What Happens During an Investigation?

Each allegation is treated individually and there may be substantial differences among investigations. Nevertheless, there are standard steps that all investigations generally follow.


  1. Receiving the report
  2. Evidence-gathering
  3. Analysis of the evidence
  4. Conclusions and report-writing
  5. Internal case review
  6. Case presentation to the facility or agency
  7. Facility or agency response
  8. OIG follow-up
  9. Case closure


1.) Receiving the Report

When OIG receives a report, it is assigned to an investigator who evaluates the information, including:

Does the report allege a crime? (Such reports must be sent to local law enforcement immediately.)

Does the report allege imminent danger which would require the removal and placement of the victim?

Does the scene need to be secured or visited immediately?

Is there any physical evidence that should be collected?

Are photographs (of the scene, injuries, or other evidence) needed?

Who are the possible witnesses?

Is there enough evidence to permit an investigation?

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2.) Evidence-Gathering

The investigator's next actions depend on how the above questions are answered. Usually, when OIG receives the report, any emergency medical or safety issues have been resolved. The investigator coordinates the next steps with the appointed OIG Liaison at the facility or agency, normally an employee who has received OIG investigations training. Under the OIG Investigator's guidance, the OIG Liaison may complete interviews and/or collect pertinent documentation (such as injury reports or photographs).

Based on the evidence collected to this point, the investigator develops an investigative plan. This may include a list of those subjects who need to be interviewed or re-interviewed and the documentation that needs to be collected.

As the need arises, expert opinion testimony may also be required to answer questions brought out during the investigation.

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3.) Analysis of Evidence

When all of the information has been gathered, the investigator analyzes the evidence to determine what happened. In some cases, contradictory information may exist. The investigator weighs each piece of evidence, considering factors including the relative proximity of witnesses, whether obstacles obscured their views, whether other factors may influence their testimony. Contradictions can often be explained this way.

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4.) Conclusions and Report-Writing

After sifting through the collected information, the investigator must determine whether a preponderance - more than half - of the evidence supports the allegation or not. At this point, the investigator writes a preliminary report, summarizing the evidence used to arrive at the conclusion, as well as the conclusion itself.

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5.) Internal Case Review

All cases are reviewed by investigative supervisors who, among other duties, monitor case loads and provide ongoing direction. If necessary, OIG's clinical staff review the case and, if needed, obtain additional expertise outside the department. Legal services are also available if needed.

Case reviews focus on: the quality of the case report; the strength of the attached supporting evidence; and the appropriateness of the conclusions reached by the investigator. If further investigative work is warranted or if there are errors in the case report, the case is returned to the investigator for additional work.

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6.) Case Presentation

When the case report is approved, it is signed and mailed to the facility or agency. People who were involved in the incident (the victim, the complainant, the alleged perpetrator) are notified of the result at this time.

Anyone involved may, within 15 working days, request a reconsideration of the findings if they have additional evidence that was not considered in the investigation. OIG then reviews the additional information and determines whether there are sufficient grounds to reinvestigate the case or revise the case report.

After all questions and additional issues have been resolved, the case report becomes a final.

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7.) Facility or Agency Response

Substantiated cases of abuse or neglect, and cases that identify other issues, require a response from the facility or agency. This "Written Response" is to detail the steps taken to ensure the protection of those individuals and how further occurrences of this type will be eliminated. It can and normally does take the form of discipline, training, and/or the creation of or changes to a policy or procedure.  The Written Response must be submitted to the appropriate DHS program division administrator, who reviews it for the DHS Secretary.  Approved Written Responses are then forwarded to OIG.

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8.) OIG Follow-up

OIG reviews a random sample of Written Responses to ensure that the actions listed by the facility or agency were taken.  If these actions have been taken, OIG sends an "in compliance" letter to the facility or agency; if not, then an "out of compliance" letter is sent.  OIG conducts these reviews monthly, which provides a timely review of implementation.

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9.) Case Closure

Upon case closure, the accused, the victim (and/or guardian) and the complainant are notified of the outcome. Freedom of Information Act (F.O.I.A.) requests are not honored until the case is closed and only if abuse or neglect was substantiated.

The identity of any employee found responsible for physical or sexual abuse or egregious neglect is sent to the Illinois Department of Public Health, Healthcare Worker Registry. Several levels of appeal have been built into this process to ensure that all referrals are unbiased and timely.

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