Filed Ligas Court Monitor's First Brief in Response to June 15, 2023 Status Conference

UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION

Stanley Ligas, et al., )

)

Plaintiffs, )

) Case No. 05 C 4331

v. )

) Judge Sharon Johnson Coleman

Theresa Eagleson, et al., )

) Magistrate Judge Jeffrey Cole

Defendants. )

COURT MONITOR'S FIRST BRIEF IN RESPONSE TO JUNE 15, 2023 STATUS CONFERENCE

Court Monitor's First Brief in Response to June 15, 2023 Status Conference

The Court Monitor is herein addressing the Court's interest in the findings of the 2022-2023 Ligas Compliance Measures Review. In 2019, the findings of that review were disappointing in that there were no positive findings in any of the 17 areas reviewed. The current Review shows that there can be significant improvement over this amount of time despite more to be done.

Ligas Compliance Measures 

Paragraph 4 of the Consent Decree states that "Defendants shall implement sufficient measures to ensure the availability of services, supports and other resources of sufficient quality, scope and variety to meet their obligations to such individuals under the Decree and the Implementation Plan consistent with such choices." In addition, the Court's order of June 6, 2018 recommended the development of a monitoring tool, "with an independent review component" to assess adequacy of services. With this justification, the Monitor initiated a review of 225 class members in 2019. The findings of that review were issued in the Monitor's Seventh Annual Report.

A second round of compliance reviews was initiated beginning with a pilot week in November 2022 and continued through mid-May 2023. Initially 225 class members were selected to be reviewed by a team comprised of representatives from University Illinois Chicago (UIC), the Bureau of Quality

Management (BQM), and those selected by the Monitor. However, due to the loss of one team member to a medical emergency late in this cycle, the final total of reviews completed was 215.

2022-2023 LIGAS COMPLIANCE MEASURES

Class Members Living in Community Integrated Living Arrangements (CILA)

Revision of the Ligas Compliance Measures tool and process began in September 2022 in order to streamline and ensure consistency with policy changes and other initiatives developed by the Defendants (e.g., revisions to Person Centered Planning). A final draft tool was issued in early November in preparation for training reviewers and conducting a week of pilot reviews.

Three teams of reviewers each were brought together for training in November 2022. One group was from the University of Illinois Chicago (UIC), one from BQM, and one recommended by the Monitor. The training included classroom work, document reviews, and on-site visits to class members. Pilot teams were comprised of mixed groups in an effort to ensure interrater reliability as well as consistency of interpretation and rating of findings. Each team was assigned only one class member to review per day for two days of the training, and all reviewers then conciliated their findings related to those two individuals.

Following the pilot, samples were drawn by UIC using a random selection methodology and assigned to reviewers geographically. Reviews were conducted beginning in December 2022 with all reviews completed and submitted to the project manager by mid-May 2023.

The tool is comprised of seventeen sections and each section includes measures by which compliance is to be rated Met, Not Met, N/A (Not Applicable to the individual), or CND (Could Not be Determined). Within each section are measures either identified as "red flags" (indicated in red font on the scoring sheet) and/or noted to be a requirement of the HCBS (Home and Community Based Settings) Rule (indicated with an asterisk).

The scoring reflects the number of class members who received a "Met" rating out of the possible number of "Met" ratings. Therefore, the denominator for each Measure could be different than 215 as the N/A and CND ratings were not included in the total number. N/A and CND ratings were assigned for a variety of reasons. Some examples include:

  • Documents were not provided either prior to or available at the time of the review;
  • The individual/guardian/staff or others involved were not responsive;
  • The metric did not apply to the circumstances of the individual being reviewed (e.g., questions about employment would not apply to a retired individual).

In order to be determined in compliance, within a given section each measure must be rated 85% or above, including red flag measures. Scoring within the Observation Tables in Section 3 (Safety), Section 4 (Staffing), and 5 (Day/Employment) were not factored into the overall score for each of

those sections as those tables were for informational gathering purposes to support findings and justifications within the corresponding sections. The process of conciliation and data analysis was completed with assistance from UIC.

A demographics analysis of the Ligas Compliance Measures review process found that 147 of the 215 class members reviewed were between the ages of 22 and 85. The team reviewed class members residing with 128 residential agencies across the state of Illinois. In addition to residential agencies, the sampling process for the Compliance Review ensured that all eight Independent Service Coordination (ISC) agencies were represented. If, during a review, a team member identified a concern that needed immediate action, this was communicated to the Monitor who notified the Defendants to take appropriate action.

As was the process following the 2019 Ligas Compliance Monitoring reviews, individual scorecards and findings for class members reviewed will be issued to each ISC and CILA provider for whom they are responsible. Each provider will be required to develop a Plan of Corrective Action (POCA) to address each domain that received an overall rating below 85% as well as ratings below 85% for each measure (including red flags and those noted as HCBS Settings Rule).

The following table reflects ratings for each measure and overall ratings (including red flag measures) along with Key Findings for each domain. Ratings for measures consistent with HCBS Settings Rule have also been provided for informational purposes.

2022/2023 Ligas Compliance Measures

Class Members Living in Community Integrated Living Arrangements (CILA)

SUMMARY of RATINGS by DOMAIN and KEY FINDINGS

  • DOMAINS
    Ratings of "Met" from each individual review Total N=215
    (Each measure may have a different N based on CND and N/A ratings which were not considered in the calculation)
  1. Person-centered planning/measuring outcomes: 72% Overall - 65% Red Flag
    • 26 measures
    • 7/26 measures rated 85% or above
    • 11 red flag measures
    • 2/11 red flag measures rated 85% or above
Order of question Compliance Measure Percentage of compliance and total number of respondents
A The individual's personal outcomes and preferences are fully captured within the most recent Discovery Tool document. 86% N=213
B The ISC has documented identified risks in the Discovery Tool. 91%N=214
C Risks to the individual and the strategies, supports, and safeguards to minimize risk are identified in the Personal Plan. 82% N=214
D The individual's strengths and preferences are documented in the Personal Plan. 92%N=215
E The individual's desired outcomes and barriers to outcomes are documented in the Personal Plan. 75% N=214
F Each specific service and support address the person's needs in order to achieve desired outcomes identified in the Personal Plan. 86%N=214
G The individual's preferences for leisure and recreational activities are identified in the Personal Plan. 92%
N=214
H The individual's valued activities and social roles are identified in the Personal Plan. 81%N=214
I The extent to which the person is capable of and willing to participate in decisions regarding his/her personal funds management as well as the extent to which the agency is entrusted with assisting in the management of personal funds are identified in the Personal Plan. 86%N=214
J The individual's preferences and support needs for transportation are identified in the Personal Plan. 77%N=214
K Assessments needed by the individual or required by program regulation were completed in a timely manner to inform the individual's Personal Plan development. 80% N=209
L The individual's identified needs for clinical and/or functional support are documented in the Personal Plan. 66%N=185
M The individual's priorities/interests regarding meaningful community- based activities, including the desired frequency and the supports needed are identified in the Personal Plan. 76% N=214
N The individual's desired outcomes, priorities, and interests regarding meaningful work, volunteer and recreational activities are identified in the Personal Plan. 77% N=208
O The individual's desired outcomes and priorities regarding meaningful relationships are identified in the Personal Plan. 83% N=206
P If the individual has specific desired outcomes and priorities related to health concerns and medical needs, these are identified in the Personal Plan. Health priorities identified by a treating physician, and for which the individual requires support, should be documented in the Personal Plan even where the individual's personal choice conflicts with the recommendation. 83% N=167
Q Providers who have agreed to provide identified supports and services have signed the Provider Signature Page reflecting the outcome(s) designated to that provider. 83% N=211
R The Personal Plan is completed in a timely manner. 88%N=148
S Implementation Strategies containing all desired outcomes for which the provider is responsible are received and reviewed within 20 days of the Personal Plan signature page. 69% N=210
T The Implementation Strategies address all identified risks in the areas for which the provider is responsible. 80% N=214
U The Implementation Strategies provide clear and measurable instructions to provider staff on how to consistently support the individual in implementation of their desired outcomes. 45% N=213
V Implementation Strategies include criteria by which the team can determine when the outcome has been achieved. 34% N=211
W Strategies are implemented at a frequency that enables the individual to learn new skills. 47%N=205
X Monthly/Quarterly reviews track progress toward achievement of Personal Plan outcomes using measurable data. 39% N=212
Y The person has made measurable progress toward achieving outcomes in the past year. 41%N=191
Z If the person is not successful in achieving outcomes, the team has determined why and what changes are needed. 24% N=115

