DHS OIG FY 2011 Annual Report

November 2011

To Governor Pat Quinn and Members of the Illinois General Assembly:

In accordance with the Illinois Department of Human Services Act (20 ILCS 1305) and the Adults with Disabilities Domestic Abuse Intervention Act (20 ILCS 2435), I am pleased to submit the Fiscal Year (FY) 2011 report of the Office of the Inspector General (OIG) in the Department of Human Services (DHS), entitled "Abuse and Neglect of Adults with Disabilities."

This OIG has the statutory mission of preventing and investigating abuse and neglect of adults who have disabilities and who reside in private homes, in DHS-operated facilities, or in programs operated by local community agencies and licensed, certified or funded by DHS for mental health or developmental disability services.

This annual report provides an overview of OIG's work during FY2011. It covers OIG's training, unannounced facility site visits, investigations, recommendations to prevent recurrence, referrals for services, reviews to ensure implementation of corrective actions, and other aspects of OIG's statutory mission.

The report reflects the continued increase in allegations of abuse or neglect of adults with disabilities in the community. Over the past three fiscal years, OIG has seen a 17% decrease in allegations about DHS facilities but a 21% increase in allegations about community agency programs and a 23% increase in allegations in domestic settings. As services continue to shift from facilities to the community, OIG expects these trends to continue.

Thank you for your continued confidence in OIG's commitment to preventing and investigating abuse and neglect of Illinois' residents who are facing mental and physical challenges.


William M. Davis

Inspector General

Executive Summary

During FY2011, the Office of the Inspector General (OIG) accomplished the following.

  • Presented 70 training sessions on reporting or investigating abuse or neglect, with a total of 1,275 participants.
  • Conducted unannounced site visits to all seventeen DHS facilities providing mental health or developmental disability services, making 30 recommendations to prevent abuse or neglect.
  • Referred 418 complaints that were outside OIG jurisdiction to the appropriate entity, as well as recording an additional 1,384 calls that needed no referral. 
  • Received 3,010 abuse/neglect allegations - 5.4% fewer than during FY2010 but 9.5% more than during FY2009. Compared to FY2009, OIG received:
    • 16.7% fewer allegations at facilities,
    • 20.9% more allegations at community agencies, and
    • 23.0% more allegations in domestic settings.
  • Completed 3,070 investigations into abuse/neglect allegations - 8.1% more than during FY2010 and 7.1% more than during FY2009. OIG completed those 3,070 investigations in an average of 52.2 days per case, compared to the goal of 60 days. 
  • Closed 3,065 investigations into abuse/neglect allegations - 8.0% more than during FY2010 and 6.0% more than during FY2009. OIG substantiated abuse or neglect in 411 of those investigations. Domestic cases accounted for 124 of the 411 substantiated cases and facility/agency cases for the other 287. 
  • Reviewed reports of 147 deaths of individuals who were or had been receiving services in facility or community agency programs. OIG finished the review on 75 of these deaths, plus another 60 that were reported prior to FY2011, substantiating neglect in five of those 135 deaths. 
  • Recommended administrative action in 894 cases at facilities or community agencies during FY2011, 21% more than last year and 6% more than FY2009. OIG received DHS-approved written responses in 656 of those cases, as well as another 155 completed in prior years, for a total of 811 written responses, which identified 1,183 issues, the most common being substantiated abuse/neglect. 
  • Referred to the Registry 45 employees of facilities or community agencies for substantiated physical abuse, sexual abuse, or egregious neglect. The Health Care Worker Registry is maintained by the Illinois Department of Public Health.

Table of Contents

Chapter I: Preventing Abuse/Neglect 

  1. Quality Care Board 
  2. Facility site visits 
  3. Training 
  4. Facility staffing ratios 
  5. Investigative Protocols 

Chapter II: Reporting Abuse/Neglect 

  1. Reporting policies 
  2. Non-reportable complaints 
  3. FY2010 reporting 
  4. Initial reporting timeliness 

Chapter III: Investigating Abuse/Neglect 

  1. Investigative timeliness 
  2. FY2010 closures 
  3. Reconsiderations 

Chapter IV: Stopping Abuse/Neglect 

  1. Domestic abuse intervention 
  2. Health Care Worker Registry 
  3. Written Responses 

Chapter I: Preventing Abuse/Neglect

A. Quality Care Board

The Quality Care Board was authorized in 1992 by Public Act 87-1158, which states that the Board's purpose is to "monitor and oversee the operations, policies, and procedures" of the Office of the Inspector General (OIG). The Board is empowered to provide consultation on OIG practices, to review regulations, to advise on training, and to recommend policies to improve intergovernmental relations.

