DHS OIG FY 2006 Annual Report

Executive Summary
Chapter 1 - System Improvement through Collaboration
Chapter 2 - System Improvement through Legislation
Chapter 3 - System Improvement through Development
Chapter 4 - System Improvement through Prevention
Chapter 5 - System Improvement through Information

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

September 2006

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 the Fiscal Year (FY) 2006 report of the Office of the Inspector General (OIG) in the Illinois Department of Human Services (DHS): Abuse and Neglect of Adults with Disabilities.

This annual report covers all activities and services of OIG and presents issues in investigating and preventing abuse and neglect of individuals with disabilities who live in State-operated facilities, in community agency programs that are licensed, certified or funded by DHS, or in private homes. The report also highlights OIG's legislative proposals aimed at protecting those individuals, especially in the areas of financial exploitation and sexual abuse.

OIG continues to work closely with external entities - federal, state and local law enforcement, financial institutions, health providers, social service organizations, community agencies, and other Illinois departments - and internal DHS offices, such as the divisions of Developmental Disability, Mental Health, and Rehabilitation Services, to coordinate efforts in our mutual concerns and goals for the safety and protection of adults with disabilities.

The entire Office of the Inspector General is fully committed to providing quality service and is confident in responding to allegations. I trust that you will find this report to be informative and helpful in understanding our efforts to prevent the abuse and neglect of persons with disabilities within Illinois.

Sincerely,

William M. Davis
Inspector General

Executive Summary

The Office of the Inspector General (OIG) in the Illinois Department of Human Services (DHS) has several statutory mandates relative to alleged abuse and neglect of individuals with disabilities in their own homes or in facilities or community agencies operated, licensed, certified, or funded by DHS to provide mental health or developmental services. OIG's primary roles are:

investigating these allegations;
linking individuals residing in their homes to necessary services;
making recommendations to eliminate problems identified at facilities/agencies;
monitoring if facilities and agencies take actions based on those recommendations;
conducting unannounced site visits to facilities;
training facility/agency employees and approving agency investigators; and
referring to the Nurse Aide Registry the names of facility/agency employees who are substantiated to have committed physical abuse, sexual abuse, or egregious neglect.

During State Fiscal Year (FY) 2006, which was July 1, 2005 through June 30, 2006, OIG collaborated with other offices within DHS and with external entities to work on issues affecting the system of prevention and investigation of abuse/neglect (see Quality Care Board and Program Collaborations).

OIG continues to work with the Department, the Governor's office, and the General Assembly to improve the system through laws addressing issues that arise. Nine new laws will help prevent, ensure reporting of, and improve investigating of abuse and neglect of individuals with mental, developmental or physical disabilities (see Chapter 2).

Increased review of reporting has improved reporting by community agencies (see sections on reporting). Full implementation and further developments in OIG's internal case management system has improved tracking and increased documentation, while still meeting the regulatory time frames (see sections on case management/timeliness).

The system of prevention and investigation have also been improved through OIG's unannounced site visits to facilities (see Site Visits), authorizations of community agency investigative protocols (see Authorization Reviews), clinical reviews and investigations (see Clinical Reviews), identification of issues in cases to which facility/agency are required to respond in writing (see Written Responses), and training of OIG and facility/agency staff (see Training).

During FY 2006, OIG:

Received 2,339 allegations of abuse/neglect, nearly seven percent more than last year, as well as 155 deaths (see Allegations Reported);
Closed 2,238 allegations, substantiating 14.4% of these compared to a substantiation rate of 13.5% in FY 2005 (see Cases Closed); and
Referred 83 employees' names to the Department of Public Health's Nurse Aide Registry because of substantiated findings of physical abuse, sexual abuse, or egregious neglect, thereby effectively preventing them from working in any direct service setting in Illinois (see Nurse Aide Registry).

Chapter 1 - System Improvement through Collaboration

The Office of the Inspector General (OIG) within the Illinois Department of Human Services works collaboratively with the Department, its facilities and licensed/funded community agencies, other State agencies, local social service and law enforcement agencies, private entities and individuals to prevent abuse and neglect of individuals with mental and physical disabilities.

OIG was initially created in March 1988 following passage of the Abused and Neglect Long Term Care Facility Residents Reporting Act in August 1987. The law granted OIG the authority to investigate allegations and conduct annual unannounced site visits to State-operated facilities providing mental health or developmental services. OIG continues to work jointly with facility staff and management to prevent abuse and neglect.

In 1995, OIG's statutory authority to investigate was specifically extended to programs operated by community agencies that are licensed, certified, or funded by the Department to provide those services. OIG does not conduct unannounced site visits at agencies as it does at facilities. However, in both settings, OIG is statutorily required to follow-up to ensure that actions taken to correct problems are actually implemented.

In 1999, the General Assembly and Governor again extended OIG's authority to investigate to include private homes, or "domestic" settings, beginning in July 2000. In domestic settings, the law limited OIG's scope to individuals between 18 and 59 years of age, but expanded it to include individuals with physical disabilities. OIG works closely with local law enforcement, medical, and social service entities to connect individuals to needed services even where abuse or neglect cannot be administratively proven.

Rule 50 and Rule 51

Two administrative regulations govern the reporting and investigating of allegations of abuse or neglect within OIG's jurisdiction. Each was developed with the involvement of many stakeholders and other interested parties.

The first is officially designated Illinois Administrative Code, Title 59, Chapter I, Part 50, but is commonly referred to as Rule 50. It describes types of abuse as defined by statute - physical injury, sexual abuse, and mental injury - as well as repeating the definition of neglect. It requires reporting of allegations, along with specific information about the people and the alleged incident, within four hours. Deaths also need to be reported to OIG; but if there is no allegation or suspicion of abuse or neglect, they must be reported within 24 hours.

The second is Illinois Administrative Code, Title 59, Chapter I, Part 51, and known as Rule 51. This rule repeats the statutory definitions and requirements: the person must be between 18 and 59 years of age, reside in a domestic setting, have a disability that impairs his/her ability to seek help, and consent to OIG doing an investigation.

Organization

OIG is organized primarily along functional and geographic lines.

The Bureau of Intake and Assessment manages the OIG Reporting Hotline (1-800-368-1463), which averaged 1,200 calls each month during FY 2006. Intake investigators complete intake forms on the calls that allege abuse/neglect or report a death and email those forms to the appropriate investigative bureau. OIG's Hotline is located in Springfield and is answered 24 hours a day, seven days a week.

Investigative assessment of alleged domestic abuse, neglect or exploitation (Rule 51 cases) are handled by the Adults with Disabilities Abuse Project. This bureau covers the entire state of Illinois but has two investigators stationed in Springfield and two in the Chicago suburb of Hines. An Investigative Team Leader, stationed in Rockford, also handles a caseload.

Investigations of alleged abuse/neglect of individuals in DHS's mental health centers (MHC), developmental centers (DC), and community agency programs (Rule 50 cases) are currently divided into four geographic bureaus.

The North Bureau covers 20 counties in northern and northwestern Illinois and the northern third of Cook County. The bureau has investigative jurisdiction over four DHS facilities: Singer MHC (Rockford), Elgin MHC (Elgin), Mabley DC (Dixon), and Kiley DC (Waukegan), and 1,853 program locations operated by community agencies.

The Metro Bureau covers the southern two-thirds of Cook County along with eight other counties south and southwest of Cook. The bureau has investigative jurisdiction over seven DHS facilities: Chicago-Read MHC (Chicago), Madden MHC (Hines), Tinley Park MHC (Tinley Park), Howe DC (Tinley Park), Ludeman DC (Park Forest), Shapiro DC (Kankakee), and Fox DC (Dwight), and 1,841 program locations operated by community agencies.

The Central Bureau covers 46 counties in central Illinois, from Knox to St. Clair. The bureau has investigative jurisdiction over three DHS facilities: Jacksonville DC (Jacksonville), McFarland MHC (Springfield), and Alton MHC (Alton), as well as 1,401 program locations operated by community agencies.

The South Bureau covers 27 counties in southern Illinois. The bureau has investigative jurisdiction over four DHS facilities: Murray DC (Centralia), Choate DC (Anna), Choate MHC (Anna), and Chester MHC (Chester), as well as 647 program locations operated by community agencies.

The Bureau of Compliance and Evaluation handles a wide variety of OIG's other statutory responsibilities, information management, and support for OIG. Statutory responsibilities include: unannounced site visits to facilities; Community Agency Investigative Protocol authorization; Written Response status report monitoring and Compliance Reviews; Nurse Aide Registry reporting; and FOIA requests. The bureau maintains OIG's comprehensive database, runs reports, conducts special studies, handles inventory control, manages an electronic Case File Repository, maintains the OIG intranet site, and provides training.

Quality Care Board

The Quality Care Board was initially authorized in 1992 (P.A. 87-1158) to "monitor and oversee the operations, policies, and procedures" of OIG to ensure that its abuse/neglect investigations are prompt and thorough. The Board may provide consultation on OIG policies, protocols, review regulations, advise on training, and recommend ways to improve OIG's intergovernmental relationships.

The law provides that the Board is to have seven members, appointed by the Governor with advice and consent of the State Senate. The Board members must be qualified by professional knowledge or experience in the areas of law, investigatory techniques, or the care of those with mental illness or developmental disabilities. At least two must either have a disability or have a child with a disability. The members are unpaid but may be reimbursed for travel and other relevant expenses.

Current Board members are:

Rita Ann Burke (Makanda), appointed July 8, 2005;
Thane A. Dykstra (Joliet), appointed July 8. 2005;
Nathaniel Gibson (Springfield), appointed June 29, 2005;
Keith W. Kemp (Chicago Heights), appointed June 24, 2005; and
Brian Neal Rubin (Buffalo Grove), appointed June 24, 2005;

The remaining two Board members have been selected but had not yet received final approval as of the end of June 2006.

As specified in the law, the Board meets once each quarter. During FY 2006, the Board met on October 12 and December 7, 2005, and February 22 and May 3, 2006.

Issues the Quality Care Board discussed in FY 2006 included:

Reporting of allegations - Some community agencies have reported no, or very few, allegations of abuse or neglect. To ensure that this is not due to a lack of reporting, the Board recommended that agencies be required to train all staff, contractors and volunteers in reporting. OIG has taken a number of steps on these issues (see Chapter 3).
Video cameras - A few facilities have installed (or are considering) video cameras in common areas, such as hallways and dining rooms, which may both prevent incidents and provide evidence in supporting or against allegations. Some Board members questioned the appropriateness of these video cameras. Their concern was that the video cameras may infringe on the individuals' privacy and interfere with the goal of maintaining a normal living environment. The discussion is ongoing.
Timeliness of investigation - The Board members also discussed timeliness of OIG's investigations, especially in cases where employees are on paid time off pending the investigatory outcome. OIG monitors timeliness very closely and has been taking steps to shorten the time frames while not affecting quality (see Chapter 3).
Registry appeals - OIG staff discussed the process through which employees appeal to prevent having their names referred to the Nurse Aide Registry. At the appeal hearing, the administrative law judge determines whether the employee's conduct warrants reporting to the Registry. Board members asked about appeals where employees had won. OIG staff noted that the administrative law judge has discretion to make such rulings and that OIG works closely with the DHS Office of Legal Services to respond to all appeals.
Background checks - One Board member noted that, under current law, community agencies are required to conduct criminal background checks on employees, but only in State records, not federal records. Thus, background checks are not required for any prospective employee who moves from another state. The Board suggested that legislation be proposed to resolve this issue.
Police officer training - The Board members expressed an interest in what training is offered to police officers regarding how to approach individuals who have developmental disabilities or mental illness. An administrator from the Division of Mental Health responsible for training law enforcement spoke to the board about its program. Examples of other successful training were an initiative by the National Alliance for the Mentally Ill of Greater Chicago with the Chicago Police Department and with the Kane County Sheriff's office were also discussed.

