In addition to commissioning three independent reviews of the facility, many steps have been taken to improve CMHDC and the SODC system. Actions include:
Security Cameras
Thirty-nine outdoor, and 75 indoor security cameras are being activated at Choate Mental Health and Developmental Center. Dozens more are being added in common indoor areas, where there is a low or no reasonable expectation of personal privacy (as opposed to resident bedrooms, restrooms, etc.). IDHS is carrying out additional security camera installation in all seven SODCs.
Staffing
- Increased security staff by 5 positions including one security officer chief.
- Increased onsite investigatory staff by 2 positions.
- Increased management presence in living areas and professional staff presence after hours.
- Consistent work to reduce staff vacancies:
- Continuous posting, broad advertising of positions
- Hosting on-campus job fairs to expedite hiring
- Working with Central Management Services to onboard employees as quickly as possible
- Increased starting wages for new employees
New Leadership
Ryan Thomas was appointed IDHS' first-ever Chief Resident Safety Officer on March 6. Her singular focus is the safety and welfare of SODC residents. She brings over 16 years of regulatory compliance, including at the Joint Commission for accrediting care facilities. Her entire career has been devoted to resident and patient safety, and change management. She is charged with implementing safety improvements at all seven SODCs. A new DD Division Director (Tonya Piephoff) was appointed in June, and a new Director at the Choate Center (Stephany Hoehner) started in August.
Independent, Third-Party Onsite Monitoring
Equip for Equality investigation staff conducting chart reviews, staff interviews, and monitoring of unit conditions. Visit dates include July 29, 2022, August 9, 2022, and October 20-21, 2022; EFE went to Choate December (7 and 8) and January (26 and 27).
Safety Engagement
- On June 26, a Safety Summit was hosted in Carbondale where CMHDC staff and leadership, IDHS staff, representatives from SIU School of Medicine, parents and guardians, advocacy groups, and local legislators developed safety action plans for topics including:
- leadership and mid-management involvement and support for resident safety,
- communication about errors, handoffs and information exchange,
- reporting and responding to resident safety events,
- communication openness, and
- continuous improvement.
- A staff town hall was held on July 7, 2023, to review the results from the culture of safety survey and the action plans developed to enhance the resident safety program. The implementation teams received related training throughout the month and are leading kickoff meetings in August.
- In response to recent recommendations from the IDHS OIG, additional phones and locked bulletin boards were installed onsite to ensure employees and residents have access to safety information and the means to easily report abuse and neglect.
- IDHS has appointed 20 Safety Champions across all 7 SODCs who will work to:
- Promote a safe working environment
- Raise awareness about potential hazards
- Address safety concerns in real-time
Training and Consultation
- New and re-training sessions for all staff, on topics including staff and resident culture of safety trainings, human rights, trauma informed care, guardianship, building therapeutic environment, PICA protocols, abuse reporting, requirements regarding reporting, cooperation for investigations, retaliation, leadership and accountability for supervisors, implicit bias, and active treatment.
- Illinois Crisis Prevention Network has provided ongoing support for individualized behavior plan for residents in need of enhanced support.
Increased Penalties for Misconduct
OIG achieved changes in State (Health Worker Registry) law to bar people from working in healthcare if they materially obstruct resident/patient abuse investigations.
Visible, Physical Improvements to Choate living areas and homes.
Completed a pilot environmental improvement project in 2 homes - Redbud and Dogwood - which are rolling out Center-wide.
Incident Tracking System Improvements
Improvement of tracking by unit/shift/supervisor/staff (i.e. time/place/person) of facility incidents.
Illinois State Police (ISP) Collaboration
ISP's Division of Internal Investigation came on-site to conduct an assessment of the Center including a review of security, physical structure needs, etc.
Supported updates to staff training with a focus on team building and collective accountability.
Human Rights Commission Collaboration
At the suggestion of SIU School of Medicine, IDHS is partnering with the HRC to develop training to address Anna's racial climate and confront the legacy of prejudice and mistreatment on the campus of CMHDC.
NASDDDS Technical Assistance
Used ICDD funding to receive technical assistance from the National Association of State Directors of Developmental Disabilities Services (NASDDDS) on building additional I/DD community capacity.
Technical assistance grew from FY22 capacity report - An Evaluation of Community Capacity Barriers and Opportunities for Expansion in Illinois for Adult DD Waiver Services - focusing on support for residents and capacity for SODC system improvements.
