DHS OIG FY 2016 Annual Report

November 2016

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) 2016 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 FY2016. It covers OIG's trainings, 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's residents who are facing mental and physical challenges.


Michael J. McCotter

Inspector General

Executive Summary

During FY2016, the Office of the Inspector General (OIG) accomplished the following:

  • Hired 13 new investigators increasing the total number of investigators to 31.
  • Eliminated the Community Agency Protocol which allows OIG investigators to thoroughly investigate all cases.
  • Instituted improved management techniques to improve oversight of investigations.
  • Established an internal audit team to review quality of investigations.
  • Streamlined the investigation process on multiple fronts.
  • Fielded 7,648 phone contacts through the OIG Hotline.
  • Received 3,305 abuse or neglect allegations

Compared to FY2015, OIG received:

  • 3.3% fewer allegations at community agencies and
  • 5% more allegations at facilities.
  • Received 228 reports of deaths of individuals who were or had been receiving services in facility or community agency programs. OIG closed 236 death cases during FY2016. Of the 236 closed death cases, neglect was substantiated in 17 cases and issues were identified in 50 other cases.
  • Referred 1,426 complaints that were outside OIG's jurisdiction to the appropriate entity.
  • Closed 3,319 investigations into abuse or neglect allegations. OIG substantiated abuse or neglect in 363 of those investigations. Community agency cases accounted for 315 of the 363 substantiated cases (87%) and facility cases for the remaining 48 cases (13%).
  • Recommended administrative action in 916 cases at facilities or community agencies during FY2016. OIG received DHS-approved written responses in 867 of those cases, as well as another 114 completed from prior years, for a total of 981 written responses. A total of 1,316 issues were identified, the most common being substantiated abuse or neglect.
  • Presented 29 in-person training sessions on reporting abuse or neglect, with a total of 426 participants.
  • E-mailed 50.30(f) training PowerPoint presentations and post-test to 244 participants.
  • Conducted unannounced site visits to all fourteen DHS facilities providing mental health or developmental disability services, making fifteen recommendations to prevent abuse or neglect.
  • Referred to the IDPH Health Care Worker Registry 63 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.

Abuse and Neglect of Adults with Disabilities

Table of Contents

  1. Chapter 1: Preventing Abuse and Neglect
    1. Quality Care Board
    2. Unannounced Site Visits
    3. Training
    4. Facility Staffing Ratios
  2. Chapter II: Reporting Abuse and Neglect
    1. Non-Reportable Complaints
    2. Referrals
    3. FY2016 Reporting
    4. Community Agencies
  3. Allegation Type
    1. Deaths
  4. Chapter III: Investigating Abuse and Neglect
    1. FY2016 Closures
    2. Trends in Closures
    3. Trends in Investigative Findings
    4. Reconsiderations
  5. Chapter IV: Stopping Abuse and Neglect
    1. Health Care Worker Registry
    2. Data and Trends in Registry Referrals
    3. Type of Referrals
    4. Written Responses
    5. FY2016 Issues
    6. FY2016 Actions Taken
    7. FY2016 Implementation Status Reports
    8. FY2016 Compliance Reviews
  6. Conclusion

Chapter 1: Preventing Abuse and Neglect

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. 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

Thane A. Dykstra, New Lenox, Illinois

Untress Lamont Quinn, Shiloh, Illinois

Neil Posner, Chicago, Illinois

The Board's quarterly meetings in FY2016 were held on: September 15, 2015, February 11, 2016, and April 14, 2016. The meeting originally scheduled for June 9, 2016 was re-scheduled for July 21, 2016. All meetings were held by teleconference.

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 2016 Site Visit Issues

OIG's site visit protocol was initially created on January 16, 1997.

OIG's site visit protocol for FY2016 included an overview of the following:

Preliminary Investigative Steps:

  • Overall quality and thoroughness of interviews and securing the scene;
  • Facility-level staff training for OIG liaisons, security and non-security staff responsible for incident management and investigations in addition to the following OIG-provided training: Basic Investigative Skills, OIG Rule 50, Investigative Refresher Course and First Responder Training - ensuring training is current and up to date; and
  • Prevention of conflicts of interest and ensuring the integrity of each facility investigation.