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/neglect in community agencies and state facilities. Standing members of the workgroup include the following, although other stakeholders, such as advocacy groups and associations, may be invited when appropriate:

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

Issues discussed by the OIG Program Coordination workgroup during FY06 have included the following:

Promotion of Rule 50 training for new hires and refresher courses for staff, volunteers and contractual workers in community agencies and facilities using an updated computer-based training module on Rule 50, which has allowed agencies and facilities to more easily provide in-house training;
Distribution of a new handbook on Reporting Abuse and Neglect of Adults with Disabilities - This handbook ensures that persons know what to report, when to report, and how to report abuse and neglect;
Review of reports on abuse and neglect statistics and actions taken;
Consensus on abuse and neglect policy recommendations;
Development of a new First Responder's training for supervisors, managers, and direct care staff, which was created and presented beginning in the fall of 2005 - This training is designed to identify important functions of and provide direction to those initially responding to possible incidents of abuse and neglect; and
New laws affecting OIG investigations and the implications for community agency and facility staff.

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 collaborate with DHS operations administrators and facility administrative staff to address issues of safety within the facilities.

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.

Office of Executive Inspector General

OIG also serves as DHS's liaison to the Office of Executive Inspector General under the Governor, pursuant to the Governor's Executive Order 3 and Administrative Order 6. As liaison, OIG forwards to the Office of Executive Inspector General any reports of alleged employee misconduct received from DHS management or through OIG's Reporting Hotline. Additionally, the Office of Executive Inspector General may ask OIG to gather information from DHS as part of investigations or inquiries that office may be conducting.

Chapter 2 - System Improvement through Legislation

During FY 2006, several OIG-initiated pieces of legislation were enacted. These laws seek to prevent abuse/neglect, ensure reporting, improve OIG's capacity to investigate, and facilitate cooperation with other administrative and criminal investigative entities.

Four of these were passed during the General Assembly's Spring 2005 session and signed in August 2005, after the start of FY 2006. Four others were passed during the Spring 2006 session and were signed in June 2006, before the end of the fiscal year. A ninth was passed during the Spring 2006 session, although it was not signed until shortly after the end of the fiscal year. Five of the nine new laws address alleged abuse/neglect at agencies or facilities; the other four address domestic abuse/neglect/exploitation.

Below are the nine new laws and an actual case from FY 2006 that is an illustrative example where this new law did or would have improved the system and helped prevent abuse and neglect.

Required Reporting

Public Act 94-853 (signed and effective June 13, 2006) makes it a Class A misdemeanor for a facility or community agency employee (including a volunteer or contractual staff) to intentionally report an abuse/neglect allegation late or not at all. These employees are already required to report allegations to OIG.

Example:

An employee, after being discharged for physical abuse, alleged that she had witnessed another employee yell and scream at an individual a year and a half before. OIG could not substantiate the allegation because neither the alleged victim nor the accused employee could recall any such incident occurring. Rule 50 mandates allegations be reported to OIG within four hours and facility/agency policies usually require immediate reporting. However, the law has not provided for any penalties, even if the delay is the primary reason for the inability to substantiate the allegation. With the new law, employees, volunteers, contract workers, and subcontractors who intentionally fail to report allegations of abuse or neglect may be charged with a Class A misdemeanor.

Sexual Conduct Felony

State's attorneys have sometimes declined to prosecute employees who had sex with individuals despite clear and convincing evidence that the incidents took place. They cited two main reasons. First, they thought that jurors might perceive the individuals as being able to legally consent despite their disabilities. Second, they thought it was not clearly illegal - state law bars prison guards from having sexual contact with inmates, but no law specifically applied to mental health or developmental disability programs. OIG sought to address these issues in a new law.

Public Act 94-1053 (signed and effective July 24, 2006) makes it a Class 3 felony for any facility or community agency employee to knowingly engage in any sexual contact with a person who has a disability and is receiving residential services in the facility/agency, whether it was consensual or not. It does not apply if the employee was already married to the person or was unaware (and had no reason to know) the person was receiving services. In addition, the law now requires that a convicted person register as a sex offender and is prohibited from employment in any health care setting.

Example:

A facility employee had allegedly forced a female resident to have sexual intercourse with him on two occasions. The alleged victim, who has very limited communication ability, initially indicated that the employee had raped her, then indicated it did not occur, and finally indicated that it had happened but she did not want to get him into trouble. The individual was examined by a specially trained nurse and a rape kit was completed. The individual's clothing had DNA evidence confirming sexual intercourse with the accused employee. As a result, the employee was discharged for sexual abuse. With the new law, even if reportedly consensual, the act could be considered a Class 3 felony; however, this case occurred early in the fiscal year, before the law became effective.

Notifying Law Enforcement

Public Act 94-428 (signed and effective August 2, 2005) allows OIG to notify the appropriate law enforcement entity of possible criminal acts at community agencies, rather than always calling the Illinois State Police. OIG is still required to notify law enforcement within 24 hours of determining that a reported allegation may involve a criminal act.

Example:

OIG received an allegation that a 60 year old woman, who had been diagnosed with a mental illness and a developmental disability, had been fondled over her clothing on the breast by a male community agency employee. With the new law, OIG was able to refer the allegation directly to the local police agency that had jurisdiction, rather than to the Illinois State Police. The local police conducted an investigation and could not get to the level of proof required for a criminal conviction. OIG then conducted an administrative investigation, re-interviewing all the witnesses, but was unable to get to the preponderance level needed to administratively substantiate the allegation.

Domestic Abuse Program Guardianship

Public Act 94-418 (signed and effective August 2, 2005) requires OIG to seek guardianship when the alleged perpetrator in a Domestic Abuse Program case is the guardian and there is an "immediate and urgent necessity" for a temporary substitute, rather than in every case where the guardian is the alleged perpetrator.

Example

An individual was reportedly found lying in a urine-soaked bed, her hands and legs tied to the bed by cloth and belt restraints. During the OIG investigation, the guardian admitted to tying her daughter in bed when she became aggressive and too hard to handle, as well as at night to prevent her from getting up. OIG found the home had a strong smell of urine and had animal feces of the floor. The individual had an extremely offensive body odor and wore a dirty smock. OIG also noted that the individual had a cut on the top of her head, which had not been treated. When OIG asked the guardian why, although she received more than $200 per day to provide care, she had not sought medical attention for her daughter, the guardian said she did not have enough money for car fare. OIG contacted the Office of State Guardian to begin pursuing guardianship. OIG also substantiated physical abuse and neglect by the guardian and, through a local pre-admission screening agency, immediately secured a safe placement for the individual.

Financial Information

Public Act 94-495 (signed and effective August 9, 2005) allows financial institutions like banks to give information to OIG - and to the Illinois Department on Aging, public guardians and law enforcement - if the investigator or the institution has any suspicion that a customer has been or may become a victim of domestic financial exploitation.

Example:

Four adults with developmental disabilities had reportedly been left without someone to care for them when their father died. An uncle had secured power of attorney over the four but had allegedly failed to provide adequate care for them. OIG found that the four were living in an unfit home: it did not have running water or gas; it had electricity but no fans or air conditioning; it was dirty and cluttered; and none of the appliances worked, so they were unable to bathe, wash their clothes, cook or keep food from spoiling. The uncle reportedly would drop off sandwiches, pizza and other types of prepared foods, but had done little to improve the condition of the home despite receiving over a thousand dollars each month from Social Security on their behalf. He also had control of the trust fund that their father had left them. OIG secured emergency placement for the four and sought permanent guardianship through the Office of the State Guardian. With the new law, OIG was able to get financial documents from the bank during the investigation, preventing any further exploitation of the four individuals by their uncle.

Financial Agents' Records

Public Act 94-500 (signed and effective August 9, 2005) requires someone who is an agent (guardian or otherwise acting for a person who is incapacitated) to give records of all financial actions he/she took as the agent, if OIG requests them for a Domestic Abuse Program investigation.

Example:

OIG received an allegation of financial exploitation of a 45 year old individual who has a developmental disability. The caller alleged that the individual's financial guardian, who had power of attorney, was getting two Social Security checks ($149 and $469) each month on behalf of the individual, yet was not providing for the care or paying any of the bills for the individual. When asked by OIG, the caller provided financial documents from the bank, court proceedings, and notices from Social Security. Not only was OIG able to find that the financial guardian had been exploiting the individual, but OIG determined that he had been protecting the individual from exploitation by his parents. That is, the individual had received a $200,000 settlement from a car accident, yet his parents had spent all that money and were trying to charge him for living expenses. OIG was instrumental in getting a van and a mobile home put in the individual's name, since his money had been used to purchase them. Further, his parents will be able to get reimbursed for expenses incurred in providing care for the individual only with proper receipts. With the new law, OIG can obtain financial records in cases such as this without having to depend on voluntary compliance by financial agents.

Subpoenas and Confidentiality

Public Act 94-851 (signed and effective June 13, 2006) allows OIG's Domestic Abuse Program (DAP) to issue subpoenas for potential witnesses and records. It also says that any financial records obtained during the DAP investigation are confidential and may only be released with the consent of the victim/guardian or in response to a court order or a subpoena.

Example:

A woman discovered that her sister had nearly $9,000 in charges on her credit card, including items for a car, even though her sister had been unable to drive since a stroke and her license had been revoked due to her dementia. The woman reported this concern to the local police, who investigated. They found that the alleged perpetrator was a friend of the victim's daughter, who claimed that her friend had given her the credit card number to use. The alleged perpetrator had charged over $30,000.00 in goods and services, including a new car, which she had later totaled. This allegation occurred before the new law was passed, but the local police had already obtained credit card records and the contract to purchase the vehicle, and so OIG was able to obtain copies from them. With the new law's subpoena power, if the local police had not been involved first, OIG would have been able to get the financial records and give them to the police to pursue criminal charges.

Licensed Professionals

Public Act 94-852 (signed and effective June 13, 2005) allows disclosure of OIG's Rule 50 investigative reports to the Illinois Department of Financial and Professional Regulation for that department's investigation of licensed professionals. In addition, the law also allows verbal disclosure of the Domestic Abuse Program's investigative finding, as well as any subsequent referrals, to a licensed professional who made the initial allegation to OIG.

Example:

OIG received an allegation that a licensed practical nurse (LPN) had verbally and physically abused two individuals during mammography exams at a local hospital. Two hospital technicians stated that they had witnessed the LPN yelling, grabbing and shoving one of the individuals. They also stated that, when she was taking the individual out of the room in a wheelchair, she became frustrated and jammed the individual's knee into the metal door frame. They denied having seen the LPN abuse the other individual. Consequently, OIG substantiated both verbal and physical abuse by the LPN. With the new law, OIG was also able to notify the Department of Financial and Professional Regulation of the findings, facilitating that department's investigation of the LPN as a licensed professional.

