DHS OIG FY 2005 Annual Report

Department of Human Services
Office of the Inspector General
901 Southwind Road
Springfield, IL 62703

September 2005

To Governor Rod R. Blagojevich and Members of the Illinois General Assembly:

In accordance with the Abused and Neglected Long-Term Care Facility Residents Reporting Act (210 ILCS 6.7) and the Adults with Disabilities Domestic Abuse Intervention Act (20 ILCS 2435), I am pleased to submit to you this Fiscal Year 2005 Report of the Office of the Inspector General (OIG) in the Illinois Department of Human Services. This report is also available, along with previous annual reports, at www.dhs.state.il.us

The OIG presents to the stakeholders an FY05 report that is inclusive of all activities and services within the OIG. This annual report highlights issues related to the investigation of abuse and neglect of adults with disabilities not only in state operated facilities and in licensed and funded agencies, but in private homes as well, and it identifies the efforts made to ensure the protection and safety of adults who are disabled. Also included are highlights of some of our collaborative efforts with other state agencies that will better ensure that adults with disabilities are living in environments free from abuse and neglect.

I trust that you will find this report to be informative and helpful in our collective efforts to prevent the abuse and neglect of adults with disabilities within Illinois.

Kind regards,

Robert F. Furniss

Interim Inspector General

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Executive Summary

The Office of the Inspector General (OIG) in the Illinois Department of Human Services (DHS) has statutory authority to investigate alleged abuse and neglect of adults with mental or developmental disabilities in DHS facilities or community agencies and adults with mental, developmental, or physical disabilities in their own homes.

During Fiscal Year (FY) 2005, OIG received 2,191 allegations of abuse or neglect, reversing a recent trend. Compared to FY04, OIG received 43% more at facilities, 38% more at agencies, and 28% more in domestic settings. OIG attributes this to a clearer understanding of what is reportable.

At the developmental centers, the first half of the morning is the most common time for allegations. At the mental health centers, the most common time are the evening hours. OIG notified the department, which plans specific actions to address the issue.

The facilities and agencies have improved their timeliness in reporting initial allegations - late reports have dropped from 21% in FY03 to 18% in FY05. OIG continues to flag late reports on the Intake form and in a monthly report to the department.

OIG is completing investigations faster, averaging 48 days per case in FY05 compared to 85 days per case in FY04. OIG has taken specific steps to conduct more timely and thorough investigations.

More abuse and neglect allegations were substantiated in FY05 than FY04, although the overall substantiation rate dropped. OIG attributes the drop in rate to the increase in reporting of allegations.

In domestic settings, exploitation has been substantiated more often. Compared to only one or two per year previously, OIG was able to substantiate 7 cases in FY05. Two new laws granting OIG greater access to financial records should help further.

In FY05, OIG reported to the Department of Public Health's Nurse Aide Registry the names of 62 facility or agency employees who were found to have committed abuse or neglect. This is a 13% increase over last year. The increase is partly due to completion of appeals on cases filed in the statute's first two years.

OIG continues to make improvements in the system of preventing, identifying, reporting, and investigating abuse and neglect. During FY05, OIG:

• Increased initial and annual training requirements for OIG investigators.
• Created a new Investigative Plan for each case, speeding case actions;
• Established new time requirements for critical interviews;
• Improved case management, making it a real-time system;
• Developed new weekly and monthly status reports that reflect the most recent status on each case;
• Monitored receipt of Written Responses - actions taken by the facility or agency in response to the findings in a case - conducting compliance reviews on a sample;
• Improved its intranet site, with on-line links to OIG Directives, staff phone directories, case report formats, and State training resources;
• Made multiple recommendations during unannounced site visits to the facilities, thereby preventing possible abuse or neglect; and
• Worked collaboratively with DHS's program divisions to address issues.

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Table of Contents

• Chapter 1:  Introduction
  • Administrative Rules
  • Organization
  • OIG Hotline
  • Program Collaborations
• Chapter 2: Impact of OIG
  • Impact Case Summaries
  • Clinical Reviews
• Chapter 3: System Enhancements
  • Intranet-based Training
  • OneNet: Intranet Page
  • Investigative Plan
  • Investigative Case Actions
  • Timeliness of Interviews
  • Videotaping at Facilities
  • 45-day Case Status
  • Streamlined Case Review
• Chapter 4: Compliance and Training
  • Unannounced Site Visits
  • Annual Investigative Authorizations
  • Written Responses
  • Written Response Compliance Reviews
  • Public Information
  • External Training
  • Internal Training
• Chapter 5: Statistical Information
  • Allegations Reported
  • Timeliness of Initial Reporting
  • Timeliness of Investigation
  • Case Closures
  • Investigative Findings
  • Service Plan Referrals
  • Registry Referrals
  • Facility Census and Direct Care Staffing
  • FY05 Statistical Tables

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Chapter 1: Office of the Inspector General

Introduction

The Office of the Inspector General (OIG) was initially created by the Abused and Neglected Long Term Care Facility Residents Reporting Act in August 1987. The primary purpose of OIG was to investigate allegations of abuse or neglect in the State-operated facilities providing mental health or developmental disability services.

The Office of the Inspector General was created in March 1988. The first annual report covered through Fiscal Year 1989, which ended June 30, 1989.

As more adults began receiving those services in smaller, privately owned, and community-based settings, an expansion of OIG's investigative authority into those settings became necessary. In November 1995, the General Assembly passed and the governor signed legislation expanding OIG's authority to investigate allegations of abuse or neglect in community agency programs licensed, certified, or funded by the Department of Human Services (DHS) to provide mental health or developmental disability services.

In December 1999, the General Assembly and the governor again expanded OIG's investigative role. Beginning in July 2000, OIG was given authority to investigate in domestic settings any allegation of abuse, neglect, or exploitation of an adult between 18 and 59 years of age with a physical, mental, or developmental disability.

The mission of OIG is to assist persons with physical and mental disabilities by investigating all reports of abuse, neglect or exploitation, in order to foster humane and caring treatment of persons with disabilities.

Administrative Rules

In 1996, when the legislature authorized OIG's investigative authority into community agency programs, DHS created a task force to write rules to guide the reporting and investigation of allegations of abuse or neglect in those settings and in the facilities. The resulting administrative regulation, known as Rule 50, became effective in October 1997.

Following the expansion into domestic settings, OIG worked with the Illinois Attorney General's office and a committee of interested external entities to write a separate administrative rule, since the new law defined abuse and neglect differently, added financial exploitation, applied a looser standard of proof, and granted OIG authority to petition for guardianship of persons whose current guardian is alleged to committing the abuse or neglect. The new administrative regulation, known as Rule 51, became effective with OIG's new authority in July 2000, the start of Fiscal Year 2001.

Rule 51 repeats the statutory requirements for eligibility, which are that the alleged victim must:

• Be at least 18 years of age and not older than 59;
• Have a disability that impairs his/her ability to seek help;
• Reside in a domestic living situation, which includes board and care homes and unlicensed residential settings;
• Be allegedly abused, neglected, or exploited with that domestic living situation; and
• Consent to OIG doing an investigation ("assessment") and also, separately, consent to services offered by DHS.

Organization

For Rule 50 investigations, those at DHS mental health centers (MHCs), developmental centers (DCs), or community agency run programs, OIG has divided the state into four jurisdictional areas. Rule 51 investigations (domestic settings) are done primarily by one bureau which covers the entire state.

In FY05, OIG's investigative bureaus were:

• North Bureau, covering 20 counties in northern and northwestern Illinois, including four DHS facilities - Singer MHC (Rockford), Elgin MHC (Elgin), Mabley DC (Dixon), and Kiley DC (Waukegan) - and 1048 program locations operated by 106 community agencies.
• Metro Bureau, covering Cook and eight counties south and southwest of Chicago, including seven DHS facilities - Chicago-Read MHC (Chicago), Madden MHC (Chicago), Tinley Park MHC and Howe DC (Tinley Park), Ludeman DC (Park Forest), Shapiro DC (Kankakee), and Fox DC (Dwight) - and 2667 program locations operated by 246 community agencies.
• Central Bureau, covering 46 counties in central Illinois, including three DHS facilities - Jacksonville DC (Jacksonville), McFarland MHC (Springfield), and Alton MHC (Alton) - and 1468 program locations operated by 133 community agencies.
• South Bureau, covering 27 counties in southern Illinois, including four DHS facilities - Murray DC (Centralia), Choate DC and Choate MHC (Anna), and Chester MHC (Chester) - and 541 program locations operated by 72 community agencies.
• Adults with Disabilities Domestic Abuse Program (ADDAP) Bureau conducts domestic investigative assessments statewide with investigators assigned to regions similar to the Rule 50 bureaus. Investigators in this "Adults with Disabilities Domestic Abuse Intervention Project" (ADDAP) may also conduct Rule 50 investigations.

OIG Hotline

In order to facilitate reporting of complaints, OIG maintains an Intake Hotline, staffed during business hours by investigators. These investigators record the allegation into the OIG database, provide initial investigative direction if needed, and electronically transmit the intake to the appropriate bureau.

After normal business hours, an answering service takes incoming calls. When necessary, the answering service immediately contacts the appropriate bureau chief. This process allows for a prompt response by OIG where needed, and the intake can be recorded later by an OIG Intake investigator.

The OIG Hotline frequently also gets calls regarding other issues affecting adults receiving publicly funded or licensed services. Since these issues are not within OIG's statutory authority, the calls are always routed to the agency or office most appropriate for addressing the issue.

Other Statutory Responsibilities

The statutes addressing OIG describe responsibilities beyond investigating. These other responsibilities are handled by other administrative bureaus within OIG. They include:

• Conducting unannounced site visits to the DHS-operated mental health or developmental centers;
• Training and authorizing community agencies and agency staff to conduct investigations;
• Reporting to the Illinois Department of Public Health's Nurse Aide Registry the names of employees who are substantiated to have committed physical or sexual abuse or egregious neglect; and
• Conducting implementation reviews to ensure facilities/agencies have taken actions planned in response to OIG investigative findings.

Each of these statutory responsibilities is discussed more fully later in this FY05 Annual Report.

Program Collaborations

OIG believes that preventing abuse and neglect requires collaboration with others. In conjunction with DHS' commitment to improve service delivery through integrating resources and information, the OIG actively works with divisions and other agencies within the state to discuss information and plan joint activities.

To further this goal, OIG has created the OIG Program Coordination workgroup, the purpose of which is to reduce the impact of and coordinate solutions aimed at preventing abuse and neglect within community agencies and state facilities. Standing members of the workgroup include the following:

• Division of Developmental Disabilities;
• Division of Mental Health;
• Division of Rehabilitation Services;
• Bureau of Accreditation, Licensure and Certification;
• Illinois Department of Public Health; and
• Illinois Department of Healthcare and Family Services (formerly the Illinois Department of Public Aid).

Other stakeholders, such as advocacy groups and associations, may be invited when appropriate.

Issues discussed by the OIG Program Coordination workgroup during FY05 have included the following:

• Promoting enhanced Rule 50 training for community agencies and facilities;
• Reviewing the draft OIG Reporting Manual;
• Discussing and reviewing abuse and neglect statistics;
• Recommending support for the development of an integrated monitoring system;
• Identifying potential harm; and
• Eliminating risk.

In addition, the OIG participates on the DHS Proactive State Operated Facilities Committee, which focuses on improving services and resources with the state operated facilities. Through OIG's attendance, we are able to promptly address how changes within the facilities may impact the safety of residents.

The OIG also serves as a member of the Advisory Board for Equip for Equality, which is the federally appointed protection and advocacy agent for the state of Illinois.

Chapter 2: Impact of OIG

Impact Case Summaries

During FY05, OIG again made an impact on the care and treatment of adults with disabilities. Employees who are proven to have committed abuse and neglect are nearly always terminated from employment with the facility or agency.

Yet OIG's impact extends beyond supporting disciplinary action for abuse or neglect. Even if the allegation is not substantiated, OIG may raise issues that the State-operated facility or community agency must then address.

The following cases are examples of OIG investigations that show OIG's impact on the service delivery system during FY05.

Substantiated Abuse

Case A-1

An employee allegedly pushed a non-verbal resident with developmental disabilities into a wall and then pushed him out of the room, down the hall, into his bedroom, and onto his bed, where the employee allegedly choked him with a belt. Another resident witnessed this abuse and the alleged victim had marks around his neck that corroborated the witness's account. OIG substantiated physical abuse. The employee was fired. He pleaded guilty to resident abuse and was sentenced to 18 months of probation and fined $1,000.

