Audience

Public is welcome to attend.

Date/Time

October 30, 2012 at 1:00 PM 

Location

Division of Rehabilitation Services Office
207 South Prospect
Bloomington, IL

Agenda

  1. Introduction of Quality Care Board members/Office of Inspector General staff
  2. Rule 50 discussion - Deputy Inspector General Robert Furniss
  3. Rule 51 discussion - Acting Inspector General Daniel Dyslin
  4. By-Laws of the Quality Care Board
  5. Ethics Training
  6. Setting meeting dates for 2013 - January, April, July and October
  7. Miscellaneous Issues

Minutes

Present: Susan Keegan, Chairperson; Untress Quinn;Ginny Conlee;Cathy Contarino;Ed Baker; Thane Dykstra; Dan Dyslin; Robert Furniss; and Chris Milbrandt, Bill Diggins, Bureau Chief, (Rule SO) Central Investigations was present during the meeting

Introductions

By the Quality Care Board members and Office of Inspector Generi:JI staff

Rule 50 discussion

Rule 5O focuses on state-operated facilities and facilities that are licensed, funded, or certified by DHS to provide Mental Health (MH) and Developmental Disability (DD) services. Rule 5O has been around since 1985. In 1987, various agencies were combined into DHS and we were the last major development. In 2001,our Domestic Abuse Program (DAP) was created. The bills were passed, the program was created, and existing OIG investigative staff was transferred into the DAP bureau to investigate allegations of abuse, neglect, and financial exploitation. The cases are generated by calls to our hotline. Our hotline investigators evaluate the information they are given. They ask questions to determine if the matter is reportable to OIG under Rule 5O. Most of the calls they receive are from staff or other people involved in the mental health industry because they are required reporters. They have an obligation to report abuse or neglect to OIG within four hours.

If the Hotline takes a case, it refers the matter to the appropriate geographical Rule 50 bureau. of which there are four: Northern, Southern, Central, and Metro. In addition to having cases assigned to OIG, there are situations in which the OIG will assign cases to certified agency investigators who have to go through our training and subscribe to our investigative protocol. However,they cannot investigate and reach a finding in cases of physical and sexual abuse or egregious neglect, though they can assist OIG with those matters During the last fiscal year, we accepted more than 2,300 Rule 5O cases, in addition to approximately 1,200 Rule 51 cases.

We have 19 Rule 50 investigators, including investigative team leaders.  Each of the four bureaus is headed by a bureau chief, and the Northern and Metro bureaus have Investigative Team Leaders (ITLs). The ITL assigns and monitors cases, and also carries a caseload. We also have clinical coordinators who are registered nurses on staff. Two of them are OIG employees, with the others employed under contracts. One of them is primarily involved in site visits through our Bureau of Compliance and Evaluation (BCE). The other three consult and provide their medical expertise when such issues arise during an investigation.

The cases have three sets of findings: Unfounded: No credible evidence that something happened;Unsubstantiated- there is not a preponderance of evidence that supports that finding;Substantiated- there is a preponderance, basically 51%, of evidence. In other words, it is more likely than not that something occurred.

Definitions of various allegations were changed a couple of years ago to provide greater protection to individuals. Brief definitions of the allegations follow:

  1. Mental Abuse-threatening, demeaning or insulting words r actions by staff directed toward or about an individual.
  2. Financial Exploitation-Unauthorized use or conversion of individuals' money or property by staff. We do not have a set dollar amount for financial exploitation because we recognize that individuals may place great value on property that does not cost a lot of money. When talking about referring cases to agencies for investigation,the agencies are doing quite a lot of these because the monetary value of the property is too low for a criminal investigation and it is a management/employee issue. On the other hand, we have had complicated cases regarding transfers of thousands of dollars, mishandling of client accounts, and ATM withdrawals over one or two years.
  3. Neglect -a deterioration of an individual condition that is a direct result of a staff member's action or omission. The definition includes acts or omissions that expose an individual to significant risks to their health or safety. For example, we would substantiate an allegation of neglect against staff who allowed an individual to elope and run onto a highway, even if no harm came to that person.
  4. Egregious Neglect-a significant deterioration in condition, often involving medical intervention or death. The definition also includes callous disregard, leading to an individual's serious deterioration.
  5. Physical Abuse-nonaccidental physical contact with individuals that causes harm or is of an insulting or provocative nature. This is quite a low threshold, and can include a shove, slap on the hand and even self-defense. In some cases, we believe that some of those who technically meet the definition of physical abuse should not go onto the Registry because their actions were in self-defense or a provoked,reflexive response rather than an attempt to injure someone. For example, we had to substantiate a case in which a bus driver slapped down the hands of an individual who grabbed her breast. In such obvious cases when the employee appeals,OIG might stipulate,indicating that we do not believe the person should go on the Registry and be barred from employment. The administrative law judge (AU) would review and grant the stipulation if deemed appropriate. The threshold may be low, but OIG must seek to provide maximum protection for these vulnerable individuals.  We are out to protect the individuals. It is the AU's job to determine if someone's conduct warrants placement on the registry.
  6. Sexual Abuse-Engaging in sexual contact with an individual,soliciting or exploiting an individual for sex or inciting individuals to engage in sexual activity. Up until six years ago when OIG urged passage of a law protecting individuals, there were no statutes on the books making it a crime for a staff person to have sex with an individual. We have expanded the definition of sexual abuse to include solicitation of a sexual act and exploitation to include staff who have taken videos or pictures of individuals of a sexual nature or incited them to engage in sexual activity.

