DHS OIG FY 2017 Annual Report

November 2017

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) 2017 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 Mental Health (MH) and Developmental Disability (DD) state-operated facilities (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 FY2017. It covers investigations, reviews to ensure implementation of corrective actions, unannounced facility site visits, OIG's trainings, 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.

Sincerely,

Michael J. McCotter

Inspector General

Executive Summary

During FY2017, the Office of the Inspector General (OIG) accomplished the following:

• Received 3,694 abuse or neglect allegations, an increase of 11% over

FY2016:

• 14.3% more allegations at community agencies and
• 5.6% more allegations at facilities.
• Closed 3,600 investigations into abuse or neglect allegations, an increase of 8.5% over FY2016. OIG substantiated abuse or neglect in 470 of those investigations. Community agency cases accounted for 418 of the 470 substantiated cases (89%) and facility cases for the remaining 52 cases (11%).
• Received 200 reports of deaths of individuals who were or had been receiving services in facility or community agency programs. OIG closed 196 death cases during FY2017. Of the 196 closed death cases, neglect was substantiated in 11 cases and issues were identified in 45 other cases.
• Received 8,391 phone contacts through the OIG Hotline, an increase of 9.7% over FY2016.
• Recommended administrative action in 1,245 cases at facilities or community agencies during FY2017. OIG received DHS-approved written responses in 881 of those cases, as well as another 97 completed from prior years, for a total of 978 written responses. A total of 1,351 issues were identified, the most common being substantiated abuse or neglect.
• Referred to the IDPH Health Care Worker Registry (HCWR) 70 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.
• Referred 1,207 complaints that were outside OIG's jurisdiction to the appropriate entities for follow up.
• Conducted unannounced site visits to all fourteen DHS facilities providing mental health or developmental disability services, making seven recommendations to prevent abuse or neglect.
• Hired three new investigators, increasing the total number of investigators to 32.
• Presented OIG Investigative Steps training to 42 facility staff members (three in-person, 20 via webinar, and 19 via e-mailed narrated PowerPoint) and emailed Rule 50.30(f) to 375 facility and community agency staff (an increase of 53.7% over FY2016).
• Began testing new web-based forms designed to streamline the Intake process

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. FY 2017 Site Visit Issues
   4. Site Visit Dates
   5. Training
   6. Facility Staffing Ratios
2. Chapter II: Reporting Abuse and Neglect
   1. FY2017 Reporting
   2. Initial Reporting Timeliness
   3. Non-Reportable Complaints
3. Chapter III: Investigating Abuse and Neglect
   1. FY2017 Case Completions
   2. FY2017 Closures
   3. Trends in Closures
   4. Trends in Investigative Findings
   5. Investigative Timeliness
   6. Reconsiderations
4. Chapter IV: Stopping Abuse and Neglect
   1. Health Care Worker Registry
   2. Written Responses
   3. 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 (Term expired November 3, 2015)
• Thane A. Dykstra, New Lenox, Illinois (Term expired November 3, 2013)
• Untress Lamont Quinn, Shiloh, Illinois (Term expired November 3, 2013)
• Neil Posner, Chicago, Illinois (Resigned from board effective August 31, 2017)

The Board has not had full membership for several years and has had difficulty maintaining a quorum to conduct business. The Inspector General and the QCB Chairperson have been in regular contact with the DHS Secretary and the Governor's Office to fill the open positions. This continues to be a high priority for the Inspector General.

The Board's quarterly meetings in FY2017 were held on: July 21, 2016, September 29, 2016, December 19, 2016, February 9, 2017, and May 11, 2017. 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 constructive feedback that will allow the facilities to take steps to prevent abuse and neglect in the future.

FY 2017 Site Visit Issues

OIG's site visit protocol was initially created on January 16, 1997. The site visit protocol for FY2017 included an overview of the following:

DD Facilities:

Facility Response to OIG Allegations Occurring at Agencies:

• How facilities are notified when an allegation occurs involving individuals attending day programming off-site;
• Facility response to the allegations/safeguards in place to prevent issues from occurring with other individuals at the same site.