Case A-2

An employee allegedly struck an individual with developmental disabilities three times on the top of the head with her knuckles. OIG found a witness and got an admission from the employee that she had done it intentionally, so physical abuse was substantiated. The employee was fired. He pleaded guilty to a misdemeanor battery charge and was sentenced to six months of court supervision and fined $179.

Case A-3

An employee allegedly threw a resident to the floor and kicked him in the head. During the OIG investigation, the employee admitted putting him down on the floor, causing him to hit his head. OIG substantiated physical abuse, and the employee was fired. The State's Attorney filed felony charges against the former employee, and the case is still pending.

Case A-4

An employee allegedly hit a resident on the head with an escrima stick (a South American martial arts weapon). The resident had bruises on his shoulders and a head laceration requiring staples to close. The case was referred to the local police for investigation as well. When interviewed, the resident provided a detailed statement but refused to press charges. Since he is his own guardian, the State's Attorney directed the police to stop investigating. When OIG then investigated, the employee admitted that he had brought the escrima stick to work, intending to hit the resident, and that he had hit the resident on the head with it. OIG substantiated physical abuse and gave the admission to the local police. However, despite efforts of the local police and OIG, the State's Attorney still refused to prosecute. The employee was fired.

Case A-5

A contractual housekeeper was accused of sexually abusing a female resident. He repeatedly denied the allegation when interviewed by a female OIG investigator, but admitted to it when interviewed by a male OIG investigator. OIG substantiated sexual abuse and mental injury, and he was fired. It was later discovered that the housekeeper had begun working for a nursing home. However, when OIG reported his name to the Nurse Aide Registry, the employee was fired by the nursing home but was not prosecuted criminally.

Case A-6

An individual receiving services alleged that on numerous occasions, an employee had sexually touched him, while lying in his bed. Based primarily on the individual's consistent and credible statements, OIG substantiated sexual abuse. The employee was fired and his name was reported to the Nurse Aide Registry, but he was not prosecuted criminally. In addition, OIG noted that the agency did not have a policy regarding transporting adults to employees' personal residences, so the agency developed one.

Case A-7

An employee took an individual with mental illness to an isolated room intentionally to insult him. In response, the individual attacked the employee and was placed in full leather restraints. While the individual was in restraints, the employee allegedly returned and slapped him in the face. OIG substantiated mental and physical abuse, and the employee was fired. Criminal charges were filed but dropped when the individual failed to show up for court.

Substantiated Neglect

Case B-1

Although a resident had a well-known history of wandering, two employees left him alone while on an outing to a bookstore. He wandered away and was found approximately 90 minutes later, sitting in an unattended vehicle. The recipient required hospitalization for dehydration, renal insufficiency and hyperkalemia. OIG substantiated neglect and the two employees were fired.

Case B-2

An employee allegedly choked an individual who was agitated. The investigation found that the employee came to calm her down, but no credible evidence supported the allegation. However, the investigation also found that, at the time of this incident, the employee was assigned to provide "arm's length" supervision of another individual. He admitted that he left this assignment to talk to the victim, so the facility suspended him for five days.

Case B-3

On two occasions, a resident grabbed a bottle of medications that were being prepared by direct care staff and swallowed at least ten pills. OIG substantiated neglect by the employees in both cases. In addition, DHS's Bureau of Quality Assurance and System Improvement went to the agency to conduct a medication administration review (Rule 116). That Bureau suspended the right of any staff to dispense medication until all were fully retrained; nurses from the Illinois Department of Public Health administered medications in the interim.

Case B-4

A home's fire alarm sounded at 1:00 a.m. and the fire department personnel evacuated the seven residents who had developmental disabilities. The employee was not present; he admitted to leaving the residents alone and unsupervised for more than seven hours while he went to rent movies. None of them suffered any physical injuries. However, two residents were emotionally distressed because there was no employee to give directions when the fire alarm sounded or help when the firefighters arrived. OIG substantiated neglect with mental injury.

Case B-5

An individual with developmental disabilities was reportedly physically abused by two employees. The victim had 247 bruises and marks on her body. OIG proved that the injuries were caused by other adults and not by the two employees. However, OIG substantiated neglect by the agency in failing to ensure enough staff were present to prevent the injuries from being inflicted by the other adults. OIG recommended that the agency ensure that staff-to-patient ratios are always adequate. DHS had the victim removed from the residence.

Case B-6

An employee transferred an individual from his wheelchair to his bed by herself, despite knowing that his habilitation plan required a two-person lift. During this transfer, she bumped his head on the entertainment center next to his bed, causing a small cut to his forehead. OIG substantiated neglect, and the technician resigned.

Reporting of Allegations

Case C-1

An individual alleged abuse on a Human Rights Violation form, but it was 14 days before the facility reported it to OIG. In light of the delay, OIG recommended that the facility review its internal process for these forms. The facility responded by adopting a new procedure that ensures that forms go directly to the facility's OIG liaison for review for possible reporting to OIG. The allegation ultimately could not be substantiated due to the alleged victim's lack of credibility.

Case C-2

A nurse alleged that another nurse and other staff threw an individual onto the floor and held her down while giving her medication. Due to inconsistencies in the evidence, the allegation was not substantiated. However, the nurse making the allegation admitted that she had told a third nurse about it, but neither of them reported it for several weeks. The facility was going to discipline these two nurses for late reporting, but they both resigned from employment.

Case C-3

An employee alleged that she had witnessed many instances of physical abuse in the previous six months. In each instance alleged, the investigation found evidence that it could have occurred as alleged - for example, the victim or the accused employee was not at the location of the alleged abuse or there were no injuries noted at the time of alleged physical abuse. Although the allegations were unfounded, OIG recommended action against the employee for failing to report allegations promptly even though she had been trained in reporting. The agency fired her since she had failed to report so many abuse allegations promptly,.

Case C-4

A nurse allegedly refused to give a prescribed medication to a resident despite continuing symptoms. OIG substantiated the allegation but also found that the residence manager had removed all postings of the OIG Hotline number and had threatened to fire staff if they continued to call. Based on this and other cases, OIG alerted the DHS Division of Developmental Disabilities, Illinois Department of Public Aid, Guardianship and Advocacy Commission, and Equip for Equality of the agency's ongoing problems.

Other Administrative Issues

Case D-1

A caller alleged sexual misconduct by a part time worker who drove adults from their CILA to their work program. The allegations were not substantiated due to the accuser's lack of credibility and the driver's credibility. However, the driver thought it was appropriate to date the adults. Based on OIG's recommendation, the agency has since established a training program for these drivers to ensure they understand proper ways to interact with the adults.

Case D-2

An individual alleged that he was physically abused by an employee who was trying to convince him to take his medication. OIG found that, during medication administration, employees who are not nurses had been encouraging reluctant adults to take prescribed medications, resulting in a hostile and non-therapeutic approach. OIG was not able to substantiate the abuse allegation but did recommend that the facility stop this practice and have only clinically trained personnel handle medication administration.

Case D-3

OIG did not substantiate an allegation that a part-time employee was sexually abusing adults, since the alleged victim denied it and the witness was not considered credible. However, OIG found that part-time employees were not being trained in abuse/neglect or in proper interpersonal conduct when dealing with the adults receiving services. The agency has now established a training program for its part-time employees.

Case D-4

An individual with a recent history of eating inappropriate objects was taken to a local hospital for medical treatment. Facility staff were assigned to watch him, but he ate a rubber glove which later had to be removed surgically. OIG found that, when the facility staff went on lunch break, the hospital's nursing staff would watch the individual. Most likely, it was during one of these times that the individual ate the glove; the hospital staff did not watch him constantly and did not know why they were to watch him. OIG found that having hospital staff watch adults during breaks was the common practice, even though the hospital staff may not have been told what behaviors they were to watch for. The facility's medical director began working with the hospital to establish new guidelines to ensure that adults sent to the hospital are appropriately supervised there and that the hospital staff are aware of the adults' behaviors.

Case D-5

OIG received an allegation of neglect in securing, storing, and dispensing old medications. OIG found evidence that the allegation was false. However, OIG found that the person making the allegation had been fired by the agency for an unrelated reason, yet had documents from patients' clinical files. The agency has since established programs to remind staff of HIPAA privacy regulations. The agency also retrained its staff in proper medication security and disposal measures.

Emergencies / emergency placement

Case E-1

A caller alleged that a woman with moderate mental retardation was being sexually abused by her stepfather. Within 24 hours, OIG interviewed the woman with local law enforcement present. She gave clear and consistent accounts and claimed that she had been telling her family and friends for some time. Her mother, however, believed that the woman was not being truthful but was re-living earlier sexual abuse by her biological father. Based on the mother's explanation, the other family members and friends had dismissed the claims and no one had reported them to the police. OIG interviewed the stepfather, who admitted having sex with the victim for the past two years and twice a month in the past six months. Based on the woman's testimony, the police charged the stepfather with a felony. OIG removed the woman from the home and the case was referred to the Division of Developmental Disabilities for placement and services.

Case E-2

A caller reported that two adults with disabilities - brother and sister - were being mistreated by another brother's widow; for example, the man had blood in his stool yet his sister-in-law refused to get him examined. Relatives took him to the hospital, where he was found to be dehydrated and have many bruises and several untreated injuries, as well as suffering from leukemia and another cancer that had spread to multiple sites. During OIG's investigation, a neighbor reported that she had witnessed the two eating from the garbage cans in the past. Upon discharge from the hospital, OIG arranged for the man to live with different family members, and he reportedly liked living with his new family. His sister refused to be moved from her sisters-in-law's care. OIG referred both adults to the Division of Rehabilitation Services for services.

Case E-3

A caller reported seeing a wire news story about a woman who had been brain dead and fed through a tube for two years but whose husband had begun starving her to death. OIG obtained the family's address from the news outlet and went to the home that day. The husband initially insisted he was still feeding her, but the son admitted that he and his stepfather had not fed her for more than 25 days. The husband denied OIG access to assess the woman and called the local police. However, when the police arrived and OIG explained our legal authority to have the woman removed from the home and seek guardianship, the husband relented. A nurse from the police department and an OIG investigator witnessed the woman being fed by her mother, who also lived in the home and had disagreed with not feeding her. The husband agreed to let his mother-in-law become guardian and take care of the woman. OIG gave them the names of attorneys that would help with guardianship, and OIG referred the family both to the Division of Rehabilitation Services for respite care services and to the Division of Mental Health for an assessment of the need for counseling services.

Case E-4

A woman with profound mental retardation was in the care of an elderly grandmother who was suffering from dementia and poor physical health. Her physician said that the woman's health was at risk by her grandmother's poor mental and physical health; for example, the grandmother had trouble remembering and following simple instructions and difficulty answering simple questions like when she fed the woman last. Since a guardian had never been appointed for the woman, OIG located her mother, who agreed with having the woman moved to a community agency residence. OIG then referred the woman to the local screening agency to find a new home for the victim. OIG also referred the case to the Division of Developmental Disabilities to ensure she got a home and the services she needed.

Law enforcement / orders of protection

Case F-1

Local police contacted OIG and reported that they discovered a man with mental illness who was being neglected by his father. The son had been found living in the garage, in a four-by-twelve foot room containing a twin bed and a workbench but no bathroom or running water. The son had defecated and urinated on the floor, had no clothes except the soiled clothing he was wearing, and had no shoes. OIG had the son immediately taken to the hospital for an examination. The father admitted that he did not think his son was fit to live in the house, so he had made the son live in the garage for about six months. The father worked six days a week and, when at work, he padlocked his son in the garage; he was also the payee of his son's Social Security disability income. The father was arrested by the police. He was found guilty, placed on three years of probation, fined a few thousand dollars, and ordered to pay court and medical costs. OIG had the son placed in another residence upon release from the hospital and referred the case to the Division of Mental Health for an assessment for services.

Case F-2

Local police and fire officials called OIG when they found a man, who had developmental disabilities, locked in his bedroom. Both the man and the bedroom walls were covered with feces and urine. His mother admitted locking her son in his bedroom during the night for nine months. She also admitted that she was overwhelmed with her son's care and had not cleaned his room for several days. The man's sister also admitted locking him in his room when she was not home. A home support program was set up for the family, and staff from a local community agency began monitoring the family to ensure compliance. The case was then referred to the Division of Developmental Disabilities for an assessment of further services.

