DHS OIG FY 2008 Annual Report

December 2008

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

This Fiscal Year (FY) 2008 Annual Report of the Office of the Inspector General (OIG) in the Illinois Department of Human Services is submitted in accordance with the Department of Human Services Act (20 ILCS 1305/1-17) and the Adults with Disabilities Domestic Abuse Intervention Act (20 ILCS 2435).

After the passage of enabling legislation in 1987, OIG was created the following year to investigate allegations of abuse and neglect of people who receive mental health or developmental disability services in Illinois and to seek ways to prevent it. This annual report presents a retrospective that reflects modifications relative to how the State understands abuse and neglect, handles allegations, manages investigations, and responds proactively and reactively to prevent recurrence.

This annual report highlights all activities and services of OIG during FY 2008, which began July 1, 2007 and ended June 30, 2008. The report describes activities undertaken to prevent abuse and neglect, such as unannounced facility site visits and cooperation with external entities. Also, it provides information about OIG-conducted external training and on improvements in OIG's reporting and investigating processes. Tables are included to show allegations received, cases closed, and statutorily mandated census figures and staffing ratios.

By placing this past year's information within the context of a 20-year history, this annual report provides insights into the proactive steps Illinois has taken to improve the lives of its citizens who have disabilities.

Sincerely,

William M. Davis

Inspector General

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Abuse and Neglect of Adults with Disabilities:
DHS Office of the Inspector General FY08 Annual Report - A 20-year Retrospective

EXECUTIVE SUMMARY

Fiscal Year (FY) 2008 was the 20th year of the Office of the Inspector General (OIG) in the Illinois Department of Human Services. During FY 2008, OIG: 

• Received 2,668 allegations of abuse or neglect - 4% more than during FY 2007 and 14% more than during FY 2006 - although a shift in location of the allegations mirrored a continuing shift of primary residences from DHS facilities to community agencies and an emphasis on more thorough reporting at the agencies:
  • 797 at the facilities- 8% fewer than FY 2007, and 13% fewer than FY 2006,
  • 1,229 at the agencies- 18% more than FY 2007, and 38% more than FY 2006,
  • 642 in domestic settings- 2% less than FY 2007, but 22% more than FY 2006;
    
• Completed 2,747 investigations - 7% more than during FY 2007 and 15% more than during FY 2006 - some were reported in prior years, and OIG continues to improve in completing investigations more quickly:
  • 2,009 investigations at facilities or community agencies (Rule 50), done in an average of 44 days per case, compared to:
    • 1,938 done in FY 2007 in an average of 46 days per case (4% faster),
    • 1,788 done in FY 2006 in an average of 53 days per case (17% faster);
  • 738 investigations in domestic settings (Rule 51), done in an average of 32 days per case, compared to:
    • 619 done in FY 2007 in an average of 37 days per case (14% faster),
    • 608 done in FY 2006 in an average of 42 days per case (24% faster); and
      
• Closed 2,741 investigations - 9% more than during FY 2007 and 22% more than during FY 2006 - and substantiated a higher percentage of those cases:
  • 451 were substantiated, of which 193 were in domestic settings, compared to:
    • 353 substantiated (117 in domestic settings) in FY 2007 (up 28%), and
    • 322 substantiated (110 in domestic settings) in FY 2006 (up 40%); and
  • 455 were not substantiated, but OIG cited administrative issues, compared to:
    • 435 during FY 2007 (5% more), and
    • 283 during FY 2006 (61% more); and
      
• Handled reports of 144 deaths of individuals, completing reviews on 75 of these deaths plus 26 reported in FY 2006, substantiating neglect in five of those 101 deaths.
  

During FY 2008, OIG also accomplished the following:

• Conducted an unannounced site visit to each of the eighteen DHS facilities, making 120 recommendations aimed at preventing abuse and neglect;
• Created and distributed an OIG Investigative Protocol for DHS Facilities, and began an annual review and approval process for facility staff who assist in OIG investigations;
• Received and recorded 1,279 reports that did not meet the statutory definitions of abuse, neglect, or domestic exploitation, referring those reports to the appropriate state or local entity or back to the facility or community agency for resolution of issues raised;
• Conducted 65 training sessions on reporting and investigating allegations at facilities and community agency programs, with a combined total of 1,336 participants statewide;
• Mandated that all investigations be assigned within one working day, and streamlined the use of investigative plans;
• Made substantial improvements to OIG's comprehensive database, for example:
  • Automatically listing on each intake the five most recent cases involving the same victim or same accused (whether reportable to OIG or not),
  • Adding non-reportable incidents to the monthly listings sent to the facilities,
  • Completely automating the request, approval, printing, and tracking of OIG's administrative subpoenas,
  • Displaying last action taken for pending investigations on most internal case management reports, and
  • Producing all case initiation and completion letters from the database automatically.
• Produced multiple data reports for the program divisions on administrative leave, case reporting and completion, and data patterns found in allegations reported; and
• Cited late reporting in 175 cases, required 671 Written Responses from facilities and community agencies, and conducted 130 Written Response Compliance Reviews, all of which are higher than any previous year.

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Table of Contents

Chapter 1: Illinois State Laws on DHS-OIG

• FY08: New Statutes

Chapter 2: Administrative Rules and Policies on Abuse and Neglect

• FY08: Directives Updates

Chapter 3: OIG's Organization and Database

• FY08: System Coordination

Chapter 4: Allegations and Incidents Reported

• FY08: More Intakes

Chapter 5: OIG's Investigations

• FY08: Faster Completions

Chapter 6: Unannounced Facility Site Visits

• FY08: Site Visit Findings

Chapter 7: OIG-Conducted Training

• FY08: Improving Training

Chapter 8: Investigative Protocols

• FY08: Facility Investigative Protocols

Chapter 9: Written Responses to Case Findings

• FY08: More Written Responses

Addenda:

• A: Census and Staffing Ratios
• B: Sample FY 2008 Cases

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Chapter 1:  ILLINOIS STATE LAWS ON DHS-OIG

FY85-FY87: The Beginnings

• growing awareness of abuse and neglect led the then Department of Mental Health and Developmental Disabilities in April 1985 to create the Office of Internal Review. The office was to review all new allegations of abuse and neglect by staff and other "unusual" incidents at the Department's facilities and flag immediate actions that needed to be taken. Then, the office was to review the written reports of investigations conducted by facility personnel into these allegations and give recommendations for administrative actions to prevent recurrence.
• departmental policy, adopted in May 1985, did not define abuse or neglect, but it established requirements for reporting and investigating allegations and other incidents. By January 1986, the office had a supervisor, five investigation reviewers, and two compliance review analysts. Gradual increases in allegations reported clearly showed the need for an office of this type.

However, advocacy groups questioned the office's effectiveness. It appeared understaffed and was relying on facility personnel to investigate allegations. It did not report directly to the department director and did not provide any public reporting of findings and recommendations. As a result, the General Assembly and the Governor decided to establish Illinois' first ever Inspector General.

FY88-FY91: The Initial Legislation

The new law, Public Act (P.A.) 85-223, was signed August 26, 1987. It amended the Department of Public Health's Long Term Care Facility Residents Reporting Act (a statute that regulates nursing homes) to:

• Create the position of Inspector General, reporting to the department's director;
• Apply to any program or other entity licensed or operated by the department for mental health and developmental disabilities (including community agency programs);
• Require reporting of allegations to the Nursing Home Hotline of the Illinois Department of Public Health (IDPH) and criminal allegations to the Illinois State Police (ISP);
• Allow the Inspector General to recommend sanctions to the department and to IDPH, such as the closure of units; and
• Require an annual report to the Governor and General Assembly.

This legislation also provided definitions for abuse and neglect. Abuse was "any physical injury, sexual abuse or mental injury inflicted on a resident other than by accidental means." This definition, which existed in that statute prior to the law creating the Inspector General position, did not specify that abuse was by a caregiver or other employee. However, at the time, the law was interpreted to apply to actions by staff. Neglect was "a failure in a long term care facility to provide adequate medical or personal care or maintenance, which failure results in physical or mental injury to a resident or in the deterioration of a resident's physical or mental condition." These definitions of abuse and neglect have not substantially changed since that time.

In FY 1990, to further clarify the intent of the statute, P.A. 86-1013 was passed and signed on January 3, 1990. It changed appointment of the Inspector General to the typical process of nomination by governor with consent of the Senate. It specifically removed community agencies from a requirement for reporting to the Office of the Inspector General (OIG), but it reinforced reporting at the department-operated facilities by doing the following:

• Prohibited any screening of allegations by administrators;
• Required reporting to OIG first, and then to ISP; and
• Required facilities to bar employees suspected of abuse from contact with all individuals receiving services until completion of the investigation.

This act added further oversight of OIG by mandating biennial program audits by the Illinois Auditor General. In addition, a "sunset" provision was added, which specified a date that OIG's authorization to exist would expire: December 31, 1990.

The annual report requirement and the sunset provision provided for closer legislative oversight as well. In FY 1991, P.A. 86-1416, which was signed September 11, 1990, granted the Guardianship and Advocacy Commission and Protection and Advocacy (now Equip for Equality) access to copies of OIG's final reports. The law also extended OIG's sunset to July 1, 1991.

P.A. 87-124, which was not formally signed until July 13, 1991 (just after the start of FY 1992), extended OIG's sunset to January 1, 1993, but made no other changes. Technically, since this act was signed after OIG's sunset date, the act had to recreate the entire OIG statute.

FY92-FY95: A Proactive Approach

In contrast to those minor changes, P.A. 87-1158, which was signed September 18, 1992, codified OIG's developing proactive approach of preventing abuse and neglect. First, the law mandated that OIG conduct an unannounced site visit to each department facility each year.

This law also required that OIG set up training programs for all department employees on preventing and reporting abuse and neglect. OIG was further required to establish a comprehensive program to ensure that everyone conducting investigations receives initial and ongoing training on investigative techniques, communication skills, and the appropriate means of contact with individuals receiving services in the facilities.

In addition, P.A. 87-1158 created a "Quality Care Board" of seven members with various related backgrounds to "...monitor and oversee the operations, policies, and procedures of the Inspector General to assure the prompt and thorough investigation of allegations of neglect and abuse." The Board members were to be unpaid, but travel expenses were reimbursed; this approach remains true.

Finally, this act required OIG's annual report to include facility census and direct care staffing ratios, and it extended OIG's sunset to December 31, 1995.

FY96-FY99: Into the Community

More significant changes were made in FY 1996. Recognizing the need for a uniform system of protection for individuals with disabilities across settings and OIG's role as an objective and effective investigator body, the legislature passed and the governor signed P.A. 89-427 on December 7, 1995. This act expanded OIG's investigative authority into programs licensed, funded, or certified by the department; yet it mandated that OIG not conduct any investigations that would be redundant to those conducted by another State agency. It also required OIG to promulgate an administrative rule.

In addition, to eliminate the possibility of a conflict of roles between investigating and licensing, OIG was prohibited from any supervision or involvement in "routine programmatic, licensure, or certification operations." Finally, P.A. 89-427 extended OIG's sunset until January 1, 2000.

In FY 1998, P.A. 90-512, which was signed August 22, 1997, mandated that OIG require a "written response" - what OIG had been calling a corrective action plan - from the agency or facility on cases OIG substantiated or found another administrative issue. The agency or facility was required to specifically address issues aimed at preventing abuse and neglect.

The following year, the legislature passed P.A. 91-169, which merely extended OIG's sunset date to January 1, 2002. This act was not formally signed until July 16, 1999 (FY00).

FY00-FY01: Into Private Homes

OIG's authority was again extended by P.A. 91-671, which was signed December 22, 1999. The law, the "Abuse of Adults with Disabilities Intervention Act" (20 ILCS 2435), gave OIG an entirely new authority to investigate in private homes where adults with disabilities were being abused, neglected, or exploited.

To be eligible for the program, an individual must be between 18 and 59 years of age, reside in a domestic living situation, and have a disability that impairs his/her ability to seek help on his/her own. Except in emergencies, the individual must consent to the assessment before it can begin. Emergency actions OIG was authorized to pursue included medical evaluation, residential placement, orders of protection, and temporary guardianship.

Since the legislation was to become effective July 1, 2000, OIG and the Department of Human Services (DHS) worked diligently through the remainder of FY 2000 to prepare for the expanded responsibility. An internal ad hoc committee developed an administrative regulation ("rule"), policies, and tools for the new program. Since no additional funding was appropriated with this added responsibility, OIG staffed the program by shifting investigative staff and absorbing travel and equipment costs within the office's regular FY 2001 budget. To date, OIG still has not received additional funding to pay for the costs of this expanded statutory responsibility.

OIG's authority to investigate in local communities and private homes highlighted the need for a badge as official identification of OIG investigators. However, P.A. 91-883, which was signed on June 30, 2000, and addressed a different issue, effectively removed authorization for badges for OIG investigators. However, P.A. 93-423, which was signed August 5, 2003, again authorized DHS to issue badges to OIG investigators.

FY02-FY05: Preventing Recurrence

Beginning in FY 2002, the statute was expanded several times to add more measures aimed at preventing recurrence of abuse/neglect when OIG substantiates it.

The Illinois Department of Public Health (IDPH) maintains a registry of people in Illinois who are trained and licensed as nurse aides. P.A. 92-473 required OIG to begin referring to this Nurse Aide Registry (now the "Health Care Worker Registry") the name of anyone substantiated to have committed physical abuse, sexual abuse, or egregious neglect. Extensive appeals processes were included, both to prevent reporting to the Registry and to remove from the Registry after rehabilitation. This law was signed August 22, 2001, and became effective January 1, 2002.

P.A. 92-358, signed August 15, 2001, again merely extended OIG's sunset, this time from January 1, 2002 to January 1, 2004. P.A. 93-636, which was signed December 31, 2003, removed the sunset provision completely and reaffirmed OIG's independence by separating OIG's budget from DHS' overall budget. P.A. 93-636 also put the Quality Care Board directly within OIG.

P.A. 93-636 also made substantial changes in the handling of Written Responses, which are required of facilities or community agencies in cases that OIG substantiates as abuse/neglect or makes other recommendations. DHS retains responsibility for receiving and approving Written Responses, but OIG was given responsibility to monitor implementation in two ways: OIG must obtain regular status reports in all cases where implementation is delayed, and OIG must conduct compliance reviews on a random sample of approved Written Responses to ensure that the action was actually taken.

Finally, some cases have involved alleged actions by licensed professional staff, such as nurses, doctors and social workers, yet the Illinois Department of Financial and Professional Regulation has responsibility for investigations governing their licenses. P.A. 94-852, signed June 13, 2005, specifically allows OIG to disclose its investigative reports to the Illinois Department of Financial and Professional Regulation for its investigation of licensed professionals.

FY06-FY07: System Improvement

From its experience, OIG proposed ways to improve the system of reporting, investigating, and preventing abuse and neglect. In FY 2006 and FY 2007, the following statutes were approved.

Regarding Rule 50 Investigations

P.A. 94-428, which was also signed August 2, 2005, allows OIG to notify the appropriate law enforcement entity of possible criminal acts at community agencies. Previously, a narrow reading of the statute would have required that OIG always had to report to the Illinois State Police, even if it were not on State property and involved no State employees.

To ensure timely and thorough reporting, P.A. 94-853, signed June 13, 2006, makes it a Class A misdemeanor for a facility or community agency employee (including a volunteer or contractual staff) to intentionally report an abuse/neglect allegation late or not at all.

P.A. 94-934, which was signed June 26, 2006, fills a void by adding owners / operators of a community agency to the persons who OIG may refer to the Illinois Department of Public Health's Health Care Worker Registry.

P.A. 94-1053, signed July 24, 2006, makes it a Class 3 felony for any facility or community agency employee to knowingly engage in any sexual contact with a person who has a disability and is receiving residential services in the facility/agency, whether it was consensual or not.

Regarding Rule 51 Investigations

P.A. 94-418, signed August 2, 2005, specifies that OIG is to seek guardianship when the alleged perpetrator in a Domestic Abuse Program (DAP) case is the guardian and there is an "immediate and urgent necessity" for a temporary substitute. This change avoided an implication that OIG had to pursue guardianship every time the guardian was the alleged perpetrator.

P.A. 94-495, signed August 9, 2005, gives OIG a broader ability to obtain records from banks and other financial institutions during domestic exploitation cases. The financial institution may release records if OIG or some other entity suspects a customer has been or may become a victim of domestic financial exploitation, nor longer requiring the financial institution itself to suspect exploitation. This statute also benefited others, as it also applied to financial exploitation investigations being conducted by the Department on Aging, by public guardians, and by law enforcement.