MH Facilities:

Continuity of Care Following Discharge:

• How facilities ensure medications, doctors' orders, etc. follow the individual to their new placement;
• Facility response to allegations involving deaths occurring within 14 days of discharge.

All Facilities:

Response to Updated Sexual Abuse Definitions:

• Safeguarding against sexual contact between individuals - no sexual contact permissible in MH facilities according to program directive, sexual contact in DD facilities only if individual has outlined in behavior plan and, if applicable, guardian has approved;
• Response to sexual abuse allegations in MH and DD facilities.
• Health Care Worker Registry Checks - How facilities check to see if employees are on the HCWR; both upon hire throughout their employment.

Site Visit Dates

In FY2017, the dates of the site visits were as follows:

• Alton Mental Health Center October 25, 2016
• Chester Mental Health Center June 16, 2017
• Chicago-Read Mental Health Center November 16 and 17, 2016
• Choate Developmental Center December 14, 2016
• Choate Mental Health Center December 15, 2016
• Elgin Mental Health Center December 20 and 22, 2016
• Fox Developmental Center May 23, 2017
• Kiley Developmental Center June 6 and 7, 2017
• Ludeman Developmental Center May 17 and 18, 2017
• Mabley Developmental Center May 10 and 24, 2017
• Madden Mental Health Center November 17 and 18, 2016
• McFarland Mental Health Center October 13, 2016
• Murray Developmental Center May 25 and June 21, 2017
• Shapiro Developmental Center May 17, 2017

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 appropriate personnel 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 sixty working days after the site visit follow-up was completed.

Each facility was asked to submit to OIG a written plan to address the report's recommendations within sixty days of the site visit's closure. Receiving this written plan assists OIG in planning the next year's site visits, 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 FY2017, OIG made seven site visit recommendations, which is 47% less than those made in FY2016. Two of the recommendations were made for the third year and included thorough completion of physical examination forms (Alton Mental Health Center) and completion of competency evaluations for supervisory positions (Madden Mental Health Center). Four of the remaining recommendations were made to ensure that all on-site employees have necessary background checks and keep appropriate documentation (Choate Developmental Center, Choate Mental Health Center, Fox Developmental Center, and Ludeman Developmental Center). The remaining recommendation for FY2017 was to ensure that the facility revise its OIG Rule 50 policy to include the updated definition of Sexual Abuse (Choate Mental Health Center).

Training

During FY2017, OIG implemented alternative ways to deliver mandated training other than in-person training sessions. The following sections detail the type of training and how it is delivered.

Rule 50

Up until FY2016, OIG provided in-person training on Rule 50, normally in conjunction with investigative training. On January 1, 2016, when the Community Agency Protocol was eliminated, this type of training was discontinued in favor of a web-based PowerPoint presentation accessible by both facility and community agency staff. This presentation is maintained and kept current by OIG staff.

Investigative Training

To ensure community agencies and state operated facilities met their obligations under the mandated provisions of Rule 50.30(f), a new Rule 50.30(f) training presentation was created for this sole purpose. 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 facility and community agency must have at least one person on staff that 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. This authorization is good for two years, after which the class must be re-taken.

During FY2017, Rule 50.30(f) was e-mailed to 453 facility and community agency staff, an increase of 51% over FY2016. Of those 453 presentations e-mailed, 312 resulted in an approved facility or community agency investigator.

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.

During FY2017, OIG presented OIG Investigative Steps training to 42 facility staff members (three in-person, 20 via webinar, and 19 via e-mailed narrated PowerPoint presentation.)

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.

Table 1 below shows the census figures and ratios for each type of facility for FY2017. 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, 2017; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2017 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, 2017, 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, 2017

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	222	44,160	104	159.7	1.54
Chester MHC	473	98,394	276	332.4	1.2
Chicago-Read MHC	605	41,900	124	180	1.45
Choate MHC & DC*	326	78,674	197	340.6	1.73
Elgin MHC	1,228	137,858	369	450.6	1.22
Fox DC	105	37,104	93	136.7	1.47
Kiley DC	203	68,541	157	349.2	2.22
Ludeman DC	401	140,857	329	540	1.64
Mabley DC	114	39,097	95	163.25	1.72
Madden MHC	2,307	40,312	79	166.1	2.1
McFarland MHC	374	48,517	135	136.69	1.01
Murray DC	222	76,448	179	336.74	1.88
Shapiro DC	507	172,633	464	807.5	1.74
DD facility totals	1,878	613,354	1,514	2,673.90	1.77
MH facility totals	5,109	411,141	1,087	1,425.49	1.31

* 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.

