DHS OIG FY 2013 Annual Report

November 2013

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

In accordance with Section 1-17 of the Illinois Department of Human Services Act (20 ILCS 1305) and the Abuse of Adults with Disabilities Intervention Act (20 ILCS 2435/5), I am pleased to submit the Fiscal Year (FY) 2013 report of the Office of the Inspector General (OIG) in the Department of Human Services (DHS), entitled Abuse and Neglect of Adults with Disabilities.

This OIG has the statutory mission of investigating and reporting upon allegations of abuse and neglect of adults who have disabilities and who reside in private homes, in DHS-operated MH and DD facilities, and in programs operated by local community agencies that are licensed, certified or funded by DHS to provide mental health or developmental disability services.

This annual report provides an overview of OIG's work during FY2013. It covers OIG's training, unannounced facility site visits, investigations, referrals for services, reviews to ensure implementation of corrective actions, and other aspects of OIG's statutory mission.

OIG is committed to preventing and addressing instances of abuse and neglect of Illinois' residents who are facing mental and physical challenges.


Michael J. McCotter

Inspector General

Executive Summary

During FY2013, the Office of the Inspector General (OIG) accomplished the following:

* Presented 106 training sessions on reporting or investigating abuse or neglect, with a total of 1,975 participants.

*  Conducted unannounced site visits to all sixteen DHS facilities providing mental health or developmental disability services, making 47 recommendations to prevent abuse or neglect.

*  Received 4,143 abuse or neglect allegations - 20% more than during FY2012. Compared to FY2012, OIG received:

  *  7% more allegations at facilities,

  *  21% more allegations at community agencies, and

  *  27% more allegations in domestic settings.

*  Referred 1,324 complaints that were outside OIG's jurisdiction to the appropriate entity, as well as recording an additional 367 calls that needed no referral.

*  Closed 3,618 investigations into abuse or neglect allegations - 5% more than during FY2012 and 17% more than during FY2011. OIG substantiated abuse or neglect in 398 of those investigations. Domestic cases accounted for 82 of the 398 substantiated cases and facility/agency cases for the remaining 316 cases.

*  Received 158 reports of deaths of individuals who were or had been receiving services in facility or community agency programs. OIG closed 129 death cases during FY2013. Of the 129 closed death cases, neglect was substantiated in six cases and issues were identified in 11 other cases.

*  Recommended administrative action in 813 cases at facilities or community agencies during FY2013. OIG received DHS-approved written responses in 693 of those cases, as well as another 67 completed from prior years, for a total of 760 written responses. A total of 998 issues were identified, the most common being substantiated abuse or neglect.

*  Referred to the IDPH Healthcare Worker Registry 52 employees of facilities or community agencies for substantiated physical abuse, sexual abuse, or egregious neglect. The Health Care Worker Registry is maintained by the Illinois Department of Public Health.

*  Pursuant to P.A. 98-0049 (HB 948), effective July 1, 2013, OIG's responsibility for investigating domestic cases under 20 ILCS 2435/, (Rule 51), involving adults with disabilities was transferred to the Department on Aging under a new Illinois statute, the Adult Protective Services Act . Under this new statute, the Department on Aging has jurisdiction to investigate allegations of abuse, neglect, and financial exploitation of elderly adults living in their own homes and adults with disabilities aged 18-59 who live in domestic settings in the community.

Table of Contents

Chapter I: Preventing Abuse or Neglect

A. Quality Care Board Page 1

B. Unannounced Site VisitsPage 1

C. TrainingPage 3

D. Facility Staffing Ratios Page 4

E. Investigative Protocols Page 5

Chapter II: Reporting Abuse or Neglect

A. Reporting Policies Page 6

B. Non-reportable Complaints Page 7

C. FY2013 Reporting Page 8

D. Initial Reporting TimelinessPage12

Chapter III: Investigating Abuse or Neglect

A. Investigative Timeliness Page 13

B. FY2013 Closures Page 14

C. Reconsiderations Page 17

Chapter IV: Stopping Abuse or Neglect

A. Domestic Abuse Intervention Page17

B. Health Care Worker RegistryPage 19

C. Written Responses Page 22

Chapter I: Preventing Abuse or Neglect

A. Quality Care Board

The Quality Care Board was authorized in 1992 by Public Act 87-1158, which states that the Board's purpose is to "monitor and oversee the operations, policies, and procedures" of the Office of the Inspector General (OIG). The Board is empowered to provide consultation on OIG practices, to review regulations, to advise on training, and to recommend policies to improve intergovernmental relations.

The law provides for the Board to have seven members, each appointed by the governor with consent of the State Senate. The members must be qualified by professional knowledge or experience in law, investigatory techniques, or the care of people who have mental illness or developmental disabilities. At least two members must either have a disability themselves or have a child with a disability. The members are not paid, but OIG may reimburse them for any costs for travel.

The Quality Care Board Members are:

Susan M. Keegan, Chair, Chicago, Illinois, Appointed 9/28/2012

G. Virginia Conlee, Springfield, Illinois, Appointed 09/28/2012

Thane A. Dykstra, Joliet, Illinois, Re-appointed 08/19/2010

Untress Lamont Quinn, Cahokia, Illinois, Appointed 09/28/2012

Ed Baker, Coal City, Illinois, Resigned 8/22/2013

Cathy Contarino, Resigned 3/7/2013

Neil Posner, Chicago, Illinois, Temporarily appointed 11/8/2013

The Board's quarterly meetings in FY2013 were held on: 7/17/12 (teleconference), 10/30/12 (face to face in Bloomington), February 28, 2013 (face to face in Bloomington) and April 30, 2013 (teleconference).