Registry Reporting

Public Act 94-934 (signed and effective June 26, 2006) fills a void by including owners / operators of a community agency to the employees who may be referred to Illinois Department of Public Health's Nurse Aide Registry. This prohibits them from being involved in any way in providing services. In addition, the law clarifies that a union member cannot be reported to the Registry until his/her 50.90 appeal is concluded.

Example:

No allegation involving an owner or operator of a community agency was substantiated during FY 2006. In an earlier case, a physician-owner of an agency was found to have bitten an individual on her right arm and back, and OIG referred her name to the Registry. However, she continued to work with individuals. She claimed that, since she was the owner and not an "employee" of the agency, the law that required listing employee perpetrators on the Registry did not apply to her. So, she continued to have contact with other individuals receiving services. With this new law, OIG would have been able to report her to the Registry, effectively removing her from direct services.

Chapter 3 - System Improvement through Development

OIG continues to develop improvements to its system. During FY 2006, OIG created and implemented several actions to improve the reporting, investigating, and responding to allegations of abuse or neglect.

Non-Reporting

Staff of facilities and community agencies are required by Rule 50 to report to OIG allegations of abuse/neglect of individuals receiving direct services. During FY 2005 and FY 2006, OIG recognized that many agencies had reported no allegations of abuse/neglect at their programs since at least May 2002, the date of the last Rule 50 revision. OIG took significant steps toward reducing non-reporting.

On August 2, 2005, OIG mailed a clarification memo to the facilities and agencies, reiterating the definitions for allegations of mental injury and neglect and clarifying what is reportable under those definitions.
Also in August 2005, OIG printed and sent to agencies and facilities a handbook on reporting and investigating abuse/neglect, to encourage reporting. OIG continues to distribute copies of this handbook at OIG-conducted trainings and upon request.
OIG has notified the DHS program divisions of this issue, and the divisions re-enforced with the agencies the requirement for reporting.
OIG added another training course, entitled "First Responder," and now conducts four external training courses: Rule 50, First Responder, Basic Investigative Skills, and Investigative Skills Refresher.
For FY 2006 unannounced site visits at facilities, OIG looked at a sample of injuries and non-reportable incident forms at the facility to find indications of under-reporting. As noted in the next chapter's section on site visits, no such indications were found.
In December 2005, OIG created a self-contained Rule 50 training module and put it into the DHS electronic learning database. OIG then e-mailed this module to facilities and community agencies in February 2006.
On March 10, 2006, OIG sent a non-reporting letter to each agency that had not reported any allegations of abuse or neglect in its programs, requesting a copy of the agency's reporting policy and confirmation that staff had been trained.

Non-reporting is difficult to show and impossible to measure: allegations that OIG never receives cannot be counted. However, agencies and facilities self-reported 50% more allegations during FY 2006 than during FY 2004 (1,509 to 1,010), which shows significant improvement.

Timeliness of Initial Reporting

Administrative Rule 50 requires that facilities and agencies report every abuse/neglect allegation 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 reporting in a variety of ways.

During intake, when an agency or facility calls the OIG Hotline to report an allegation ("self-report"), OIG's Intake investigators ask when the allegation was discovered by staff. If the allegation is not reported timely, the caller is given an opportunity to provide the reasons for the lateness.

The database also automatically compares the date/time of discovery to the date/time of the intake. If a self-report is late, the intake will have "Case was reported late" automatically printed on the intake form that is sent to the investigative bureau. If the date or time of discovery is not specific and the database can only determine that it may have been late, "Check for late reporting" automatically prints. The OIG investigative bureau can then follow up during the investigation.

The OIG investigative bureaus 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.

Each month, OIG sends to the DHS program divisions a list of cases that were reported late. Those divisions can then follow up with the facilities and agencies that have been reporting late to OIG. This monthly list identifies each late allegation, along with the date/time it was discovered and the date/time it was reported to the OIG Hotline.

Finally, OIG discusses late initial reporting at meetings of the OIG Program Coordination workgroup, which meets regularly to discuss issues important to the prevention of abuse/neglect.

As a result of the proactive steps, the timeliness of initial reporting has significantly improved. Over the past four fiscal years, fewer self-reports have been late:

25% (295 of 1,161 self-reports) in FY 2003;
23% (228 of 1,010 self-reports) in FY 2004;
18% (261 of 1,413 self-reports) in FY 2005; and
17% (259 of 1,509 self-reports) in FY 2006.

Further, in FY 2006, well over half of the late reports (58%) were only one day or less late.

Late reporting continues to be a more significant problem of the community agencies than the facilities. Of the 259 late "self-reports" received during this fiscal year, 208 (80%) were from agencies. Further, those 208 represented 28.1% of the agency self-reports, while only 6.6% of the facility self-reports were late. As noted on the previous page, OIG continues to work with agencies and facilities to improve reporting.

Case Management

During FY 2006, OIG's Automated Case Tracking System became an even more integral part of the management of investigative cases in OIG.

Investigative Plan - Beginning July 1, 2005, OIG requires all its investigators to use a standard investigative plan document, initially produced by the database. The goal of the plan is to ensure adequate and timely development of each investigation by building in quality from the start. The investigative plan accomplishes this by providing for immediate supervisory review of each intake and identification of all interviews and documentation initially relevant to the case. Further, by keeping the investigative plan a "working document," the investigator and his/her supervisors can respond to developments in the case, adjusting the plan as needed.
Investigative Case Actions - Immediately prior to the start of FY 2006, OIG developed and implemented a method of recording in the database steps in the investigation. This process improves the individual investigator's management of his/her caseload and the investigative supervisor's tracking and oversight of all open investigations. During FY2006, the number of pre-defined steps has grown, as the database has responded to investigative needs.
Evidence Forms - Occasionally, OIG collects physical evidence on a case. The forms for chain of custody and storage of the evidence were automated, so that the database can now more readily track and locate where evidence has been delivered or is stored.
Daily Report - OIG has an internal daily case management report that looks at various types of currently open cases as of the close of the previous day. Examples include counts of cases by type of allegation or by bureau, counts of cases where staff are on paid administrative leave, and counts of older ("backlogged") cases by investigator. During the fiscal year, this report was modified to run faster and to count all older cases.
Case Report Forms - OIG simplified the standard investigative case report blanks and moved them to a location that makes them easier to access and use.
Letter Processing Address Form - OIG also automated the internal form used for sending notification and findings letters on investigative cases. Previously, the investigators had to handwrite these forms; now, they are printed automatically and the investigators only need correct errors. Not only does this make creating letters easier, but it helps ensure that the database has correct addresses.
Unfounded Allegations at Intake - Individuals sometimes allege abuse/neglect but then immediately deny it, claiming they were just angry or upset. Previously, if that happened, OIG still went through the full case distribution and assignment process. Near the end of FY 2006, OIG began a simplified process: OIG's Intake investigator directs investigatively trained agency/facility staff to gather evidence and, when this is received, prints a case report from the database. This way, OIG avoids the administrative steps of assigning the case to a field investigator, developing an investigative plan, and re-writing a case report - these unfounded cases get done more quickly and easily.

Intranet Pages

In addition to an internet website, DHS has an internal internet ("intranet") for its staff and calls this intranet "OneNet" to emphasize the entire department working together as one for the benefit of the people in Illinois. OneNet includes such things as a searchable directory of all DHS staff, links to other DHS offices, all DHS Administrative Directives and forms, an Employee Handbook, announcements, relevant forms published by the Department of Central Management Services, and other information helpful for conducting State business.

OIG has further developed its part of the DHS OneNet. During FY 2005, OIG had made the following changes to OneNet:

An internal phone directory with cell phones and pager numbers;
Relevant Illinois laws and administrative rules;
OIG Directives;
Published documents, such as OIG's annual report, a brochure, and a handbook on the reporting of abuse/neglect;
Links to map directions; and
Instructions for encrypting e-mails.

During FY 2006, OIG continued development of its OneNet pages. OIG verified that all the OIG Directives were updated and also added:

Links to the Executive Office of the Inspector General's reporting forms and directions on how to use them;
The OIG database user's manual;
National investigative standards;
OIG investigative case report formats;
Additional forms, including those for recording DHS inventory transfers and for requesting and record training; and
Training courses on Rule 50 and responding to FOIA requests.

In FY 2006, OIG also updated its internet site including Quality Care Board meeting announcements, a Rule 50 training module, updated the training calendar, new training registration forms and procedures, and information about the new Inspector General.

Since OIG has offices in at least fifteen cities around the state, OneNet provides a way for staff to connect to needed and current information. OneNet allows OIG staff to complete investigations and other statutorily mandates more easily and quickly.

Timeliness of Investigation

Rule 50 expects that, absent exceptional circumstances, OIG's investigations should be completed in 60 working days or less. Through efforts such as new legislation, improved case management, and additional information on OneNet, OIG has worked to make investigations and their management better.

In FY 2006, OIG completed its Rule 50 investigations faster than the required 60 days. 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 53 days per case, which is slightly above FY 2005's average of 48 days per case.

During FY 2003, OIG's Rule 50 investigations took an average of nearly 60 days per case and, during FY 2004, they averaged 85 days per case. Thus, the FY 2006 average of 53 days per case means that, for two consecutive years, OIG has averaged completing its investigations in well under the required 60 days per case.

Some steps that OIG had taken to improve investigations resulted in increased expectations for cases, and so lengthened the time it takes for OIG to investigate. In addition, the FY 2006 budget for OIG had two fewer investigative positions authorized than the FY 2005 budget and had three vacant positions for most of the year. OIG also lost four other investigators for lengthy periods due to leaves of absences. Yet, in FY 2006, OIG completed more investigations than the previous year and still averaged less than 60 days. OIG is doing more with less, fulfilling its timeliness while improving investigations.

Further, under the leadership of new Inspector General William M. Davis, OIG has re-emphasized these dual goals of completing cases quickly and appropriately. Early in his tenure, he led the investigative bureau chiefs in identifying effective steps that could be taken:

Intake completing investigations of recanted allegations;
Bureau chiefs using a task monitoring function within email to set time frames;
OIG completing unfounded cases more efficiently;
Investigators not interviewing individuals who have given apparently full initial statements or using telephone interviews;
OIG assigning more mental injury allegations to agencies to investigate;
Investigative bureaus closing unfounded cases by the bureau chief more often;
OIG obtaining short term clerical assistance; and
OIG's database tracking death cases separately from investigative bureau cases.

These steps have been implemented. The goal of further improvement in both the timeliness and the quality of OIG's investigations remains of prime importance.

Chapter 4 - System Improvement through Prevention

Unannounced Site Visits

OIG is statutorily mandated (210 ILCS 30/6) to conduct annual unannounced site visits to all eighteen DHS psychiatric hospitals and developmental centers. OIG is responsible for detecting potential causes of abuse and neglect with a goal of allowing facilities to take steps to prevent incidents from occurring.