A similar bill also signed on August 9, 2005, P.A. 94-500, requires someone who is an agent (guardian or otherwise acting for a person who is incapacitated) to give records of all financial actions he/she took as the agent, if OIG requests them for a DAP case.

P.A. 94-851, a related bill which was signed June 13, 2006, allows OIG to issue subpoenas for potential witnesses and records in a DAP case. It specifies that any financial records obtained during that investigation are confidential and may only be released with the consent of the victim/guardian or in response to a court order or a court subpoena.

FY08: New Statutes

Passed late in spring 2007 and signed after the start of FY 2008 were two bills addressing OIG. The first, P.A. 95-373, which was signed August 23, 2007, prohibits assessing OIG for guardian ad litem or legal fees when OIG is petitioning for guardianship under the Abuse of Adults with Disabilities Intervention Act.

P.A. 95-545, which was signed August 28, 2007, moved all the sections governing OIG from IDPH's statute to a new section in the DHS Act (20 ILCS 1305/1-17). No substantive changes were made in the wording of any section. Addressing this original issue of the statutory location of OIG's legislation is the first step in correcting the original problems in the definitions of abuse and neglect.

OIG did not suggest legislation during the spring 2008 legislative session.

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Chapter 2:  ADMINISTRATIVE RULES AND POLICIES ON ABUSE AND NEGLECT

FY85-FY88: The Beginnings

As noted in Chapter 1, a departmental policy on reporting and investigating abuse/neglect had been adopted in May 1985. The policy did not define abuse or neglect, but it did describe procedures for reporting to the Office of Internal Review and to the Illinois State Police (ISP) and for investigating allegations and other incidents.

The law that created OIG did define abuse and neglect, but it did not establish specific internal procedures for reporting and investigating these allegations. Thus, one of the first needs after the creation of OIG was a revision to the departmental policy.

As a preliminary step, the first Inspector General, Philip V. Fisher, distributed a memo, dated June 17, 1988. It reiterated the policy's list of reportable allegations and "unusual" incidents, detailed the procedures for reporting to OIG, and mandated requirements for investigation and subsequent administrative action.

FY89-FY91: A Focus on Reporting

The departmental policy was formally revised effective May 12, 1989. It mirrored the law's requirement for reporting first to the Department of Public Health (IDPH), then to ISP, and finally to OIG. This policy also built on the statutory definitions of abuse and neglect to describe categories of abuse and neglect that remain to this day.

• "Physical abuse shall include but is not limited to the hitting, kicking, pinching, choking, shoving, pushing, biting, slapping, punching, striking with an object, burning, or cutting of a recipient by an employee or other direct physical act by an employee that is the proximate cause of psychological harm or physical injury to a recipient."
• "Sexual abuse shall include but is not limited to any sexual penetration or sexual conduct between a recipient and an employee."
• "Verbal/psychological abuse [now called "mental injury"] shall include but is not limited to the use of words, signs, and/or gestures by an employee to a hearing, hearing impaired, or non-hearing, and/or blind recipient or actions taken by an employee which are either commonly understood by person to, or the employee knows will for that particular recipient, intimidate, demean, curse, harass, cause emotional anguish or distress, ridicule, or threaten harm to the recipient or words, signs and/or gestures or actions which the employee knows for that particular recipient will or is likely to incite and/or precipitate maladaptive and/or regressive behavior by that recipient."
• "Neglect shall include but is not limited to:

1. Any failure to carry out required and appropriate clinical services... that is the proximate cause of psychological harm or physical injury to a recipient.
2. Any failure to carry out required habilitation... or required treatment... that is the proximate cause of psychological harm or physical injury to a recipient.
3. An act or omission which endangers… a recipient's physical or psychological health or safety or fails to respond to an obvious need of the recipient.
4. The failure to provide for the recipient's personal hygiene needs or the withholding of food or fluids or clothing or… other personal care items....
5. The failure to provide and/or ensure immediate and/or appropriate medical attention to and reporting of physical injuries to a recipient or recipients."

Thus, the departmental policy's definition limited "abuse" to an action by staff, just like the law does for "neglect." Unlike abuse, however, neglect did not require documented harm or injury. Actions placing a recipient at significant risk were reportable as neglect regardless of outcome.

The departmental policy listed several kinds of other incidents that were reportable to OIG, including serious injury, unauthorized absence, sexual activity between residents, theft of resident property, and improper employee conduct. OIG rarely investigated these incidents but did review the subsequent facility investigation carefully for possible issues.

A January 1990 revision of the departmental policy expanded the category of reportable injuries. Serious injuries were still reportable separately, but now all injuries that appeared to have been inflicted by another individual other than by accidental means were reportable to OIG. This wording was straight from the law's definition of abuse, which did not clearly define abuse as an act by an employee.

Therefore, all of the minor injuries that occur in a normal day - the scrapes, slight bruises, and red marks - became reportable to OIG, especially when the individual was nonverbal and could not explain how an injury occurred. The number that were reported to OIG increased dramatically. In the six months before January 1990, OIG received only 123 injuries of this type; in the six months beginning January 1990, OIG received 2,574.

This January 1990 revision also changed the reporting procedure to require reporting to OIG first and then to the ISP, which enabled faster reporting to OIG. Then, a September 1990 revision required that the facilities report allegations immediately by phone. Immediately was "no later than the end of the next working day after the incident was discovered" (PPD 01.05.06.03, effective 9/24/90).

FY92-FY97: Few Reporting Changes

While significant changes were occurring within OIG and in the eventual creation of the Department of Human Services, the departmental policy remained unmodified for seven years. By memo effective December 9, 1996, however, the department's director mandated that the facilities begin notifying OIG within one hour of discovery of allegations of abuse or neglect.

OIG also began re-evaluating the reporting of injuries without an allegation, which, in FY 1995, accounted for 65% of all incidents reported to OIG. In FY 1997, OIG conducted a study that analyzed individual-on-individual injuries reported in FY 1994 - FY 1996. The study found "...more than 95% of these are minor scratches, red marks, bruises, scrapes, cuts, and bites that require little or no medical treatment." The study found no patterns in day of the week, time of day, or characteristics of the individuals involved, and it noted the rates of such injuries per individual remained stable or declined.

The study added that these injury reports diverted OIG resources from investigation and review of abuse/neglect allegations. Thus, the study supported ending the reporting of individual-on-individual injuries to OIG without an allegation or suspicion of abuse/neglect by an employee.

FY98-FY00: Rule 50 and Rule 51

The facilities are operated by the department, so a departmental policy is adequate regulation. The passage of legislation extending OIG's authority into programs operated by local community agencies that were licensed, certified, or funded to provide mental health or developmental disability services, however, necessitated an administrative rule.

This rule was initially drafted by a Task Force comprising individuals with disabilities, family members, legislators, advocacy groups, and representatives of community agencies, trade associations, and DHS. The draft began in FY 1996 and was modified during comment periods in FY 1997 and FY 1998. After formal comment periods, the Joint Committee on Administrative Rules issued no objection to the new rule. Thus, Rule 50 (officially, Illinois Administrative Code, Title 59, Chapter I, Part 50) was adopted and became effective October 19, 1998.

Two of the definitions were very similar to the original departmental policy. Physical abuse remained essentially unchanged. Actions that were considered abusive are reportable to OIG as abuse 'with or without injury'. The definition of sexual abuse replaced "sexual penetration or sexual conduct" with the phrase "sexual penetration, molestation, or exploitation."

Mental abuse ("mental injury") "…includes verbal abuse, psychological abuse or exploitation by an employee." Each of these was defined separately. Verbal abuse was the "use of words" and psychological abuse was the "use of signs, gestures or other actions," but the rest of those two definitions remained the same. Exploitation was "any act of forcing, compelling, or coercing an individual(s) to perform services for the advantage of another, with or without an injury." Exploitation (other than sexual) was now considered a type of abuse.

The definition of neglect was substantially expanded. The five subparts in the departmental policy were combined into two - any failure to carry out required services or to respond to an obvious need - and another four were added. These four were any act or omission resulting in: an injury; an unauthorized absence; sexual conduct by individuals; or exploitation by another individual.

However, the most significant change in the policy was the omission of "other incidents" - i.e., non-serious individual-on-individual injuries, unauthorized absences, sexual activity between residents, and theft of resident property - when there was no specific allegation or suspicion of abuse or neglect by staff. The facilities and agencies were to have internal review processes, and these incidents would be OIG-reportable only if the reviewers (or anyone else) suspected or alleged abuse or neglect by an employee.

Rule 50 further focused the types of injuries that had to be reported to OIG. Five types of injuries were reportable even without any allegation or suspicion of abuse/neglect; these were:

• Suicide attempts with serious or non-serious injury;
• Serious self-inflicted injuries;
• Serious injuries of accidental means or unknown cause;
• Repeated injuries - that is, three or more in a month; and
• Injuries involving multiple victims.

"Serious injuries" were injuries that might threaten life, transmit a serious infectious disease or become serious later, as well as those requiring emergency medical treatment, and OIG conducted investigations on nearly all of these injuries.

Separately, after passage of the Adults with Disabilities Domestic Abuse Intervention Act, OIG developed an administrative rule to govern its investigations ("assessments") into allegations of domestic abuse, neglect, or exploitation. Rule 51 (Illinois Administrative Code, Title 59, Chapter 1, Part 51) described the program's authority, established responsibilities, set requirements for service plans, gave time frames for conducting investigations, and specified confidentiality restrictions. Rule 51 was effective July 1, 2000, and it has remained unchanged.

FY01-FY02: Serious Injuries and Registry Reporting

In FY 2001, OIG began working on a revision to Rule 50 primarily to address two issues: initial reporting of serious injuries, and reporting of people substantiated to have committed abuse.

First, Rule 50's definitions for reportable injuries had eliminated the largest category of reportable incidents to OIG, but it had also greatly increased the number reported as "serious injuries." OIG received 578 serious injuries during FY 1998 but received 1,557 during FY 2001. The jump in reports and the cost in OIG investigative resources were large.

As a result, OIG developed a separate serious injury review process. Every serious injury was still reviewed by an investigator, who, if he/she suspected abuse or neglect, could reclassify and investigate it as such or require the facility or community agency to investigate it and provide additional information or a complete investigative report. During FY 2001, of the 1,557 serious injuries reported, 521 were returned for more information or an investigation.

The remaining serious injuries were sent to the OIG Bureau of Compliance and Evaluation (then called Bureau of Support Services) to look for reasonable suspicion of abuse/neglect and, if any, to return the case to the investigations bureau for more information and possible investigation. The bureau also analyzed these injuries for any patterns or trends and referred them to the OIG site visitors, if preventative measures seemed warranted. In FY 2001, only 145 (14%) of the 1,036 serious injuries reviewed were returned to an investigations bureau for more information. Site visitors returned three additional serious injuries for investigation after their review.

Nearly two-thirds of these serious injuries resulted from accidents or unknown causes, nine percent by self-injurious behavior, and eight percent by other individuals receiving services. Only nine of the 1,557 injuries reported (less than one percent) were ultimately substantiated to have involved neglect.

Since very few of these had any allegation or suspicion of abuse/neglect - and even fewer resulted in a finding of abuse/neglect - OIG decided to ask to eliminate routine reporting of serious injuries and instead require the facilities and community agencies to have objective internal reviews of all injuries and to report to OIG only those with a suspicion of abuse/neglect.

Second, a new law that required reporting to the Illinois Department of Public Health's Nurse Aide Registry (now Health Care Worker Registry) necessitated a revision to Rule 50 to define "egregious" neglect and to describe the appeals processes for referring to this Registry. OIG also took the opportunity to review and recommend other changes to the rule. An internal committee drafted substantial revisions that focused the limited resources of OIG onto a more narrow understanding of abuse/neglect and investigation.

This draft revision was completed and adopted as an emergency rule on January 1, 2002. The Inspector General then held a series of meetings with interested persons and organizations affected by the new requirements. Finally, after a period for public comment, the revised Rule 50 was adopted on May 24, 2002.

The most significant changes in the new Rule 50 were:

• Physical abuse ("physical injury") was defined as physical harm caused by a non-accidental act, rather than a direct act of physical mistreatment;
• Mental abuse ("mental injury") now required there be harm or reasonably expected harm to the individual;
• Exploitation was no longer reportable to OIG, as it was seen as not covered by the definition of mental injury;
• Neglect required physical or mental injury or deterioration in the individual's condition;
• Serious injuries were reportable to OIG only if a specific allegation or suspicion of abuse/neglect by staff had been made;
• Deaths were reportable only if occurring within (or shortly after discharge, deflection, or transfer from) a residential program or on-site in a non-residential program;
• Allegations of abuse/neglect were always to be reported by phone to OIG's hotline, rather than by fax or mail;
• Facilities and community agencies were allowed up to four hours to report allegations, not just within one hour;
• "Days" (such as in the 60-day goal for investigations) was defined as working days; and
• Aggravating and mitigating circumstances be identified whenever a case of abuse or neglect was substantiated.

Subsequently, the department's policy was revised to reflect these changes as well. Both Rule 50 and the department's policy have remained unchanged since this point.

FY03-FY07: Clarification

The new Rule 50 definitions of mental injury and neglect resulted in a larger than expected decrease in allegations of those types. From FY 2001 to FY 2004, mental abuse allegations received by OIG dropped 65% (471 to 166) and neglect allegations dropped 55% (459 to 207), while allegations of physical abuse and allegations of sexual abuse both increased.

Therefore, on August 2, 2005, OIG mailed a clarification memo to the facilities and agencies, reiterating the definitions for allegations of mental injury and neglect and clarifying what is reportable under those definitions. OIG also adjusted the Rule 50 training that it conducted to emphasize a correct understanding of the definitions. As a result, in FY 2006, mental abuse allegations rebounded 63% (to 358) and neglect allegations rebounded 48% (to 329).

FY08: Rule and Directive Updates

In FY 2008, OIG made minor changes in Rule 50 and in OIG directives, primarily to reflect the change in the statutory location of the law creating OIG and in the name of the Department of Public Health's Health Care Worker Registry (formerly Nurse Aide Registry). Substantive changes to the directives in the assignment of the investigation, the development of the investigative plan, and the reconsideration process are reflected in the relevant section of this Annual Report.

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Chapter 3:  OIG'S ORGANIZATION AND DATABASE

FY85-FY87: The Beginnings

Prior to the statute authorizing OIG, the department had formed an Office of Internal Review to receive reports of allegations and incidents, oversee investigations, and act as liaison with the Illinois State Police. A State Police lead investigator was hired on contract to manage this new office. A handwritten table ("log") with sequential numbers was used to keep track of new allegations and closed cases. The law creating the position of Inspector General was passed and signed in August 1987, and the department conducted a nationwide search.

FY88-FY92: Formation of OIG

The first Inspector General, Philip V. Fisher, was a career law enforcement officer who had most recently been regional administrator for the federal Drug Enforcement Administration. He was appointed, and OIG was created, on March 7, 1988.

Inspector General Fisher inherited the six investigators and the organization of the existing Office of Internal Review. Four additional investigators were hired for the Chicago area beginning May 1, 1988. Three offices were set up: five investigators and the Inspector General in Chicago (at Chicago-Read MHC); four investigators, including a lead investigator for downstate, in Springfield (at McFarland MHC); and one investigator in Centralia (at Murray DC).

Three more investigators were hired over the next year, bringing the total to thirteen investigators in 1990. A lead investigator was designated for the upstate office as well. Field investigator assignments for facilities were rotated annually.

Instead of continuing centralized case numbering using a handwritten log, OIG gave each facility a block of numbers and required they be assigned to allegations and incidents as directed by OIG. Then, in September 1988, OIG created a relational database to record case numbers and track cases. OIG began sending monthly reports back to the facilities to monitor open and completed investigations and to reconcile differences.

FY92-FY95: New Leadership, New Directions

New Inspector General

Philip V. Fisher retired on December 31, 1991, and Governor Jim Edgar appointed a mental health advocate, C.J. Dombrowski, on March 1, 1992. She envisioned OIG as having a proactive role in ensuring quality service, not just preventing abuse and neglect.

First, OIG created a second database, one for facilities to track cases and for OIG to use for more extensive data analysis. Data required on each incident included: date, shift, and time of the alleged incident; unit, location, and type of room where it occurred; and diagnosis, age, competency, and sensory deficits of the victim. The facilities sent monthly exports to OIG on diskette for automatic import into this combined database.

Second, during FY 1993, Inspector General Dombrowski reorganized OIG into three bureaus.

• The Bureau of Community Review absorbed the department's Bureau of Certification and Licensure, but it monitored facilities as well as community agency programs.
• The Investigations Bureau continued to conduct abuse/neglect investigations at the department facilities.
• A new Legal and Advocacy Services Bureau handled consent decree compliance monitoring, policy reviews, citizen advocacy organizations, data analysis, internal audits, and the OIG annual report.