B. Unannounced Site Visits

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

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

Site Visit Dates

In FY2013, each OIG site visit was conducted by a team of two OIG staff, one of whom was a registered nurse. The dates of the site visits were as follows:

Alton MHCMarch 19-20, 2013

Chester MHC October 3-4, 2012

Chicago-Read MHC August 7-8, 2012

Choate DC October 1-2, 2012

Choate MHC October 2-3, 2012

Elgin MHC July 24-25, 2012

Fox DC January 15, 2013

Jacksonville DC September 12-13, 2012

Kiley DC August 21-22, 2012

Ludeman DC February 6-7, 2013

Mabley DC March 7-8, 2013

Madden MHC  December 11-12, 2012

McFarland MHC July 10-11, 2012

Murray DC November 27-28, 2012

Shapiro DC January 16, 2013

Singer MHC September 11-12, 2012

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

Each site visit ended with an exit conference, where the overall findings of the site visit were presented. A formal report of the findings was provided to the facility within 60 working days of the site visit. The facility was asked to send OIG a copy of any written plan the facility might develop to address the report's recommendations within 60 days of the site visit's closure. Receiving this written plan assists OIG in planning the following year's site visit, as OIG follows up on the facility's actions in response to the recommendations made the prior year. It also greatly reduces repeat recommendations for the upcoming year.

FY2013 Site Visit Survey Topics:

  • Bowel Monitoring
  • Choking
  • Nursing Care Plans
  • Emergency Evacuation
  • Equipment Maintenance
  • Supervisor/Leadership Training

In FY2013, OIG made 47 site visit recommendations. Four of the 47 were repeat recommendations from FY2012 and one recommendation remained for the third year. Five systemic patterns or findings were identified. Staff willingly participated in the site visits and worked efficiently and professionally with site visitors to address issues that may lead to abuse or neglect. The support of the facility administration and the division was evident in each site visit.

C. Training

OIG has always been committed to training as a primary means to prevent abuse or neglect and to ensure reporting occurs when abuse or neglect is alleged. OIG continually strives to update its training presentations and to add additional training topics to its schedules to further accomplish this goal. The statute has long mandated basic training of all facility and community agency employees on identifying and reporting abuse or neglect. Rule 50 requires that facilities and community agencies provide basic training to all full- and part-time employees, which includes owners/operators, contractors, subcontractors, and volunteers at least biennially.

FY2013 Training

According to statute, OIG offers and conducts three primary trainings for agency and facility staff. The first and most popular course is Rule 50 training. This training instructs attendees on the overall function of OIG with emphasis on the definitions and reporting requirements of all agency and facility employees (required reporters). Rule 50 mandates all employees to be trained upon hire and at least biennially thereafter. In FY2013, OIG conducted fifty Rule 50 trainings throughout the State with a total attendance of 1,236.

The second OIG-conducted course, "Basic Investigative Skills," is a two-day course concentrating on all aspects of conducting an investigation, with a special emphasis on allegations involving persons with developmental disabilities or mental illness. OIG mandates this course at least once for every facility or community agency staff person who is approved to conduct investigations. During FY2013, OIG trained 329 agency and facility staff on the skills to conduct a basic investigation . OIG continues to modify their training topics to assist agency and facility staff in meeting compliance with Rule 50 requirements relating to their investigative responsibilities.

The third course, "Investigative Skills Refresher," is a one-day refresher class for individuals who have completed the first two courses within the past two years. It reviews the definitions and emphasizes the key points in conducting an investigation and discusses problem areas that the investigators may have experienced in the past two years. During FY2013 OIG provided an investigative skills refresher training to 410 agency and facility staff.

In addition to the three primary trainings, the Training Department provides training to OIG staff in a wide range of topics to meet their required fiscal year goal of five (5) continuing education training hours. OIG staff were 100% compliant in meeting their training requirements. Some of the training topics provided this fiscal year were: Excel, Word, Rule 50, Financial Abuse Specialist Team Training Film, "Intellectual Disability", "The Story of Sid" and Lou Holtz's "Do Good".

D. Facility Staffing Ratios

By law, OIG's annual report must include facility census figures which includes counts of the number of individuals receiving services in each facility and the ratios of direct care staff to those individuals. OIG has always presented that ratio as of June 30th, which is the last day of each fiscal year.

Tables 1a and 1b below show the census figures and ratios for each type of facility for FY2013. The tables present census figures three ways:

* Counting every individual only once, regardless of the number of times he or she is admitted during the year, give an "unduplicated count." This count is in the first column.

* A more detailed method is to count every day that those individuals are in the facility or on temporary transfer to another location; this is the "person-days" or "on-books bed-days." This count is given in the second column.

* The third column is census taken on June 30, 2013; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2013, is the one used to calculate a direct care staff to patient ratio. The number of direct care staff is counted in Full-Time Equivalents, which counts part-time staff as only a fraction. That count, again as of June 30, 2013, is shown in the fourth column of the tables.

The June 30th census figures are then divided by the June 30th direct care staff figures to calculate a direct care staff to patient ratio, which is given in the fifth column.

Table 1a: Census and Staffing Ratios, DHS Psychiatric Hospitals, June 30, 2013

DHS Facility Unduplicated count of individuals served Person-days


annual totals) Inpatient census on June 30 Direct care staff (full-time equivalent) Direct care to patient ratio

Alton MHC 262 43,432 119 133 1.12

Chester MHC 464 87,467 237 281 1.19

Chicago-Read MHC 886 37,504 107 221 2.07

Choate MHC 372 28,010 77 83 1.08

Elgin MHC 1068 142,293 389 607 1.56

Madden MHC 3154 49,239 135 179 1.33

McFarland MHC 623 39,568 120 204 1.70

MH facility totals 6,829 427,513 1,184 1,708 1.44

Table 1b: Census and Staffing Ratios, DHS Developmental Centers, June 30, 2013

DHS Facility Unduplicated count of individuals served Person-days


annual totals) Inpatient census on June 30 Direct care staff (full-time equivalent) Direct care to patient ratio

Choate DC 193 60,132 167 249 1.49

Fox DC 118 42,132 117 170 1.45

Kiley DC 237 76,745 213 269 1.26

Ludeman DC 441 150,546 418 512 1.22

Mabley DC 99 36,123 99 131 1.33

Murray DC 253 95,350 253 424 1.68

Shapiro DC 577 199,333 547 850 1.55

DD facility totals 1,918 660,361 1814 2,605 1.44

E. Investigative Protocols

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

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

OIG may assign the full investigation to a community agency only if the agency has applied for and adopted OIG's Investigative Protocol and been authorized by OIG. This process is an effective way to obtain commitments by the agency or facility to investigate objectively, to avoid any appearance of a conflict of interest, and to designate specific employees as investigators.