These last three categories involve more serious allegations. A substantiated finding in these cases will cause referral of a staff person's name to the Health Care Worker Registry, maintained by the Department of Public Health. There is an appeal process before the accused are placed on the registry. Once people are on the registry for a period of time they can file an appeal to have their names removed.

  1. Question: Does that keep them from being employed?

    Response: Yes, it should. State-operated facilities and CILA providers should check the registry before hiring staff, but we seen paid caregivers hired into domestic settings who were on the registry. The Registry is on the IDPH website, and anyone can check it to see if a potential caregiver's name is on it.

    Findings- Even when we do not substantiate a case, we can make recommendations to address issues uncovered during an investigation. We can recommend that the facility or agency address inappropriate staff conduct in some way. In an elopement case, we may find that the alarm system is inoperable or has been disarmed by staff, and will recommend repair.

    Written Responses -An agency or facility has to file a written response to OIG's recommendation within 30 days that contains a plan to address the problem identified. OIG's Bureau of Compliance and Evaluation (BCE) does unannounced site visits at all state-operated facilities.  Part of their review assesses how well facilities have carried out the written responses. The divisions take quite an active role of keeping in touch with the agencies and facilities to ensure timely filing of written responses and assess follow up measures.

    Involvement of Law Enforcement -If,in the course of our investigation, we uncover credible evidence that a crime has been committed, we have to refer the matter to law enforcement within 24 hours. We have, in some cases, had situations in which individuals have been killed. When our Hotline receives credible evidence during an initial call,the staff will call law enforcement immediately. In most of these cases,the facility or agency has already involved the authorities. The Illinois State Police investigate crimes at the state-operated facilities, and local law enforcement entities would handle other criminal matters either uncovered by, or reported to,OIG. Sometimes there is interplay between these polices agencies.

    Reconsideration Process- Can be initiated by a facility, agency, employee, or guardian of a person. If one of these parties takes issue with the outcome of an investigation, they can request reconsideration. They have to supply new information that was not provided during the initial investigation. We have an obligation to respond to these requests within a designated amount of time.

    House Resolution 201- Contains statistics on agencies. These statistics are listed on the DD website.

    In the course of our work, bureau chiefs or even an investigator will find themselves going to the same facility frequently or will have a number of similar events occur at the same place, (many incidents of bowel obstruction, for example). When OIG has concerns about a particular agency or troublesome trends, our staff will meet with BALC and BQM to discuss these issues. These meetings have led to meetings with providers. We are trying to keep track of these trends.

    Non-reportables- Some of them are obviously non-reportable,such as an individual complaining that he did not get his cigarettes. The hotline will make a referral to the proper entity. These intakes end up as a report. They are also sent out to the bureaus on the off-chance the bureau chief may know this agency and detect a pattern that may merit an investigation. This is another check to ensure that OIG is looking into all matters that may concern us.

  2. Question: What is not covered? Is there anything that is not licensed by another state agency? What is excluded?

    Response: We do not investigate matters involving DCFS, private hospitals, nursing homes, the elderly, assisted living facilities, or skilled nursing facilities. We have several agencies with niche services. The Governor's Office has recognized that there are several agencies dealing with protective services and is considering ways to consolidate them to provide a better service network.

    Interplay with other agencies- Periodically IDPH will be involved in some of our investigations of a programmatic nature. They have a mandate to investigate complaints within five days, and OIG will stand down until they have completed their work. BALC and BQM receive our intakes and may contact us if the intakes relate programmatic problems, such as no heat or food at an agency. We coordinate efforts with these entities when appropriate.