One OIG employee was assigned to a "Quality Care Line," a phone number for receiving and channeling issues, complaints, and problems to the appropriate person within the department. Established in FY 1993, this Quality Care Line did not handle abuse/neglect allegations.

In FY 1994, to properly evaluate clinical issues in investigations, OIG hired a registered nurse to act as Clinical Liaison. That year, OIG assumed direct oversight of facility employees who had been conducting investigative work for OIG, effectively doubling the number of its investigators. The next year, an investigative supervisor was reassigned as OIG's first training coordinator.

FY96-FY00: Reorganization for Expansion

New Inspector General

Inspector General Dombrowski resigned October 15, 1995, and Patricia M. Curtis, a prominent advocate for people with developmental disabilities, was named Inspector General. She re-focused OIG's efforts on abuse/neglect prevention, sought to work more collaboratively with the department and external systems, and significantly reorganized OIG as well.

• The new law that authorized OIG to conduct investigations in community agencies also prohibited OIG from being involved in routine programmatic and licensure issues. Thus, the certification/licensure functions returned to DHS, although some staff remained in the Bureau of Investigations, and OIG's case reports no longer cited secondary issues.
• Citizen advocacy group support returned to the program divisions, and consent decree monitoring and legal representation of OIG staff returned to the department's Office of Legal Counsel.
• The OIG database was moved to a Wide Area Network, a computer arrangement that allowed access by all OIG employees, regardless of where they were located, and data about OIG-conducted investigations at community agency programs were moved into this same database.
• A new Bureau of Evaluation and Review was formed in January 1996, responsible for annual unannounced site visits and under-reporting audits at facilities, for research studies and special reports, for quality assurance audits of OIG's database and OIG case files, and for review of the Written Responses and system issues raised in investigations.
• The Quality Care Line was renamed the OIG Reporting Line, and an investigator was added to receive calls. Agencies and facilities were to call this number to report allegations. By the end of the year, OIG had negotiated a contract with an answering service to receive calls during off-hours and immediately page the appropriate field investigator. OIG management staff took turns backing up the field investigators.

Also in FY 1996, most of the appointments to the Quality Care Board were approved, and the Board began meeting quarterly. With the extension of OIG's authority into the community, OIG also began meeting quarterly with the department's other divisions to discuss issues and to improve coordination of prevention and response activities.

Bureau of Investigations

In early FY1997, the need to ensure consistency of OIG's investigations across settings resulted in a change in the organizational structure of the Bureau of Investigations. Instead of being divided by type of program - facilities and community agencies - the bureau was sub-divided into two areas: North and South. Each of these two areas was further divided into "networks" - North and South each had three - and each network had a chief and a lead investigator, called a "Network Team Leader" (now "Investigative Team Leader" or ITL). The team leaders were front line supervisors, involved in overseeing all investigations being conducted by the OIG field investigators.

The following year, North and South were reduced from three to two networks. Each team leader remained responsible for supervising the OIG investigators, but they no longer reviewed the draft case report. Instead, OIG appointed non-supervisory "first-level case reviewers," whose role was to ensure the quality of the case report, the strength of the attached supporting documentation, and the appropriateness of the conclusions.

OIG Hotline

The new Rule 50 required OIG to have a "hotline" available 24 hours a day for receiving abuse/neglect allegations or deaths and to provide assistance with filing the appropriate OIG incident report form. At the beginning of FY 1998, OIG converted its internal Reporting Line to an OIG Hotline and staffed it with investigators. These "Intake" investigators also received the faxed reports of allegations and other incidents.

In October 1997, OIG's Hotline accepted responsibility for an existing intake and referral system within DHS for allegations of domestic abuse (including exploitation) and neglect of adults with disabilities. OIG had no statutory authority in private residences, so OIG always referred these calls to an appropriate entity. The appropriate entity, however, was typically not readily known to the Intake investigators. As a result, the staff in OIG's Bureau of Investigations, who were located around the state, started handling the referrals.

Other Changes

During the 1998 legislative session, ten new OIG positions were approved to meet the additional responsibilities of investigating at community agencies. One of the ten new positions was used to hire another registered nurse as a second Clinical Coordinator. These staff members were hired in FY 1999 and, at the start of FY 2000, the expanded Bureau of Investigations was split into four bureaus: Chicago-North, Chicago-South, Central, and South.

Community agency cases were given new numbers to match the format for numbering OIG used for the facilities. The four investigative bureaus now fully integrated investigations at facilities and community agencies.

Inspector General Curtis resigned September 30, 1999, and Ernest C. Neuman, a career manager with the Illinois State Police was Acting Inspector General from October 1999 into April 2000. In FY 2000, OIG developed and posted webpages within the department's website. In addition to links to Illinois laws and administrative rules that govern OIG, the webpages included:

• "How to Report Abuse and Neglect to OIG," a step by step discussion of the process;
• "What Happens During an OIG Investigation," a brief introduction of what to expect;
• A list of phone numbers for complaints not under OIG jurisdiction;
• A set of downloadable documents, such as recent OIG annual reports; and
• Eventually, an OIG training calendar.

The passage of P.A. 91-671 ("Adults with Disabilities Domestic Abuse Intervention Act") in December 1999 added an entirely new statutory role to OIG starting July 2000: investigating in private homes. No additional money has ever been appropriated, so OIG formed the Domestic Abuse Program in June 2000 using existing staff and funding that had been appropriated for facility and community agency investigations.

This development of the Domestic Abuse Program in OIG highlighted the need for ongoing coordination between OIG and several divisions and offices within DHS. Alleged victims were sometimes eligible for, but not currently receiving, services from DHS or needed more or different services. Further, issues that were raised in these cases, as well as in Rule 50 cases, benefited from multiple perspectives. Steps taken to prevent abuse/neglect were applicable to other programs and locations.

Thus, OIG formed a coordination workgroup with representatives from the DHS program divisions (Mental Health, Developmental Disabilities, and Rehabilitation Services), relevant offices within DHS (Employee Services and Bureau of Accreditation, Licensure and Certification). This workgroup met infrequently and eventually ended in FY 2001.

FY01-FY04: Focus on Investigative Management

New Inspector General

On July 1, 2000, Odell Thompson, Jr., a career Illinois State Police officer, was appointed Inspector General. He developed OIG's current mission, core values, and vision statement. He formally separated the North, Metro, Central, and South investigations bureaus, each with a bureau chief and one "Investigative Team Leader" (ITL). He established "best practice teams" to examine and propose improvements in OIG's functions, and he created a standardized OIG investigative case report format and implemented it at the end of FY 2001.

OIG's 1989 database was still used to track and report on investigations but did not capture names and other data and had limited accessibility. The 1993 Incident Tracking System held only facility cases and relied on facilities for data-entry. OIG had other databases for training, inventory and specific types of cases. Inspector General Thompson designated a Database Best Practice Team to begin working with the department to design an all-encompassing database.

The resulting OIG Comprehensive database, implemented in December 2001, incorporated all of OIG's existing databases and created an automated process for intakes. This process allowed Intake investigators to obtain more information, assign case numbers, categorize cases, find prior cases involving the alleged victim and perpetrators, and notify the appropriate investigative bureau by email. All of this now happened electronically. Facilities were told to call in every allegation or death to the OIG Hotline, faxing only the remaining other incidents.

Unfortunately, staffing issues became more pronounced. In FY 2001, OIG implemented the new Domestic Abuse Program without added resources. Additional staffing was budgeted in FY 2002, but, due to restrictions from an economic downturn, OIG could not fill the positions. Then, during the Early Retirement Initiative in late 2002, twelve staff took early retirement and all funded but vacant positions were permanently cut. Instead of gaining additional staff, OIG lost 18% of its entire headcount and has not recovered since: OIG ended FY 2003 with 26 investigators and ended FY 2008 with 25 investigators.

New Inspector General

On February 16, 2003, Odell Thompson resigned, and Deputy Inspector General Sydney R. Roberts took over as Acting Inspector General. She was named Inspector General on May 1, 2003. IG Roberts was a career law enforcement professional and held a law degree, and she earned a Master's degree in Criminology and Criminal Justice.

OIG added three functions to its database in FY 2004:

• automatic flagging of late initial reporting;
• a daily report showing status of cases; and
• a set of four quarterly investigative case management reports.

Then, in March 2004, DHS converted the data tables to IBM DB2 software, while the rest of the database remained in Access2000. This pioneering arrangement provided greater stability, automatic back-ups, and faster function for OIG staff in outlying offices.

FY05-07: System Improvement

During FY 2005, OIG renewed its commitment to developing ongoing working relationships with DHS and other State service entities to improve service delivery and prevent abuse and neglect. The re-formed OIG Program Coordination workgroup discussed critical incidents, high risk situations, and trends/patterns related to abuse and neglect findings. The workgroup's goal was to increase successful outcomes and activities aimed at preventing abuse and neglect of adult individuals with disabilities and to maintain the confidence of their families and the public.

Standing members of the workgroup were the following:

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

Other stakeholders, such as advocacy groups and associations, might also participate.

New Inspector General

On August 15, 2005, Sydney Roberts resigned; Deputy IG Robert Furniss was appointed Acting Inspector General. On February 1, 2006, William M. Davis, an Illinois State Police officer and career law enforcement administrator was named Inspector General. He took a comprehensive approach to improving the office. To ensure consistency, he continued Deputy IG Furniss' direct management of the investigative bureaus.

To improve case management, OIG created a way to enter investigative case actions in real-time and even when off-line. The field investigator could enter and revise case actions, and the actions automatically uploaded to the database when he/she next signed into DHS' computer network.

NonReportables

Complaints not meeting Rule 50's definitions abuse or neglect were previously not recorded in the database. However, in December 2006, at the recommendation of the Illinois Auditor General, OIG altered its database to save these "NonReportables."

During FY 2008, OIG recorded 1,279 non-reportable complaints or occurrences into its database. Although this process can be burdensome at times, the information can be helpful in identifying potential allegations of abuse or neglect. The information is also useful during OIG's annual unannounced site visits to the facilities, as a facility's failure to address such occurrences in a timely manner may result in abuse or neglect. For example, repeated injuries to an individual may indicate the need for revisions to a habilitation plan, additional staffing, outside assistance with an aggressive peer, or changes in placements. Licensing and certification issues may be referred to DHS' administrative offices, or remedial training in Rule 50 and Rule 51 may be warranted.

Recants

Infrequently, an individual makes an allegation and shortly thereafter admits it had not happened. These "recanted" allegations consumed a lot of OIG resources in recording, sending, assigning, monitoring, and writing a case report. To address this, OIG instituted a new process: when receiving such a recant, the Intake investigator asks that a trained facility/agency investigator interview the individual. If the individual still admits it had not happened, the Intake investigator immediately completes an "unfounded" report. Further, OIG revised the database to enable this report to be created automatically, saving even more time.

FY08: System Coordination

Quality Care Board

The OIG Quality Care Board is mandated by statute to comprise seven members appointed by the Governor and to meet quarterly to monitor and oversee OIG. In FY 2008, it continued to meet quarterly as required: August 22 and October 24, 2007, and January and April 24, 2008. The Board had one vacancy during FY 2008. The current six members, all of whom have been appointed through November 3, 2009, are as follows:

• Rita Ann Burke, Chair (parent);
• Thane A. Dykstra (provider);
• Nathaniel Gibson (provider);
• Keith W. Kemp (parent);
• Brian Neal Rubin (parent); and
• Maria Ester Lopez (provider).

The Board members reviewed OIG's quarterly reports on the status of cases, including the number opened and closed, the timeliness of investigations, and the findings. The Board members gave input and feedback into OIG's progress on its strategic objectives and related goals.

Board members reviewed the OIG Symposium, which was conducted in September 2007. The members provided strong support for the specialized training for OIG staff, law enforcement and DHS staff on interviewing victims of abuse and neglect with disabilities.

In addition, the Board invited the Illinois Council on Developmental Disabilities to give a presentation on its purpose, operations, and priorities. Finally, the Board received presentations from OIG staff on functions such as the Bureau of Hotline and Intake and the FY 2008 Abuse and Neglect Prevention Project.

OIG Program Coordination Workgroup

In FY 2008, OIG continued to work collaboratively with the DHS program divisions and other internal and external state entities to encourage proactive steps to prevent abuse/neglect. A top priority for OIG is to ensure that the department's contracts with service providers included requirements aimed to reduce, prevent, and report abuse and neglect.

As a result, beginning in FY 2009, the contracts (Attachment B, Section VIII, to the Division of Mental Health's agreement and Attachment A, Section VIII, of the Division of Developmental Disability's agreement) will require all service providers to:

• Implement a local policy on reporting abuse/neglect that includes Rule 50's definitions of abuse and neglect, prohibition of screening, reporting time frames, and preservation of evidence;
• Ensure an agency "OIG Liaison" successfully completes OIG's investigative skills training at least once every two years;
• Ensure that an individual's parent or guardian is notified whenever an allegation involving him/her is being investigated by OIG;
• Evaluate all injuries to individuals and other adverse or unusual events through a formalized and ongoing internal systemic review process, which does all of the following at least quarterly:
• Examines the circumstances and data to determine how and why the injury or event occurred, including determining all related processes and systems;
• Identifies risk points and their potential contribution, such as evaluating the appropriateness of the individual's treatment plan and level of supervision; and
• Identifies, communicates, documents, implements and evaluates improvements in processes, systems, or treatment to prevent future such injuries or events, including specifying: the staff responsible for implementation, when the actions will be implemented, and how the effectiveness of the action will be evaluated.

Internal Coordination

The Bureau of Training and Technical Assistance was merged into the Bureau of Compliance and Evaluation (previously called the Bureau of Support Services) to improve internal coordination. The combined bureau is responsible for many statutorily mandated and department-required activities, such as:

• Annual unannounced site visits to the department's mental health facilities and developmental centers;
• OIG's comprehensive database, its maintenance and routine management reports;
• Annual facility and community agency investigative protocol authorizations, including reviews and approval of individual agency and facility investigators;
• Written Response tracking, input, and Compliance Reviews;
• OIG's electronic Case File Repository, including maintaining automatic saving of cover letters for investigative case reports;
• Reporting to the Health Care Worker Registry operated by the Illinois Department of Public Health;
• Annual and monthly inventories of State equipment; and
• OIG training - developing the training calendar, handling registrations, conducting training sessions, and sending training certificates.

The Bureau is also responsible for maintaining OIG's website. New DHS and OIG websites were launched in August 2007. The websites are much easier to navigate and provide information about the department's services. The websites also allow OIG staff to access the same information even when out of the office on investigations or site visits.

Database Upgrades

In FY 2008, OIG made substantial upgrades to its OIG Comprehensive database, which holds all case-related data on over 38,000 investigations, as well as training, inventory, and community agency information, some of which is provided by the department's Bureau of Accreditation, Licensure and Certification. Upgrades to the database during FY 2008 included the following:

• Initial intake reports on facility cases now identify the trained facility investigators, just like intake reports on community agency cases identify those at the agencies.
• The database automatically adds to initial intake reports a list of the five most recent cases in which the accused was involved and the last five in which the victim was involved.
• All case initiation and completion memos are now automatically created and printed by the database.
• Subpoenas are now completely automated: they can be requested, approved, printed, and tracked in the database.
• The cause of death and means of death are now separate fields, and the clinical coordinators can now independently enter and update these.
• Real-time case management was enhanced by reports now displaying the last action taken on the cases, as well as the date of that last action.
• Monthly reports to the facilities now include lists of calls determined by OIG to not be reportable under Rule 50, so the facilities can more easily follow-up on them.
• The e-mail notification confirming registration at an OIG-conducted training now includes the name of the registrant.
• Inventory records on OIG's computers now identify the processor speed, the operating memory, the hard disc drive size, and the installed software.

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Chapter 4:  ALLEGATIONS AND INCIDENTS REPORTED

FY88- FY08: Trends

The table below provides a snapshot of changes in allegations and incidents received by OIG over the past twenty years. Five fiscal years were chosen to show the changes over time:

• FY 1989, which was OIG's first full fiscal year;
• FY 1993, in which OIG created the Incident Tracking System and Quality Care Line;
• FY 1999, after the addition of community agency programs (Rule 50);
• FY 2003, after the addition of domestic abuse responsibilities (Rule 51); and
• FY 2008, which is OIG's 20th fiscal year.

