DHS OIG FY 2015 Annual Report

November 2015

To Governor Bruce Rauner and Members of the Illinois General Assembly:

In accordance with Section 1-17 of the Illinois Department of Human Services Act (20 ILCS 1305), I am pleased to submit the Fiscal Year (FY) 2015 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 Office of the Inspector General has the statutory mission of investigating and reporting allegations of abuse and neglect of adults who have disabilities and who reside 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 FY2015. 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 FY2015, the Office of the Inspector General (OIG) accomplished the following:

  • Presented 105 training sessions on reporting or investigating abuse or neglect, with a total of 1,844 participants.
  • Conducted unannounced site visits to all fourteen DHS facilities providing mental health or developmental disability services, making 51 recommendations to prevent abuse or neglect.
  • Received 3,343 abuse or neglect allegations

Compared to FY2014, OIG received:

    • 10% less allegations at facilities, and
    • 4% more allegations at community agencies.
  • Referred 1,488 complaints that were outside OIG's jurisdiction to the appropriate entity
  • Closed 3,330 investigations into abuse or neglect allegations. OIG substantiated abuse or neglect in 388 of those investigations. Community agency cases accounted for 340 of the 388 substantiated cases (88%) and facility cases for the remaining 48 cases (12%).
  • Received 196 reports of deaths of individuals who were or had been receiving services in facility or community agency programs. OIG closed 179 death cases during FY2015. Of the 179 closed death cases, neglect was substantiated in five cases and issues were identified in 39 other cases.
  • Recommended administrative action in 914 cases at facilities or community agencies during FY2015. OIG received DHS-approved written responses in 744 of those cases, as well as another 117 completed from prior years, for a total of 861 written responses. A total of 1,096 issues were identified, the most common being substantiated abuse or neglect.
  • Referred to the IDPH Health Care Worker Registry 48 employees of facilities or community agencies for substantiated physical abuse, sexual abuse, financial exploitation, or egregious neglect. The Health Care Worker Registry is maintained by the Illinois Department of Public Health.

Table of Contents

  1. Chapter I: Preventing Abuse or Neglect
    1. Quality Care Board Page 1
    2. Unannounced Site Visits Page 1
    3. Training Page 3
    4. Facility Staffing Ratios Page 4
    5. Investigative Protocols Page 6
  2. Chapter II: Reporting Abuse or Neglect
    1. Non-reportable Complaints Page 7
    2. FY2015 Reporting Page 8
    3. Initial Reporting Timeliness Page13
  3. Chapter III: Investigating Abuse or Neglect
    1. Investigative Timeliness Page 14
    2. FY2015 Closures Page 14
    3. Reconsiderations Page 17
  4. Chapter IV: Stopping Abuse or Neglect
    1. Health Care Worker Registry Page 18
    2. Written Responses Page 21

Abuse and Neglect of Adults with Disabilities

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

Thane A. Dykstra, New Lenox, Illinois, Re-appointed 8/19/2010 Untress Lamont Quinn, Shiloh, Illinois, Appointed 09/28/2012

Neil Posner, Chicago, Illinois, Appointed 11/8/2013

The Board's quarterly meetings in FY2015 were held on: July 10, 2014 (teleconference),

March 24, 2015 (teleconference), and June 13, 2015 (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.

FY 2015 Issues

OIG's site visit protocol was initially created on January 16, 1997. Minimal changes have been made to the protocol in the past seventeen years, primarily adding a second site visitor in 1999 and clinical coordinator in 2005. Because of many factors, including additional responsibilities as well as contractual and staffing constraints, the decision was made in FY15 to update the protocol, thereby making more efficient use of existing staff resources, as well as adding a fresh approach to OIG's statutory responsibilities. This new approach was more of a tracer methodology, whereby staff took relevant issues and followed them through from the beginning of the admissions process through discharge.