Key Findings:

  • The Discovery Tool was very often copied and pasted to the Personal Plan. Although this improved as the new Person-Centered Planning process recommendations (May 2022) and documents (October 2022) phased in, it continues to be a problem.
  • The Personal Plan development often did not include input from supporting provider agencies or persons who know the individual best (e.g., direct support staff). Many providers indicated that they were not aware of the Plan outcomes until the Plan was provided, providing evidence that the ISC and the provider are not working together at all in the development of the Personal Plan.
  • Personal Plan outcomes often reflected activities in which the person already engages in, and has been engaged in for a number of years, or were most often deficiency driven, rather than reflecting growth and development of new skills, interests, or activities. A common example of an outcome is that the individual attends their day program.
  • *Many individuals reviewed had Personal Plan outcomes not obviously related to things they indicated they wanted for themselves. At times the outcomes were related to what family members wanted for the person. This was true even for some individuals with strong self- advocacy skills.
  • There was a disconnect between the Personal Plan outcomes and the agency Implementation Strategies. It was not always clear why certain outcomes were chosen by the agency from the Personal Plan. Previous guidance from the Division has required providers to choose at least one outcome from the Personal Plan, so some providers only chose one outcome from the Personal Plan.
  • Some agency staff reported that when they were included in Personal Plan meetings, their suggestions for more measurable outcomes were rebuffed and were told by the ISC that the outcomes could only be what the individual stated.
  • Provider agency Implementation Strategies often were appended to a document that contained all the elements of a Personal Plan, or were developed through a planning meeting process, but which differed significantly from the Personal Plan authored by the ISC.
  • Often, the agency wrote a preface to the Implementation Strategies which was more easily understood than the Personal Plan itself. Some agencies called this an Individual Support Plan (ISP) and attached it to the Implementation Strategies. The ISP is terminology that pre- dates the Personal Plan, showing that some providers may not fully understand or embrace the current process.
  • Frequently there were outcomes in the Personal Plan that were not reflected in agency Implementation Strategies and there were Implementation Strategies in the agency plans/strategies that addressed outcomes that were not included in the Personal Plan further showing that ISCs and providers are not working together in the Personal Plan process.
  • Implementation Strategies often did not include criteria by which the team could determine whether strategies had accomplished the desired outcome.
  • Implementation Strategies often did not include sufficient instruction to staff to ensure consistent implementation of outcomes, necessary supports to be provided to the individual, or criteria for documentation.
  • Documentation to reflect implementation of Personal Plan outcomes did not reflect sufficient information regarding the individual's participation in the activity or what was accomplished by the activity that would indicate the individual's benefit. Most often, documentation was anecdotal in that it reflected the number of times an activity was completed. For example, "went to the community" or "helped in the kitchen" or "chose a game to play."
  • Measurable data was often not available or not provided in monthly or quarterly reviews in order to measure the individual's performance over time in order to assess implementation and progress toward goal achievement or if outcomes or Implementation Strategies should be revised.
  • There was often no evidence that provider or ISC recognized or took action to address lack of implementation or lack of progress toward outcomes. For example, an ISC visit note indicated that the individual has been refusing to participate in two of three outcomes over the past quarter, but there was no action taken to review or revise these outcomes.

2. Independent Support Coordination

    • RATINGS: 68% Overall - 75% Red Flag
      • 10 measures
      • 2/10 measures rated 85% or above
      • 5 red flag measures
      • 2/5 red flag measures rated 85% or above
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A There is evidence the individual/guardian was provided a choice of Independent Support Coordinator (ISC). 43% N=188
    B There is evidence the ISC has demonstrated competency in assisting the individual in development of a Personal Plan that describes the services and supports necessary to implement the individual's desired outcomes. 70%N=214
    C CRISIS TRANSITION PLAN and FUNDING REQUEST document (IL462-0140) is completed in a timely manner. 87% N=23
    D In-person visits with the individual served completed at least 2x/year: once for the development of the Personal Plan, and once at least 4-6 months later (unless greater frequency is requested by the individual and/or guardian). Waiver participants should receive monitoring and visits based on their needs. Additionally, other types of contacts, e.g., phone calls, electronic mail, or video conferencing, may be conducted as well. 79%N=213
    E Personal Plan is updated when significant changes occur. 44% N=80
    F The ISC has sufficient contact with the individual and his or her providers throughout the Personal Plan year to ensure that services are in place and to identify needs for changes in supports and services 77%N=211
    G There is evidence that the ISC reviewed data during contacts with the individual and other monitoring activities to determine whether progress is being made on desired outcomes. 45%
    N=208
    H The ISC has contact with the individual's guardian, family, advocate, and/or other significant people to assess satisfaction and improve coordination of services. 76%N=200
    I The ISC completes any necessary follow-up to CIRAS reports or OIG investigations. 81% N=72
    J The ISC has assisted the individual and/or guardian in understanding his/her right to appeal adverse actions and facilitated the appeal process upon request. The ISC has assisted the individual and/or guardian in understanding his or her right to report suspected abuse, neglect, exploitation, or mistreatment. 89%N=208

Key Findings:

  • As of July 1, 2019, when the number of ISC agencies was decreased from 17 to 8, there was no evidence of choice for affected individuals. Choice was limited to the ISC agency operating in the region where the individual resided. Although reviewers found very few instances where individuals and/or their decision-makers had requested a change, there did not appear to be a system in place to process and honor such requests.
  • The roles of the ISC and the ISC agency were not always identifiable by either the person, the guardian, or sometimes even the agency staff, including the name of the actual ISC. Turnover at ISC agencies continues to be a problem.
  • The ISC was not regularly notified when changes are needed that would have an effect on the person and the Personal Plan.
  • There was inconsistent quality noted in the Individual Monitoring and Interview notes (the template used by ISCs for their quarterly visits). While some ISCs completed notes with substantive detail, others were not adequate. Outcome progress monitoring was generally poor, most often perfunctory statements that the goal was "ongoing" or that the individual was making progress with no supporting detail.
  • Case Management supports and monitoring are core individual and systems safeguards. Yet, evidence that the ISC reviewed data during contacts with the individual and other monitoring activities to determine whether progress is being made on desired outcomes was present in only 45% of the individuals reviewed.
  • A requirement for quarterly ISC visits was implemented beginning July, 2022, yet many ISCs were not meeting this new directive. In some cases, visits were made by an ISC agency representative, rather than the assigned ISC.
  • ISC quarterly visits made to the CILA, or to the CDC did not always gather information for both entities.