Table 1: Allegations and Other Incidents Reported to OIG in Selected Fiscal Years

Type of Report	FY 1989	FY 1993	FY 1999	FY 2003	FY 2008
Physical abuse	535	710	864	955	1,315
Sexual abuse	73	79	119	101	141
Mental abuse (1)	121	152	362	292	499
Neglect	114	67	481	397	713
Allegations	836	1,008	1,826	1,745	2,668
Deaths	99	124	294	154	144
Serious injuries (2)	1,001	383	844	0	0
Other injuries (2)	180	5,504	2,896	0	0
All others (3)	1,336	1,204	634	25	0
Incidents	2,616	7,215	4,668	179	144

(1) Includes domestic exploitation beginning in FY 2001.

(2) Non-serious injuries were omitted from the original Rule 50; serious injuries without any allegation or suspicion of abuse or neglect were removed in 2002.

(3) Improper employee conduct, unauthorized absences or sexual activity of those receiving services, and theft of property or criminal acts - Reportable now only when abuse or neglect is alleged.

FY08: More Intakes

The tables on this and the following page show more detailed information about the locations and types of allegations OIG received in FY 2008.

Community agency totals distinguish residential from non-residential programs. At MH facilities, the "forensic" units - those for individuals who are committed by court order or who have aggressive behaviors - are listed separately from the facility's non-forensic units.

Table 2a: Rule 50 Allegations and Deaths Received in FY 2008 - Mental Health Services Only

Mental Health Center or Agency Program	Physical abuse	Sexual abuse	Mental abuse	Neglect	Alleg. Total	Death repts.
Alton (civil)	23	3	12	3	41	0
Alton (forensic)	28	3	26	7	64	0
Chester (forensic)	108	7	30	16	161	0
Chicago-Read	6	1	4	5	16	3
Choate (1)	28	1	12	7	48	0
Elgin (civil)	5	3	1	2	11	2
Elgin (forensic)	8	1	9	10	28	3
Madden	18	2	9	3	32	0
McFarland	19	4	13	2	38	0
Singer	7	1	3	2	13	0
Tinley Park	7	0	5	2	14	3
Facility totals	257	26	123	59	466	11
Residential	15	10	19	12	56	12
Non-residential	8	11	12	8	39	0
Agency totals	23	21	31	20	95	12
Rule 50 MH Totals	280	47	155	79	561	23

(1) Mental Health units only.

Table 2b: Rule 50 Allegations and Deaths Received in FY 2008 - Developmental Services Only

Developmental Center or Agency Program	Physical abuse	Sexual abuse	Mental abuse	Neglect	Alleg. Totals	Death repts.
Choate (1)	40	1	5	1	47	0
Fox	2	0	0	3	5	2
Howe	45	4	12	19	80	8
Jacksonville	61	4	18	9	92	5
Kiley	20	0	2	2	24	1
Ludeman	12	0	2	3	17	0
Mabley	14	0	1	0	15	0
Murray	13	0	2	2	17	3
Shapiro	28	0	6	0	34	5
Facility totals	235	9	48	39	331	24
Residential	391	31	144	220	786	91
Non-residential	192	26	73	57	348	6
Agency totals	583	57	217	277	1134	97
Rule 50 DD Totals	818	66	265	316	1465	121

(1) Developmental disability units only.

Table 2c: Rule 51 Allegations and Deaths Received in FY 2008 - Domestic Settings Only

Disability Type	Physical abuse	Sexual abuse	Mental abuse	Neglect	Financial exploitation	Totals(2)
Developmental	142	22	22	160	17	363
Physical	38	1	2	112	18	171
Mental health	37	5	2	46	18	108
Rule 51 totals	217	28	26	318	53	642

(2) Excludes complaints not reportable under the administrative rule.
 

Timeliness of initial reporting

Rule 50 requires that allegations of abuse or neglect be reported to OIG within four hours. Deaths must be reported within 24 hours. OIG emphasizes and monitors timeliness of initial reporting by the facilities and community agencies in the following ways:

• Training - During the OIG-conducted Rule 50 training, OIG instructs the facility and agency representatives on OIG time requirements.
• Intake - On new intakes, the database automatically checks the date/time the allegation was reportedly discovered and the date/time it is being reported to OIG. If the allegation is not being reported timely, the intake prints out with a timeliness flag.
• Investigation - During any ensuing OIG investigation, the investigator looks at reporting of the allegation and, if an issue of late reporting or failure to report is identified, the final OIG case report will cite it as an issue with a recommendation for action.
• Written Response - If the case report cites the issue, the facility or agency is required to identify the actions being taken to address the issue. OIG conducts a compliance review on randomly selected 20% of those, to ensure implementation.
• Monthly reports - Each month, OIG sends the divisions a list of cases reported late to OIG. The divisions then follow up with facilities and agencies that are reporting late.
• Quarterly meetings - OIG meets quarterly with division staff to coordinate efforts at preventing abuse and neglect, including ways to address late reporting patterns.

FY 2008 status

During FY 2008, a total of 260 allegations or deaths were reported late by facilities and agencies to OIG. This is about 16% of all allegations and deaths that were self-reported. Community agency reporting is late far more often than is facility reporting. Larger agencies generally report more late than do small agencies, but they also report far more on time.

DD agencies have been reporting more allegations overall to OIG than MH agencies, but they have also been reporting more timely. During this fiscal year, the DD agencies reported late 185 (20%) of the 910 allegations and deaths that they reported and OIG closed. The MH agencies reported late 32 (39%) of the 82 allegations and deaths that they reported and OIG closed. Further, the DD agencies are getting better, dropping to this rate of 20% late from 27% late in FY 2006, while the MH agencies are not doing better, rising to this rate of 39% late from 32% late in FY 2006.

The DD facilities continue to report only about six percent late to OIG. The actual number of late reports from facilities has been dropping, but so have the total number of allegations and deaths they report. MH facilities were late in reporting seven percent of the allegations and deaths during FY 2008, compared to nine percent late during FY 2007.

Abuse and neglect prevention summaries

Every six months, OIG analyzes the data on allegations received, looking for patterns and trends of abuse and neglect in facilities and agencies. The goal is to recommend proactive steps to prevent future abuse or neglect.

OIG did two prevention summaries in FY08, one for the last half of FY 07 data and compared data from each time period with data from the prior respective semi-annual time periods for the past two fiscal years.

At both facilities and community agencies, OIG looked at allegations by the time of day and day of week. OIG checked allegation rates, late reporting, substantiation rates, and the timely submission and implementation of Written Responses. At agencies, OIG also examined disability type, program type (residential versus non-residential), as well as the number that had never reported any allegations to OIG. At facilities, OIG also looked at allegations by shift, time of day, and unit, as well as the number occurring before, during or after restraint/seclusion and the number involving staff placed on administrative leave.

Findings and recommendations

The two prevention summaries completed in FY 2008 found several patterns or trends and made the following recommendations.

Peak times: About half of the allegations identified a specific day or time. Incidents at community agencies allegedly occurred more frequently during the middle part of the day. At DD facilities, they allegedly occurred mostly in afternoon; at MH facilities, early evening was most common. OIG recommended that agencies review their programs and procedures during mid-day, that DD facilities review mid to late afternoon, and that MH facilities review evenings.

Mondays: OIG found no statistically significant patterns or trends by day at agency programs or at MH facilities. But, DD facilities had fewer allegations on weekends and a spike on Mondays. OIG recommended that the DD facilities consider possible causes, such as individuals returning from weekend outings, resumption of weekday programming from less structured weekends, and administrative staff returning to work.

Appropriate reporting: A continuing reduction in allegations at MH CILAs while those at MH outpatient programs continue to rise, prompted OIG to recommend that agencies consider possible reasons, including appropriateness of reporting. High levels of allegations at Jacksonville DC and Alton MHC (especially Unit FC-B) led OIG to recommend that the facilities consider possible reasons for higher reporting levels as well.

Fewer non-reporting agencies: Only 65 community agencies reported no allegations, about half as many as the beginning of FY 2002, partly due to increased emphasis on training in Rule 50. OIG recommended that the sixteen agencies that have sought authorization to conduct investigations in spite of no self-reporting be encouraged to continue applying for authorization.

Less late reporting: Agencies and facilities have continued to report some allegations late to OIG, but they are getting steadily better at timely reporting. OIG recommended that they continue to focus on timely self reporting.

More substantiations: Substantiations also increased by 30% among DD agencies and by 10% among all facilities since FY06. OIG recommended that agencies and facilities send more staff for training in "first response" to allegations and in investigative skills training, in order to better ensure the preservation and collection of initial evidence.

More Written Responses: The number of facility cases in which OIG cited a substantiation or other administrative issue requiring a Written Response increased by 19% since the first half of FY 2006; the number has increased 88% at community agencies.

Later approvals: The tardiness of approved Written Responses has been getting worse, especially those from DD agencies, where over 75% were received over 30 or more days late, and at DD facilities, where over 60% were received late. OIG recommended that the divisions work to submit approved Written Responses to OIG in a timely manner, to ensure that prompt actions are taken to prevent abuse/neglect.

OIG meets regularly with a committee of representatives from across DHS to encourage and support proactive steps to improve the prevention of abuse/neglect (see the end of Chapter 2). These semi-annual prevention summaries are part of the feedback into the group.

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Chapter 5:  OIG INVESTIGATIONS

FY85-FY87: The Beginnings

Prior to OIG's creation, investigations into abuse/neglect allegations were conducted by facility staff, and these were reviewed by the department's Office of Internal Review.

FY89-FY90: OIG's Responsibility

OIG initially continued the same approach to investigations. Each facility was required to report allegations on a standardized incident form. The facility conducted an investigation and sent OIG a final report. An OIG investigator, and then the Inspector General or a lead investigator, carefully reviewed the report. However, OIG began to accept or take over more investigations.

The Illinois Auditor General's program audit of FY 1989 - FY 1990 recommended that OIG take responsibility for all investigations not accepted by the Illinois State Police (ISP). OIG implemented the change: OIG did 66% of non-ISP investigations in July-August 1989 and 100% by April 1990. OIG has since investigated every abuse/neglect allegation at a facility.

FY91-96: Increasing Professionalism

OIG contracted for a full week of specialized investigative training with a nationally recognized investigative training firm in May 1988. In FY 1991, OIG issued an OIG Investigator's Manual and conducted a statewide training on the requirements. Continuing education and ongoing internal training were begun as well, such as on using an investigative lead sheet.

In FY 1994, OIG conducted an internal investigative case file audit to assess compliance with established requirements. The report recommended requiring supervisory review of all initial reports, streamlining case file documentation requirements, documenting supervisory reviews, and conducting a final file review. With minor changes, all recommendations were adopted.

OIG then converted its Investigator Manual into an OIG Procedure Manual. Many new requirements were added: for example, using a standard checklist of needed documentation; taking photos if an injury is alleged; following certain directions when gathering evidence; and including in the case report the training and disciplinary history of the accused staff.

Considering this Procedure Manual too restrictive for its investigations, in FY 1996, OIG replaced it with the OIG Guidelines for Investigations, which reflected information from many sources, such as the 'Quality Standards for Investigations' published by the President's Council on Integrity and Efficiency. The Guidelines allowed investigators and supervisors the ability to use professional judgment in conducting investigations.

FY97-FY01: Choosing Investigations

The new statute and Rule 50 allowed OIG to choose which abuse/neglect allegations to investigate at the community agency programs. One approach was a study to determine common causes of abuse or neglect which might then be flags for new allegations; this approach also provided for improved prevention efforts.

Causal Study

OIG conducted a study of substantiated cases to determine common causal factors. The study reviewed 115 substantiated cases of abuse or neglect that were closed in FY 1996 and the first half of FY 1997. The victims were not different from the overall population - personal characteristics such as disability, age, or gender were similar.

Common causal factors leading up to the incident were:

• Behavior by the individual, but for abuse cases only - escalating behavior or agitation on the part of the eventual victim, and resistance to staff or to unit rules, while in neglect cases, the individual was most often sitting quietly or asleep;
• Stress and other staff problems - a power struggle with the victim, perceived potential for staff injury, and staffing issues like excessive overtime, insufficient staffing, and temporary assignment; and
• Systemic problems - ineffective supervision, the staff's failure to carry out duties, uncorrected inappropriate but routine staff behavior, and reliance on trainees or other new employees, unfamiliar with the individuals.

A follow-up study using 359 cases over three fiscal years (FY 1996 through FY 1980) found the same factors. OIG investigators were encouraged to consider these issues when conducting investigations and when providing recommendations for corrective action. Disciplinary action may be insufficient to address the causes of a particular case of abuse or neglect.

Complaints and Self-Reports

OIG also distinguished "self-reports" - those allegations and incidents reported through the community agency's formal reporting system - from "complaints" - those allegations reported through any other means. OIG always investigated a "complaint," unless it was not reportable or was within another department's jurisdiction.

Self-reports, on the other hand, often came to OIG with the investigation underway. So, OIG typically let the agency continue and reviewed the agency's investigative report and attached documentation and, at that point, either accepted the report for case closure or began an OIG investigation.

Investigative Descriptors

OIG sometimes allowed the facility or agency to start an investigation or chose to use trained facility or agency investigators for some of the work. In FY 1998, in order to better represent how it handled investigations, OIG developed three descriptors:

• Conducted, in which OIG did the entire investigation;
• Directed, in which OIG asked the facility/agency to conduct initial investigative steps; and
• Reviewed, in which OIG relied on the facility or agency to conduct the entire investigation and send a report for OIG's review.

However, in FY 2001, OIG realized that the extent to which OIG relied on agency or facility investigators was a continuum, OIG ceased referring to "Directed" investigations; that is, even "Conducted" investigations might rely on agency or facility investigators to gather documents and evidence or obtain written statements from staff. Then, OIG stopped referring to "Reviewed" investigations as being "OIG investigations" at all. OIG did not assign OIG investigations to the facilities or to the agencies, and so the descriptors were no longer used.

FY02-07: Standardizing and Streamlining Investigations

To address the subjective and sometimes vague directions in the Guidelines for Investigations, in FY 2002, OIG created an OIG Directives Manual. It was expanded over the next few years, as directives replaced guidelines and new directives were written.

Case Initiation

One directive specified which allegations at community agencies OIG was required to investigate; OIG investigates all allegations at facilities. This directive was thus consistent with Rule 50, which was revised in FY 2002 and which also eliminated the reporting to OIG of injuries absent any allegation of abuse or neglect by an employee.

In FY 2004, OIG developed a form called the Case Initiation Report (CIR). The CIR had two functions. First, it documented the opening of an OIG investigation. Second, it could be used to close unfounded allegations without further investigation.

The following year, OIG developed a new Investigative Plan and discontinued the CIR. The Investigative Plan was a streamlined document that automatically pulled information directly from the main database, including dates and times, elements of the offense and names of the people involved. Thus, it was faster and helped the investigator plan all aspects of the investigation. It also allowed the investigative supervisors to identify necessary documents and interviews in the investigation before it began.

Case Management

At the same time, OIG developed the Investigative Case Actions discussed in Chapter 3. This provided a true 'real-time' electronic case management system: supervisors and reviewers were able to view the field investigators entries and to include directions and suggestions back to the investigator. Further, weekly status reports automatically showed the date of the last action and included the latest case status entered by the supervisors.

Case Completion

Unfounded and unsubstantiated allegations had been reviewed by the bureau chief and the Inspector General or Deputy IG. To speed case review, starting in FY 2002, draft case reports for investigations into allegations that were determined to be unsubstantiated or unfounded no longer needed review above the investigative bureau chief level. Then, starting in FY 2004, bureau chiefs were allowed to approve investigative reports on substantiated cases of mental injury and neglect that is not egregious without review by the Inspector General or Deputy IG.

Beginning with the start of FY 2005, all internal DHS distribution of OIG case reports was to be done by encrypted email. A year later, when the State's encryption program no longer worked well with the electronic mail system, encryption was not required.

During FY 2006, OIG became aware of an increasing number of clearly unfounded allegations: i.e., allegations that have no credible evidence. To address these cases, OIG first encouraged the investigative bureau chiefs to write up a final case report upon receipt of the allegation and initial evidence, rather than assigning it to a field investigator.

As noted in Chapter 3, allegations reported to the OIG Hotline are infrequently "recanted" - i.e., the individual made the allegation and then admitted it did not happen. While not wanting to ignore the initial claim, OIG was expending valuable resources on an allegation that even the person who made it no longer believed. So, OIG developed a process for Intake investigators to handle such "recants." During FY 2007, Intake investigators completed cases on 61 recanted allegations; during FY 2008, they completed cases on 71 recanted allegations.

FY08: Faster Completions

Case Management Changes

In FY 2008, OIG began requiring that all investigations be assigned within one working day, which gets the investigative plan started more quickly. However, OIG also eliminated the requirement for an investigative plan where it was considered unnecessary, specifically: when Intake closes out an unfounded allegation; when an alleged victim of domestic abuse refuses to consent to an OIG investigation; and when a clinical coordinator reviews medical documents in connection with an investigation for which an investigative plan has already been completed. These steps save time and speed completion of OIG investigations.