Case F-3

A woman and her daughter, both of whom have mental illness, were allegedly being abused by her son, who was on parole at the time. Reportedly, the son was physically abusing the two women, locking them in their rooms, and forcing them to give him their Social Security disability income. Both victims said they were too intimidated by his aggressive behavior to file charges against him. The son admitted to physically abusing them and locking them in the house so they could not get out. He further admitted to drug abuse but said he did not need their money to live on any longer because he found a job. He reportedly moved out of state to avoid being sent back to jail when OIG reported the matter to the police and helped the two women secure orders of protection against him. OIG also referred the case to the Division of Mental Health to ensure that the two women receive services they need.

Case F-4

A woman with developmental disabilities alleged that her aunt, who was also her guardian, had kicked her in the chest and struck her with a broom across her legs and thighs. The alleged victim had a bruise on her arm and was taken to the local emergency room for an examination. While there, the alleged victim stated that she feared her aunt and did not want to return home. OIG found a temporary place for her with a community agency. Then, when the aunt refused to cooperate with the investigation, OIG reported the aunt to the local police and sought an order of protection. OIG also started guardianship procedures. The aunt agreed to give up guardianship and the court granted guardianship to the Illinois Guardianship and Advocacy Commission. The case was referred to the Division of Developmental Disabilities for service plan development. Interestingly, a month prior to the allegation, OIG had cited the aunt for neglect of another disabled adult in her care, but at the time the niece had not alleged any abuse.

Guardianship

Case G-1

The father of a man with developmental disabilities was already in prison when the man's mother was sentenced to prison as well. She left the man in the care of her twin 17-year-old sons. A month later, the police arrested the twins, too, and took the man to the hospital for an evaluation. He was found to be malnourished - he had had difficulty swallowing, but his mother had refused to allow the insertion of a feeding tube. With OIG's assistance, the hospital filed a guardianship petition and the Illinois Guardianship and Advocacy Commission became his guardian. He was placed in a local community agency residence and the case was referred to the DHS Division of Developmental Disabilities for an assessment for services. OIG appreciated the help of Division of Hispanic Affairs for translating in this case, as the man's parents did not speak English well.

Case G-2

The mother of a woman with severe mental retardation was allegedly neglecting her and interfering with any outside efforts to care for either of them. OIG found the woman with extremely poor hygiene and decubitus ulcers. The home was cluttered with trash, a litter box was overflowing with waste, and a slop bucket in the kitchen with food scraps was a breeding ground for flies that filled the home. Due to its condition, the home was condemned by the county building inspector. The mother still complained that caretakers were outsiders coming into her home and telling her what to do, and she just wanted everyone out of her home. OIG petitioned for guardianship of the victim, and the court gave guardianship to the Illinois Guardianship and Advocacy Commission, granting them the power to seek medical care and appropriate placement for her. OIG referred the case to the Division of Developmental Disabilities for services.

Exploitation

Case H-1

A 52 year old individual suddenly moved out of his father's home and left no forwarding address. The father finally found him a year later, married to a woman who used to work with him. They were living in the home of the woman's sister and brother-in-law; the individual lived in the basement and the woman's room was on the second floor. The woman had purchased a $35,000 vehicle for her brother-in-law, had cashed out the individual's $3,500 IRA, and was trying to close out his $63,000 IRA. The individual, who had no debts when at home with his father, had $21,000 in credit card debts. After OIG was notified and began an investigation, the woman purchased a home despite being unemployed and the individual having only a minimum wage job. OIG substantiated financial exploitation and referred the matter to the local police. A physician declared the individual incompetent and the court granted guardianship to a member of his family. The court also froze his assets to prevent further exploitation by the woman and her family. A grand jury is considering criminal charges.

Case H-2

A woman with mental illness was befriended by her hairdresser and agreed to move in with her hairdresser and a friend of the hairdresser. The hairdresser and friend got power of attorney over the woman's finances and became payees for her Social Security check. The friend became the woman's Personal Assistant, paid for by the DHS Division of Rehabilitation Services, and bought a mobile home using $25,000 cash. They refused to allow the woman any unsupervised contact with anyone else and ordered her not to answer the door or phone if they were not home. When they took out a life insurance policy on the woman without her knowledge, the issue was reported to OIG. OIG got the woman removed from the home, helped her change her Social Security payee, and ended the power of attorney. The woman, who had sold her own $200,000 home and had received an inheritance of $56,000 prior to moving, had no money at all in the bank; the money was being deposited into a private account of the hairdresser's friend. At this point, OIG referred the matter to the Social Security Administration's Office of the Inspector General and to the local police and the State's Attorney. The police began a criminal investigation and requested that OIG focus on getting services for the woman. OIG got help from a local mental health service provider and ensured that the DHS Division of Rehabilitation Services obtained a new Personal Assistant for her.

Clinical Reviews

OIG has two registered nurses who are trained investigators and function as Clinical Coordinators. They investigate all deaths in State-operated facilities or community residential programs licensed or funded to provide mental health or developmental services.

The Clinical Coordinators also assist other investigators with cases involving treatment issues; for example, in allegations of neglect by staff in monitoring a medical condition.

Deaths in Facilities

During FY05, there were 48 deaths of adults receiving services in, or recently discharged from, a facility. No abuse or neglect was found in any of the deaths.

Forty-one of the 48 deaths - were the result of natural causes, and in the developmental centers. Heart disease, cancer, and pneumonia were the leading causes of death.

The remaining seven were by suicide, but five of the seven occurred after discharge from the facility. Neglect by the facility was not alleged in any of the five suicides.

One of the two remaining suicides occurred in the facility and the other while absent without permission. These two are as follows:

• The suicide in the facility was by an individual with mental illness and a history of talking about suicide. Upon admission, he was put on one-to-one supervision by staff. The next morning, the psychiatrist found him calmer, more rational, and denying he would harm himself. So, he was changed to visual checks every 15 minutes. Two days later, the individual was still calm and giving no signs that he was going to harm himself. Still, he hanged himself with his pajamas. Although visual checks were made only ten minutes apart when he was found, he could not be resuscitated. Neglect was not found.
• The other death occurred while the individual was still "on the books" but was not in the facility. She had been given a pass so her mother could take her to visit a community agency that had agreed to provide services for her long-standing substance abuse and psychiatric problems. However, she left her mother and went off with her boyfriend. The mother immediately notified the facility, which asked the police to find and return her. The facility was notified two days later that the individual had collapsed at the friend's home. The coroner's inquest determined the death was due to an accidental overdose of illegal drugs. Neglect by the facility was not suspected or found.

Deaths in Agencies

During FY05, there were 74 deaths of adults receiving services within, or recently discharged from, a community agency program. No abuse or neglect was found in any of these deaths.

Again, 70 of the 74 deaths - were the result of natural causes, and mostly in the developmental programs. Heart disease, cancer, and pneumonia were again the leading causes of death.

Three of the other four were accidents. Two of the adults died from choking on food, even though they had no special meal precautions. In comparison, during FY04, five deaths in community agency programs were the result of choking.

In one of the choking deaths, the adults in the residence had no special precautions for eating, and so the agency did not require that at least one employee be present during every meal. At OIG's recommendation, the agency change the policy to add this requirement.

The remaining accidental death was of an individual with mental illness who lived in a supervised residential apartment building with her husband. She also had a history of drug abuse and overdosed on a mixture of cocaine and her prescription depression medication. A coroner's inquest determined that her death was an accident.

Another death by overdose was ruled a suicide. This individual with mental illness had been deflected from a DHS facility and was being provided services by an agency. She died of an overdose of heroin.

During FY05, one other suicide was reported from an individual receiving services from a community agency. The individual, who lived independently in an agency-supervised residence, drowned in a river. The coroner's inquest determined that his death was a suicide.

Although OIG substantiated neither abuse nor neglect in any of the other deaths closed in FY05, OIG did make a recommendation in one case. In that case, a maintenance worker who had also been a paramedic determined that an individual was dead and so did not start CPR. Although the coroner later determined that the individual was indeed dead at the time, OIG recommended that the agency retrain all its non-medical staff to begin CPR immediately, even if the individual appears to be dead already.

Other Clinical Issues

OIG substantiated neglect in clinical issues in seven cases during FY05, two at facilities and five at community agencies.

Failure to adequately monitor was the most common reason for the finding of neglect.

• In one of the facility cases and two of the agency cases, the staff failed to observe a developing medical problem and, as a result, it worsened and the individual eventually had to be hospitalized.
• In the other facility case, three adolescents were not adequately supervised, and they were able to engage in sexual activity on the unit.

A similar issue with staff failure occurred In one community case, where an individual did not receive her medication for seven days and subsequently was hospitalized for psychosis.

Poor communication between the nurses resulting in harm to an individual was the basis of the finding of neglect in the remaining two community agency cases:

• The result in one case was negative consequences from an interaction between two prescribed medications; and
• The result in the other case was that a walker was not ordered promptly and the individual fell, sustaining fractures.

OIG also made clinical recommendations in cases that were not substantiated as abuse or neglect. For example, in investigations during FY05, OIG recommended:

• Assistive devices when necessary to lift and ambulate adults, thereby preventing injury;
• Bowel monitoring, especially when an individual is receiving medications that may cause constipation;
• A better system of communication between the program and the home injuries;
• Improved continuity of care between the facility and local hospitals, when adults are sent for treatment or evaluation;
• Notifying nurses and supervisors sooner when an individual is ill or shows deterioration in his or her physical or mental condition;
• Shorter assignments of one-on-one staff to patient monitoring;
• Training of direct care staff on the fragility of bones in adults who have osteoporosis; and
• Unit physicians be required to attend meetings of behavior intervention committees.

Chapter 3: System Enhancements

During FY05, OIG again sought ways to further improve the system of reporting and investigating abuse/neglect and death. OIG proactively addressed these issues, implementing enhancements to the system. This chapter discusses some of these.

Intranet-based training

OIG has long had a comprehensive program for staff training. However, in the face of the ongoing State fiscal constraints, OIG has sought creative ways to ensure continued training of its staff. One effective means has been computer-based training similar to the annual State of Illinois ethics training that was conducted on-line again in FY05.

DHS maintains an "internal internet" (see "OneNet" below) with an intranet-based training program that is used by DHS's central office, regional offices, and facilities. OIG has fully integrated into this training system, allowing OIG staff to take intranet-based trainings already developed by DHS. OIG staff have taken topics such as Advanced Confidentiality, Patient Safety, Restraints, and Infection Control.

In addition, OIG has been developing its own intranet-based training courses, in order to continuously improve investigative skills and provide opportunities for personal growth. During FY05, OIG developed:

• OIG Rule 50,
• OIG Rule 51,
• Whistleblower Act,
• OIG Investigative Directives,
• Investigative Skills Refresher,
• Evidence Collection,
• Injury Assessments,
• Overview of the OIG Bureau of Compliance and Evaluation, and
• Grammar and Punctuation, as well as eight remedial grammar modules.

These intranet based courses can be assigned to staff to access when they are at their computers and have the time to focus on learning. No travel time or costs are incurred, and a live trainer is not required.

Finally, the system provides special reports that, for example, show the number and percentage of staff taking the test who missed a particular question. The question might lead to additional training being offered in a particular area.

Intranet-based training has been an excellent and adaptable means of ensuring that OIG staff continuously improve in necessary skills to perform their jobs.

OneNet: Intranet Page

The DHS OneNet is an "internal internet" for DHS staff. OneNet includes information helpful in conducting State business.

Since OIG staff are located at many worksites around the state, OneNet can give the staff ready access to needed and current information, This, then, allows them to work more efficiently, thereby improving OIG's investigations and other work.

For example, OIG's OneNet site includes or has links to phone directories of OIG and DHS staff. In addition, it has lists of helpful phone numbers of agencies to which to refer issues and concerns that are not in OIG jurisdiction. These lists include locations that adults might contact to receive further assistance.

OIG's OneNet also has links to training resources - to the intranet-based training (see immediately above) and to schedules and registration forms for training offered by DHS and by other State agencies, such as basic and advanced computer training, which may be useful in meeting the ongoing continuing education requirement for OIG investigators.

The OneNet site has quick links to relevant Illinois statutes and to the two administrative rules governing OIG-reportable incidents. The site also maintains an up-to-date set of OIG's Directives, which are accessible only by OIG staff.

Accessible and printable versions of some published documents are available. The site has the OIG's annual reports, the domestic abuse program brochure, and the DHS Employee Handbook. Links to national investigative standards, such as Principles and Standards for Offices of Inspector General, published by the Association of Inspectors General, are also on the OneNet site.

In addition, OIG's OneNet site has links to other useful information. Commonly used DHS forms and the DHS Administrative Directives are accessible, as are map directions, which are especially helpful to OIG investigators to get to private residences where abuse or neglect of adults with disabilities has been alleged.