The site visits focus on systemic issues that contribute to preventing abuse/neglect. In FY 2006, OIG reviewed nine issue areas, focusing on how facilities find, report, and correct problems before they rise to the level of abuse/neglect. OIG made 58 recommendations, most of which related to the following:

Training of staff on reporting abuse/neglect allegations;
Obtaining and addressing concerns of consumers; or
How the internal patient safety and human rights committees receive, analyze and record reports of complaints/allegations and outcomes of recommendations.

Site Visit Dates

In FY06, the site visits were conducted by a team consisting of two to three OIG staff, one of whom is a registered nurse (RN). OIG's FY 2006 unannounced site visits were as follows:

FY 2006 Site Visit Dates
Facility	Date
Alton MHC	August 25-26, 2005
Chester MHC	January 31, 2006
Chicago-Read MHC	November 28-29, 2005
Choate DC	July 26-27, 2005
Choate MHC	July 26-27, 2005
Elgin MHC	July 27-28, 2005
Fox DC	October 31, 2005
Howe DC	January 25-26, 2006
Jacksonville DC	December 20, 2005
Kiley DC	August 25-26, 2005
Ludeman DC	February 27-28, 2005
Mabley DC	September 27-28, 2005
Madden MHC	December 28-30, 2005
McFarland MHC	September 27-28 and November 2-4, 2005
Murray DC	March 14, 2006
Shapiro DC	November 29-30, 2005
Singer MHC	October 25-26, 2005
Tinley Park MHC	March 28-29. 2006

FY 2006 Site Visit Issues

The Site Visit Plan for FY 2006 addressed nine primary issues of concern, which are detailed below. The goal was to identify problem areas in how the facilities were finding concerns, reporting them as needed, and correcting them before they rose to the level of abuse or neglect. OIG also followed up on all recommendations from FY 2005 site visits, to ensure action was taken.

Site Visit Issue 1:
Nursing Overtime

Nurses who are mandated to work a double-shift or who are sent ("detailed") to work on a different unit than their regular unit may be at a higher risk of neglecting special needs of individuals. Thus, OIG reviewed the facility's use of overtime for nursing coverage, focusing on these two issues. Nursing overtime records and medication errors were reviewed for a three-month period.

In the records reviewed, no patterns or relationships were noted between nursing overtime and allegations cases reported or medication errors.

One medication error had occurred when the staff nurse pulled the wrong time tray. The recipient received his morning medication in the evening, and his evening medication in the morning, but suffered no ill effects. OIG recommended that the facility review the dispensing process to prevent such problems.

Another medication error occurred when a staff nurse accidentally pulled a double-dose of a medication from the Documed cabinet. The error was caught by standard check procedures on the unit, and the medication did not reach the individual. However, OIG found that the nurse had not followed proper procedures and that no physician's order was on profile for the individual to receive that medication. Further, in an earlier investigation, OIG had recommended the facility improve the procedures for using the Documed cabinet. Thus, OIG recommended that the facility take more substantial actions to correct use of the Documed cabinet.

Site Visit Issue 2:
Injuries to Individuals

Injuries inflicted by another individual or that occur during restraint or other staff involvement might be suspected to have occurred due to neglect or abuse by employees. OIG reviewed all the injury reports for these two types of injuries during a three-month period.

Two injuries were alleged to be from abuse/neglect. One was not initially alleged to have been the result of abuse by staff; when it was, the allegation was investigated by OIG and found to be unsubstantiated. In the other case, an employee had failed to fasten the safety belt when putting an individual into a wheelchair; the individual fell and cut his head. OIG did not substantiate abuse/neglect, but the employee was given additional training on preventing injuries.

No other injuries appeared to have been due to abuse or neglect, and the medical response appeared to have been adequate. In addition, the facilities all conduct administrative reviews of all injuries, to identify instances that may be suspicious for abuse or neglect by staff. OIG provided no other recommendations on this issue.

Site Visit Issue 3:
Shift Communication

Lack of communication between shifts has been implicated in abuse/neglect cases in the past. OIG reviewed communication between nurses; that is how oncoming shift nurses and nurses detailed from another unit are told about patient needs and identification. OIG reviewed facility policies related to shift communication and expectations for nursing staff detailed from another living unit. OIG will follow up on this recommendation, as it does on all recommendations.

All of the facilities except one were found to have a formal written policy on shift communication. These policies appeared to be thorough and adequate. OIG recommended that the facility formalize shift change communication in written policy to ensure the staff are fully aware of their duties and responsibilities associated with the care of the individuals for whom they are responsible.

Site Visit Issue 4:
Patient Safety Initiative

OIG reviewed a patient safety issue that was identified by the facility as an issue on which they took substantial action to reduce the potential for abuse or neglect.

Three facilities identified improvements to the physical buildings: locks on bathroom doors and cleaning supply cabinets, and repair of back-up generators. Seven facilities identified administrative initiative: changes in staff notification or medication ordering procedures, and violence prevention programs.

The remaining nine facilities identified treatment related issues. These included:

implementation of a new policy or form regarding injury reporting;
a focus on contraband searches; and
improved patient supervision procedures.

OIG commended two facilities for their initiatives. One facility identified a new requirement for physicians to write all medication orders using generic names, which reduces the risk of errors. The other facility established an extensive process to evaluate its entire medication management system. This initiative should also have a substantial impact on reducing medication errors and improving overall patient safety.

OIG made recommendations regarding the implementation of these initiatives. OIG recommended the use of current year data as a baseline for measuring improvements. OIG recommended another facility use the OIG Rule 50 training module as an annual requirement for all staff.

Site Visit Issue 5:
Contraband Policies

Illegal drugs and weapons are generally prohibited, but glass bottles and sharp items also pose a substantial safety risk. OIG reviewed the facility's policies and practices relative to all these items ("contraband") on living units.

All mental health facilities had a formal policy covering contraband, although two did not provide clear definitions of contraband items. OIG recommended that these policies be revised and that another facility's policy provide more detailed information on how to dispose of contraband. OIG also recommended training in the policy at another mental health facility.

OIG commended two mental health facilities for their comprehensive policies and their efforts at clearly identifying contraband for the staff, individuals, and visitors.

Few developmental facilities had a formal policy covering contraband, although all had policies related to weapons, intoxicants and illegal narcotics and noted that the DHS Handbook prohibits these items. Staff interviewed at one facility did not have a clear understanding of contraband items, and OIG recommended that the facility train its staff in this area.

One facility had had problems with contraband related to the recent ban on smoking. OIG offered several recommendations: revising unit rules to include increased supervision of offenders, posting unit rules so visitors are aware of them, developing a smokers' support group, and holding more unit meetings to discuss the issues.

Site Visit Issue 6:
Abuse/Neglect Training

Inadequate training has been cited as a cause of substantiated abuse/neglect and as a necessary step in preventing recurrence. OIG reviewed the training of facility employees, both in new employee orientation and in ongoing refresher training, in the definitions and reporting requirements of OIG Rule 50.

One facility had no internal facility policy on reporting and investigating abuse/neglect, utilizing only the DHS policy and Rule 50. OIG recommended that the facility develop an internal policy, describing how the requirements were to be implemented at the facility.

OIG recommended that two other facility policies be revised to include the time requirements for reporting, as these were currently not mentioned in the facility's policy. OIG also recommended that the staff then be trained in the appropriate reporting time frames.

Six facilities had no requirement for ongoing or refresher training in identifying and reporting abuse and neglect. OIG recommended that these facilities train their staff at least biennially. OIG also suggested that the facility use the OIG-developed Rule 50 training module distributed during FY 2006 for this training.

Finally, OIG recommended that one facility establish in policy its practice of reviewing abuse and neglect allegations on a regular basis for prevention issues.

Site Visit Issue 7:
Non-Reportable Complaints

OIG reviewed the facility's handling of non-OIG-reportable complaints -- specifically, those recorded on security incident reports and unauthorized absence forms -- to ensure underlying problems are addressed before they worsen and rise to the level of abuse or neglect.

All incidents that were reviewed during the site visit were correctly not reportable to OIG. At one facility, one incident was not reviewed by the Incident and Injury Review Committee; OIG recommended that they all be reviewed.

OIG also noted that the systems at two facilities lacked adequate documentation of appropriate follow-up by the internal review committees. OIG recommended that these be more thoroughly documented.

Relatedly, OIG recommended that two other facilities consider writing a short narrative on internal forms that shows the resolution of the occurrence.

Site Visit Issue 8:
Complaint Resolution

Patient safety concerns and human rights complaints may identify issues that, if left unresolved, may worsen and result in abuse or neglect. OIG reviewed how the facility's internal patient safety and human rights committees receive and analyze complaints and document outcomes of corrective actions.

OIG found that ten facilities had committees that function well and are consistent in following up on unresolved issues and identifying outcomes. OIG recommended that the remaining facilities address problems identified during the site visit: no meetings or missing meeting minutes due to staffing problems; and lack of thorough follow-up or resolution of issues raised.

One facility had developed but not yet implemented a consumer complaint process. OIG recommended the facility implement it as soon as possible.

Notably, one facility had, upon the recommendation of the Human Rights Committee, revised the Patient Handbook with substantial input from individuals at the facility.

Site Visit Issue 9:
Consumer Perspective

Individuals provide a different perspective on services provided by the facility. OIG reviewed results of patient surveys on violence and on patient care to identify issues that, from a consumer perspective, may be precursors to allegations of abuse or neglect.

OIG found that one facility had not conducted a patient survey in FY 2005 and another had not conducted one since FY 2003. OIG recommended that these two facilities conduct patient surveys on at least an annual basis. For facilities that conducted surveys only on discharge, OIG recommended that surveys be done of individuals while still at the facility as well.

Survey completion rates varied from facility to facility. OIG recommended that facilities with low return rates make efforts to increase participation and, based on other facilities' experiences, OIG gave some specific examples of how this might be accomplished.

One facility had a 100% return rate, since residents and guardians complete the surveys during their annual review. Another facility had a high rate of completion because staff complete the surveys when individuals and/or their guardians are unwilling or unable to do so. OIG recommended that this facility increase individual participation, rather than risk inflating scores by having staff complete them.

Finally, OIG recommended that four facilities review identified problem areas, to see if there are any issues from a consumer perspective that might relate to abuse/neglect.

Conclusion:
Summary of Trends or Patterns

OIG site visitors looked for trends or patterns across the facilities or from year to year. Few facilities had repeated problems in areas where OIG had made recommendations during the FY 2005 site visit. OIG recommended that these issues be addressed promptly. The FY 2007 site visit protocol will also include specific follow-up to prior recommendations to ensure actions are taken to reduce abuse and neglect at facilities.

OIG's unannounced site visits are an integral part of the system improvement activities through which OIG seeks to prevent abuse and neglect.

Annual Investigative Authorization Review

Rule 50 grants OIG the right to accept an abuse/neglect investigation conducted by a community agency, but only on three conditions.

First, OIG must have previously authorized the agency to conduct investigations that fiscal year. This process requires the community agency adopt the "Investigative Protocol for Community Agencies" written by OIG, agree to adhere to those standards, and formally request authorization. The authorization process is done annually, to ensure a regular review of each agency.

Second, OIG must have assigned that particular case to the agency for investigation. An agency is allowed to conduct an investigation into an allegation of abuse/neglect only upon OIG assigning that case to the agency.