The law provides for the Board to have seven members, each appointed by the governor with consent of the State Senate. The members must be qualified by professional knowledge or experience in law, investigatory techniques, or the care of people who have mental illness or developmental disabilities. At least two members must either have a disability themselves or have a child with a disability. The members are not paid, but OIG may reimburse them for any costs for travel.

Due to the resignations of a few members, the Quality Care Board finished FY2011 with only four members:

  • Rita Ann Burke of Makanda, Chair;
  • Ed Baker of Coal City;
  • Thane Dykstra of Joliet; and
  • Brian Neal Rubin of Buffalo Grove.

The Board's quarterly meetings in FY2011 were held by teleconference on August 18, 2010; November 15, 2010; January 11, 2011; and April 12, 2011.

B. Unannounced Site Visits

OIG is statutorily mandated by the Department of Human Services Act (20 ILCS 1305/1-17) to conduct annual unannounced site visits to the DHS facilities providing developmental disability or mental health services. The site visits are part of the statutory mission of OIG to prevent abuse and neglect.

The site visits thus seek to cover a wide range of activities, initiatives, and potential problem areas related to abuse and neglect. Each year, unique issues are identified for site visits. These issues are reviewed with the goal of providing actionable feedback that will allow the facilities to take steps to prevent abuse and neglect in the future.

OIG's site visit team met in May 2010 to develop and choose the issues for the FY2011 site visits, which were then put into a site visit protocol. The team also planned the dates of OIG's FY2011 site visits, ensuring that no facility would be visited in a month that the site visit had been conducted at that facility in the prior three fiscal years.

OIG's FY2011 site visits were as follows:

  •  Alton MHC-February 16-17, 2011
  •  Chester MHC-November 3-4, 2010
  •  Chicago-Read MHC-  July 20-21, 2010
  •  Choate DC-September 21-22, 2010
  •  Choate MHC-September 22-23, 2010
  •  Elgin MHC-December 13-14, 2010
  •  Fox DC-July 14-15, 2010
  •  Jacksonville DC-  December 7-8, 2010
  •  Kiley DC-March 23-24, 2011
  •  Ludeman DC-August 24-25, 2010
  •  Mabley DC-September 7-8, 2010
  •  Madden MHC  -November 15-16, 2010
  •  McFarland MHC-  January 18-19, 2011
  •  Murray DC-October 19-20, 2010
  •  Shapiro DC-August 11-12, 2010
  •  Singer MHC-October 26-27, 2010
  •  Tinley Park MHC-  April 13-14, 2011

To reduce the travel costs associated with the site visits, OIG sent a preliminary request for documents (e.g., relevant policies). OIG batched these requests, sending them out to three facilities at a time, so that no facility was forewarned about the date of the site visit. In addition to reducing the travel costs to OIG, receiving these documents in advance also lessens the site visits interruption of facility operations.

Each site visit began with an entrance conference, where the site visitors introduced themselves, provided an explanation of the site visit plan, and identified the administrative staff to be interviewed. The OIG site visit team reviewed relevant documentation and interviewed administrative personnel, as well as direct care staff on the units, to discuss the issues and see the processes in place.

Each site visit then ended with an exit conference, where the overall findings of the site visit were presented. A formal report of the findings was provided to the facility within sixty working days of the site visit. The facility was asked to send OIG a copy of any written plan the facility might develop to address the report's recommendations. Receiving this written plan assists OIG in planning the following year's site visit, as OIG will be following up on the facility's actions in response to the recommendations made the prior year.

Issues and Overall Recommendations

Repeat recommendations:

During the FY2010 unannounced site visits to the facilities, OIG had made a total of 47 recommendations aimed at preventing abuse and neglect.

For FY2011, OIG reviewed all 47 recommendations made during the FY2010 site visits, looking at the actions the facility took and the outcomes of those actions.

OIG found that the facilities had completed adequate corrective action on 37 of the 47 recommendations, and OIG made only ten repeat recommendations. These primarily revolved around a persistent issue with the facilities not using a current DHS form or fully implementing a current DHS policy regarding internal reporting of medication incidents. Ten of the seventeen facilities had no repeat recommendations.

OIG recommended that the divisions continue to ensure that all facilities follow DHS program directives and use official DHS forms until revisions are formally adopted.

Dietary restrictions:

Individuals with dietary restrictions can suffer harm from neglect if a facility fails to identify those restrictions or by failing to adequately monitor both what food the individuals receive and how it is served.

For FY2011, OIG reviewed the facility's process for identifying and ensuring compliance with any dietary restrictions.

