Facility Investigative Protocol

Department of Human Services - Office of the Inspector General

Pat Quinn, Governor
Michelle R.B. Saddler, Secretary
William M. Davis, Inspector General

DHS Facility Investigative Protocol for Calendar Year 2012

DATE ISSUED: 12/24/07

REVISION DATE: 10/26/10; 11/15/11

CLASSIFICATION LEVEL: UNCLASSIFIED

I. PURPOSE

To establish a uniform policy and describe procedures for DHS-operated facilities to assist, unless directed not to by OIG, in conducting investigations of alleged abuse, alleged neglect, and deaths, as required in statute and administrative regulation.

II. AUTHORITY

III. POLICY

The policies and procedures in Program Directives 02.01.06.010 and 02.01.06.020 are incorporated by reference. The procedures herein are intended to further specify requirements for investigations in the DHS operated facilities providing mental health or developmental disability services.

IV. PROCEDURES

1. Annual Review Process
   1. Annual Application: Each authorized representative must ensure that at least one (1) facility employee is assigned to assist with abuse/neglect investigations. A record of such employee(s) must be submitted to the OIG Protocol Coordinator at the beginning of each calendar year on the prescribed application form.
      1. Since authorization is only for a calendar year, the facility must submit an annual renewal application each calendar year.
      2. The application requires the authorized representative's signature and the facility's adoption of this Investigative Protocol to govern all investigations under Rule 50.
   2. OIG Liaison: Each authorized representative shall designate one employee as the facility's OIG Liaison. The employee may also be an investigator.
      1. This employee must have successfully completed OIG-conducted Rule 50 training within two years of the start of the calendar year for which the facility is seeking authorization.
      2. Once designated, the employee must successfully complete the OIG-conducted Rule 50 training no less frequently than once every two years.
   3. Facility Investigators: Each authorized representative shall designate at least one full-time employee as a facility investigator. 
      1. Investigator Training
         1. Each designated investigator must have successfully completed either of the two options below within two years of the start of the calendar year for which the facility is seeking authorization:
            1. Both the OIG-conducted Rule 50 training and Basic Investigative Skills (BIS); or
            2. OIG-conducted Investigative Skills Refresher (if the prerequisites of Rule 50 and Basic Investigative Skills have been met).
         2. Approval for training: Registration for OIG Rule 50 training requires no approval; however, registration for Basic  Investigative Skills training requires prior approval by the OIG Protocol Coordinator.
            1. The potential registrant must be in a position that does not create any appearance of a conflict of interest. To determine this, the following information is required for each registrant:
               1. Full name and date of birth (for identification)
               2. Job title and detailed description of job duties
               3. Areas of supervision, if any;
               4. Name and job title of immediate supervisor; and
               5. Name of facility.
            2. The potential registrant must be an employee who is or will be designated as a facility investigator or the OIG Liaison.
            3. OIG's approval for attending BIS training is on a case-by-case basis, and OIG has sole discretion over who may register for BIS training. OIG may allow authorized representatives to attend as space allows, for the purpose of learning the investigative responsibilities expected of designated facility investigators.
      2. Maintaining eligibility for investigative authorization
         1. To maintain eligibility for investigative authorization, an investigator must attend either of the training options below within two years of the start of the calendar year for which the facility is seeking authorization:
            1. OIG-conducted Rule 50 and Basic Investigative Skills; or
            2. OIG's Investigative Skills Refresher.
         2. If the investigator fails to maintain the two year training requirement, OIG Rule 50 and Basic Investigative Skills training must be taken prior to reapplying for authorization.
      3. Investigative authorization
         1. The authorized representative must submit the name of each employee designated to be an investigator.
         2. Each employee's job title, responsibilities, training dates, and name and title of his/her supervisor must be listed.
         3. The original application form must be signed by the authorized representative and mailed to: OIG Protocol Coordinator, Elgin Mental Health Center, 750 S. State Street, Elgin, IL  60123
         4. Once the application is received, OIG either approves or denies authorization for each proposed investigator.
            1. If approved, investigative authorization is for that calendar year.
            2. No investigative function shall be performed on abuse/neglect cases by anyone who is not an OIG-authorized investigator.
         5. Prohibited persons: Due to potential conflicts of interest, the following persons are prohibited from being approved as facility investigators for the purpose of assisting in investigations of alleged abuse/neglect or death;
            1. The authorized representative, assistant facility director, assistant hospital administrator, personnel, labor relations staff, or any family member of these; and
            2. Any person who has a substantiated finding of abuse or neglect against him/her.
            3. Any other person who OIG determines has potential conflict of interest.
         6. OIG makes the final decision regarding qualifications and authorizations of investigators. Employees who are trained after the facility receives approval must apply separately.
         7. If an authorized investigator's job title and/or duties change, the OIG protocol Coordinator must be notified.  It is the facility's responsibility to ensure that there is no appearance of a conflict of interest.