Third, the agency employee who is assigned as investigator to the case must previously have been trained and approved by OIG to conduct investigations. The employee must have:

Successfully completed OIG training in Rule 50 subsequent to January 1, 2002;
Successfully completed OIG training in investigative skills within the past three years;
No appearance of a conflict of interest, such as being executive director, assistant executive director, human resource director, member of a collective bargaining unit, or a family member of any of those; and
Been listed for approval as an investigator in the agency's annual authorization request, or, if trained later, the agency must have formally requested OIG approval of the person as an investigator.

Further, Rule 50 currently requires OIG to take primary responsibility for all investigations of physical abuse, sexual abuse, or neglect with a serious injury. Thus, although OIG may ask agency investigators to collect evidence or handle part of the investigation, such as interviews, agencies may conduct investigations only into allegations of mental injury or neglect without a serious injury and only upon specific approval by OIG.

Protocol Update

For FY 2006, OIG updated two sections of the Investigative Protocol for Community Agencies to clarify the requirements for reporting and investigating contained in Rule 50.

To assist OIG in reviewing the agency's applicants for approval as investigator, Section VII.A now lists required information the agency must submit. Specifically, it requires: the applicant's job title, responsibilities, and supervisor's name and title, to determine there is no appearance of a conflict of interest; the applicant's date of birth, for identifier purposes; and dates of training by OIG in Rule 50, Basic Investigative Skills, or the new Investigative Skills Refresher.

In addition, Section VII.F.4 of the Protocol now reiterates Rule 50's prohibition against an agency conducting abuse/neglect investigations without OIG's approval, although the agency may conduct investigations into internal matters such as policy violations.

FY 2006 Authorizations

At the start of FY 2006, a total of 386 community agencies were under OIG's investigative jurisdiction, but only 363 of them provided direct care to individuals. Of these, 129 agencies submitted requests and were authorized by OIG to investigate on a case-by-case basis.

The number of agencies authorized has been decreasing over the past few years: 191 in FY 2004, 184 in FY 2005, and 129 this past year. OIG attributes the decrease in authorizations to two main factors. First, OIG has increased the training requirements and the documentation necessary for applications. Second, Rule 50 limits the types of allegations that agencies may be allowed to investigate: only mental injury or neglect without serious injury.

OIG is developing ways to streamline the process and increase agency participation, such as notifying authorized agency investigators of training expiration dates on training certificates and identifying conflicts of interest in the Protocol.

Clinical Reviews

OIG has two registered nurses who are trained investigators and function as Clinical Coordinators. They investigate all deaths in Department-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 FY 2006, there were 51 deaths of individuals receiving services in a facility, or recently discharged from one. The leading causes of death were heart disease and pneumonia, followed by cancer, sepsis, and renal disease. No abuse or neglect was found in any of the deaths, but three of the deaths were notable.

In the first of these deaths, a coroner's jury reviewed a death at a facility from a bowel obstruction. The individual had adhesions from a previous surgery for a gunshot wound. The coroner's jury decided the manner of death was "undetermined." OIG made several recommendations to the facility for assessing bowel elimination by all individuals.
One death in FY 2006 was by suicide. The individual had diagnoses of major depression, alcohol abuse, antisocial personality disorder, and interpersonal problems. He reportedly had been experiencing anxiety about his girlfriend and grief over his mother's recent suicide. Upon admission, he had expressed thoughts of suicide by overdosing but denied a history of suicidal ideation or any attempts. He was placed on frequent observation, meaning staff checked on him every 15 minutes. After two weeks, a psychiatrist determined that he had responded well to treatment and so discontinued the frequent observation and declared him eligible for discharge. Before the order to discontinue the checks was communicated to all staff, the individual hanged himself in his bathroom. The OIG investigation found no evidence of abuse/neglect or issues of clinical concern.
One death was due to accidental choking; the individual choked on breakfast sausage. He had been transferred from one unit to another without his dietary orders being rewritten on the new unit. OIG's investigation found that sausage was allowed on the individual's diet, so neglect was not found. OIG did make recommendations that the facility ensure dietary orders are properly renewed and communicated to all dietary and direct care staff.

Deaths in agencies

During FY 2006, there were 106 deaths of individuals currently or recently receiving services in a community agency. Again, nearly all of the deaths were from natural causes, with heart disease, cancer, and pneumonia the most common causes. Neglect was substantiated in one death.

An employee took the individual to the hospital for treatment of an upper respiratory condition but left with him before an assessment and medical treatment was provided. The employee told other staff that the individual had been given treatment, such as cough syrup and extra fluids. The individual's condition worsened over the next few days, and he was sent back to the hospital; he died from pneumonia while en route. Egregious neglect was substantiated, and the employee was discharged and reported to the Registry.

Four suicides by individuals receiving services from community agencies were reported in FY 2006. The four cases revealed no issues of abuse or neglect, but one raised clinical issues.

An individual had recently been discharged after several months in a facility for treatment of schizophrenia. The agency's plan was to transition her from the facility to a group home and then to an apartment. However, she was found dead in her apartment several days after discharge. The investigation revealed that she had not been admitted to the group home nor received her medications as prescribed. Neglect could not be substantiated, but OIG made several operational and clinical recommendations for improvement in care.

Seven deaths during FY 2006 were from accidental causes. One died after being struck by a car, one died from a head injury, and three deaths involved drugs or alcohol. The remaining two deaths raised possible issues, so OIG conducted investigations.

The first involved an individual who died from complications after being hospitalized after choking at her day treatment site. A coroner's jury determined her death to be an accident. OIG's investigation did not find neglect but did make recommendations for the agency to more clearly identify the roles and expectations of the nurses in emergency situations.
The second involved an individual who died from an overdose of Clozaril. OIG's investigation revealed that Clozaril had accumulated in his body in toxic amounts (called "bioaccumulation") due to a medical condition known as megacolon, and no abuse or neglect was found in this case. A coroner's jury ruled it an accidental death.

Other Clinical Issues

During FY 2006, OIG substantiated several cases of neglect involving clinical issues at agencies. Most were at one agency and involved poor follow up care and treatment of individuals. In FY 2005, OIG had substantiated neglect at the agency and made recommendations that the agency establish policies and procedures to ensure that physician's appointments, recommendations, and orders are not overlooked. OIG made other recommendations involving direct support staff and medication administration errors. Investigations found that training procedures were not followed, and OIG recommended the agency staff return for retraining on the relevant rule (Rule 116).

OIG also made clinical recommendations in cases that were not substantiated as abuse/neglect. For example, in investigations during FY 2006, OIG recommended:

Bowel elimination assessments and monitoring for individuals at risk for constipation and impaction and subsequent bowel obstruction;
Further training of clinical staff in the risk of suicide after hospitalization and in individuals with schizophrenia;
CPR be administered and staff understand appropriate procedures;
Nurses follow up on medication on discharge to ensure medication is received;
Improvements in monitoring individuals for safety in residential apartments;
Guidelines for the safe use of sleep medications; and
Discussion of medical problems at treatment team meetings.

Further, OIG made recommendations for actions regarding specific individuals, such as particular nursing interventions and improved communication with the parent/guardian.

Conclusion

OIG's two Clinical Coordinators also fulfill a liaison role. While reviewing or investigating cases, they may speak with the county coroner, forensic pathologists, local law enforcement, or the State Police. In one instance, an individual died unexpectedly and the family had been unable to find out the cause of death. The Clinical Coordinator was able to help the family speak with the pathologist and get information from the autopsy, thereby putting closure on the death.

The Clinical Coordinators have also provided expert testimony when needed. They have testified regarding investigative evidence during coroner's inquests, providing critical information for determining the manner of death, which helps agencies find out if corrective actions are needed. They have also testified regarding investigative evidence during Nurse Aide Registry hearings. Referrals to the Registry of the names of employees who have a substantiated physical abuse, sexual abuse or egregious neglect finding is very important in preventing abuse and neglect, as it keeps those persons from being employed in providing services to vulnerable adults.

OIG's Clinical Coordinators provide ongoing reviews of medical care, treatment, and habilitation issues in OIG's investigations, making recommendations as needed to identify and prevent abuse and neglect of individuals with disabilities.

Written Responses

The law requires that, whenever OIG substantiates abuse or neglect or identifies an administrative issue relative to preventing or reporting abuse/neglect, the community agency or facility must submit a response in writing. The "Written Response" must include the actions that have been taken or will be taken to protect individuals from abuse or neglect, to prevent recurrence, and to eliminate problems. It must also include the dates of implementation and completion and the name of the administrative person responsible for implementation.

The facility or agency must return the Written Response to the appropriate DHS program division for review and approval. After approval, the division sends it to OIG for review. If some identified action(s) is not yet completed, the facility or agency must send OIG implementation status updates until completion. OIG also reviews a random sample of the Written Responses to ensure that all actions listed in the Written Responses are completed.

Required Written Responses, FY 2006

When substantiating abuse/neglect or identifying another issue, OIG sends an initial Written Response form with the case report to the agency/facility. The form lists the OIG finding and has columns for the agency/facility to identify actions, date of implementation and person responsible for implementation.

During FY 2006, OIG required Written Responses in 495 cases, 24% more than last fiscal year and 22% more than FY 2004. Of these 495 cases in FY 2006, agencies were sent 352 (71%) of the initial Written Response forms and facilities were sent 143 (29%).

Timeliness of Written Responses, FY 2006

The agency/facility is to submit the completed Written Response to the appropriate DHS division within 30 days of the case report becoming final. On a monthly basis, OIG identifies delinquent Written Responses to the appropriate DHS division for follow-up.

During FY 2006, most approved Written Responses sent to OIG were delayed; 56% (277 of 495) of the approved Written Responses were received more than 30 days after case closure. This response time is considerably worse than FY 2005, as only 35% percent of approved Written Responses were received late last year.

It appears, however, that the delay is in receiving DHS approvals, not in agency/facility response. OIG has been working with the divisions to improve timeliness.

Issues Cited, FY 2006

OIG cites a wide range of issues on Written Responses. For tracking purposes, OIG groups them into 38 categories, six of which refer to the type of substantiated abuse/neglect.

Other than these six, the two issues cited most frequently by OIG in the 396 approved Written Responses received during FY 2006 were: failure to report an allegation, and late reporting of an allegation. Together, they were cited in more than one-fifth of all Written Responses approved in FY 2006. Overall, OIG recorded citing 21% more issues in FY 2006 than in FY 2005 or FY 2004, but failure to report and late reporting together were the most common in all three years.

Citing these initial reporting issues is one way that OIG has been encouraging agencies and facilities to report as required by Rule 50. OIG's efforts to get agencies and facilities to improve the timeliness of reporting incidents will continue.

Actions Taken, FY 2006

Actions taken by agencies and facilities to address the cited issues and to help prevent recurrence or eliminate the problems identified typically show even greater variation. Thus, OIG also groups the actions taken into categories for tracking purposes.

In the 396 approved Written Responses received by OIG during FY 2006, OIG found 952 actions taken by agencies or facilities. The most frequent action taken during FY 2005 and FY 2004 had been re-training of the accused employee; during FY 2006, it was discharge of the accused employee, with re-training a close second. Group re-training (for example, training all nurses on a medication administration requirement) was third in all three years, but was reported 15 times in FY 2004 and 120 times in FY 2006.