Once the case is assigned, the investigative supervisors utilize a task tracking function on their computers to alert them when the case has been open for twenty days. At that point, they meet with the case's investigator to determine remaining investigative tasks, identify any difficulties they might have encountered and formulate a timetable for completion.

Timeliness of OIG Investigations

OIG continued to make improvements to case management, such as having bureau chiefs write case reports on clearly unfounded allegations and having Intake monitor some mental injury investigations conducted by OIG-approved agency investigators. The result is that OIG cases are now being completed faster. During FY 2008, the 2,009 investigations that OIG completed in facilities and community agencies took an average of 44 days per case, and the 738 completed in domestic settings took an average of 32 days per case.

This "average days to completion" is a standard that OIG has used throughout its existence, and Rule 50 calls for cases to be completed within 60 days per case absent exceptional circumstances. OIG has recently done much better, as shown in the table below.

Table 3: Average Days to Completion for OIG Rule 50 Investigations by Location

Location	FY2003	FY2004	FY2005	FY2006	FY2007	FY2008
Facilities	77	70	43	51	39	37
Communityes	82	85	56	56	53	49
Overall	79	77	48	53	46	44

OIG has also been increasingly successful in keeping fewer cases with exceptional circumstances from remaining open for an extended period of time. During FY 2008, only fifteen cases took longer than 200 days to complete, which is a significant improvement over previous years.

• FY 2004 - 94 cases
• FY 2005 - 42 cases
• FY 2006 - 24 cases
• FY 2007 - 20 cases
• FY 2008 - 15 cases

The most common reason for lengthy delays has been OIG's need to wait until the Illinois State Police or other law enforcement authority has completed its investigation and any prosecution. If time OIG spent waiting for law enforcement is subtracted, only four of the fifteen cases in FY 2008 would have taken longer than 200 days. Indeed, subtracting law enforcement time, those fifteen cases averaged less than 100 days to complete. The Illinois State Police and local law enforcement authorities have recently been willing to allow OIG to begin its investigation before a prosecutorial decision has been rendered.

Case Findings, FY 2008

When the preponderance of the evidence found during an investigation indicates that abuse or neglect occurred, the allegation is called "substantiated." This level of proof is typical in administrative investigations. Even if OIG does not substantiate a case, however, OIG still may give administrative recommendations addressing other issues in the case. Both these cases and substantiated cases require a Written Response, as described in Chapter 9. The tables that follow show findings in cases closed by OIG during FY 2008.

Table 4a: Rule 50 Allegations and Deaths Closed in FY 2008 - Mental Health Services Only

(Subst. = substantiated)

Mental Health Center or Agency Program	Abuse subst.	Neglect subst.	Other issue	Not subst.	Finding totals	Closed deaths
Alton (civil)	0	0	2	35	37	0
Alton (forensic)	2	3	6	48	59	0
Chester (forensic)	1	1	19	126	147	0
Chicago-Read	0	1	3	11	15	3
Choate (MH only)	1	1	2	46	50	1
Elgin (civil)	0	1	2	9	12	0
Elgin (forensic)	0	2	11	29	42	1
Madden	0	0	11	23	34	0
McFarland	3	0	1	23	27	0
Singer	2	0	2	8	12	0
TinleyPark	0	0	0	5	5	1
Facility totals	9	9	59	363	440	6
Residential	10	1	10	26	47	10
Non-residential	8	2	15	19	44	0
Agency totals	18	3	25	45	91	10
Rule 50 MH Totals	27	12	89	408	531	16

Note: Includes one death from a facility that was substantiated for neglect.

Table 4b: Rule 50 Allegations and Deaths Closed in FY 2008 - Developmental Services Only

(Subst. = substantiated)

Developmental Center or Agency Program	Abuse subst.	Neglect subst.	Other issue	Not subst.	Finding totals	Closed deaths
Choate (DD only)	1	0	6	54	61	0
Fox	0	3	1	2	6	1
Howe	2	3	19	44	68	5
Jacksonville	4	4	15	77	100	2
Kiley	1	1	8	25	35	0
Ludeman	1	3	4	21	29	0
Mabley	0	0	1	11	12	0
Murray	3	0	6	9	18	1
Shapiro	4	0	1	32	37	2
Facility totals	16	14	61	275	366	11
Residential	85	42	219	422	768	71
Non-residential	43	19	91	186	339	3
Agency totals	128	61	310	608	1107	74
Rule 50 DD Totals	144	75	371	883	1473	85

Note: Includes one death from a facility and three deaths in agency programs substantiated as neglect.

Table 4c: Rule 51 Allegations Closed in FY 2008 - Domestic Settings Only

Disability Type

(Subst. = substantiated)

Disability Type	Abuse subst.	Neglect subst.	Exploitation subst.	Refused consent	Not subst.	Totals
Developmental	82	52	2	43	246	425
Physical	8	11	4	37	61	121
Mental health	11	20	3	52	105	191
Rule 51 Totals	101	83	9	132	412	737

Note: Excludes complaints not reportable under the administrative rule.

The preceding tables show that OIG substantiated abuse or neglect by staff in 258 cases during FY 2008 (see table below), which is 9% more than the 236 substantiated during FY 2007. Including domestic cases, OIG substantiated 451 cases in FY 2008. Substantiations have continued to rise, from 309 in FY 2005 to 322 in FY 2006, to 353 in FY 2007, and to 451 this fiscal year.

Table 5: Substantiated Cases by Setting, FY 2008

Location	Abuse substanatiated	Neglect substantiated	Total substantiated
DHS facilities	25	23	48
Community agencies	146	64	210
Domestic settings	101	83	193 *
Totals	272	170	451 *

* includes nine substantiated exploitation cases

Domestic settings saw the largest increase over last year - a 65% increase (from 117 to 193) - while total closed domestic cases rose 29%. Substantiated neglect nearly doubled, abuse was close to 50% higher, and exploitation had a more than 25% increase.

At DHS facilities, compared to last fiscal year, OIG closed 16% fewer cases overall (984 to 823), yet substantiated 29% fewer (35 to 25) abuse cases and the same number of neglect cases. The overall drop in substantiations was thus entirely due to fewer substantiated abuse cases.

At community agency programs, OIG closed 16% more (1102 to 1282) cases overall in FY 2008 than in FY 2007. OIG substantiated 18.5% more cases of neglect (54 to 64) and 17.7% more cases of abuse (124 to 146).

Thus, a substantiation rate - the number of substantiated cases divided by the number closed - provides a better comparison across locations and years.

Table 6: Substantiation Rates by Fiscal Year and Setting

Location	FY2004	FY2005	FY2006	FY2007	FY2008
DHS facilities	7.2%	4.5%	6.3%	5.9%	5.8%
Community agencies	19.1%	18.4%	17.5%	16.2%	16.4%
Domestic settings	13.3%	21.9%	19.9%	19.3%	26.2%
Overall	12.6%	13.5%	14.4%	14.0%	15.9%

Clinical Coordinator Issues

FY08 reported deaths

As shown above, OIG received reports of 144 deaths during Fiscal Year 2008, of which 109 were from residential community agency programs and 35 from DHS facilities. OIG requires reporting of a death up to two weeks after discharge or transfer to a local hospital and, as a result, most deaths actually occurred in a hospital.

In both agency and facility program, most of the reported deaths were of individuals who had developmental disabilities (DD), rather than a mental health (MH) diagnosis: 97 of the 109 from agency programs, and 24 of the 35 from facilities.

The most reports of deaths came from the two largest facilities. In FY 2007, eight deaths were reported of individuals formerly residing at Shapiro DC, by far the largest DHS developmental center, and four at Howe DC. In FY 2008, eight deaths were of individuals who had been residing at Howe DC and five at Shapiro DC. No single community agency accounted for more than seven deaths in its programs.

Those who died and had been residents in DD community agency programs were, on average, somewhat older than those who died and had been a resident of a DD facility: 61 compared to 54. Similarly, those who died and had been a resident in an MH agency program were, on average, slightly older than those who died in the MH facilities: 52 compared to 45.

The vast majority of deaths were reported as having occurred in a natural manner, without any allegation of abuse or neglect by the agency or facility staff. OIG still reviews all deaths and may conduct a full investigation of any death.

FY08 closed death cases

Investigations of deaths typically take longer than other investigations, as OIG usually faces delays in getting death records such as results of an autopsy, toxicology report, and a coroner's jury verdict. Therefore, deaths reported in a fiscal year are often not completed until the following fiscal year.

Eleven of the deaths reported from community agency program locations and two of the deaths reported from DHS facilities were both reported and closed during FY 2008. An additional 74 deaths reported from agency programs and fifteen reported from the facilities were closed in FY 2008. Together, OIG closed 101 death cases during FY 2008.

Of the 101 deaths, cardiac and respiratory related illnesses were the most common causes of death, with asphyxia, choking, and a seizure disorder following. The majority of deaths were determined to have been natural in manner without any question of the level of care provided by the facility or agency.

Two particular deaths showed the high level of care provided. Individuals with Down syndrome have historically had much shorter life expectancies. However, it is now common for them to live to 50 years of age or beyond. One individual, a 67-year old with Down syndrome collapsed in her home and was rushed to a hospital, where she died of lack of oxygen to the brain. The staff of the home were proud she had lived such a long life.

Another individual, a 76-year old who had Down syndrome, complained of chest pain. He was rushed to the hospital but did not survive the long emergency bypass surgery. He had lived with his roommate since he was eleven years old, and employees of the hospital and the agency cried upon hearing of his death.

Substantiated neglect in FY 2008 cases

OIG substantiated neglect in five other deaths. One was discussed in last year's annual report, since the investigation was completed that year. Of the four remaining deaths in which OIG substantiated neglect, two were at agencies and two at facilities.

• An individual was found lying in his bed, unresponsive. The investigation determined that the employee who found the individual had left to notify a supervisor and did not follow the facility's medical emergency protocol. That action substantially delayed medical staff arriving to the scene, though the individual may not have survived anyway. The employee was discharged by the facility.
• An individual hanged himself while on 15-minute observation checks. The investigation found that the employee assigned to the observation checks had let him stay unobserved in the room used for restraints and had not conducted the checks as required. OIG determined this to be egregious neglect. OIG also substantiated neglect by two other facility employees who had failed to complete observation checks as required. The first employee resigned and the supervising nurse was terminated.
• The only employee assigned to a CILA during a mealtime left pancakes on the counter as she was feeding an individual. Another individual, who was on a pureed diet due to high risk of choking, ate some of the pancakes and began choking. The employee panicked and was unable to respond to the emergency. Instead, two flooring contractors who were present called 911 and did CPR. The individual died. OIG substantiated neglect against the supervisor for knowingly leaving only one staff in the home during meal time with individuals at high risk for choking. The supervisor was retrained and may no longer work independently. OIG also substantiated egregious neglect against the employee. The coroner's jury determined the manner of death to be homicide; to date, no criminal charges have been filed. This employee was discharged and the CILA was closed.
• Four individuals with known dietary restrictions went on an outing from a CILA, along with two employees and a trainee. The employees were not given special instructions, although they had been trained in the individuals' diets and programs. On the outing, the two employees bought everyone fried chicken from a fast food restaurant, which violated the dietary restrictions, and then ate with their backs to the four individuals, leaving the trainee to supervise them. An individual at high risk for choking began banging his head, then jumped up and bit his wrist. The trainee urged the two employees to call 911, but they said the actions were due to medication changes, and they put everyone back in the van. On the way, the individual was unresponsive and, when they arrived home, did not respond to CPR. OIG substantiated neglect and determined it to be egregious. A coroner's jury determined the death to be accidental but caused by "extreme neglect" by the two employees, both of whom had resigned.

Recommendations in FY 2008 cases

OIG also made some administrative recommendations in these deaths and in six other deaths. In several cases, OIG recommended staff be reminded of the requirement for timely notification to OIG of reportable deaths. Other recommendations were in the following areas.

• Clinical staff training - OIG recommended that the facility or agency:
  • Increase training of all staff in seizure disorders and seizure medications;
  • Conduct competency training for staff on reading an individual service plan;
  • Conduct refresher training with nurses on medication administration, medical observation, critical thinking, and notification of physicians; and
  • Have the DHS Bureau of Quality Management do training and follow-up on medication-related incidents.
• Clinical assessments - OIG recommended that the facility or agency:
  • Consider one-to-one monitoring for all individuals who are admitted for the risk of suicide;
  • Require the clinical staff carefully consider placement of individuals with seizure disorders who have undergone surgical procedures, due to high risk of death;
  • Ensure the medical staff more clearly document the individual's medical condition and rationale for treatment, so progress can be easily identified;
  • Ensure nurses follow standard care for injuries and documentation;
  • Improve progress note documentation; and
  • Conduct functional evaluations and formal risk assessments with individuals prior to discharge determination and planning.
• Patient monitoring - OIG recommended that the facility or agency:
  • Require medical alert identification for individuals who need it;
  • Train all direct care staff in recognition of illness and skin breakdown;
  • Ensure that outings have adequate staff to monitor individuals and that at least one employee have a cell phone for emergency contact;
  • Require nurses ensure that individuals on outings receive their medications and are properly monitored if self-medicating;
  • Address employees sleeping while on duty; and
  • Develop procedures to prevent injuries and infections and to document assignment of medication administration.
• Emergency response - OIG recommended that the facility or agency:
  • Routinely re-train all staff on current medical emergency procedures;
  • Mandate cardiopulmonary resuscitation (CPR) training for all direct care staff, especially those who accompany individuals on outings;
  • Ensure that every residential living unit has emergency medical equipment and that this be easily accessible and checked regularly;
  • Make all staff going on outings aware of the location and phone number of the nearest medical facilities, in case of emergency;
  • Develop standard procedures to alert staff of individuals who are at high risk for choking;
  • Regularly retrain staff in CPR and the need to begin it when an individual is unresponsive, unless a physician has determined the individual has died; and
  • After any emergency, separate the staff involved in the incident, sequester the medical record, secure the scene, and photograph the scene and any injuries immediately.

The benefit of clinically trained investigators has become even more apparent during the past fiscal year. Thus, OIG has contracted for an additional clinical coordinator (a registered nurse) to assist with participating in and reviewing investigations during FY 2009.

Health Care Worker Registry

OIG is mandated to report to the Health Care Worker Registry, which is operated by the Illinois Department of Public Health, the names of facility or community agency employees who were substantiated to have committed physical abuse, sexual abuse, or egregious neglect. OIG continued to refer names as required.

The statute that mandates this referral also provides that each employee should have an appeals process available to stop his/her name from being referred. This appeals process, known as a 50.90 appeal (since that is the section of Rule 50 that describes this appeal), is handled by an administrative law judge (ALJ) within the DHS Bureau of Administrative Hearings, and final decisions are made by the DHS Secretary.

In FY 2006, OIG became more involved in preparing for appeal hearings. OIG also developed a stipulation process: beginning September 11, 2006, OIG may agree to a "stipulation" not to contest the 50.90 appeal if the physical abuse does not appear severe enough to warrant reporting to the Registry. The process involves input from DHS-Legal, and the final decision is still up to the ALJ and the Secretary. The change, as well as the discussions leading up to it, substantially reduced the rate of appeals upheld.

FY 2008 appeals

A total of 48 appeals were pending at some point in FY 2008; seven had been filed in FY 2007. Final decisions were made by the Secretary on 35 of these 48 appeals. Of these 35 decisions:

• Six were withdrawn and two dismissed, so the employee's name was referred;
• Fourteen were denied, and the employee's name was referred;
• Three were stipulations, meaning DHS agreed not to refer the name; and
• Ten were granted, and the employee's name was not referred to the Registry.

Thus, OIG referral was upheld in 14 of 24 (58%) of the appeals where a full hearing was held and a decision rendered during FY 2008.

FY 2008 referrals

However, most employees being referred to the Registry did not file appeals. Including those employees, OIG referred the names of 73 employees to the Registry during FY 2008, which is seven more than last fiscal year but eleven less than the 84 referred in FY 2006.

The findings that resulted in referrals have remained relatively stable over time. In FY 2008, of all 73 employees that were referred, 59 (81%) were for physical abuse; nine (12%) were for sexual abuse; and five (7%) were for neglect that was determined to be egregious.

Again this year, most of the employees that OIG referred to the Registry were community agency employees (59 of the 73).

Removals

The statute on OIG's referrals to the Registry also allow employees who are referred to appeal for removal, although only once every twelve months. During FY 2008, four people filed such an appeal. Of these four appeals, two were lost and one was dismissed; so, all three people stayed on the Registry. The fourth appeal was still pending at the end of the fiscal year.