OIG reviews the employee's position title and job functions to rule out any potential or real conflict of interest, verifies that the person has attended OIG-conducted investigative skills training within the past two years and has no substantiated cases against him/her.

OIG may then, on a case by case basis, assign the full investigation to the community agency, but only in allegations of mental abuse, financial exploitation valued under $300, or neglect that is not thought to be egregious. When an investigation is assigned to a community agency, however, OIG remains involved by assigning an OIG investigator to monitor and assist with the investigation. This monitoring investigator sends an investigative plan to the agency investigator to follow, remains available to provide guidance, and is responsible for the first-level review of the final investigative report. Even when a case is assigned to the agency, OIG retains the right to assume full investigative responsibility for the case at any time during the investigation.

Renewal of an approved agency or facility investigative protocol is not automatic and OIG considers the performance of the agency or facility when determining whether to renew the authorization. In June of 2012, the Inspector General's Office elected to change the authorization date to a calendar year basis for both agencies and facilities. To accommodate that change, an extension for existing community agency protocols was granted to cover the time frame of July 1, 2012 through December 31, 2012. An additional extension was granted for both facilities and agencies, covering the time frame of January 1, 2013 through December 31, 2013 as changes to the protocol program were occurring. Currently, an application must be submitted each year but beginning January 1, 2014 this will change to a biennial application process. It is also OIG's prerogative to rescind an agency's approved protocol if deemed appropriate.

During calendar year 2013, 139 community agencies were authorized by OIG to conduct investigations. A total of 528 agency and 101 facility employees were designated and approved as investigators.

Chapter II: Reporting Abuse or Neglect

OIG maintains a 24-hour Hotline, to receive reports of alleged abuse or neglect and to respond immediately, if needed. The Hotline also allows facilities and community agencies to meet the statutory four-hour time frame for reporting.

The Hotline also receives reports of deaths when there is no allegation of abuse or neglect, including when: the death occurs within fourteen days after discharge or transfer elsewhere, any death occurring within 24 hours after deflection from a residential program or facility, or any death occurring within a residential program or facility or at any Department-funded site. If abuse or neglect is suspected, the death must be reported to OIG within four hours and OIG will conduct a full investigation.

A. Reporting Policies

Rule 50.20(d) mandates that all community agencies and facilities have a local policy detailing procedures for reporting abuse or neglect allegations and deaths. Beginning in 2010, OIG reviewed all community agency and facility abuse or neglect reporting policies to ensure compliance with statutory and Rule 50 changes. As of June 30, 2013, OIG has received and reviewed 317 community agency policies on reporting abuse and neglect and all were deemed acceptable.

B. Non-Reportable Complaints

The OIG Hotline receives frequent calls about incidents or complaints that do not meet the abuse or neglect definitions or other reporting requirements in Rule 50 or Rule 51. The Hotline investigator explains why it is not reportable to OIG and, if applicable, may either refer or directly transfer the caller to the correct reporting entity.


Issues that need follow-up, but are not within OIG's jurisdiction, need to be referred to the most appropriate entity. OIG may make the referral itself or instruct the caller on where and how to report the allegation.

Table 3 below shows the referral locations for Non-Reportables received this fiscal year.

Table 3: Referrals of Non-Reportable Complaints Received in FY2013

Referral Location Non-Reportable

Facility or Agency Complaint Non-Reportable

Domestic Setting Complaint

Local community agency or facility 845 14

Illinois Department of Public Health 47 7

Department of Children and Family Services 18 5

Local law enforcement authority 12 91

Department on Aging 5 15

DHS Division of Rehabilitation Services 5 39

DHS - BALC  11 0

DHS Division of Developmental Disabilities 10 4

DHS Division of Mental Health 17 5

Illinois State Police 2 0

Other 49 41

None needed 85 282

Referred out to unknown agency 82 0

Totals 1,188 503

Frequently, Non-Reportables are calls from a representative of the community agency or facility, self-reporting an issue or incident that is not reportable. OIG instructs the caller to handle it internally and to call OIG back if any indication of abuse or neglect is found. Individuals may also call in Non-Reportables that can be referred back to the facility or community agency to address. Together, these accounted for 71% of referrals in FY2013. Referrals were made in 1103 of the 1188 (93%) non-reportable complaints.

Referrals were made in 221 of the 503 (44%) non-reportable domestic setting complaints. A third of these referrals were made to local law enforcement or another state agency with jurisdiction. Some of the reasons for not referring a complaint are: the individual is able to seek assistance, the individual is not impaired, the alleged victim had already taken steps to seek help for the issue (ie. changing caregivers or obtaining different guardian), or the alleged victim's situation had already been resolved (ie. moved to a different residence).

C. FY2013 Reporting

During FY2013, OIG received a total of 4,143 allegations of abuse or neglect. The counts by type and location are shown in the table below. Financial exploitation is included in abuse, as defined in Rule 50. Tables 5a through 5c, on the following pages, show a more detailed breakdown by allegation type and location.

Table 4: Summary of Allegations Received by OIG in FY2013

Location Abuse allegations Neglect allegations Total allegations

DHS-operated facilities 622 175 797

Community agencies 1,312 808 2,120

Domestic settings 541 685 1,226

Total 2,475* 1,668 4,143

*Contains the following financial exploitation allegations: 12 from DHS-operated

facilities, 85 from community agencies, and 65 from domestic settings.

Overall, allegations reported to OIG continue to increase from year to year. Total allegations increased by 20% since FY2012 and 38% since FY2011. The most significant increase since last year is in the domestic setting at 27%, followed by community agencies at 21% and facilities at 7%. However, if total allegations are compared by location from those in FY2013 to those in FY2011, there has been a 62% increase in domestic setting allegations, a 37% increase in community agency allegations, and a 12% increase in facility allegations.