The framework for the visit included:

  • Admission processes - qualifications of professional staff, relevancy and thoroughness of forms, overall quality of treatment of individual being admitted;
  • Overall stay experience - perceived treatment by staff, relevance of programming, privacy, use of privileges vs. rights, use of referrals;
  • Human rights process - accessibility, utilization of consumer groups, facility follow up, tracking of trends/patterns; and
  • Discharge - emphasis on positive outcomes, continuity of care.
Site Visit Dates

In FY2015, each OIG site visit was conducted by a team of two OIG staff. The dates of the site visits were as follows:

Site Date(s)
Alton MHC January 22 and 23, 2015
Chester MHC March 18 and 19, 2015
Chicago-Read MHC March 9 and 10, 2015
Choate DC November 12 and 13, 2014
Choate MHC November 13 and 14, 2014
Elgin MHC May 12 and 13, 2015
Fox DC May 18 and 19, 2015
Kiley DC April 22 and 23, 2015
Ludeman DC January 28 and 29, 2015
Mabley DC September 4 and 5, 2014
Madden MHC September 17 and 18, 2014
McFarland MHC January 15 and 16 and February 6, 2015
Murray DC June 23 and 24, 2015
Shapiro DC January 29 and 30, 2015

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 observe processes.

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.

In FY2015, OIG made 51 site visit recommendations. Eight of the 51were repeat recommendations from FY2014. Two systemic patterns or findings were identified. These included developing and implementing medical staff policies and procedures on physician competency assessments and developing a formalized evaluation process for ancillary clinical contracted services, individualized and specific to the type of services provided.

C. Training

OIG is 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 and neglect. Rule 50 requires that facilities and community agencies provide basic training to all employees, which includes owners/operators, contractors, subcontractors, and volunteers at least biennially.

Rule 50 additionally requires agencies and facilities to have someone trained to perform the preliminary steps of the investigation that are outlined in Rule 50, Section 50.30(f).

FY2015 Training

According to statute, OIG offers and conducts three primary trainings for agency and facility staff. The first and most attended 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 be trained upon hire and at least biennially thereafter. In FY2015, OIG conducted 51 Rule 50 trainings throughout the state with a total attendance of 966.

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 under the auspices of the Community Agency Investigative Protocol program. In FY2014, OIG modified this two day training into two distinct sections, simply identified as Day 1 and Day 2. BIS-Day 1 may be attended by any facility or agency staff and teaches attendees how to conduct the preliminary steps of an investigation, as required by Rule 50, Section 50.30(f). These steps include securing the scene, collecting and preserving evidence, taking appropriate photographs

and taking statements. BIS-Day 2 focuses on the investigative assignment procedures, how to conduct a professional investigative interview, document the investigatory interview, and write an investigative report. Each student learns the interviewing process by participating in multiple role playing exercises. During FY2015, OIG trained 254 staff in Day 1 Basic Investigative Skills and 259 staff in the complete two-day training for a total of 513 staff trained.

The third course, "Investigative Skills Refresher," is a one-day refresher class for staff members who have completed the OIG-conducted Rule 50 class and the two-day Basic Investigative Skills course within the past two years, and are Authorized Investigators in the Community Agency/Facility Investigative Protocol program. It reviews Rule 50 definitions and emphasizes the key points of conducting an investigation. During FY2015, OIG provided Investigative Skills Refresher training to 365 agency and facility staff at 24 training sessions.

The total number of training sessions conducted for the agencies and facilities in FY2015 was 101, with a grand total of 1,844 attendees.

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 FY2015. 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 which gives 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, 2015; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2015, 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, 2015, is shown in the fourth column of the tables.

