DHS OIG FY 2004 Annual Report

Office of the Inspector General
160 N. LaSalle, 7th Floor
Chicago, IL 60601

September 2004

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

I am pleased to submit to you this Fiscal Year 2004 Report of the Office of the Inspector General (OIG) in the Illinois Department of Human Services

State law required two annual reports from OIG on abuse/neglect investigations, one pursuant to the Abused and Neglected Long-Term Care Facility Residents Reporting Act (210 ILCS 6.7) and the other pursuant to the Adults with Disabilities Domestic Abuse Intervention Act (20 ILCS 2435).

This year the OIG has combined both annual reports to present to the stakeholders an FY04 Report that is inclusive of all activities and services within the OIG. This holistic approach, highlights important issues related to the investigation of abuse and neglect of individuals with disabilities not only in the state funded facilities, licensed and funded agencies but in private homes as well and the efforts made to ensure the protection and safety of individuals who are disabled.

I trust that you will find this report to be informative and helpful in our collective efforts to prevent abuse and neglect of Illinois citizens.

Kind Regards,

Sydney R. Roberts, JD
Inspector General

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Executive Summary

This report discusses the Office of the Inspector General (OIG) in the Department of Human Services and OIG's investigations whether in facilities or private agencies that provide mental disability services or in private domestic residences.

Facilities and Community Agencies

In FY 2004, OIG received 1,182 allegations of abuse and neglect, continuing a trend toward fewer allegations: 1,907 in FY 2001; 1,637 in FY 2002; and 1,397 in FY 2003.

With the Early Retirement Incentive and a loss of experienced staff, OIG's investigations began taking longer, resulting a backlog. OIG acted to improve timeliness and enhance the system:

• Ensured timely reporting of allegations by identifying late facility or agency calls;
• Improved case management through new supervisory expectations and new regular database reports;
• Streamlined case review to shorten the time a draft report is in review;
• Began using encrypted e-mail to send reports to facilities and administrators;
• Created an internal case file repository and ensured that all case reports from FY 2004 were included;
• Expedited requests for reconsideration or clarification;
• Implemented a new legal requirement that OIG track Written Response compliance by corrective action plans as approved by the respective Department Divisions
• Reviewed and revised the procedures for Nurse Aide Registry referrals to the Department of Public Health;
• Completed a database conversion and upgrades to improve stability and case management.

During FY 2004, OIG conducted 27 training classes, training 363 staff in reporting expectations and 278 staff in basic investigative skills. OIG also authorized 191 community agencies to conduct mental injury investigations.

As a result, OIG improved the timeliness of its investigations during FY 2004, finishing the final quarter of the fiscal year with an average of 61 working days/case, approximating the sixty day expectation in Rule 50.

Domestic Abuse Program

During FY 2004, OIG received 457 calls alleging domestic abuse, neglect or exploitation; 452 calls were eligible, a 25% increase over last fiscal year.

Neglect allegations increased 66%, while abuse and exploitation allegations changed slightly. Neglect has risen steadily over the program's four years but dropped in the second half of FY 2004.

The program closed 452 cases in FY 2004:

• 51 complaints were ineligible;
• 109 victims refused the assessment;
• 232 were not substantiated; and
• 60 were substantiated -
  • 33 substantiated abuse,
  • 26 substantiated neglect, and
  • 1 substantiated exploitation.

Most substantiated cases were referred to the Division of Developmental Disabilities for development of a service plan to link individuals to needed services.

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Department of Human Services' Office of the Inspector General

1.1 OIG Annual Report

This section of the FY 2004 Report covers the role of the Office of the Inspector General (OIG) in investigating and preventing instances of abuse, neglect, or death of individuals receiving mental health or developmental disability services in a program operated, licensed, accredited, certified or funded by the Department of Human Services (DHS). This report is required by law (210 ILCS 6.7).

1.1.1 Law and Mission

In 1987, the Abused and Neglected Long Term Care Facility Residents Reporting Act was amended to create the Office of the Inspector General and mandated the Inspector General investigate allegations of abuse and neglect in facilities operated by the DHS legacy Department of Mental Health and Developmental Disability (See 210 ILCS 30/6.2).

During the 1992 session, the legislature passed a bill expanding OIG's role by requiring OIG to conduct annual unannounced site visits to these facilities. This bill was signed into law in September 1992.

In November 1995, the legislature approved a further expansion of OIG's authority to investigating allegations of abuse/neglect and deaths in community agency programs that are licensed, funded or certified by the department and not licensed by another State agency. This bill was signed into law in December 1995 as Public Act 89-427.

Pursuant to this law, the department created a Task Force comprising representatives from a wide range of involved entities and individuals to create an administrative rule to guide reporting and investigating. The result was Rule 50, officially known as 59 Illinois Administrative Code, Chapter I, Part 50, which became effective in October 1997.

In July 2000, the legislature again expanded the jurisdiction of OIG. Through Public Act 91-671, OIG was mandated to conduct investigative assessment of allegations of abuse, neglect or exploitation of adults with disabilities who live in domestic settings.

During the 2001 session, the legislature again amended the statute to give OIG statutory authority to report to the Department of Public Health's Nurse Aide Registry the names of employees of State-operated facilities and community agencies who committed and have a substantiated finding of physical abuse, sexual abuse or egregious neglect against them. This law had an effective date of January 1, 2002 and Rule 50 was thus revised (final Rule 50 became effective May 24, 2002).

The mission of OIG is to assist agencies and facilities in prevention efforts by investigating all reports of abuse, neglect and mistreatment in a timely manner, to foster humane, competent, respectful and caring treatment of persons with mental and developmental disabilities.

1.1.2 New Legislation

During Fiscal Year 2004, two significant pieces of legislation affecting OIG became law. These are described in more detail in section 1.8.

Public Act 93-636

Effective December 31, 2003, this law:

• Separates OIG's budget from DHS's;
• Removed the "sunset" provision of OIG;
• Requires OIG to monitor written responses by facilities and agencies of cases that are substantiated or have other issues or recommendations; and
• Puts the Quality Care Board under OIG.

Public Act 93-423

This law, which also became effective December 31, 2003, allows DHS to issue badges to employees who are not peace officers, if the badge is needed to carry out official duties. OIG is now developing badges for its investigators.

1.1.3 Organizational Structure

For Rule 50 investigations, OIG is divided into four jurisdictional bureaus: North, Metro, Central and South.

The North Bureau covers twenty counties: Boone, Bureau, Carroll, DeKalb, DuPage, Henry, JoDaviess, Kane, Lake, Lee, Marshall, McHenry, Mercer, Ogle, Putnam, Rock Island, Stark, Stephenson, Whiteside, and Winnebago. This area includes 2,116 program sites operated by 178 community agencies, as well as four State-operated facilities:

• Elgin MHC (Elgin),
• Kiley DC (Waukegan),
• Mabley DC (Dixon), and
• Singer MHC (Rockford).

The Metro Bureau covers nine counties: Cook, Ford, Grundy, Iroquois, Kankakee, Kendall, LaSalle, Livingston, and Will. This area includes 2,529 program sites operated by 201 community agencies, as well as seven State-operated facilities:

• Chicago-Read MHC (Chicago),
• Fox DC (Dwight),
• Howe DC (Tinley Park),
• Ludeman DC (Park Forest),
• Madden MHC (Hines),
• Shapiro DC (Kankakee), and
• Tinley Park MHC (Tinley Park).

The Central Bureau covers 46 counties: Adams, Bond, Brown, Calhoun, Cass, Champaign, Christian, Clark, Coles, Crawford, Cumberland, DeWitt, Douglas, Edgar, Effingham, Fayette, Fulton, Greene, Hancock, Henderson, Jasper, Jersey, Knox, Logan, Macon, Macoupin, Madison, Mason, McDonough, McLean, Menard, Montgomery, Moultrie, Morgan, Peoria, Piatt, Pike, Sangamon, Schuyler, Scott, Shelby, St. Clair, Tazewell, Vermilion, Warren, and Woodford. This area includes 1,338 program sites operated by 111 community agencies, as well as three State facilities:

• Alton MHC (Alton),
• Jacksonville DC (Jacksonville), and
• McFarland MHC (Springfield).

The South Bureau covers 27 counties: Alexander, Clay, Clinton, Edwards, Franklin, Gallatin, Hamilton, Hardin, Jackson, Jefferson, Johnson, Lawrence, Marion, Massac, Monroe, Pope, Perry, Pulaski, Randolph, Richland, Saline, Union, Wabash, Washington, Wayne, White, and Williamson. This area includes 537 program sites operated by 63 community agencies, as well as four State-operated facilities:

• Chester MHC (Chester),
• Choate DC (Anna),
• Choate MHC (Anna), and
• Murray DC (Centralia).

A map of these bureaus is displayed below:

Figure 1. Rule 50 Bureaus

1.1.4 Program Collaborations

OIG maintains good working relationships with the other entities with statutory or administrative authority to receive allegations of abuse or neglect. Some have an investigatory role, while others have an oversight role. See page 34, Table 1 which lists the entities that are to receive allegations of abuse and neglect of individuals with disabilities and shows the target population and the primary jurisdiction, if limited.

1.2 Impact of Rule 50 OIG Investigations

1.2.1 OIG Substantiations

OIG's most direct impact is when it substantiates abuse or neglect. Here are some examples of substantiated cases during FY 2004.

Impact of Nurse Aide Registry (NAR)

Physical Abuse

An agency reported an allegation to the local police that a staff member hit an individual on the head with a bat. Despite having relevant injuries and giving consistent testimony, the individual refused to press charges. In OIG's investigation, the accused staff member admitted to hitting the individual to protect himself when the individual became aggressive toward him. Physical abuse was substantiated. Thus despite the fact that the victim was unwilling to press criminal charges, through our investigation OIG will nonetheless be able to request that the accused be placed on the Nurse Aide Registry thereby preventing him from further employment in a publically funded department which services persons with disabilities. As a result of this finding the employee was terminated.

Sexual Abuse

An investigation into a sexual abuse allegation found that the accused male employee admitted to having been in a female client's residence at 10:30 pm. He did not have authorization, did not tell his supervisor, and did not document his visit, all of which violated agency policy. The two watched a pornographic movie and engaged in sexual acts. The client could describe identifying marks and the allegation was substantiated. The accused in this case will similarly be referred to the Nurse Aide Registry.

Substantiated mental injury example

A staff member allegedly left an individual in a medically necessary standing device for nearly twice as long as ordered. The staff member allegedly tried to coerce the underweight individual to request release by using a communication device or the employee would throw away his dinner. When the individual failed to comply, the staff member allegedly threw the dinner away and did not offer him another meal that evening. The investigation substantiated both abuse by mental injury and neglect. As a result of this finding the employee received a suspension.

Substantiated neglect example

While running in a dining room, an individual slipped and fell, striking his head on a wooden chair. Staff immediately notified a supervisor and an RN. The nurse did not properly assess the individual's condition, told staff to move him several times without immobilizing his neck, and neither notified a physician nor sought medical treatment for two hours. The individual was later found to have had a severe cervical fracture and died several weeks later. The allegation of neglect was substantiated. As a result of this finding one employee will be referred to the Nurse Aide Registry while the other will be disciplined.

Substantiated abuse and neglect example

An individual sustained a fractured toe and severe bruising to several areas of her body. The investigation substantiated that staff had punched her and struck her with a large wooden pole. The investigation also revealed that other staff on duty had witnessed the abuse but did not try to stop it or to get medical attention. Both abuse and neglect were substantiated. As a result of this findings the three (3) employees were terminated.

For a complete analysis of the impact of OIG investigations refer to page 23.

1.2.2 Other OIG Issues: The impact of OIG investigations is not limited to substantiated cases.

Often OIG also makes an impact by identifying other issues that require administrative action by the facility or agency. Below are several OIG cases completed in FY04 that provide examples of the types of other issues OIG investigations find. Other impacts of OIG are given later under Written Responses (section 1.3.7).

Hot water regulators

An individual who had just soiled himself was told to step into a bathtub and turn on the water. The employee left him standing in the water for about 10 minutes before checking the temperature. The individual received second degree burns on both feet, requiring hospitalization. OIG not only substantiated neglect, but recommended that the agency install governors on all hot water heaters to ensure that the tap water does not reach scalding temperatures.

An individual was found with second degree burns on his legs, stomach and neck. The investigation found that the burns were suffered when the individual took a shower and the staff had not checked to ensure the controls on the hot water heater were working. Further, the agency's nurses had not provided appropriate medical care for two days. OIG made recommendations to the agency to address all these issues to prevent further scaldings.

Staffing ratios

An individual, who had been allowed to go the restroom unescorted, left the building and ran onto a highway where he was struck by a vehicle and died. The agency did not have enough staff on duty supervising the day training program, so there was no one to escort the recipient to the restroom. In addition to substantiating neglect, OIG recommended the agency develop a policy to ensure proper staffing ratios at all times.

