DHS OIG FY 2018 Annual Report

November 2018

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) 2018 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 FY2018. 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, including a new graphical section on trends in reporting.

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

Sincerely,

Michael J. McCotter

Inspector General

Executive Summary

During FY2018, the Office of the Inspector General (OIG) accomplished the following:

• Received 3,874 abuse or neglect allegations, an increase of 4.9% over FY2017:
• 0.4% fewer allegations at community agencies and
• 19.2% more allegations at facilities.
• Received 219 reports of deaths of individuals who were or had been receiving services in facility or community agency programs.
• Closed 3,398 investigations into abuse or neglect allegations, a decrease of 5.6% over FY2017. OIG substantiated abuse or neglect in 371 of those investigations. Community agency cases accounted for 332 of the 371 substantiated cases (89.5%) and facility cases for the remaining 39 cases (10.5%).
• OIG closed 190 death cases during FY2018. Of the 190 closed death cases, neglect was substantiated in 11 cases and issues were identified in 39 other cases.
• Received 8,611 phone contacts through the OIG Hotline, an increase of 2.6% over FY2017.
• Recommended administrative action in 1,091 cases at facilities or community agencies. OIG received DHS-approved written responses in 962 of those cases, as well as another 407 completed from prior years, for a total of 1,369 written responses. A total of 1,966 issues were identified, the most common being substantiated abuse or neglect.
• Referred to the IDPH Health Care Worker Registry (HCWR), 78 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 1,255 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, which after retirements, increased the total number of investigators to 31.
• Presented OIG Investigative Steps training to 63 facility staff members via e-mailed narrated PowerPoint and e-mailed Rule 50.30(f) to 304 facility and community agency staff (a decrease of 19.0% over FY2017). Of the e-mailed Rule 50.30(f) presentations, 256 staff members were certified as having passed the accompanying test, while 43 facility staff members were certified under OIG Investigative Steps.

Table of Contents

1. Abuse and Neglect of Adults with Disabilities
   1. Chapter 1: Preventing Abuse and Neglect
   2. Chapter II: Reporting Abuse and Neglect
   3. Chapter III: Investigating Abuse and Neglect
   4. Chapter IV: Stopping Abuse and Neglect

Abuse and Neglect of Adults with Disabilities

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 for most of FY2018 were:

• 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)

Two quarterly Board meetings were held in in FY2018: September 25, 2017 and December 14, 2017, both via teleconference. Neither meeting had a quorum of members attending.

At the end of June 2018, the Board membership was totally replaced by the following new members:

• David Friedland, Chair
• Dr. John Pingo
• Cathy Lomasney
• Merlin Lehman

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 2018 Site Visit Issues

OIG's site visit protocol was initially created on January 16, 1997. In addition to addressing follow up recommendations from FY2017, the site visit protocol for FY2018 included an overview of the following:

Annual Treatment/Service Plan Reviews

• Policy and systems processes to ensure timely completion of reviews
• Thoroughness of documentation in Individual Service Plans or Treatment Plans

Thoroughness of Rule 50 Training via the One Net

• Facility policies regarding training
• Tracking Rule 50 training for employees who may be on leave

Thoroughness of Facility Rule 30.30(f) Steps

• Facility processes for conducting initial investigative steps
• Elimination of any perceived conflict of interest among staff who conduct investigative steps

Environmental Safety/Equipment Maintenance

• Proper maintenance of medical equipment - medication refrigerators, AEDs, oxygen tanks
• Clean, clutter-free environment
• Routine environmental checks and appropriate, timely follow-up to issues discovered

Administrative Leave or Reassignment Processes

• Thorough tracking of staff on reassignment
• Ensuring that reassigned staff have no contact with individuals and are not assigned to individual care areas

Documenting and Tracking Sex Offenders at Facilities

• Compliance with the program directive, "Pre-Admission, Admission, Retention, Discharge/Transfer of Identified Sex Offenders"
• Ensuring safety of the identified sex offender and other individuals living in the same area

Site Visit Dates

In FY2018, the dates of the site visits were as follows:

• Alton Mental Health Center February 2 and 3, 2018
• Chester Mental Health Center June 27 and 28, 2018
• Chicago-Read Mental Health Center April 18 and 19, 2018
• Choate Developmental Center June 20-22, 2018
• Choate Mental Health Center June 20-22, 2018
• Elgin Mental Health Center March 14 and 15, 2018
• Fox Developmental Center March 18, 2018
• Kiley Developmental Center May 1 and 2, 2018
• Ludeman Developmental Center May 21-June 5, 2018
• Mabley Developmental Center March 14 and 15, 2018
• Madden Mental Health Center December 14, and 15, 2017
• McFarland Mental Health Center June 7 and 8, 2018
• Murray Developmental Center June 12, 2018
• Shapiro Developmental Center May 21 and 22, 2018

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 FY2018, OIG made 56 recommendations, compared to seven made in FY2017. One fourth-year recommendation was noted at Madden Mental Health Center. OIG recommended the facility create discipline-specific competency evaluations for professional staff to ensure they were adequately meeting the unique needs of the individuals we serve. Upon further discussion with the Hospital Administrator and Medical Director, the issue was referred to the Department of Mental Health for review and recommendations for possible sanctions.

OIG also found the following:

Annual Treatment/Service Plan Reviews: Ten recommendations were made at six facilities (two mental health and four developmental disabilities centers). Most were documentation issues - either lack of signatures or proper completion/updates of the treatment or service plan. At two developmental centers, there were violations of the 365-day requirement to conduct annual reviews within that time frame. Additionally, it was recommended that one facility re-train their staff on this requirement.

Rule 50 Training Via the OneNet: No recommendations were made on this issue. OIG found that all fourteen facilities adequately trained staff on this requirement and some enhanced the training with classroom instruction. Each facility tracked staff who were away from the facility for various types of leave and ensured they were trained upon their return on Rule 50 and other core modules specific to their facility.

Rule 50.30(f) Investigative Steps: Thirteen recommendations were made on this issue. At five facilities, either the facility did not have a checklist to document these steps or their current checklist needed updates. Five facilities needed to train additional staff to conduct 50.30(f) initial investigative steps, either because their security staff conducted them all the time or because they did not have staff on each shift who were able to step in quickly to begin the process. One facility did not immediately separate witnesses, citing lack of staffing as the reason, and another did not conduct or facilitate a separate Rule 50.30(f) training for those staff.

Environmental Safety: This section had by far the most recommendations - 20 recommendations at nine facilities. However, without exception, all fourteen facilities had issues ranging from fairly minor, immediately-correctible areas (light bulb replacements, loose drywall tape, cigarette butts outside entrances, employee use of facility refrigerators, overall cleanliness), to more serious, potentially hazardous situations (no anti-slip flooring, excessive clutter impeding egress in and out of areas, electrical hazards, non-documentation of medication refrigerator temperatures, ligature risks, uncharged oxygen tank). At two developmental centers, site visitors noted vehicles ignoring stop signs and traveling at high speeds throughout campus. The Division of Developmental Disabilities was made aware of this situation, which posed a significant risk to the individuals who were observed walking through the same areas at the time.

Administrative Reassignment: Six recommendations were made at six facilities. Four facilities did not have a reassignment policy or form to document staff reassignment status. Two mental health facilities allowed reassigned staff to have individual contact and work on patient units, in direct contradiction to program directives and OIG Rule 50 requirements.

Illinois Sex Offender Registry: Six recommendations were made at six facilities regarding this issue. Three facilities did not routinely conduct Illinois Sex Offender Registry and other background checks prior to admission of an individual, one facility needed its treatment plan form updated, and one facility did not have all required signatures on treatment plans of individuals either on the Illinois Sex Offender Registry or who have identified sexually-related issues which could pose a risk to themselves or individuals surrounding them. Another facility did not follow through with making all required notifications to receiving facilities or community placements.

Training

Internal OIG Training

OIG Directives require that each staff member with investigative credentials must take at least three classes during the fiscal year. Due in part to Public Act 100-1098, the theme for FY2017 was departmental rules and trainings consisted of PowerPoints on Rule 50, Rule 115 (Standards and Licensure Requirements for Community Integrated Living Arrangements), Rule 116 (Medication Administration by Non-licensed Staff in Community Settings), Rule 119 (Minimum Standards for Certification of Developmental Training Programs), in addition to which two other courses on Head Trauma and Traumatic Brain Injury, and Choking and Special Diets were offered.