The June 30th direct care staff figures are then divided by the June 30th census 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, 2015

DHS Facility Unduplicated count of individuals served Person-days (on-books annual totals) Inpatient census on June 30 Direct care staff (full-time equivalent) Direct care to patient ratio
Alton MHC 233 44,016 121 169 1.4
Chester MHC 481 90,671 264 361.4 1.37
Chicago-Read MHC 734 40,586 112 181.5 1.62
Choate MHC 240 28,572 75 96.1 1.28
Elgin MHC 1,209 141,109 397 508.4 1.28
Madden MHC 2,351 42,570 106 197.3 1.86
McFarland MHC 461 47,643 137 155.59 1.14
Total 5,709 435,167 1,212 1,669.29 1.38

Table 1b: Census and Staffing Ratios, DHS Developmental Centers, June 30, 2015

DHS Facility Unduplicated count of individuals served Person-days (on-books annual totals) Inpatient census on June 30 Direct care staff (full-time equivalent) Direct care to patient ratio
Choate DC 184 56,136 152 325.6 2.14
Fox DC 112 40,208 110 159.7 1.45
Kiley DC 202 70,002 187 380.8 2.04
Ludeman DC 424 147,594 397 606 1.53
Mabley DC 105 36,738 99 173.78 1.76
Murray DC 230 82,197 219 406.27 1.86
Shapiro DC 541 184,797 492 922.59 1.88
DD facility totals 1,798 617,672 1,656 2,974.74 1.8

*Figures provided by the DHS Budget Office

E. Investigative Protocols

Rule 50, Section 50.30(f), mandates that all facilities and all community agencies take some initial steps in response to allegations of abuse and 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 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 administrative actions it deems necessary, but it must request permission from OIG before conducting its own full investigation.

Per Section 50.40(c) of Rule 50, OIG may ask the agency to conduct a full investigation, but only if the agency has voluntarily applied for and adopted OIG's Investigative Protocol after being 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.

Prior to being approved as an agency investigator, OIG reviews the employee's position title and job function to rule out any potential or real conflict of interest. OIG verifies that the person has attended OIG-conducted Rule 50 and an investigative skills training course within the past two years and has no substantiated cases against him/her.

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. OIG may rescind an agency's approved protocol if deemed appropriate.

During FY2015, 129 community agencies were authorized by OIG to conduct investigations. A total of 705 agency employees and 112 facility employees were trained, designated, and approved as investigators.

Chapter II: Reporting Abuse or Neglect

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

The Hotline receives reports of deaths if abuse or neglect is suspected but also in the following circumstances: Any death occurring within 14 days after discharge/transfer, 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.

A. 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. 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.

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 suspected. Individuals may also call in non-reportables that can be referred back to the facility or community agency to address. Together, these accounted for 90% of referrals in FY2015. Referrals were made in 1,447 of the 1,488 (97%) non-reportable complaints.

Table 2 below shows the referral locations for non-reportables received this fiscal year.

Table 2: Referrals of Non-Reportable Complaints Received in FY2015

Referral Location Count
Local community agency or facility 1,346
Illinois Department of Public Health 6
Department of Children and Family Services 3
Department of Housing and Family Services 6
Local law enforcement authority 13
Department on Aging 3
DHS Division of Rehabilitation Services 2
DHS Division of Developmental Disabilities 23
DHS Division of Mental Health 10
Illinois State Police 1
Other 29
None needed 41
Totals 1,488

B. FY2015 Reporting

During FY2015, OIG received a total of 3,343 allegations of abuse or neglect. The counts by type and location are shown in Table 3 on the following page. Financial exploitation is included in abuse, as defined in Rule 50. Tables 4a and 4b, on the following pages, show a more detailed breakdown by allegation type and location.

Table 3: Summary of Allegations Received by OIG in FY2015

Location Abuse allegations Neglect allegations Total allegations
DHS-operated facilities 700 188 888
Community agencies 1,531 924 2,455
Total 2,231 1,112 3,343

* Contains 12 financial exploitation allegations from DHS-operated facilities and 130 from community agencies.

Total abuse allegations in DHS-operated facilities and community agencies increased by 2.5% since FY2014 and 15% since FY2013. In these same settings, allegations of financial exploitation (a subset of abuse) increased in FY2015 by 14.5% from FY2014 and 46% since FY2013.