Reportable and Non-Reportable Cases Reported to OIG:

* Thoroughness of facility investigations - timely initial response and thorough, appropriate follow-up actions.

Site Visit Dates

In FY2016, the dates of the site visits were as follows:

Site Date(s)
Alton Mental Health Center April 20, 2016
Chester Mental Health Center June 23, 2016
Chicago-Read Mental Health Center December 2 and 3, 2015
Choate Developmental Center May 4 and 5, 2016
Choate Mental Health Center May 4 and 5, 2016
Elgin Mental Health Center May 26, 2016
Fox Developmental Center April 29, 2016
Kiley Developmental Center May 26, 2016
Ludeman Developmental Center January 28 and 29, 2016
Mabley Developmental Center May 19, 2016
Madden Mental Health Center December 3 and 4, 2015
McFarland Mental Health Center November 18, 2015
Murray Developmental Center June 20, 2016
Shapiro Developmental Center May 31, 2016

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 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 was provided to each facility within 60 working days after site visit follow-up was completed.

The facility was asked to send OIG a written plan the facility developed to address the report's recommendations within 60 days of the site visit's closure. Receiving this written plan assists OIG in planning the next year's site visit, as OIG follows up on the facility's actions in response to recommendations made the prior year. It also greatly reduces repeat recommendations for the upcoming year.

In FY2016, OIG made 15 site visit recommendations. Seven of the 15 were repeat recommendations from FY2015. Five of those repeat findings included developing and implementing medical staff policies, procedures and evaluations on physician competency assessments, individualized and specific to the type of services provided. Six other recommendations were made to thoroughly investigate, document and follow up on incidents deemed non-reportable by OIG and referred back to the facilities for action.


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 further accomplish this goal. Both the statute and Rule 50 have long mandated basic training of all facility and community agency employees on identifying and reporting abuse and neglect, including owners/operators, contractors, subcontractors, and volunteers, at least biennially.

Rule 50 additionally requires agencies and facilities to train someone to perform initial incident response which is outlined in Rule 50, Section 50.30(f).

FY2016 Training

In the first half of FY2016, OIG conducted ten Rule 50 trainings throughout the state with a total attendance of 221. However, in response to both internal and external budget constraints and retirements, OIG was forced to find alternative ways to deliver mandated training. In the second half of FY2016, OIG engaged in a two-pronged initiative to provide the mandated training. First, the facilities and community agencies were notified of an updated Rule 50 PowerPoint Presentation on the OIG website located at https://www.dhs.state.il.us/page.aspx?item=33337. This training was designed to be completed by the training coordinators at each location, thus relieving them of the burden of scheduling time off and travel to send staff to in-person training. Second, OIG began an ongoing, in-depth survey of the way in which the community agencies train Rule 50 to their employees with an eye toward improving the quality and consistency of the training conducted by the agencies.

Investigative Training

During the first half of FY2016, OIG conducted a review and analysis to determine the overall effectiveness of the OIG Community Agency Protocol, which gave OIG the option to assign less serious non-registry reportable cases to the agency. The review revealed only 20% of community agencies participated in the protocol. Based on this review, it was determined that this process was not the most effective and efficient use of OIG's and the community agencies' resources and the protocol was ended on January 1, 2016. As a result the Basic Investigative Skills and Investigative Refresher trainings were no longer needed or offered after this date. To ensure community agencies and state operated facilities met their obligations under the mandated provisions of Rule 50.30(f), a new online Rule 50.30(f) training was created for the agencies. As the OIG Facility Protocol was retained, another training program specifically targeted for facility investigative staff was also created, entitled OIG Investigative Steps.

Rule 50.30(f)

Rule 50, Section 30(f) mandates that every community agency must have at least one person on staff who has been trained in the OIG-approved methods to preserve evidence for initial incident response and for whom there is no conflict of interest. Upon request, this training is sent out to those agency and facility staff members who have not had a substantiated finding of abuse or neglect within the past three years. The training consists of a PowerPoint presentation on the skills required under 50.30(f), as well as a short post-test to promote competency. Upon receipt of a passing grade on their test, the staff member is considered authorized to perform these duties.