         8. OIG reserves the right to revoke the authorization of an investigator at any time.
2. Incident Management
   1. Immediate actions: The authorized representative or designee shall ensure the immediate care and protection of the victim and other individuals and shall ensure immediate reporting as appropriate.
      1. Request emergency response when necessary.
         1. When a medical emergency exists, immediately contact 911 for assistance;
         2. When law enforcement assistance is needed, immediately contact the law enforcement agency which would provide the most immediate response; and
         3. In the event of any allegation of abuse or neglect or any situation where a victim's health is in question, the facility shall immediately seek appropriate professional medical attention.
      2. Ensure that OIG is notified (Hotline number is 800-368-1463) as required. OIG is the primary DHS liaison to the Illinois State Police (ISP) and will report to ISP when there is credible evidence of a potential criminal act.  However, the facility shall report to ISP when requested by OIG.
      3. The authorized representative shall also remove alleged accused employee(s) from having contact with all individuals at the facility when there is credible evidence supporting the allegation of abuse pending the outcome of any further investigation, prosecution or disciplinary action against the employee.
   2. Initial response: Unless otherwise directed by OIG, the authorized representative shall ensure that these preliminary steps of the investigation are initiated by an authorized facility investigator.
      1. Secure the scene of the incident, when applicable.  This involves cordoning off the area, preventing access to the area, and preventing the removal of objects from the area where the incident occurred.
         1. The facility investigator shall secure the scene whenever there is the probability of phycial  or visual evidence which may assist in the investigation.
         2. When the scene needs to be secured, nothing in the scene will be altered until directed to do so by the investigator responsible for the scene (i.e., floors shall not be washed, furniture and other objects shall not be touched or moved, etc.).
         3. The facility will consult OIG in the event there are any questions about this activity.
      2. Securing all relevant physical evidence.  After securing the scene, unless the facility is directed otherwise by law enforcement or OIG, the facility investigator shall do the following:
         1. Prior to the collection of evidence, the evidence in question will be photographed and/or diagramed.
         2. Collect all relevant evidence and place it in an appropriate container.
            1. An appropriate container is a paper bag, an envelope, or a cardboard box.
            2. Be sensitive to evidence contamination.  Bare hands contaminate.  Use gloves and/or tongs to pick up evidence.
            3. Secure the paper bag, envelope, or cardboard box with tape and/or staples.
            4. Complete the evidence log, and maintain the "chain of custody."
         3. When the allegation is a question of sexual abuse, involving the possible exchange of bodily fluids, the facility investigator shall contact the appropriate law enforcement agency or OIG prior to the collection of any such evidence and then, unless directed otherwise, shall:
            1. Strongly encourage the victim not to shower or bathe, as this might destroy evidence which could be obtained during a medical examination;
            2. Collect the clothing of the victim and place each item in a separate paper bag;
            3. If the sexual abuse occurred on a bed or other like item, then roll the sheets together and placed them in an appropriate container (e.g. large paper bag or cardboard box).
      3. When applicable, identify and seperate accused staff and any potential witnesses until an initial written statement is provided or an interview can be done.
      4. Copy and impound relevant documents, as appropriate.
         1. Original documents shall be impounded in cases such as suicides, deaths with questionable circumstances, and in any other cases which the actual original documents themselves may be evidence in the investigation.
         2. Otherwise, copying documents is sufficient. If in doubt, the facility investigator shall consult OIG.
      5. Maintain all collected evidence in a secure space. This may be a locked filing cabinet, safe, locker, or room where access is limited. It is important that no one have access to the evidence except the facility investigator.  The chain of custody must be maintained and documented for all evidence collected.
      6. Notify OIG within one working day of the existence of collected evidence. Then transfer custody of all evidence as soon as is possible to the OIG or law enforcement entity responsible for the investigation.
   3. Photographs
      1. Individuals and/or their guardian shall be requested to consent to photographs.
      2. All photographs should be labeled as follows and listed in the photograph log.  Annotate, on a label that is then affixed to the back of each photograph, identifiers including the following:
         1. Name of area/object or victim;
         2. Location of the area/object or injury;
         3. Date and time of the photograph;
         4. Name of the person taking the photograph; and
         5. OIG case number, when known.
         6. Number photographs in series (e.g., 1 of __, 2 of __, etc.)
      3. Injuries: Whenever an allegation of abuse or neglect is received alleging an injury, the facility investigator shall photograph the site of the alleged injury whether or not the injury is visable.
         1. If an individual refuses to alllow a photograph upon an allegation, the facility shall instead obtain a physician's thorough description of the injury documented on an Injury Report.
         2. Always include an identifying photograph showing the injury along with the identity of the injured person in the same photograph; denote that on the photo log.