FY 2008 Service Plan Referrals

When a domestic abuse/neglect/exploitation case is substantiated, the law requires that OIG refer the victim to the appropriate program division in DHS for development of a service plan. After OIG refers the case to the division, the individual has the legal right to refuse to consent to the service plan, but still may accept some services.

During FY 2008, OIG substantiated 193 allegations in domestic settings. The program division to which these individuals were referred in FY 2008 and the four previous fiscal years are shown in the table below.

Table 7: Service Plan Referrals from Substantiated Domestic Cases

DHS Division	FY2003	FY2004	FY2005	FY2006	FY2007	FY2008
Developmental Disabilities	45	44	83	62	76	107
Rehabilitation Services	11	11	29	42	35	74
Mental Health	2	5	6	6	6	12
Totals	58	60	119	110	117	193

In FY 2008, once again, the majority of the referrals were to the DHS Division of Developmental Disabilities. Infrequently, OIG will also refer an individual to a second division for the possibility of receiving additional needed services. OIG made no formal second referrals during FY 2008, although multiple referrals for local or state services are often made during the course of an investigation or immediately afterwards.

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Chapter 6:  UNANNOUNCED FACILITY SITE VISITS

FY85-88: The Beginnings

Prior to the creation of the Office of the Inspector General, the Office of Internal Review conducted site visits only to familiarize the staff in the office with the facilities.

FY89-92: Walk-Throughs

OIG field investigators' frequent presence at the facilities provided an opportunity for additional observations. Thus, in FY 1990, Inspector General Fisher required the OIG field investigators to conduct unannounced walk-throughs of their assigned facilities at least twice a year. The goal was to increase OIG's visibility, to encourage reporting and cooperation with investigations, and to identify issues that might prevent abuse and neglect. It was unclear whether the walk-throughs made a difference in the number of allegations reported to OIG.

Therefore, in FY 1992, in an effort to ensure reporting of allegations and incidents, OIG began conducting unannounced semi-annual facility reviews for under-reporting. Twice a year, around the time of the walk-through, each field investigator was required to review the facility's internal records on-site to find indications of allegations and incidents that should have been reported to OIG but were not.

FY93-96: Facility Surveys

A new law in 1992 provided for an annual unannounced site visit to each facility, but it gave OIG no further guidance as to their purpose. Starting in FY 1993, OIG conducted "facility surveys" using the staff of the Bureau of Certification and Licensure, which had been moved to OIG. These staff conducted surveys at community agencies, and so they were able to assess the overall quality of care provided to individuals at the facility and review corrective actions for problems previously identified by external entities.

In FY 1996, with the return of the survey staff to the department, OIG modified its approach to site visits. Believing that they should be broadly related to the prevention of abuse and neglect, OIG geared the site visits to assess the facility's response to the needs and rights of individuals receiving services; thus, they were consumer-focused and outcome-based. In November 1995, a new OIG Site Visit Coordinator began development of a formal site visit protocol.

The under-reporting audits were still done concurrently with site visits. In FY 1996, for example, the audits found that nearly all allegations and incidents had been reported to OIG as required. Only ten allegations or incidents had not been reported, and four of these were serious injuries.

FY97-07: Site Visit Protocol

The new unannounced site visit protocol was adopted on January 16, 1997. It established the practice of identifying a set of issues before the start of the fiscal year, then reviewing them at each facility. Subsequent changes have been: the addition of a second site visitor in FY 1999; the cessation of annual under-reporting audits after FY 2001 (seen as outside OIG's responsibility); and the inclusion of the clinical coordinators in FY 2005.

OIG's basic approach to site visits, however, has remained relatively unchanged. Issues broadly related to preventing abuse/neglect are identified and serve as the focus of the year's site visits.

FY 1997 and FY 1998 site visit issues were:

• Completion of clinical evaluations timely and thoroughly;
• Restraint use;
• Handling of human rights complaints;
• Response to occurrences involving recipient behavior;
• Follow-through of non-reportable incidents;
• Training records for staff and specialized training for professional staff; and
• Consumer satisfaction surveys.

FY 1999 and FY 2000 site visit issues were:

• Follow-up on findings of accreditation and other surveys;
• Thoroughness of Human Rights Committee reviews;
• Allegations and incidents for underlying causes;
• Implementation of a program of continuous quality enhancement;
• Issues in semi-annual quality indicator reports and restraint usage;
• Interaction of the facility staff and individuals; and
• Consumer satisfaction surveys of individuals, guardians, and others.

FY 2001 site visit issues were:

• Facility handling of all injuries, restraints, and unauthorized absences;
• Serious injuries for patterns or trends;
• Effectiveness of Human Rights Committee and behavioral committees;
• Substantiated allegations for underlying causes, patterns or trends;
• Implementation of actions in the Written Responses;
• Facility abuse/neglect prevention initiatives; and
• Annual clinical treatment/habilitation reviews.

FY 2002 site visit issues were:

• Shift change procedures;
• Supervision levels, especially special observations and special precautions;
• Policies and procedures to prevent contraband;
• Facility thoroughness in investigating serious injuries;
• Patterns and trends in investigations; and
• Written Responses, for other issues and actions taken.

FY 2003 site visit issues were:

• Implementation of all the Rule 50 changes (i.e., training of facility staff, posting of OIG's Hotline number, updating of the facility's policy, and Registry checking);
• Hotline reporting, quality and issues;
• Unauthorized absences;
• Escorting individuals at the facilities; and
• Thoroughness of OIG and facility investigations for underlying issues.

FY 2004 site visit issues were:

• Posting of OIG Hotline number;
• Handling of non-reportable complaints;
• Implementation of WR actions;
• Impact of Early Retirement on patient care; and
• Policies related to patient safety.

FY 2005 site visit issues were:

• Efforts at preventing violence and restraints;
• Medication administration;
• Facility review of serious and patient-on-patient injuries;
• Handling of non-reportable occurrences;
• Abuse/neglect prevention initiatives; and
• Written Response implementation follow-up.

FY 2006 site visit issues were:

• Nursing coverage/overtime and detailing;
• Communication between shifts;
• Identification and control of contraband;
• Resident injuries resulting from assault or during employee intervention;
• Training in Rule 50;
• Handling of NonReportable incidents; and
• Follow-through on consumer satisfaction survey results.

FY 2007 site visit issues were:

• Follow-up on FY 2006 recommendations;
• Quality of progress notes;
• Follow-through on nursing assessments and external medical consultations;
• Continuity of care and treatment across programs;
• Emergency drills;
• Training in Rule 50 and, where appropriate, investigative skills; and
• Follow-through on human rights complaints.

FY 2008 site visit issues were:

• Follow-up on FY 2006 and FY 2007 recommendations, esp. emergency drills;
• Quality of progress notes;
• Analyzing facility's regular injury review processes;
• Suicide risk assessment and documentation;
• Special needs identification and training of staff;
• Medication administration;
• Weight monitoring; and
• Policies and practices on sex offenders who are residents.

FY08: Site Visit Findings

In FY 2008, site visits were conducted at every department facility providing mental health and developmental disability services, as shown below. As in previous years, OIG site visits were conducted by at least two staff: a registered nurse, and a compliance reviewer. Each site visit report was completed within 60 working days of the date of the site visit. The dates of the FY 2008 site visits and the date of the site visit report are listed below.

Table 8a - Dates of FY 2008 Site Visits and Reports

Facility	Site Visit Date	Report Date
Alton MHC	Nov. 15-16, 2007	Dec. 19, 2007
Chester MHC	July 31 - Aug. 2, 2007	Oct. 24, 2007
Chicago-Read MHC	March 25-26, 2007	April 23, 2008
Choate DC	Jan. 10-11, 2008	Feb. 28, 2008
Choate MHC	Jan. 8-9, 2008	Feb. 28, 2008
Elgin MHC	Feb. 20-22, 2008	March 31, 2008
Fox DC	Sept. 19-20, 2007	Dec. 19, 2007
Howe DC	Nov. 6-7, 2007	Nov. 30, 2007
Jacksonville DC	Feb. 7-8, 2008	Feb. 29, 2008
Kiley DC	Dec. 18-19, 2007	Jan. 15, 2008
Ludeman DC	March 17-18, 2008	April 7, 2008
Mabley DC	Jan. 16-17, 2008	Feb. 25, 2008
Madden MHC	Jan. 30-31, 2008	April 23, 2008
McFarland MHC	March 6-7, 2008	April 4, 2008
Murray DC	Dec. 5-6, 2007	Jan. 17, 2008
Shapiro DC	Oct. 9-10, 2007	Oct. 29, 2007
Singer MHC	July 30 - Aug. 1, 2007	Sept. 28, 2007
Tinley Park	Oct. 17-18, 2007	Nov. 9, 2007

During its FY 2008 unannounced site visits, OIG made 120 recommendations, eighteen of which were repeated from prior site visits. OIG will be following up on all recommendations during the FY 2009 site visits.

OIG also examined all 120 recommendations for patterns or trends, which resulted in recommendations to the department's program divisions as systems issues. These common issue recommendations were:

• A lack of prompt and appropriate action addressing prior years' recommendations;
• An absence from facility policy of requirements for conducting medical emergency drills on every shift on every unit, for a specific frequency of those drills, or for mandated follow-up to ensure that issues identified in those drills were effectively addressed;
• Inadequate summaries of investigation or documentation of follow-up action taken on each case OIG had returned to the facility as not reportable under Rule 50;
• A failure to adhere to policies on medical record documentation, especially regarding written progress notes or corrections to them;
• Inconsistent approvals by the Human Rights Committees for assistive devices for individuals with special needs;
• Inadequate review to ensure that all individuals receive medications per policy and to ensure that privacy is maintained during the medication pass;
• A failure to ensure staff adhere to weight monitoring protocols; and
• Inadequate policies addressing individuals receiving treatment who are also sexual offenders, specifically in initially identifying them, restricting their housing placement, and addressing the issue in treatment or habilitation plans.

In light of the large number of repeated recommendations, OIG considered ways to assist the facilities in determining and implementing actions to address the recommendations and to assist OIG site visitors in conducting the following year's site visit. Therefore, beginning with FY 2009 site visit reports, OIG will be requesting each facility to send OIG copies of any corrective action plans the facility develops, whether for internal or external management. OIG will be asking the facility to send these to OIG within 60 days of receiving the site visit report, which will help in planning the following year's site visit.

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Chapter 7:  OIG-CONDUCTED TRAINING

FY85-FY87: The Beginnings

In the years leading up to the creation of OIG, each of the facilities had a policy on reporting unusual events and conducted training of its staff on that policy. The department oversaw this "prevention and identification of abuse and neglect" to ensure consistency. The 1987 law that authorized OIG, then, included two references to training, one focused on direct care staff and the other on OIG investigators.

FY88-92: Initial Training

Immediately after his appointment, the first Inspector General arranged for a week-long training conducted by nationally recognized investigative training specialists, who modified their training to address the special difficulties in investigating allegations involving individuals with mental and developmental disabilities. This training was held the first week of May 1988, and continuing education became an expectation. OIG also helped modify the department's existing prevention and identification training to include reporting and cooperating with investigations.

FY93-95: Standardizing Training

In FY 1993, OIG conducted a complete inventory of required training of facility employees and reviewed current training plans and materials. OIG found wide differences in how training needs were assessed, how training was delivered, how training classes were evaluated, and how training completion was recorded. This variability was true for the facilities' prevention and reporting trainings, so the department provided technical assistance in improving the trainings.

Among the needs OIG identified was "a training series on Basic Investigative Techniques" for all facility managers. So, OIG contracted with Labor Relations Alternatives, a nationally recognized organization, to provide training on directed statement-taking for all facility management staff, as well as for all OIG investigators. This training occurred in FY 1994 and FY 1995.

FY96-98: Expanding Training

In August 1995, OIG named an OIG Training Coordinator and created a Bureau of Training and Technical Assistance. The Training Coordinator began conducting the statement-taking training, under terms of a copyright agreement with Labor Relations Alternatives. In addition, OIG set minimum training expectations for its investigators, raised the requirement for continuing education to ten hours per year, and expanded its library of written and videotaped training materials.

As the department had long conducted mandatory training on the prevention and identification of abuse/neglect, OIG focused on the next steps: a comprehensive program for facility staff in the initial investigative response: providing immediate medical attention, securing the scene, preserving evidence, and obtaining initial statements.

OIG began these "first response" trainings at the facilities, conducting six of them in FY 1996. The trainings were then expanded to community agency staff the following year. However, it became apparent that these trainings needed to cover investigative principles, analysis of evidence, and writing the report. Thus, this First Response class was discontinued and the material folded into a new Basic Investigative Skills class.

OIG hired a second trainer in the latter half of FY 1997 to handle the increased number of trainings conducted at community agencies.

FY99-02: Rule 50 Training

With the promulgation of Rule 50, OIG created a short training program on its reporting and investigative expectations, targeted primarily to facility and community agency leadership. During February and March 1999, twenty-three training events were held around the State with a combined total of 1,840 participants.

In the following months, OIG re-worked that training on Rule 50's reporting and investigating expectations into a standardized training. In the next three years, that Rule 50 training was modified several times, especially after the emergency rule was adopted in January 2002.

In late FY 2002, OIG also discontinued providing a separate statement-taking class. Instead the material was folded into the ongoing Basic Investigative Skills class, which became a two-day course for facility or agency staff who would be doing initial investigative work for OIG.

FY03-07: Updating Training

In FY 2004, OIG started using the DHS intranet for on-line training of OIG staff. OIG was fully integrated into this system, so OIG staff could take intranet-based trainings that the department had already developed. Further, OIG began developing its own intranet-based training courses.

In FY 2005, OIG also resurrected a previously discontinued class on the expectations for an investigative "first response" to an allegation. The class was targeted at facility or agency managers who would not become trained investigators, enabling them to take appropriate first steps that would assist in the investigation. This class again was not well-attended.

In August 2005, OIG printed and sent to agencies and facilities a handbook on reporting and investigating abuse/neglect. The goal was to inform direct care staff and encourage reporting. OIG distributed copies at its trainings. OIG has updated the handbook twice since.

Also in FY 2006, OIG became aware of the growing need for updated skills training for agency and facility investigators without requiring them to attend the full two-day Basic Investigative Skills class again. Thus, OIG developed a one-day Investigative Skills Refresher class. It reviewed the investigation-related requirements in Rule 50 and focused on reviewing interviewing skills and report-writing expectations.

Facility and agency investigators must have attended either the Basic Investigative Skills or the Investigative Skills Refresher class within two years of the start of the protocol approval period to remain authorized to conduct investigative steps at OIG's direction.

FY08: Improving Training

Internal training

OIG requires that each of the investigative staff successfully complete five continuing education courses each year. The courses must include at least one course each in investigative skills, computer skills, and personal growth. All investigative staff met their continuing education requirements for FY 2008.

In September 2007, OIG held a statewide training meeting for all OIG employees. This meeting included short training sessions on diversity and personal enrichment. The meeting also included a presentation by the Illinois Department of Public Health on its role in inspections and surveys, and how that relates to OIG. The presentation was given by the Special Investigations Unit, which focuses on detection and prevention of abuse and neglect in long-term care facilities. OIG personnel learned how similar that Unit's efforts are to OIG's and identified where and how IDPH and OIG can work more closely together.

A full day of the meeting was for training on interviewing adults with disabilities who are victims of abuse. This training was presented by Dr. Nora Baladerian, a nationally renowned expert on the subject. Drawing on her 35 years specializing in issues of abuse of individuals with developmental disabilities, Dr. Baladerian offered guidance that OIG has incorporated into its investigations of abuse and neglect. OIG also obtained several copies of her training DVD on the subject, allowing each of OIG's investigative bureaus to have at least one copy.

OIG also participates in the monthly training of new DHS employees through the standard DHS New Employee Orientation. These sessions are held on a monthly basis in both Chicago and Springfield, and OIG supplies a presenter at each location.

External training

OIG spent much of FY 2008 working to improve the training experience for attendees. First, in late FY 2007, OIG had created a Training Registration Form in fillable Adobe Acrobat format and put it onto OIG's website, for use in registrations for FY 2008. Having the form available on-line facilitates training registrations.

A concerted effort to structure training curricula for OIG courses resulted in improved training handouts, approaches, and evaluations. Toward the end of FY 2008, OIG hired another trainer to help improve these further, as well as to increase the number of classes.

OIG continues to provide training of facility and community agency staff involved in responding to and investigating allegations and deaths. At the same time, OIG cannot train all employees of over 360 community agencies and eighteen DHS facilities. So, in August 2007, OIG distributed an updated version of the electronic Rule 50 training that the agencies and facilities can use to train their own employees. OIG also continued conducting training sessions at various locations around the state.

The first training course offered by OIG has been four hours training on the definitions, requirements, and expectations in administrative Rule 50.