OIG Investigative Steps

While OIG has discontinued the Community Agency Investigative Protocol, the Facility Investigative Protocol is still in effect. As facility investigators are required to actually interview involved subjects (something that is not covered in the Rule 50.30(f) training), OIG developed the OIG Investigative Steps class as a refresher on the techniques in Rule 50.30(f) training along with an interviewing skills component. The Rule 50.30(f) class is considered a pre-requisite for taking this class. In preparation to make this class available via the Internet, three in-person classes were held in which 46 students were trained.

New OIG Investigator Training

OIG hired 13 new investigators during FY2016, increasing the number of investigators to 31, an increase of 72%. To ensure the new investigators are ready to conduct the highly complex and confidential investigations required under Rule 50, OIG has formalized a combination of in-person classroom and field training. The classroom portion lasts approximately two weeks and covers such topics as:

  • Department of Human Services Act
  • Rule 50
  • OIG Directives
  • Confidentiality
  • Health Insurance Portability and Accountability Act
  • Interviewing and Communicating with People with Disabilities
  • Developmental Disabilities and Mental Illness
  • Investigations Involving Medical Issues and Deaths
  • Investigative Planning
  • Collection and Custody of Physical Evidence
  • Interviewing Techniques*
  • Format for OIG Investigative Reports and Report Writing*
  • Restraint and Seclusion
  • Testimony at Administrative Hearings/Courtroom Testimony

*The Report Writing and the Interviewing Techniques instruction are accompanied by instructor demonstration and then class participation in role play and practice exercises.

After the classroom portion is completed, the new investigator is released back to their assigned bureau to begin field training, which is designed to advance a new investigator from an observer to the performer. The field training period is for a minimum of three weeks and encompasses applying the skills learned in the classroom to the field. The new investigator consistently receives both instruction and critical assessment from an experienced OIG investigator. They are under constant evaluation by the Field Training Investigator, the Investigative Team Leader and/or Bureau Chief. The leadership team can keep the new investigator assigned in that role until the Bureau Chief decides to conclude the new investigator's field training and assign them a case load, return them to the training department for retraining, or possibly decide not to certify the new investigator. Those decisions are made by the Bureau Chief, in conjunction with the Inspector General or his/her designee.

Facility Staffing Ratios

By law, OIG's annual report must include facility census figures which include 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 30, which is the last day of each fiscal year.

Tables1 below show the census figures and ratios for each type of facility for FY2016. 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, 2016; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2016 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, 2016, 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 ration, which is given in the fifth column.

Table 1 Census and Staffing Ratios, DHS State-run Facilities, June 30, 2016

DHS Facility Unduplicated count of individuals served Person-days (on-books annual totals) Inpatient census on June 30 Direct care staff Direct care to patient ratio
Alton MHC 222 45,035 122 165 1.35
Chester MHC 485 96,815 259 355.4 1.37
Chicago-Read MHC 689 41,141 108 177 1.64
Choate MHC & DC* 340 77,908 210 390.6 1.86
Elgin MHC 1,222 145,031 389 490.1 1.26
Fox DC 111 38,897 96 170.7 1.78
Kiley DC 197 68,758 158 361.8 2.29
Ludeman DC 412 143,342 387 550.5 1.42
Mabley DC 108 38,030 103 165.28 1.6
Madden MHC 2,417 39,763 94 177.7 1.89
McFarland MHC 424 49,684 136 155.59 1.14
Murray DC 214 75,947 182 343.74 1.89
Shapiro DC 515 176,817 474 875.99 1.85
DD facility totals 1,897 619,699 1,610 2,858.61 1.78
MH facility totals 5,459 417,469 1,108 1,520.79 1.37

* NOTE: Beginning FY2016, Choate MH&DC no longer separates staff by MH and DD.

Figures provided by the DHS Budget Office

Chapter II: Reporting Abuse and 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.