While total neglect allegations in DHS-operated facilities and community agencies have decreased by 5% since FY2014, this is still an increase of 18.5% over FY2013.


During FY2015, OIG received 888 total allegations of abuse and neglect at the DHS-operated facilities, a 10% decrease in allegations from FY2014. Of the total allegations at facilities in FY2015, there were 700 allegations of abuse which includes 12 allegations of financial exploitation. Abuse allegations accounted for 79% of total allegations at facilities.

OIG also received 188allegations of neglect at facilities, for 21% of the total allegations. While previous years have shown a steady upward trend, the number of neglect allegations decreased by 17.5% since FY2014.

Community Agencies

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 FY2015, allegations at community agencies accounted for 73% 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 rebalancing the provision of services toward community care and away from state-operated facilities remains a high priority.

During FY2015, OIG received 2,455 total allegations at community agencies. This is a 4% increase in allegations from FY2014. Of the total allegations, there were 1,531 allegations of abuse, which includes 130 allegations of financial exploitation. This year, the percentage of abuse allegations to total allegations increased to 62% whereas in FY2014 it had fallen to 60% after having been at 62% in FY2013 and 65% in FY2012.

OIG also received 924 allegations of neglect at community agencies in comparison to the 940 received during FY2014.

Allegation Type

Tables 4a and 4b show the allegations and death cases that OIG received during FY2015 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 FY2015, 196 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. This is a 12% increase in deaths reported from FY2014. OIG closed 179 death cases during FY2015, a 7% decrease from FY2014. Of the 179 closed death cases, neglect was substantiated in five and 39 other cases were unsubstantiated or unfounded with issues identified.

Table 4a: Allegations and Deaths Received in FY2015, Mental Health Services Only

Location Physical abuse Sexual abuse Mental abuse Financial exploita- tion Neglect Total received Death reports
Alton MHC (civil) 1 26 5 20 0 6 57 0
Alton (forensic) 2 10 2 9 0 4 25 0
Chester MHC 64 9 36 0 21 130 0
Chicago-Read MHC 12 6 12 3 14 47 1
Choate MHC 34 8 11 4 4 61 2
Elgin MHC (civil) 16 6 4 0 18 44 4
Elgin (forensic) 29 10 18 3 17 77 2
Madden MHC 18 2 10 1 16 47 2
McFarland MHC (civil) 19 24 16 0 22 81 0
McFarland (forensic) 3 5 3 0 7 18 0
Facility subtotals 231 77 139 11 129 587 11
Community agencies:
Residential 12 5 28 11 14 70 21
Non-Residential 9 24 21 28 12 94 2
Agency subtotals 21 29 49 39 26 164 23
Rule 50 MH totals 252 106 188 50 155 751 34
  1. Civil units are for individuals who are not committed to the facility by the criminal judicial system.
  2. Forensic units are for individuals who are criminally court-committed.

Table 4b: Allegations and Deaths Received in FY2014, Developmental Services Only

Location Physical abuse Sexual abuse Mental abuse Financial exploitation Neglect Total received Death reports
Choate DC (civil) 1 48 1 21 0 10 80 0
Choate DC (forensic) 2 14 0 1 0 1 16 0
Fox DC 2 0 1 0 2 5 0
Kiley DC 30 1 1 0 5 37 1
Ludeman DC 41 1 7 1 14 64 4
Mabley DC 3 0 1 0 11 15 2
Murray DC 15 0 4 0 12 31 4
Shapiro DC 42 1 6 0 4 53 7
Facility subtotals 195 4 42 1 59 301 18
Community agencies:
Residential 671 48 271 88 709 1,787 138
Non-Residential 220 9 83 3 189 504 6
Agency subtotals 891 57 354 91 898 2,291 144
Rule 50 DD totals 1,086 61 396 92 957 2,592 162
  1. Civil units are for individuals who are not committed to the facility by the criminal judicial system.
  2. Forensic units are for individuals who are criminally court-committed.