 - During FY 2008, OIG conducted 26 Rule 50 classes with a total of 681 attendees.

OIG's second course, entitled, "First Responder," was for any agency or facility staff member who might have been called to respond to the scene of alleged abuse or neglect. The course outlined required actions, such as ensuring the health and safety of all involved and securing the scene pending the arrival of investigators.

 - During FY 2008, OIG conducted 8 First Responder classes with a total of 55 attendees.

This course has suffered from low attendance, so OIG was not getting this critical information to its target audience. Therefore, during FY 2008, OIG considered alternatives and decided to instead incorporate the "first responder" responsibilities into the Rule 50 course. This transition was completed by the end of FY 2008, so the OIG-conducted Rule 50 course will become a six-hour training beginning in FY 2009.

The third OIG-conducted training, "Basic Investigative Skills" (BIS), is a two-day course which is required for any community agency or facility employee who has been nominated to potentially be an authorized agency investigator. The course covers the basics of conducting an investigation, such as the initial assessment, securing a scene, collecting and retaining evidence, photography, investigative planning, interviewing, and writing an investigative report.

 - During FY 2008, OIG conducted 18 BIS classes with a total of 233 attendees.

The final OIG-conducted training, "Investigative Skills Refresher," is a one-day course designed to refresh the skills of authorized investigators. It covers a review of the investigative components of Rule 50 and of the steps in conducting an investigation. This course is limited to those who are already trained investigators.

 - During FY 2008, OIG conducted 13 Refresher classes with a total of 367 attendees.

The table below shows the number of participants in OIG-conducted training over the past twelve years, since OIG began a formal external training program.

Table 8b: Participants at OIG-conducted Trainings by Course and Fiscal Year

Fiscal Year 

Fiscal Year	OIG Rule 50	First Responder	Statement Taking	Basic Inves- tigative Skills	Inv. Skills Refresher
FY 1997	-	35	-	205	-
FY 1998	-	0	12	457	-
FY 1999	1661	0	27	336	-
FY 2000	607	3	69	422	-
FY 2001	265	34	53	239	-
FY 2002	460	1	25	313	-
FY 2003	394	0	-	304	-
FY 2004	363	0	-	278	-
FY 2005	873	33	-	512	-
FY 2006	660	387	-	259	258
FY 2007	790	164	-	296	106
FY 2008	681	55	-	233	367

External Presentations

Finally, during FY 2008, OIG participated in the Chicago Police Department's training of its Crisis Intervention Teams (CIT). This ever-expanding team of officers works daily with individuals who have mental health or physical/developmental disabilities within the City of Chicago, to bring safe and speedy resolutions to public safety and health issues.

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Chapter 8:  INVESTIGATIVE PROTOCOLS

FY85-88: The Beginnings

Since its inception, OIG has relied to some extent on investigative work by staff of the facilities or the community agencies. To ensure quality, OIG established requirements for all cases, provided training to facility and agency staff, and given direction in particular cases.

FY89-95: Departmental Policy

Since OIG's investigative jurisdiction was limited by law to departmental facilities, OIG was able to include requirements regarding investigations into the departmental policy, such as a mandate for full cooperation with OIG, and these were then binding on all facility staff.

In FY 1989, OIG spearheaded a revision to the existing department policy to more clearly specify requirements regarding training and integrity of the investigators, timeliness of investigations, bargaining unit representation, record maintenance, confidentiality, and special procedures for deaths or allegations involving individuals under 18 years of age.

On September 24, 1990, the department revised the policy again to include mandates and prohibitions that OIG had identified as recurrent issues.

• Timely reporting of allegations was reinforced and specified as meaning "immediately, and in no event later than the end of the reporting person's shift."
• The prohibition of screening allegations was broadened to prohibit even review by unit or facility administration prior to reporting to OIG.
• Non-reportable allegations were required to be recorded on appropriate forms and maintained by the facility.
• Facilities were mandated to notify OIG and send documentation of all corrective action taken as a result of the case.

FY96-01: Investigative Policy Reviews

With the extension of OIG into community agency programs, a single departmental policy was no longer sufficient, so Rule 50 included minimum requirements for investigations. The rule also noted that, upon receiving an allegation, OIG would "determine whether OIG, or the community agency with an OIG approved method of investigation may take primary responsibility for investigating the allegation" (Rule 50, Section 50.40(a)).

Thus, OIG required the facilities and community agencies to submit their internal policies covering investigations. The OIG Bureau of Evaluation and Review was given the function of reviewing these agency and facility investigative "protocols" using the same standards and procedures for community agencies and facilities.

The community agencies lagged behind the facilities in submitting their investigative protocols and in complying with the mandates of Rule 50. By FY 2000, only nineteen of the 395 agencies had submitted a protocol and OIG had approved only twelve of those nineteen.

FY02-07: OIG Protocol for Agencies

Due to the delays in getting approved protocols, OIG decided to write an "OIG Investigative Protocol for Community Agencies." OIG sent it to the community agencies, asking each to decide if it wanted to assist in conducting investigations and, if so, to adopt the Protocol and submit names of investigators. OIG reviewed these staff individually, to ensure adequate training and no apparent conflict of interest, and notified the agency of the approved investigators.

OIG allowed a community agency to investigate only after OIG had previously authorized the agency to conduct investigations and assigned that particular investigation to the agency. This change allowed community agencies to elect not to investigate. Still, a large number did submit the protocol authorization form and names of trained investigators. OIG authorized: 193 agencies in FY 2003; 191 agencies in FY 2004; and 184 agencies in FY 2005.

For FY 2006, OIG began requiring agency investigators to attend investigative training at least every three years. Also, due to the changes in the FY 2002 version of Rule 50, OIG had restricted the types of allegations agencies could be assigned to investigate. Partly as a result, the number of agencies requesting and receiving authorization dropped to 129 in FY 2006.

With OIG's encouragement, an increased number of community agencies were approved in FY 2007 (162). For FY 2008, OIG clarified the training requirement for agency investigators, changing it from "one OIG-conducted investigative skills course every three years" to "within two years of the start of the fiscal year."

In FY 2008, the number of approved agencies dropped again (to 150). The four most common reasons agencies gave for not seeking authorization were the following:

• A desire to have outside, independent, and consistent investigations;
• Apparent conflicts of interest arising from few employees working in a small agency;
• Limited resources, especially limited funding; and
• Too few incidents to invest the time needed in obtaining training and getting approval of agency investigators.

Agency A/N reporting policies

In late FY 2006, OIG requested abuse/neglect reporting policies from some community agencies that had not reported to the OIG Hotline. Of those received, many had not been updated since before May 2002, when Rule 50 was last revised, and most appeared to be missing four basic elements from Rule 50: definitions of abuse, neglect, and related terms; time requirements for reporting; prohibition of screening; and incident management (e.g., securing the scene).

In October 2006, OIG sent letters to all 363 community agencies that provide direct mental health or developmental disability services, asking them to submit their local abuse/neglect reporting policies. Along with the request, OIG sent a sample policy containing the core elements and requirements of Rule 50 to help in updating the policies, if necessary.

In January 2007, OIG sent a separate request with an abbreviated sample policy to 23 agencies that provide only screening or other administrative services. In total, OIG sent out 385 letters; counting recent agency closures and mergers, OIG expected responses from 375 agencies. Despite numerous phone calls, emails, and letters, however, by the end of FY 2007, OIG had received abuse/neglect reporting policies from 363 (97%). Of these 363 agencies that did respond, only 331 (91%) had all four of those basic elements.

FY08: Agency Policies and Facility Protocols

Agency reporting policies

After calls, emails and letters from OIG, as well as contacts by the DHS divisions, by June 1, 2008, only nine (5%) of the agencies still had policies that did not cover all four basic elements. Thus, on June 9, OIG sent memos to the Division of Developmental Disabilities and the Division of Mental Health, requesting sanctions against the nine remaining agencies. As of June 30, all three MH agencies were in compliance; one of the six DD agencies is no longer providing developmental services and the other five were brought into compliance shortly after the end of FY 2008.

OIG also decided to hold the department-operated facilities and community agencies to the same standards. OIG had been reviewing the positions and the investigative training of staff at each facility who had been handling initial investigative steps for OIG.

Rule 50 does not allow OIG to assign an abuse/neglect investigation to a facility; however, since the facility investigators are on-site, they are still able to take some of the initial investigative steps for OIG. Further, the facilities routinely must investigate a wide variety of complaints and unusual events that are not reportable to OIG under Rule 50.

So, in November and December 2007, OIG developed an "OIG Investigative Protocol for Facilities," which described procedures for the facilities to assist in conducting investigations of alleged abuse or neglect and deaths.

The Protocol specifies the roles and responsibilities of the facility's OIG Liaison, investigators, and staff in response to abuse/neglect allegations. It covers investigative procedures for reportable and non-reportable allegations. The Protocol details specific requirements, such as that the designated investigative staff must have successfully completed OIG-conducted investigative skills training within the last two years and must not be in a position that creates an appearance of a conflict of interest.

As with agencies, the facilities are required to annually apply for and obtain authorization from OIG, although this is done on a calendar year basis for facilities, while the agencies are still reviewed on a fiscal year basis.

On December 24, 2007, OIG distributed the OIG Investigative Protocol for Facilities and a letter describing the process to all eighteen department-operated facilities. By then, all eighteen facilities already had a designated OIG Liaison, and seventeen had at least one designated investigator with current OIG investigative skills training. Subsequently, the protocols were formally adopted by each facility, and, as of March 6, 2008, OIG had authorized all eighteen facilities as having an approved protocol and at least one approved investigator.

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Chapter 9:  WRITTEN RESPONSES

FY85-88: The Beginnings

Investigating becomes effective when the findings are used to take corrective action to prevent similar occurrences. A requirement for documenting such corrective actions was in the department policy two years prior to the statute creating OIG. That policy simply stated that, upon the conclusion of any investigation, the facility was required to submit a written summary report that included the administrative actions taken as a result of the findings.

FY89-95: Disciplinary Action Documentation

The first department policy promulgated after the creation of OIG expanded on this simple requirement. This policy, effective May 12, 1989, stated that OIG would not close a case until the facility sent a memorandum detailing corrective actions or noting they would be taking none. Any corrective action had to be documented, and the documentation had to be retained in the facility investigative file.

A policy revision effective September 24, 1990, mandated that, if any administrative action was taken against an employee, the facility had to send OIG a copy of the specific documentation of the disciplinary action taken. The facility was still required to maintain in its investigative file the documentation of other corrective actions the facility took to prevent recurrence.

FY96-97: Second Cover Memos

OIG's investigative case reports always had a cover memo stating whether abuse/neglect was substantiated or not. In FY 1996, OIG discussed how best to draw attention to systemic issues raised in a case that appeared to need corrective action to prevent abuse/neglect. These might be: absent or unclear policies; structural and physical plant issues; clinical concerns; staff practices that needed to be changed; or patterns of flawed case handling.

This effort was complicated by two concerns. First, the statute that passed in FY 1996 contained a prohibition against OIG being involved in routine programmatic and licensure issues. Second, identifying systemic issues might be seen as an "excuse" for abuse or neglect.

To handle these concerns, in FY 1997, OIG sent a "second cover memo" on any case that identified such systemic issues. This second cover memo was sent separately to the facility or community agency, which was then required to submit a corrective action plan - that is, a written description of the actions that it would take to protect individuals and address issues identified in the case, along with implementation dates for those actions.

FY98-02: Written Responses

A law passed in early FY 1998 expanded on this idea. It mandated that facilities and community agencies submit a "written response" to every case that was substantiated as abuse/neglect or had other issues (P.A. 90-512). Unlike the corrective action plans, the facility or community agency was to send the Written Response to the DHS Secretary - that is, to the respective program division - for review and approval.

During FY 1999, OIG's unannounced site visit team (see Chapter 7) designed a process to review implementation of facility Written Responses. This process involved conducting interviews, reviewing facility policies, and checking for documentation of training and personnel actions, to determine if the Written Response had been fully implemented.

This process was followed in FY 2000 and FY 2001 as well; in all three years, Written Responses had been fully implemented. As a result, and because the department still had the responsibility for approving Written Responses, OIG discontinued the process in FY 2002.

FY03-07: Compliance Reviews

On December 31, 2003, a new law assigned OIG the statutory responsibility for monitoring implementation of the Written Responses - that is, for ensuring that the facilities and community agencies actually complete the corrective actions they identified. The monitoring involved two requirements: to obtain status reports in all cases where implementation was delayed, and to conduct compliance reviews on a sample in order to verify implementation.

Thus, OIG developed a protocol for laying out how to handle the implementation status reports and the Written Response Compliance Reviews on a random 20% sample. OIG piloted the protocol the last three months of FY 2004, reviewing eleven cases - two were not yet fully implemented, and only one was out of compliance.

Subsequently, the Compliance Reviews have found facilities and agencies to consistently be in compliance. Documentation of corrective actions was obtained in all 75 Compliance Reviews during FY 2005, all 73 during FY 2006, and all 109 during FY 2007.

FY08: More Written Responses

OIG required 722 Written Responses during FY 2008, eight percent more than the 670 required in FY 2007 and 43% more than the 506 required during FY 2006. This increase from FY 2006 was greater in DD programs (from 431 to 598), but percentage-wise was greater in MH programs (75 to 124), which might imply a general across-the-board increase.

However, Written Responses required from DD facilities decreased from 103 in FY 2006 to 99 in FY 2007 (-4%) and to 92 in FY 2008 (-7%), while in MH facilities and in both MH and DD agency programs they increased. The main reasons for the decrease in Written Responses from DD facilities were the decrease in their overall reports and the improvement in timeliness of initial reporting. Conversely, the single biggest jump was in DD agencies, which saw increases from 328 in FY 2006 to 459 in FY 2007 (40%) and to 506 in FY 2008 (10%). These increases appear to be due to an increase in overall reports.

These increases have been the primary cause for a continuing problem with OIG receiving the approved agency Written Responses from the DHS Division of Developmental Disabilities in a timely fashion. The statute does not specify a time requirement for receiving an approved Written Response. However, OIG tracks the timeliness, because an OIG investigative report becomes final 30 days after it is completed and the final report is to include the Written Response. Between FY 2006 and FY 2008, the percentage of approved DD agency Written Responses that OIG received later than 30 days from completion date remained above 70%. Recent changes in the Division of DD resulted in a significant improvement toward the end of FY 2008.

Written Response issues

Since OIG may cite multiple issues in a single Written Response, OIG cites more issues than it sends Written Responses. Among the 671 Written Responses approved during FY 2008 and received by OIG, a total of 986 issues were cited. The table below shows frequency of issues in approved Written Responses by fiscal year.

Table 8c: Frequent Issues in Approved Written Responses by Fiscal Year

Issues	FY2006 Count	FY2006 Percent	FY2007 Count	FY2007 Percent	FY2008 Count	FY2008 Percent
Substantiations	181	30.0	187	23.5	244	24.7
Failure to report	110	18.3	196	24.6	98	10.0
Late reporting to OIG	34	5.6	68	8.5	175	17.7
Inappropriate action	48	8.0	57	7.2	63	6.4
Monitoring/staffing	36	6.0	29	3.6	49	5.0
Nursing practices	42	7.1	47	5.9	28	2.8
Hab/Treatment plan	17	2.8	49	6.2	47	4.8
Investigative error	14	2.3	35	4.4	78	7.9
All other issues	120	19.9	128	16.1	204	20.7
Total issues	602	100%	796	100%	986	100%

The most common specific issues that OIG cited were late reporting (175) and failure to report (98). Community agencies constituted the largest percentage of both late reporting (78%) and failure to report (79%).

Substantiated abuse/neglect, if counted all together, was cited more often than late reporting. That is, substantiated neglect was cited in 83 cases, substantiated mental abuse in 77 cases, substantiated physical abuse in 75 cases, and substantiated sexual abuse in nine cases. These 244 issues contrast with FY 2007, when substantiations accounted for 187 issues.

Compliance Reviews

As noted earlier, OIG conducts compliance reviews on a random 20% sample of approved Written Responses received. OIG does this monthly: at the end of the previous month, OIG selects the sample from Written Responses approved during the prior month. Thus, for example, Written Responses reviewed for FY 2008 Compliance Reviews were approved by the DHS program divisions during the time period of May 1, 2007, through April 30, 2008.

During that time period, the DHS divisions approved 652 Written Responses, 480 from community agencies and 172 from facilities. OIG conducted Compliance Reviews of a 20% random selection: 96 from community agencies, and 34 from facilities. In these 130 Written Responses, OIG conducted on-site reviews in 27 cases, conducted phone interviews in 18 additional cases, and conducted reviews of documentation in the remaining 85 cases.