    A Community Integrated Living Arrangement (CILA) is a home containing up to eight beds that falls under DHS jurisdiction. Day training sites are also covered. An Intermediate Care Facility has over eight beds and falls under IDPH jurisdiction. Originally Rule SO's focus was on state-operated facilities. Now, any community provider of mental health and developmental disabilities services that is licensed,funded, or certified by Department of Human Services falls within our purview.

  3. Question: Thresholds has some community houses. Are those covered by DHS?

    Response: If it is a CILA with eight beds or under, most likely yes.

  4. Question: Do you get referrals from other state organizations that say that a matter is yours because it is eight beds?

    Response: Yes, from IDPH, DCFS, Office of the Executive Inspector General. We have seen,over the past seven to eight years, an increase of 7- 10% in matters called into our Hotline. Also, the Department put our hotline number on the website, so we are experiencing an even greater increase of up to 30% this year. For example,Central Bureau averages about SO cases a month but handled 92 cases in October.

  5. Question: Does this include individuals living in their own place?

    Response: No. People living in a private home falls under Rule 51.

    Acting Inspector General (AIG) Dyslin wanted to clarify with regard to the reports. Deputy Inspector General (DIG) Furniss talked about findings within a report, which would be substantiated, unsubstantiated, unfounded, and then about the report containing recommendations. Recommendations can be made for a facility, whether it is state-operated, a CILA,or a provider regardless of the finding.

  6. Question: You can have a recommendation that is stand alone?

    Response: Right. You have an individual with no injuries. Witnesses said nothing happened. Another example is an elopement case where we found that the alarm on the door wasn't working. Nobody did anything wrong here, but the systems are not working. OIG does not get involved in too many programmatic issues. Generally if we have a substantiated finding, there is going to be a recommendation.

    OIG does not recommend disciplinary action, nor do we have any involvement with the disciplinary process or decisions to place employees on administrative leave. In response to a Department of Justice finding, the Department of Developmental Disabilities places all employees who are the alleged accused in OIG cases on leave or reassignment. This policy can cause problems for providers because a disgruntled individual can put off an entire shift of staff by calling in unfounded complaints against them. In such situations, and also when a particular client might call in ten to 12 times in a day, OIG will work with the facility to preliminarily assess the situation to put off as few staff as possible. We might also suggest telephone restrictions for such "frequent fliers."

  7. Question: The 2,300 Rule 50 cases, are they active cases?

    Response: 2,300 cases were opened. Is it likely some didn't go anywhere? Probably.

    Our substantiation rate varies between 10 -13%, about 900 cases per year. We have approximately 800 pending Rule 50 investigations right now and 200 open Rule 51investigations assigned to the five statewide investigators.

    Agency Investigators- A small percentage of the agencies, 140 or about 15-20%, sign onto our investigative protocol to perform investigative tasks on OIG cases. Supervisory staff in the bureaus, either a bureau chief or an Investigative Team Leader (ITL), will assign cases to agency investigators and monitor the investigation. In some cases, an OIG investigator may act as a "buddy investigator" to assist. The Metro and Northern Bureaus feel they have to use agency investigators whenever they can due to the size of their caseloads, but the other bureaus call on agencies less frequently. Sometimes, an agency investigation may take longer because the investigator has other assigned duties at the agency.

    OIG must complete Rule 5O cases within 60 working days, but given a burgeoning caseload,this is not always possible. Recently, OIG's average completion rate fell to 41%, but we have always felt that was the best possible mark. We have seen a steady climb since then as the caseload has increased, but we are still under 60 days. There are a lot of other pressures, too. Providers have staff on administrative leave that they want back at work. OIG saw a 15% increase in cases, and we anticipate the increase may reach 30%. At this point,the caseload averages 50 cases per investigator, with Metro investigators carrying 60-70 cases on average. Breaking this figure down by the time in an average work week, investigators have about ten minutes to devote to each case per day.

    Rule 51 discussion- Please see the memorandum dated October 30, 2012 from Daniel Dyslin to Members of the Quality Care Board that was distributed at the meeting.

    The Domestic Adults Protection program (DAP), created by Rule 51, is OIG's fifth bureau. Rule 51 differs from Rule 50 because the accused is a family member, neighbor, volunteer, or a stranger, rather than an employee of a DHS funded entity. Unlike Rule So, DAP investigates cases involving developmentally disabled or mentally adults between the ages of 18-59 years of age living in a private home. Cases involving people over that age limit fall under the Department on Aging, and those younger would be referred to DCFS.