In FY2018, DHS made a wide technological leap in switching from Microsoft Office 2010 to Microsoft Office 365. In response, OIG offered two classes in the use of Microsoft Word along with mandatory Ethics training, a review of the investigative training mandated for facility and community agency investigators entitled Rule 50.30(f), and an updated training on Rule 50. Also, through our relationship with the Department of Health and Family Services Office of the Inspector General, thirteen investigators were able to attend a class on the highly respected REID Technique of Investigative Interviewing and Positive Persuasion.

Outside OIG Training

During FY2018, 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 meet 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 FY2018, Rule 50.30(f) was e-mailed to 304 facility and community agency staff, a decrease of 19% over FY2017. This decrease is partially due to the two-year certification period and the fact that 50.30(f) training is not required after the Investigative Steps training. Of those 304 presentations e-mailed, 256 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 FY2018, OIG presented OIG Investigative Steps training to 63 facility staff members via e-mailed narrated PowerPoint presentation, of which 43 received certification.

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 FY2018. 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, 2018; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2018 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, 2018, is shown in the fourth column of the tables.

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

Table 1: Census and Staffing Ratios, DHS State-run Facilities, June 30, 2018

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	210	37,484	104	142.6	1.37
Chester MHC	455	99,043	272	295.4	1.09
Chicago-Read MHC	308	47,563	140	189.9	1.36
Choate MHC & DC*	312	82,195	233	392.6	1.68
Elgin MHC	1,082	130,012	344	451.2	1.31
Fox DC	101	34,398	92	133.7	1.45
Kiley DC	206	70,705	191	358	1.87
Ludeman DC	392	139,356	382	590.6	1.55
Mabley DC	112	39,692	108	171.25	1.59
Madden MHC	2,160	37,371	94	144.5	1.54
McFarland MHC	372	50,605	138	148	1.07
Murray DC	229	79,117	225	357.74	1.59
Shapiro DC	501	172,853	470	815.97	1.74
DD facility totals	1,853	618,316	1,701	2,819.86	1.66
MH facility totals	4,587	402,078	1,092	1,371.60	1.26

* 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.

FY2018 Reporting

During FY2018, OIG received a total of 3,874 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 FY2018

	Abuse allegations	Neglect allegations	Total allegations
DHS-operated facilities	931	242	1,173
Community agencies	1,579	1,122	2,701
Total	2,510	1,364	3,874

* Contains 20 financial exploitation allegations from DHS-operated facilities and 153 from community agencies.

Chart of Table 2: Summary of Allegations Received by OIG in FY2018

Total abuse allegations in DHS-operated facilities and community agencies increased in FY2018 (2,510 versus 2,454 in FY2017), mirroring the change from FY2016 to FY2017 where abuse allegations again increased by 227 cases. In these same settings, allegations of financial exploitation (a subset of abuse) decreased by 7.0%, as opposed to FY2017 which showed a large increase of 59% over FY2016.

Likewise, total neglect allegations in DHS-operated facilities and community agencies have increased by 9.7% over FY2017.

Facilities

During FY2018, OIG received 1,173 total allegations of abuse and neglect at the DHS-operated facilities, a 19.2% increase in allegations from FY2017. Of the total allegations at facilities in FY2018, there were 931 allegations of abuse which includes 20 allegations of financial exploitation. Abuse allegations accounted for 79.4% of the total allegations at facilities.

OIG also received 242 allegations of neglect at facilities, for 20.6% of the total allegations. The number of neglect allegations increased by 16.3% over FY2017, mirroring the 20.9% increase of FY2017 over FY2016.

Chart detailing: Summary of Facility Allegations from FY2016 to FY2018

 

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 FY2018, allegations at community agencies accounted for 69.7% of all allegations OIG received. This high percentage is reflective of the number of individuals receiving services by community agencies.

During FY2018, OIG received 2,701 total allegations at community agencies. This is a 0.4% decrease in allegations from FY2017. Of the total allegations, there were 1,579 allegations of abuse, which included 153 allegations of financial exploitation. This year, the proportion of all allegations represented by abuse allegations was 58.5%. In comparison, FY2017 had a rate of 61.8%, as opposed to 68.5% in FY2016 and 60.0% in FY2015.

OIG also received 1,122 allegations of neglect at community agencies, an increase of 8.4% over the 1,035 received during FY2017.