An individual shaving himself in a bathroom alone at night injured himself with his electric razor. The individual's plan requires that an employee be in the same room with him at all times during the day but does not require this if he is up at night. Instead, the facility allows staffing ratios of one staff to sixteen individuals on the night shift. OIG recommended these staffing levels be reviewed.

Dangerous items

Following a verbal altercation, one individual used a key that a staff member had left hanging on a hook above the stove, took a knife from a locked closet in the kitchen, and attacked another individual, cutting him on the chest and stomach. The aggressor was arrested by the local police. The agency had no policy addressing knives or employees' keys, so OIG recommended policies addressing these.

An individual on one-on-one supervision by his social worker grabbed and swallowed the social worker's nonprescription medication. The facility did not have, and so developed, policies requiring professional staff to be aware of supervision levels and clarifying expectations regarding contraband, including medications.

Supervision by the staff

A fight in a day room between two individuals left one badly injured. The individuals were in a group that was not adequately being monitored. The facility revised its staffing practices so that each employee is assigned to a specific group of individuals at all times.

An individual moved from one living unit to another and soon afterwards swallowed a coin. The staff on the new unit were not aware that the individual was on precautions because he eats inedible items. The facility created a procedure requiring staff to be trained in an individual's plan before he or she is moved.

Professional staff issues

A medication mix-up resulted when a nurse from a different living unit was assigned to dispense medications. OIG found there was no procedure for adequate identification of individuals at medication times. The facility revised the policy to a previous approach that required identification and annual training on medication administration that had previously had good results.

An individual was admitted to a facility from an agency program where she had been feeling sick. The medication she was receiving at the agency was not immediately available, so a physician ordered a substitute and blood test, which was normal. She did not improve and a second blood test showed very high levels of one of her other medications, due to drug interactions. OIG recommended retraining physicians and nurses on drug administrations and interactions and on documenting these in progress notes.

While at day training, an individual swallowed a metal ring and two batteries and needed surgery. He had not tried to eat inedible items for two years and the day training site's copy of his habilitation plan was outdated but nearly identical to the current one. OIG did not substantiate neglect, but recommended that the facility's treatment professionals ensure that day programs get current habilitation plans.

1.2.3 Clinical Reviews

OIG has two full-time clinical investigators, who are registered nurses, who assist investigators in planning, conducting and drawing conclusions in OIG cases. These clinical investigators also investigate all deaths, act as lead investigators in cases involving medical issues, and review agency or facility conducted investigations that address clinical issues. The clinical investigators may seek the assistance and opinions of the Clinical Services, Division of Mental Health, Division of Developmental Disabilities, to assist in determining the appropriateness of medical care provided by a facility or agency.

Death cases

The majority of death cases completed in FY 2004 were due to natural causes that involved cardiac failure, cancers and pneumonia. These recipients lived well beyond their life expectancy considering their disabilities and associated serious medical problems, due to advances in medical technology and science and the medical professionals who provide health care. No trends or patterns were identified in these natural causes of death.

Deaths in residential community programs

The clinical investigators reviewed deaths from community agency operated residential programs that had two or more deaths during the last fiscal year. This reviewed the entire state.

Heart disease was the leading cause of death. This includes conditions such as hypertension, acute heart attack, and terminal cardiac myopathy.

Pneumonia was the second leading cause. All of these individuals had many co-existing medical problems such as cerebral palsy, gastrostomy tubes, and mobility problems.

It is not surprising the cases of pneumonia, the individuals served are extremely fragile and other medical conditions present prevent normal swallowing, gag reflex and mobility. No problems were identified within any particular agency and it appears the individuals are receiving surprisingly good care considering the amount of care they require and their living situations.

Five deaths were due to choking. Three of the choking deaths were determined to be accidental with no identifiable issues of concern regarding the care provided.

Substantiated/recommendation deaths

In five deaths occurring in community setting, OIG substantiated neglect or made recommendations. One is discussed later; the other four are:

This particular place is now closed, however recommendations were made in the area of documenting frequent observation of individuals.

This case was substantiated. The individual died from asphyxiation from choking. The individual was served regular food when he was to have all of his food pureed. The individual was also left unattended during this time while staff conducted personal business.

This case was also a substantiated case of choking. The individual died of choking on peanut butter. The investigation revealed the QMRP failed to communicate dietary instructions to the staff at the day training site.

This case was substantiated due to failure to provide adequate supervision to clients and a failure to implement established treatment plans.

Recommendations

Based on these reviews, the clinical investigators made the following recommendations:

Initiating CPR is a concern that has not appeared in this past year but has recently become more important due to the increased number of chronically ill older recipients. The recommendation was made to the facility directors to view their policies regarding CPR and to ensure that employees are competent in performing this skill.

DD facilities

Clearly the DD facilities had the greatest number of deaths.

Howe DC, Ludeman DC, Fox DC, and Murray DC all had five or more deaths. There were no identifiable patterns or trends noted in any of the cases to suggest problems with inadequate care. Shapiro Center had 12 deaths in the past fiscal year. All of the deaths have been carefully reviewed with no particular identifiable patterns or trends. This Center is a large facility and the population has multiple medical problems. Many individuals are surprisingly old, and with advanced technology individuals are living much longer than once expected.

Only one death case was substantiated. The case involved unclear policy and interpretation of Lithium monitoring. As a consequence the individual received inadequate monitoring and care becoming toxic. He was transferred to the local hospital where he developed pneumonia and died.

MH facilities

There was only one case with recommendations made to improve care. The case involved the death of a young man after discharge to the hospital for pneumonia. The family complained McFarland failed to send vital medical information needed to treat the patient. It was discovered the information was indeed faxed but lost at the hospital. McFarland now keeps a communication log of all communications sent regarding the medical care of their patients.

There were no suicides occurring within the hospitals and three that occurred after discharge. There were no issues found in any of these cases such as a questionable discharge or inappropriate placement.

Neglect cases

Even though there don't appear to be any particular problems identified within certain agencies, the following are concerns that seem to appear throughout.

Burn incidents have decreased, but even one is too many. Directives have been established to monitor the water temperature, but how well this is being done is questionable. Locks should be placed on the controls as they are on thermostats.

Dragging individuals has appeared in several cases. It appears this has happened from frustration of staff, lack of assistance, and lack of proper training to handle the situation. Dragging injuries are very painful and can cause some severe burns quickly, and it is also undignified.

The clinical investigators did not recommend that peanut butter be removed from all diets, but noted that it is easily choked on by many individuals especially in this population due to dry mouth, difficulty swallowing and improper chewing.

Lastly, a common complaint among community physicians is lack of medical history provided to them from agencies when they are expected to provide treatment to individuals who cannot communicate their needs.

Two other cases that the clinical investigators believed to be significant were:

This case involves the unfortunate death of a woman due to a bowel obstruction which may have been avoided had she received proper nursing assessments and treatment. Communication was also very poor and her symptoms were not communicated to the nurses and physician resulting in a delay in treatment that was too late.

This case involves an individual who died as a result of choking on a peanut butter sandwich. The investigation revealed dietary instructions were not communicated to the DT center that would have alerted the staff to monitor the individual and avoid peanut butter when he had a known choking problem.

1.3 System Enhancements

During FY 2004, OIG proactively enhanced its abuse/neglect reporting, investigating, case management, and prevention efforts in numerous ways. This section describes many of these system enhancements, which are described below under the following headers:

• 1.3.1 Ensuring Timely Reporting
• 1.3.2 Improving Case Management
• 1.3.3 Streamlining Case Review
• 1.3.4 Encryption for E-mailing
• 1.3.5 Case File Repository
• 1.3.6 Reconsiderations/Clarifications
• 1.3.7 Written Response Complaince
• 1.3.8 Nurse Aide Registry Referrals
• 1.3.9 Database Conversion and Upgrades

1.3.1 Ensuring Timely Reporting

Time frames for self-reporting

Prompt reporting of allegations of abuse or neglect, deaths, and other incidents is critically important for quality investigations. OIG has taken several proactive steps to ensure that facilities and agencies report all allegations and incidents in a timely manner. These steps address self-reporting - reporting by the facility or agency directly - not reporting by complainants such as patients or their families.

In FY 2002, OIG revised administrative Rule 50 to establish clear and reasonable time frames for initial reporting. Staff at facilities or community agencies must report each initial allegation of abuse and neglect within four hours of becoming aware of it. Deaths must be reported to OIG within 24 hours. In all cases, basic information must be gathered during that time frame, so that the initial report is adequate for OIG to determine how to proceed.

Additional steps

During FY 2004, OIG implemented three specific system enhancements aimed at ensuring timely reporting of allegations to OIG by facilities and agencies.

• OIG Intake investigators now ask for an explanation whenever a facility or agency staff reports an allegation or incident beyond the required time frames. The Intake investigator then includes any explanation in the completed Intake form sent to the investigative bureau.
• Printed intakes now automatically flag a case if an allegation or death is reported beyond the required time frames. This late reporting flag is a statement immediately below the date and time of the report; it says simply, "Case was reported late." The investigative bureau can then follow up during the investigation. If the database cannot determine if the report was late or not (for example, if the date the allegation was discovered is unknown), the flag prints out as: "Check for late reporting." Investigators who then receive the intake know to check into that issue.
• OIG sends to the DHS program divisions a monthly list of late reported cases, so the DHS program divisions can follow up with the facilities and agencies that reported late. This monthly report prints each division on a separate page, and then sorts the cases in case number within each facility or agency, which allows for easier follow-up by the division.

Results

By taking proactive steps, OIG has improved the timeliness of initial reporting. During FY 2003, 295 of 1,161 self-reports were late to OIG (25%); during FY 2004, only 228 of 1,010 self-reports were late (23%). For further discussion of the timeliness of initial reporting during FY 2004, please see section 1.5.4.

1.3.2 Improving Case Management

Case Initiation Reports

OIG developed a form called the Case Initiation Report (CIR). The CIR has two functions: to document the opening of an OIG investigation; and to close unfounded allegations.

Documenting opening of an investigation

When an allegation is reported to OIG, an intake investigator takes the information and forwards a completed intake form to the appropriate OIG investigative bureau. The chief of that bureau assigns the case to a bureau investigator to review the initial evidence and complete a CIR, usually within three working days.

Once the investigator reviews the initial evidence that has been gathered for the case, he/she will make a determination if the case should be opened and to whom it should be assigned. He or she completes a CIR with this information and forwards it to the bureau chief for review and approval. So the CIR documents what initial action was taken on the case, why it was opened for investigation and to whom it is assigned.

This form enables the investigator and bureau chief to review and take appropriate action more quickly. This has led to a faster response to allegations that previously would not have had any action on them until the investigator had time to review it. Interviews are conducted sooner, while the information is still fresh in the minds of the individuals involved in the case. The case report's information can thus be more accurate and detailed.

The CIR also officially documents what has been done initially on a case and whether OIG opened an investigation, referred the complaint out to an appropriate entity, or closed the case. This form has improved OIG case management by both speeding initial case handling and documenting the reasons for the initial actions taken.

Closing unfounded allegations

The Case Initiation Report (CIR) can also be used to document that an allegation is without any credible evidence supporting it ("unfounded") and then close the case.

If the investigator's initial review of the case finds no credible evidence supporting the allegation, the case may be closed without any further investigation. If the case is closed as unfounded, the investigator is still required to write a summary of the evidence to show there is no credible evidence. This summary and the decision to close the case are documented with the CIR.

The form may also be used for this purpose later in the investigation. That is, if an investigator determines during the course of the investigation that no credible evidence exists to support the allegation, he or she may use the CIR to recommend closing the case as unfounded.

"Unfounded" cases may still raise important issues, such as the need to address concerns that may have prompted the unfounded allegation. The CIR allows the investigator to close the case as "unfounded with recommendations" to the facility or agency.

Using the CIR to close unfounded allegations has allowed cases to be closed down quicker and easier, as the report is shorter and easier to write than a full investigative report. This has had a positive impact on OIG operations as it has quickly closed cases with no credible evidence, thus reducing the investigative time for the case and reducing the backlog of cases OIG has historically faced. It also allows OIG to focus investigative time and energy on cases with more substance.

Daily and Quarterly Reports

During FY 2004, OIG developed new daily and quarterly case management reports. The goal is to provide OIG's investigative managers current and retrospective information to assist in managing cases and the caseloads of field investigators.

Daily report

After each workday, OIG runs a daily report and places it in a computer network directory that allows the report to open automatically on OIG staff computers in every office around the state when they are turned on.

The daily report, entitled, "Case Management Highlights" for the day, contains six sections.