3. Independent Support Coordination

    • RATINGS: 86% Overall -  84% Red Flag - 88% HCBS Settings Rule 
      • 7 measures
      • 4X/7 measures rated 85% or above
      • 4 red flag measures
      • 2/4 red flag measures rated 85% or above
  • Residential Observations Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    3aa The home is clean, odor free, and well maintained (floors, carpets, walls, furniture, kitchens, baths, etc.) 92% N=212
    3bb Kitchen and laundry appliances are in working order. 99% N=207
    3cc The individual has personal possessions, furnishings, and decorations of his/her choice, not just in bedrooms, but throughout the living areas. Are there photos/mementos of friends and family observable?The home should reflect the preferences, age, culture of the individuals, throughout the home. In shared spaces, compromise should be reached among the varied preferences of all living in the home. 88% N=210
    3dd The individual can move freely throughout the home (with the exception of housemates' personal rooms). There are no designated staff areas (except in the case of live-in staff or agency-leased office area, if applicable) where individuals are not allowed. Any "off limit" areas should be specific to the needed supports of an individual and not "blanket restriction" of all persons in the home. 96% N=207
    3ee The individual has basic necessities such as clothing, utilities, furnishings, grooming supplies. 99% N=209
    3ff The home has an adequate supply of food, including basic commodities (e.g., sugar, flour, condiments). Food is appropriately stored. There is an adequate supply of enteral nutrition formula if the individual receives food enterally. Enteral nutrition formula is not expired. 98% N=205
    3gg The home has an adequate supply of dishes, utensils, pots, pans, bakeware, etc. 100% N=204
    3hh No safety hazards (e.g., dangling wires, broken/exposed electrical outlets, broken windows) are noted in the home. 96%N=212
    3ii A fire extinguisher is located in the kitchen. A functional smoke detector is located outside bedrooms (or rooms used for sleeping) and on each level of the home. Carbon monoxide detectors are installed in homes with gas furnaces and appliances. 98% N=204
    3jj Supplies and information are in place to allow the individual and staff to identify and respond to emergency situations in a quick and efficient manner.
    Emergency contact phone numbers are readily available in easily accessible locations, including the OIG Hotline number.
    Contact names and numbers for investigators are posted or available to individuals, families, and staff.
    Basic first aid supplies are available in the home and in all vehicles.    		 99% N=203
    3kk Outside areas of the home, and the yard, is safe and accessible to the individual from the home. 99% N=213
    3ll Garbage is disposed of properly and is contained. 100% N=25
    A Home reflects the individual's preferences/culture, is safe, and well maintained. 89%N=212
    B Individualized adaptations specified in the individual's Personal Plan are present and in working order. 89% N=47
    C Regular drills for fire and weather emergencies (e.g., tornado, earthquake) are conducted and documented as required. 96%N=205
    D There is a process to notify Fire and EMS personnel about significant medical or evacuation issues with individuals in the home. 98% N=135
    E If the individual, family, and/or guardian reported any concerns about the person's health, safety, or environment, appropriate action has been taken to address. 84% N=85
    F Based on review and receipt of ISC monitoring reports for the past year, any problems or concerns noted about person's health, safety or environment were promptly and appropriately addressed. 72% N=104
    G Based on record review, observations, and interviews does the reviewer note any concerns about the person's health, safety, or environment? 70%N=191

Key Findings:

  • For the most part, individuals' homes were adequate, clean, well-stocked with food, dinnerware and cookware, and were well maintained. However, the home furnishings did not always reflect the individuals' preferences and interests and very few individuals had personal possessions or decorations (e.g., family photos, mementos, culturally significant items) in their bedrooms or other areas of the home.
  • Fire and emergency drills were conducted as required.
  • Often there was no clear understanding from either documentation or interviews with staff as to whether Fire and EMS personnel had been notified or were aware of medical or evacuation needs of individuals living in the home. 
  • ISCs were not always promptly and appropriately addressing noted issues regarding the person's health, safety, or environment. Most often, ISC monitoring reports did not reflect concerns or issues. For over half of the individuals reviewed, team members indicated they had concerns about the person's health, safety, or environment following the on-site visit.

4. Staff Presence, Conduct, Competence (Including Sufficient Numbers, Staff Training, Staff Knowledge of Plan/preferences, Provision of Services as Documented in Plan)

    • RATINGS: 90% Overall - 91% Red Flag - 95% HCBS Settings Rule 
      • 8 measures
      • 7/8 measures rated 85% or above
      • 5 red flag measures
      • 4/5 red flag measures rated 85% or above
      • 3 measures consistent with HCBS Settings Rule
      • 3/3 measures consistent with HCBS Settings Rule rated 85% or above
  • Staffing Observations Table Day Res
    4aa Staff treat the individual, co-workers, visitors, persons calling on the telephone, etc. with dignity and respect. 97% N=158 92% N=212
    4bb Staff serve as positive role models related to appearance, interactions, and demeanor. 98%N=157 99%N=202
    4cc Staff do not engage in personal business while working with the individual. Staff do not air complaints and grievances with others while in the presence of persons receiving services. 100% N=158 99% N=202
    4dd Staff demonstrate competency in person-specific training needed to support the individual (e.g., sign language, behavior management, dining support, etc.) Staff demonstrate competency in communicating in the individual's preferred language (including alternative communication systems such as sign language). 96% N=140 94% N=189
    4ee Individuals are noted to be neat, clean, dressed for the weather/conditions while reviewers are in the home. When needs arise, they are addressed promptly in a private and respectful manner that avoids calling undue attention to the individual. 98% N=155 99% N=195
    4ff Staff interactions foster the individual's ability to make personal choices. 98% N=151 97% N=192
    4gg Staff interactions promote learning of functional skills and overall independence such as personal care, dressing, eating, household chores, cooking, etc. 97% N=145 94% N=187
    A The staff meet the qualifications and have completed the Direct Support Professional training curriculum to be a DSP. 96%
    N=206
    B The staff is qualified and trained to administer medications.. 94%
    N=188
    C The staff have completed Rule 50 OIG training. 95%
    N=208
    D Adequate staff are present during the week and on weekends to provide the services and supports in the individual's Personal Plan. 90%
    N=207
    E Staffing is adequate to facilitate the individual's desired community life outcomes. 86%
    N=206
    F If the individual has been approved for 1:1 support, he/she is receiving that support.. 88%
    N=17
    G Review of documentation and direct observation reflects staff are providing services (type, frequency and duration) as documented in the Personal Plan/Implementation Strategies designed to achieve the individual's desired outcomes. 79%
    N=204
    H The individual's services are delivered by competent staff/supports that understand their role and the person's needs, preferences, and desired outcomes related to his/her Personal Plan. 88%
    N=207

Key Findings:

  • Overall, there was significant improvement in the area of staff presence, conduct and competence from the 2019 compliance review.
  • Documentation reflected that staff had been trained to be DSPs, to administer medications, and had completed Rule 50 OIG training.
  • Staff working with individuals were caring and knowledgeable, respectful to the individuals and others, and responsive to their needs. 
  • Staff were familiar with class members' personal preferences and had received training specific to the needs of the individuals and their person-specific supports and services.
  • Many observations revealed a propensity for staff to "do for" individuals rather than teach them the needed skills for greater self-sufficiency.
  • Staff were not always familiar with the Personal Plan and were therefore not always providing services as indicated or the strategies that they were required to implement.