Deaths with allegations of abuse/neglect are required to be reported like other allegations of abuse/neglect. Rule 50 also requires all deaths absent any allegation of abuse/neglect be reported to the Hotline within 24 hours. This includes 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.

FY2017 Reporting

During FY2017, OIG received a total of 3,697 allegations of abuse or neglect. The counts by type and location are shown in Table 2 below. Financial exploitation is included in abuse, as defined in Rule 50. Tables 3a and 3b, on the following pages, show a more detailed breakdown by allegation type and location.

Table 2: Summary of Allegations Received by OIG in FY2017

Location	Abuse allegations	Neglect allegations	Total allegations
DHS-operated facilities	776	208	984
Community agencies	1,678	1,035	2,713
Total	2,454	1,243	3,697

* Contains 22 financial exploitation allegations from DHS-operated facilities and 164 from community agencies.

Chart of Table 2: Summary of Allegations Received by OIG in FY2017

Total abuse allegations in DHS-operated facilities and community agencies increased in FY2017 (2,454 versus 2,227 in FY2016), while FY2016 stayed relatively the same as in FY2015. In these same settings, allegations of financial exploitation (a subset of abuse) increased by a large margin, 59.0%, as opposed to FY2016 which showed a decrease of 17.6% over FY2015.

Likewise, total neglect allegations in DHS-operated facilities and community agencies have increased by 15.3% over FY2016.

Facilities

During FY2017, OIG received 984 total allegations of abuse and neglect at the DHS-operated facilities, a 5.6% increase in allegations from FY2016. Of the total allegations at facilities in FY2017, there were 776 allegations of abuse which includes 22 allegations of financial exploitation. Abuse allegations accounted for 78.9% of the total allegations at facilities.

OIG also received 208 allegations of neglect at facilities, for 21.1% of the total allegations. The number of neglect allegations increased by 20.9% over FY2016, reversing the trend started in FY2014 where neglect cases decreased by 17.5% between FY2014 and FY2015, then again between FY2015 and FY2016 where the decrease was 8.5%.

Chart detailing: Summary of Facility Allegations from FY2015 to FY2017

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, a value duplicated in FY2017. This high percentage is reflective of the number of individuals receiving services by community agencies.

During FY2017, OIG received 2,713 total allegations at community agencies. This is a 14.3% increase in allegations from FY2016. Of the total allegations, there were 1,678 allegations of abuse, which included 164 allegations of financial exploitation. This year, the proportion of all allegations represented by abuse allegations was 61.8%. In comparison, FY2016 had a rate of 68.5%, as opposed to 62% in FY2015 and 60% in FY2014.

OIG also received 1,035 allegations of neglect at community agencies, an increase of 14.2% over the 906 received during FY2016.

Chart detailing: Summary of Community Agency Allegations from FY2015 to FY2017

Allegation Type

Tables 3a and 3b show the allegations of abuse and neglect, and death cases that OIG received during FY2017 by type of allegation and program location. The tables list facilities individually. Where there are "forensic" units (those for individuals who are committed by a criminal court order), they are differentiated 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.

Deaths

During FY2017, 200 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. This is a 12.3% decrease over FY2016, reversing the trend of increasing deaths since 2014. OIG closed 196 death cases during FY2017, a 16.9% decrease over the 236 closed during FY2016. Of the 196 closed death cases, neglect was substantiated in 11 while the remaining 185 found no suspicion of abuse or neglect. In 44 of the 185 unsubstantiated cases, issues were identified which required a written response from the facility/agency.