OIG found that the facilities have thorough processes for identifying food restrictions upon admission and for ensuring that the dietary orders reflect those restrictions. The facilities also have adequate processes for monitoring delivery and serving of food. Incidents of individuals receiving food items that are inappropriate may be the result of unit staff failure to follow the defined procedures.

OIG made no overall recommendation to the divisions regarding this issue.

Training of nurses:

Turnover of nurses and use of contractual staff may raise questions of adequate training in the special needs of individuals in DHS facilities. Lack of adequate training may result in neglect.

For FY2011, OIG reviewed each facility's training process for new and contractual nurses.

OIG found that all facilities had comprehensive training programs in place to adequately prepare a new nurse to render services effectively and safely. These training programs include a general orientation and a separate nursing orientation, which includes topics that would assist the nurse to communicate and respond effectively with the specialized populations and their behaviors. These orientations are followed by a structured on-the-job nursing training. All but two of the facilities had the nursing orientation training requirements spelled out in writing to inform new nurses of the expectations.

OIG made no overall recommendation regarding this issue.

Discharge planning:

The closure of Howe DC provided insights into the difficulties individuals face moving from one residence to another. Moving can be stressful, and research in other settings has shown that such stress may increase the risk of abuse or neglect.

For FY2011, OIG reviewed how each facility incorporates transition planning and education into the discharge planning process.

OIG found that all facilities' policies specified the interdisciplinary team's responsibilities for identifying and preparing an individual for discharge. All facilities described processes that included efforts at preparing the individual for the transition; e.g., at DD facilities, individuals are given the chance to have pre-placement visits at prospective new residences, to become familiar with the environment and the staff.

OIG made no overall recommendation regarding this issue.

Reporting policies:

State law and Rule 50 mandate that each facility have an abuse/neglect reporting policy and that each policy include the current statutory definitions.

For FY2011, OIG reviewed whether the facility policy has the current definitions and that it includes the prohibition for retaliation for reporting and the mandate for cooperation with abuse/neglect investigations.

OIG found that three facilities had not fully updated their policies to match the Rule. Notably, during FY11, DHS also revised Program Directives, "Prevention and Identification of Abuse and Neglect," and, "Reporting and Investigating Abuse and Neglect."

OIG recommended that the divisions assist the facilities to update abuse/neglect policies as needed, especially in light of the two newly revised DHS Program Directives.

Biennial training:

State law mandates that, at least every two years, all facility and agency employees be trained in identifying and reporting abuse/neglect. This mandate covers full- and part-time employees, contractors, and volunteers.

For FY2011, OIG reviewed the facility's training policy and materials, to ensure that the biennial training requirement has been implemented and the training materials are consistent with the provisions of the statute.

OIG found that all of the facilities' policies require initial and at least biennial training in Rule 50. However, six facilities had not trained all their staff, including contractual medical staff and volunteers, and three facilities were using training materials containing outdated definitions and requirements.

OIG recommended that the divisions ensure that all employees, including contractual and volunteer staff, are trained upon hire and at least biennially in reporting abuse and neglect, as required by Rule 50.

Financial exploitation:

The new statute signed in FY10 added financial exploitation as a type of abuse allegation to be reported to OIG. Theft or misappropriation of an individual's money or property had previously been reportable, but the 1995 statute had seemed to omit it.

For FY2011, OIG reviewed how the facility had been handling financial exploitation cases since the statute was signed and whether any allegations cases had been handled internally by the facility, rather than being reported to OIG as required.

OIG found that all but one facility had adequate processes for tracking individuals' property, including money. Facility personnel at all facilities were familiar with the procedures for reporting allegations of financial exploitation to OIG and for internal follow-up on those allegations that OIG referred back to them.

OIG made no recommendations to the divisions regarding this issue.


In all, OIG made 30 site visit recommendations in FY2011, down from 47 in FY2010. Further, only ten of the 30 were repeat recommendations from last year. Additionally, as noted above, OIG made three recommendations to the Division of Mental Health and the Division of Developmental Disabilities, down from six in FY2010.

C. Training

OIG has always been committed to training as a primary means to prevent abuse/neglect and to ensure reporting, investigating, and corrective action when it is alleged to have occurred. The statute has long mandated basic training of all facility and community agency employees on identifying and reporting abuse/neglect. Rule 50 requires that facilities and community agencies provide such a basic training to all full- and part time employees, contractors, subcontractors, and volunteers at least biennially.

FY2011 Training

Following promulgation of the new Rule 50 in March 2010, OIG distributed to the community agencies and facilities a pre-packaged training that covered the definitions of the various types of abuse and neglect and discussed what is and what is not appropriate as a first response to allegations and incidents.