Chart detailing: Summary of Community Agency Allegations from FY2016 to FY2018

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 FY2018, 219 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. This is a 9.5% increase over FY2017, as opposed to the 12.3% decrease in FY2017. OIG closed 190 death cases during FY2018, a 3.1% decrease over the 196 closed during FY2017. Of the 190 closed death cases, neglect was substantiated in 11 while the remaining 179 found no suspicion of abuse or neglect. In 39 of the 179 unsubstantiated cases, issues were identified which required a written response from the facility/agency.

Table 3a: Allegations and Deaths Received in FY2018, Mental Health Services Only

Location	Physical abuse	Sexual Abuse	Mental Abuse	Financial Exploitation	Neglect	Total Received	Death Reports
Facilities:
Alton MHC (civil) 1	25	3	9	1	6	44	0
Alton (forensic) 2	45	5	24	2	17	93	0
Chester MHC	98	8	39	1	24	170	2
Chicago-Read MHC	12	1	10	0	2	25	0
Choate MHC	15	8	16	1	14	54	0
Elgin MHC (civil)	11	14	17	1	11	54	1
Elgin (forensic)	35	23	24	3	21	106	0
Madden MHC	23	2	9	1	12	47	1
McFarland MHC (civil)	15	8	11	1	11	46	1
McFarland (forensic)	14	7	4	1	4	30	0
Facility subtotals	293	79	163	12	122	669	5
Community agencies:
Residential	16	14	38	18	28	114	20
Non-Residential	9	17	19	41	15	101	2
Agency subtotals	25	31	57	59	43	215	22
Rule 50 MH totals	318	110	220	71	165	884	27

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 FY2018, Developmental Services Only

Location	Physical Abuse	Sexual Abuse	Mental Abuse	Financial Exploitation	Neglect	Total Received	Death Reports
Facilities:
Choate DC (civil) 1	61	5	23	1	18	108	0
Choate DC (forensic) 2	1	0	0	0	0	1	0
Fox DC	5	1	2	0	9	17	9
Kiley DC	87	2	15	1	21	126	1
Ludeman DC	45	2	16	2	31	96	2
Mabley DC	9	1	2	1	17	30	3
Murray DC	27	0	4	2	18	51	3
Shapiro DC 3	54	1	10	1	5	71	7
Facility subtotals	289	12	72	8	119	500	25
Community agencies:
Residential	688	50	314	92	927	2,071	164
Non-Residential	168	19	74	2	152	415	3
Agency subtotals	856	69	388	94	1,079	2,486	167
Rule 50 DD totals	1,145	81	460	102	1,198	2,986	192

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, 2017 to June 30, 2018.

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, FY2016 through FY2018

		Late from Agencies		Late from Facilities
Fiscal Year	Total Self-Reports*	DD	MH	DD	MH	Total Late	Percent Late
FY2016	2,908	287	35	22	36	380	13.1
FY2017	3,195	272	38	22	26	358	11.2
FY2018	2,825	189	28	22	20	259	9.2

*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 1,158 of the 1,255 (92.3%) 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 FY2018

Referral Location	Count
Local community agency or facility	1,006
Illinois Department of Public Health	13
Department of Children and Family Services	1
Department of Health and Family Services	4
Department of Rehabilitation Services	1
Local law enforcement authority	11
Department on Aging	11
DHS - BALC/OCAPS	6
DHS Division of Developmental Disabilities	49
DHS Division of Mental Health	11
Office of Executive Inspector General	4
Other	41
None needed	97
Total	1,255

Trend Analysis

During the course of an investigation, beginning with the initial report to OIG via the Hotline to the closure of the case itself, massive amounts of data are received and inputted into the OIG Comprehensive Database. While primarily used for the creation of investigative reports and case management, OIG is beginning to move outside the box and analyze this data in the belief that the prevention of abuse and neglect is as important, if not more so, than the investigation of incidents that have already occurred. To this end, the following graphs show trends in the reporting and timing of incidents. As OIG proceeds further into this realm, we will continue to update the graphs and techniques used to better achieve our objective.

Time of Discovery

The following graph shows the time, if know, the actual incident was discovered. Not shown are the 815 incidents where the time of discovery was not specified by the complainant. This lack of information can be attributed to the number of allegations made by complainants outside the facility's or community agency's employ.