  8. Question: What happens if they think there is something going on, but the alleged victim is too afraid to cooperate?

    Response: It is a challenge OIG faces almost daily. The Rule 51 staff are really performing assessments to determine if someone needs or wants services rather than investigating wrongdoing, which is the focus of Rule 5O. Because those involved are private citizens, they can refuse to participate in an assessment or receive any help. OIG terms such matters as "refused consents," which, outside of referrals we may make in some cases, ends our involvement. Also, OIG does not have the resources to circle back and check on every case that is called into the Hotline.

    We have five investigators for the entire state, including one investigator for the entire Southern Bureau, which extends from south of Springfield to the southern tip of the state. The investigators drive their own vehicles, wait for six months for travel reimbursement, and work in often unsanitary and dangerous environments, and are still expected to provide service to those involved in the 1300 cases they take annually.

    Recent articles in the Belleville News-Democrat led to an Executive Order requiring OIG to refer cases to law enforcement and the coroner when the subject dies before an assessment can be completed. These matters usually involve someone who dies within a few days,or even a few hours, of the Hotline call. Previously, OIG termed these cases as "ineligible" because the deceased could no longer benefit from any services the state could provide. As a practical matter,OIG can do nothing in these matters, but the articles pounced on the "ineligible" term and accused OIG of doing nothing to help a dying person. Many of those who criticized OIG on this basis mistakenly attributed police powers to us, and have suggested that we have the power to remove individuals from their homes on our own authority. Ironically, in nearly every case identified in the article, the coroner's offices and law enforcement were involved, and a lack of documentation allowed the newspaper's charge that OIG did nothing to stand. However, OIG has followed up on every one of the cases to ensure referrals were made.

    However, most of the cases of Rule 50 neglect involve family members who are simply not up to the difficult task of caring for a disabled person. This can be true even if the victims have suffered serious deterioration in their conditions. We dispute the critics' notion that such matters involve criminal conduct, which begs the question of whether referrals to law enforcement are appropriate or would do any good. In any case,OIG will certainly be referring more of these matters. Proposed legislation would require OIG to inform law enforcement on every call to the Hotline, which seems completely excessive and unworkable. We believe that law enforcement agencies, which deflect our referrals in many cases, would strongly object to this misguided proposal.

    On a related issue,under Rule 51, a substantiated finding will not lead to referral to the Health Care Workers Registry, a sanction available under RULE 50 when OIG substantiates physical and sexual abuse or egregious neglect against a staff person. Some have called for HCWR placement for the private citizens we deal with under Rule 51. While we concede that it might be appropriate to refer caregivers paid with state funds in some cases, we would consider placement of a relative overwhelmed by the task of caring for a loved one an injustice.
  9. Question: lf the investigator under Rule 51 suspected something, could they call law enforcement to investigate at that time?

    Response: Yes, even in refused consent cases, OIG can refer matters to law enforcement, or other appropriate agencies such the fire department of building inspector. However, we believe that investigators have, on occasion, taken a refused consent too literally, so we have encouraged them to be more proactive in making referrals even in refused consent cases.

    As DHS closes facilities, more individuals will transition to community agencies and private living arrangements. We believe that this will shift and increase the caseloads. Trinity and The Hope Institute are in the business of doing emergency crisis intervention. To be eligible for the crisis teams, a person must be funded by a Medicaid waiver, which would fall under Rule 50.

  10. Question: In order to substantiate a Rule 51 case, do you know what standard we are using?

    Response: We are using "reason to believe" to substantiate, which is essentially a probable cause standard. This means that, in Rule 51 cases, we would refer a substantiated case to law enforcement while in Rule 50, we would have to find credible evidence before making a referral.

    The articles also asserted that coroners' offices claimed they had never heard from OIG. One of our investigators had attended two autopsies at the office of one of the coroners mentioned. In most cases, we would not even deal with the chief medical examiner, but a member of their staff. We suspect that, in the face of this reporter's badgering,the coroners found it expedient to deflect blame on OIG. Once again, lack of documentation allowed this inference to be made.

    The Hotline investigators face a difficult task. They often are provided with very little information and may not even know the identity of the caller. After hours, an answering service takes the calls, so there may be even less information on the intake. Although all of the hotline intake staff are Internal Security Investigators, few if any of them have had experience in this kind of work, so they must learn on the job.