OIG recorded about the same number of actions taken in FY 2006 as in FY 2005 and FY 2004, indicating that agencies and facilities are consistently taking actions in response to findings in OIG cases. Actions that an agency or facility takes become proactive steps to prevent recurrence of abuse/neglect.

Compliance Reviews, FY 2006

The law mandates that OIG conduct a random review of completed actions in order to monitor compliance with the requirements. OIG conducts these "Written Response Compliance Reviews" on a monthly basis.

The process begins near the end of each month with a random selection of approved Written Responses received during the previous month. OIG's Compliance Reviewers conduct an initial review of each selected Written Response and related documentation submitted, developing a plan for checking implementation. This plan is then reviewed in a joint meeting with supervisors and a database manager, to ensure quality, consistency and accuracy.

The Compliance Reviewer may involve any level of investigation. It usually begins with contacting the agency or facility to obtain further documentation, such as training records, revised policies, and verification of administrative action against an employee. Sometimes, this desk review is adequate to document the actions were taken: for example, if an employee resigned in lieu of any action against him/her, the copy of the resignation or personnel action may be sufficient.

The Compliance Reviewer often makes a visit to the agency or facility site to review additional documentation, interview staff and observe operations. These visits are typically scheduled in advance with the authorized representative or OIG liaison. Upon completion of a review, OIG sends a letter to the authorized representative indicating whether the agency or facility is in compliance or not.

During FY 2006, OIG conducted 73 Compliance Reviews on a randomly selected sample of approved Written Responses received each month, May 1, 2005 through April 30, 2006. OIG selects separate random samples of agency and facility Written Responses.

Of the 73 randomly selected approved Written Responses:

54 were from agencies, and 29 were from facilities;
39 involved on-site visits, and 34 required only reviews of documentation;
73 resulted in "in compliance" letters, and none in "not in compliance" letters.

Few patterns were noted in Written Responses reviewed during Compliance Reviews this year. The fact that no compliance reviews resulted in "not in compliance" letters indicates that agencies and facilities are consistently implementing the actions they identified.

As in FY 2005, the most common issue in Written Responses checked during Compliance Reviews was discipline or other administrative actions taken against staff for abuse, neglect, or other misconduct. Documentation of these actions consistently showed proof of implementation.

The second most frequently cited issue in reviewed Written Responses was a failure to report allegations timely or at all; this was especially true at the agencies. Re-training in abuse/neglect reporting was documented, but OIG still went on-site to interview employees identified as having failed to report timely or at all.

OIG's Compliance Review process has emphasized that agencies and facilities will be monitored for implementation of corrective actions. Random reviews of implementation encourage agency and facility administrators to follow through with corrective actions designed to decrease abuse/neglect and improve the safety of individuals receiving services. Further, the Compliance Reviewers have found that OIG's recommendations have caused agencies and facilities to take a multi-faceted approach to improving their systems for preventing abuse and neglect.

Training

OIG is committed to providing training as a primary means to prevent abuse/neglect and to adequately report, effectively investigate, and thoroughly respond when it allegedly occurs. OIG conducts training of its own staff, of facility and community agency staff, and of external entities such as law enforcement and medical organizations.

Internal Training

OIG requires its investigative staff to successfully complete five continuing education courses. These five courses must include at least one each in investigative skills, computer skills and personal development. In FY 2006, all investigative staff met the annual training requirements. In previous years, OIG has held at least one statewide training meeting, which consisted of two days of intensive training. Due to budgetary restraints, OIG did not have a statewide training meeting in FY 2006 and so addressed continued education in other ways.

OIG arranged for trainings by DHS management and by law enforcement, such as methamphetamine awareness training by the Illinois State Police. OIG also increased its use of video and computer-based training. OIG obtained video training materials from educational institutions and law enforcement entities through partnerships to share resources. OIG further expanded its own computer-based training by developing courses on the following:

Injury Assessment;
Grammar & Punctuation (eight modules);
Whistle Blower Act;
Health Information Portability & Accountability Act (HIPAA) and OIG;
Freedom of Information Act Requests; and
Nurse Aide Registry Process.

External Training

In FY 2006, OIG offered four courses for staff of State-operated facilities and staff of community agencies providing mental health or developmental services.

The first is a half-day training regarding the administrative regulation that governs the reporting of abuse & neglect to OIG, "Rule 50." During FY 2006, OIG also sent all agencies and facilities a self-running module of a computer-based version of the Rule 50 training. This facilitates local efforts at training all direct care staff and ensures that they receive a consistent and clear presentation of Rule 50's requirements.

In FY 2006, OIG conducted 27 Rule 50 classes with 660 attendees.

The second course, Basic Investigative Skills, is a two-day course concentrating on all aspects of conducting an investigation. This course is required for anyone who an agency wishes to designate and receive authorization from OIG to conduct investigations.

In FY 2006, OIG conducted 21 Basic Investigative Skills classes with 295 attendees.

OIG now also provides Investigative Skills Refresher, which is a one-day refresher course offered for those who have already completed the Basic Investigative Skills training. The Investigative Skills Refresher course emphasizes the key points of conducting an investigation, such as preserving evidence and conducting interviews, and includes a review of Rule 50.

In FY 2006, OIG conducted 23 Investigative Skills Refresher classes with 258 attendees.

In FY 2006, OIG began a new course for any staff who may be called to respond to an incident or allegation of abuse or neglect, even if not an investigator. This "First Responder" training is a half-day course that concentrates on ensuring the health and safety of individuals, securing a scene and preserving evidence.

In FY 2006, OIG conducted 11 First Responder classes with 387 attendees.

In all, during FY 2006, OIG conducted 82 classes with a total of 1,600 attendees. The 82 classes is more than a 50% increase from the 53 classes OIG conducted in FY 2005.

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

Public Information

To ensure that agency and facility employees are properly trained in Rule 50, during FY 2006, OIG developed a handbook entitled "Reporting of Abuse & Neglect of Adults with Disabilities." This handbook is distributed at every training conducted by OIG, and a copy was mailed to every facility and agency under the jurisdiction of OIG. OIG encouraged agency and facility leadership to distribute the handbook to all staff.

OIG staff also gave formal and informal presentations to organizations around the state, distributing literature and speaking publicly about the programs within OIG. During FY 2006, OIG staff gave presentations to the following groups: Salvation Army in Rockford, Crusader Clinic in Rockford, Community Crisis Center in Elgin, the 17th Judicial Circuit Court, and Piatt County Mental Health Center. OIG also set up displays at the Illinois State Fair, at the DuQuoin State Fair, and at conferences on elder abuse and criminal justice.

Chapter 5 - System Improvement through Information

Allegations Reported

During FY 2006, OIG received a total of 2,339 abuse/neglect allegations, an increase of 7% over last fiscal year. The counts by type and location are shown in the table below. Tables 5.A through 5C (below) show a more detailed breakout of type and location.

Table 1. Allegations Received in FY 2006 by Type and Setting
Location	Abuse allegations	Neglect allegations	Total allegations
DHS-operated facilities	819	102	921
Community agencies	666	227	893
Domestic settings	224	255	525^*
Totals	1,709	584	2,339^*

^* Includes 46 allegations of domestic exploitation.

Facilities

The State-operated facilities accounted for the largest number of allegations, just as they had in FY 2004 and FY 2005. Also as in previous years, the facilities had the most abuse allegations of any setting but the fewest neglect allegations. Abuse allegations accounted for 90% of the allegations received about facilities in FY 2004, 91% in FY 2005, and 89% in FY2006.

At facilities, OIG received 40% more allegations than in FY 2004 and 2% fewer allegations than in FY 2005. The 2% drop appears to result from a 21% rise in neglect allegations being offset by a 4% decrease in abuse allegations, and this decrease appears to due to Choate DC. Omitting Choate DC's numbers, abuse allegations at facilities rose 13%.

During FY 2005, two individuals residing in Choate DC accounted for a doubling of total allegations reported about the facility. That is, in FY 2003 and 2004, that facility had averaged 112 abuse allegations; in FY 2005, the total jumped to 228. Nearly all of these investigations found the abuse allegation to be unfounded. These two individuals now receive services elsewhere and, this year, Choate DC returned to the more typical level of 110 abuse allegations.

Agencies

OIG saw another large increase in allegations received about community agencies providing mental health or developmental disability services. Total allegations received about community agencies in FY 2006 was 27% higher than FY 2005. The increase in FY 2006 was in both MH and DD programs and in both abuse allegations (up 21%), and neglect allegations (up 32%).

This increase also follows a 38% increase last year over FY 2004. That is, OIG received 70% more abuse/neglect allegations at the agencies in FY 2006 than just two years before. OIG attributes the increase in reporting about agencies to DHS' and OIG's continued proactive stance toward improving the reporting and prevention of abuse/neglect (see Chapter 3). OIG's commitment is shown in actions such as the August 2005 letter to all community agencies clarifying the definitions of neglect and mental abuse, development and distribution of a handbook on reporting, and the creation and distribution of a Rule 50 training module for direct care staff.

Domestic

Overall, OIG received fewer allegations from domestic settings, but this was entirely due to a drop in neglect allegations. While OIG gets more abuse allegations overall, from domestic settings, OIG gets more neglect allegations. Thus, changes in neglect allegations can over-shadow changes in the other types. From domestic settings in FY 2006, OIG got slightly more allegations of abuse (up 4%) and exploitation (up 7%), but slightly fewer neglect allegations (down 6%).

This change continues a pattern over the past two years. As noted in Table 2 below, early in the Domestic Abuse Program, the percentage of domestic cases that alleged abuse had been decreasing, while allegations of neglect and exploitation were increasing. Since that time, abuse allegations have been steadily increasing and exploitation has stayed relatively stable. Neglect has dropped back to just under 50% of total domestic allegations received by OIG. OIG anticipates that the percentages will stabilize at these general proportions as the Domestic Abuse Program continues.

Table 2. Domestic Allegations by Percent across Six Fiscal Years
Fiscal Year	Percent abuse	Percent neglect	Percent exploitation
FY 2001	57%	35%	8%
FY 2002	44%	45%	11%
FY 2003	45%	42%	12%
FY 2004	35%	56%	8%
FY 2005	41%	51%	8%
FY 2006	43%	48%	9%

Table 5. Allegations and Deaths Reported to OIG during FY 2006 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	Death
Alton MHC¹	6	6	4	0	16	0
- Alton forensic	33	3	39	2	77	0
Chester MHC	93	1	16	3	113	2
Chi-Read MHC	13	4	4	7	28	1
Choate MHC ²	33	5	6	4	48	1
Elgin MHC ¹	5	2	3	0	10	2
- Elgin forensic	10	3	10	2	25	1
Madden MHC	8	0	6	3	17	2
McFarland MHC ¹	21	3	4	1	29	2
- McFar. forensic	0	0	0	0	0	0
Singer MHC	19	4	14	6	43	2
Tinley Park MHC	8	0	3	4	15	0
Facility subtotals	249	31	109	32	421	13
Residential	9	10	17	15	51	21
Non-residential	1	7	11	2	21	1
Agency subtotals	10	17	28	17	72	22
Rule 50 - MH Totals	259	48	137	49	493	35

¹ Non-forensic units only.

² Mental health facility only.