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. These are categorized as non-reportables. 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 refers the caller to the appropriate entity and instructs the caller 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. Referrals were made in 1,262 of the 1,426 (88.5%) non-reportable complaints. Table 2 below shows the referral locations for non-reportable complaints made by OIG this year.

Table 2: Non-Reportable Complaint Referrals Made by OIG in FY2016

Referral Location Count
Local community agency or facility 1,262
Illinois Department of Public Health 4
Department of Children and Family Services 1
Department of Housing and Family Services 4
Local law enforcement authority 10
Department on Aging 1
DHS Division of Developmental Disabilities 19
DHS Division of Mental Health 3
Office of Executive Inspector General 6
Other 28
None needed 84
Total 1,426

FY2016 Reporting

During FY2016, OIG received a total of 3,305 allegations of abuse or neglect. The counts by type and location are shown in Table 3 below. 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 abuse.

Table 3: Summary of Allegations Received by OIG in FY2016

* Contains 19 financial exploitation allegations from DHS-operated facilities and 98 from community agencies.

Location Abuse allegations Neglect allegations Total allegations
DHS-operated facilities 760 172 932
Community agencies 1,467 906 2,373
Total 2,227 1,078 3,305

Total abuse allegations in DHS-operated facilities and community agencies stayed relatively the same in FY2016 (2,227 versus 2,231 in FY2015), while FY2015 increased by 2.5% over FY2014. In these same settings, allegations of financial exploitation (a subset of abuse) decreased by 17.6% since FY2015, while FY2015 increased 14.5% over FY2014.

Likewise, total neglect allegations in DHS-operated facilities and community agencies have decreased by 3% since FY2015.


During FY2016, OIG received 932 total allegations of abuse and neglect at the DHS-operated facilities, a 5% increase in allegations from FY2015. Of the total allegations at facilities in FY2016, there were 760 allegations of abuse which includes 19 allegations of financial exploitation. Abuse allegations accounted for 81.5% of the total allegations at facilities.

OIG also received 172 allegations of neglect at facilities, for 18.5% of the total allegations. The number of neglect allegations decreased by 17.5% between FY2014 and FY2015, reversing the previous trend of increasing neglect allegations. Likewise in FY2016, neglect allegations at the DHS-operated facilities decreased by 8.5%.

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 FY2016, allegations at community agencies accounted for 73.4% of all allegations OIG received. This high percentage is reflective of the number of individuals receiving services by community agencies.

During FY2016, OIG received 2,373 total allegations at community agencies. This is a 3.3% decrease in allegations from FY2015. Of the total allegations, there were 1,467 allegations of abuse, which included 98 allegations of financial exploitation. This year, the proportion of all allegations represented by abuse allegations increased to 68.5% as opposed to 62% in FY2015 and 60% in FY2014.

OIG also received 906 allegations of neglect at community agencies, a decrease of 2% over the 924 received during FY2015.

Allegation Type

Tables 4a and 4b show the allegations and death cases that OIG received during FY2016 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 FY2016, 228 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. This is a 16.3% increase over FY2015 which in turn was a 2% increase from FY2014. OIG closed 236 death cases during FY2016, a 31.8% increase over the 179 closed during FY2015. Of the 236 closed death cases, neglect was substantiated in 17 while 50 other cases that were not substantiated had issues identified.

Table 4a: Allegations and Deaths Received in FY2016, Mental Health Services Only

Location/Facilities Physical abuse Sexual abuse Mental abuse Financial exploitation Neglect Total received Death reports
Alton MHC (civil) 1 24 6 6 1 5 42 0
Alton (forensic) 2 16 1 8 0 8 33 0
Chester MHC 73 5 33 1 13 125 3
Chicago-Read MHC 12 4 7 1 5 29 1
Choate MHC 28 6 15 2 4 55 0
Elgin MHC (civil) 36 9 23 2 29 99 0
Elgin (forensic) 33 6 23 6 26 94 0
Madden MHC 31 5 6 1 13 56 0
McFarland MHC (civil) 16 11 10 3 15 55 0
McFarland (forensic) 4 4 1 0 0 9 0
Facility subtotals 273 57 132 17 118 597 4
Community agencies: 10 7 16 13 27 73 20
Non-Residential 11 17 29 22 12 91 1
Agency subtotals 21 24 45 35 39 164 21
294 81 177 52 157 761 25
Rule 50 MH totals