As noted in last year's Annual Report, OIG now distributes some reports internally to DHS by electronic mail (e-mail), rather than paying for postage. Since the information is confidential, the e-mails must be encrypted. Detailed directions for encrypting e-mails and for re-setting forgotten passwords are given on the OneNet site.

Finally, the site has direct links to general information about OIG, such as the history of the office, prior inspectors general, and a biography of Sydney Roberts, the most recent Inspector General.

OIG also has an internet site.

which includes this general information about OIG and provides links to OIG's published reports and to other protective agencies and service advocacy organizations. OIG lists those organizations for information, not as an endorsement.

Investigative Plan

Development

One of OIG's ongoing goals is to complete thorough and timely investigations. To seek continued quality improvement and progress in meeting this goal, OIG has developed a written Investigative Plan and is now requiring one for every investigation.

In early FY05, Inspector General Sydney Roberts authorized a workgroup comprising staff from all areas of OIG and charged it with creating a format for an investigative plan. The workgroup met numerous times over seven months and regularly sought the input from staff not on the workgroup.

A primary focus in creating the investigative plan was to make it thorough yet not overly complex, so it would not take more time and effort to complete. A secondary focus was to integrate the plan with OIG's comprehensive database, so that information about the allegation could be automatically inserted into the plan.

Once the Investigative Plan was approved for use, investigative staff were trained in its use during two joint bureau meetings in June 2005, one in northern Illinois and one downstate.

OIG investigators started using the Investigative Plan for some of their cases immediately. Starting July 1, 2005, an Investigative Plan is required for all investigations.

Utilization

The Investigative Plan is a streamlined document that helps the investigator plan all aspects of the investigation. It replaces the Case Initiation Report, which included much less information. The new Investigative Plan includes information about investigative leads and the investigator's planned direction.

One of the exciting aspects of this plan is that, when the plan is initially created, it automatically pulls information directly from the database such as dates and times of the allegation, elements of the alleged offense, and the names of the victim, accused and potential witnesses.

This streamlines the work of the investigator, who previously had to look up and enter much of that information manually into the Case Initiation Report. It also improves the investigation's accuracy by automatically listing every person named by the caller at the time the allegation is reported to OIG.

The assigned investigator then indicates what investigative work he or she is planning to complete, such as interviews to conduct and documents to gather. The plan also requires information about investigative activities regarding injuries, scene preservation and evidence gathering, seeking to ensure that they are completed when appropriate.

Each case's Investigative Plan must be completed within three working days of the allegation being reported to OIG. The plan must also be reviewed and approved by the investigator's supervisor.

This plan is also flexible so that it can be used in all types of investigations that OIG conducts. The plan covers any special information needed for every type of investigation.

In addition, the Investigative Plan is a working document that can change as the investigator gathers more information. An updated plan can be re-printed at any stage in the investigation.

Overall, the new Investigative Plan improves the thoroughness and timeliness of investigative planning, while streamlining and increasing the accuracy of the planning process. It shows OIG's commitment to enhancing the system without slowing it down.

Investigative Case Actions

A significant achievement during FY05 was the development of a true "real-time" electronic case management system despite the difficulty of running such a real-time system across fifteen computer network servers around the state.

Spurred by an audit recommendation, OIG developed and piloted a new Automated Case Tracking (ACT) system. Since it is a component of the existing OIG database and not just a stand-alone system, it integrates information about an investigation with initial intake and case closure data.

With the ACT system, the OIG investigator is able to record his/her actions on a case into the Investigative Case Actions form, while supervisors and reviewers are able to view those entries and to include directions and suggestions to the investigator. These dual functions will improve the ability of investigators and supervisors to work toward successful completion of cases.

Another benefit of the new system is that it enables the OIG Hotline staff to more easily record and transmit to the case investigator any updated information received after the initial intake is completed and forwarded to the investigative bureau.

Further, weekly reports now automatically show the date of the last action and include the latest case status entered by supervisors. If more than three weeks have elapsed since the last action, that date prints in red.

Case status can be recorded on investigations by community agencies, the Illinois State Police, and local law enforcement agencies as well.

Along with the new Investigative Plan, this ACT system of Investigative Case Actions was fully implemented June 17, 2005. Together, they will significantly enhance OIG's investigations.

Timeliness of Interviews

As part of OIG's continuous improvement of the reporting and investigating processes, the timeliness of initial interviews were identified as an area for improvement. The Auditor General's most recent audit also noted this issue and suggested time frames for initial interviews of the alleged victim, alleged perpetrator, and any named witnesses.

Thus, with the introduction of the Investigative Plan on July 1, 2005, OIG Directives require that, barring extenuating circumstances, OIG investigative staff must conduct all critical interviews -- that is, victims and eyewitnesses -- within five working days of case assignment. If any critical interview is not conducted within the expected time frame, the investigator must document in the case file the specific extenuating circumstances.

Supervisory staff were expected to review for timeliness of interviews as part of their regular case review process. However, OIG is also developing an internal peer review process which, among many other things, will look at the timeliness of interviews.

Videotaping at Facilities

A major development in OIG investigations in FY05 was the increasing use of videotape evidence at Alton MHC. Although not a system enhancement made by OIG, Alton MHC's initiative in installing cameras in common living areas improved investigations. In FY05, videotape evidence was used in several cases and was crucial in supporting administrative action. Just as important, videotape evidence also contradicted allegations in many unfounded cases.

The presence of a videocamera may also have a secondary effect of improving the quality of services provided. If staff in an agency or facility program are aware of the possibility of being videotaped, they may be more conscientious in providing services.

OIG's experience with the use of videotape by Alton MHC has been very positive, and it equally supports adults in abuse and neglect allegations and supports staff in unfounded allegations. OIG is actively supporting the expanded use of videotape systems in other facilities and in community agency programs.

45-day Case Status

Meeting OIG's commitment to complete its investigations within sixty working days requires a special review of investigations that are approaching that length and are still active. Thus, each bureau submits a 45-day Report identifying the cases that have reached that milestone.

Although OIG has employed some form of a 45-day case status report for several years, FY05 ushered in the use of a uniform reporting form that includes more information and incorporates data from the Automated Case Tracking ("ACT") system (see above).

In addition, the ACT system highlights cases on which there has been no recorded investigative activity for ten working days. The bureau chief must now identify the reason for the delay in completing the case, which may involve consultation with the assigned investigator. The bureau chief further indicates what action is needed to complete the case, as well as an anticipated completion date.

The bureau chief enters this information directly into the OIG's main database, and the 45-day Reports are produced from that database. The reports are available to all investigative staff, providing a peer review component and further accountability.

The 45-day Report typifies OIG's proactive approach to identifying problem cases and ensuring that all OIG investigations are completed in a timely fashion

Streamlined Case Review

Over the course of FY05, OIG reduced the time needed to complete investigations more than 60%, from 74 days to 46 days. Much of the improvement has been in the time to conduct the investigation. However, reductions in review time have also occurred, and further reductions are expected over the next year due to the new case management OIG developed and implemented at the end of FY05.

First, the new Investigative Plan requires supervisory review at the outset, encouraging even more coordination between the investigator and his or her supervisor. Involving the supervisor in the planning should reduce the time needed to review the draft investigative report.

Second, the Investigative Plan, which can be sent electronically, records the names of pertinent witnesses and other details of the allegation, as well as relevant information - such as evidence collection, necessary referrals and other important data - that will focus the investigator's approach. The investigative plan thus performs the same function as the Case Initiation Report and the Investigative Checklist, neither of which now need to be completed by case reviewers.

Third, the Automated Case Tracking (ACT) system (see above) provides a means for ongoing real-time case management and thus review. Investigators record completed "investigative case actions," selecting from a menu of various tasks, as the investigation is being conducted. Supervisors may then access the ACT system to review case actions and to add questions and comments to the assigned investigator, enabling them to provide direction without having to schedule time to meet with him or her or to view the paper file. Conducting such ongoing electronic review will enhance accountability and speed the review process without hindering investigators' work in the field.

Further, the investigator can use the system's "investigative case actions" to document steps in the investigation. This system then allows the investigator and his or her supervisor to keep track of what has been done and what an investigator is doing. It can also be printed out at any step in the investigation, covering the purpose of the former contact sheets, activity summary sheets, and other manual forms, thereby eliminating other forms without losing their purpose.

The ACT system also performs a direct "tickler" function, flagging cases on which no investigative activity has been conducted within the previous ten working days. This flagging is done on the weekly case management reports.

In addition, the 45-day Reports (see above) and other monthly reports increase the ongoing interaction of the investigator with his or her supervisor in addressing problems delaying completion of the investigation. This interaction thus permits supervisors to take a more proactive role in spotting aging cases and providing the support and oversight necessary to complete them.

Much of the review process can be handled electronically, with draft investigative case reports and individual interview summaries being sent by email between investigator, supervisor and case reviewer.

As the Automated Case Tracking ("ACT") system with investigative case actions form allows supervisors to become more intimately involved with each case and monitor plans and direct and investigations more effectively. This issues can be addressed before the investigative case report is initially drafted.

Chapter 4: Compliance and Training

Beyond investigating allegations, OIG seeks to prevent abuse and neglect through a variety of statutorily mandated activities, which are described below.

Unannounced Site Visits

The statute (210 ILCS 30/6.) requires OIG to conduct unannounced site visits annually to each of the DHS-operated developmental center and mental health centers.

OIG site visits focus on systemic issues that contribute to preventing abuse and neglect, which may vary from year to year. Yet, the goal remains: to cover a wide range of activities, initiatives and potential problem areas related to the prevention of abuse and neglect.

In FY05, the site visits were conducted by a team consisting of two to three OIG staff, one of whom is a registered nurse. OIG's FY05 unannounced site visits were:

• Alton MHC, 09/07/04;
• Chester MHC, 11/10/04;
• Chicago Read MHC, 07/15/04;
• Choate DC, 11/18/04;
• Choate MHC, 11/16/04;
• Elgin MHC, 12/15/04;
• Fox DC, 12/21/04;
• Howe DC, 10/27/04;
• Jacksonville DC, 11/23/04;
• Kiley DC, 11/08/04;
• Ludeman DC, 11/03/04;
• Mabley DC, 12/01/04;
• Madden MHC, 10/11/04;
• McFarland MHC, 10/27/04;
• Murray DC, 11/12/04;
• Shapiro DC, 07/28/04;
• Singer MHC, 08/11/04; and
• Tinley Park MHC, 11/01/04.

The OIG site visit protocol for FY05 addressed seven primary issues of concern.

Site Visit Issue 1: Findings and Written Response Follow-up

When OIG substantiates a case or identifies an administrative issue, the facility must submit a "Written Response" with the actions it will take, along with a projected implementation date. During FY05 site visits, OIG reviewed the Written Responses prepared since the previous site visit.

Findings

During the FY05 site visits, OIG reviewed 25 cases of substantiated neglect; 24 cases of substantiated physical abuse; 3 cases of substantiated mental injury; and 80 cases with other administrative issues. Some cases had more than one finding.

The most common administrative issues were a failure to perform job duties, such as poor supervision of adults or documentation errors (33) and either the failure to report or late reporting of allegations to OIG (30).

As in previous years, nearly all Written Responses had been implemented, although with some minor discrepancies; for example, one facility had a Written Response that did not accurately reflect the action taken, and another facility had completed all actions but not by the documented implementation date.

Training was the most common action taken, and the most common trainings were in the areas of: initial reporting of allegations; providing adequate supervision to adults receiving services; and interacting appropriately with those adults.

The second most common action overall - suspensions - were most often for interacting inappropriately with adults, failing to monitor adults adequately, or failing to report an allegation. A discharge was the typical response when abuse or neglect was substantiated.

Other administrative actions against staff included: enhanced job supervision by the supervisor; assignment to a different job and an added job performance objective.

Policies and procedures were also revised as a result of OIG investigations, often in areas dealing with patient safety; for example:

• Reducing one-on-one supervision shifts from seven hours to two hours to ensure staff are more alert and watchful;
• Revising expectations for the use and storage of disposable razors, to protect adults who lack skill in using them;
• Requiring physicians who examine injuries to document whether it might be the result of abuse or neglect;
• Detailing the physician's duties and responsibilities when adults are returned from hospital stays;
• Mandating that bed checks during night shift be staggered and not done all at once; and
• Requiring employees to secure their personal possessions in areas not accessible to adults.

Recommendation

The OIG site visit team recommended that the facilities document all actions accurately and thoroughly.