Table 5.B - Rule 50, Developmental Disability Services Only
Location	Physical abuse allegation	Sexual abuse allegation	Mental abuse allegation	Neglect allegation	Allegation totals	Death
Choate DC ¹	98	1	11	5	115	2
Fox DC	2	0	0	4	6	2
Howe DC	58	0	31	15	104	9
Jacksonville DC	94	4	11	14	123	1
Kiley DC	21	2	2	15	40	1
Ludeman DC	16	0	2	4	22	5
Mabley DC	6	0	1	7	14	1
Murray DC	24	0	0	3	27	5
Shapiro DC	38	0	8	3	49	11
Facility subtotals	357	7	66	70	500	37
Residential	266	20	105	159	550	80
Non-residential	148	22	50	51	271	3
Agency subtotals	414	42	155	210	821	83
Rule 50 - DD Totals	771	49	221	280	1321	120

Table 5.C - Rule 51, Domestic Settings
Disability Type	Physical abuse allegation	Sexual abuse allegation	Mental abuse allegation	Neglect allegation	Financial exploitation allegation	Allegation totals ²
Developmental	123	17	6	119	24	289
Physical	38	5	5	97	8	153
Mental	25	3	3	39	14	84
Rule 51 Totals	185	25	14	255	46	525

¹ Developmental Center only. Includes four physical abuse allegations on the forensic unit.

² Excludes complaints that were not reportable per the administrative rule.

Domestic Allegation Sources

Each year, OIG looks at the sources of calls regarding domestic abuse, neglect or exploitation. During FY 2001, the first year of OIG's Domestic Abuse Program, the community agencies accounted for 27% of the allegations received. Family members or friends (12%) and hospitals (11%) were the next two most common.

Since that year, the community agencies have continued to constitute the largest percentage of calls to OIG reporting domestic allegations. In FY 2004, 2005, and 2006, these agencies reported 25%, 22%, and 24% of the calls, respectively.

Family members and friends have also continued to be a large source of domestic allegations. In FY 2004, they accounted for 25% of all initial calls; in FY 2005 and 2006, they have accounted for 17% and 18%, respectively. Hospitals have remained a common source, too, accounting for 17% of the domestic calls to OIG in FY 2004, 16% in FY 2005, and 17% in FY 2006.

Staff in the DHS Division of Rehabilitation Services, especially in the Home Services Program, accounted for ten percent of the calls to OIG reporting domestic allegations. These staff have accounted for about ten percent each year since the inception of OIG's Domestic Abuse Program, except for FY 2005, in which they accounted for 16%.

Ineligible Referrals

Every year, OIG receives a number of allegations that do not meet the statutory requirements to be considered domestic abuse, neglect, or exploitation. For example: the individual may be under 18, older than 59, deceased, or no longer living in the home; the alleged perpetrator may not be a person with access to the home; or the alleged mistreatment may not be abuse, neglect or exploitation as defined in the law. Although these issues do not fall within OIG's jurisdiction, OIG still takes the case and refers the caller to other entities that may be able to offer assistance, such as the local police or a social service agency.

In FY 2006, OIG received 51 reports of situations that were ineligible for the Domestic Abuse Program. This was a 50% increase over FY 2005, when only 34 ineligible calls were received by OIG. The 34 received in FY 2005 was more than double the number received in FY 2004; prior to that time, ineligible calls had been decreasing. However, as the Domestic Abuse Program continues and becomes more well-known, OIG anticipates receiving more complaints that will need to be referred to another entity.

OIG also now data-enters referrals for needed services even when the case is ineligible. Nearly half of the domestic calls received (242 of 525) were referred for services during FY 2006. The largest number were referrals to the DHS Division of Rehabilitation Services, which received 106 of the 242 referrals.

Outside of DHS, the largest number of referrals was to local law enforcement, since many allegations also are criminal in nature. The Domestic Abuse Program's statutory role is on assessing the alleged victim, rather than on taking action against any alleged perpetrator, so referral to law enforcement is appropriate when evidence substantiates the allegation.

Cases Closed

During FY 2006, OIG closed 2,353 total cases - 921 at facilities, 878 at agencies, and 554 in domestic settings. This compares to:

FY 2005's 2,293 - 952 at facilities, 798 at agencies, and 543 in domestic settings; and
FY 2004's 2,091 - 915 at facilities, 724 at agencies, and 452 in domestic settings.

OIG accomplished this with the equivalent of only 24 investigators and front-line supervisors and only two Clinical Coordinators.

Of the total, 2,238 were allegations of abuse, neglect, or domestic exploitation and 115 were deaths (Tables 6.A through 6.C detail these closures by programs within disability settings). Broken out by service setting, OIG closed:

1,218 allegations of abuse/neglect and 91 death reports in DD settings;
466 allegations of abuse/neglect and 24 death reports in MH settings; and
554 allegations of abuse, neglect or exploitation in domestic settings.

Compared to FY 2005, these totals show an 3% increase in allegations closed and a 6% decrease in deaths closed.

OIG also substantiated slightly more allegations of abuse, neglect, or domestic exploitation. During FY 2005, OIG substantiated 13.5% of total cases; in FY 2006, OIG substantiated 14.4%. Table 3 summarizes these substantiated cases by location and disability types.

Table 3. Substantiated Abuse and Neglect by Setting, FY 2006
Location	Abuse substantiated	Neglect substantiated	Total substantiated
Facilities	41	17	58
Agencies	114	40	154
Domestic	73	34	110^*
Totals	228	91	322^*

^* includes three cases of substantiated domestic exploitation.

The increase in substantiations was fairly evenly distributed across locations and settings. The only decrease was in substantiated abuse cases in domestic settings (dropping from 80 in FY 2005 to 73 in FY 2006), while the greatest increase was in substantiated abuse cases in facilities (rising from 28 in FY 2005 to 41 in FY 2006). Substantiated neglect cases rose in all three settings, most notably in community agencies (rising from 34 in FY 2005 to 40 in FY 2006).

Table 6. Findings in Allegations Closed by OIG during FY 2006 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	Not substan-tiated	Findings totals	Closed death cases
Alton MHC ¹	3	0	2	13	18	0
- Alton forensic	1	0	3	81	85	0
Chester MHC	1	0	2	103	106	1
Chicago-Read MHC	0	0	1	27	28	0
Choate MHC ²	0	0	4	41	45	2
Elgin MHC ¹	0	0	3	6	9	0
- Elgin forensic	1	0	4	12	17	1
Madden MHC	0	0	2	12	14	1
McFarland MHC ¹	1	0	3	26	30	2
- McFar. forensic	1	0	0	0	1	0
Singer MHC	3	0	6	36	45	0
Tinley Park MHC	0	0	2	4	6	0
Facility subtotals	11	0	32	361	404	7
Residential	7	2	9	23	41	16
Non-residential	8	0	4	9	21	1
Agency subtotals	15	2	13	32	62	17
Rule 50 - MH Totals	26	2	45	393	466	24

¹ Non-forensic units only.

² Mental health facility only.

Table 6.B - Rule 50, Developmental Disability Services Only
Location	Abuse substan-tiated	Neglect substan-tiated	Other issue found	Not substan-tiated	Findings totals	Closed death cases
Choate DC ¹	3	3	4	143*	153	1
Fox DC	1	0	3	1	5	2
Howe DC	1	3	6	61	71	8
Jacksonville DC	2	4	12	85	103	1
Kiley DC	6	5	9	27	47	0
Ludeman DC	1	0	1	15	17	5
Mabley DC	1	0	6	4	11	1
Murray DC	6	1	7	8	22	5
Shapiro DC	9	1	5	35	50	8
Facility subtotals	30	17	53	379	479	31
Residential	69	28	125	289	511	58
Non-residential	30	10	60	128	228	2
Agency subtotals	99	38	185	417	739	60
Rule 50 - DD Totals	129	55	238	796	1218	91

Table 6.C - Rule 51, Domestic Settings
Disability Type	Abuse substan-tiated	Neglect substan-tiated	Exploita-tion sub-stantiated	Refused consent	Not substan- tiated	Findings totals 2
Developmental	58	20	1	62	170	311
Physical	9	10	1	60	79	159
Mental	6	4	1	34	39	84
Rule 51 Totals	73	34	3	156	288	554

¹ Developmental Center only. Includes four unsubstantiated allegations on the forensic unit.

² Excludes complaints that were not reportable per the administrative rule.

The percent of closed cases that were substantiated have fluctuated over the past three years. That is, OIG substantiated abuse, neglect or domestic exploitation:

Facilities - in 7.2% of cases in FY 2004, 4.5% in FY 2005, and 6.3% in FY 2006;
Agencies - in 19.1% of cases in FY 2004, 18.4% in FY 2005, and 17.5% in FY 2006; and
Domestic - in 13.3% of cases in FY 2004, 21.9% in FY 2005, and 19.9% in FY 2006.

Per the statutory requirements, domestic cases (Rule 51) use a different definition of substantiated, with a lower threshold or standard of proof.

Rule 50 recommendations

When OIG completes a case and either substantiates it or identifies other issues needing attention, the facility or community agency is required to respond in writing, identifying corrective actions that have been taken or will be taken to prevent recurrence. Written Responses, and how OIG follows up on implementation, are discussed in the previous chapter's section on Written Response Compliance Reviews.

During FY 2006, OIG made more recommendations to facilities and community agencies. In addition to the 212 substantiated cases, OIG identified issues in another 283 cases.

These 283 cases (in which OIG did not substantiate abuse/neglect but identified another issue) shows a continued rise over the past few fiscal years. In FY 2003, OIG identified issues in 101 non-substantiated cases; this doubled to 202 cases in FY 2004 and 209 cases in FY 2005. In FY 2006, the 283 non-substantiated cases with another issue represent another 35% increase. This trend shows OIG's ongoing commitment to improving care and treatment.

Service Plan Referrals

In substantiated Domestic Abuse Program cases, the law requires that OIG refer the case and alleged victim to the appropriate division in DHS for primary development of a service plan. After OIG refers the case to the division, the individual has the legal right to refuse to consent to the service plan, but may accept some services.

During FY 2006, OIG substantiated 110 cases of domestic abuse, neglect or exploitation. All of these were referred to the most appropriate DHS division, but two cases were referred to two divisions. One was referred to the Division of Mental Health in addition to the primary referral to the Division of Developmental Disabilities; the other was referred to the Division of Mental Health in addition to the primary referral to the Division of Rehabilitation Services. The goal in each case was to connect the individual to services that addressed all his/her needs.

Table 4 below shows these primary service plan referrals by DHS division. The largest number continue to be referred to the Division of Developmental Disabilities, but it has recently dropped. The Division of Rehabilitation Services, which accounted for only 18% of the service plan referrals in FY 2004, accounted for 38% in FY 2006.

Table 4. Referrals from Substantiated Domestic Cases
DHS Division	FY 2003 referrals	FY 2004 referrals	FY 2005 referrals	FY 2006 referrals
Developmental Disabilities	45	44	83	62
Rehabilitation Services	11	11	29	42
Mental Health	2	5	6	6^*
Totals	58	60	119	110

^* OIG referred two additional individuals to DMH whose primary referral was to another division.

Census and Staffing Ratios

Table 7 below presents the statutorily required information on direct care staffing ratios, as well as the numbers of people served in each facility.