5. Employment/day Activiti5.5es, Community Integration

    • RATINGS: 53% Overall - 52% Red Flag - 54% HCBS Settings Rule 
      • 10 measures
      • 1/10 measures rated 85% or above
      • 6 red flag measures
      • 0/6 red flag measures rated 85% or above
      • 4 measures consistent with HCBS Settings Rule
      • 0/4 measures consistent with HCBS Settings Rule rated 85% or above
  • Day/employment Observations Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    5aa The facility/building is clean, odor-free, and well-maintained. 97% N=162
    5bb As you arrive, take note of the surroundings. Is the landscaping well kept? Does it appear safe? 99%N=162
    5cc Is the facility located to promote community integration? 90% N=158
    5dd Is there room for small groups and individual activities? 96% N=207
    5ee The individual has basic necessities such as clothing, utilities, furnishings, grooming supplies. 61% N=140
    5ff Did the direct support staff treat (name) in a respectful manner during the observation? 97%N=150
    5gg Were the person's rights respected? 99% N=152
    A The individual has been offered opportunities to participate in work or job exploration including non-segregated volunteer work and/or trial work options. 49% N=187
    B If the individual desires new or different employment, but there are barriers to achievement, the team has addressed these barriers, including referrals for supporting services (e.g., therapies or behavioral support) and coordination of assistive technology. 29% N=69
    C The individual is engaged in supported or competitive employment as desired. 31%N=90
    D The employed individual has necessary supports to successfully achieve his or her responsibilities (e.g., job coach, natural supports). 93% N=30
    E For an individual receiving day services in the community, activities are planned and completed in integrated locations considering his/her preferences as documented in the Personal Plan. 62% N=100
    F For an individual who attends a facility-based day habilitation program or workshop, there is justification in his/her Personal Plan that activities offered are meaningful to the person. 64% N=108
    G For an individual who attends a facility-based day habilitation program or workshop, regular opportunities are also provided for community inclusion. 70% N=111
    H If the individual is retired, he/she has opportunities to engage in activities of interest during the day, including choosing and attending community- based senior citizen day programs, if desired. 48% N=23
    I If the individual desires more or different community outings, but there are barriers to achievement, the team has addressed these barriers, including referrals for supporting services (e.g., therapies or behavioral support) and coordination of assistive technology. 65% N=75
    J The individual has been offered opportunities for considering adult education programs if so desired. 40% N=98

Key Findings:

  • Illinois Employment First  is supported by Illinois State Law, Executive Order and policies that promote community-based, integrated employment as the first option for employment-related services for individuals with disabilities, physical, intellectual, or behavioral. The idea is that all Illinois citizens, regardless of disability, are capable of full participation and integration in their communities and that includes employment. Illinois has adopted an Employment First policy via the Employment First Act (20 ILCS 40) in 2013. This law states that "competitive and integrated employment shall be considered the first option when serving persons with disabilities of working age" and requires all State agencies to follow the policy as well as ensure its effective implementation within their programs and services. Additionally, Illinois has an Executive Order (14-08) that requires the participation of multiple state agencies to fully implement Employment First across the State. The HCBS Final Settings Rule indicates that all HCBS must be delivered in settings that are integrated in, and support full access to, their community. This includes opportunities to seek employment and work in competitive settings within the community, engage in community life, control personal resources, and receive services in a similar way as individuals who do not receive HCBS.
  • The 2022/23 Ligas Compliance Review found that person-centered planning significantly failed to address the Illinois Employment First initiative as well as the principles set forth in the HCBS Settings Rule, and guidance relative to person-centered planning to include opportunities to seek employment and work in competitive integrated settings.
  • Individuals with identified interests were not provided with opportunities for work or job exploration. 
  • 147 (64%) of the individuals in the review sample were aged 50 and under and only 24 individuals were employed in community jobs such as fast food, movie theatre, restaurant, grocery store, thrift store, etc.
  • Barriers to employment had not been identified with assessment of supports necessary for the person to become successfully employed.
  • Some individuals who were employed were often not working at the frequency they desired.
  • Many individuals reviewed spent their days in segregated facility-based programs and some participated in community-based activities.
  • Activities provided at facility-based day programs were not always meaningful to the person nor consistent with their preferences and desires indicated in their Personal Plan.
  • Many of the day facilities were located in large warehouse type buildings. While it was described that individuals "work", their days were comprised of tasks such as shredding, working puzzles, coloring, or just sitting and waiting out their day between snacks and lunch. In cases where the agency had some contract work, individuals were paid a sub-minimum wage for completion of the task and oftentimes did not have materials available to complete the contract activity.
  • Day program facilities were inconsistent in their application of increasing community access. Some had no means for any community access, while others were providing some group outings via an agency van monthly.
  • For individuals whose day programs were community-based, only 62% were provided regular opportunities for community inclusion. These activities were often not meaningful to the person or based on their desires or interests and were most often provided in groups rather than individualized.
  • Even for individuals with a stated desire for adult education or community-based senior citizen programs, there was little evidence to support they had been provided these opportunities.

6. Leisure, Recreation, Social Relationships (Including Connection to Family and Friends)

    • RATINGS: 53% Overall - 81% Red Flag - 79% HCBS Settings Rule 
      • 8 measures
      • 4/8 measures rated 85% or above
      • 4 red flag measures
      • 1/4 red flag measures rated 85% or above
  • Leisure, Recreation, Social Relationships (Including Connection to Family and Friends) Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A People of significance with respect to social relationships to the individual are identified in the Personal Plan. 93% N=215
    B The individual's desired outcomes and priorities regarding meaningful relationships and personal connections are implemented and respected. 83%N=196
    C The person is maintaining his/her desired role in the community. 79% N=184
    D The individual has leisure activities (e.g., magazines, hobby materials, videos, etc.) available in the home aside from television, consistent with his/her preferences and interests. 97% N=213
    E The individual participates in a variety of desired experiences and in preferred activities during evenings and weekends and is supported and encouraged to participate in his/her local community in ways that are meaningful to him/her and documented in the Personal Plan. 71% N=205
    F The individual has opportunities to attend religious services as often as desired and at the house of worship of his/her choosing (and not of staff or housemates' preference.) 87% N=137
    G The individual has information about membership to self-advocacy or other community organizations and is supported to become a member and attend if so desired. 41% N=151
    H The individual has adequate access to and use of generic services and natural supports as desired. 89%N=208

Key Findings:

  • While some improvement was noted from 2019, desired outcomes regarding meaningful relationships and personal connections were being implemented and respected for only 82% of the individuals reviewed. Most often, even though the individual's Personal Plan identified people of significance to the individual, there were generally no supports in place to assist the individual in maintaining or expanding social relationships.
  • Documentation indicated that only 71% of the individuals reviewed were participating in a variety of experiences and preferred activities during evenings and weekends. Lack of staff was noted as a barrier for some individuals to participate in activities during evenings and weekends.
  • Individuals were not maintaining desired roles in the community as evidenced by lack of participation in community events and organizations, lack of involvement in social and recreational activities, and lack of being recognized or known by name by others in the community. 
  • Less than half of the individuals reviewed were knowledgeable about community organizations that promote self-advocacy, nor were they being supported to attend and to join such organizations.