However, OIG also continues to conduct a more thorough Rule 50 course, as well as two other courses, which provide training in investigative skills.

The OIG-conducted Rule 50 training is required biennially for all facility and community agency staff who function as formal liaisons with OIG. However, other administrative staff are encouraged to attend as well. This one-day class was the most popular: during FY2011, OIG conducted 30 of these Rule 50 classes with a total of 768 attendees.

The second OIG-conducted course, "Basic Investigative Skills," is a two-day course concentrating on all aspects of conducting an investigation, with a special emphasis on allegations involving persons with developmental disabilities or mental illness. OIG mandates this course at least once for every facility or community agency staff person who is designated to conduct investigations. During FY2011, OIG conducted nineteen Basic Investigative Skills classes with a total of 261 attendees.

The third course, "Investigative Skills Refresher," is a one-day refresher for individuals who have completed the first two courses within the past two years. It reviews the definitions and emphasizes the key points in conducting an investigation. During FY2011, OIG conducted 21 Investigative Skills Refresher classes with a total of 246 attendees.

Successful completion of one of the two investigative skills courses within two years of the start of the fiscal year is required for anyone who wishes to be designated as an investigator on the agency's annual protocol authorization application to OIG. Once approved, the investigator can handle investigative functions under OIG's direction for the entire fiscal year. However, OIG retains the right to take over an abuse/neglect investigation at any point.

D. Facility staffing ratios

By law, OIG's annual report must include facility census figures - that is, counts of the number of individuals receiving services in each facility - and the ratios of direct care staff to those individuals. OIG has always presented that ratio as of June 30, which is the last day of each fiscal year.

Tables 1a and 1b (below) show the census figures and ratios for each type of facility for FY2011. The tables present census figures three ways.

  • Counting every individual only once, regardless of the number of times he or she is admitted during the year give an "unduplicated count." This count is in the first column.
  • A more detailed way is to count every day that those individuals are in the facility or on temporary transfer to another location; this is the "person-days" or "on-books bed-days." This count is given in the second column.
  • The third column of counts is a simple census on June 30, 2011; that is, the number of individuals actually in the facility on that day.

That census figure on June 30, 2011, is the one used to calculate a direct care staff to patient ratio. The number of direct care staff is counted in Full-Time Equivalents, which counts part-time staff as only a fraction. That count, again as of June 30, 2011, is shown in the fourth column of the tables.

The June 30th census figures are then divided by the June 30th direct care staff figures to calculate a direct care staff to patient ratio, which is given in the fifth column.

Table 1a: Census and Staffing Ratios, DHS Psychiatric Hospitals, June 30, 2011

DHS Facility  Unduplic. count of people served Person-days (on-books totals) Inpatient census on June 30, 2011 Direct care staff in FTEs D.C. staff to patient ratio
Alton MHC 315 45,636 125 166.0 1.33
Chester MHC 464 88,069 237 328.2 1.38
Chicago-Read MHC 1,188 41,710 113 182.0 1.61
Choate MHC 288 21,336 144 258.1 1.79
Elgin MHC 1,444 139,135 369 461.7 1.25
Madden MHC 2,727 45,640 116 191.9 1.65
McFarland MHC 702 39,402 106 133.2 1.26
Singer MHC 758 25,059 61 94.1 1.54
Tinley Park MHC 1,660 22,874 61 110.2 1.81
MH facility totals 9,469 468,861 1,267 1,783.2 1.41

Table 1b:
Census and Staffing Ratios, DHS Developmental Centers, June 30, 2011

DHS Facility Unduplic. count of people served Person-days (on-books totals) Inpatient census on June 30, 2011 Direct care staff in FTEs D.C. staff to patient ratio
Choate DC 211 59,466 79 116.0 1.47
Fox DC 127 43,759 117 173.6 1.48
Jacksonville DC 219 74,463 196 316.5 1.61
Kiley DC 228 81,098 218 377.5 1.73
Ludeman DC 429 151,216 413 618.0 1.50
Mabley DC 95 33,339 90 143.3 1.59
Murray DC 302 105,138 276 465.6 1.69
Shapiro DC 591 209,517 562 1,010.0 1.80
DD facility totals 2,279 757,996 2,016 3,362.6 1.67

E. Investigative Protocols

Rule 50 mandates that facilities and community agencies take some initial steps in response to allegations that are made. Most importantly, they are to ensure the health and safety of involved individuals and staff, including ordering medical examinations when applicable. They are also to secure the scene and preserve evidence. If the allegation is of abuse, the facility or community agency must also remove the accused staff from having contact with any individuals pending the outcome of the investigation.