Before the start of each year, DHS budgets for the expected number of individuals who will need services in each facility on an inpatient basis. Budgeted beds is a way to compare facility sizes, although the actual count of individuals may fluctuate from day to day.

Since the count fluctuates, another way to compare facilities is to add up all the days that those beds are used during the year. That is, the number of individuals receiving services ("on the books") times the number of days they were inpatients ("bed-days"). The on books bed-days count includes the day of admission and the day of discharge.

Individuals who are admitted to a facility more than once during a year would raise the census totals for a whole year. So, DHS also counts unduplicated individuals served in each facility, which counts each person only once.

Direct care staff are employees that provide services directly to individuals. Since some facilities have part time workers, DHS converts the counts of staff to "full-time equivalents."

The direct care staff to patient ratio is the number of full-time equivalent direct care staff on June 30, 2006, divided by the facility census on that same day. Facilities with relatively low staffing ratios may use more contractual workers or rely on services provided by another facility.

Table 7. Census and Direct Care Staff to Patient Ratios at DHS Facilities, June 30, 2006
Facility	Budgeted Beds	On-Books Bed-Days ¹	Individuals Served ²	Direct Care Staff ³	Staffing Ratio ⁴
Choate DC	183	62,548	196	245.77	1.48
Fox DC	160	56,576	162	167.20	1.11
Howe DC	420	150,903	428	537.10	1.35
Jacksonville DC	258	94,882	268	328.50	1.28
Kiley DC	250	92,883	262	329.80	1.33
Ludeman DC	420	151,695	428	500.50	1.21
Mabley DC	88	35,958	104	130.89	1.36
Murray DC	345	124,991	354	394.55	1.16
Shapiro DC	630	226,330	641	946.99	1.56
DD facility subtotals	2,754	996,766	2,843	3,581.30	1.34
Alton MHC	125	45,686	375	175.00	1.43
Chester MHC	280	101,157	451	354.57	1.28
Chicago-Read MHC	130	46,748	1,724	197.00	1.77
Choate MHC	79	29,662	600	105.33	1.62
Elgin MHC	390	134,222	1,233	512.20	1.39
Madden MHC	175	44,433	2,991	191.65	1.84
McFarland MHC	118	42,433	710	133.18	1.08
Singer MHC	76	28,553	683	105.67	1.63
Tinley Park MHC	100	32,154	1,522	120.50	1.72
MH facility subtotals	1,473	505,048	10,289	1,895.10	1.45

¹ The total number of days (from admission to discharge) for all individuals residing in the facility.

² An unduplicated count of all individuals residing in the facility during the fiscal year.

³ The number of direct care staff, but part-time staff are counted in full-time equivalents.

⁴ The direct care staff to patient ratios on June 30, 2006.

Nurse Aide Registry

By law, OIG is required to report to the Illinois Department of Public Health (IDPH) Nurse Aide Registry 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, certified, or funded by DHS.

Reconsiderations, Grievances, and Appeals

If OIG substantiates a case, an accused person has three avenues of recourse to avoid having his/her name placed on the Registry. First, when OIG first completes an investigation and notifies the person of the substantiations, he/she may file a "reconsideration" request with OIG within 15 days of the date of the letter. Reconsiderations require that the person identify information that was not considered during the OIG investigation and that could change the outcome. If the finding is changed, OIG will not refer the person's name to the Registry.

Second, the person may file an employee grievance or other internal facility/agency personnel action. This is separate from a 50.80 appeal, which appeals the action as well. Since OIG rarely gets notified of grievances, OIG cannot track these. When notified, however, OIG delays referring the person's name to the Registry until a decision is rendered or three months have passed. If OIG has substantiated physical abuse, sexual abuse, or egregious neglect, but the person wins the grievance, OIG does not refer the person's name to the Registry (see Chapter 2).

Third, the person may file a direct appeal to DHS not to refer his/her name to the Registry. This is called a 50.90 appeal, after the section in Rule 50 that addresses it. This appeal does not seek to change the finding, but to determine if there are reasons for not referring the name to the Registry. If the administrative law judge decides, for example, that the act was not severe enough to warrant referral, OIG will not refer the person's name to the Registry.

Once a person's name has been referred to the Registry, he/she may petition in writing to DHS to remove the name. When this occurs, OIG is typically asked to conduct an investigation of the petition. Specific factors examined in the investigation, which then serve as the basis of the hearing officer's decision, include:

Evidence that the employee has been rehabilitated, trained or educated and able to perform duties in the public interest;
Evidence of the employee's conduct since the name was placed on the Registry; and
Evidence of the employee's candor and forthrightness in presenting information in support of his/her petition.

If, based on the hearing officer's judgment, the decision is in favor of removal, OIG sends a request to the Department of Public Health to remove the employee's name and the finding from the Registry.

FY 2006 Referrals

FY 2006 is the fourth full year in which OIG reported employee names to the Nurse Aide Registry. During FY 2006, OIG referred 83 employees' names; this totaled to 85 referrals to the Registry, since one employee was reported based on three separate substantiations. These 85 referrals reflect a 37% increase over the 62 referrals in FY 2005. It is also a 24% increase over FY 2004 and more than three times the number in FY 2003, the first full year of Registry reporting.

Community agency employees continue to constitute the majority of all names referred to the Registry. In FY 2006, nearly 70% (59 of 85) of the names OIG referred were agency employees. Agency employees accounted for more referrals in FY 2003 (78%) and FY 2005 (87%), but fewer referrals in FY 2004 (57%). Conversely, referrals of facility employees' names have fluctuated from 13% to 43% of total referrals.

Most referred employees, regardless of location, are direct care staff. Licensed professionals and administrative staff accounted for only four of 26 facility employee names and only eight of 59 agency employee names referred during FY 2006. Until this fiscal year, none of OIG's referrals of facility employee names to the Registry were licensed professionals or administrative staff.

Reasons for Referral

Physical abuse is the leading reason for referral, accounting for 73 of the 85 referrals in FY 2006. Although the percentage (86%) is lower than FY 2004 and 2005 (89% and 92%, respectively), the actual count is higher: only 48 were referred in FY 2004 and only 57 in FY 2005.

Sexual abuse is the second leading reason for referral and showed a marked increase in FY 2006 over prior years. This fiscal year, eleven of the 85 referrals (13%) were the result of substantiated sexual abuse. In FY 2004 and FY 2005, respectively, sexual abuse accounted for five of 54 (9%) and five of 62 (8%).

Egregious neglect accounted for only one referral in FY 2006. Only one referral in FY 2004 and no referrals in FY 2005 were for substantiated egregious neglect.

FY 2006 Appeals

In FY 2006, there were 37 requests for an appeal to not be referred to the Registry (50.90 appeal). Twelve of these appeals were filed by facility employees and 25 by community agency employees. Eight won their appeals in FY 2006, although all of these were filed in previous fiscal years.

Also in FY 2006, there were two requests for removal from the Registry, both from community agency employees. Those two appeals are still open, but two earlier appeals were decided in the employee's favor.

OIG coordinates with the Bureau of Administrative Hearings in the DHS Office of Legal Services, as well as with the Department of Public Health, in monitoring appeals, supporting hearings, referring names, and requesting removal of names, as appropriate.

Conclusion

OIG plays several integral roles in the effort to prevent abuse and neglect of individuals. One role is to investigate allegations, but OIG has also been charged with reporting the names of employees who are substantiated to have committed physical abuse, sexual abuse and egregious neglect to the Nurse Aide Registry.

Over the past four fiscal years, OIG has reported the names of 188 employees to the Nurse Aide Registry. As of June 30, 2006, 177 are still on the Registry; only eleven names have been removed. Of the eleven cases, five were ruled in the public interest by an administrative law judge: two cases involved acts of self-defense by the perpetrator, the other three involved significant efforts at re-training and rehabilitation by the perpetrators. The remaining six cases were overturned in arbitration cases filed by a labor union in which the arbitrator found that there was not "just cause" to terminate the employment of the employee. When an arbitration award reverses a discharge, the employee's name must be removed from the Registry according to a new state law (see Chapter 2).

Since OIG began reporting to the Registry, 55 employees have won referral appeals and their names were not reported to the Registry.

Each fiscal year has seen an increase in the number of employees reported to the Nurse Aide Registry which emphasizes the increasing effectiveness of the process. In addition, it shows the continuing need to protect people with mental illness or developmental disabilities from abusive employees by denying those employees the ability to work in DHS funded facilities and agencies.

DHS OIG FY 2006 Annual Report

Executive Summary

Chapter 1 - System Improvement through Collaboration

Rule 50 and Rule 51

Organization

Quality Care Board

Program Collaborations

Office of Executive Inspector General

Chapter 2 - System Improvement through Legislation

Required Reporting

Sexual Conduct Felony

Notifying Law Enforcement

Domestic Abuse Program Guardianship

Financial Information

Financial Agents' Records

Subpoenas and Confidentiality

Licensed Professionals

Registry Reporting

Chapter 3 - System Improvement through Development

Non-Reporting

Timeliness of Initial Reporting

Case Management

Intranet Pages

Timeliness of Investigation

Chapter 4 - System Improvement through Prevention

Unannounced Site Visits

Site Visit Dates

FY 2006 Site Visit Issues

Site Visit Issue 1: Nursing Overtime

Site Visit Issue 2: Injuries to Individuals

Site Visit Issue 3: Shift Communication

Site Visit Issue 4: Patient Safety Initiative

Site Visit Issue 5: Contraband Policies

Site Visit Issue 6: Abuse/Neglect Training

Site Visit Issue 7: Non-Reportable Complaints

Site Visit Issue 8: Complaint Resolution

Site Visit Issue 9: Consumer Perspective

Conclusion: Summary of Trends or Patterns

Annual Investigative Authorization Review

Protocol Update

FY 2006 Authorizations

Clinical Reviews

Deaths in Facilities

Deaths in agencies

Other Clinical Issues

Conclusion

Written Responses

Required Written Responses, FY 2006

Timeliness of Written Responses, FY 2006

Issues Cited, FY 2006

Actions Taken, FY 2006

Compliance Reviews, FY 2006

Training

Internal Training

External Training

Public Information

Chapter 5 - System Improvement through Information

Allegations Reported

Facilities

Agencies

Domestic

Table 5. Allegations and Deaths Reported to OIG during FY 2006 Sorted by Administrative Rule and Service Type

Domestic Allegation Sources

Ineligible Referrals

Cases Closed

Table 6. Findings in Allegations Closed by OIG during FY 2006 Sorted by Administrative Rule and Service Type

Rule 50 recommendations

Service Plan Referrals

Census and Staffing Ratios

Nurse Aide Registry

Reconsiderations, Grievances, and Appeals

FY 2006 Referrals

Reasons for Referral

FY 2006 Appeals

Conclusion

Site Visit Issue 1:
Nursing Overtime

Site Visit Issue 2:
Injuries to Individuals

Site Visit Issue 3:
Shift Communication

Site Visit Issue 4:
Patient Safety Initiative

Site Visit Issue 5:
Contraband Policies

Site Visit Issue 6:
Abuse/Neglect Training

Site Visit Issue 7:
Non-Reportable Complaints

Site Visit Issue 8:
Complaint Resolution

Site Visit Issue 9:
Consumer Perspective

Conclusion:
Summary of Trends or Patterns