Locations that have more than two open administrative leave cases - Facilities or agencies that have more than two cases where at least one staff member is on paid leave while the investigation is ongoing, and how many of the cases are over 45 working days old;

Pending investigations by Bureau - The number of cases each OIG investigative bureau has that have not yet been completed, and how many of these are over 60 working days old;

OIG investigators with more than five unsubmitted cases over 60 days old - OIG investigators who have more than five active investigations that have not yet been submitted for review;

Types of allegations with more than 20 open cases - Categories of allegations (physical, abuse, domestic neglect, sexual abuse, serious injury, etc.) that are most common among active OIG investigations;

Locations with more than 15 open cases - Facilities and agencies where OIG has more than 15 active investigations; and

Locations with open law enforcement cases - Facilities and agencies where local law enforcement agencies are investigating at least two of the open cases.

Each time an OIG employee turns on his or her State computer, the daily report automatically opens, displaying the entire one-page report. This highlights critical areas for attention and supports investigative management.

Quarterly reports

In addition to the daily report, the computer directory contains three quarterly reports that provide data about intakes, closures, and active OIG investigations and highlight specific performance indicators. These reports thus represent another system enhancement for OIG to improve case management.

The first quarterly report is in two parts. The first page, Quarterly Investigative Management Report - Status by Bureau, is OIG's main report. It shows data about OIG investigations overall and by bureau. Information on the report shows counts of OIG investigations opened, active, completed, and closed (i.e., the reconsideration period has ended) during the quarter, along with percentages by bureau. This report also shows the average working days to completion for OIG investigations and the findings in closed cases.

A second page of this report gives Status by Facility. It shows the same basic information as the main report, but excludes Domestic Abuse Program (Rule 51) cases. This report breaks out the information by facility, rather than by bureau. A single line summary of all OIG investigations at community agencies allows comparisons to all OIG investigations at the facilities.

The second quarterly report is the Quarterly OIG Investigations Management Report - Status by Agency. It provides the same basic information as the main report, but again excluding Rule 51 cases. This report breaks out the information by community agency. Since OIG may delegate to trained agency investigators the responsibility to investigate allegations of mental injury or neglect, two extra columns report the number of investigations assigned to the agencies and the number of pending at the end of the quarter.

The final quarterly report is entitled Quarterly Investigative Management Report, by Bureau and Investigator. It also provides the same basic information as the main report, but it breaks the information down by OIG investigator within each bureau. So this report allows direct comparisons between investigators within and across bureaus.

Administrative Leave Monitoring

System enhancements

When an employee is alleged to have committed abuse or neglect, the facility or community agency may place him or her on a paid leave of absence pending the outcome of the ensuing investigation. Since the employee is being paid while not working, OIG has always put a priority on completing such "administrative leave" cases.

Beginning in mid-FY 2004, OIG took steps to further enhance the handling of these cases. First, OIG began sharing information with DHS Personnel on OIG and State Police investigations in which a facility employee was on administrative leave for alleged abuse/neglect. By notifying DHS Personnel directly when a case had been closed, OIG might speed administrative action.

In addition, OIG and DHS formed a committee to ensure consistency in: placing employees on administrative leave; notifying facilities of credible evidence; taking actions during an investigation; and monitoring of administrative leave cases.

Finally, OIG began including tentative completion dates in regular monitoring reports. As a result of all these steps, OIG has been able to help reduce the costs of administrative leave cases.

Results

In November 2003, at the onset of the system enhancements, 58 facility employees were on paid administrative leave during an OIG investigation. Of those, seventeen were in cases that OIG had already completed yet the employee remained on administrative leave. During the following months, OIG completed more than 70 cases involving administrative leave.

At the end of June 2004, 40 facility employees were on paid administrative leave due to OIG investigations and all but six of these had already been completed. Consequently, 85% fewer employees were on paid administrative leave for outstanding OIG investigations, although another 22 were on administrative leave for Illinois State Police investigations.

1.3.3 Streamlining Case Review

When an OIG investigator drafts a case report detailing the findings of the investigation, he/she submits it to an investigative manager for review and approval. Occasionally, this reviewer sends the case report back for clarification, corrections, or additional investigative work.

Review time can add significantly to the length of time to completion. During FY 2003, review time (including any additional investigative work) accounted for nearly 40% of the total time to completion for OIG investigations. With the loss of staff due to the Early Retirement Incentive (ERI), OIG faced the prospect of substantial increases in review time for its cases. As a result, even with the loss of staff due to ERI, review time has decreased.

Near the beginning of FY 2004, OIG streamlined its internal review process for draft case reports in order to use staff time more efficiently and to reduce the backlog of cases, as well as to compensate for the loss of staff due to ERI. The overall goal of the new process is to enable OIG to close investigations more efficiently and quickly, while not sacrificing quality.

The most significant change in the case review process was to allow the Bureau Chiefs to approve substantiated cases of mental injury and neglect that is not egregious. Formerly, these would have required another level of review. Now, these reports are reviewed in the same manner as cases that are unsubstantiated or unfounded. As a result, OIG reports can be completed and sent to the relevant facility or community agency more quickly.

All substantiated allegations of physical abuse, sexual abuse, or egregious neglect still require review by the Inspector General or designee. The accused persons in these cases will be reported to the Illinois Department of Public Health's Nurse Aide Registry (section 1.3.8).

1.3.4 Encryption for E-mailing

OIG sends its completed investigative case reports to the authorized representatives and to appropriate DHS managers when abuse, neglect, or other administrative issue is substantiated. To make distribution faster, less expensive and more reliable, OIG has been working toward transmitting all internal DHS copies by electronic mail ("e-mail").

However, to keep protected health information secure as required by the Health Information Portability and Accountability Act (HIPAA), OIG has first been encouraging and facilitating the department's move to encryption of e-mails. Reports will then get to their intended recipient more directly, with less chance of mishandling, wrong delivery, or loss.

Beyond simply creating a "paperless office," the encryption and e-mailing process enhances the system in specific ways:

• It speeds the distribution of investigative reports that require action.
• It ensures that the case reports reach their destination, providing automatic responses when not deliverable.
• It decreases the amount OIG spends on paper and postage.
• It allows for immediate replies from facilities and from DHS managers.
• It reduces the chance of inappropriate release of protected health information.

Beginning with the start of FY 2005, all internal DHS distribution of OIG case reports will be done by encrypted e-mail.

1.3.5 Case File Repository

Rapid access to information is critical in many endeavors, and such is the case in investigations. Thus, Inspector General Roberts envisioned an electronic library holding all OIG investigative case reports in one location, allowing OIG users to access them while still maintaining security.

To this end, OIG staff wrote the programming necessary and, during FY 2004, implemented the Case File Repository holding OIG intakes, typed interviews, investigative case reports, interviews and initial written responses. The program features a simplified Windows-type graphical interface and built-in security running in tandem with local server and wide area network security. The Repository is in a single location and access is secure and limited to OIG staff.

All documents on the Repository are "read-only," which means that they cannot be altered and then re-saved. Only clericals can add new documents and only database managers can replace them.

All OIG staff have direct access to the Repository from their computers. Further, the Repository opens automatically on every desktop computer when the computer is turned on, displaying the latest daily case management report.

The Repository enhances OIG investigations by making previous case reports available to all staff. For example, investigators receiving a new case can read previous reports involving an alleged victim or accused employee.

1.3.6 Reconsiderations/Clarifications

Requests

State law allows the facility or agency, alleged victim, his/her guardian, and any accused person to request that OIG clarify or reconsider the finding in an OIG investigation (Section 6.2(b-5) of 210 ILCS 30).

Rule 50 lists specific requirements for these reconsideration or clarification requests (Section 50.60(b) of 59 Illinois Administrative Code, Chapter I, Part 50). Any request for reconsideration or clarification of an OIG investigative report must meet the following requirements:

• The request must be submitted to OIG in writing.
• A request from a facility or community agency must be on letterhead, signed by the authorized representative.
• The request must clearly identify whether it is asking for reconsideration or clarification.
• A reconsideration request must include information that was not in the report and that could change the finding.

Process

The respective bureau chief initially reviews the request to determine whether it is a request for clarification or for reconsideration request. If it is requesting clarification of the findings, the bureau chief handles it with a letter.

If it is requesting a reconsideration, the process has involved convening a committee of seven high-level OIG staff to review the information presented to determine, first, if it is new information and then, if so, if it changes the outcome of the investigation. This committee met on every request, regardless of the information presented, and the process was cumbersome and time-consuming.

System enhancement

During FY 2004, OIG revised the process for handling reconsideration requests: the committee membership was changed to ensure additional objectivity, and a threshold for convening the committee for a hearing was established.

Committee membership

The reconsideration committee now comprises the following staff: the Inspector General, the Deputy Inspector General, the Special Assistant to the Inspector General, one investigative bureau chief, one investigative team leader, and one investigator. Also present but non-voting are: the investigative bureau chief for the case at issue, one staff member from OIG Training, one staff member from OIG Policy Development, and an administrative assistant to the Inspector General.

Threshold for meeting

The new process does not require the entire committee convene for every reconsideration, but meets as determined by the Inspector General. When a request for a reconsideration is received, the respective bureau chief completes a Reconsideration Review Form, which calls for an analysis of the information presented in the request and a formal recommendation whether to grant the reconsideration request or not.

The bureau chief sends the completed form along with the reconsideration request and a copy of the investigative report to both the Inspector General and the head of Policy Development. The head of Policy Development reviews the documents, discusses the issues with the involved bureau chief if necessary, and then forwards a recommendation to the Inspector General.

The Inspector General may concur with these recommendations, making a decision immediately. If, on the other hand, the Inspector General determines that input from the full committee is needed either to decide the issues raised or to discuss a training or policy issue, the full reconsideration committee is convened.

1.3.7 Written Response Compliance

When OIG substantiates abuse, neglect, or other administrative issue in an investigation, the facility or agency where the incident occurred is required by law to provide a response in writing. The law requires that the Written Response detail the actions that will be taken to address the findings and list implementation dates for each of those actions. DHS program divisions, as the Secretary's designees, are responsible for reviewing and approving Written Responses.

On December 31, 2003, however, OIG was given new statutory responsibility for reviewing the implementation of Written Responses. The new law, Public Act 093-0636, requires that OIG monitor compliance with the approved Written Responses; that is, OIG must follow up to ensure completion of the actions identified. Follow-up may include site visits, telephone contacts, or requests for written documentation.

The law further requires that OIG review any implementation plan that takes more than 120 days, as well as monitor compliance through a random review of the corrective actions.

In response to the new legislative mandate, OIG revised an existing OIG Directive (SS03-005) in February 2004. OIG also drafted a protocol to operationalize the policy and, after a trial period, the protocol was implemented in April 2004.

WR Compliance Procedures

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

For each case, the Compliance Reviewer gives the agency or facility: an overview of the process, including the new law's goal and requirements; a copy of the Written Response being reviewed; and a detail of the planned review - documents needed, persons to be interviewed, etc. The Compliance Reviewer determines if the corrective actions have been implemented and then sends a letter indicating whether the agency or facility is in compliance or not.

WR Compliance Findings

During April through June 2004, OIG reviewed eleven Written Responses, conducting six desk reviews and four site visits; another site visit is planned after the corrective action is completed. Eight were found in compliance, two are waiting future activity, and one was out of compliance.

1.3.8 Nurse Aide Registry Referrals

Overview

In FY 2002, a new law was passed mandating that OIG refer to the Illinois Department of Public Health's Nurse Aide Registry the name of any employee with a substantiated fining of physical abuse, sexual abuse, or egregious neglect of an individual in a program operated, licensed, or funded to provide mental health or developmental services.

The purpose of the mandate was to ensure that there would be a public record of such findings. Thus, for example, agencies and facilities would be able to check the names of job applicants in a public record for prior instances of abuse or egregious neglect. Anyone so listed would in effect be barred from working with individuals with mental disabilities.

However, since the Department of Public Health's Nurse Aide Registry is accessible to hospitals, nursing homes, respite care programs and other settings with vulnerable populations, they can also avoid hiring inappropriate persons.

OIG thus has a significant impact on the system of services by helping to ensure that persons who have a history of abuse or neglect of individuals with mental disabilities in one setting do not get hired into a similar setting.

Due Process Rights

Because the loss of employment is a serious consequence, certain rights were mandated by the law and have been built into the administrative regulation (Rule 50). To ensure that names are not inappropriately listed, five avenues of review are available to accused employees. They may:

• Ask OIG to reconsider the case finding based on new or omitted facts not considered during the investigation (a "reconsideration");
• Request a DHS administrative law judge to review the type or severity of discipline or administrative action taken against the employee (a "Rule 50.80 appeal");
• Request a DHS administrative law judge to determine that the evidence presented is insufficient or the planned administrative action is too severe to support listing the employee's name on the Nurse Aide Registry (a "Rule 50.90" appeal);
• File a formal complaint against any administrative action taken against the employee, if a bargaining unit employee (a "grievance"); and
• Ask a DHS administrative law judge, once listed on the Registry to remove the name from the Registry based on evidence that the employee has been rehabilitated and it is now in the public interest to remove his or her name (a "Rule 50.100" appeal).