Table 3a: Allegations and Deaths Received in FY2017, Mental Health Services Only

Location	Physical abuse	Sexual abuse	Mental abuse	Financial exploitation	Neglect	Total received	Death reports
Facilities:
Alton MHC (civil) 1	7	6	7	1	2	23	0
Alton (forensic) 2	16	1	16	1	10	44	0
Chester MHC	79	8	34	6	31	158	1
Chicago-Read MHC	8	5	3	0	4	20	1
Choate MHC	24	4	11	2	8	49	0
Elgin MHC (civil)	25	13	18	5	18	79	1
Elgin (forensic)	20	16	25	2	24	87	2
Madden MHC	17	5	11	0	9	42	2
McFarland MHC (civil)	16	9	16	0	14	55	0
McFarland (forensic)	1	1	8	3	6	19	0
Facility subtotals	213	68	149	20	126	576	7
Community agencies:
Residential	13	14	38	16	19	100	25
Non-Residential	8	16	33	50	20	127	1
Agency subtotals	21	30	71	66	39	227	26
Rule 50 MH totals	234	98	220	86	165	803	33

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 3b: Allegations and Deaths Received in FY2017, Developmental Services Only

Location	Physical Abuse	Sexual Abuse	Mental Abuse	Financial Exploitation	Neglect	Total Received	Death Reports
Facilities:
Choate DC (civil) 1	67	3	23	1	17	111	3
Choate DC (forensic)2	5	0	0	0	0	5	0
Fox DC	8	0	0	0	4	12	3
Kiley DC	79	4	21	0	21	125	2
Ludeman DC	31	0	3	1	24	59	3
Mabley DC	11	0	0	0	8	19	3
Murray DC	17	1	5	0	4	27	2
Shapiro DC 3	43	1	2	0	4	50	8
Facility subtotals	261	9	54	2	82	408	24
Community agencies:
Residential	707	44	292	89	833	1,965	136
Non-Residential	202	16	131	9	163	521	7
Agency subtotals	908	60	424	98	996	2,486	143
Rule 50 DD totals	1,169	69	478	100	1,078	2,894	167

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, 2016 to June 30, 2017.

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 listing 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 4: Late Reporting by Program and Disability Type, FY2015 through FY2017

Fiscal Year	Total Self-Reports*	Late from Agencies - DD	Late from Agencies - MH	Late from Facilities - DD	Late from Facilities - MH	Total Late	Percent Late
FY2015	2,927	265	19	22	22	328	11.2
FY2016	2,908	287	35	22	36	380	13.1
FY2017	3,195	272	38	22	26	358	11.2

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

FY2016 showed a slight decrease in the number of self-reports, whereas FY2017 showed a large jump of 9.9%. Conversely, the trend in late-reporting showed a decrease of 5.8% for FY2017 versus an increase of 15.9% during FY2016. This is attributed to OIG's outreach to the facilities and agencies through a directed mailing of a PowerPoint presentation about late reporting to all executive directors, as well as a strict policy of noting late reporting in case-initiating cover memos and completed case reports.

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.

Referrals

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 1,122 of the 1,207 (93.0%) non-reportable complaints. Table 5 below shows the referral locations for non-reportable complaints made by OIG this year.

Table 5: Non-Reportable Complaint Referrals Made by OIG in FY2017

Referral Location	Count
Local community agency or facility	1,034
Illinois Department of Public Health	3
Department of Children and Family Services	1
Department of Housing and Family Services	7
Local law enforcement authority	9
Department on Aging	2
DHS - BALC/OCAPS	5
DHS Division of Developmental Disabilities	21
DHS Division of Mental Health	5
Office of Executive Inspector General	5
Other	30
None needed	85
Total	1,207

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.

FY2017 Case Completions

As noted earlier in this report, the number of allegations and investigations opened by OIG has steadily increased over the past several years. In FY2017, OIG opened 3,694 investigations, which is an 11% increase over the previous year. During the same fiscal year, OIG closed 3,600 investigations, which is an 8.5% increase of the previous year.

Chart detailing: FY15-FY17 Opened and Closed Investigations Comparison

FY2017 Closures

The findings in abuse or neglect allegations and in death cases OIG closed during FY2017 are presented in the four tables that follow.

Abuse/Neglect Cases

OIG conducts administrative investigations and is bound by the Administrative Code to the "preponderance of evidence" standard. This is defined as "proof sufficient to persuade the finder of fact that a fact sought to be proved is more likely true than not". By law, OIG uses three findings for its case reports:

• "Substantiated", meaning there is a preponderance of evidence;
• "Unsubstantiated" meaning there is not a preponderance of evidence to support the allegation; and
• "Unfounded" meaning there is no credible evidence supporting the allegation.