C. 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". 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 four fiscal years.

Table 5: Late Reporting by Program and Disability Type, FY2012 through FY2015

Fiscal Year Total Self-Reports* Late from Agencies Late from Facilities Total Late Percent Late
FY2012 2,144 199 17 25 22 263 12.3
FY2013 2,584 250 24 18 32 324 12.5
FY2014 2,977 276 23 14 28 341 11.5
FY2015 2,927 265 19 22 22 328 11.2

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

After increasing for the previous three years, FY2015 showed a slight decrease in the number of self-reports. The number of self-reports decreased by 1.7% from the previous year while the percentage of late reporting decreased by only 0.3%. The Divisions of MH and DD have been very responsive to this issue and it is reflected in the decreasing percentage of late reporting.

Chapter III: Investigating Abuse or Neglect

This OIG has the statutory mission of investigating allegations of abuse and neglect of adults who have disabilities and who reside 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. 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) accept 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 below). Until the past two years, OIG was able to stay below the statutorily defined investigative limit of 60 days. The reasons for this increase are two-fold; reports of abuse/neglect have increased from 2,917 in locations under Rule 50 to 3,343 in FY2015 and OIG has been unable to fill a number of positions vacated by retirements.

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

Investigations FY2011 FY2012 FY2013 FY2014** FY2015**
Number completed 3,070 3,420 3,472 3,037 3,160
Average total days* 52.2 48 56.1 79.4 96.6
Average OIG days* 50.2 45.9 54.8 78.6 95.5

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

**Includes data for Rule 50 cases only. All other years include data for Rule 51 cases.

B. FY2015 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 of abuse or neglect occurred is more likely true than not. "Unsubstantiated" means there is not a preponderance of evidence that supports the allegation. "Unfounded" cases have no credible evidence supporting the allegation.

The findings in abuse or neglect allegations and in death cases OIG closed during FY2015 are presented in the two tables that follow. The column entitled "Other issue(s) only" shows cases in which OIG did not substantiate abuse or neglect during an investigation, but identified an issue(s), and recommended that the facility or agency take administrative action to address each issue. These cases are unfounded or unsubstantiated with issues. The column entitled "Not substantiated" shows cases determined to be unfounded or unsubstantiated with no issues.

Table 7a: Cases Closed in FY2015, 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 0 0 1 44 45 0
Alton (forensic) 2 1 2 1 21 25 0
Chester MHC 8 4 13 126 151 0
Chicago-Read MHC 0 1 3 36 40 1
Choate MHC 0 0 2 55 57 0
Elgin MHC (civil) 0 0 1 44 45 1
Elgin (forensic) 0 0 2 72 74 1
Madden MHC 1 1 3 51 56 2
McFarland MHC (civil) 0 2 4 56 62 0
McFarland (forensic) 0 1 0 16 17 0
Facility subtotals 10 11 30 521 572 5
Community agencies:
Residential 1 3 12 57 73 21
Non-Residential 2 2 14 76 94 1
Agency subtotals 3 5 26 133 167 22
Rule 50 MH Totals 13 16 56 654 739 27
  1. Civil units are for individuals not committed by criminal court order.
  2. Forensic units are for individuals who are committed by criminal court order.

Table 7b: Cases Closed in FY2015, Developmental Services Only

Location Abuse substan- tiated Neglect substan- tiated Other issue only Not substan- tiated Allegation findings totals Closed death cases
Choate DC (civil) 1 4 3 7 59 73 0
Choate DC (forensic) 2 0 0 1 13 14 0
Fox DC 1 0 1 2 4 4
Kiley DC 2 2 1 26 31 2
Ludeman DC 1 1 12 53 67 5
Mabley DC 0 7 5 2 14 0
Murray DC 0 4 3 20 27 3
Shapiro DC 2 0 1 64 67 7
Facility totals 10 17 31 239 297 21
Community agencies:
Residential 77 157 329 1,049 1,612 128
Non-Residential 35 58 95 314 502 3
Agency totals 112 215 424 1,363 2,114 131
Rule 50 DD Totals 122 232 455 1,602 2,411 152
Trends in Closures

During FY2015, OIG closed 3,151 investigative cases of abuse or neglect. Including 179 closed death cases, OIG closed a total of 3,330 cases. Total allegations and death reports received in FY2015 totaled 3,539 which is 6.3% more allegations received than cases completed.