OIG's Impact: Referrals

In FY 2004, OIG reported 54 employees to the Nurse Aide Registry. All were for substantiated abuse or egregious neglect of individuals with mental disabilities.

In comparison, in FY 2003, OIG reported 27 names, which shows the increasing effectiveness of the process. The law allowing OIG to report names to the Registry became effective for incidents occurring after January 1, 2002, so no names were reported in FY 2002.

By offense

In FY 2004, the most common reason for referral was physical abuse, accounting for 49 of the 54 referrals. Four referrals were for sexual abuse; one was for egregious neglect (see Table 2). In FY 2003, all referrals were for physical abuse, except for one, which was for sexual abuse.

Table 2. Registry Referrals by Offense, FY 2004

	Facilities	Agencies	Totals
Physical abuse	20	29	49
Sexual abuse	2	2	4
Egregious neglect	0	1	1
Totals	22	32	54

By location

Also obvious from the table is the larger number of referrals being from agencies. This was also true in FY 2003. Community agency employees accounted for 21 referrals in FY 2003 but 32 referrals in FY 2004 (a 160% increase).

However, there was a greater increase in reported names being from the facilities between the two years. Facilities' employees accounted for six referrals in FY 2003 but 22 referrals in FY 2004 (a 360% increase).

Therefore, about 40% of the names referred to the Registry in FY 2004 were employees of facilities, while less than a quarter of the FY 2003 referrals were.

Most facilities and agencies did not have any employees whose names were ultimately referred to the Nurse Aide Registry during FY 2004. Several facilities and agencies had only one. However, seven facilities and four agencies had more than one employee who was referred to the Registry in FY 2004.

Facilities from which former employees were reported to the Nurse Aide Registry in FY 2004 were:

• Kiley DC, five;
• Chester MHC, three;
• Shapiro DC, three;
• Choate DC, two;
• Elgin MHC, two;
• Jacksonville DC, two;
• Singer MHC, two;

Agencies from which former employees were reported to the Nurse Aide Registry in FY 2004 were:

• Charleston Transitional Facility, four;
• Bethphage, three;
• Graywood Foundation, three;
• St. Clair Associate Vocational, two.

By job type

Nearly all of the referrals in FY 2003 and FY 2004 were direct care staff: i.e., employees who provide service directly to the individuals. However, none of these were professional staff, such as nurses and social workers. Few of the referrals were of administrative personnel, and these are only from community agencies (see Table 3).

Table 3. Registry Referrals by Job Type, FY 2004

	Facilities	Agencies	Total
Direct care staff	22	28	50
Professional staff	0	0	0
Administrative staff	0	4	4
Total	22	32	54

1.3.9 Database Conversion and Upgrades

During FY 2002, OIG implemented a new comprehensive database putting all investigative, training, and records data into one place. This allowed for direct input of intakes by the OIG Hotline staff, automatic case numbering, faster initial case handling, better case management, direct access by investigative managers, improved tracking of cases that might result in referral to the Nurse Aide Registry, and more extensive analysis of patterns and trends through a variety of data reports.

OIG is continuing to evolve the database into an increasingly usable tool to improve the efficiency and quality of investigations.

• In the fall of 2003, OIG staff developed new daily and quarterly case management reports (see above). The reports enable investigative management to maintain better control of caseloads.
• In January 2004, OIG staff automated most of the process of importing information about agencies from the database maintained by the DHS Bureau of Accreditation, Licensure and Certification. This data is imported monthly to ensure that information taken by the OIG Hotline Intake staff have the most current DHS information possible.
• In early March 2004, OIG and staff of the department's Management Information Systems completed a unique conversion, separating the database tables, which were put into DB2 software, from the rest of the database, which remained in Access 2000. The goal of this conversion was to enable greater stability, automatic back-ups and faster function for OIG's management staff in outlying offices.

OIG anticipates additional modifications to enhance OIG's functioning. Ideas include incorporating OIG personnel and budget data, creating downloads to DHS's Disclosure Tracking System for HIPAA, and orchestrating the connection to the Clinical Inpatient System to obtain more accurate patient information.

1.4 Public Information / Assistance

1.4.1 Presentations

During FY 2004, OIG made several public presentations on the role of the office in investigating and preventing abuse and neglect. The following is a list of the public speaking engagements conducted by OIG:

• Mar. 24, 2004
  Clay County Rehabilitation Services
• Apr. 28, 2004
  Association of Retarded Citizens (ARC)
• Apr. 30, 2004
  Illinois Association of Inspectors General
• June 10, 2004
  Hillsboro Medical Association

1.4.2 Training

OIG conducts training of community agency and facility staff on the requirements of Rule 50 and in Basic Investigative Skills. By ensuring that those staff understand the requirements in the Rule and by building competence in their initial response to incidents and allegations, OIG has improved the system of reporting and investigating, regardless of who eventually conducts the investigation.

During the time period immediately following the Early Retirement Incentive, OIG's two training coordinators were temporarily reassigned to assist in reducing the backlog of investigations and so improve timeliness. Training by OIG began again in mid-FY 2004.

OIG conducted 27 training sessions attended by a total of 641 people during FY 2004. The trainings were conducted on the following dates:

Administrative Rule 50

• Oct. 7, 2003 - 18 trained
• Oct. 14, 2003 - 24 trained
• Oct. 21, 2003 - 24 trained
• Nov. 4, 2003 - 42 trained
• Nov. 18, 2003 - 32 trained
• Dec. 2, 2003 - 29 trained
• Dec. 9, 2003 - 29 trained
• Feb. 10, 2004 - 13 trained
• Feb. 19, 2004 - 28 trained
• Feb. 24, 2004 - 16 trained
• Feb. 26, 2004 - 29 trained
• Mar. 11, 2004 - 37 trained
• Mar. 16, 2004 - 30 trained
• Apr. 8, 2004 - 12 trained

14 classes with a total of 363 trained

Basic Investigative Skills

• Oct. 8, 2003 - 14 trained
• Oct. 15, 2003 - 32 trained
• Oct. 22, 2003 - 17 trained
• Nov. 5, 2003 - 36 trained
• Nov. 19, 2003 - 23 trained
• Dec. 3, 2003 - 26 trained
• Dec. 10, 2003 - 25 trained
• Mar. 2, 2004 - 12 trained
• Mar. 23, 2004 - 29 trained
• Apr. 13, 2004 - 12 trained
• May 11, 2004 - 28 trained
• May 25, 2004 - 10 trained
• June 16, 2004 - 14 trained

13 classes with a total of 278 trained

New classes are scheduled for the fall of 2004.

1.4.3 Internet Website

The OIG's Internet website for OIG, was redesigned this fiscal year to improve public information and communication.

The website includes basic information about OIG and about abuse and neglect of individuals with disabilities. Topics covered include information and links to other protective agencies, a discussion of reporting, and an account of the investigation process.

The website also provides information to community agencies that provide mental health and developmental services, which are OIG's partners in preventing abuse and neglect. Copies of Rule 50 and of the agency investigative protocol can be printed from the website.

New this year:

• The site has been reorganized within the DHS website so that finding it and navigating within it are easier.
• The site has been modified to make it more accessible to people with disabilities.
• "About OIG," a webpage on the site, now has a biography of Inspector General Sydney R. Roberts, putting a face on the office.
• That same webpage has an updated history of the Office to include recent changes and accomplishments.
• The latest annual reports and OIG brochures are posted in "OIG Documents."
• The site now has a calendar of upcoming OIG training events with locations to assist community agency staff in obtaining updated training on Rule 50 and investigative skills.

OIG has been working on adding a registration database, which will allow community agency staff to register on-line for these trainings on Rule 50 and investigative skills. OIG hopes to have this webpage operational early in FY 2005.

1.4.4 Annual Protocol Authorizations

OIG will accept an investigation conducted by a community agency only after OIG has previously authorized the agency to conduct investigations and has assigned that particular case to the agency for investigation.

Authorization includes the agency completing four steps. First, the agency typically attends OIG-conducted Rule 50 training (see 1.4.2: Training). The agency should then train its staff on the expectations for reporting allegations. The text of Rule 50 can be found on the OIG website.

Second, at least one agency investigator must have successfully completed the OIG-conducted Basic Investigative Skills training course (see 1.4.2: Training).

Third, the agency must have adopted the OIG Investigative Protocol for Community Agencies as agency policy. The Protocol established procedures for reporting and investigating allegations of abuse and neglect.

Finally, the agency must be authorized to conduct investigations. The authorization process is in place to obtain commitments from the agency regarding desire to investigate, documentation of training, designation of investigators, and avoidance of any conflicts of interest. This authorization is for one fiscal year and must be approved by the Inspector General.

Re-authorization is not automatic. An annual review form must be submitted by the agency in May or June each year for the following fiscal year. Agency practices for the preceding year are considered during the re-authorization process and may result in denial.

For FY 2004, 191 community agencies were authorized by OIG to conduct investigations. The remaining 208 agencies either chose not to seek or were denied OIG authorization to conduct investigations.

1.5 Statistical Tables and Trends

1.5.1 Allegations Reported

By type

During FY 2004, OIG received 1,182 allegations of abuse or neglect. By type of allegation, OIG received the following:

• 716 allegations of physical abuse;
• 96 allegations of sexual abuse;
• 164 allegations of mental injury; and
• 206 allegations of neglect.

Allegations involving individuals with developmental disabilities accounted for 848, or 72% of the total, while allegations involving individuals with mental illness accounted for the remaining 334, or 28% of the total (see Tables 5 and 6 on pages 35 and 36).

These numbers do not include domestic abuse, neglect, or exploitation (457 cases), which are described in Domestic Abuse Program's annual report later in this report.

Further, these allegations do not include deaths that were reported to OIG. During FY 2004, OIG received reports of 135 deaths, which were discussed under Clinical Reviews (see 1.2.3).

By location

The facilities are listed in alphabetical order within service type in the tables on the next page. Forensic units are for individuals committed through the criminal courts or with behavioral problems requiring a more secure setting.

Since there are many more agencies, allegations at agencies are grouped into program types:

• CILAs, which are Community Integrated Living Arrangements;
• Other residential programs;
• DT programs, which are Developmental Training programs (DD service only);
• MH outpatient programs are non-residential based direct services (MH service only);
• Vocational programs; and
• Other community programs not classifiable elsewhere (e.g., MH day programs).

Again this year, more allegations were reported at the facilities than at community agencies providing mental health or developmental disability services. Allegations at facilities accounted for 55.6% of all allegations received during FY 2004 (see Table 4 below).

Table 4. Abuse/Neglect Allegations, FY 2004

	Abuse	Neglect	Totals
Facilities	589	68	657
Agencies	387	138	525
Totals	671	177	1182

As the table shows, the larger number from facilities is only in abuse allegations; two-thirds of the neglect allegations were at agency programs. However, among abuse types, sexual abuse and mental abuse allegations are nearly even, while only physical abuse allegations were more commonly at facilities, as shown below.

Figure 2. Allegations by Type and Location, FY 2004

	Facilities	Agencies
Physical abuse	458 (64%)	258 (36%)
Sexual abuse	49 (51%)	47 (49%)
Mental abuse	82 (50%)	82 (50%)
Neglect	68 (33%)	138 (67%)

1.5.2 Trends in Allegations

By allegation type

Between FY 2001 and FY 2004, allegations of abuse or neglect have decreased 38%. However, the bulk of the decrease has been in allegations of neglect and abuse by mental injury. As noted in last year's annual report, the definitions of these two types of allegations were changed in late FY 2002, and the decrease is largely attributable to those changes.

Allegations of physical abuse and sexual abuse decreased only 18% and 8.6%, respectively, since FY 2001. Further, since FY 2002, allegations of physical abuse have decreased only 7.6% and allegations of sexual abuse have increased 14% from 84 allegations to 96.

Since OIG investigates practically all allegations of physical or sexual abuse, the number of allegations investigated by OIG has not decreased proportionately.

By location

As facilities have closed and the number of individuals served has decreased, fewer allegations have been received about facilities. In FY 2001 and FY2002, over 60 percent of the allegations OIG received were from facilities. In FY 2004, only 55.5% were from facilities.