Beyond these initial steps, the facility or community agency may take no other investigative steps without the permission of OIG or a criminal investigating entity. The facility or community agency may take administrative actions it deems necessary, but it must request permission from OIG before conducting its own investigation.

OIG may assign the full investigation to a community agency only if the agency has been through the investigative authorization process. This process is an effective way to obtain commitments by the agency or facility to investigate objectively, to avoid any appearance of a conflict of interest, and to designate specific employees as investigators.

The facility or community agency must first adopt OIG's Investigative Protocol - there is one for facilities and one for community agencies - and then apply to OIG for authorization. The application must include the names and job functions of the persons designated to be OIG Liaison and investigators, including an assurance these persons have no conflict of interest conducting investigations.

To approve a designated person as an investigator, OIG reviews his or her position title and job functions for any possible conflict of interest. OIG also checks that the person has attended OIG-conducted investigative skills training within the past two years and has no substantiated cases against him/her.

Once OIG has reviewed and approved a facility or community agency application, the designated investigators have additional responsibilities in every allegation. Specifically, unless otherwise directed by OIG, a designated investigator must do the following: secure the scene and all possible evidence; identify and separate possible witnesses; conduct initial interviews of persons involved; and photograph the scene, evidence, and any injuries. Again, no further investigative steps may be done until allowed by OIG or the investigating agency.

OIG may then assign the full investigation to the community agency - but only in allegations of mental abuse, financial exploitation valued under $300, or neglect that is not alleged to be egregious. When an investigation is assigned to a community agency, however, OIG remains involved: an OIG investigator is assigned to monitor and assist the investigation. This monitoring investigator sends an investigative plan to follow, remains available to provide guidance, and is responsible for the first-level review of the final investigative report.

Renewal of an approved agency or facility investigative protocol is not automatic. An application must be submitted each year: Community agency authorizations are for a fiscal year; facility authorizations are for a calendar year. OIG considers the performance of the agency or facility when determining whether to renew the authorization.

FY2011 community agency investigative authorizations

In May 2010, just prior to FY2010, OIG had distributed an email to all 382 community agencies providing services within OIG's investigative jurisdiction. The email included a letter from the Inspector General providing an overview of the annual authorization process and links to three websites: the investigative protocol; the annual application form; and the OIG training calendar.

Ultimately, a total of 135 community agencies applied and were authorized by OIG for FY2011. A total of 389 agency employees were designated and approved as investigators.

CY2011 DHS-operated facility investigative authorizations

In November 2010, prior to calendar year 2011, OIG distributed an email to the seventeen State-operated mental health or developmental disability facilities. By January 1, 2011, OIG had authorized all seventeen facilities. Each facility had a designated liaison with OIG; as few as two and as many as 21 employees were designated and approved as facility investigators.

Chapter II: Reporting Abuse/Neglect

OIG maintains a 24-hour hotline, to receive reports of alleged abuse/neglect and to respond immediately if needed. The hotline also allows facilities and community agencies to meet the statutory four-hour time frame for reporting: willful failure by those employees to report an allegation is a Class A misdemeanor.

The hotline also receives reports of deaths within 24 hours, even when the death occurred up to fourteen days after discharge or transfer elsewhere. If abuse or neglect is suspected, the death must be reported to OIG within four hours and OIG will do a full investigation.

A. Reporting Policies

Rule 50.20(d) now mandates that all community agencies and facilities have a local policy detailing procedures for reporting abuse/neglect allegations and deaths. Thus, OIG has been reviewing all community agency and facility abuse/neglect reporting policies.

On April 9, 2010, the community agencies were asked to submit their revised policies; the facilities' policies were likewise reviewed during the FY2011 site visits. OIG's review of these updated policies is focusing on the following statutory requirements:

  • Current definitions of physical abuse, sexual abuse, mental abuse, financial exploitation, neglect and egregious neglect;
  • Requirement for initial training in Rule 50 upon hiring and biennially thereafter for all employees, including contractors and volunteers; and
  • The prohibition of retaliation against an employee for reporting an allegation, since retaliation is a violation of subsection k(3) the act.

As of April 30, 2011, OIG had reviewed and accepted all seventeen facility policies. During FY11, DHS also revised its program directives "Preventing and Identifying Abuse and Neglect" ( and "Reporting and Investigating Abuse and Neglect" (

As of June 30, 2011, OIG had received 317 community agencies' policies on reporting abuse and neglect. Of these policies, 295 had been deemed acceptable, and OIG was working with the other 22 to address issues identified.