Allegations of abuse or neglect at the community agencies comprise the largest percentage of total allegations of any setting over the past several years. In FY2013 and in the two previous years, allegations at community agencies accounted for nearly 51% of all allegations OIG received. This high percentage of allegations is reflective of the number of individuals receiving services by community agencies. OIG expects this percentage to increase as Governor Quinn continues to make rebalancing the provision of services toward community care and away from state operated facilities a high priority.

Total abuse allegations increased by 12% since FY2012 and 22% since FY2011. Allegations of financial exploitation (a subset of abuse) increased in FY2012 from five to twelve (240%) at

facilities and from 65 to 85 (31%) at community agencies. Allegations in domestic settings remained steady at approximately 65.

Total neglect allegations reflected the largest increases, 33% since FY2012 and 69% since FY2011. The percentage of allegations that are neglect has steadily risen. In FY2013, neglect allegations account for 40% of all allegations as compared to 32% in FY2011.


During FY2013, OIG received 797 total allegations of abuse and neglect at the DHS-operated facilities, a 7% increase in allegations from FY2012 and a 12% increase from FY2011. Of the total allegations at facilities, there were 622 allegations of abuse including twelve allegations of financial exploitation In FY2013, abuse allegations accounted for 78% of total allegations a decline from FY2012 (82%) and FY2011 (83%).

OIG also received 175 allegations of neglect at facilities. While the neglect allegations only account for 22% of the total allegations, the number of neglect allegations has been on a steady upward trend. The number of neglect allegations increased by 28% since FY2012 and 47% since FY2011.

Community Agencies

During FY2013, OIG received 2,120 total allegations at community agencies. This is a 21% increase in allegations from FY2012 and a 37% increase from FY2011. Of the total allegations, there were 1,312 allegations of abuse, which includes 85 allegations of financial exploitation. Similar to the facilities, the percentage of abuse allegations to total allegations has steadily declined over the past several years. In FY2013, abuse allegations accounted for 62% of total allegations, in FY2012 65% and in FY2011 68%.

OIG also received 808 allegations of neglect at community agencies. While the neglect allegations only account for 38% of the total allegations, the number of neglect allegations has been on a steady upward trend. The number of neglect allegations increased by 33% since FY2012 and 67% since FY2011.


OIG's jurisdiction in domestic settings began July 1, 2000 and is limited to individuals between the ages of 18 and 59 who have a physical or mental disability that prevents them from seeking

assistance on their own. Thus, OIG receives only a part of all complaints of abuse, neglect, or financial exploitation in domestic settings.

During FY2013, OIG received 1,226 allegations in domestic settings, which was a 27% increase in allegations from FY2012 and a 62% increase from FY2011. Of the total allegations, there were 541 allegations of abuse, which includes 65 allegations of financial exploitation. Similar to the facilities and community agencies, the percentage of abuse allegations to total allegations has steadily declined over the past several years. In FY2013, abuse allegations accounted for 44% of total allegations, in FY2012 48% and in FY2011 49%.

OIG also received 685 allegations of neglect at domestic settings. In FY2013, the neglect allegations accounted for 56% of the total allegations, up from 52% in FY2012 and 51% from FY2011. The number of neglect allegations increased by 36% since FY2012 and 79% since FY2011.

Allegation Type

Table 5a, 5b and 5c shows the allegations and deaths that OIG received during FY2013 by type of allegation and program location. The tables list facilities individually and, at mental health facilities, separate "forensic" units (those for individuals who are committed by a criminal court order) from "civil" units (all others).

Allegations and deaths reported by community agencies are grouped into residential programs like community integrated living arrangements (CILAs) and non-residential programs like developmental training programs.

During FY2013, 158 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. OIG closed 129 death cases during FY2013. Of the 129 closed death cases, neglect was substantiated in six, and 11 other cases were unsubstantiated or unfounded with issues identified.

Table 5a: Allegations and Deaths Received in FY2013, Mental Health Services Only

Location Allegations Received 

Death reports

 Physical abuse Sexual abuse Mental abuse Financial exploita-tion Neglect Total received 


Alton MHC (civil) 1  


14 16 1 7 59 0

Alton (forensic) 2  12 4 17 0 5 38 0

Chester MHC 82 6 35 1 27 151 2

Chicago-Read MHC 13 0 5 0 10 28 1

Choate MHC 24 7 12 1 5 49 1

Elgin MHC (civil) 21 7 4 0 25 57 3

Elgin (forensic) 27 7 17 3 11 65 1

Madden MHC3 15 6 11 0 11 43 0

McFarland MHC (civil) 7 3 8 1 6 25 1

McFarland (forensic) 2 1 7 0 6 16 0

Singer MHC 2 0 1 0 0 3 1

Facility subtotals 226 55 133 7 113 534 10

Community agencies:

Residential 10 10 28 14 18 80 24

Non-Residential 7 13 28 18 10 76 1

Agency subtotals 17 23 56 32 28 156 25

Rule 50 MH totals 243 78 189 39 141 690 35

1 Civil units are for those individuals not committed by criminal court order,

2 Forensic units are for those individuals who are committed by criminal court order.

3 Includes one forensic physical abuse case

Table 5b: Allegations and Deaths Received in FY2013, Developmental Services Only

Location Allegations Received 

Death reports

 Physical abuse Sexual abuse Mental abuse Financial exploita-tion Neglect Total received 


Choate DC 21 1 5 2 16 45 1

Fox DC 5 0 0 0 1 6 0

Jacksonville DC 21 0 3 0 6 30 1

Kiley DC 27 0 5 2 6 40 0

Ludeman DC 36 1 3 1 10 51 3

Mabley DC 8 0 1 0 11 20 0

Murray DC 16 1 4 0 8 29 2

Shapiro DC 32 1 5 0 4 42 2

Facility subtotals 166 4 26 5 62 263 9

Community agencies:

Residential 502 37 273 48 574 1434 107

Non-Residential 199 16 103 5 206 529 7

Agency subtotals 701 53 376 53 780 1,963 114

Rule 50 DD totals 867 57 402 58 842 2,226 123

Table 5c: Allegations and Deaths Received in FY2013, Domestic Settings Only

Disability Type Allegations Received

 Physical abuse Sexual abuse Mental abuse Financial exploitation Neglect Self Abuse Self Neglect Death Total received

Developmental disability 260 36 37 35 327 2 15 5 717

Mental health 38 10 5 22 89 0 15 2 181

Physical disability 70 2 13 8 221 3 18 10 345

Rule 51 totals 368 48 55 65 637 5 48 17 1,243

D. Initial Reporting Timeliness

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

Each month, OIG sends the DHS program divisions a report of each "self-report" determined to be late. This report includes each late report, number of days late and the overall percentage late. The table below provides this information for the past three fiscal years.