Minor increases from FY 2002 to FY 2004 were noted at the following facilities:

• Chicago-Read MHC - 19 to 22
• Choate DC - 111 to 118
• Fox DC - 1 to 3
• Howe DC - 55 to 64
• Jacksonville DC - 46 to 66

Roughly the same number of allegations were received in FY 2002 as in FY 2004 at:

• Kiley DC - 34 to 36
• Ludeman DC - 26 to 25
• Madden MHC - 21 to 19
• Murray DC - 15 to 13
• Singer MHC - 23 to 20

Decreases in the number of allegations received between FY 2002 and FY 2004 were at:

• Alton MHC - 83 to 45
• Chester MHC - 118 to 105
• Choate MHC - 26 to 22
• Elgin MHC - 146 to 26
• Mabley DC - 19 to 10
• McFarland MHC - 24 to 18
• Shapiro DC - 53 to 27
• Tinley Park MHC - 33 to 16

In FY 2002, parts of Elgin MHC and Alton MHC were closed, significantly reducing the number of individuals served, which may partly explain the decrease in allegations received at those facilities. Other facilities have also experienced substantial changes in individuals served (see Table 12 in the appendix).

As would be expected, residential programs also constitute the largest portion of the allegations received in the community. Residential programs accounted for 66% of community agency allegations in FY 2002 and for 68% in both FY 2003 and FY 2004.

By disability type

Allegations of abuse/neglect involving programs providing developmental disability (DD) services account for the largest portion of allegations received by OIG. During FY 2004, nearly 72% of the allegations received were at DD programs.

This reflects a steady increase over the past few years. The percentage of allegations received at DD programs each year has been: 70% in FY 2002, 71% in FY 2003, and 72% in FY 2004.

The disparity is even greater in community agency programs. During FY2004, just over 93% were from DD programs. In FY 2002, it was 87.5%; in FY 2003, it was 92%. The amount of time spent and intensity of services received in mental health programs in the community is far less than in DD programs, decreasing the opportunity for interactions that might produce allegations.

1.5.3 Trends in Deaths Reported

Deaths reported to OIG dropped significantly with the change in Rule 50. Before January 2002, deaths of individuals receiving any outpatient services were reportable to OIG even if the death was unrelated to the services provided. The change in the rule specifically removed this requirement. As a result, the number of deaths reported from community agencies between FY 2001 and FY 2003 dropped from 393 to 95. Deaths not from a residential program accounted for nearly all the drop.

Reported deaths of individuals receiving services at community agencies decreased slightly to 85 in FY 2004. Nearly all of these were again at residential programs.

Reported deaths of individuals receiving services at facilities also decreased slightly, but remained relatively stable: 54 in FY 2001; 52 in FY 2002; 59 in FY 2003; and 50 in FY 2004.

1.5.4 Timeliness of Reporting

Timeliness of facilities and agencies in initial reporting of allegations to OIG continues to be a concern. During FY 2004, of the allegations reported by the facilities, 9% were reported late; of the allegations reported by agencies, 39% were reported late.

The facilities did better during FY 2004, reporting nine percent late compared to fifteen percent late during FY 2003. The agencies also did better, but only slightly, reporting 39% late in FY 2004 compared to 40% in FY 2003.

DD facilities reported a lower percentage late (9%) than MH facilities (11%). DD agencies and MH agencies each reported 39% late. Since DD agencies report so many more allegations than do MH agencies, DD programs overall report later than do MH programs.

As noted earlier, in section 1.3.1, OIG has taken several steps to encourage and ensure that allegations are reported promptly.

1.5.5 Timeliness of Investigation

Rule 50, the administrative regulation governing reporting and investigating of abuse and neglect allegations, includes an expectation that cases are to be completed in 60 working days.

Recently, with the loss of experienced staff due to the Early Retirement Incentive and the difficulty in hiring new staff due to the continuing fiscal crisis, OIG has had difficulty in completing its investigations within the expectation. However, with substantially fewer allegations received and several improvements in case management, OIG was able to make significant progress toward reducing outstanding cases and improving timeliness during FY 2004.

Reduction in active investigations

OIG began the fiscal year with a total of 492 active investigations, nearly half of which (242) were already over 60 working days old ("backlogged"). With an emphasis on completing investigations and system enhancements that improved case handling, OIG substantially reduced the number of active and backlogged cases. OIG finished FY 2004 with 184 active investigations and only 75 of those were already over 60 working days old.

Improvement in timeliness

The FY 2004 average time to completion for OIG Rule 50 investigations was 77 working days. However, this high number is due in part to OIG's effort to complete older cases. A large number of backlogged investigations initially keeps the average completion time high, but eventually the average time drops.

Indeed, during the fourth quarter of FY 2004, completed OIG Rule 50 investigations were averaging only 61 working days. Two of the four bureaus averaged less than 45 working days. OIG continues to find ways to improve case handling and investigation and will work toward becoming even more timely in completing investigations.

1.5.6 Findings in Cases Closed

By finding

When OIG closes a case - whether by completing an OIG investigation or accepting a report of an investigation conducted by a community agency or a law enforcement entity - the "findings" or conclusions of the case become final. As required in the law, OIG uses three main findings:

• Substantiated, meaning the preponderance of evidence found during the investigation indicates that abuse or neglect occurred;
• Unsubstantiated, meaning there is credible evidence that the abuse or neglect occurred, but the preponderance of evidence does not support the allegation;
• Unfounded, meaning that except for the allegation itself, no credible evidence was found that supports that abuse or neglect occurred; and
• Other issues - meaning that, regardless of the finding relative to the allegation, some other administrative issue was found which, if addressed, might prevent future incidents.

In the Tables 8 and 9 on pages 37 and 38, cases that were determined to be unsubstantiated and unfounded but with other issues are combined. Similarly, cases that are determined to be unsubstantiated and unfounded and without any other issues are listed together. Thus, the four findings in those tables are as follows:

• Abuse substantiated;
• Neglect substantiated;
• No abuse or neglect; other issue - the allegation was unsubstantiated or unfounded but an administrative issue was identified which the agency/ facility should address;
• No abuse or neglect; no other issue - the investigation found no abuse, neglect or other issue.

The tables show that OIG closed 1,639 cases in FY 2004. Since OIG received 1,182 allegations of abuse/neglect and 135 deaths, the outstanding cases in OIG's caseload dropped substantially.

Abuse was substantiated in 130 cases closed in FY 2004; neglect was substantiated in 74 other cases. OIG found "other issues" in 202 cases that were otherwise not substantiated.

By location

Although accounting for slightly more allegations, facilities account for fewer of the substantiated cases, as shown in Table 7 below. In FY 2004, a total of 66 cases of the substantiated cases were at facilities, while 138 cases were at agency programs. More than twice as many cases were substantiated to be abuse or neglect at facilities than at community agencies.

Table 7. Abuse/Neglect Findings, FY 2004

	Abuse	Neglect	Totals
Facilities	35	31	66
Agencies	95	43	138
Totals	130	74	204

Likewise, substantiations at the facilities were not patterned similarly to allegations. Howe DC had the second-highest number of both closed cases and substantiations. However, two other facilities (Choate DC and Chester MHC) accounted for 27% of closed cases at facilities but only 11% of those that were substantiated. Conversely, two other facilities (Kiley DC and Murray DC) accounted for only 8% of closed cases at facilities but 26% of those substantiated.

Residential settings accounted for 154 of the 204 substantiated abuse or neglect cases (75%). Developmental Training programs, which are a service for individuals with developmental disabilities, accounted for 22% of the remaining substantiated cases.

By disability type

Greater numbers of allegations are received about DD programs than about MH programs. So it would be expected that more substantiations would be at DD programs. During FY 2004, this was again the case: Abuse or neglect was substantiated in 186 cases in DD programs and 19 in MH programs.

This was true for both abuse and neglect. Over 90% of the substantiated abuse cases and substantiated neglect cases during FY 2004 occurred in DD programs. The greater need for physical and verbal interventions in DD settings is presumably a large factor in this difference.

1.5.7 Trends in Findings

Abuse and neglect

Substantiated abuse allegations have decreased over the past few years, but were higher this year than last. During FY 2004, OIG substantiated abuse in 130 cases, compared to 162 in FY 2002 and 96 in FY 2003.

There were more substantiated abuse cases at facilities, at agencies, and in DD programs during FY 2004 than during FY 2003. The number of substantiated abuse cases at MH programs was nearly the same: 12 in FY 2004 compared to 13 in FY 2003.

Neglect was also substantiated more at facilities, at agencies, and in DD programs during FY 2004 than in FY 2003; and again was nearly the same in MH programs (6, compared to 7 last year).

Further, substantiated neglect has also decreased over the past few years, but was higher this year than last. However, it did not rise as much, with 74 substantiated cases in FY 2004, compared to 109 in FY 2002 and 51 in FY 2003.

During FY 2004, cases at community agencies accounted for 95 of the 130 substantiated abuse cases (73%) and 43 of the 74 substantiated neglect cases (58%). In FY 2002 and FY 2003, cases at community agencies accounted for around the same percentage of abuse cases (81% and 70%, respectively), but a higher percentage of neglect cases (72% and 64%, respectively).

Other issues

Regardless of the finding relative to abuse or neglect, the law allows OIG to identify other administrative issues that the facility or agency is to address in a Written Response. These issues may be contributing factors in the incident or may, if addressed, help prevent abuse or neglect in the future. Further, OIG has recently begun to cite a failure of a facility or agency to report allegations in a timely manner as an "other issue."

Table 10 below summarizes the trends in abuse, neglect, and other issues in cases closed by OIG during each fiscal year.

Table 10. Findings, FY 2002 - FY 2004

Finding	FY 2002	FY 2003	FY 2004
Abuse	162	76	130
Neglect	109	51	74
Other issue*	100	101	202
No finding	1499	1355	1232

*Does not duplicate substantiated abuse/neglect cases.

The table shows the increase in abuse and neglect findings noted earlier, but also the large increase in findings of other issues. OIG identified "other issues" in twice as many unsubstantiated or unfounded cases in FY 2004 than in FY 2003.

Since substantiated abuse/neglect and other issues require a Written Response, the number of cases requiring a Written Response from the facility or agency dropped from 371 in FY 2002 to 228 in FY 2003 and then rose to 406 in FY 2004.

1.5.8 Actions Taken in Closed Cases

Table 11 shows actions taken in cases closed during FY 2004. An agency or facility may take several actions in response to a case, there may be more than one action taken in a closed case. However, since most cases are closed before the actions taken have been finalized, not all of the 406 cases closed during the year are included in the table.

Actions taken against staff pursuant to an OIG Finding

Substantiated physical abuse resulted in the resignation or discharge of the employee(s). Infrequently, an employee who committed less severe physical abuse may, as a result of arbitration or civil service hearing, receive a lengthy suspension. Written and oral reprimands, on the other hand, are generally given to other employees; e.g., those who knew about the incident but failed to promptly report it.

Substantiated sexual abuse led to the resignation or discharge of the employee. The other actions listed were against those not directly involved.

Substantiated mental injury resulted in the widest range of actions against staff: disciplinary action, increased supervision, training, and/or performance evaluation objectives related to their interaction with individuals.

Substantiated neglect also resulted in a wide range of administrative actions. Five death cases resulted in administrative actions, three involving discharge of an accused employee and two requiring training.

Other actions taken

Further, in many of these cases, policies and procedures were created or revised, to prevent similar occurrences in the future. For further discussion and examples, please see Written Response Compliance (section 1.3.7).

Table 11: Actions Taken Identified in Cases Closed During Fiscal Year 2004

Original allegation	Cases closed	Identified Actions Taken
Physical abuse	75	Staff: Resignation, Discharge, Suspension, Written Reprimand, Oral reprimand, Counseling, Reassignment, Training, Supervision; Other: Policy created/modified, Procedure created/modified, Habilitation plan modified
Sexual abuse	4	Staff: Resignation, Discharge, Written reprimand, Reassignment, Training; Other: Procedure created/modified
Mental injury	43	Staff: Resignation, Discharge, Suspension, Written reprimand, Oral reprimand, Counseling, Reassignment, Training, Supervision, Performance evaluation objective; Other: Policy created/modified, Habilitation plan modified
Neglect	67	Staff: Resignation, Discharge, Suspension, Written reprimand, Counseling, Reassignment, Training; Other: Policy created/modified, Procedure created/modified, Habilitation plan modified
Death	5	Staff: Discharged, Training; Other: Policy created/modified, Procedure created/modified

1.6 Unannounced Site Visits

1.6.1 Introduction

The statute creating OIG, Public Act 87-1158, requires OIG to conduct annual, unannounced site visits at the State-operated mental health and developmental centers. OIG conducts the site visits once each fiscal year.

The act thus gives OIG a dual role regarding abuse and neglect. In addition to the more traditional approach of conducting investigations into allegations of abuse and neglect, 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. Further, actionable information gathered from the site visit at one facility on prevention or patient care issues can be shared with other facilities that may be having difficulty with a similar issue.