Time of Initial Reporting to OIG

The following graph shows the time the incident was actually reported to OIG. This graph is being used to make the OIG 24-hour Hotline more responsive to the needs of those reporting allegations of abuse and neglect, and deaths. As can be readily seen, this graph is almost a mirror image of the graph showing Discovery Times. This is directly attributable to the work schedules of facility/community agency staff, as well as the sleeping patterns of the individuals served.

Time of Incident

The following graph shows the time of the actual incident as reported to OIG. Not shown are the 2,874 incidents where the incident time was not specified by the complainant. The graph again follows the general shape of the two preceding graphs.

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.

FY2018 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 FY2018, OIG opened 3,874 abuse/neglect investigations, which is a 4.8% increase over the previous year. (Death cases are broken out separately.)

During the same fiscal year, OIG closed 3,398 investigations, which is a 5.6% decrease of the previous year. The reasons for this decrease are numerous. Cases continue to shift to the community agencies and away from the facilities, resulting in less centralization of cases by location and more travel. Investigative experience is another factor. 73% of our investigators (25) have been with OIG three years or less, while 9% (three) have been here four to five years, and only 18% (six) have been here ten years or more. Of the 25 hired in the last three years, only eight had prior investigative experience. To solve the experience problem, OIG partnered with CMS in the creation of a new Option A for investigators, which requires experience in an identifiable investigative title to get an "A" grade for the ISI2 job title. However, even with investigative experience, conducting abuse/neglect investigations in developmental disabilities and mental health settings takes a large amount of experience to learn all the rules and regulations in effect. This requires regular training and mentoring from management and experienced investigators. While this ensures competent investigators in the long term, it takes experienced employees away from completing investigations, which slows down completion of cases in the short term. The hiring of staff is just the beginning of the process to improve on the timeliness of investigations and will take time to see noticeable improvement.

Chart detailing: FY16-FY18 Opened and Closed Investigations Comparison

FY2018 Closures

The findings in abuse or neglect allegations and in death cases OIG closed during FY2018 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 credible evidence, but less than 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 FY2018, Mental Health Services Only

Location	Abuse substantiated	Exploitation substantiated	Neglect substantiated	Other issue only	Not  substantiated	Allegation findings totals
Facilities:
Alton MHC (civil) 1	0	0	0	1	26	27
Alton (forensic) 2	1	0	0	1	78	80
Chester MHC	2	0	1	10	152	165
Chicago-Read MHC	0	0	0	2	29	31
Choate MHC	1	0	5	9	25	40
Elgin MHC (civil)	0	0	0	10	51	61
Elgin (forensic)	0	0	0	20	81	101
Madden MHC	1	0	0	5	32	38
McFarland MHC (civil)	0	0	0	1	38	39
McFarland (forensic)	0	0	0	0	8	8
Facility subtotals	5	0	6	59	520	590
Community agencies:
Residential	4	2	1	11	68	86
Non-Residential	2	1	1	13	92	109
Agency subtotals	6	3	2	24	160	195
Rule 50 MH Totals	11	3	8	83	680	785

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 FY2018, Developmental Services Only

Location	Abuse  substantiated	Exploitation substantiated	Neglect substantiated	Other issue only	Not substantiated	Allegation findings totals
Facilities:
Choate DC (civil) 1	1	0	6	14	61	82
Choate DC (forensic) 2	0	0	0	0	2	2
Fox DC	0	0	3	1	9	13
Kiley DC	0	0	5	26	102	133
Ludeman DC	1	0	5	22	36	64
Mabley DC	1	0	3	6	22	32
Murray DC	0	0	1	10	31	42
Shapiro DC	2	0	0	10	65	77
Facility totals	5	0	23	89	328	445
Community agencies:
Residential	83	8	175	420	1,100	1,786
Non-Residential	20	0	35	71	255	381
Agency totals	103	8	210	491	1,355	2,167
Rule 50 DD Totals	108	8	233	580	1,683	2,612

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 FY2018, Mental Health Services Only