    The Hotline intake staff must determine, among other things: (1) Is it in a state­ operated facility? (2) If it isn't in a state-op, do they provide DD or MH services? (3) Are the services licensed, funded, or certified by DHS? (4) What are the allegations? (5) Do they constitute abuse, neglect or financial exploitation? (6) Is it a community case in a domestic environment? (7) If it is a domestic case, is the person 18- 59 years of age living in a domestic environment? (8) To complicate things, does the person have a disability that prevents him/her from seeking help on their own?

    On the domestic side, the investigators will visit any home that is involved in a case accepted for an assessment. Even in refused consent cases, there must be a face-to-face visit. For some of these people,this program might be the only chance they will have to get out of the situation they are in or receive the services they need. We receive calls from neighbors and, more frequently, calls from required reporters. We have even received calls from store employees who observe what they feel is abuse toward disabled people.

  11. Question: What do we do with the people that live alone and don't want anyone coming into their home? They live in terrible conditions and may have disability or mental health issues, but are their own guardians.

    Response: If we have a suspicion,it is not unusual for us to call and request a well-being check. We have included,in certain situations, building inspectors, the fire department and law enforcement. In many cases, the police have already been involved, and we may have them accompany us in situation that may involve some danger.

    Activity of the Board in the past- This is going to be a busy year because we are being faced with potentially sweeping changes. In the past,the Board has provided critical support and input when we have gone though the legislative or rulemaking process. We have also tried to keep the Board updated about any trends and problems we have seen with respect to agencies.

    In the past, we have discussed open cases, which could be problematical as they concern confidential information. There are issues affecting the department that we felt the Board should know about such as potential litigation, closures or licensure issues. Information pertaining to potential litigation is an exception to required disclosure under the Open Meetings Act. The Board may go into closed session to discuss confidential information, such as open cases. If the Board chose to do so, you could motion to close the meeting. It is a quality control function. We will review the Open Meetings Act to ascertain what information or discussions could be addressed in closed sessions.

  12. Question: Couldn't you excise or redact the information?

    Response: Yes but some information, such as the identities or location of the people involved can still be ascertained.

    We have tried to have presentations by various members of our staff about some of the things we are doing. We have had presentations on site visits, the process of seeking guardianship and other matters we considered to be of interest to the Board. We would welcome any topics the members suggest.

    One word of caution on the licensure function. OIG has no licensure authority and cannot suspend or cancel licenses of programs or agencies, which is within BALe's purview. We can recommend sanctions against facilities and agencies to the Secretary, who would have the authority to impose them.

    By-Laws of the Quality Care Board: Chairperson Keegan thinks that the Board needs to look at the duties and members should be mindful of them. The Board's responsibilities and mission are significant issues with which we have struggled in the past. Rita Burke, who is no longer with the Board, tried to get clarification of the duties from the Governor's Office and Attorney General's Office without success. The duties and responsibilities need clarification and may require revision.

    The Board needs to see the policies and protocols of abuse and neglect, and the operations and regulations of the facilities for review. The members received the training calendar, and Rules 50 and 51are on line. Perhaps the members could observe various OIG functions to evaluate how staff are doing and offer suggestions for changes. At the January meeting,Chairperson Keegan would like to set up working groups and have the members identify issues related to the Board's functions. Chairperson Keegan is going to talk to the Governor's Office letting them know that this is a huge mandate for a small Board. We noted that, given the DHS legislative Committee's assumption that the Board was charged with expansive oversight powers,the Governor's office should be advised that this was not the case and a volunteer board of this size would have severe practical limitations in assuming such responsibilities. We reminded the Board that OIG staff are their guests, and the Board could decide to go into executive session or exclude them entirely from meeting.

    Board members requested certain information and documents. We suggested that the documents are voluminous, such as directives and facility and agency policies. As a starting point, we will provide the members with the table of contents for the directives. Obviously, OIG staff would provide the members with any specific documents they request.

Ethics Training

All of the Quality Care Board members turned in their Acknowledgement forms.

Meeting dates for 2013

Requesting conference room at DRS office, 207 South Prospect, Bloomington, Illinois

  • January 24th at 1:00 p.m.
  • April 30th at 1:00 p.m.
  • August 29th and 3:00p.m.
  • November 14th at 1:00 p.m.

Miscellaneous Issues

  • Motion to adjourn the meeting Acting IG Dyslin; seconded Cathy Contarino.
  • Meeting adjourned at 3:00 p.m.