For example, the first step in one mental health center's restraint prevention program was a standardized Anger Avoidance Questionnaire which was administered by a unit nurse after the person had been admitted and had a chance to adjust to being on a facility unit. At another mental health center, the Questionnaire was administered by a nurse during the admissions process, which the site visitor found resulted in most answers left blank. Without good answers, the chance to avoid confrontations and prevent restraint use would be reduced. The site visitor shared the first facility's approach and the second facility agreed to try it.

1.6.2 OIG Site Visit Protocol

Protocol Development

Since site visits focus on systemic issues which contribute to preventing abuse and neglect, the site visitors consider a wide range of issues that directly affect the individuals who receive services at the facilities. To identify these issues, the site visitors have involved OIG investigators, facility leadership, Department administrative staff, external sources, and reviews of investigations. All of these issues are condensed into a set procedure - a "protocol"- to be used at each facility during the coming fiscal year. Thus, the protocol varies from year to year. Further, it allows for tailoring the process to the uniqueness of each facility's population and services.

Protocol for FY 2004

The site visit protocol for FY 2004 addressed six primary issues of concern.

The first issue was ensuring that facilities took actions in response to findings in OIG cases. The site visit protocol involved reviews of Written Responses (section 1.3.7) to ensure that all actions were actually completed. In addition, if any patterns or trends were noted since the previous site visit, that information was shared with the facility's administrators.

The second issue included in this year's protocol was looking at the impact of the Early Retirement Incentive on patient care. Since ERI resulted in the loss of some of the facilities' most experienced staff, the site visit protocol involved reviews to determine how the facility was addressing the loss of staff.

The third issue was reviewing policies and procedures related to patient safety. The facility administrators were asked about policies and procedures in this area and asked to identify a patient safety activity that OIG might review. The protocol called for examining that procedure or activity to see what impact it had and whether it could apply to other facilities.

A related issue was reviewing how the facility handled non-reportable complaints. The site visit protocol included examining these complaints, which do not meet the legal definition of abuse or neglect, to review how they were handled as an assessment of facility commitment to patient care and safety.

The fifth issue was ensuring that the OIG Hotline number was clearly posted on patient units and staff were adequately trained. Rule 50 now requires posting of the OIG Hotline number "in plain sight" in areas where individuals receive services, to facilitate reporting. The site visit protocol included checking all living units for the OIG Hotline number and checking that staff were trained in the new Rule 50.

The sixth issue was assessing how the facility responded to the recommendations from the FY 2003 site visits. The site visit protocol called for following up on site visits or recommendations from the previous year, to ensure continuity.

To identify issues particular to a facility, the site visitors review a sample of OIG investigations since the previous site visit. Information about the cases was put into a matrix, which was then used to identify high-risk or high-volume areas. Further, other issues may be identified while observing at the facilities. These issues may result in OIG making additional recommendations.

1.6.3 Summary

OIG's site visits in FY 2004 again provided an important role in preventing abuse and neglect and in improving services to individuals. This year, the site visits identified the following:

• All State-operated facilities had adequately addressed and completed all actions in Written Responses and all recommendations from FY 2003 site visits;
• The Early Retirement Incentive has posed difficulties for the facilities, which relied on overtime to maintain minimum staffing levels initially, and mental health centers continue to have a shortage of direct care staff;
• The facilities have demonstrated a focus on patient safety through a variety of activities designed to reduce the circumstances in which abuse or neglect are likely to occur;
• All facilities investigate incidents that do not meet the definition of abuse or neglect but may require administrative intervention, yet only 13 of the 17 facilities document these investigations thoroughly;
• OIG Hotline number postings are improved over FY 2003, but several developmental centers remain out of compliance; and
• Several recommendations were made to facilities based on site visitor observations.

Based on the findings of FY 2004 site visits, the FY 2005 site visit protocol should address the following: serious injuries, patient-on-patient injuries, non-reportable occurrences, procedures for handling patient aggression, and abuse/neglect prevention initiatives.

The OIG unannounced site visit process has shown itself to be an effective and efficient tool to identify policies, procedures or practices that might increase the risk of abuse or neglect in State facilities. Along with other external reviews, OIG site visits have resulted in improved services to patients and individuals throughout the Illinois state operated facility system.

1.7 New Legislation

Public Act 93-636

House Bill 88 was introduced during the 93rd General Assembly in the Spring 2003 session. It amended the statute authorizing the Inspector General position (210 ILCS 30 / 6.2). It passed both chambers, but Governor Rod Blagojevich submitted an amendatory veto to the legislature on August 20, 2003. Both chambers accepted the changes on November 19, 2003, the governor certified the changes on December 31, 2003, and the new law became effective on that date.

Four pieces of the new law directly affect OIG. First, the law creates a separate budget for OIG, while leaving it housed in DHS. The practical effect of this change is to appropriate monies to OIG that are separate and distinct from the overall budget for DHS.

Second, the law removed the sunset clause for OIG. Prior to this change, the authorizing statute always had a definite end date, which the legislature and governor had to renew for OIG to continue its existence. The new law provides a sense of permanency to OIG which did not exist prior to this change.

Another change the law made was to move the Quality Care Board from DHS broadly to under OIG directly. The Quality Care Board consists of members appointed by the governor who are qualified by professional knowledge in the area of law, investigatory techniques, or in the areas of mental illness or developmental disabilities. The board's duties are to monitor and oversee the operations, policies, and procedures of OIG to ensure prompt and thorough investigations of allegations of abuse and neglect.

Finally, Public Act 93-636 also requires OIG to monitor written responses, which are submitted by State-operated facilities and community agencies to indicate actions they will take in response to investigations that substantiate abuse or neglect or have other findings requiring administrative action. The facility or agency must submit a written response to OIG within 30 days of a final report. The new requirement mandates OIG to track the written responses for timely submission and, once the written response is approved, OIG must monitor compliance with the written response through a random review of completed written responses.

Public Act 93-423

House Bill 1032 passed both houses of the legislature in May 2003 and was signed into law by Governor Blagojevich on August 5, 2003, becoming effective on that date. This bill, which OIG supported, amended the authorizing statute for DHS (as well those for other State agencies). It allowed DHS to issue badges to employees not exercising the powers of a peace officer, if the badge is needed to carry out official duties.

This amendment to the statute has a positive effect on the operations of OIG. A badge is more representative of an OIG investigator's official duties than a simple identification card. Further, a badge engenders greater cooperation and respect from those with whom investigators work, particularly sworn law enforcement officers.

1.8 Census and Staffing Ratios

The statute requiring this annual report mandates that it include information on the direct care staff-to-patient ratios at the State-operated facilities. The table on page 39 presents this information. The tables show three ways to count patients, but only the facility census on June 30, the last day of the fiscal year, is used to calculate direct care staffing ratios.

Facilities with relatively low staff-to-patient ratios may use more contractual workers or may have more contracts with local agencies for day training or other activities. Conversely, facilities with relatively high staff-to-patient ratios may have staff who provide services used by other facilities or may serve individuals who have more specialized needs.

Adults with Disabilities Domestic Abuse Intervention Program (DAP)

2.1 DAP Annual Report

This section of the Annual Report covers the role of the Office of the Inspector General (OIG) in investigating and initiating needed serves to adults with mental or physical disabilities who reside in a domestic setting.

2.1.1 Law and Mission

Enabling Legislation

OIG's Domestic Abuse Program was created by Public Act 91-671 which became law in December 1999. The effective date was July 1, 2000, the beginning of Fiscal Year 2001. This is now the fourth year of the program in OIG.

The statute, the "Abuse of Adults with Disabilities Intervention Act" (20 ILCS 2435), authorizes OIG to conduct investigative assessments of allegations of abuse, neglect, or exploitation of adults with disabilities who live in domestic settings. The intent of the statute is to prevent, reduce or eliminate abuse, neglect and exploitation of adults with disabilities. Consistent with this intent, the statute seeks to facilitate provision of services through DHS and, when necessary, outside the Department.

Implementation

OIG worked with the Illinois Attorney General's office and a committee of interested external entities to create an administrative rule governing implementation of the statute. The rule making process resulted in Rule 51 (59 Illinois Administrative Code, Chapter I, Part 51) which was effective on July 1, 2000. OIG also has developed internal directives for receiving initial reports, conducting investigative assessments, and referring substantiated cases.

Rule 51 repeats the statute's requirements for eligibility. To be eligible for the program, the alleged victim must:

• Be older than 17 years of age and younger than 60;
• Have a disability which impairs his or her ability to seek help; and
• Resides in a domestic living situation, which includes board and care homes and unlicensed residential settings.

The alleged abuse, neglect, or exploitation must have taken place in that domestic living situation.

An alleged victim must consent before an assessment can begin. However, if the intake information indicates a possible emergency situation, initial steps such as contacting a local law enforcement agency will be taken prior to obtaining the individual's consent.

In situations where a guardian of the individual is the alleged perpetrator, the statute authorizes OIG to pursue temporary guardianship. OIG can also pursue an order of protection or move an alleged victim where necessary.

Mission

The mission of OIG's Domestic Abuse Program is thus to conduct investigative assessments of alleged abuse, neglect, or exploitation of adults with disabilities, to obtain emergency services where necessary, to facilitate service delivery through referrals to the appropriate DHS office, and thereby prevent or eliminate abuse, neglect, and exploitation of adults with disabilities.

The statutory requirements for the annual report for this program underscore this mission. In addition to statistical data of numbers of reports and assessments, the annual report is also to include data on referrals to law enforcement and other referral resources, numbers of service plans completed, and also information on public education efforts and training provided to persons or agencies responsible for the statute's implementation.

Legislative update

A legislative proposal submitted during the 2004 Spring Session of the 93rd Illinois General Assembly was initiated by OIG through the DHS Office of Legislation. This proposal became Senate Bill 3174 and passed both chambers by May 12, 2004. The bill was signed into law by Governor Blagojevich on July 15, 2004, becoming Public Act 93-0751.

This law creates a new exception to the Mental Health and Developmental Disabilities Confidentiality Act (740 ILCS 110 / 10). The exception allows OIG's Domestic Abuse Program investigators to obtain medical and psychiatric records when the individual and/or guardian is unable or unwilling to sign a consent form. This new exception will enable OIG to gather pertinent information about the victim, enabling the investigator to conduct a more thorough assessment, and to facilitate referrals for services. Of particular importance is OIG's ability to obtain evidence necessary when petitioning for guardianship in order to prevent further abuse, neglect, or exploitation.

2.1.2 Description of the Process

Allegations are received through OIG's Intake Hotline. The Intake staff send the intake report to all DAP investigators, the Investigative Team Leader (ITL), and the bureau chief. The ITL assigns the case based on the address of the alleged victim, the caseloads of the various investigators, and any experience a particular DAP investigator has with the family.

The DAP investigator may interview the complainant if additional information is required, and then interview the alleged victim and/or guardian and obtain consent to conduct the investigative assessment. If consent is granted, the investigator proceeds. The investigator may obtain emergency services, assist in finding immediate housing, pursue guardianship, and report possible crimes to local law enforcement based on evidence found during the case.

When the investigator completes the investigative assessment, the draft report is reviewed by the ITL, who, upon approving it, forwards the case to the bureau chief for review. If the case is substantiated, the bureau chief forwards it to the Inspector General for final review. Otherwise, the bureau chief's review is final. In all cases, the case processing and closure is done by the bureau chief.

Final cases that substantiate abuse, neglect, or exploitation of adults with disabilities are referred to the appropriate division in DHS for the development of a service plan. The service plan must address the issues raised in the report and to provide necessary services to prevent recurrence of the abuse, neglect or exploitation. In cases that are not substantiated but the individual might benefit from services, the investigator may make phone referrals to entities that provide or assess for services.

2.1.3 Organizational Structure

The Domestic Abuse Program is a separate bureau within OIG, due to the differences in definitions, authority, and expectations in the law. DAP has a bureau chief, investigative team leader, and six investigators. DAP has divided the State into six regions, with one investigator assigned to each region (see map below).

 

Figure 2. Rule 51 Regions

Beginning in Fiscal Year 2005, the Northeast and Northwest regions are being combined. Since Fiscal Year 2002, the Northeast region has consisted of four counties: DuPage, Kane, Lake, and McHenry. DuPage will be moving to the new "Metro" region and the remaining three counties will combine with the Northwest region, which has included the following eight counties:

Boone, Carroll, DeKalb, JoDaviess, Kane, Lake, Lee, McHenry, Ogle, Stephenson, Whiteside, and Winnebago.

The current North Central region covers 28 counties. Four of them - Grundy, Kankakee, Kendall, and Will - are being combined with DuPage County from the Northeast region and Cook County, which currently is its own region, into a new "Metro" region.