Site Visit Issue 2: Facility Efforts to Reduce Abuse/Neglect

Facilities often develop other initiatives to prevent abuse and neglect from occurring. The site visit examined these local efforts, as well as patient safety policies generally.

Findings

The statewide initiative to reduce violence and restraint use (described above) was the only significant effort at the DHS mental health centers to prevent abuse and neglect. However, some facilities had undertaken other initiatives; example one facility had instituted a "Patient for a Day" program, in which new employees stayed with patients throughout the day attending therapies, eating meals, participating in activities and socializing together. This program seeks to increase staff identification with and understanding of patient issues and concerns, thereby reducing situations in which abuse and neglect are likely to occur.

The facilities had revised 140 policies related to patient safety; also, one facility had revised its entire policy manual since the previous site visit. The policies the site visit team reviewed showed ongoing efforts to provide a safe environment in which to live and work.

The DHS developmental centers reported addressing abuse and neglect by compiling data on issues such as the number and type of allegations made, the number of cases opened or closed and whether or not they were substantiated, and the number and type of complaints received. This data is analyzed for patterns and trends to determine if a particular unit, shift or employee has had multiple allegations concerning them.

Facilities use this information to remediate situations with increased risk to adults. For example:

• One facility added more supervisors and activities to the afternoon shift after it was learned that the shift had an increased incidence of aggression and restraint use.
• Another facility established a task force to analyze reporting practices to help find out how to ensure prompt initial reporting. A staff survey was used to identify attitudes toward reporting. All employees were given a job performance objective asking if they had observed abuse or neglect and whether or not they reported it.

The DHS developmental centers changed 94 policies related to individual safety in efforts to reduce abuse and neglect by creating an environment where safety is a priority.

Recommendation

The OIG site visit team recommended that the mental health centers consider gathering more data on individual injuries and abuse/neglect incidents and conducting inquiries on them all individually, not just primarily in aggregate or only serious ones.

Site Visit Issue 3: Preventing Violence and Restraints

Aggression often leads to injury. Staff response to aggression, including the use of restraints, may aggravate the situation, increasing the risk of injury. Reducing aggression should thus decrease the need for restraint, lowering the risk of injury and decreasing the chance for abuse.

Findings

In FY05, the Division of Mental Health partnered with the National Technical Assistance Center for State Mental Health Center Planning (NTAC) to reduce violence and restraint use in all DHS mental health centers. The program uses a wide ranging approach addressing leadership, training, perceptions and input from staff and adults, assessment, and the use of debriefing and data to inform practice. The results at four facilities were as follows:

• At Elgin MHC during FY04, restraint episodes were cut by 28% and time in restraint fell by 54%, compared to FY03. Seclusion episodes decreased by 51% and time in seclusion dropped by 62%.
• At McFarland MHC, from the last quarter in FY04 to the first in FY05, restraint episodes fell by 36% and time in restraint dropped by 30%. Seclusion episodes stayed the same, but time in seclusion dropped by 30%.
• At Choate MHC, from the last quarter in FY04 to the first one in FY05, seclusion episodes decreased 40% while restraint episodes increased slightly - but one individual accounted for half of all those restraint episodes.
• At Chester MHC, again comparing the first quarter in FY05 to the fourth quarter in FY04, restraint episodes fell 9% and time in restraint dropped 64%. Seclusion episodes remained the same, but time in seclusion was cut 58%.

The DHS developmental centers did not have a specific comprehensive or division-sponsored violence and restraint reduction program. However, each facility still made efforts to reduce restraints (developmental centers do not use seclusion). The results at four facilities are highlighted here:

• Mabley DC trained its direct care staff in non-confrontation to reduce power struggles between adults and staff, put more supervisors on each shift to ensure that behavior programs were implemented consistently, and improved how functional analysis of aggressive behavior was done. From FY04's first half to its second half, episodes of restraints dropped 6% and time in restraints fell 28%.
• Choate DC revised its restraint policy, removed restraint from about 40% of programs, began debriefing techniques after restraints, revised program schedules for adults, and increased active treatment in the evening hours when restraint was needed most often. Programs for adults with sexually aggressive behaviors were also redesigned. From the last quarter in FY04 to the first quarter of FY05, the facility cut restraint episodes 58%.
• Murray DC took restraints out of all program plans, consulted with experts on how to deal with aggressive adults, and then trained staff in those techniques and in defusing potentially violent situations. From FY04's first half to its second half, the facility cut restraint episodes by 16% and time in restraint by 28%.
• Jacksonville DC started collecting more information about each episode of inappropriate behaviors, wrote a "Restraint Information Guide" for staff, and did extensive staff training on using restraint as a last resort. Other guides were written on dealing with pica behavior, borderline personality disorders, and dementia. The facility had no significant change in restraint use in the second half of FY04.

Recommendation

The OIG site visit team recommended that the Division of Development Disabilities also consider adopting a division-wide approach to violence and restraint reduction.

Site Visit Issue 4: Facility Injury Reviews

OIG reviewed policies and data related to patient injuries, with special attention to injuries from peer aggression (individual-on-individual injuries), injuries that were serious and review processes for all injuries.

Findings

Of all injuries reviewed at developmental centers in FY05, only 2% were serious and 10% were caused by peer aggression. At the DHS mental health centers, 15% were serious and 23% caused by peer aggression.

Injuries resulting from peer aggression get special attention at the DHS facilities. Typically, when adults are aggressive, an analysis of why the aggression occurred is completed. At developmental centers this occurs during a formal process called a "functional analysis". In psychiatric hospitals, the multi-disciplinary treatment team meets to discuss the motivation for peer attacks. Most often, behavioral programs are written and medication adjustments are made in an attempt to reduce peer aggression. Less frequently, adults are transferred to other rooms or units within the centers.

Injuries that are serious injuries are often reviewed by several committees to ensure appropriate response to the injuries and completeness of follow-through. One facility failed to document two injuries in the progress notes but had documented it elsewhere. All of the others had followed their processes correctly.

Injury review processes are well developed at all facilities. Data is consistently kept and monitored for patterns. When patterns occurred, facility administrators responded in various ways. For example:

• A facility noted that many falls were occurring in unit bathrooms. The facility responded by changing the floor surface of the bathrooms.
• A facility noted that the medically involved residents had suffered many broken bones. The facility established a "fracture review committee" to closely examine all fractures and assessed the individual to see if he or she had osteoporosis. If so, special vitamins and minerals were added to the diet.
• A facility noted inconsistent treatment responses to peer aggression. The facility created a "clinical review team" to conduct reviews on injuries related to peer aggression and determine the most appropriate interventions.

Some facilities have developed additional forms for reporting and reviewing injuries. One facility, for example, has written procedures specific to potential brain injuries. Another requires that each injured individual be interviewed privately by the nurse, to reduce the possibility that other staff might discourage him/her from alleging abuse.

At a third facility, however, the additional required forms appear to be confusing and redundant. This might adversely impact accurate and timely reporting.

Recommendation

The OIG site visit team recommended that the facility review its apparently confusing and redundant reporting forms.

Site Visit Issue 5: Facility Handling of Non-Reportables

Rule 50 requires facilities to report to OIG any allegation of abuse/neglect of adults but not other employee misconduct, such as failing to document behaviors or fighting between staff. To ensure the facilities had addressed these incidents appropriately, OIG again reviewed a random sample of these during the FY05 site visits.

Findings

In FY05, the facilities again dealt with a wide variety of non-reportable complaints. Four examples of complaints and facility actions in response are as follows:

• A supervisor doing rounds found an individual taking a bath unsupervised even though her plan required staff monitor her while bathing. She was unharmed. The facility reprimanded the employee who had been assigned to monitor her.
• An individual was found on the bus, unharmed, five minutes after the other adults had gotten off at the workshop. The facility reprimanded the employee responsible for getting all adults off the bus at the workshop that day.
• An individual returned, unharmed, to his unit twenty minutes late from an on-grounds pass. His program plan was changed to require supervision whenever he was off the unit.
• An employee was alleged to have kissed an individual, but the accuser later recanted the allegation. The facility found that the employee had been dancing with adults, so she was disciplined for her conduct.

Two facilities continued to have no system to track issues to detect patterns or trends, to ensure that actions were implemented or to document completion of actions taken. A third facility had no centralized process for documenting actions taken; four of their twelve complaints had no documentation that all actions had been completed.

Recommendation

The OIG site visit team recommended that the three facilities improve how they document investigative and remedial actions.

Site Visit Issue 6: Medication Administration

An area at risk for abuse and neglect is in the administration of psychotropic and other medication. Thus, the nurse member of the OIG site visit team reviewed policies and conducted interviews about medication administration and error reporting. Where possible, medication passes on the units were observed and charts were examined.

Since medication error reporting depends on nurses reporting their own errors, counseling and retraining is used when incidents occur. If the error is caused by neglect, however, OIG investigates and discipline may result.

Findings

To satisfy accreditation standards, the DHS mental health centers have well-developed systems to track types and severity of medication errors. This data is reviewed by several administrative staff and by internal committees, all of which recommend actions to prevent future similar errors.

Most facilities use multiple ways to identify patients, especially for nurses who are temporarily assigned and unfamiliar with the patients. Some examples are: identification cards, pictures in the medication administration books, and regularly assigned staff standing by to ensure patients are correctly identified.

The DHS developmental centers are not subject to the same accreditation standards and so do not have the same unified system of data collection on medication errors. They do, however, collect data on medication errors. Most often the pharmacy collects the data, but, at some facilities, the director of nursing does this; in either case, the data is distributed to various internal departments and committees, which review the data for trends and patterns and may recommend actions to remediate systemic problems.

Three facilities did not have adequate systems to collect and analyze medication error data. One had no electronic method of collecting data, relying solely on paper analysis. Another facility tracks only nurses' errors - the pharmacy analyzes its own errors twice a year - and does not track physician errors at all. The third facility tracks error data adequately, but the review committee analyzes data that is three quarters old, so remediation is delayed.

Recommendation

The OIG site visit team recommended that the three facilities improve their data collection on medication errors and that the developmental centers look at medication errors in a systematic way.

Site Visit Issue 7: Facilities Response to Recommendations

The final issue was assessing how the facilities responded to the recommendations from the FY04 OIG site visits and from surveys by external organizations such as the Illinois Department of Public Health (IDPH), Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), Commission on Accreditation of Rehabilitation Facilities (CARF), and DHS central office (SB 472 reviews). The site visit team reviewed all surveys to check for completion of recommended actions.

Findings

The FY04 OIG site visits had a total of 33 recommendations. The facilities had taken action on all but one. In that instance, OIG had recommended the facility improve how it tracks non-reportable complaints and that the system include what actions were planned, what actions were taken, and what issues were left to be resolved. OIG made the same recommendation again.

Since the last site visits, the DHS mental health centers had three IDPH surveys (21 recommendations), four JCAHO surveys (14 recommendations), and five SB 472 reviews (no recommendations). All of these had been acted upon with one exception: a facility had not yet replaced all doors as part of a Capital Development Board project.

Also since the last site visits, the DHS developmental centers had had nine IDPH surveys (84 recommendations), five CARF surveys (32 recommendations), and six SB 472 reviews (27 recommendations). All but one recommendation had been completed: a facility had not yet trained adults and their families in recognizing and reporting abuse and neglect.

Recommendation

The OIG site visit team recommended that the three remaining recommendations be completed promptly.

Site Visit Conclusion

The site visit process continues to be an effective and efficient tool to identify policies, procedures or practices that increase the risk of abuse or neglect in the facilities. Along with other external reviews, OIG site visits have resulted in improved services to disabled adults throughout the state of Illinois.

Annual Investigative Authorizations

Rule 50, the administrative regulation that governs allegations and investigations into abuse and neglect, allows OIG to accept an investigation that is conducted by a community agency, but only when:

• OIG has previously authorized the agency to conduct investigations;
• OIG has assigned that particular case to the agency for investigation; and
• The investigator assigned to the case has previously been trained and authorized by OIG to conduct investigations.

Rule 50 is available on OIG's internet site at www.state.il.us/agency/dhs/rules/ad50oig.pdf

Process

Authorization of a community agency to investigate comprises four steps.

First, the agency must adopt the OIG Investigative Protocol for Community Agencies as agency policy. The Protocol establishes expectations for reporting and investigating abuse/neglect allegations and deaths, and the agency may operationalize these expectations in agency procedures. The Protocol is available on the internet at www.dhs.state.il.us/organization/Secretary/OIG/protocol

Second, the agency must identify and submit names of employees who will investigate. These employees must have:

• No job responsibilities that might lead to the appearance of a conflict of interest - such as being executive director, assistant executive director, human resource director, member of a union, or a family member of any of these;
• Successfully completed the OIG-conducted Rule 50 training since January 1, 2002; and
• Successfully completed an OIG-conducted Basic Investigative Skills training at least once within the last three years.