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 6a: Abuse/Neglect Cases Closed in FY2017, Mental Health Services Only

Location	Abuse substantiated	Exploit. substantiated	Neglect substantiated	Other issue only	Not substantiated	Allegation findings totals
Facilities:
Alton MHC (civil) 1	0	0	0	2	21	23
Alton (forensic) 2	0	0	1	3	36	40
Chester MHC	5	0	5	7	87	104
Chicago-Read MHC	0	0	0	1	11	12
Choate MHC	0	0	3	5	37	45
Elgin MHC (civil)	2	0	0	9	86	97
Elgin (forensic)	3	0	2	13	69	87
Madden MHC	3	0	1	4	30	38
McFarland MHC (civil)	0	0	5	2	49	56
McFarland (forensic)	0	0	0	1	17	18
Facility subtotals	13	0	17	47	443	520
Community agencies:
Residential	8	0	5	15	69	97
Non-Residential	4	1	1	16	105	127
Agency subtotals	12	1	6	31	174	224
Rule 50 MH Totals	25	1	23	78	617	744

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 6b: Abuse/Neglect Cases Closed in FY2017, Developmental Services Only

Location	Abuse substantiated	Exploit. substantiated	Neglect substantiated	Other issue only	Not substantiated	Allegation findings totals
Facilities:
Choate DC (civil) 1	1	0	2	20	64	87
Choate DC (forensic) 2	0	0	0	0	4	4
Fox DC	0	0	1	0	8	9
Kiley DC	4	0	3	25	76	108
Ludeman DC	0	0	5	10	34	49
Mabley DC	0	0	4	5	10	19
Murray DC	2	0	0	4	17	23
Shapiro DC	0	0	0	2	36	38
Facility totals	7	0	15	66	249	337
Community agencies:
Residential	95	7	210	438	1,231	1,981
Non-Residential	42	0	45	103	348	538
Agency totals	137	7	255	541	1,579	2,519
Rule 50 DD Totals	144	7	270	607	1,828	2,856

Death Cases

OIG includes one additional finding when dealing with death investigations, that of "Death Review". This finding is used to designate those deaths that, upon review by OIG Clinical Coordinators, were found to have no indication of abuse or neglect being involved in the death. This is differentiated from "Not Substantiated" where a full investigation was completed after an allegation of abuse or neglect was made or suspected.

Table 6c: Death Cases Closed in FY2017, Developmental Services Only

Location	Abuse substantiated	Exploitation substantiated	Neglect substantiated	Other issue only	Not substan- tiated	Death Review	Totals
Facilities:
Alton MHC (civil) 1	0	0	0	0	0	0	0
Alton (forensic) 2	0	0	0	0	0	0	0
Chester MHC	0	0	0	0	0	1	1
Chicago-Read MHC	0	0	0	0	0	0	0
Choate MHC	0	0	0	0	0	0	0
Elgin MHC (civil)	0	0	0	0	0	1	1
Elgin (forensic)	0	0	0	0	0	1	1
Madden MHC	0	0	0	2	0	0	2
McFarland MHC (civil)	0	0	0	0	0	0	0
McFarland (forensic)	0	0	0	0	0	0	0
Facility subtotals	0	0	0	2	0	3	5
Community agencies:
Residential	0	0	0	4	2	18	24
Non-Residential	0	0	0	1	0	0	1
Agency subtotals	0	0	0	5	2	18	25
MH Death Totals	0	0	0	7	2	21	30

Table 6d: Death Cases Closed in FY2017, Developmental Services Only

Location	Abuse  substantiated	Exploitation substantiated	Neglect substantiated	Other issue only	Not   substantiated	Death Review	Totals
Facilities:
Choate DC (civil) 1	0	0	0	0	0	4	4
Choate DC (forensic) 2	0	0	0	0	0	0	0
Fox DC	0	0	0	0	0	2	2
Kiley DC	0	0	0	0	0	2	2
Ludeman DC	0	0	0	2	0	2	4
Mabley DC	0	0	0	0	0	1	1
Murray DC	0	0	0	1	0	1	2
Shapiro DC	0	0	0	1	0	8	9
Facility totals	0	0	0	4	0	20	24
Community agencies:
Residential	0	0	9	29	15	78	131
Non-Residential	0	0	2	4	1	4	11
Agency totals	0	0	11	33	16	82	142
DD Death Totals	0	0	11	37	16	102	166