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 FY2016, Developmental Services Only

Location Physical abuse Sexual abuse Mental abuse Financial exploitation Neglect Total received Death reports
Choate DC (civil) 1 56 6 18 0 18 98 1
Choate DC (forensic) 2 4 0 0 0 0 4 0
Fox DC 6 1 1 0 2 10 3
Kiley DC 48 2 8 1 3 62 3
Ludeman DC 34 3 1 1 18 57 3
Mabley DC 19 0 3 0 4 26 1
Murray DC 12 0 1 0 7 20 4
Shapiro DC 3 49 2 5 0 2 58 13
Facility subtotals 228 14 37 2 54 335 28
Community agencies: Residential 645 44 299 57 720 1,765 4 164
Non-Residential 192 17 82 6 147 444 11
Agency subtotals 837 61 381 63 867 2,209 175
Rule 50 DD totals 1,065 75 418 65 921 2,544 203

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.

3 Shapiro is the largest state operated developmental center in Illinois with the largest geriatric population and the largest population of individuals with high medical needs.

4 This number includes all allegations received from July 1, 2015 to June 30, 2016.

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 three fiscal years.

Table 5: Late Reporting by Program and Disability Type, FY2014 through FY2016

Fiscal Year Total Self-Reports Late, DD Agencies Late, MH Agencies Late, DD Facilities Late, MH Facilities Total Late Percent late
FY2014 2,977 276 23 14 28 341 11.5
FY2015 2,927 265 19 22 22 328 11.2
FY2016 2,908 287 35 22 36 380 13.1

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

FY2015 showed a slight decrease in the number of self-reports, a trend continued in FY2016. The number of self-reports decreased by 0.6% from the previous year while the percentage of late reporting increased by 1.9%. While the Divisions of Mental Health and Developmental Disabilities have been very responsive to this issue, OIG has initiated an outreach to the facilities and agencies through a directed mailing of a PowerPoint presentation to all executive directors, as well as a review of all agency-conducted Rule 50 training of their staff.

Chapter III: Investigating Abuse and 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 and takes seriously our responsibility to protect individuals with mental health and developmental disabilities.

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 investigation until ISP/LLE has completed its criminal investigation. If a criminal investigation results in a referral of 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). For the past three years, OIG's average time to completion has remained above the statutorily defined investigative limit of 60 days. The reasons were the increasing number of allegations, the inability of OIG to fill a number of positions vacated by retirements until this year, and a mounting backlog of cases. Since December 1, 2015, OIG has hired 13 new investigators , increasing the number of investigators to 31, an increase of 72%. With this additional staff and changes to our internal training methods, OIG is confident that FY2017 will show a reduction in our average completion time.

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

Investigations FY2014 FY2015 FY2016
Number completed 3,037 3,160 3,639
Average total days* 79.4 96.6 115.4
Average OIG days* 78.6 95.5 111.9

*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 or local law enforcement investigations.

FY2016 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 FY2016 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 FY2016, Mental Health Services Only

Location Abuse substan- tiated Neglect substan- tiated Other issue only Not substan- tiated Allegation findings totals Closed death cases
Facilities: Alton MHC (civil) 1 0 0 0 62 62 0
Alton (forensic) 2 2 0 4 22 28 0
Chester MHC 3 2 6 102 113 2
Chicago-Read MHC 0 2 0 42 44 1
Choate MHC 0 0 3 74 77 1
Elgin MHC (civil) 0 1 9 56 66 4
Elgin (forensic) 1 2 2 84 89 1
Madden MHC 1 1 8 39 49 2
McFarland MHC (civil) 1 3 4 66 74 0
McFarland (forensic) 0 0 0 8 8 0
Facility subtotals 8 11 36 555 610 11
Community agencies: Residential 1 0 12 47 60 17
Non-Residential 1 0 12 67 80 3
Agency subtotals 2 0 24 114 140 20
Rule 50 MH Totals 10 11 60 669 750 31