Location	Abuse substantiated	Exploitation substantiated	Neglect substantiated	Other issue only	Not substantiated	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	1	0	1
Chicago-Read MHC	0	0	0	0	0	1	1
Choate MHC	0	0	0	0	0	0	0
Elgin MHC (civil)	0	0	0	0	0	0	0
Elgin (forensic)	0	0	0	0	0	1	1
Madden MHC	0	0	0	0	0	1	1
McFarland MHC (civil)	0	0	0	0	0	1	1
McFarland (forensic)	0	0	0	0	0	0	0
Facility subtotals	0	0	0	0	1	4	5
Community agencies:
Residential	0	0	0	7	3	14	24
Non-Residential	0	0	0	0	0	2	2
Agency subtotals	0	0	0	7	3	16	26
MH Death Totals	0	0	0	7	4	20	31

Table 6d: Death Cases Closed in FY2018, Developmental Services Only

Location	Abuse substan- tiated	Exploit. substan-tiated	Neglect substan- tiated	Other issue only	Not substan- tiated	Death Review	Totals
Facilities:
Choate DC (civil)1	0	0	0	0	0	0	0
Choate DC (forensic) 2	0	0	0	0	0	0	0
Fox DC	0	0	0	0	0	8	8
Kiley DC	0	0	0	0	0	0	0
Ludeman DC	0	0	0	0	0	1	1
Mabley DC	0	0	0	0	0	4	4
Murray DC	0	0	0	0	0	2	2
Shapiro DC	0	0	0	1	2	3	6
Facility totals	0	0	0	1	2	18	21
Community agencies:
Residential	0	0	11	30	16	77	134
Non-Residential	0	0	0	1	2	1	4
Agency totals	0	0	11	31	18	78	138
DD Death Totals	0	0	11	32	20	96	159

Trends in Closures

During FY2018, OIG closed a total of 3,588 cases (a decrease of 5.5% in relation to FY2017), which includes 3,399 investigative cases of abuse or neglect and 190 death cases. Total allegations and death reports received in FY2018 totaled 4,094, 14% more than the number of cases closed, and 5.1% more than the 3,897 cases received during FY2017.

Chart detailing: Trends in Closures

Trends in Investigative Findings

OIG substantiated abuse or neglect in 382 investigations. The substantiation rate or the percentage of allegations that are substantiated is shown in Table 7. After hitting a high last year, the rate of substantiation has decreased across all locations.

Table 7: Substantiation Rates by Location and Fiscal Year, FY2016

Location	FY2016	FY2017	FY2018
MH State Facility	3.20%	5.70%	1.80%
DD State Facility	7.50%	6.10%	6.00%
MH Community Agency	1.30%	7.60%	5.00%
DD Community Agency	13.90%	15.40%	14.40%
Total	10.70%	12.70%	10.60%

Chart of Table 7: Substantiation Rates by Location and Fiscal Year, FY2016 through FY2018

 

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 time frame has been removed from administrative rule, it is still a requirement in OIG Directives and is the timeframe used to complete investigations as quickly as possible, while maintaining accuracy and thoroughness. Some of the issues that affect timely completion of investigations are the overall number of cases in OIG's caseload, the complexity of the cases within the caseload, and referrals to law enforcement for 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, although rarely, 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 June of 2018, OIG hired three new investigators who, with several retirements factored in, brought our total number of investigators to 31. While this number appears to be on par with the previous year, it must be noted that OIG considers all investigators with less than four months training as probationary. In addition, with the assistance of CMS, OIG has created an enhanced requirement for all investigator trainees of a minimum of two years of actual investigative experience. This, hopefully, will shorten the training required before a new investigator is able to assume a full workload. While FY2018 investigative times did rise, they are still significantly lower than those of FY2016.

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

Investigations	FY2016	FY2017	FY2018
Number completed	3,639	3,895	3,543
Average total days*	115.4	97.9	102.8
Average OIG days*	111.9	97.8	103

*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 FY2018, OIG received 163 requests to reconsider the findings of 153 investigations (some cases had multiple requests), 50.3% of which were substantiated cases. Of the 163 requests, OIG granted 35 (involving 33 cases) and denied 128 (involving 122 cases) as no new information was provided, a requirement of OIG Rule 50. Of the 33 cases with granted reconsiderations, OIG revised no case report(s).

On August 17, 2018, Public Act 100-0943 was signed by Governor Rauner, with an effective date of January 1, 2019. Although the effective date is, as of the date of this report, a number of months away, most of these mandated practices are already in place for the Request for Reconsideration process, and those that are not are effective immediately. The Request for Reconsideration has always been accomplished through a multi-level review process and will continue to so. As practiced by OIG and mandated by this Act, one reviewer of the reconsideration request will not have participated in the investigation or approval of the original report. This person historically has been, and will continue to be, the last reviewer to make a recommendation to the Inspector General. Another mandated change is that requestors are no longer required to provide "additional information" to file a Request for Reconsideration.