7. Personal Funds Management

    • RATINGS: 94% Overall - 93% Red Flag - 94% HCBS Settings Rule 
      • 9 measures
      • 48/9 measures rated 85% or above
      • 4 red flag measures
      • 4/4 red flag measures rated 85% or above
      • 1 measure consistent with HCBS Settings Rule
      • 1/1 measure consistent with HCBS Settings Rule rated 85% or above
  • Personal Funds Management Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A If designated in the Personal Plan and/or Implementation Strategy, training has been designed and implemented to help the individual learn skills necessary for greater independence in management of his/her personal funds. 74% N=128
    B The individual has access to his/her personal spending money. 92% N=205
    C The agency does not restrict the individual's access to or choice in spending his/her personal money without required approval of a Human Rights Committee. 94% N=168
    D Personal funds not held by the individual are securely stored and each person's funds are separately stored and accurately accounted. Individuals who are able to independently access funds are not prevented from doing so based on agency policy and/or practice. 93% N=167
    E The individual's personal needs allowance is rightfully distributed each month and records are maintained regarding utilization of these funds. 93% N=183
    F For individuals earning money through employment, he/she determines how this income is used. (See 7c) 95%N=84
    G The cost of household supplies, groceries, utilities, furnishings, rent, etc. which are not funded by the provider are fairly shared with housemates, etc. 98% N=149
    H The individual is able to participate in preferred activities with respect to financial feasibility. 98%N=211
    I The person has the resources to obtain possessions and supplies necessary for comfortable daily living. 99% N=213

Key Findings:

  • Although Discovery Tools and Personal Plans were designed to specify the extent to which the individual was capable of participating in personal funds management, consideration of training was not maximized in the area of supporting them in gaining necessary skills for more independent management of their personal funds.
  • Review of documentation and interviews with staff and individuals showed that, for the most part, individuals had access to their money and had enough money to participate in preferred activities and to make purchases of personal items.

 8. Transportation

    • RATINGS: 83% Overall - 83% Red Flag
      • 3 measures
      • 1/3 measures rated 85% or above
      • 3 red flag measures
      • 1/3 red flag measures rated 85% or above
  • Transportation Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A The individual is supported to have access to the community with the freedom to come and go as desired using varying modes of transportation. 80% N=182
    B If there are barriers to the individual having his/her preferred access and inclusion with regards to transportation, the team has assessed the need for adaptation, orientation, assistive technology, or other necessary supports. 77%
    N=77
    C Considering 8a and 8b above, the individual is supported to regularly participate in unscheduled and scheduled activities/events using varying transportation modes. 88% N=211

Key Findings:

  • While there was improvement over the 2019 ratings for this area, individuals were not being supported to access transportation with as much independence as possible, barriers had not been adequately assessed, and supports had not been developed to address identified barriers.
  • In rural areas, public transportation was limited and could not support individuals' access to the community for participation in scheduled and unscheduled events. More often, individuals relied on agency vehicles (i.e., vans) for transportation.
  • On a positive note, review team members did encounter some individuals who were accessing their communities by taxi, accessible local transportation, Uber, and who lived close enough to town to walk to local resources.

 9. Health Care

    • RATINGS: 95% Overall - 80% Red Flag
      • 15 measures
      • 47/15 measures rated 85% or above
      • 6 red flag measures
      • 2/6 red flag measures rated 85% or above
  • Health Care Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A A health assessment, which identifies the individual's health care needs, has been completed with sufficient substantive commentary. 84% N=215
    B The individual receives all medical and nursing/health care services and supports per his/her health care professional's recommendations. 88%N=207
    C The individual receives preventative testing and/or care based on recommended professional guidelines for medical conditions, gender, and age (e.g., GYN exams, pap smears, mammograms, prostate exams, colonoscopy) consistent with physician's recommendations. 78% N=161
    D The individual has at least annual dental exams. These are more frequent if recommended by dentist. 84% N=204
    E If the individual has a seizure disorder that is unstable or not well- controlled, he or she has been evaluated by a neurologist and the primary care physician has considered and implemented recommendations for treatment. 81% N=37
    F Recommendations for health care services and supports are completed in a timely manner and there is no pattern of missed or frequently rescheduled appointments. 86% N=208
    G All medical and healthcare supports and services are properly documented by the service provider at the time of service provision in the individual's record. 84% N=212
    H There is a written plan/instruction to address routine care/monitoring to be provided related to the individual's specific medical condition(s). 60% N=176
    I If the individual is noted to have unexplained weight loss/gain, GERD, diabetes, or swallowing issues, he/she is promptly taken to an appropriate practitioner for evaluation. 91% N=64
    J Medications are securely stored in a locked location (double-locked for controlled substances). 97% N=196
    K Staff are able to locate information to explain the reason why the individual is taking a specific medication and to explain the potential side effects. 95% N=187
    L Medication errors occur infrequently, and when they do occur, are properly documented, reported, reviewed, and addressed. 91% N=177
    M The individual has all necessary medical services and supports as recommended by their team and health care professionals. 89%N=209
    N If the individual needed crisis respite services during the past 12 months, these services were provided in his/her home whenever possible. If the individual needed out-of-home crisis respite services during the past 12 months, these services were available in an appropriate crisis respite home/facility. 76% N=17
    O The individual is offered counseling services, if needed, and agency ensures these services are being provided as recommended. 69%N=72

Key Findings:

  • For the most part, individuals reviewed were receiving medical and nursing/health care services and supports (88%).
  • Physician recommended assessments, examinations, and follow-up consultations were not always completed in a timely manner (86%).
  • Additionally, individuals were not receiving preventative testing or screening for medical conditions, gender and age (e.g., GYN exams, mammograms, prostate exams). In cases where the individual or guardian had refused, evidence was not available to demonstrate that alternative, less intrusive screenings had been explored.
  • There was a lack of written care plans for health issues, both long-term (e.g., seizures, constipation, GERD, diabetes management) and short-term (e.g., sprain, tooth pain). Review team members found a written plan/instruction to address routine care/monitoring to be provided related to the individual's specific medical condition(s) for only 60% of individuals.
  • Medication appeared to be securely stored in locked locations. Medication Administration Records (MARs) for the most part accurately indicated all prescribed medications and instructions for administration.
  • Staff, when interviewed, were able to articulate or locate information to explain the reason why the individual is taking a specific medication and to explain the potential side effects.
  • Only 76% of the individuals who were noted as needing crisis respite services during the past 12 months, received such services either in the individuals' home or in an appropriate crisis respite home/facility.
  • For individuals noted as needing counseling services, only 69% received these services as recommended.
  • Individuals noted to have unexplained weight loss/gain, GERD, diabetes, or swallowing issues, were evaluated for treatment.

 10. Vision, Hearing, Sensory Supports and Services

    • RATINGS: 85% Overall - 86% Red Flag
      • 12 measures
      • 5/12 measures rated 85% or above
      • 9 red flag measures
      • 4/9 red flag measures rated 85% or above
  • Vision, Hearing, Sensory Supports and Services Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A An individual who has a visual impairment has been evaluated for current needs and recommendations from evaluations have been addressed in a timely manner. 89% N=117
    B An individual who has prescribed eyeglasses is supported in use and care. 97% N=90
    C Surgical or other interventions have been explored for the individual noted to have cataracts or other treatable disease(s) of the eye, as recommended by an ophthalmologist. 83% N=29
    D An individual whose visual impairment interferes with his/her orientation or mobility has been evaluated by a qualified specialist for training in orientation or mobility techniques or other training needed to support independent function (e.g., self-feed techniques, dressing, kitchen safety, street-crossing strategies, service animal). 43% N=7
    E If adaptive devices (e.g., cane for mobility, tactile cues on clothing) have been recommended, they are used consistently across all life environments, and staff demonstrate competency in proper use and techniques employed. 80% N=10
    F An individual who has hearing loss has been evaluated for current needs and recommendations from evaluations have been addressed in a timely manner. 68% N=19
    G An individual who has been prescribed hearing aids is supported in their use and care. 73% N=11
    H An individual with hearing loss has adaptive devices to support independent function (e.g., visual alerts, bed-shaker for fire alert), and staff demonstrate competency in proper use and techniques employed. 71% N=7
    I Recommended specialized services that aid in increasing the individual's ability to access his/her environment more independently (e.g., sign language, services for the deaf) are being provided. 100% N=5
    J For an individual who is deaf and uses sign language, he/she has staff who have been trained and can communicate with him/her. 100% N=5
    K An individual who demonstrates self-stimulatory behavior that interferes with daily life has been evaluated regarding sensory deficits, and therapeutic plans or programs regarding his/her sensory deficits are implemented consistently and across all life areas. 90% N=10
    L The individual is provided with intervention(s) designed to provide alternative means of sensory stimulation and reduce the self-stimulatory behavior that interferes with daily life; staff demonstrate competency in implementing the intervention(s). 80% N=10