While investigative caseloads are increasing, OIG has experienced a reduction in staffing over the past several years. Although the Auditor General in the last several audits has noted that OIG needs additional investigative staff to meet goals, several investigative bureaus have not been at full investigative contingent for the past three years. Over the past several years, the hiring process for filling vacant investigative positions has taken in excess of five months. OIG continues to improve efficiencies, streamline internal processes, redistrict bureau boundaries, and reposition staff into high volume areas to meet this challenge.

Trends in Investigative Findings

OIG substantiated abuse or neglect in 388 investigations. 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.

Table 8: Substantiation Rates by Location and Fiscal Year, FY2011 through FY2015

Location FY11 FY12 FY13 FY14 FY15
DHS facilities 4.20% 6.70% 6.30% 4.30% 5.40%
Community agencies 15.50% 16.10% 14.00% 16.40% 14.00%
Overall total 11.60% 13.20% 11.70% 12.70% 11.70%

C. Reconsiderations

During FY2015, OIG received 130 requests to reconsider the findings of 114 Rule 50 investigations, 70% of which were substantiated cases. Of the 130 requests, OIG granted 14 (involving 13 cases) and denied 94 (involving 87 cases) as no new information was provided, a requirement of Rule 50. Of the 13 cases with granted reconsiderations, OIG revised 10 case reports. Of those 10, four had changes in findings or issues. The reconsideration process continues to show that OIG investigative findings are largely accurate and that OIG is responsive to new information.

Chapter IV: Stopping Abuse or Neglect

OIG's statutory mission reaches beyond investigating. As noted at the outset of this report, OIG has been given the responsibility of acting to prevent abuse and neglect from occurring. Further, OIG is required to stop abuse and neglect as it occurs. This role is evident 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. Health Care Worker Registry

Since January 1, 2002, once all appeals are exhausted, 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.

Additionally, on July 16, 2014, Governor Pat Quinn signed into law Public Act 98-0711, which is OIG's initiative regarding financial exploitation. Therefore, any act of financial exploitation which occurred on or after that date is now potentially reportable to the Health Care Worker Registry.

Data and Trends in Registry Referrals

During FY2015, 48 employees were referred to the Registry. Four referrals involved facility employees and 44 involved agency employees. All four facility employees referred to the Registry were direct care staff. Seven of the 44 agency staff referred were administrative (one program supervisor, two housekeeping/maintenance staff, one house manager, two access team leaders and one case management coordinator). One staff was a professional staff (registered nurse). The other 36 agency staff were direct care staff.

Type of Referrals
Physical Abuse:

Physical abuse is defined as staff's non-accidental and inappropriate contact with an individual that causes bodily harm. It also includes actions that cause bodily harm as a result of an employee directing an individual or person to physically abuse another individual. Substantiated physical abuse accounted for 34 of the 48 referrals (71%) this fiscal year - four facility staff (two MH and two DD) and 30 DD agency staff.

Sexual Abuse:

Sexual abuse is defined as any sexual behavior, sexual contact, or intimate physical contact between an employee and an individual, including an employee's coercion or encouragement of an individual to engage in sexual activity that results in sexual contact, intimate physical contact, sexual behavior, or intimate physical behavior.

In FY2015, six employees (13%) were referred to the Registry for sexual abuse. All six were DD agency employees.

Egregious Neglect:

Egregious neglect is a finding of neglect as determined by the Inspector General that represents a gross failure to adequately provide for, or a callous indifference to, the health, safety, or medical needs of an individual and results in an individual's death or other serious deterioration of an individual's physical condition or mental condition. In FY15, five names (10%) were referred to the Registry for egregious neglect. Three were DD agency employees and two were mental health agency employees.