Table 2: Late Reporting by Program and Disability Type, FY20011 through FY2013

Fiscal Year Total Self-Reports* Late from Agencies Late from Facilities Total Late Percent Late


FY2011 1,923 185 19 24 14 242 12.6

FY2012 2,144 199 17 25 22 263 12.3

FY2013 2,584 250 24 18 32 324 12.5

*Reported to OIG by the facility or community agency.

FY2013 showed the highest number of self-reports to date. The number of self-reports increased by 21% from the previous year and the percentage of late reporting remained relatively the same.

Chapter III: Investigating Abuse or Neglect

OIG's primary statutory mission is to investigate allegations of abuse or neglect of individuals receiving mental health or developmental disability services in a program operated, licensed, certified, or funded by DHS (20 ILCS 1305/1-17) or of adults with mental, developmental or physical disabilities that impair their ability to seek assistance and whom reside in domestic settings (20 ILCS 2435/5). OIG is committed to conducting timely and thorough investigations.

A. Investigative Timeliness

Rule 50 states that investigative case reports are to be submitted within 60 working days from assignment, unless there are extenuating circumstances. One such circumstance preventing completion within 60 days is an ongoing criminal investigation. When the Illinois State Police (ISP) or local law enforcement (LLE) accepts an allegation for criminal investigation, OIG is prohibited from beginning its administrative investigation until ISP/LLE has completed its criminal investigation. If a criminal investigation results in a referral for prosecution, OIG is often prohibited from beginning until the State's Attorney makes a prosecutorial decision.

For this reason, OIG counts total time and OIG time separately (see Table 6 and 6a below). OIG completed its Rule 50 investigations within the regulatory standard of 60 working days. Rule 51 cases were completed in an average of 44 days. Average completion time of Rule 51 cases is not affected by criminal investigations.

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

Investigations FY2011 FY2012 FY2013

Number completed 3070 3420 3472

Average total days* 52.2 48.0 56.1

Average OIG days* 50.2 45.9 54.8

*Average total days includes all time from initial report until case closure; while average OIG days

omits time for delays necessitated by pending ISP/LLE investigations.

Table 6a: Average Time to Completion for Rule 50 and Rule 51 Investigations

FY13 Investigations Rule 50 Rule 51 All

Number completed 2372 1100 3472

Average total days* 61.5 44.2 56.1

Average OIG days* 59.7 44.2 54.8

B. FY2013 Closures

By law, OIG uses three findings for its case reports. For Rule 50 cases, "Substantiated" means there is a preponderance of evidence that supports that the allegation it is more likely true than not that the abuse or neglect occurred. "Unsubstantiated" means there is not a preponderance of evidence that supports the allegation. "Unfounded" cases have no credible evidence supporting the allegation.

In Rule 51 cases, abuse or neglect may be substantiated by a "reason to believe" abuse or neglect has occurred. Substantiated cases in domestic settings are not reported to the IDPH's Healthcare Worker Registry.

The findings in abuse or neglect allegations and in death cases OIG closed during FY2013 are presented in the three tables that follow. The column entitled "Other issue(s) only" shows cases in which OIG did not substantiate abuse or neglect, but identified an issue or issues and recommended that the facility or agency take administrative action to address it (unfounded with

issues and unsubstantiated with issues). The column entitled "Not substantiated" shows cases determined to be unfounded with no issues and unsubstantiated with no issues.

Table 7a: Cases Closed in FY2013, Mental Health Services Only

Location Abuse substan-tiated Neglect substan-tiated Other issue only Not substan-tiated Allegation findings totals Closed death cases


Alton MHC (civil) 1  1 1 1 48 51 0

Alton (forensic) 2  1 0 3 40 44 0

Chester MHC (forensic) 2 4 13 116 135 0

Chicago-Read MHC 0 0 1 16 17 1

Choate MHC 0 1 2 46 49 0

Elgin MHC (civil) 0 1 7 36 44 1

Elgin (forensic) 0 0 8 53 61 2

Madden MHC 1 1 2 47 51 1

McFarland MHC (civil) 2 1 5 16 24 0

McFarland (forensic) 0 0 0 12 12 0

Singer MHC 3 0 0 4 7 1

Tinley Park MHC 0 0 0 6 6 0

Facility subtotals 10 9 42 440 501 6

Community agencies:

Residential 4* 0 14 44 62 19

Non-Residential 7** 1 8 51 67 1

Agency subtotals 11 1 22 95 129 20

Rule 50 MH Totals 21 10 64 535 630 26

1 Civil units are for those individuals not committed by criminal court order.

2 Forensic units are for those individuals who are committed by criminal court order.

  • Includes two substantiated financial exploitation cases
  • Includes one substantiated financial exploitation case

Table 7b: Cases Closed in FY2013, Developmental Services Only

Location Abuse substan-tiated Neglect substan-tiated Other issue only Not substan-tiated Allegation findings totals Closed death cases


Choate DC 4 3 4 32 43 1

Fox DC 0 0 0 6 6 2

Jacksonville DC 0 0 3 39 42 3

Kiley DC 0 1 5 30 36 0

Ludeman DC 0 1 9 24 34 3

Mabley DC 3 5 3 7 18 0

Murray DC 3 3 4 18 28 2

Shapiro DC 3 2 1 32 38 3

Facility totals 13 15 29 188 245 14

Community agencies:

Residential 71* 110 282 766 1,229 86

Non-Residential 36** 40 99 250 425 3

Agency totals 107 150 381 1,016 1,654 89

Rule 50 DD Totals 120 165 410 1,204 1,899 103

*includes five substantiated financial exploitation cases

**includes one substantiated financial exploitation case

Table 7c: Cases Closed in FY2013, Domestic Settings Only

Location Abuse substan-tiated Neglect substan-tiated Exploitation substan- tiated Refused consent* Not substan- tiated Findings Totals Deaths

Developmental disability 47 25 0 93 472 637 5

Mental health 2 0 0 68 80 150 3

Physical disability 4 4 0 91 203 302 6

Rule 51 Totals 53 29 0 252 755 1,089 14

The statute governing OIG's duties and responsibilities in domestic settings allows an alleged victim to refuse consent for the assessment or services. That is, in 252 domestic cases above, the alleged victim did not consent to OIG conducting an assessment of whether abuse or neglect occurred.