B. Non-Reportable Complaints

The OIG Hotline receives some calls about incidents or complaints that do not meet the abuse or neglect definitions or other reporting requirements in Rule 50 or Rule 51. The Hotline investigator explains why it is not reportable to OIG and may directly transfer the caller to the correct entity. The Hotline investigator also completes a "Non-Reportable" entry into the main OIG database, so they are listed if reportable allegations are received on the same person.


Many of these "Non-Reportables" do not require any follow-up, such as a crime that has already been handled by the local police. Other examples are: a complaint of domestic abuse after the person has moved out of Illinois, a natural death more than 14 days after leaving a service provider, and a programmatic issue that has already been resolved.

Issues that need follow-up but are not within OIG jurisdiction need to be referred to the most appropriate entity. OIG may make the referral itself or instruct the caller on where and how to refer it. Infrequently, a caller may raise multiple issues that require OIG to make a second referral; this occurred in six of the 1,782 Non-Reportables that OIG received during FY2011. Table 3 below shows the referral locations for Non-Reportables received this fiscal year.

Table 3: Referrals of Non-Reportable Complaints Received in FY2011

Referral Location Non-reportable facility or agency complaint Non-reportable domestic complaint
Local community agency or facility 172 16
Illinois Dept. of Public Health 19 14
Dept. of Children and Family Services 24 4
Local law enforcement authority 12 9
Department on Aging 0 25
DHS Div. of Rehabilitation Services 1 21
DHS - BALC * 6 0
DHS Division of Developmental Disabilities 13 6
DHS Division of Mental Health 5 2
Illinois State Police 2 0
Other 15 29
None needed 979 405
Totals 1,248 534

*DHS Bureau of Accreditation, Licensure, and Certification

Most often, Non-Reportables are calls by a representative of the community agency or facility, self-reporting an issue or incident that is not reportable, in which case OIG just notifies the caller to handle it internally and to call OIG back if any indication of abuse or neglect is found. Individuals may also call in Non-Reportables that can be referred back to the facility or community agency. Between both of these types of Non-Reportables, 47% of referrals in FY2011 were referrals back to the facility or agency.

In domestic allegations as well, a community agency may already be providing services and would be in the best position to determine what additional services may be needed. During FY2011, OIG referred to a local community agency about 13.2% of Non-Reportables about domestic settings.

However, 1,384 calls - just over three-fourths of all received - needed no referral at all. For facility or community agency cases, the reason is most often a duplicate call or a complaint of an issue already resolved. Similarly, with domestic complaints, the most common were a resolution of the problem: that is, the alleged victim had already taken steps to seek help for the problem, such as changing caregivers; or the alleged victim's situation had already been resolved, such as moving to a different residence or getting a different guardian.

C. FY2011 reporting

During FY2011, OIG received a total of 3,010 allegations of abuse or neglect. The counts by type and location are shown in the table below; here, financial exploitation is included in abuse, as defined in Rule 50. Tables 5a through 5c on the following pages show a more detailed breakout by allegation type and location.

Table 4: Summary of Allegations Received by OIG in FY2011

Location Abuse allegations Neglect allegations Total allegations
DHS facilities 593 119 712
Community agencies 1,059 484 1,543
Domestic settings 372 383 755
Total 2,024 986 3,010

Overall, allegations reported to OIG continue to increase from year to year. During FY2009, OIG received 2,748 allegations, a seven percent increase over the 2,562 allegations received just two years prior. In the two years since, allegations received increased another 9.5% to this year's 3,010 allegations.

The increase has entirely been in the community. Allegations about community agencies increased 22.5% from FY2007 to FY2009 and then another 20.9% from FY2009 to FY2011. Allegations in domestic settings fell 5.8% from FY2007 to FY2009, but they then jumped 23% from FY2009 to FY2011.

On the other hand, the number of allegations about facilities continues to decrease. Further, as fewer individuals are served in facilities, allegations about facilities have constituted a progressively smaller portion of total allegations that OIG receives. Since FY2009, the facilities' on-books patient-days have dropped 7.9% and the proportion of total allegations that are about facilities has dropped 7.4 percentage points.

Allegations of abuse/neglect at the community agencies have been rising faster than in other settings over the past several years. In FY2005, allegations at community agencies accounted for one-third (33%) of all allegations OIG received. By FY2007, they accounted for two-fifths (41%), and in FY2011, they account for about one-half (51%). These changes underscore the growing number of individuals receiving services by community agencies.


During FY2011, OIG received 593 allegations of abuse at the DHS facilities, including eight allegations of financial exploitation. OIG also received 119 allegations of neglect at facilities.