The remaining 24 counties in the North Central region are:

Bureau, Champaign, Ford, Fulton, Hancock, Henderson, Henry, Iroquois, Knox, LaSalle, Livingston, Marshall, McDonough, McLean, Mercer, Peoria, Putnam, Rock Island, Schuyler, Stark, Tazewell, Vermillion, Warren, and Woodford.

These will be merged into the Central region, which currently consists of the following counties:

Adams, Brown, Calhoun, Cass, Christian, Clark, Coles, Cumberland, DeWitt, Douglas, Edgar, Effingham, Greene, Logan, Macon, Macoupin, Mason, Menard, Montgomery, Moultrie, Morgan, Piatt, Pike, Sangamon, Scott, and Shelby.

However, five of these counties - Calhoun, Clark, Cumberland, Effingham, and Jersey - will be moved to the South region which will retain its current 32 counties:

Alexander, Bond, Clay, Clinton, Crawford, Edwards, Fayette, Franklin, Gallatin, Hamilton, Hardin, Jackson, Jefferson, Johnson, Lawrence, Madison, Marion, Massac, Monroe, Pope, Perry, Pulaski, Randolph, Richland, Saline, St. Clair, Union, Wabash, Washington, Wayne, White, and Williamson.

2.2 Impact Summaries

The mission of the Domestic Abuse Program covers conducting investigative assessments, obtaining emergency services if necessary, and referring individuals for other services, including to appropriate DHS offices for service plans. Here are some examples of how OIG fulfilled that mission.

2.2.1 Substantiated Assessments

Example of substantiated abuse

An individual was allegedly not allowed to be in his home during the daytime. He was forced to use a bucket in the corn crib as a toilet and was used as a target for paint ball games. In the winter, he reportedly went to neighbors' homes to be fed and get warm. Abuse and neglect were substantiated and he was referred for services and a new residence.

Example of substantiated neglect

An individual was admitted to a hospital with an infectious skin condition. The alleged perpetrator admitted that she had not sought medical attention and that she was overwhelmed with trying to care for the victim. Neglect was substantiated and the victim was placed in a skilled residential setting where he could receive the care he required.

Example of substantiated exploitation

A care giver allegedly took six hundred dollars from an individual. The investigation found that a total of $6,140 had been taken. The care giver admitted that she took the money without his permission and that she knew it was wrong, but she felt that he owed her that much and she was a single parent with bills to pay. Exploitation was substantiated; the case was also referred to the local police for prosecution.

2.2.2 Emergency Services

Examples of emergency placement

A hospital reported that an individual arrived in poor condition: he was malnourished, had an abscessed tooth, and had blood in his urine. OIG visited the home and found it in bad condition also. The individual's brother was his payee for Social Security benefits, but could not explain how the money had been spent. Neglect and exploitation were substantiated and the individual was moved to a new residence.

An individual and his two young brothers were left at home alone when their father fled the state to avoid criminal charges. The assessment found that the victim had been physically abused by one of his brothers. DCFS took custody of the two brothers and OIG moved him temporarily to his father's girlfriend's home and then to a community agency-operated Community Integrated Living Arrangement (CILA).

Examples of guardianship

An individual was staying in abandoned buildings rather than with his grandmother - he alleged that he had been bitten by mice, roaches, and bugs in her home. The grandmother was the payee for Social Security benefits, but was not providing any care and did not know where he was. OIG asked the police to locate the victim, found a developmental center that would be able to take him. When the police found him, OIG obtained temporary guardianship and moved him to the developmental center. The center then pursued finding a permanent guardian.

An individual's mother passed away and he was left in the care of a cousin. Three weeks later, the individual was near death when found by paramedics. OIG secured an emergency petition for guardianship and he went to a nursing home when he was discharged from the hospital. The cousin tried to sell assets from the home, so OIG had the guardian ad litem obtain an injunction. The Office of State Guardian eventually became the guardian.

2.2.3 Referrals

Examples of referral for service plans

An individual alleged that her stepfather had sexually assaulted her. The mother denied knowing about it, but the alleged victim said that the mother did know and had threatened to throw her out of the house if she reported it. OIG found that the stepfather was a registered sex offender and had already been arrested and jailed for sexually abusing the alleged victim and her cousin when they were children. OIG notified the police and he was arrested. OIG sought emergency placement and referred the case to the Division of Developmental Disabilities for development of a service plan.

An individual claimed that his black eye was from being struck by his mother; she had allegedly abused in a previous case. OIG substantiated abuse, found a placement for him in a community agency-operated Community Integrated Living Arrangement (CILA), referred him to the Division of Developmental Disabilities for a service plan, and facilitated getting guardianship awarded to the Office of State Guardian.

Examples of referral to law enforcement

An individual reported being sexually abused twice by her mother's boyfriend. The mother had witnessed the first time but, when he promised not to do it again, she did not report him. OIG substantiated the case and contacted the police. The police arrested the man, who was a registered sex offender. They also arrested the victim's mother on obstruction of justice charges when she tried to coerce her daughter into denying the allegation.

An individual with cerebral palsy alleged that she had been financially exploited. The individual was able to seek and obtain help independently, so she was not eligible for a DAP assessment. However, OIG referred the case to the local police and State's Attorney, who filed criminal charges against the alleged perpetrator.

Examples of referral for other services

An individual denied being financially exploited by his housekeeper and his daughter. However, through the assessment, the individual claimed to hear unidentified voices to which he responded. Although the case could not be substantiated, OIG made a referral for a psychiatric evaluation and possible services.

An individual was allegedly being neglected and exploited. There was no evidence to support the claim and the alleged victim denied it. However, she said she was unable to attend a day training program as she no longer had any transportation. OIG contacted the day training program, which was willing to work with the family to get her back into the day training program.

Refusal to consent

An individual with multiple sclerosis which confined her to her bed, allegedly was being neglected by her son and was being found each morning in her own waste. The alleged victim noted that her paid care giver initially did not show up regularly and then finally just stopped coming. It took a couple days to find a new care giver, who DHS then approved for six hours every day. The alleged victim said that her son and his wife tried to visit and help as much as possible and she did not want to be bothered by anyone else. She asked that the assessment stop and so OIG closed the case as refusal to consent to an assessment.

An individual was allegedly being neglected by her niece, who was the care giver. The individual had muscular dystrophy, which confined her to her bed. Allegedly, she had been found laying in feces and had decubitus ulcers with wound dressings that were covered in puss and feces. However, the alleged victim denied that she was being neglected and refused to consent to the completion of the assessment, so OIG closed the case as refusal to consent to an assessment.

2.3 System Enhancements

New boundaries

As noted above, DAP's regional boundaries will be changing in FY 2005, putting the Northeast and Northwest regions back into one - "North". In November 2003, the former Northwest region investigator who became the Investigative Team Leader (ITL), after the previous ITL left OIG.

The North Central region will be divided between the Central region and a newly renamed Metro region. This will free up one investigator, who will move into the Metro region, doubling the number of investigators in this heavy reporting region. These changes should even out caseloads and reduce travel costs for the DAP investigators.

Multiple referrals

The law creating the program mandates that DAP refer substantiated cases to the appropriate division within DHS. However, DAP often finds individuals with multiple needs, requiring multiple referrals. Thus, DAP requested that the database OIG uses to track cases be modified to allow for referrals to several agencies beyond the primary service plan referral.

2.3.1 Program Collaborations

During the course of an investigative assessment, a DAP investigator may need to work with a variety of outside entities. DAP routinely works with local law enforcement agencies, fire departments, States Attorneys and building code enforcement entities. DAP works collaboratively with hospital social service departments, local mental health centers, day training programs, and agencies providing residential services.

Further, when pursuing guardianship, DAP works in cooperation with the Illinois Guardianship and Advocacy Commission, the Attorney General's General Law Division, the Cook County Public Guardian, and local county guardianship offices.

The following are other entities with which DAP has collaborated during the fiscal year:

• Drug Enforcement Administration;
• Illinois State Police;
• Pre-Admission Screening (PAS) agencies;
• Illinois Department of Children and Family Services;
• Illinois Department on Aging;
• Illinois Department of Healthcare and Family Services; and
• U.S. Social Security Administration.

2.3.2 Ad Hoc Committee

During FY 2000, the Illinois Attorney General formed an Ad-Hoc Committee composed of members of several organizations that had helped to write the legislation creating the Adults with Disabilities Domestic Abuse Program. The committee started meeting to discuss the act's implementation and other issues concerning persons with disabilities.

The committee has been especially helpful in drafting and providing support for legislation to address issues that arise. The committee supported the successful legislation granting DAP investigators access to previously confidential but relevant mental health records. The committee has also discussed and pledged support for several proposed changes.

In addition to staff from DAP, from DHS Legal Services, and from the Illinois Attorney General's office, the committee consists of representatives of these organizations:

• Center for Disability and Elder Law;
• Council for Disability Rights;
• Council on Developmental Disabilities;
• Equip for Equality;
• Illinois Assistive Technology Project;
• Illinois Guardianship and Advocacy Commission;
• Illinois Network of Centers for Independent Living; and
• Statewide Independent Living Council.

2.4 Public Information

As required by statute, OIG actively promotes public awareness and understanding of the program. Distribution of DAP literature and public speaking engagements were the primary method of promotion and were targeted to the general public and to social service, law enforcement and medical entities.

2.4.1 Presentations

DAP's managers and investigators often make formal presentations about the Adults with Disabilities Domestic Abuse program to public, law enforcement, and state and local government agency staff. For example, during one three-month time frame, OIG staff made presentations about the DAP program to the following organizations:

• Mar. 5, 2004
  Washington County Law Enforcement
• Mar. 24, 2004
  South Star Services
• Apr. 28, 2004
  Association of Retarded Citizens (ARC)
• May 12, 2004
  Division of Rehabilitation Services, Zone 2
• May 13, 2004
  Division of Rehabilitation Services, Zone 4
• May 14, 2004
  Division of Rehabilitation Services, Zone 1
• May 20, 2004
  Illinois Attorney General's office and the Springfield Police Academy

In addition to public speaking engagements, OIG staff frequently made personal visits to law enforcement and medical professionals promoting the function and mission of OIG. Typically, this is done during an investigation in the local area, which underscores the need for the program.

2.4.2 Internet site

The Office of the Inspector General's website includes information about OIG and the program. It provides the statutory criteria for eligibility for the program, as well as the details a caller should have when reporting an allegation.

The latest annual reports and the OIG brochure for the program are available under an "OIG Documents" link. The brochure and a description of the program are available in Spanish.

The website also includes information about abuse, neglect, and exploitation of adults with disabilities and links to other protective agencies and service advocacy organizations.

2.5 Allegations and Findings

2.5.1 Allegations Reported, FY 2004

By allegation type

Rule 51, the administrative regulation governing the program, defines abuse, neglect, and exploitation as follows:

"Abuse means causing any physical, sexual, or mental injury to an adult with disabilities..." It excludes instances where treatment is "by spiritual means through prayer alone."

"Neglect means the failure of another individual to provide an adult with disabilities with, or the willful withholding... of the necessities of life, including but not limited to, food, clothing, shelter, or medical care."

"Exploitation means the illegal... use of the assets or resources of an adult with disabilities." It includes misappropriation "...by undue influence, by breach of a fiduciary relationship, by fraud, deception or extortion, or... in a manner contrary to law."

During FY 2004, OIG received 457 calls alleging abuse, neglect or exploitation of an adult with disabilities in a domestic setting. This includes five cases that were later determined to be ineligible for the program, but still was more complaints than any previous year.

Of the 452 eligible calls received by OIG during the fiscal year:

• 162 alleged abuse;
• 254 alleged neglect; and
• 36 alleged exploitation.

The five calls describing ineligible situations included two instances where the alleged victim had moved out of the State of Illinois and three instances where the alleged victim was able to seek and obtain help on his/her own.

2.5.2 Trends in Allegations, FY 2001- 2004

By allegation type

In actual numbers, nearly as many allegations of abuse in domestic settings were reported to OIG in FY 2004 (162) as in FY 2003 (164) and more than in FY 2002 (145). At the same time, however, two-thirds more allegations of neglect were received in FY 2004 (254) than in those previous two years (153 and 149, respectively).

As shown in the table below, the percentage of complaints alleging abuse has thus decreased, the percentage alleging neglect has increased, and the percentage alleging exploitation has returned to FY 2001 levels. The percentages of abuse and neglect have nearly reversed.

Table 13. Allegations in Percentages by Fiscal Year

Allegation	FY01	FY02	FY03	FY04
Abuse	57%	44%	45%	35%
Neglect	35%	45%	42%	56%
Exploitation	8%	11%	12%	8%

By caller

During FY 2004, 26% of the calls received alleging domestic abuse, neglect, or exploitation were reported by family or friends. Another 25% were reported by community agencies that are licensed or funded by DHS to provide or screen for mental health or developmental disability services. Hospitals, including social workers and nurses, accounted for 17% of the calls. DHS staff, including Home Services staff, account for ten percent.