         3. Consider the individual's privacy in all photographs.  Further, no photograph shall be taken of the genital area or of a female's breast unless absolutely necessary for evidentiary purposes. If necessary, only the injured area shall be photographed and other areas shall be covered. If at all possible, the photographs shall be taken by a person of the same gender as the alleged victim
         4. Photograph the area injury first with an item of standard size (e.g., a ruler, dollar bill, or quarter) and then without that item; denote that on the photo log.
         5. If bruising is present, ensure the photographs are clear and reflect the color and size of the bruising. Also, document in writing the color and size of the bruising. If the photograph is not taken immediately after the alleged incident occurred, denote that on the photo log.
         6. If an alleged injury is not visible immediately, subsequent checks should be made at reasonable time intervals.  If the injury does become visible, photographs should be taken of the now visible injury, being certain to note the date and time of the subsequent photographs.
      4. Areas/objects
         1. Prior to entering an incident scene which needs to be photographed, photograph the overall scene. This can be accomplished by taking a photograph as the investigator enters the incident scene and from several different angles within the incident scene
         2. When possible, photograph objects exactly as found and from different angles, including an overhead perspective if possible. Photograph the object with a ruler or other standard-sized item placed next to the object as a reference to size.
   4. Diagrams
      1. When initially collecting items as evidence, unless the item has already been photographed in its initial location, the facility investigator shall sketch a diagram to show the spatial relationships between the evidence and the other items in the room. This diagram can be placed on a plain sheet of white paper, but it shall include the name of the investigator, time and date drawn and the area it depicts.
      2. When a facility investigator is conducting an interview of a person which concerns the placement of people or items, the facility investigator may collect a diagram from each witness. This will assist in the recall by the interviewee, but will also aid as a comparison of one person's statement of location with others.
3. Investigation: The facility investigator shall conduct initial investigative steps, unless directed not to do so by OIG.
   1. Objectivity and integrity
      1. The facility shall ensure that there is the absence of real or apparent conflict of interest or bias by the investigator.
      2. No person identified in the "prohibited persons" section shall assist in conducting interviews or otherwise be involved in investigations into alleged abuse/neglect or deaths at the facility.
      3. Under no circumstances is an interview to be conducted by a facility employee who is from or supervises the unit or office where the incident occurred or is in the same collective bargaining unit as the person(s) involved.
   2. Interviews for written statements
      1. Statements and interviews
         1. When possible, all witnesses shall be separated until an initial statement can be taken.
         2. In addition to initial written accounts that may be required of staff present at the time of an alleged incident, facility staff who are trained and authorized by OIG as facility investigators shall conduct interviews for the purpose of obtaining detailed written statements.
         3. Any person having knowledge about the allegation or the incident shall be interviewed.
      2. Conducting an interview
         1. Ideally, an interview and written statement should be obtained immediately upon the report of an allegation, but no later than two working days from the report. If it is not possible for the facility investigator to immediately interview and obtain a written statement from a staff member, then the facility investigator shall require that staff member write a statement. The investigator can then utilize this statement to interview and secure a more detailed statement from the staff member later.
         2. Interviews shall occur in a location that is quiet, private and free from distractions.
         3. Every interview shall cover the elements of the offense, and the fundamental investigative questions of who, what, when, where, why and how from each interviewee.
      3. Representation during interviews:
         1. If an interviewee is represented by AFSCME Council 31, the facility investigator must advise him/her of his/her right to have a union representative present during the interview.  If the interviewee indicates their choice is to have a representative, then the interview cannot proceed without the presence of the representative.
         2. For any other interviewees, they may choose to request representation at an interview if he or she has reasonable grounds to believe that the interview may be used to support disciplinary action against him or her. If the investigator denies the request, the employee's statement may not be used in any subsequent disciplinary proceeding against that employee.
         3. The authorized representative or designee that employs the interviewee does not have the right to be present at an investigative interview.
         4. No person, including the union representative, has the right to interfere in or obstruct an investigatory interview.
   3. Investigatory Materials: When OIG requests documents related to an investigation, the OIG Liaison or facility investigator shall respond within the time frame designated by OIG, unless there are extenuating circumstances. In such case, OIG will set a new time frame for the documents to be submitted.
   4. OIG Non-Reportable Incidents
      1. Each authorized representative shall ensure that a central file is maintained and secured on all OIG non-reportable incidents. Each OIG non-reportable incident should be fully investigated by the facility. At a minimum, each case file is to contain a copy or copies of:
         1. Full documentation of the incident,
         2. A description of follow-up through committee review(s),
         3. A detailed account of the actions taken,
         4. Measure(s) to be taken to protect the alleged victim(s), and
         5. A statement of the outcomes.