Key Findings:

  • Individuals with vision impairments had been evaluated for current needs but were not always being supported in the use and care of prescription eyeglasses and surgical or other interventions had not always been explored for cataracts or other treatable disease(s) of the eye.
  • Individuals whose visual impairment interferes with his/her orientation or mobility had not been evaluated by a qualified specialist for training in orientation or mobility techniques or other training needed to support independent function.
  • Individuals with hearing loss had not been evaluated for current needs, did not have adaptive devices to support independent function, and for those who had been prescribed hearing aids were not supported in their use and care.

 11. PT/OT/SLP/Other Communication Supports and Services

    • RATINGS: 29% Overall - 26% Red Flag
      • 5 measures
      • 0/5 measures rated 85% or above
      • 4 red flag measures
      • 0/4 red flag measures rated 85% or above
  • PT/OT/SLP/Other Communication Supports and Services Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A An individual who receives, or has identifiable needs for, speech, occupational, or physical therapy services, has current evaluations in his/her record for the therapy services. 20% N=42
    B Evaluations and plans of care include appropriate and measurable therapy goals. 50%N=12
    C Written instructions have been developed to provide clear steps and direction to direct support staff for implementing therapy related activities (e.g., range of motion, stretching, bathing, ambulation, use of equipment and devices) including the frequency and setting in which therapy related activities are to be conducted. 27% N=15
    D Therapy services plans of care are implemented consistently as recommended. 50%N=12
    E Documentation of services reflects measurable progress toward established therapy goals, outcomes, and/or therapy objectives. If the therapy objective is to prevent further decline, measurable information is provided to document that functional status has been maintained. 23% N=13

Key Findings:

  • The review team met individuals with indicators of need for therapy services, but the individuals' planning teams had not recognized these needs as a barrier or requested evaluations or assessments. For example, review team members observed individuals with unsteady gait, limitations of movement, and communication barriers which were not being addressed.
  • The review team found a general lack of physical, occupational, or speech therapy evaluations for individuals who could benefit from these services.
  • For individuals who were receiving therapy services, evaluations and plans of care rarely included measurable goals and written instructions did not provide clear direction to staff for implementation.
  • Therapy services were not consistently implemented, and documentation did not reflect measurable progress.
  • Availability of physical, occupational, and speech therapy services with appropriate qualifications to work with adults with intellectual disabilities who presented as likely needing ongoing oversight/services was limited in most geographic areas of the state.

 12. Adaptive Equipment and Assistive Technology

    • RATINGS: 29% Overall - 26% Red Flag
      • 5 measures
      • 2/5 measures rated 85% or above
      • 5 red flag measures
      • 2/5 red flag measures rated 85% or above
  • Adaptive Equipment and Assistive Technology Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A The person's need for adaptive equipment and assistive technology has been assessed. 65% N=57
    B The person has received all recommended adaptive equipment and assistive technology. 55% N=89
    C The person uses adaptive equipment and assistive technology for positioning, ambulation, and/or communication to increase his or her safety, independent participation in daily activities, community participation. 80% N=50
    D All prescribed adaptive equipment and assistive technology is available, clean, in good repair (including having charged batteries), and available to the person at all appropriate times and during community activities. 93% N=54
    E Staff demonstrate competency in proper use and techniques of all prescribed equipment and devices. 93%N=46

Key Findings:

  • The review team met individuals with indicators of need for adaptive equipment and assistive technology, but the individuals' planning teams had not recognized this need as a barrier or requested evaluations or assessments.
  • Not all individuals for whom adaptive equipment and assistive technology had been recommended had received their equipment or devices.
  • Individuals with adaptive equipment (e.g., wheelchairs, walkers, shower chairs) were not always using the equipment as prescribed to increase their independence.
  • Adaptive equipment was not always available for use across all life environments or was not always clean or in good repair.
  • Staff were not always aware of, nor could they demonstrate proper use of, prescribed equipment and devices.

 13. Dining/Dietary Supports and Services

    • RATINGS: 88% Overall - 79% Red Flag
      • 5 measures
      • 4/5 measures rated 85% or above
      • 3 red flag measures
      • 2/3 red flag measures rated 85% or above
  • Dining/Dietary Supports and Services Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A If the individual has a condition or illness that places him or her at risk of choking/aspiration, he or she has been assessed for safe dining practices, including food texture and liquid consistency and a corresponding plan/strategy has been developed. 46% N=67
    B If the individual is at risk for choking and/or aspiration, he or she receives adequate support for safe eating and drinking in all environments according to an established mealtime plan/strategy. 86% N=36
    C All special dining supplies (e.g., non-slip mats, special utensils, cups) listed in his/her dining plan/strategy are present. 94% N=17
    D When an individual has a specific, prescribed diet, he/she is achieving or maintaining goals of the diet. 85%N=88
    E Meals served are per the individual's preferences and dietary needs. 95% N=200

Key Findings:

  • There was improved performance in the area of Dining/Dietary Supports and Services compared to the 2019 review.
  • Homes visited had adequate supplies of food and food was appropriately stored. However, special equipment was not always present to support individuals per their prescribed dining plans.
  • Individuals noted to be at risk of choking/aspiration had not been assessed for safe dining practices, including food texture and liquid consistency, and a corresponding plan/strategy had not been developed.
  • As in 2019, the reviewers found that prevailing practices for keeping individuals with choking/aspiration risks were often not followed. In many instances, the supporting agency was not aware of common adaptations to support individuals with safe oral intake. Individuals were found to be both over-supported and under supported in this area. For example, some individuals with documented risk of choking/aspiration did not have common adaptations available beyond texture modifications. Metered cups, adapted utensils and other supplies that are in common use to assist similarly situated individuals were rarely found. Individuals were observed receiving full physical support from staff at mealtime, where they could likely have eaten with much greater independence, if appropriate mealtime supplies were provided and supervision calibrated to their individual needs.
  • Individuals with specific prescribed diets were noted to be achieving or maintaining goals of the diet and meals were based on individuals' preferences and dietary needs.