The ratio of neglect to abuse has steadily risen over the past three years, as neglect allegations have increased faster than abuse allegations, driven partly by the FY10 changes in definitions. Compared to allegations received during FY2009, the ratio of neglect to abuse has risen from 16.6% to 20.1%.

Community agencies

During FY2011, OIG received 1,059 allegations of abuse, of which 59 were allegations of financial exploitation. OIG also received 484 allegations of neglect at the community agencies during the fiscal year.

At community agencies since FY2009, both allegations of abuse and allegations of neglect have increased substantially, due most significantly to the statutory change in definitions and a greater awareness of reporting. Since FY2009, at community agencies, allegations of abuse have risen 12% and allegations of neglect have risen 45%. Since FY2007, at community agencies allegations of abuse have risen 37% and allegations of neglect have risen 78%.


As noted earlier in this report, OIG's jurisdiction in domestic settings began in FY2001 and is limited to individuals between the ages of 18 and 59 who have a physical or mental disability that prevents them from seeking help on their own. Thus, OIG receives only a fraction of all complaints of abuse, neglect, or financial exploitation in domestic settings.

During FY2011, OIG received 755 allegations in domestic settings, which included 383 allegations of neglect, 317 allegations of abuse, and 55 allegations of financial exploitation. During FY2009, OIG received 614 allegations, which is an average of 11% more allegations each year.

Allegation Type

The tables below show the allegations and deaths that OIG received during FY2011 by type of allegation and program location. The tables list facilities individually and, at mental health facilities, separate "forensic" units (those for individuals who are committed by a criminal court order or who have aggressive behaviors) from "civil" units (all others). Please note that Chester MHC is an entirely forensic facility.

Allegations and deaths reported about community agencies are grouped into residential programs like community integrated living arrangements (CILAs) and non-residential programs like developmental training programs.

Table 5a: Allegations and Deaths Received in FY2011, Mental Health Services Only

Location Physical abuse allegs. Sexual abuse allegs. Mental abuse allegs. Financial exploit'n allegs. Neglect allegs. Total allegs. Death reports
DHS Facilities
Alton MHC (civil*) 8 1 8 0 4 21 0
Alton (forensic**) 31 9 29 1 32 102 0
Chester MHC 89 3 23 0 7 122 4
Chicago-Read MHC 4 2 5 0 5 16 4
Choate MHC 15 2 9 0 5 31 0
Elgin MHC (civil) 8 3 6 1 1 19 0
Elgin (forensic) 7 4 11 1 4 27 1
Madden MHC 17 3 13 1 6 40 0
McFarland MHC (civil) 13 3 3 0 3 22 1
McFarland (forensic) 4 1 3 0 2 10 0
Singer MHC 12 0 5 2 3 22 1
Tinley Park MHC 4 0 5 0 5 14 1
Facility subtotals 212 31 120 6 77 446 12
Community agencies
Residential sites 14  12 28  5  13  72 15
Non-residential sites 9 9 14 8 9 49 1
Agency subtotals 23 21 42 13 22 121 16
Rule 50 MH totals 235 52 162 19 99 567 28

*Civil units are for individuals who are not committed to the facility by the judicial system.

**Forensic units are for individuals who are court-committed or who have aggressive behaviors.  Chester MHC is entirely forensic.

Table 5b: Allegations and Deaths Received in FY2011, Developmental Services Only

Location Physical abuse allegs. Sexual abuse allegs. Mental abuse allegs. Financial exploit'n allegs. Neglect allegs. Total allegs. Death reports
DHS Facilities
Choate DC 23 3 14 0 5 45 1
Fox DC 2 0 1 1 3 7 2
Jacksonville DC 48 1 17 0 7 73 1
Kiley DC 21 0 2 0 5 28 2
Ludeman DC 31 0 2 0 12 45 6
Mabley DC 12 1 0 0 1 14 2
Murray DC 20 0 1 0 7 28 2
Shapiro DC 22 0 1 1 2 26 7
Facility subtotals 179 5 38 2 42 266 23
Community agencies
Residential sites 435 40 178 42 371 1066 92
Non-residential sites 154 19 88 4 91 356 4
Agency subtotals 589 59 266 46 462 1422 96
Rule 50 DD totals 768 64 304 48 504 1688 119

Table 5c: Allegations Received in FY2011, Domestic Settings Only

Disability type Physical abuse allegs. Sexual abuse allegs. Mental abuse allegs. Financial exploit'n allegs. Neglect allegs. Total allegs. received
Developmental disability 187 23 19 31 207 467
Mental health 26 3 2 9 49 89
Physical disability 42 0 15 15 127 199
Rule 51 totals 255 26 36 55 383 755

D. Initial reporting timeliness

Since the speed of getting allegations reported to OIG is sometimes critical to a successful investigation, Rule 50.20(a) retains the previous time requirements for reporting: four hours for any allegation of abuse or neglect; and 24 hours for deaths absent any allegation of abuse or neglect. In addition, the statute declares an employee's willful failure to report timely to be a Class A misdemeanor.