Trends in Closures

During FY2017, OIG closed a total of 3,796 cases (an increase of 6.8% over FY2016), which includes 3,600 investigative cases of abuse or neglect and 196 death cases. Total allegations and death reports received in FY2017 totaled 3,897, slightly more than the number of cases closed, and 10.3% more than the 3,533 cases received during FY2016.

Chart detailing: Trends in Closures

Trends in Investigative Findings

OIG substantiated abuse or neglect in 481 investigations. The substantiation rate or the percentage of allegations that are substantiated is shown in Table 7. The rate of substantiation at MH facilities has grown since FY2015, while the rate at DD facilities has decreased during this same time frame. The rates at community agencies have fluctuated slightly over time with no real trends noted.

Table 7: Substantiation Rates by Location and Fiscal Year, FY2015 through FY2017

Location	FY2015	FY2016	FY2017
MH State Facility	3.60%	3.20%	5.70%
DD State Facility	8.50%	7.50%	6.10%
MH Community Agency	4.80%	1.30%	7.60%
DD Community Agency	14.70%	13.90%	15.40%
Total	11.70%	10.70%	12.70%

Chart of Table 7: Substantiation Rates by Location and Fiscal Year, FY2015 through FY2017

Investigative Timeliness

Until May 26, 2017, when Rule 50 was last amended, OIG investigative case reports were mandated to be submitted within sixty working days from assignment, unless there are extenuating circumstances. Although this artificial time limit has been removed, OIG still strives to complete investigations as quickly as possible, while maintaining accuracy and thoroughness. One such circumstance which delays completion of a case by OIG is an ongoing criminal investigation. When the Illinois State Police (ISP) or local law enforcement (LLE) accepts a case for criminal investigation, OIG, by agreement, suspends its administrative investigation until ISP/LLE has completed its investigation. If a criminal investigation results in a referral of prosecution, OIG will continue to suspend its investigation until the State's Attorney makes a prosecutorial decision or judicial proceedings have been completed. During this investigative down time, OIG makes monthly contact with the appropriate agency for a status update to track the progress of the investigation. At times, LLE will give OIG permission to complete the administrative investigation while the criminal investigation is ongoing.

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 administratively defined investigative limit of sixty days. The primary reasons were the increasing number of allegations and the inability of OIG to fill a number of positions vacated by retirements over the last several years. During FY2016, OIG hired 13 new investigators. In FY2017, OIG hired an additional three investigators, bringing the total number of investigators up to 33. With this additional staff, OIG was able to increase the number of cases completed while reducing its average completion time to 97.8 working days, a decrease of 14.1 working days or 12.6%.

Table 8: Average Time to Completion for All OIG Investigations, by Fiscal Year

Investigations	FY2015	FY2016	FY2017
Number completed	3,160	3,639	3,895
Average total days*	96.6	115.4	97.9
Average OIG days*	95.5	111.9	97.8

*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.

Chart of Table 8: Average Time to Completion for All OIG Investigations, by Fiscal Year

Reconsiderations

After an investigation has gone through the review phase and the results are initially sent out to the involved facility or community agency, there is a 15 day time frame during which the facility/agency, accused, or victim can request a reconsideration of the findings based on new evidence not discovered during the initial investigation. During FY2017, OIG received 149 requests to reconsider the findings of 132 Rule 50 investigations (some cases had multiple requests), 66.7% of which were substantiated cases. Of the 149 requests, OIG granted 20 (involving 17 cases) and denied 129 (involving 115 cases) as no new information was provided, a requirement of OIG Rule 50. Of the 17 cases with granted reconsiderations, OIG revised one case report, which had a change in findings.