14. Behavioral Supports and Services

    • RATINGS: 74% Overall - 74% Red Flag - 75% HCBS Settings Rule 
      • 11 measures
      • 1/11 measures rated 85% or above
      • 11 red flag measures
      • 1/11 red flag measures rated 85% or above
      • 5 measures consistent with HCBS Settings Rule
      • 1/5 measures consistent with HCBS Settings Rule rated 85% or above
  • Behavioral Supports and Services Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A A comprehensive Functional Behavioral Assessment has been completed. 63% N=142
    B The Behavior Support Plan (BSP) was developed from the Functional Behavioral Assessment. 72%
    N=138
    C The BSP is written in plain language that is easy to understand and describes strategies and how to implement them. The strategies described in the BSP are personalized (not generic) and include teaching and reinforcing alternate behaviors. 80% N=136
    D The Behavior Support Plan includes the least restrictive or least intrusive methods possible in the behavioral approaches, strategies and supports designed to address the challenging behavior. 83% N=132
    E Staff responsible for the support and supervision of the individual who has a behavior support plan know how to implement the person's plan and the specific interventions included. 74% N=126
    F The Individual's Behavior Support Plan provides a method for collection of behavioral data to evaluate treatment progress. 85%N=132
    G All behavior supports and services are properly documented at the time of service provision in the agency's record for the individual. 83% N=114
    H The Individual's Behavior Support Plan includes a description of the person's behavior that justifies the inclusion of the restrictive/intrusive intervention(s) and/or limitation on rights. 63% N=94
    I The Behavior Support Plan includes a specific plan to minimize, fade, eliminate or transition restrictions and limitations to more positive interventions, 59% N=95
    J If behavior support plan includes rights restrictions or restrictive interventions, BSP has been reviewed by a human rights committee (HRC) prior to implementation and at least annually thereafter. 77% N=93
    K Clinical justification for use of restrictive interventions or rights limitations in an emergency is documented in the individual's record. 75%N=55

Key Findings:

  • Many individuals with noted behavioral challenges had not received a comprehensive Functional Behavioral Assessment.
  • Most Behavior Support Plans (BSPs) were written in easily understandable language to facilitate implementation of strategies.
  • In several cases, behavior support plans were not always written by licensed professionals but were developed by the agency's QIDP.
  • For those individuals with restrictive or intrusive interventions in their BSPs, the plan did not include a description of the behavior justifying the interventions or limitation of rights.
  • Not all restrictive plans had been reviewed by a human rights committee.
  • Most Behavior Support Plans (BSPs) did not include strategies for teaching and reinforcing alternative behaviors.
  • BSPs that included restrictive/intrusive methods to address challenging behaviors did not always include a plan to minimize, fade, eliminate, or transition restrictions and limitations to more positive interventions.
  • Fewer than half of the direct support staff could articulate implementation of individuals' behavior support services.
  • BSPs did not always include a method of data collection to evaluate progress or a schedule to review the effectiveness of the plan.

 15. Mental Health Supports and Services

    • RATINGS: 74% Overall - 72% Red Flag - 79% HCBS Settings Rule 
      • 11 measures
      • 2/11 measures rated 85% or above
      • 10 red flag measures
      • 1/10 red flag measures rated 85% or above
      • 1 measures consistent with HCBS Settings Rule
      • 0/1 measures consistent with HCBS Settings Rule rated 85% or above
  • Mental Health Supports and Services Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A Individuals receiving psychotropic medications have a current comprehensive psychiatric evaluation that documents the operating diagnosis or condition for which medication is prescribed, includes rationales for any prescribed psychotropic medication, and includes an analysis of the risks and benefits of recommended treatment.. 57%N=138
    B An individual who is prescribed medications for a psychiatric disorder who has no other challenging behavior and no restrictive interventions has a current psychiatric treatment plan/medication management plan in place.. 67%N=42
    C An individual who is prescribed medications for a psychiatric disorder who also displays challenging behavior has a current BSP in place along with a current psychiatric treatment plan/medication management plan. 64%N=118
    D Documentation of informed consent for all psychotropic medications is present in the individual's records.. 81% N=136
    E The individual's psychotropic medication regimen has been reviewed at least annually by a Human Rights Committee.. 79%N=137
    F Staff are able to locate information to explain the reason why the individual is taking a psychotropic medication and to explain the potential side effects.. 93%N=126
    G Agency has a documentation system in place for tracking targeted symptoms/index behaviors and providing this information to the individual's prescribing practitioner in order to evaluate the benefits/risks of continuation. 62%N=135
    H Documentation indicates the prescribing physician has re-evaluated the effectiveness of the individual's psychotropic medication regimen. 72% N=133
    I Individual were not prescribed psychotropic medications. If such medications were ordered for emergency use, there were specific parameters requiring prescribing physician authorization prior to administration. 97%N=94
    J Agency ensures that tardive dyskinesia screenings (e.g., AIMS, DISCUS, MOSES, MEDS), are completed (as appropriate) at least every six months, and that documented comprehensive informant completed side effect screens are completed, minimally, on those individuals who are unable to verbally report medication side effects.. 77%N=128
    K If the individual has a history of admissions to psychiatric facilities, agency has developed a plan or strategy to aid in preventing future psychiatric admissions. 52%N=23

Key Findings:

  • For individuals receiving psychotropic medications, prescribing physicians rarely developed medication plans that: explained the diagnostic rationale; identified the intended purpose of the psychotropic medication being prescribed; described symptoms associated with diagnosed mental health conditions; or defined the expected outcomes. The lack of such a plan makes it difficult, if not impossible, to objectively determine the appropriateness or effectiveness of class members' prescribed medication regimens.
  • Agencies were not observed to have appropriate documentation systems in place to track targeted symptoms/index behaviors to provide to the prescribing physician in order for the physician to evaluate the benefits/risks of continuing the medication.
  • Medication to address factors contributing to individuals' challenging behavior or symptom of a diagnosed co-occurring psychiatric disorder was administered as part of a formal plan that includes other supporting interventions (e.g., Behavior Support Plan, Treatment Plan) for only 64% of the individuals reviewed.
  • Individuals' medication regimens had not always been reviewed by a Human Rights Committee (79%). These reviews, where completed, were not thorough and included little to no documentation of rationale for approval.
  • Individuals with a history of admissions to psychiatric facilities did not have an adequate plan or strategy for crisis diversion or to aid in preventing future psychiatric admissions.

 16. Protection From Harm

    • RATINGS: 90% Overall - 90% Red Flag
      • 4 measures
      • 3/4 measures rated 85% or above
      • 4 red flag measures
      • 3/4 red flag measures rated 85% or above
  • Protection From Harm Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A The individual and/or guardian knows who to contact to report abuse, neglect, exploitation, or mistreatment. 89% N=201
    B If the individual was a victim of abuse, neglect, exploitation, or mistreatment, actions were taken to address the person's and/or guardian's complaints, concerns, harm. 92% N=25
    C If there is (or was) an investigation, the individual has received appropriate protection while the case is (or was) under review. 100% N=16
    D There is evidence that:
    •  Appropriate follow-up on investigations of abuse, neglect, exploitation, mistreatment involving the individual has occurred.
    • Measures/actions were identified, planned, and implemented to prevent future/similar events involving the individual.
    • Actions were taken to implement and/or address recommendations resulting from the investigative findings.
    		 83%N=12

Key Findings:

  • The 2022/23 Compliance Review process saw a marked improvement in Rights and Autonomy over 2019 findings.
  • The majority of individuals and/or their guardians reported they knew who to contact to report abuse, neglect, or exploitation, and how and to whom to report such mistreatment.
  • In those instances when an individual had been a victim of abuse, neglect, exploitation, or mistreatment, documentation (when available) reflected appropriate actions had been taken to address the individual's (or guardian's) complaints, concerns, or harm.
  • Documentation indicated that during an investigation, individuals were not always provided appropriate protection while the case was under review (e.g., staff involved were not removed from working with the individual).
  • For those individuals involved in an investigation, there wasn't always evidence of appropriate follow-up or actions taken to address recommendations resulting from the investigation. Additionally, actions had not always been identified, planned, or implemented to prevent future or similar events.