Financial Exploitation:

Financial exploitation is taking unjust advantage of an individual's assets, property, or financial resources through deception, intimidation, or conversion for the employee's facility's or agency's own advantage or benefit. In FY2015, three employees (6%) were referred to the Registry for financial exploitation. All three were DD agency employees involved in the same case.

B. 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.

FY2015 Issues

In FY2015, OIG sent an initial written response to facilities or community agencies in 914 cases. OIG received the approved written responses in 744 of those 914 cases. OIG also received 117 written responses that had been required during a prior fiscal year, totaling 861 approved written responses received during FY2015. In the 861 written responses received, there were a combined total of 1,096 issues identified.

Table 9: Issues Cited in Approved Written Responses Received, FY2012 through FY2015

FY2012 FY2013 FY2014 FY22015
Issues Count Percent Count Percent Count Percent Count Percent
Substantiations 399 30.1 325 32.7 407 33.5 384 35.1
Late reporting 196 14.8 146 14.6 194 15.9 159 14.5
Nursing practices 103 7.8 92 9.2 45 3.7 90 8.2
Investigative error 22 1.7 28 2.8 32 2.6 30 2.7
Service plan 116 8.7 99 9.9 118 9.7 79 7.2
Inappr. Interaction 89 6.7 70 7 80 6.6 60 5.5
Failure to report 177 13.3 47 4.7 66 5.4 53 4.8
Monitoring/staffing 96 7.2 36 3.6 37 3 61 5.6
All other issues 128 9.7 155 15.5 239 19.6 180 16.4
Total issues 1,326 100 998 100 1,218 100 1,096 100

This table shows that the count of total issues OIG cited in FY2015 was 10% less than in FY2014. Substantiations by OIG remain the highest percentage of cited issues.

FY2015 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. See Table 10.

During FY2015, the facilities and agencies performed 1,695 actions (an 8.7% decrease from FY2014) to address the 1,096 issues (a 10% decrease from FY2014) identified in the 986 cases with an approved Written Response.

Table 10 - FY2015 Actions Taken

Type Number taken
Administrative change 9
Counseling 76
Discharged 230
Fired (other cause) 6
Group training 225
Hab./Treatment change 81
Nothing 32
Oral Reprimand 26
Policy change 164
Procedural change 70
Reassignment 15
Resignation 91
Retirement 6
Re-Training 313
Reviewed 190
Structural repair 1
Structural upgrade 16
Supervision 16
Suspension 29
Transferred 12
Written Reprimand 87
FY2015 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).

FY2015 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 sample 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 FY2015 compliance reviews, OIG randomly selected 136 of the written responses approved, and then added the 9 written responses that were pending over 120 days for a total of 145 compliance reviews. Table 10 below shows the breakdown of all 145 compliance reviews by disability type and location.

Table 10: FY2015 Compliance Reviews on Approved Written Responses

Type Number taken
Administrative change 9
Counseling 76
Discharged 230
Fired (other cause) 6
Group training 225
Hab./Treatment change 81
Nothing 32
Oral Reprimand 26
Policy change 164
Procedural change 70
Reassignment 15
Resignation 91
Retirement 6
Re-Training 313
Reviewed 190
Structural repair 1
Structural upgrade 16
Supervision 16
Suspension 29
Transferred 12
Written Reprimand 87

OIG's compliance reviews seek documentation that the actions listed in the approved written response were actually completed. 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 and timely reporting of abuse and neglect.

During FY2014, OIG issued two "out of compliance" letters to two DD community agencies which did not provide documentation that all actions listed on the approved Written Response had been implemented. OIG worked with both of these agencies and outstanding actions were later completed. The status of both compliance reviews was changed to compliant.

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 individuals in Illinois who are receiving mental health or developmental disability services.