Trends in Closures

OIG continues to strive to keep up with the increase in allegations received. During FY2013, OIG closed 3,618 allegations compared to the 4,159 new allegations received. Including the 129 closed death cases, OIG closed a total of 3,747 cases.

The number of allegations closed continues to increase each year. During FY2013, OIG closed 5% more allegations than in FY2012 and 17% more than in FY2011. While investigative caseloads are increasing, OIG has experienced a 25% reduction in staffing over the past 10 years. OIG continues to seek improved efficiencies, streamlining of internal processes and possible geographic redistricting of Bureaus to meet this challenge.

Trends in Investigative Findings

The substantiation rate or the percentage of allegations that are substantiated, is shown in Table 8. The rates of substantiations at facilities and agencies have fluctuated slightly over time with no trends noted. The substantiation rate in domestic settings has fluctuated as well over the past several years with a fairly significant decrease in rate in FY2013. This decrease in substantiation rate is most likely due to the increased community awareness of OIG's function and its Hotline number which contributed to a 27% increase in number of allegations received in FY2013. Another possible reason is the fact that 148 incomplete cases were transferred to the Illinois Department on Aging at the end of the fiscal year when the Adult Protective Services Bureau assumed jurisdiction.

Table 8: Substantiation Rates by Location and Fiscal Year, FY2011 through FY2013

Location FY11 FY12 FY13

DHS facilities 4.2% 6.7% 6.3%

Community agencies 15.5% 16.1% 14.0%

Domestic settings 15.9% 14.6% 7.4%

Overall total 12.8% 13.6% 10.5%

C. Reconsiderations

During FY2013, OIG received 134 requests to reconsider the findings of 119 OIG Rule 50 investigations. Of the 134 requests, OIG granted 32 (involving 29 cases); the remaining 102 requests were denied because no new information was provided, which is a requirement of Rule 50. Of the 29 cases with granted reconsiderations, OIG revised 26 case reports. Of the 26 revised case reports, 10 had changes in findings or issues. OIG received requests for reconsideration in approximately 38% of all Rule 50 substantiated cases. Only 1% of the case reports were revised and of these only 0.4% had changes to findings or issues. The reconsideration process continues to show that OIG investigative findings are largely accurate and that OIG is responsive to new information that can change the finding.

Chapter IV: Stopping Abuse or Neglect

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

A. Domestic Abuse Intervention

OIG continued to have separate statutory authority under 20 ILCS 2435/ (Rule 51) through FY2013 to take immediate action to intervene in domestic situations where abuse, neglect, or financial exploitation is being substantiated or will be substantiated. However, pursuant to P.A. 98-0049 (HB948), effective July 1, 2013, OIG's responsibility for investigating domestic cases involving adults with disabilities was transferred to the Department on Aging under a new Illinois statute, the Adult Protective Services Act . Under this new statute, the Department on Aging has jurisdiction to investigate allegations of abuse, neglect, and financial exploitation of elderly adults living in their own homes and adults with disabilities aged 18-59 who live in domestic settings in the community.

The FY2013 statute describes three primary interventions in domestic cases: Emergency placement in a different residence; a formal order of protection obtained through the local court system; and initiation or a change of guardianship, either to a different family member or the Office of State Guardian.

Emergency Placement

The most common type of emergency intervention is the removal of the individual from a situation where there is risk of great bodily harm or death. Upon investigating an allegation,

OIG may find an individual in an emergency situation which requires transport to a hospital or other facility.

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

Order of Protection

OIG may instead find that the problem is the alleged perpetrator, not the individual's home. OIG may help the individual pursue this remedy against the alleged perpetrator or if the person is non-verbal, pursue on their behalf. Since this intervention is time-limited and requires the cooperation of the alleged victim, it is used infrequently.


If the alleged perpetrator is also the individual's guardian, and the evidence indicates there is an immediate and urgent necessity, OIG shall seek the appointment of a temporary substitute guardian. OIG first tries to find a suitable family member to assume guardianship. If that fails, OIG discusses the case with the Illinois Guardianship and Advocacy Commission, Office of State Guardian. If that Office agrees to accept the case, OIG then petitions the court to appoint a person from Guardianship and Advocacy as the guardian. This intervention has long-term benefits for care and treatment decisions.

Table 9 below shows the breakdown of emergency interventions during FY2013 and the prior two fiscal years. While variations from year to year are evident, no long-term trends in these interventions can be drawn. The reduction in the use of emergency placement in FY2013 may be due to more agencies providing emergency placement without or prior to OIG involvement.

Table 9: Emergency Interventions by Fiscal Year, FY2011 through FY2013

Intervention FY11 FY12 FY13

Orders of protection 4 4 2

Emergency placement 29 39 16

Guardianship pursued 11 15 13

FY2013 service plan referrals

When OIG substantiates a domestic case, the statute requires that OIG refer the individual to the appropriate DHS program division to develop a plan for providing needed services. Individuals referred may already be receiving services provided by DHS either directly or through a community agency. Table 10 shows the program divisions to which OIG referred individuals in substantiated cases during FY2013 and the two prior fiscal years.

Table 10: Service Plan Referrals by Fiscal Year, FY2011 through FY2013

DHS DivisionFY11 FY12 FY13

Developmental Disabilities 92 115 65

Rehabilitation Services 29 18 12

Mental Health 0 3 3

Totals 121 136 80

Most service plan referrals continue to be sent to the Division of Developmental Disabilities. In addition to service plan referrals, OIG may make a secondary referral to another division or external entity. Counting the secondary referrals, OIG made 201 referrals in substantiated domestic cases. Secondary referrals would include such agencies as: local law enforcement, Illinois Department of Public Health and the Illinois Department of Human Services Division of Alcoholism and Substance Abuse.