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 FY2018:

• 78 employees were referred to the Registry;
• One employee was referred to the Registry for two separate cases of physical abuse;
• Three referrals involved facility employees and 75 involved agency employees;
• 64 of the employees referred to the Registry were direct care staff and fourteen were administrative staff; and
• 70 employees worked for the Division of Developmental Disabilities and eight worked for the Division of Mental Health.

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 57 of the 78 referrals (73%) this fiscal year - three facility staff and 54 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 FY2018, ten community agency employees (13%) were referred to the Registry for sexual abuse, five in a DD setting and five 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 FY2018, there were two (3%) such referrals, both in agency DD settings.

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 FY2018, nine agency employees (11%) were referred to the Registry for financial exploitation, eight of them DD employees and one MH employee.

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.

FY2018 Issues

In FY2018, OIG sent 202 initial written responses to facilities and 889 to community agencies for a total of 1,091 written responses covering as many cases. OIG received the approved written responses in 962 of those 1,091 cases. OIG also received 407 approved written responses that had been required during a prior fiscal year, totaling 1,369 approved written responses received during FY2018. In the 1,369 written responses received, there were a combined total of 1,966 issues identified.

Table 9: Issues Cited in Approved Written Responses Received, FY2016 through FY2018

Issues	FY2016		FY2017		FY2018
	Count	Percent	Count	Percent	Count	Percent
Substantiations	392	29.8	407	30.1	478	24.3
Late reporting	178	13.5	204	15.1	257	13.1
Nursing practices	140	10.6	101	7.5	165	8.4
Investigative error	109	8.3	134	9.9	205	10.4
Service plan	131	10	105	7.8	392	19.9
Inappr. Interaction	79	6	67	4.9	83	4.2
Failure to report	64	4.9	70	5.2	65	3.3
Monitoring/staffing	62	4.7	104	7.7	79	4
All other issues	161	12.2	159	11.8	242	12.4
Total issues	1,316	100	1,351	100	1,966	100

This table shows that the count of total issues OIG cited in FY2018 was 45.5% more than in FY2017, which was in turn 2.7% more than in FY2016. As can be seen from the following table, the large increase for FY2018 is directly attributable to the large increase in the number of written responses processed during the year that were actually from a prior year. Written responses received consequent to substantiated findings accounted for the largest proportion of the written responses received.

Table 10: Number of Written Responses and Issues Received

Fiscal Year	Number of Written Responses Received from cases during the Year	Number of Written Responses Received from Prior Year(s)	Total Number of Written Responses Received	Total Number of Issues
FY2016	860	124	984	1,316
FY2017	881	97	978	1,351
FY2018	962	407	1,369	1,966

FY2018 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 FY2018, the facilities and agencies performed 2,383 actions (a 39.5% increase over FY2017) to address the 1,966 issues identified in the 1,369 cases with an approved Written Response. See Table 11.

Table 11 - FY2018 Actions Taken

Type	Number of Actions Taken
Retraining	520
Group Training	393
Discharged	320
Procedural Change	183
Reviewed by Agency/Facility	170
Resignation	134
Policy Change	103
Written Reprimand	102
Counseling	86
Habilitation/Treatment Change	74
Nothing	67
Administrative Change	45
Fired (Other Cause)	39
Suspension	38
Transferred	38
Oral Reprimand	24
Reassignment	16
Structural Upgrade	10
Supervision	8
Structural Repair	7
Performance Evaluation	2
Retirement	4
Total	2,383

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.

FY2018 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.

FY2018 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%, in most cases OIG does up to 15% on a monthly basis. 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 FY2018.

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 FY2018 compliance reviews, OIG randomly selected 213 of the written responses approved, and then added the 3 written responses that were pending over 120 days for a total of 216 compliance reviews. Table 11 below shows the breakdown of all 216 compliance reviews by disability type and location.

Table 11: FY2018 Number of Compliance Reviews on Approved Written Responses

Location	DD Programs	MH Programs	Totals
DHS facilities	24	12	36
Community agencies	160	20	180
Totals	184	32	216

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.