Third, every year, the agency must submit to OIG a request for authorization. The authorization process requires commitments from the agency to investigate allegations, document training, designate investigators, and avoid any appearance of a conflict of interest. OIG grants authorization for one fiscal year.

Renewal of investigative authorization is not automatic. An annual review form is sent to every agency about the first of May each year for the following fiscal year. Agencies who wish to be authorized must submit the form and required information.

OIG reviews agency submissions carefully. Agency practices for the preceding year are considered during the renewal process and may result in denial.

FY05 Authorizations

In FY05, a total of 394 community agencies were under OIG's investigative jurisdiction. Of that total, 184 community agencies submitted requests and were authorized by OIG to investigate on a case-by-case basis.

The number of agencies authorized has been decreasing slowly over the past few years: in FY03, in FY04, and then 184 this past year.

The remaining 210 community agencies declined to submit a request or were denied authorization to investigate. These agencies are still required to comply with statutory and Rule 50 requirements regarding the reporting and investigating of allegations.

Written Responses

Programs operated, licensed, or funded by DHS to provide mental health (MH) or developmental disability (DD) services are mandated by State statute to respond in writing to findings in OIG investigations; this response is known as a "Written Response." The law requires a Written Response for cases in which abuse or neglect is substantiated or an administrative issue is identified. The Written Response must address in a concise and reasoned manner the actions that the agency or facility will take or has taken to protect the resident or patient from abuse or neglect, prevent reoccurrences, and eliminate problems identified. The Written Response must include projected implementation dates for all such actions.

During FY05, a total of 402 investigations required a Written Response. The largest number (262) were from investigations at agencies providing DD services, followed by 71 from investigations at facilities providing DD services. The remainder were from investigations at facilities (43) or agencies (26) providing MH services.

Trend: More timely Written Responses

State law requires that the Written Response is sent within 30 days of the date of the completed investigation report. The agency or facility is to send the Written Response to the appropriate DHS division for approval. The approval process can sometimes be lengthy, so not all Written Responses sent by OIG are received and "approved" by the end of the fiscal year.

The distribution of the 413 approved Written Responses follows the same pattern: agencies providing DD services had 277, facilities providing DD services had 71, facilities providing MH services had 38, and agencies providing MH services had 27.

During FY05, most Written Responses were received timely. Only 23 of the 413 were received late. Facilities were more likely to be late than agencies - twelve were from DD facilities and five from MH facilities, while only six were from agencies (all from those providing DD services).

Trend: Reporting problems remain

Two of the most common problems in Written Responses dealt with reporting of initial allegations to OIG. Fifty-one of the Written Responses cited late reporting of allegations to OIG, and 85 cited a failure to report. Since this problem has been common in the past as well, OIG has undertaken several initiatives to address initial reporting (see Timeliness of Initial Reporting above).

Staff actions or failures other than reporting were also common problems identified. Inappropriate staff interaction with adults was addressed in 44 Written Responses.

A failure in patient or unit monitoring was identified in 19 Written Responses; a failure in medical attention was identified in 16 of them. Since a Written Response can identify multiple issues, some of these also identified reporting failures.

Written Response Compliance Reviews

A new law in FY04 (Public Act 93-0636) mandates that OIG review any implementation plan in a Written Response that takes more than 120 days. No Written Responses approved during FY05 took more than 120 days to implement.

Based on the law, OIG conducts some "compliance reviews" to ensure that what was identified in an approved Written Responses was actually implemented. OIG may follow up by phone contact, site visit, and request for documentation to ensure the corrective actions were completed.

On a monthly basis, OIG conducts a 20% random sample of Written Responses approved during the previous month. OIG's Compliance Reviewers meet to discuss the previous month's reviews and to plan the reviews of the new sample. A plan and a schedule are developed to conduct site visits and/or desk reviews, to collect information, and to verify and clarify all issues.

For each case, the Compliance Reviewer provides the agency or facility with an overview of the process, the case number of the Written Response, and a plan of the review: example, documents needed, persons to be interviewed, etc. The Compliance Reviewer determines if the corrective actions have been implemented and then sends a letter indicating whether or not the agency or facility is in compliance.

During FY05, OIG conducted compliance reviews on a randomly selected 20% sample - 75 of 374 Written Responses received during the previous time period. In these 75 Compliance Reviews, OIG conducted 46 site visits and 29 desk reviews.

In only two Written Responses, the agency had not initially implemented the actions identified; in both cases, it was because staff retraining was incomplete. Retraining was subsequently completed and both agencies are now in compliance.

As with all Written Responses, the two consistently recurring issues throughout the Written Response Compliance Review process were late reporting and the failure to report, especially at community agencies. In all cases, agency or facility staff were subsequently retrained and were able to correctly answer questions related to the reporting process.

The other three issues most frequently identified in all Written Responses were also the most common in the Written Responses Compliance Reviews. These are noted in the next section with an example for each.

Inappropriate staff interaction

An employee was substantiated to have forced medication down an individual's throat. The employee was terminated. The Written Response also recommended, and the agency said it would implement, retraining the program staff in the agency's medication administration policy. However, the Compliance Review process found that the licensed practical nurse (LPN) on duty at the time of the incident, who was responsible for administering the medication in question, had not been retrained. As a result, the agency subsequently retrained the LPN. Further, since the agency was unaware that a staff member involved in the incident had not been retrained, the agency developed a procedure to ensure that all Written Response actions are carried through to completion.

Patient / unit monitoring

A volunteer at a facility allowed an individual to have a glass bottle of cologne. The individual broke the bottle and cut himself with the glass. The volunteer had had no training in contraband or in reporting abuse/neglect, largely because the facility's policy on training of volunteers did not cover contraband or reporting of abuse/neglect. Further, the contraband policy did not mention glass objects. The Written Response recommended that the facility revise the training and contraband policies, which the facility then did. However, the Compliance Review process found that the new contraband policy still did not mention how glass cologne bottles are to be classified. As a result, the facility broadened its policy to cover both contraband and restricted use items and clarified the definition of contraband to include all glass objects.

Failure in medical attention

Upon admission to a community agency residence, an individual was found to have a high blood level of dilantin (an anti-epilepsy medication). The psychiatrist at the residence reduced his dilantin dosage and scheduled a repeat test nine days later at a local hospital. When the repeat test was done, the hospital, unaware of the individual's recent move to the agency residence, faxed the results only to the psychiatrist, but he was on vacation. So no one at the residence knew that the blood level was low, indicating a need to increase the dilantin dosage to prevent seizures. When taken back to the residence, he suffered multiple seizures with injury. The Written Response recommended that the agency establish a system to ensure follow-up on critical lab work, and the agency responded by establishing new medical procedures:

• The admitting staff were assigned to routinely update the local hospital on new admissions to the residence;
• The staff assigned to take an individual for lab work must inform the hospital that the individual is a resident of the CILA so results are faxed to the CILA; and
• The residence nurse was assigned to follow-up with the hospital if critical lab results are not returned within 72 hours.

The Compliance Review process found that OIG's recommendation had resulted in a multi-faceted response by the agency to improve the medical safety of the adults who live there and reduce the likelihood that a similar incident would occur in the future.

Conducting Written Response Compliance Reviews has put agencies and facilities on notice that they are being closely monitored for evidence of corrective actions. By establishing enforceable criteria, these Compliance Reviews encourage agencies and facilities to take actions to decrease abuse and neglect and to improve the safety of the residents.

Public Awareness

OIG continues to take the initiative to promote public awareness of its role and statutory responsibilities. This is especially true of the domestic abuse program, which partly relies on family, friends and neighbors to report alleged abuse, neglect, or exploitation of adults with physical or mental disabilities.

Distribution of literature and public speaking engagements continue to be a primary method of promotion. A brochure entitled Adults with Disabilities Domestic Abuse Program is available in English and Spanish. Further, OIG is developing a public service announcement that will provide general information on reporting domestic abuse, neglect, or exploitation of adults with disabilities in Illinois.

OIG staff often give presentations on OIG's role and the importance of reporting and investigating allegations. OIG staff also make informational visits, especially to local law enforcement agencies. The following are groups to whom OIG made informational visits or presentations during FY05.

• States Attorneys:  Crawford, Cumberland, Jasper, and Richland counties.
• Law enforcement agencies:  Marion Police Department, East Moline Police Department, Springfield Police Academy, Johnson County Sheriff's Department, White County Sheriff's Department, and District 13 of the Illinois State Police.
• Developmental service entities:  Clay County Rehabilitation Services, Disability Resource Center, Resources for Living, and the Statewide Advisory Council.
• Medical-related groups:  Hillsboro Medical Association, and Illinois Nurses Association.
• Hospitals:  Hospitals in Carmi, Centralia, Effingham, Fairfield, Lawrenceville, Mt. Carmel, Wabash, and Waterloo.
• Educational institutions:  Chicago Public Schools, Edwardsville High School special education teachers, Southern Illinois University's Medical School and its Graduate School of Social Work.

External Training

Conducted in FY05

Training conducted by OIG is targeted to prevention and reduction of abuse or neglect of adults with disabilities. This objective is partly accomplished by conducting training for staff of State-operated facilities and staff of community agencies providing mental health or developmental services.

In FY05, OIG offered two courses: one in the administrative regulation that governs the reporting of abuse and neglect (Rule 50), and the other in investigating those reports (Basic Investigative Skills).

During FY05, OIG also developed a more focused training course aimed at staff who are the first to arrive at the scene of an alleged incident (First Responder). This course was piloted once in June 2005 and is to be offered eight times in FY06.

During FY05, OIG conducted 53 classes with a total of 1,418 attendees.

• Rule 50: 29 trainings, 873 total attendees.
• Basic Investigative Skills: 22 trainings, 512 total attendees.
• First Responder: 1 training, 33 attendees.

OIG trainers continue to update presentations to address changes and to increase interest. Overall, training conducted by OIG has been well received, with average ratings on course evaluations of about 9 on a ten-point scale.

In development for FY06

To ensure that agency and facility employees are properly trained in Rule 50, OIG is developing two initiatives. First, a handbook called "Reporting of Abuse and Neglect of Adults with Disabilities" is to be sent to all agencies and facilities, encouraging them to copy and distribute it to all staff.

Second, OIG is creating a course to train a few staff from each agency to be able to train all the staff at that agency. This approach of "Train-the-Trainer" had been offered in the recent past but was discontinued due to low enrollment. With the expectation that all staff are to be trained in Rule 50, OIG will revise this training and begin offering it again in the near future.

In addition, beginning in July 2005, OIG is offering an "Investigative Skills Refresher." This one-day course is for those who have taken Basic Investigative Skills since January 2002 and want to maintain necessary skills required for abuse/neglect investigations.

Internal Training

During FY05, OIG strengthened its staff training program to emphasize continuous improvement in investigative skills and personal growth.

To implement this objective, OIG has been developing new computer-based learning courses (see Intranet-based Training) and pursuing other means to provide training.

As in previous years, OIG held a Statewide training meeting for all staff; this year it was held September 28-30, 2004 in Springfield. The Statewide consisted of two full days of intensive training on investigative planning, communicating with persons with disabilities, investigative timeliness, effective report writing, testifying in hearings, organizational effectiveness, and the Nurse Aide Registry appeals process.

Due to budgetary constraints, a second statewide was replaced by conducting more focused trainings during monthly meetings of individual bureaus within OIG. During these meetings, the bureaus may also discuss OIG directives or practices.

In June 2005, OIG trainers expanded on the idea by conducting two "combined bureau meeting" trainings - one in Hines, just west of Chicago, and the other in Lebanon, about 25 miles east of St. Louis. OIG intends to repeat these as semi-annual events, to provide cost-effective training to OIG staff.

OIG was also able to locate free training opportunities provided by other State agencies, local law enforcement entities and universities. During FY05, OIG staff attended classes at the Department of Healthcare and Family Services (formerly Public Aid), Department of Corrections, Southern Illinois University School of Medicine, and Loyola University.

During FY05, OIG has been reorganizing and expanding its internal Training Library. Out-of-date videotapes have been retired and replacements are being sought.

Finally, in February 2005, OIG revised its internal training directive to require more training of its investigative staff. Despite significant budgetary limitations, OIG was still able to accomplish these goals. By June 30, all OIG employees (other than those on approved leaves of absence) had completed the State's mandatory annual ethics training and all DHS and OIG-required courses.