After the reviews, OIG sent letters on all but four of the Written Responses indicating that the agency or facility was in compliance with the statutory requirement for implementing the actions identified. OIG returned two of the agency Written Responses to the Division of Mental Health and two of the agency Written Responses to the Division of Developmental Disabilities because OIG had concerns with the division's approval of the agency's planned actions. The divisions followed up with each of the agencies, and a compliance letter was sent after the end of the fiscal year.

As with all Written Responses, the late reporting was the most common issue OIG had cited in the Written Response reviewed during FY 2008 Compliance Reviews. Re-training of community agency or facility staff was the typical response. During the Compliance Review, re-trained employees were then interviewed on the reporting process and were typically able to correctly answer questions.

Retraining of the involved staff was the most common corrective action to other issues OIG cited as well. Discharges (including resignation in lieu of discharge) and suspensions were the two next most common actions taken by agencies and facilities.

OIG's randomly selected Compliance Reviews are instrumental in ensuring that corrective actions listed on all Written Responses are implemented. This, in turn, is a step toward preventing abuse/neglect and increasing the safety and security of the residents.

Addenda

Addendum A:

CENSUS AND STAFFING RATIOS

The state law that provides for an OIG annual report was amended in FY 1993 to mandate that the report include information on the direct care staffing ratios at the department facilities. The table on the following page shows that information for FY 2008.

Census figures and direct care staffing ratios at the facilities had been reported for the first time in OIG's FY 1992 annual report. During that fiscal year, the department had nine developmental centers, eight psychiatric hospitals, and four facilities providing both types of services. The overall inpatient census on June 30, 1992, was 7,642 individuals. The department had 8,614 direct care staff (full-time equivalents), resulting in a direct-care-staff-to-individual ratio of 1.13.

FY 1992 was also the last year that Alton MHC and Meyer MHC provided developmental services. Choate MHDC and Singer MHDC provided both types of services until FY 2002, when Singer MHC closed its developmental service units and Choate was split to two facilities.

The numbers of individuals receiving services in the department facilities and the resulting staffing ratios have changed significantly since that time. Subsequent OIG annual reports have shown a continued decline in the inpatient population and a general rise in the staffing ratio until recently. For comparison purposes, the table below shows every third fiscal year leading up to FY 2008.

Table 9: Facility Census and Staffing Ratios, FY 1993 through FY 2008 

Fiscal Year	DD: Census of Individuals	DD: Direct care staff ratio	MH: Census of Individuals	MH: Direct care staff ratio
FY 1993	4,063	1.14	2,791	1.19
FY 1996	3,655	1.19	2,040	1.78
FY 1999	3,281	1.28	1,746	1.54
FY 2002	3,058	1.33	1,548	1.61
FY 2005	2,743	1.31	1,385	1.38
FY 2008	2,385	1.45	1,351	1.38

Note:Choate MHDC included in DD only through FY 1996; Choate MHC and Choate DC split thereafter.  Singer MHDC included in MH only through FY 1996; DD units subsequently closed.

Table 10: FY 2008 Census and Staffing Ratios at the Facilities

Facility	Budgeted Beds (1)	On-Books Bed-days (2)	Individuals Served (3)	Direct care staff (4)	Staffing ratio (5)
Choate DC	161	63,457	192	227.7	1.41
Fox DC	136	51,165	145	172.9	1.28
Howe DC	340	126,615	372	529.1	1.68
Jacksonville DC	221	83,539	249	287.5	1.33
Kiley DC	221	82,100	235	327.3	1.48
Ludeman DC	366	139,939	391	497.5	1.33
Mabley DC	83	33,046	92	120.4	1.35
Murray DC	319	122,114	344	417.6	1.32
Shapiro DC	566	214,893	606	873.0	1.57
DD subtotals	2,413	916,868	2,626	3,452.9	1.45
Alton MHC	125	45,384	335	176.0	1.39
Chester MHC	302	101,382	486	351.2	1.26
Chicago-Read MHC	130	47,654	1,529	193.0	1.53
Choate MHC	79	25,544	468	97.6	1.36
Elgin MHC	390	134,928	1,275	504.0	1.34
Madden MHC	150	46,332	3,124	189.9	1.58
McFarland MHC	140	42,181	702	146.6	1.26
Singer MHC	76	26,098	622	98.9	1.39
Tinley Park MHC	100	22,430	1,339	111.7	1.72
MH subtotals	1,492	491,933	9,880	1,868.8	1.38

(1) The number of beds the facility was budgeted to have during FY 2008.

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

(3) An unduplicated count of all individuals residing in the facility during FY 2008.

(4) The number of direct care staff, but part-time employees are counted in full time equivalents.

(5) The direct care staff to individual ratios on June 30, 2008.

Addendum B:
SAMPLE FY 2008 CASES

Sample FY 2008 Cases at DHS Facilities

Staff allegedly did not conduct appropriate face checks on the unit, so two individuals were able to have sex. The OIG investigation substantiated that two employees failed to conduct all of the required face checks that night, which allowed the two individuals to engage in sexual relations for approximately two hours. The investigation also found that the two employees had falsified face check documentation. The facility disciplined both employees.

An employee allegedly grabbed an individual by the arms, pushed him to the floor, and placed him in a headlock. The OIG investigation found that the incident began when the individual was reporting a separate allegation to a unit supervisor. The employee reportedly intervened and said that he doubted the allegation, which made the individual become upset and aggressive. The investigation established that the employee grabbed the individual, they wrestled and fell to the floor, and the employee placed the individual in a physical hold, one that was never reported or documented. The investigation found that, later, the employee argued with the individual and then pushed past the unit supervisor, took the individual to the floor again, and placed him in a headlock. OIG substantiated physical abuse against the employee, who resigned. OIG also recommended action against the unit supervisor, for failure to report and document the incidents, and against two staff witnesses, for not being truthful in their initial statements about the incident. The facility gave these staff lengthy suspensions.

An employee allegedly twisted an individual's arm and dug her fingers into the individual's arm, bruising it. The OIG investigation found that the individual had become agitated and had to be placed in restraints. The injuries apparently occurred while two security officers were placing her into restraints. The injuries appeared to be accidental, so the allegation was unsubstantiated. However, OIG cited the facility for failing to photograph the injuries immediately after the allegation was made.

An individual was reportedly found in bed but unresponsive, and he was pronounced dead. Three employees were suspected of neglect. The OIG investigation found that the first employee who found the individual failed to follow the medical emergency protocol: she did not get the individual onto the floor and begin CPR. The other two employees, who arrived at least two and a half minutes later, did begin CPR. OIG substantiated neglect against the first employee, but not against the other two. The facility fired that employee, retrained the other two, revised the medical emergency protocol, and issued a reminder to all staff.

An employee allegedly hit an individual on the right side of her face. The individual had no injuries and gave conflicting accounts of the alleged incident. The OIG investigation found no witnesses to support her allegation, and the accused employee denied it. OIG determined that the allegation was unfounded.

An employee allegedly failed to secure an individual in her wheelchair as required, and the individual fell out of the chair and scraped her forehead. During the OIG investigation, the employee admitted to not using a required seat belt and, when she turned away, the individual fell out of the wheelchair. The allegation of neglect was substantiated, and the facility suspended the employee for twenty days.

An individual was admitted to a local hospital for internal bleeding and a low blood count, allegedly because she had not been receiving her medication. The OIG investigation found that the individual had not received her medication for several weeks prior to being hospitalized. OIG substantiated neglect against two physicians and three nurses for failing to adequately review her chart and renew her prescription. OIG also recommended that the facility revise its medication policy to address how to notify staff of problems with medication orders and that the facility's pharmacy maintain a record of the medication drop list.

An individual escaped from the visiting room during visiting hours. The OIG investigation found that the individual had switched clothes with one of his visitors and was allowed to leave despite being monitored by two security officers and three unit staff. OIG substantiated neglect against all five employees and cited one of them for interfering in the OIG investigation. OIG also recommended that the facility address the apparent lax security procedures.

An employee was allegedly observed - on three occasions with three different female individuals - rubbing his body against the individual in a sexual manner, though both were clothed. This act was also observed on two other occasions with two other individuals. The OIG investigation interviewed the individuals, who corroborated the allegations. OIG turned the case over to the Illinois State Police. A grand jury indicted the employee, and the case is pending.

An individual left his living unit without permission, and neglect by staff was suspected. During the OIG investigation, the individual admitted that an employee had assisted him in leaving and took him to her home, where they had sex. The individual said that the employee then drove him in the trunk of her car to a wooded area, where she let him out to complete his escape. He later stole a car and was arrested by the police. OIG turned the case over to the Illinois State Police, who used DNA evidence to support the individual's allegation. The employee was charged with a crime, and the case is still pending.

An employee allegedly choked an individual. The OIG investigation found several individuals who had witnessed the alleged choking, and the individual had injuries that were consistent with being choked. OIG turned the case over to the State Police. The employee pled guilty to aggravated battery and has been discharged from employment and placed on the Registry.

An individual was found in his bed, unresponsive and lethargic, and had to be taken to a local hospital for treatment. Blood tests showed a large amount of Cloziril, which had not been prescribed for him. The OIG investigation found that a nurse had not followed medication administration procedures and gave the individual another individual's medications. The investigation further found that other nurses had a lax approach to following the procedures, and OIG recommended that the facility monitor medication administration more closely. The facility responded by retraining the entire nursing staff in the medication administration procedures.

Sample FY 2008 Cases at Community Agencies

While on an outing, two employees allegedly bought lunch for an individual but failed to cut the food into small pieces as was required for him and failed to respond appropriately when he started choking, resulting in his death. The OIG investigation found that the two employees were aware of the individual's dietary need yet failed to follow it. The investigation also found that these two employees ate at another table, with their backs to the individuals, and left a staff trainee to supervise all the individuals. The investigation further found that, when the trainee noted that the individual was choking, the two employees put the individuals back into the van and drove them back to the CILA. OIG substantiated egregious neglect against the two employees, since the individual died, and substantiated neglect against the agency for not having considered the need for possible emergency response while on outings. The two employees resigned, and the agency revised several policies and trained staff on them.

An individual eloped from a CILA six times within four months, allegedly due to insufficient supervision by the staff. The OIG investigation found that the agency knew even before he was admitted that he had a history of leaving without permission ("eloping"), yet the agency failed to supervise him closely. The investigation further found that, when the individual started eloping from the CILA, the agency never changed his supervision level, implemented any special programs to prevent the elopements, or gave staff additional directions on how to deal with him. OIG substantiated neglect against the agency and recommended ways to address the behavior. OIG also recommended the agency discuss with the CILA neighbors positive ways to deal with him should he attempt to enter their homes again. The agency followed all the recommendations.

When an individual returned after a week-long placement at another agency, the CILA staff discovered that he had many injuries. He could not explain how he got them, so the CILA staff alleged abuse or neglect by the other agency. The OIG investigation found that the individual had been on home visit during that week, so the guardian was investigated as well. However, the investigation was unable to narrow the time frame for the injuries to after the individual returned to his CILA. Since he was not on any special supervision and the exact cause or time could not be determined, the allegation was unsubstantiated.

OIG received a report that an individual died from pneumonia while on a home visit. The OIG investigation found that the staff had been reporting to the QMRP for several days that the individual had cold symptoms, but the QMRP never contacted the agency nurse nor arranged a physician's exam. Instead, the QMRP sent the individual on a home visit, where he choked and turned blue, and he died at a local hospital. The OIG investigation substantiated neglect against the QMRP; however, a reconsideration and subsequent investigation instead substantiated neglect against the agency, since its failure to provide adequate medical care and its numerous quality assurance deficiencies contributed to the death. OIG recommended that DHS review the deficiencies and consider them when evaluating the agency's plan for expansion. OIG also recommended that the agency address its failure to provide all documents OIG requested as part of the investigation.

An employee allegedly slapped an individual on the buttocks. The OIG investigation found that the employee admitted to the incident, but the program director did not remove her from patient contact, which caused the individual more stress. Further, the investigation found the program director, who was the agency's OIG Liaison and an OIG-approved investigator, had instructed another employee to change her incident report to lessen the offense. OIG substantiated physical and mental abuse against the employee. OIG also substantiated neglect against the program director and recommended that he be removed as OIG Liaison and investigator. The agency discharged the employee, gave the program director a written reprimand, and removed the program director as OIG Liaison and investigator.

An individual's therapist allegedly flirted with her. During the OIG investigation, the therapist denied the allegation, but he admitted that he had given her his personal phone number. No other evidence or witnesses could be found, so OIG determined the allegation to be unsubstantiated. The OIG case report noted the inappropriate action of the therapist, and the agency disciplined him for violation of its code of ethics.

A Licensed Practical Nurse (LPN) allegedly allowed one individual to take another's medications on two occasions. The OIG investigation found that the LPN allowed certified staff to put the second individual's medications into his sandwich and juice, because he would not take it orally. The investigation found that the first individual ate the sandwich on one occasion and drank the juice on another; he was adversely affected, while the second individual's physical condition deteriorated due to not getting his medications. OIG substantiated neglect by the LPN and several staff for failing to properly monitor the individuals and for failing to completely document and report the error. OIG also cited the agency for failing to follow the Illinois Advanced Practice Nursing Act.

An individual, who was receiving services and support while residing in his own apartment, was allegedly living in filthy conditions with no food and not taking his medication. The OIG investigation found that, although the case manager was to provide two to three hours of services per week, he admitted to meeting with the individual only twice in three months and only in the lobby of his building. The investigation further found that the case manager falsified documents which the agency then used to bill the State. OIG substantiated neglect against the case manager and cited the case manager's supervisor for failure to report; the agency disciplined both. OIG also recommended the agency develop a policy on overseeing case manager contacts with individuals, including ways to prevent falsifying contacts and to correct billings based on false information.

Two employees allegedly dragged an individual and choked her. During the OIG investigation, the individual gave inconsistent statements about what happened, she had no relevant injuries, and her only supporting witness was her boyfriend, who admitted that he was not present at time the incident allegedly occurred. Three other individuals denied seeing any abuse. OIG determined that the allegation was unfounded.

An employee allegedly pulled an individual's hair. The OIG investigation found one employee who said that the employee had pulled the individual's hair once on a day three or four months before. The employee stated that a third employee had observed it happen many times, but that employee denied any intentional hair pulling. Rather, she noted that the individual has very difficult hair, and normal grooming may appear to be inappropriate hair pulling. Since the allegation was not reported until so much later, OIG was not able to substantiate it. However, OIG recommended that the agency take action to ensure that allegations are reported timely. The agency immediately retrained all three employees and instituted annual refresher training in identifying and reporting abuse/neglect.

Sample FY 2008 Cases in Domestic Settings

An individual with severe developmental delay was allegedly struck with a belt by his stepfather. The OIG investigation substantiated physical abuse against the stepfather and referred the incident to the local police, who arrested him and charged him with domestic battery. Since indications of ongoing problems were evident, OIG recommended the individual be removed from the home. He was moved and referred to the DHS Division of Developmental Disabilities for services.

An agency sent an individual who had profound mental retardation to the hospital, since he arrived from home in poor condition. The agency alleged that he was being neglected by his mother, who was also his guardian. The OIG investigation found the home was unsafe and substantiated neglect against the mother. After hospitalization, OIG had the individual moved to a better location, referred him to the DHS Division of Developmental Disabilities, and found a family member who agreed to both leave him there and pursue guardianship.

An individual with severe cerebral palsy arrived at an emergency room unresponsive with a temperature of 107 degrees, a blood pressure of 50/40, and feces in her ear and nose. The OIG investigation substantiated neglect against the individual's parents and recommended that, after discharge from the hospital, she be moved to a safe environment. OIG sought guardianship of the individual and obtained an order of protection to ensure that the parents did not take her from her new home. Since the parents had another child at home, OIG also contacted the Department of Children and Family Services, which removed the child from the home.

An individual with learning disabilities and severe diabetes was allegedly left at home unattended without medication. The OIG investigation found that the individual is insulin-dependent, yet the father had left her alone for several days, so OIG substantiated neglect against him. OIG moved her to an aunt's home and assisted the aunt in filing for guardianship of her niece. OIG also referred the individual's case to the Division of Developmental Disabilities to obtain necessary services for her.

An individual with autism, moderate mental retardation, and a mental illness was allegedly being neglected by her mother. Although the mother would not allow the OIG investigator into the home, substantial amounts of clutter and a significant odor were obvious. The OIG investigation also found that the individual had not been taken to medical appointments, had not been given her medications, and had poor hygiene. OIG substantiated neglect against the mother and moved the individual to an intermediate care facility for the developmentally disabled (ICFDD). OIG pursued guardianship, but the court awarded guardianship to the mother with the stipulation that the individual remain in the ICFDD.