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 FY2016, 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 2 4 20 87 113 0
Choate DC (forensic) 2 0 0 0 6 6 0
Fox DC 0 0 4 6 10 4
Kiley DC 2 1 5 57 65 4
Ludeman DC 2 2 15 46 65 6
Mabley DC 3 0 8 8 19 3
Murray DC 0 5 3 22 30 4
Shapiro DC 7 1 3 61 72 14
Facility totals 16 13 58 293 380 35
Community agencies: Residential 87 156 334 1,148 1,725 160
Non-Residential 26 44 101 293 464 10
Agency totals 113 200 435 1,441 2,189 170
Rule 50 DD Totals 129 213 493 1,734 2,569 205

Trends in Closures

During FY2016, OIG closed a total of 3,555 cases, which includes 3, 319 investigative cases of abuse or neglect and 236 death cases. Total allegations and death reports received in FY2016 totaled 3,533, slightly less than the number of cases closed.

As mentioned above, OIG experienced a significant reduction in staffing over the past several years, a trend finally broken with the hiring of 13 new investigators in 2015 and 2016. Along with this increased staffing, OIG continues to improve efficiencies, streamline internal processes and reposition staff into high volume areas to meet this challenge. Once this new staff is thoroughly trained and taking full caseloads, there should be an increase in the number of cases completed and closed.

Trends in Investigative Findings

OIG substantiated abuse or neglect in 363 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,

FY2014 through FY2016

Location FY14 FY15 FY16
MH State Facility 2.7% 3.6% 3.2%
DD State Facility 12.9% 8.5% 7.5%
MH Community Agency 7.9% 4.8% 1.3%
DD Community Agency 16.7% 14.7% 13.9%
Total 12.7% 11.7% 10.7%


During FY2016, OIG received 134 requests to reconsider the findings of 119 Rule 50 investigations, 70% of which were substantiated cases. Of the 134 requests, OIG granted 19 (involving 12 cases) and denied 115 (involving 107 cases) as no new information was provided, a requirement of OIG Rule 50. Of the 12 cases with granted reconsiderations, OIG revised three case reports. Of those three reports, two had changes in findings or issues.

Chapter IV: Stopping Abuse and Neglect

OIG's statutory mission reaches beyond investigating. As noted at the outset of this report, OIG has been working 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.

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. On August 7, 2015, OIG's governing statute was updated and the Rule 50 definition of sexual abuse was revised. It now states:

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. Sexual abuse also includes an employee's actions that result in the sending or showing of sexually explicit images to an individual via computer, cellular phone, electronic mail, portable electronic device, or other media, with or without contact with the individual; or an employee's posting of sexually explicit images of an individual online or elsewhere, whether or not there is contact with the individual. Sexual abuse does not include allowing individuals to, of their own volition, view movies or images of a sexual nature or read text containing sexual content unless the individual's guardian prohibits the viewing of those movies or images or reading of that material.

Data and Trends in Registry Referrals

During FY2016, 63 employees were referred to the Registry. Six referrals involved facility employees and 57 involved agency employees. Five of the facility employees referred to the Registry were direct care staff, while the remaining staff was a registered nurse. Of the agency staff referred, two were professional staff (QIDP and counselor), while the other 55 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 48 of the 63 referrals (76%) this fiscal year - four facility staff (one MH and three DD) and 44 DD agency staff.

Sexual Abuse: Sexual abuse is defined above. In FY2016, five employees (8%) were referred to the Registry for sexual abuse. All five were employed in DD settings - two in facilities and three in community agencies.

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 FY2016, four names (6.3%) were referred to the Registry for egregious neglect. All four were DD 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 own advantage or benefit. In FY2016, six employees (9.5%) were referred to the Registry for financial exploitation. All six were DD agency employees.

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 of DHS. The program division then reviews and approves the written response, lists the proposed actions, and sends the approved written response to OIG.