In conclusion, OIG training staff will continue to create and adapt curricula to ensure adequate training of all OIG staff involved in reporting and investigating abuse/neglect.

Chapter 5: Statistical Information

Allegations Reported

During FY05, OIG received 2,191 total allegations of abuse or neglect. The counts by type and location are shown in the table below; Tables 5.A through 5C at the end of this Annual Report show a more detailed breakout by disability type and facility.

Table 1. Allegations of Abuse and Neglect by Type and Setting, FY05 

Location	Abuse	Neglect	Totals
Facilities	853	84	937
Agencies	551	172	723
Domestic	216	272	531*
Totals	1,615	539	2,191*

*Total includes 43 allegations of exploitation.

Facilities accounted for the fewest neglect allegations and the most abuse allegations.

Trend: More allegations reported

OIG received more allegations of abuse or neglect at all settings in FY05:

About Department facilities,

• 43% more than FY04,
• 17% more than FY03;

About community agencies,

• 38% more than FY04,
• 21% more than FY03; and

In domestic settings,

• 28% more than FY04,
• 68% more than FY03.

Total domestic allegations were relatively level in FY01 through FY03.

Trend: More allegations from Choate DC

Frequent allegations made by adults receiving services in the Department's mental health facilities account for significant percentage of total allegations. However, the single largest increase in FY05 was due to frequent - and typically unfounded - abuse allegations from a few adults receiving services at Choate Developmental Center (Choate DC).

During FY03 and FY04, Choate DC accounted for 115 and 109 abuse allegations, respectively. Then, in FY05, Choate DC accounted for 228 abuse allegations, about double the previous annual totals. However, just two adults accounted for over half of those allegations and, of these, all that are closed have been unfounded.

Trend: More on certain shifts

In all facilities, the night shift has the fewest allegations of abuse and neglect. The time periods for the most allegations is not the same across disability type.

At the developmental centers, the first half of the morning (6:00 to 10:00 a.m.) is the most common time period for allegations. This time period is typically when most of the stressful interactions between the staff and adults occur - getting adults up, dressed, to breakfast, and out to daytime activities.

At the mental health centers, on the other hand, the most common time period for allegations is the evening (6:00 - 10:00 p.m.). This time period is often the least structured, allowing fewer opportunities for positive interactions between staff and adults - at least until bedtime.

In late FY05, OIG identified these time periods to the program divisions, which are now working on ways to address these issues.

Trend: More reporting from agencies

As indicated above, allegations of abuse and neglect at agencies has increased over the past three years, but with a drop in the middle year. That is, comparing FY03 to FY04, and then to FY05:

• Physical abuse allegations dropped from 288 to 258, then rose to 364;
• Mental injury allegations dropped from 111 to 85, then rose to 128;
• Sexual abuse allegations dropped from 55 to 44, then rose to 59; and
• Neglect allegations decreased from 142 to 138, then rose to 172.

OIG attributes the increase to the agencies having a clearer understanding of Rule 50 definitions and expectations. During FY05, OIG conducted many Rule 50 trainings, required investigative refresher training, and has been working on a reporting handbook for distribution to agency and facility staff.

Trend: More domestic referrals

Each year, OIG receives some calls about domestic situations that do not meet the statutory requirements for domestic abuse, neglect, or exploitation. For example, the living situation may not be a domestic one, the complaint may not meet the definitions, or the individual may be under 18, over 59, living in another state or deceased.

OIG still takes these "ineligible" calls and tries to refer the situation to the most appropriate resource. Assisting adults in ineligible calls can take a substantial amount of time.

Over the past few years, the number of ineligible calls has been decreasing - only five were received in FY04. However, in FY05, OIG received 34 ineligible calls, referring most to the police, a local service agency, or another state agency.

Trend: More domestic abuse allegations

Through FY04, the proportion of domestic allegations that alleged neglect grew steadily. FY05 reversed that trend (see Table 2). It is unclear if, in FY06, neglect allegations will return to increasing the fastest.

Table 2. Domestic Allegations by Percent

Year	Abuse	Neglect	Exploit.
FY01	57%	35%	8%
FY02	44%	45%	11%
FY03	45%	42%	12%
FY04	35%	56%	8%
FY05	41%	51%	8%

Trend: More reported by DHS-DRS staff

Over the past several years, most domestic allegations have been reported by the community agencies or by family members and friends - nearly a quarter of all domestic allegations were reported by each group. Hospitals have been second - about 16% of all domestic allegations - and then staff of DHS's Division of Rehabilitation Services (DHS-DRS) third - about 10%.

In FY05, DHS-DRS staff, including the Home Services section, reported more (86) than did hospitals (83) and nearly as many as family members and friends (91). OIG made several presentations to DRS staff around the state during FY04 and FY05, which may explain the substantial increase.

Yet community agencies continued to be the most common source for allegations of domestic abuse, neglect and exploitation. During FY05, these agencies, including pre-admission screening (PAS) agencies, accounted for 117 (22%) of the allegations.

Timeliness of Initial Reporting

Administrative Rule 50 requires that facilities and agencies must report every allegation of abuse or neglect within four hours of the time the staff first become aware of it. Deaths must be reported within 24 hours. OIG monitors the timeliness of initial reporting through four means.

First, when a representative of an agency or facility calls the OIG Hotline to initially report an allegation ("self-report") and the allegation is not reported timely, the caller is given an opportunity to provide the reasons for the lateness.

Second, the printed initial intake form automatically prints: "Case was reported late." If a date or time is not specific enough for the computer to determine only that it was possibly late, this flag says: "Check for late reporting." The OIG investigative bureau can then follow up during the investigation.

Third, OIG investigations routinely evaluate the initial reporting process. Thus, even if the caller does not indicate the allegation was reported late, the OIG investigative report may cite late reporting and recommend some type of action to address it.

Further, as a follow-up to cited late reporting, OIG sends to the DHS program divisions a monthly list of cases reported late. Those divisions can then follow up with the facilities and agencies that have reported late. This monthly report lists, for each late report, the date and time an allegation was discovered and the date and time it was reported to the OIG Hotline.

Finally, OIG discusses late initial reporting at meetings of the OIG Program Coordination workgroup.

Trend: More timely initial reporting

As a result of these proactive steps, the timeliness of initial reporting has significantly improved. During FY03, we found that 295 of the 1,161 "self-reports" (25%) were reported late. Similarly, in FY04, we noted that 228 of the 1,010 "self-reports" (23%) were reported late.

In FY05, however, only 261 of the 1413 "self-reports" (18%) were reported late. This drop is evident both in abuse allegations and in neglect allegations.

Counting just abuse allegations, the percentage reported late has dropped from 21% in FY03 and 20% in FY04 to 15% in FY05.

Counting just neglect allegations the percentage reported late has dropped from 5% in FY03 to 4% in FY04 and then to 3% in FY05.

Timeliness of Investigation

Many of OIG's system enhancements during FY05 aimed at completing investigations more promptly. Rule 50 expects that, absent exceptional circumstances, investigations should be completed in 60 days or less, and OIG cases had recently been taking longer.

In FY05, OIG completed its investigations much faster than the rule's standard. For cases completed during the fiscal year, the average time from the initial report of an allegation until the investigative case report was completed was 48 days per case.

Trend: Faster OIG investigations

During FY03, OIG investigations took an average of nearly 60 days per case, meeting the goal in Rule 50. In FY04, however, OIG investigations began taking longer, averaging 85 days per case. Thus, the FY05 average of 48 days per case means that this past year OIG completed its investigations in slightly over half the time taken during the previous year.

Case Closures

During FY05, OIG closed 2,171 abuse or neglect allegations and 122 reports of death. Broken out by service setting, OIG closed:

• 1167 allegations of abuse/neglect and 92 death reports in DD settings;
• 461 allegations of abuse/neglect and 30 death reports in MH settings; and
• 543 allegations of abuse, neglect or exploitation in domestic settings.

Tables 6.A through 6.C detail these closures by setting. The tables also give the counts by finding within disability.

During FY05, OIG closed slightly fewer cases than were received. OIG received 2,191 allegations of abuse/neglect and closed 2,171. However, OIG received 114 reports of death and closed 122, many of which were reported in FY04.

Counting only OIG-conducted investigations, OIG opened 2,201 investigations and closed 2,248, finishing the year with only 517 still active OIG investigations.

Trend: Fewer pending investigations

By closing more investigations than were opened, OIG reduced the number of cases that were still active OIG investigations. Having a smaller "backlog" allows OIG investigators to have more control of their cases, to have more time to focus on each one, and to get them done faster.

Each year from FY00 through FY04, with the exception of FY03, OIG substantially reduced the number of its pending cases by closing more investigations than it opened. During FY05, OIG further reduced the number of active investigations by again closing more cases than it opened.

Investigative Findings

During FY05, OIG closed 309 cases where the abuse, neglect, or exploitation were substantiated. The table below summarizes these cases by general program type and disability.

Table 3. Substantiated Abuse and Neglect by Type and Setting, FY05

Location	Abuse	Neglect	Total
Facilities	28	15	43
Agencies	113	34	147
Domestic	80	32	119*
Totals	221	81	309*

* Includes seven cases of substantiated domestic exploitation.

For facility and agency cases (which are governed by Rule 50), abuse or neglect was substantiated in 190. In another 209 cases, abuse/neglect was not substantiated, but OIG identified a related administrative issue that required the agency or facility take some action in response.

Trend : More abuse substantiated

In facility/agency cases, substantiated abuse grew from 75 in FY03 to 130 in FY04 and again to 141 in FY05. This trend is less pronounced at facilities. From FY03 to FY05, substantiated abuse in the facilities rose slightly (23 to 28), but it rose substantially in agency (52 to 113) and in domestic settings (33 to 80).

Substantiated domestic abuse cases fell from 37 in FY03 to 33 in FY04, but rose to 80 in FY05. That is, over the past three fiscal years, OIG has substantiated more than twice as many domestic abuse allegations.

Neglect shows a more mixed pattern. From FY03 to FY05, substantiated neglect in the facilities decreased by three (from 18 to 15), but held roughly steady in the agencies (from 33 to 34). On the other hand, substantiated domestic neglect jumped 23% (from 26 to 32). Overall, the great majority of substantiated neglect cases were in DD service locations.

Trend: Lower Rule 50 substantiation rates

One effect of more conscientious reporting of initial allegations by facility and agency staff is a decrease in "screening" and thus an increase in unfounded complaints. So, when allegations rise, the substantiation rate typically drops.

FY05 follows this pattern. Compared to FY04, OIG closed more allegations and substantiated fewer - the number closed rose 14%, while the number substantiated dropped 6.9%. Still, the substantiation rate fell only 2.6%, from 14.2% to 11.6%.

Trend: More Rule 50 recommendations

Even when not substantiating a Rule 50 case, OIG may identify an administrative issue and make recommendations to the agency or facility (see Written Responses above).

During FY05, OIG identified an issue in 209 cases that were not substantiated, compared to 202 in FY04 and only 101 in FY03. This trend shows OIG's ongoing commitment to identify issues that might lead to abuse and neglect.

Trend: More non-residential abuse

Since residential programs typically provide services for more hours each day, the community agencies' residential programs usually have more substantiated abuse allegations. This has been true every year, FY03 through FY05.

Recently, though, non-residential programs at community agencies have had a significant increase in substantiated abuse cases at community agencies:

• FY03, less than one-fourth (23%);
• FY04, over one-third (35%); and
• FY05, closer to one-half (44%).

This trend in abuse cases at community agencies is true in both mental health and developmental disability services. Since the number of initial allegations has also increased over the time period, this trend may be due simply to higher reporting.

Trend: More domestic exploitation

In FY01, the first year of the domestic abuse program, OIG substantiated no cases of exploitation in domestic settings. Then, in FY02 through FY04, OIG substantiated only one or two cases per year.

In FY05, OIG substantiated seven cases of domestic exploitation: two cases each involving adults with developmental disabilities or physical disabilities, and three with mental illness. Part of the reason for the increase has been legislative changes. First, Public Act 93-751, signed July 15, 2004, allowed OIG access to medical and psychiatric records when the individual's guardian is unwilling to sign a consent form.

Second, OIG has developed positive working relationships with local law enforcement agencies, which has assisted in notifying OIG of possible exploitation and in getting the necessary evidence to substantiate it.