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

Once all appeals are exhausted, OIG is 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, financial exploitation, or egregious neglect in a Rule 50 setting. During FY2017, 70 employees were referred to the Registry. Nine referrals involved facility employees and 61 involved agency employees. All of the employees referred to the Registry were direct care staff. One agency staff member was referred twice as a result of two separate investigations.

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 58 of the 70 referrals (82.9%) this fiscal year - nine facility staff and 49 DD agency staff.

Sexual Abuse: Sexual abuse is defined as any 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 behavior 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 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.

In FY2017, six employees (8.6%) were referred to the Registry for sexual abuse, three in a DD setting and three in a MH setting.

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 FY2017, there were three (4.3%) such referrals, two in DD settings and one in a MH setting.

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 or facility's own advantage or benefit. In FY2017, three employees (4.3%) were referred to the Registry for financial exploitation, all of them 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, either Mental Health or Developmental Disabilities. The program division then reviews and approves the written response, lists the proposed actions, and sends the approved written response to OIG.

FY2017 Issues

In FY2017, OIG sent 166 initial written responses to facilities and 1,079 to community agencies for a total of 1,245 written responses covering as many cases. OIG received the approved written responses in 881 of those 1,245 cases. OIG also received 97 approved written responses that had been required during a prior fiscal year, totaling 978 approved written responses received during FY2017. In the 978 written responses received, there were a combined total of 1,351 issues identified.

Table 9: Issues Cited in Approved Written Responses Received, FY2015 through FY2017

Issues	FY2015		FY2016		F2Y2017
	Count	Percent	Count	Percent	Count	Percent
Substantiations	384	35.1	392	29.8	407	30.1
Late reporting	159	14.5	178	13.5	204	15.1
Nursing practices	90	8.2	140	10.6	101	7.5
Investigative error	30	2.7	109	8.3	134	9.9
Service plan	79	7.2	131	10	105	7.8
Inappr. Interaction	60	5.5	79	6	67	4.9
Failure to report	53	4.8	64	4.9	70	5.2
Monitoring/staffing	61	5.6	62	4.7	104	7.7
All other issues	180	16.4	161	12.2	159	11.8
Total issues	1,096	100	1,316	100	1,351	100

This table shows that the count of total issues OIG cited in FY2017 was 2.7% more than in FY2016, which was in turn 20% more than in FY2015. Written responses received consequent to substantiated findings accounted for the largest proportion of the written responses received.

FY2017 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 FY2017, the facilities and agencies performed 1,708 actions (a 0.8% decrease over FY2016) to address the 1,351 issues identified in the 978 cases with an approved Written Response. See Table 10.

Table 10 - FY2017 Actions Taken

Type	Number of Actions Taken
Retraining	450
Discharged	291
Group Training	195
Procedural Change	113
Resignation	97
Written Reprimand	93
Reviewed by Agency/Facility	89
Counseling	83
Policy Change	65
Nothing	38
Suspension	37
Habilitation/Treatment Change	35
Administrative Change	25
Fired (Other Cause)	19
Oral Reprimand	19
Reassignment	16
Supervision	14
Retirement	9
Transferred	8
Structural Repair	7
Structural Upgrade	5
Total	1,708

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.

FY2017 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.

FY2017 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. While Rule 50 requires a minimum sample of 10%; OIG chooses to do 15%. 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. OIG works closely with the divisions to clarify actions on several written responses, resulting in no "Out of Compliance" letters being issued in FY2017.

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. 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 FY2017 compliance reviews, OIG randomly selected 154 of the written responses approved, and then added the 16 written responses that were pending over 120 days for a total of 170 compliance reviews. Table 11 below shows the breakdown of all 170 compliance reviews by disability type and location.

Table 11: FY2017 Number of Compliance Reviews on Approved Written Responses

Location	DD Programs	MH Programs	Totals
DHS facilities	16	22	38
Community agencies	122	10	132
Totals	138	32	170

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.

Conclusion

OIG takes seriously our responsibility to protect individuals with disabilities and mental illnesses throughout the entire state system. OIG continues to mentor new investigators with an eye towards improving the quality and timeliness of investigations. We continue to streamline the Intake process as well as the testing procedures used for our outside investigative training of facility and community agency staff. 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.