 17. Rights and Autonomy

    • RATINGS: 88% Overall - 88% Red Flag - 87% HCBS Settings Rule
      • 15 measures
      • 10/15 measures rated 85% or above
      • 12 red flag measures
      • 9/12 red flag measures rated 85% or above
      • 8 measures consistent with HCBS Settings Rule
      • 6/8 measures consistent with HCBS Settings Rule rated 85% or above
  • Rights and Autonomy Table
  • Order of question Compliance Measure Percentage of compliance and total number of respondents
    A The individual is provided with information about his or her rights, including the right to object to services, in appropriate language and in a way that is accessible to him/her. 93% N=203
    B The individual knows whom to contact/how to make a complaint, including anonymous complaints if desired. The individual has identified someone he/she could contact to make a complaint and understands this complaint could be anonymous. 74%N=174
    C In any situation where a complaint has been made, the issue(s) has been resolved in a satisfactory and timely manner.. 88% N=41
    D The individual is encouraged and supported to advocate for him/herself and to increase self-advocacy skills. 73% N=183
    E The individual is not subjected to coercion (including subtle coercion). 95% N=202
    F The individual is supported to express him/herself through personal choices/decisions on style of dress and grooming preferences. 99% N=213
    G The individual is supported to have visitors of his/her choosing according to stated/identified preferences. 94% N=205
    H The individual has privacy in his/her home, bedroom, or other environment(s) per identified or stated needs/preferences. 92% N=208
    I The individual is aware that he/she is not required to follow a particular schedule for waking up, going to bed, eating, leisure activities, etc. 95% N=187
    J The individual is supported to have access to food at any time, consistent with risk factors identified in the Discovery Tool and Personal Plan. 94% N=211
    K The individual is supported to have independent access to his/her home. 88% N=170
    L The individual has access to typical spaces in his/her day setting and is supported to use them. 97% N=170
    M When interventions that restrict or modify the individual's rights are used (not part of a behavior support plan), the individual's Personal Plan and/or Implementation Strategy includes a description of the need/behavior, and positive and less intrusive approaches that have been tried but have not been successful. 54%N=94
    N

    The individual, or the individual's guardian (if the individual is unable to make this decision), has given informed consent to the rights

    limitations/restrictions in place.

    		 77% N=124
    O The individual's rights are respected and staff support and advocate for the individual's rights. 82%N=210

Key Findings:

  • Overall, there was an improvement since 2019 with regard to Rights and Autonomy.
  • Observations and review of documentation did not indicate that individuals were subjected to coercion or subtle coercion.
  • Observations indicated individuals were supported to express themselves through personal choices and decisions.
  • Documentation and interviews indicated that individuals reviewed were provided with information about their rights in appropriate language or in a manner they could understand.
  • Documentation and interviews did not always indicate that individuals knew whom to contact or were not given the tools to make objections or complaints..
  • Individuals were not being empowered to self-advocate or to increase self-advocacy skills.
  • Individuals were not always supported to participate in cultural, religious, or other associations/organizations, celebrations, and experiences per their preferences.
  • Individuals were supported to have visitors of their choosing or privacy in their home/bedroom per their preferences.
  • Individuals interviewed reported they were aware they were not required to follow a prescribed schedule for waking up, going to bed, eating, etc. In addition, they were supported or encouraged to make their own scheduling choices.

2022/2023 Ligas Compliance Measures


Summary of Ratings by Domain Comparing 2019 to 2022/2023

The chart below illustrates a comparison of the ratings from the 2019 Ligas Compliance Measures Review and the 2022/2023 Ligas Compliance Measures Review. Progress was noted in several areas, especially those where HCBS Settings Rules apply, specifically in the areas of Safety, Personal Funds, and Rights and Autonomy. The 2022/2023 review also yielded findings of progress in the areas of Staff Presence/Conduct/Competence, Leisure/Recreation/Social Relationships, Transportation, and Protection from Harm. Notable also was improvement in key service areas of Health Care, Vision/Hearing/Sensory, and Dining. However, areas of Behavioral and Mental Health Services and Supports as well as Employment/Day Activities that impact the overall quality of life of class members in terms of stability in their CILA homes and success in their daily community life saw very little improvement.

Most prominent, and most concerning, was the lack of overall performance increase in Person-Centered Planning and Independent Support Coordination. Person-Centered Planning forms the foundation for the outcomes that the person desires in their life, what is important to the person, ensures personal preferences, health and welfare, and addresses risk factors with supports and strategies to minimize the identified risks. The Person-Centered plan also provides the justification for the services provided and expectations for service monitoring and quality evaluation by Independent Support Coordinators (ISCs). Areas such as those referenced above that are linked to overall satisfaction, self-determination, and greater independence, were noted to be lacking for individuals reviewed due to failure of ISCs to develop a solid and individually driven plan.

The Defendants implemented a new Person-Centered Planning initiative in May 2022 that was designed to address the shortcomings noted from the 2019 Ligas Compliance Measures review and additional stakeholder input. The Defendants contracted with the University of Illinois Chicago to evaluate the person-centered planning process and provide recommendations for improvement. Training on an overview of the evaluation recommendations along with each of the three templates (Discovery Tool, Personal Plan, and Implementation Strategies) was conducted on May 26, June 2, June 9, and June 16, 2022. The roll-out of the three templates occurred later than anticipated (October 2022) and therefore the majority of the class members reviewed had not benefitted from the new process.

Compliance Domain 2019 2022/2023
Person-Centered Planning/Measuring Outcomes 46% Overall
41% Red Flag		 72% Overall
65% Red Flag
Independent Support Coordination 47% Overall
44% Red Flag		 68% Overall
75% Red Flag
Safety (including risk mitigation, environmental maintenance) 83% Overall
74% Red Flag
64% HCBS Settings Rule		 86% Overall
84% Red Flag
88% HCBS Settings Rule
Staff Presence, Conduct, Competence (including sufficient numbers, staff training, staff knowledge of plan/preferences, provision of services as documented in plan) 77% Overall
85% Red Flag
94% HCBS Settings Rule		 90% Overall
91% Red Flag
95% HCBS Settings Rule
Employment/Day Activities, Community Integration 31% Overall
26% Red Flag
19% HCBS Settings Rule		 53% Overall
52% Red Flag
54% HCBS Settings Rule
Leisure, Recreation, Social Relationships (including connection to family and friends) 55% Overall
48% Red Flag		 81% Overall
79% Red Flag
Personal Funds Management 78% Overall
70% Red Flag
57% HCBS Settings Rule		 94% Overall
93% Red Flag
94% HCBS Settings Rule
Transportation 32% Overall
29% Red Flag		 83% Overall
83% Red Flag
Health Care 79% Overall
75% Red Flag		 85% Overall
80% Red Flag
Vision, Hearing, Sensory Supports and Services 66% Overall
67% Red Flag		 85% Overall
86% Red Flag
PT/OT/SLP/Other Communication Supports and Services 66% Overall
67% Red Flag		 85% Overall
86% Red Flag
Adaptive Equipment and Assistive Technology 60% Overall
60% Red Flag		 81% Overall
81% Red Flag
Dining/Dietary Supports and Services 71% Overall
61% Red Flag		 88% Overall
79% Red Flag
Behavioral Supports and Services 53% Overall
54% Red Flag
51% HCBS Settings Rule		 74% Overall
74% Red Flag
75% HCBS Settings Rule
Mental Health Supports and Services 63% Overall
64% Red Flag
HCBS Settings Rule		 74% Overall
72% Red Flag
79% HCBS Settings Rule
Protection From Harm 71% Overall
71% Red Flag		 90% Overall
90% Red Flag
Rights and Autonomy 61% Overall
59% Red Flag
59% HCBS Settings Rule		 88% Overall
88% Red Flag
87% HCBS Settings Rule
Overall 61%
N=225		 79%
N=215