIG's Compliance Reviews seek documentation that the actions listed in the approved Written Response were actually taken. For example, in the cases of retraining for late reporting, the Compliance Reviewers first obtain training sign-in sheets or some other document proving completion of the training and, then, interview the employee to ensure that he or she knows the definitions of abuse and neglect and knows the process and time frames for reporting allegations. The Compliance Reviewers may also review the curriculum for the training and recommend using the OIG Rule 50 training module that was distributed in April 2010.

During FY2010, OIG did not have to send any "out of compliance" letters - that is, OIG obtained from the facilities and community agencies documentation of all actions listed on approved Written Responses selected for Compliance Reviews. However, receiving some of these required additional work. It took up to six months to get documented actions taken by three community agencies and two facilities. For example, one agency and one facility each took four months to get retraining of an employee who was on leave. Another agency delayed three months in sending a revised policy, while another facility took six months to write a required policy.

OIG's randomly selected compliance reviews help ensure that inappropriate practices identified during the investigation are no longer in effect. After six years of compliance reviews, facilities and agencies are aware they may be randomly selected to produce documentation of the corrective action indicated on the Written Response.

Ensuring that corrective action has been taken helps the facility and agency to effectively address the underlying issues and allows the individuals to avoid suffering a recurrence of the abuse/neglect. It also brings OIG full-circle in preventing abuse/neglect.

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