Finally, Public Acts 94-495 and 94-500, although not signed until after the end of the fiscal year, grant OIG authority to get bank statements and other financial records, as part of an investigation of domestic abuse, neglect or exploitation. These laws should help OIG find evidence to substantiate exploitation where it is occurring.

Service Plan Referrals

The statute mandates that OIG refer every substantiated case to the appropriate DHS division for development of a plan to ensure the necessary services are provided. This "service plan referral" would be to the Division of Developmental Disabilities (DDD) if the individual has disabilities that began before age 22; otherwise, it would be to the Division of Rehabilitation Services (DRS) for those with physical disabilities or the Division of Mental Health (DMH) for those with a mental health disability.

During FY05, the 119 substantiated cases resulted in 83 service plan referrals to DDD, 29 to DRS, six to DMH, and one to DHS's Division of Alcohol and Substance Abuse.

Trend: Most still to DD Division

In every year since the program began in FY01, the most service plan referrals have been to DDD, although the percentage is dropping:

• 45 (78%) of the 58 substantiated cases in FY03;
• 44 (73%) of the 60 substantiated cases in FY04; and
• 83 (70%) of the 119 substantiated cases in FY05.

OIG sent to DRS 29 service plan referrals in FY05 (24%). That division received 19% and 18% of referrals in FY03 and FY04, respectively, although that was only eleven cases in each of those two years.

OIG sent DMH six service plan referrals in FY05, up from five in FY04 and two in FY03. Despite the increase in actual referrals, the percentage referred to DMH rose from 3% in FY03 to 8% in FY04, and then dropped to 5% in FY05.

Registry Referrals

OIG is statutorily mandated to report to the Nurse Aide Registry maintained by the Illinois Department of Public Health (IDPH) the name of any employee who is substantiated to have committed physical abuse, sexual abuse, or egregious neglect of an individual receiving services in a program operated, licensed, or funded by DHS to provide mental health or developmental services.

Three levels of appeals are available to a person whose name OIG may refer to the IDPH Nurse Aide Registry. Prior to case closure, the person may request OIG to reconsider the finding. Reconsiderations require the person to identify information that was not considered in OIG's investigation and could change the outcome.

The person may file an employee grievance or other internal facility or agency process (50.80 appeal), although OIG rarely gets notified of this appeal. The person may also file a direct appeal to not refer his or her name to the Registry (50.90 appeal).

After a person's name is placed on the Registry, once a year the person may file a request to remove his or her name (50.100 appeal). Although the Registry is maintained by IDPH, this appeal is made to DHS.

Trend: More Registry referrals

In FY05, OIG reported 62 names to the Nurse Aide Registry, a 15% increase over FY04 and more than double the number reported in FY03. The increase appears partly due to the completion of hearings on appeals filed on cases closed in FY03.

Most names referred to the Registry continue to be those of agency employees. During FY05, again well over three-quarters of the names OIG referred were agency staff. In contrast, facility employees accounted for only 13% of the referrals in FY05.

Trend: Diversity in referrals

During FY03, all but one Registry referral was for physical abuse. During FY04 and FY05, the great majority were still for physical abuse, but one FY04 referral was for egregious neglect. Further, sexual abuse accounted for five referrals in FY04 and another five referrals in FY05.

Similar trends toward a greater diversity of referrals are seen in job titles and in locations. In FY05, for the first time, OIG referred to the Registry a person who was classified in a professional job title.

Also, in FY05, OIG referred an employee from 47 different agencies or facilities, more than the 35 agencies or facilities in FY04 and significantly more than the 25 agencies and facilities in FY03.

Conclusion

OIG plays an integral part in the effort to keep people receiving services for mental illness or developmental disabilities safe from abuse and neglect. In addition to investigating allegations, OIG has statutory responsibility to refer to the Illinois Department of Public Health's Nurse Aide Registry the names of people who are substantiated to have committed physical abuse, sexual abuse, or egregious neglect. Referral effectively prevents them from working in a similar setting elsewhere. OIG accomplishes this responsibility in coordination with the DHS Office of Legal Services' Bureau of Administrative Appeals.

Over the past three fiscal years, OIG has referred to the Nurse Aide Registry the names of a total of 142 employees. As of June 30, 2005, 133 are still on the Registry; only nine names have been removed as a result of a decision by an administrative law judge or arbitrator. An additional 36 employees have won their appeal and their names were never referred to the Registry.

Facility size

The law that mandates OIG produce an annual report each year specifically requires that it include ratios of the direct care staff to the adults receiving services in each facility. Table 4 presents this information.

Patient Census

Facility size is most often shown by counting one of the following:

• inpatients a facility is budgeted to treat ("budgeted beds"),
• days that all patients were receiving services ("on-books"), or
• adults served during the year regardless of how many days they were there or how many admissions they had.

All three are given in Table 4 on the next page.

Direct care staff are those staff members who interact with the adults receiving services during the course of their regular job duties. Regular unit staff - mental health technicians, security therapy aides, nurses, caseworkers, psychologists, and others - constitute the largest percentage of direct care staff.

Since facilities have some part time workers, DHS uses an equivalent part of a full-time worker - "full-time equivalents" -- in order to compare facilities. These are then added to the regular full-time workers to arrive at the total direct care staffing levels

For comparison purposes, Table 4 also provides the overall ratios of developmental centers and psychiatric hospitals.

Table 4. Census and Direct Care Staff to Patient Ratios at the DHS Facilities, June 30, 2005

Facility	Budgeted Beds	On-Books Bed-days 1	Adults Served 2	Direct Care Staff 3	Direct Care Staff to Patient Ratio 4
State-operated Developmental Centers
Choate DC	195	69,618	214	257.7	1.52
Fox DC	171	59,181	170	161.1	1.03
Howe DC	425	156,956	444	570.6	1.38
Jacksonville DC	265	95,522	276	331.5	1.29
Kiley DC	250	95,400	274	317.5	1.24
Ludeman DC	408	156,600	441	493.5	1.18
Mabley DC	112	38,444	110	135.9	1.33
Murray DC	330	126,019	359	388.6	1.14
Shapiro DC	655	234,811	610	920.0	1.46
Total	2,811	1,032,551	2,946	3,576.3	1.31
State-operated Psychiatric Hospitals
Alton MHC	125	44,451	408	151.0	1.20
Chester MHC	280	103,451	472	365.1	1.28
Chicago Read MHC	180	58,102	1,880	207.7	1.48
Choate MHC	79	26,990	643	105.2	1.35
Elgin MHC	390	135,698	1,238	531.5	1.47
Madden MHC	148	37,502	2,171	196.8	1.76
McFarland MHC	100	41,315	728	126.1	1.13
Singer MHC	76	26,775	610	100.9	1.33
Tinley Park MHC	140	40,099	1,346	124.6	1.31
Total	1,518	514,383	9,496	1,908.7	1.38

1 The combined total of all days (from admission to discharge) for all adults receiving services.

2 An unduplicated count of adults receiving services in the facility during the fiscal year.

3 The number of direct care staff but counted as Full-Time Equivalents.

4 The direct care to patient ratios on June 30, 2005.

FY05 Statistical Tables

Table 5. Allegations and Deaths Reported to OIG during FY05 Sorted by Administrative Rule and Service Type

Table 5.A - Rule 50, Mental Health Services Only

Location	Physical abuse allegation	Sexual abuse allegation	Mental abuse allegation	Neglect allegation	Allegation Totals 1	Deaths
Alton MHC 2	8	4	2	1	15	0
Alton Forensic	42	7	32	1	82	0
Chester MHC 2	90	4	12	3	109	4
Chicago-Read MHC	15	5	5	8	33	1
Choate MHC	27	7	5	3	42	3
Elgin MHC 2	5	1	3	2	11	0
Elgin Forensic	6	3	7	1	17	1
Madden MHC	13	0	6	6	25	0
McFarland MHC 2	14	3	7	2	26	1
McFarland Forensic	2	0	2	0	4	0
Singer MHC	9	9	4	2	24	3
Tinley Park MHC	4	0	2	0	6	1
Department facility subtotals	235	43	87	29	394	14
Residential	9	7	8	3	27	16
Non-Residential	1	12	5	4	22	0
Community agency subtotals	10	19	13	7	49	16
OIG Rule 50 - MH FY05 Totals	245	62	100	36	443	30

1 Excludes complaints that were not reportable per the administrative rule.

2 Civil admission (non-forensic) units are listed separately, except Chester, which is all forensic.

Table 5.B - Rule 50, Developmental Disabilities Only

Location	Physical abuse allegation	Sexual abuse allegation	Mental abuse allegation	Neglect allegation	Allegation Totals 1	Deaths
Choate DC 2	168	6	54	11	239	3
Fox DC	2	0	0	3	5	4
Howe DC	69	2	12	13	96	5
Jacksonville DC	69	1	7	4	81	1
Kiley DC	19	0	4	12	35	1
Ludeman DC	17	0	0	3	20	3
Mabley DC	9	1	0	7	17	0
Murray DC	15	0	3	2	20	3
Shapiro DC	27	1	2	0	30	4
Department facility subtotals	395	11	82	55	543	24
Residential	246	23	81	129	479	57
Non-Residential	108	17	34	36	195	3
Community agency subtotals	354	40	115	165	674	60
OIG Rule 50 - DD FY05 Totals	749	51	197	220	1217	84

Table 5.C - Rule 51, Domestic Settings

Disability type	Physical abuse allegation	Sexual abuse allegation	Mental abuse allegation	Neglect allegation	Allegation of exploi-tation	FY05 Totals 1
Developmental	108	20	12	129	16	285
Physical	32	3	7	105	18	165
Mental	31	2	1	38	9	81
OIG Rule 51 FY05 Totals	171	25	20	272	43	531

1 Excludes complaints that were not reportable per the administrative rule.

2 Includes two physical abuse allegations and three mental abuse allegations on the forensic unit.

Table 6. Findings in Investigations Closed by OIG during FY05 Sorted by Administrative Rule and Service Type

Table 6.A - Rule 50, Mental Health Services Only

Location	Abuse substan- tiated	Neglect substan- tiated	Other issue only 1	Not substan- tiated	Finding Totals 2	Closed death cases 1
Alton MHC 3	0	0	0	14	14	0
Alton Forensic	4	0	3	61	68	0
Chester MHC 3	1	0	2	129	132	4
Chicago-Read MHC	1	0	8	20	29	2
Choate MHC	0	0	0	47	47	1
Elgin MHC 3	0	0	5	9	14	0
Elgin Forensic	0	0	3	14	17	0
Madden MHC	0	0	3	22	25	1
McFarland MHC 3	1	1	3	18	23	2
McFarland Forensic	0	0	1	3	4	0
Singer MHC	1	1	1	17	20	4
Tinley Park MHC	1	0	2	10	13	2
Department facility subtotals	9	2	31	364	406	16
Residential	5	0	11	13	29	14
Non-Residential	6	0	4	16	26	0
Community agency subtotals	11	0	15	29	55	14
OIG Rule 50 - MH FY05 Totals	20	2	46	393	461	30

1 No abuse or neglect was substantiated.

2 Excludes complaints that were ineligible per the rule and deaths with no allegation against staff.

3 Non-forensic units are listed separately, except Chester MHC, which is all forensic.

Table 6.B - Rule 50, Developmental Disabilities Only

Location	Abuse substan-tiated	Neglect substan-tiated	Other issue only 1	Not substan-tiated	Findings Totals 2	Closed death cases 1
Choate DC 2	5	2	2	214	223	4
Fox DC	1	3	0	0	4	7
Howe DC	2	1	6	72	81	4
Jacksonville DC	2	1	11	74	88	1
Kiley DC	2	3	5	13	23	1
Ludeman DC	0	1	1	16	18	4
Mabley DC	1	2	8	7	18	0
Murray DC	5	0	3	13	21	3
Shapiro DC	1	0	2	19	22	8
Department facility subtotals	19	13	38	428	498	32
Residential	58	26	87	286	457	58
Non-Residential	44	8	38	122	212	2
Community agency subtotals	102	34	125	408	669	60
OIG Rule 50 - DD FY05 Totals	121	47	163	836	1167	92

Table 6.C - Rule 51, Domestic Settings

Disability type	Abuse substan-tiated	Neglect substan-tiated	Exploita- tion sub-stantiated	Did not consent	Not substan-tiated	FY05 Totals 2
Developmental	63	18	2	4	203	290
Physical	10	10	2	4	139	165
Mental	7	4	3	4	70	88
OIG Rule 51 FY05 Totals	80	32	7	12	412	543

1 No abuse or neglect was substantiated.

2 Excludes complaints that were ineligible per the rule and deaths with no allegation against staff.