B. Health Care Worker Registry

Since January 1, 2002, OIG has been required to notify the Illinois Department of Public Health's Health Care Worker Registry of the identity of any person with an OIG substantiated finding of physical abuse, sexual abuse, or egregious neglect in a Rule 50 setting. The statutory definition of employees has been expanded and now includes, but is not limited to: Owners, operators, payroll personnel, contractors, subcontractors, and volunteers. It also includes someone who is no longer working for an agency or facility, but is the subject of an ongoing OIG investigation.

Data and Trends in Registry Referrals

FY2013 is the eleventh full year in which employee names were referred to the Health Care Worker Registry. During FY2013, OIG made 52 referrals to the Registry. Twelve referrals involved facility employees and 40 involved agency employees. One staff was referred for four separate cases; two other employees were each referred for two cases. During FY2013, eleven facility employees referred to the Registry were direct care staff and one was an administrative staff, a house manager, referred for physical abuse. Two of the 40 agency staff referred were professionals - one a counselor referred for sexual abuse and one a registered nurse referred for egregious neglect. The other 37 agency staff were direct care staff, including a volunteer referred for sexual abuse.

Type of Referrals

Physical Abuse: When referrals are due to physical abuse cases where staff's non-accidental and inappropriate contact with an individual causes bodily harm.

Substantiated physical abuse accounted for 39 of the 52 referrals (75%) this fiscal year - ten facility staff and 29 agency staff.

Among referrals for physical abuse in FY2013 were the following:

* Two individuals on way to a developmental training site became involved in a physical confrontation. The employee driving the van told one of them to hit the other back, and then actually left both of them unsupervised in the van despite their threats of physical harm to each other. When she returned to the vehicle, one had sustained a bloody nose.

* At a CILA home, an individual began singing Christmas carols while in the kitchen. An employee asked him to stop singing, however he continued to sing loudly. The employee then took a cup of water and threw it into the individual's face to make him stop.

* An employee approached an individual and, without provocation, punched him with a closed fist three or four times on the side of his head. The individual placed his hand into his adult undergarment and the employee then pinched and pulled on the skin of the individual's hand to remove it from his pants. Each time the individual repeated this behavior, the employee punched him in the groin. After the individual showed no reaction, the employee grabbed him by the back of the neck, slapping his hand against his neck in the process and hit him in the head two or three more times.

* During two separate incidents on the same day, an employee choked two individuals with sheets by placing the sheets around their necks and yanking on them while the individuals were seated. One of the individuals sustained petechia, or reddening and rash, to the face, forehead and scalp. Another employee, who later punched one of the same individuals on his arm and chest, witnessed the actions but did nothing, because he "didn't want to get involved."

* In the parking lot of an urgent care center, an employee picked an individual up out of the agency van's passenger seat and slammed her body into her wheelchair. When the individual leaned forward, the employee again pushed her back into her wheelchair, using the same force as she had earlier. The employee was charged and found guilty of criminal misdemeanor battery and was sentenced to eighteen months of court supervision.

Sexual Abuse: In FY 2013, nine employees (17%) were referred to the Registry for sexual abuse. Seven were DD agency employees and two were MH agency employees.

Among this year's referrals for sexual abuse were the following:

* An employee sexually assaulted three different individuals living in a CILA home, which included fondling and penetrating two of them. He also had a fourth substantiated physical abuse case for hitting another individual very hard on his hand.

* An employee inappropriately touched the genitals of an individual while he was showering, despite the fact that his behavior plan said he could shower independently.

* A male individual developed a crush on a married female employee, which led to him sending her over 232 phone calls and 530 text messages. They engaged in inappropriate sexual contact at a bowling alley and sent each other inappropriate nude photos. After the employee was told to cease all interactions with the individual, she continued to initiate contact and even gave him a ride in her car. The individual was manipulated into buying her jewelry and clothing for her birthday, and when the employee finally ended the relationship, the individual attempted suicide and had to be hospitalized. The staff person was charged with two counts of Criminal Sexual Misconduct With a Person With a Disability, a Class 3 Felony.

* An employee engaged in sexual activity with an individual living in a CILA. He coerced her into the relationship and told her because he was a supervisor, he would have her removed from her home in the residential setting if she failed to succumb to his advances.

Egregious Neglect: In FY2013, four names (8%) were referred to the Registry for egregious neglect. Among the cases were:

* A facility employee watched through the window of a restraint room as two other staff members physically abused an individual by striking him in the jaw and left rib cage and kneeing him in the back and throat while adjusting his restraints. The individual did not resist as he was placed into restraints. At one point, the employee who was watching the event and acting as a look-out placed his clip board over the window in order to block the view into the room. The individual's physical condition deteriorated and he required a CT scan of his injuries.

* An employee refused to allow an individual to eat his lunch because the individual pushed his lunch box toward him. The employee instead took the individual out for a run as a means to curb his behaviors and "drain some energy", and held his hand while running him up and down a hill. This caused the individual to fall with the employee falling on top of him, instantly breaking the individual's left ankle and causing a bone to puncture his skin. The individual required immediate surgery to insert a steel plate in his ankle and he was scheduled for several months of specialized care to recover. Unfortunately, prior to returning to the agency, he passed away after he choked while eating at the convalescent center.

* An individual who was on 15 minute special observation checks for suicidal ideation was found hanging five minutes after a staff person failed to complete one of his required face checks. The individual had already placed a bed sheet around his neck and hung himself from the door. The staff assigned to him was passing out meal trays in the dining area. The individual passed away the next day.