The top three groups have accounted for a growing percentage of the calls over the four years of the program:

• Family and friends accounted for:
  • 14% in FY 2001,
  • 10% in FY 2002,
  • 22% in FY 2003, and
  • 25% in FY 2004;
• Community agencies accounted for:
  • 22% in FY 2001,
  • 12% in FY 2002,
  • 22% in FY 2003, and
  • 25% in FY 2004; and
• Hospitals accounted for:
  • 8% in FY 2001,
  • 7% in FY 2002,
  • 16% in FY 2003, and
  • 17% in FY 2003.

DHS staff have accounted for roughly ten percent of the calls each of the four years.

By county and region

More calls were received regarding individuals in Cook County than in any other county: 171 of the 452 eligible calls (38%) were from Cook. In the previous three fiscal years, Cook accounted for around the same percentage: 35% in FY 2001, 25% in FY 2002, and 41% in FY 2003.

The remaining regions each accounted for nearly the same percentage of the eligible calls, although South rose slightly, from 15% to 18%. In previous years, Central and Northeast have each accounted for a larger percentage; but for both this fiscal year and last, they each accounted for only 8% of eligible calls. This is one reason why region lines are being revised for FY 2005.

By half-years

Table 14 show the counts of allegations received by six-month intervals over the four years of the program's existence. Clear trends are visible:

• Except for two relatively high half-years, domestic abuse has remained fairly level, with annual counts of abuse allegations averaging between 72.5 and 92.5;
• Domestic neglect has risen fairly steadily, with a notable spike in the first half of FY 2004, rising 50% over the previous half-year; and
• Domestic exploitation has risen more slowly, with a slight reduction this year.

Table 14. Allegations of Domestic Abuse, Neglect and Exploitation, FY 2001 - FY 2004

	FY 2001 1st half	FY 2001 2nd half	FY 2002 1st half	FY 2002 2nd half	FY 2003 1st half	FY 2003 2nd half	FY 2004 1st half	FY 2004 2nd half
Abuse	76	109	70	75	65	99	78	84
Neglect	54	59	72	77	61	92	144	110
Exploitation	16	10	12	23	19	25	17	19

2.5.3 Findings in Cases Closed, FY 2004

DAP closed 452 cases in FY 2004. Of these cases, 51 were referred to a law enforcement agency or another entity because the alleged victim was initially ineligible or later became ineligible by moving out of state, moving into a licensed residential setting, or dying.

In 109 cases, the alleged victim refused consent to proceed with the investigative assessment. As noted earlier, the law prohibits DAP from proceeding if the alleged victim refuses consent. However, the DAP investigator may still offer suggestions about where to obtain services.

Of the remaining 292 cases, DAP substantiated 60 cases in FY 2004:

• abuse was substantiated in 33 cases,
• neglect in 26 cases, and
• exploitation in one case.

DAP did not substantiate the allegation in 232 of the closed cases.

2.5.4 Trends in Findings, FY 2001-2004

Abuse, neglect, or exploitation were substantiated in comparable numbers in FY 2004 as in the previous three years. Table 15 below shows that counts of substantiated domestic cases closed during FY 2004 by finding.

Table 15. Findings in Substantiated Domestic Cases Closed

	FY 01	FY 02	FY 03	FY 04
Abuse	47	39	37	33
Neglect	24	24	20	26
Exploitation	0	2	2	1
Total	71	65	59	60

2.5.5 Service Plan Referrals

The law mandates that whenever a case is substantiated as abuse, neglect or exploitation, the individual shall be referred to an appropriate office within DHS for development of a service plan to ensure that necessary services are provided. DAP refers substantiated cases to the following three DHS divisions:

• Division of Developmental Disabilities, for adults with mental or physical disabilities with an onset before age 22;
• Division of Rehabilitation Services, for adults with physical disabilities;
• Division of Mental Health, for adults with mental illness.

Again this year, most went to the Division of Developmental Disabilities, followed by the Division of Rehabilitation Services. Of the 60 substantiated cases, 44 were sent to the Division of Developmental Disabilities. Eleven were sent to the Division of Rehabilitation Services and five were sent to the Division of Mental Health.

Table 1. Entities Receiving Allegations of Abuse and Neglect of Individuals with Disabilities

Investigative Agency Type	Investigative Agency Entity	State Statuatory Investigative Role?	Target Population Disability	Target Population Age	Primary Jurisdiction
Law Enforcement	Illinois State Police	20 ILCS 2605/2605 720 ILCS 5 / 33 210 ILCS 30 / 6	Any	Any age	State-owned property, also within State.
Law Enforcement	Local law enforcement	55 ILCS 5 / 5 65 ILCS 5 / 11	Any	Any age	In jurisdictional boundaries.
Department of Human Services	OIG's Rule 50 Investigations	210 ILCS 30 / 6.2	DD MH	Any age	DCs, MHCs and community sites
Department of Human Services	OIG Domestic Abuse Program	20 ILCS 2435 / 1	Any	18 to 59	Domestic residences.
Department of Human Services	Bureau of Accreditation Licensure and Certification	N/A	DD MH	Any age	Most community agency program sites.
Department of Human Services	Division of Developmental Disabilities	N/A	DD	Any age	DCs; funded community sites
Department of Human Services	Division of Mental Health	N/A	MH	Any age	MHCs; funded community sites
Department of Human Services	Division of Rehabilitation Services	N/A	PD	Any age	State-operated school or local Division office.
Other State Agencies	Department of Public Health	210 ILCS 30 / 6	Any	Any age	Nursing homes and hospitals.
Other State Agencies	Guardianship & Advocacy	N/A	Any	Any age	Individuals who are wards.
Other State Agencies	Department of Children and Family Services	325 ILCS 5 / 7	Any	Under 18 (under 22 if in program)	Any setting.
Other State Agencies	Department on Aging	320 ILCS 20 / 1	Any	60 and over	Any setting.
Other State Agencies	Department of Professional Regulation	20 ILCS 2105 / 155	Any	Any age	Misconduct by any medical professional.
Private, non-profit entities	Equip for Equality	405 ILCS 40 / 1 405 ILCS 45 / 3	DD MH	Any age	Any setting.

Initials: DC = State-operated developmental center; DD = Developmental disability; MH = Mental health diagnosis; MHC = State-operated mental health center; PD = Physical disability only.

Table 5. Abuse/Neglect Allegations Received by OIG in FY 2004 regarding Developmental Disability (DD) Programs

Location	Physical Abuse Allegations	Sexual Abuse Allegations	Mental Abuse Allegations	Neglect Allegations	Total Reported in FY 2004
Choate DC1	90	11	8	9	118
Fox DC	0	0	0	3	3
Howe DC	44	1	13	6	64
Jacksonville DC	46	6	7	7	66
Kiley DC	21	1	2	8	32
Ludeman DC	19	1	1	4	25
Mabley DC	5	1	0	4	10
Murray DC	9	1	0	3	13
Shapiro DC	26	0	0	1	27
Facility subtotals	260	22	31	45	358
CILAs	169	22	43	98	332
Other residential	4	1	2	2	9
DT program	73	10	23	3	137
Vocational program	1	1	2	0	4
Other community	3	1	3	1	8
Community subtotals	250	35	73	132	490
TOTALS	510	57	104	177	848

¹ - Includes three physical abuse allegations on the DD forensic unit.

Table 6. Abuse/Neglect Allegations Received by OIG in FY 2004 regarding Mental Health (MH) Programs

Location	Physical Abuse Allegations	Sexual Abuse Allegations	Mental Abuse Allegations	Neglect Allegations	Total Reported in FY 2004
Alton MHC - Civil 1	11	2	2	1	16
Alton MHC - Forensic	20	4	4	1	29
Chester MHC2	88	3	12	2	105
Choate MHC	15	2	3	2	22
Chicago Read MHC	7	3	5	7	22
Elgin MHC - Civil	4	4	7	0	15
Elgin MHC - Forensic	4	1	4	2	11
Madden MHC	10	2	6	1	19
McFarland MHC - Civil	8	1	2	1	12
McFarland MHC - Forensic	2	0	2	2	6
Singer MHC	16	2	1	1	20
Tinley Park MHC	7	3	3	3	16
Facility subtotals	198	27	51	23	299
CILAs	2	2	1	2	1
Other residential	2	2	4	3	11
MH outpatient	1	6	1	1	9
Vocational programs	0	0	0	0	0
Other community	3	2	3	0	8
Community subtotals	8	12	9	6	35
Totals	206	39	60	29	334

¹ Civil units are for individuals who do not need a forensic (commitment by a criminal court) or secure setting.
² Chester has only forensic units.

Table 8. Findings in Investigations Closed by OIG in FY 2004 regarding Developmental Disability (DD) Programs

Location	Abuse substantiated	Neglect substantiated	No abuse or neglect, but other issue	No abuse or neglect or other issue	Total closed in FY2004
Choate DC1	2	3	7	122	134
Fox DC	0	2	0	7	9
Howe DC	3	5	9	102	119
Jacksonville DC	3	3	7	65	78
Kiley DC	7	3	7	29	46
Ludeman DC	1	4	1	35	41
Mabley DC	2	4	3	5	14
Murray DC	5	2	5	12	24
Shapiro DC	4	2	6	48	60
Facility2 subtotals	28	28	45	425	526
CILAs	56	24	92	319	491
Other residential	2	0	2	5	9
DT program	30	15	27	86	158
Vocational program	1	0	2	9	12
Other community	1	1	0	2	4
Community subtotals	90	40	123	421	674
TOTALS	118	68	168	846	1200

¹ Includes one "other issues" cases on the DD forensic unit.
² Includes one Singer DC case, although the facility is now closed.

Table 9. Findings in Investigations Closed by OIG in FY 2004 regarding Mental Health (MH) Programs

Location	Abuse substantiated	Neglect substantiated	No abuse or neglect; other issue	No abuse or neglect; no other issue	Total closed in FY 2004
Alton MHC - Civil1	1	0	2	15	18
Alton MHC - Forensic	0	1	0	37	38
Chester MHC2	2	0	1	114	117
Choate MHC	0	0	5	29	34
Chicago Read MHC	0	1	5	28	34
Elgin MHC - Civil	1	0	1	18	20
Elgin MHC - Forensic	1	0	4	12	17
Madden MHC	0	0	2	23	25
McFarland MHC - Civil	0	0	3	14	17
McFarland MHC - Forensic	0	0	0	5	5
Singer MHC	2	0	1	25	30
Tinley Park MHC	1	0	1	23	25
Facility subtotals	7	3	27	352	389
CILAs	0	2	11	1	14
Other residential	3	1	3	16	23
MH outpatient	0	0	2	4	6
Vocational programs	0	0	0	0	0
Other community	2	0	1	4	7
Community subtotals	5	3	7	35	50
TOTALS	12	6	34	387	439

¹ Civil units are for individuals who do not need a forensic (commitment by a criminal court) or secure setting.
² Chester has only forensic units.

Table 12. FY 2004 Census and Staffing Levels at State-operated Facilities

	Individuals served1 Fiscal Year Counts	Average census Fiscal Year Counts	Facility2 census As of June 30, 2004	Direct care As of June 30, 2004	Staffing ratio As of June 30, 2004
Choate DC	231	194	195	256.8	1.32
Fox DC	173	164	163	183.6	1.13
Howe DC	471	438	431	584.5	1.36
Jacksonville DC	277	259	259	349.5	1.35
Kiley DC	277	266	266	346.4	1.30
Ludeman DC	445	434	433	520.5	1.20
Mabley DC	120	109	109	149.9	1.38
Murray DC	368	347	348	406.3	1.17
Shapiro DC	680	645	647	932.0	1.44
DC Totals	3,042	2,865	2,851	3,729.5	1.31
Alton MHC	339	110	110	162.0	1.47
Chester MHC	483	279	278	367.7	1.32
Chicago-Read MHC	1,789	165	157	233.0	1.48
Choate MHC	624	81	76	110.1	1.45
Elgin MHC	1,136	370	359	575.3	1.60
Madden MHC	1,950	113	71	176.4	2.48
McFarland MHC	711	102	100	126.1	1.26
Singer MHC	540	74	84	112.6	1.34
Tinley Park MHC	1,553	127	116	173.4	1.49
MHC Totals	9,125	1,421	1,351	2,036.6	1.51

¹ Total number of individuals served at some time during the fiscal year; each individual is counted only once, regardless of number of admissions to that facility.
² Total number of individuals on the facility census on June 30, 2004, including individuals on temporary visit to a hospital, home, or other residential setting.