FY2016 Issues

In FY2016, OIG sent an initial written response to facilities or community agencies in 1,027 cases. OIG received the approved written responses in 860 of those 1,027 cases. OIG also received 124 written responses that had been required during a prior fiscal year, totaling 984 approved written responses received during FY2016. In the 984 written responses received, there were a combined total of 1, 316 issues identified.

Table 9: Issues Cited in Approved Written Responses Received, FY2014 through FY2016

Issues FY2014 FY2015 FY2016
Count Percent Count Percent Count Percent
Substantiations 407 33.5 384 35.1 392 29.8
Late reporting 194 15.9 159 14.5 178 13.5
Nursing practices 45 3.7 90 8.2 140 10.6
Investigative error 32 2.6 30 2.7 109 8.3
Service plan 118 9.7 79 7.2 131 10
Inappr. Interaction 80 6.6 60 5.5 79 6
Failure to report 66 5.4 53 4.8 64 4.9
Monitoring/staffing 37 3 61 5.6 62 4.7
All other issues 239 19.6 180 16.4 161 12.2
Total issues 1,218 100 1,096 100 1,316 100

This table shows that the count of total issues OIG cited in FY2016 was 20% more than in FY2015, which was in turn 10% less than in FY2014. Written responses received consequent to substantiated findings accounted for the largest proportion of the written responses received.

FY2016 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 FY2016, the facilities and agencies performed 1,721 actions (a 1.5% increase over FY2015) to address the 1,316 issues identified in the 984 cases with an approved Written Response. See Table 10.

Table 10 - FY2016 Actions Taken

Type Number of Actions Taken
Retraining 353
Discharged 285
Group Training 235
Procedural Change 136
Written Reprimand 108
Resignation 100
Counseling 86
Reviewed by Agency/Facility 78
Policy Change 62
Habilitation/Treatment Change 60
Suspension 53
Nothing 28
Administrative Change 24
Supervision 24
Oral Reprimand 20
Transferred 19
Reassignment 18
Retirement 9
Fired (Other Cause) 6
Structural Repair 5
Total 1,721

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.

FY2016 Implementation Status Reports

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.

FY2016 Compliance Reviews

The other way OIG ensures 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. For example, in cases involving substantiated non-egregious neglect, the agency might require an employee to complete retraining, supervision discipline or a combination of all three. Once the division approves the actions, OIG might collect documents reflecting these actions. Although OIG works closely with the divisions to clarify actions on several written responses, no "Out of Compliance" letters were issued in FY2016.

OIG conducts compliance reviews on two types of written responses. First, each month OIG selects a random sample of all written responses approved by the respective division 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 FY2016 compliance reviews, OIG randomly selected 121 of the written responses approved, and then added the 25 written responses that were pending over 120 days for a total of 146 compliance reviews. Table 11 below shows the breakdown of all 146 compliance reviews by disability type and location.

Table 11: FY2016 Number of Compliance Reviews on Approved Written Responses

Location DD Programs MH Programs Totals
DHS facilities 27 13 40
Community agencies 96 10 106
Totals 123 23 146

OIG's randomly selected compliance reviews help ensure that problems and unsafe practices identified during an investigation have actually 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.


OIG takes seriously our responsibility to protect individuals with disabilities and mental illnesses throughout the entire state system. Over the past year OIG implemented many reforms to better protect individuals with developmental disabilities and mental illnesses. OIG more than doubled the number of department investigators. OIG instituted improved management techniques to free investigators to focus on their substantive work and improved oversight of investigations. Supervisors now work more hands on with investigators to provide guidance and review investigations. OIG established an internal audit team with the inclusion of a clinical nurse to select and review cases for completeness and accuracy. OIG streamlined the investigation process on multiple fronts, including moving from paper-based to electronic processes and making assignments based on investigator location. Because of these reforms and the work done by our team, Illinois' most vulnerable residents are safer now than they were in past years. OIG will continue to work to find ways to improve our investigations and ability to ensure safe, therapeutic care for individuals with developmental disabilities and mental illnesses.