* An employee, who is a registered nurse, was notified in October 2011 that a non-ambulatory, high risk individual had a sore/ulcer on her buttocks. There were no assistive devices at the CILA to reposition her, and no assessment or special care was documented by staff or the RN. By the following month, the wound had progressed to a Stage IV decubitus ulcer and was infected with feces. When the doctor debrided the wound, he ordered the individual to have specialized treatment for the wound, which was never followed up or documented by the agency or RN. The individual was subsequently admitted to the hospital with pneumonia, a urinary tract infection, and a deep ischial decubitus ulcer, representative of osteomyelitis (bacterial organisms had invaded bone tissue). She was transferred to a skilled nursing facility until January 2012, and then was readmitted to the hospital where she passed away from severe sepsis and shock due to an infected Stage IV sacral decubitus ulcer.

 C. Written Responses

 When OIG substantiates abuse or neglect or makes a recommendation regarding other administrative issues during an investigation, the facility or agency is required to respond in writing. This "Written Response" must indicate the action(s) that have been taken or are

 planned to protect the individual from future occurrences of abuse or neglect and eliminate the problem(s) identified during the investigation.

 The facility or agency has 30 calendar days from the date the investigative report is received to submit a Written Response to the appropriate program division in DHS. The program division then reviews and approves the Written Response, listing the proposed actions, sending the approved Written Response to OIG.

 FY2013 Issues

 In FY2013, OIG sent an initial Written Response to facilities or community agencies in 813 cases. OIG received the approved Written Responses in 693 of those 813 cases. OIG also received 67 Written Responses that had been required during a prior fiscal year, totaling 760 approved Written Responses received during FY2013. Those 760 Written Responses identified a combined total of 998 issues. Table 12 compares the number of issues cited across three fiscal years.

 Table 12: Issues Cited in Approved Written Responses Received, FY2011 through FY2013




 Late reporting18115.319614.814614.6

 Nursing practices18015.21037.8929.2

 Investigative error423.5221.7282.8

 Service plan 816.81168.7999.9

 Inappr. interaction806.7896.7707.0

 Failure to report837.017713.3474.7


 All other issues18715.81289.715515.5

 Total issues1,1861001,326100998100

 This table shows that the count of total issues OIG cited in FY2013 was 25% less than in FY2012. Substantiations by OIG remain the highest percentage of cited issues. The number of citings for late reporting decreased by 26% from FY2012. Failure to report was cited 47 times, which is a 73% decrease from FY2012. Improvements in late reporting and failure to report allegations indicate successful training and increased effort by agency and facility staff.

 FY2013 Actions Taken

 OIG may identify multiple issues in a single case, and each issue may require multiple actions. Any single action may involve many people (e.g., a group training of ten employees) or many

 documents (e.g., a revision of three related forms). For consistency of reporting, OIG counts actions taken.

 During FY2013, the facilities and agencies performed 1,515 actions to address the 998 issues identified in the approved Written Responses.

 OIG categorizes the actions taken into 22 types. During FY2013, the most common action taken continues to be retraining of the involved employee(s), which was completed in 317 issues that were raised in approved Written Responses. Related to this is general group retraining, which may involve a single unit, a job function, a range of job titles, or the entire staff of the facility or agency, which was completed in a total of 172 issues.

 After training, the most common action is disciplinary action involving at least one employee: i.e., discharge (201); suspension (54); written reprimand (87); and oral reprimand (27). Three times at least one employee had been fired for other reasons; sixteen times at least one was reassigned; and 56 times at least one employee resigned in lieu of disciplinary action. Counseling (68); increased supervision (nine); and performance evaluation objectives (four)

 were other actions taken with employees. OIG does not recommend any specific disciplinary action be taken in connection with its investigated cases.

 Policy or procedural revisions were made in 206 issues; modifications were made to habilitation or treatment plans in 75 issues; administrative changes were made in 14 issues; and some repairs/upgrades to buildings and other structures were completed in ten issues.

 FY2013 Implementation Status Reports

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

 The facility or community agency must list on the Written Response the date that all actions were implemented. If all actions were not implemented by the time the Written Response was approved, the facility or community agency must send an implementation status report to OIG every 60 days until every listed action is implemented. On a monthly basis, OIG sends the facility or community agency a reminder letter about any implementation status reports that are overdue. The letter also indicates what is needed to complete the actions on the case(s).

 FY2013 Compliance Reviews

 The other way that OIG ensures that the actions are implemented is through obtaining actual documentation proving that implementation occurred. These "Compliance Reviews" are outlined in Section 50.80(d) of Rule 50.

 OIG conducts Compliance Reviews on two types of Written Responses. First, each month, OIG selects a random sample of all approved Written Responses received during the prior month - Rule 50 requires a minimum of 10%; OIG chooses 15%. Second, each month, OIG adds to that

 sample every approved Written Response that has been approved for longer than 120 days, but for which the actions listed on it have not yet been implemented.

 For FY2013 Compliance Reviews, OIG randomly selected 128 (16.7%) of the 768 required Written Responses approved from May 1, 2012 through April 30, 2013, and then added all of the remaining 13 Written Responses that were pending over 120 days. Table 13 below shows the breakdown of all 141 Compliance Reviews by disability type and location.

 Table 13: FY2013 Compliance Reviews on Approved Written Responses

 LocationDD ProgramsMH ProgramsTotals

 DHS facilities111425

 Community agencies1088116


 OIG's Compliance Reviews seek documentation that the actions listed in the approved Written Response were actually taken. For example, in the cases of retraining for late reporting, the Compliance Reviewers first obtain training sign-in sheets or some other document proving completion of the training. The reviewers must also obtain: a signed acknowledgment of understanding from the employee, a successfully completed test or interview the employee to ensure that he/she understands the definitions of abuse and neglect and timely reporting requirements. The Compliance Reviewers may also review the curriculum for the training and recommend using the OIG Rule 50 training module that was distributed in April 2010.

 During FY2013, OIG sent two "out of compliance" letters, to one DD community agency and one DD facility which did not provide documentation that all actions listed on the approved Written Response had been implemented.

 OIG's randomly selected compliance reviews help ensure that problems and unsafe practices identified during an investigation have been corrected by the facility or agency. Ensuring that corrective action has been taken helps the facility and agency to effectively address the underlying issues and allows the individuals to avoid suffering a recurrence of the abuse or neglect. It also brings OIG full-circle in preventing abuse or neglect of people in Illinois who are receiving mental health or developmental disability services.