OIG monitors new intakes for timeliness in allegations reported to OIG by staff of the community agency or facility where the alleged abuse/neglect occurred; this is called a "self-report" (does not apply to domestic cases). If an allegation is reported late, the database will flag the intake as late reporting. Then, the field investigator will investigate as to why it was late. If it was late, the final investigative report will mention the late reporting, and the Written Response will list it as needing corrective action.

Each month, OIG sends the DHS program divisions two reports - one of reporting by community agencies, one of reporting by facilities. The reports show how many "self-reports" were reported to OIG late and the percentage late; for each late intake, the reports shows how many days it was late. The table below shows this information for the past seven fiscal years.

Table 2: Late Reporting by Program and Disability Type, FY2005-FY2011

Fiscal Year Total self-reports Number late by agency  Percent late by agency Number late by  facility  Percent late by facility Total number late Total percent  late
FY2005 1,419 18 14 24 31 257 18.1
FY2006 1,514 186 24 35 16 261 17.2
FY2007 1,603 174 27 24 29 254 15.8
FY2008 1,642 185 32 18 24 259 15.8
FY2009 1,909 172 17 16 20 225 11.8
FY2010 2,033 163 15 33 21 232 11.4
FY2011 1,923 185 19 24 14 242 12.6

*Reported to OIG by the facility or community agency itself.

The table shows that, until this year, OIG had been seeing a fairly steady decrease in the percentage of self-reports that were late. The recent rise in late reports has been largely due to community agency reporting, mostly by DD agencies. Interestingly, since self-reports dropped in FY2011 while the overall number of allegations increased, OIG appears to be getting more allegations reported directly by individuals, family members, advocates, and other agencies.

Chapter III: Investigating Abuse/Neglect

OIG's primary statutory mission is to investigate allegations of abuse or neglect of individuals receiving mental health or developmental disability services in a program operated, licensed, certified, or funded by DHS (20 ILCS 1305/1-17) or of adults with mental, developmental or physical disabilities in domestic settings (20 ILCS 2435/5). OIG is committed to conducting timely and thorough investigations.

A. Investigative timeliness

Rule 50 states that investigative case reports are to be submitted within 60 working days from assignment, unless extenuating circumstances prevent it. One such circumstance preventing completion within 60 days is the time required to get death certificates or medical records on deceased individuals.

A more common circumstance is an ongoing criminal investigation. When the Illinois State Police (ISP) accepts an allegation for criminal investigation, OIG is prohibited from beginning its administrative investigation. If the criminal investigation results in a referral for prosecution, OIG is often prohibited from beginning until the State's Attorney makes a prosecutorial decision.

Thus, OIG counts total time and OIG time separately (see Table 6). Although investigations took longer in FY2011 than in the past two years, OIG has still completed its Rule 50 and Rule 51 investigations within the regulatory standard of 60 working days.

Table 6: Average Time to Completion for All OIG Investigations, FY2006-2011

Investigations FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
Number completed 2,333 2,494 2,744 2,866 2,840 3,070
Average total days* 50.8 44.3 40.8 37.7 39.9 52.2
Average OIG days* 47.7 42.6 39.1 36.6 38.0 50.2

*Average total days includes all time from initial report until case closure; average OIG days omits time for delays necessitated by pending Illinois State Police investigations.

One part of the length of time required for investigation is the time needed for supervisory and management review of draft investigative case reports. OIG has recently focused on trying to reduce the time needed for these case reviews without sacrificing improved quality.

B. FY2010 closures

By law, OIG uses three findings for its case reports. "Substantiated" means a simple preponderance of the evidence supports the allegation - that it is more likely true than not. "Unsubstantiated" means some evidence supports the allegation but it was less than a preponderance. "Unfounded" cases have no evidence supporting the allegation.

The findings in abuse/neglect allegations and in death cases OIG closed during FY2011 are presented in the three tables that follow. The column entitled "Other issue(s) only" shows cases in which OIG did not substantiate abuse/neglect but identified an issue or issues and recommended that the facility or agency take administrative action to address it.

Table 7a: Cases Closed in FY2011, Mental Health Services Only

Location Abuse substan -tiated Neglect substan -tiated Other issue only Not substan -tiated Alleg. findings totals Death cases closed
DHS facilities
Alton MHC (civil*)  0 0 0 19 19 0
Alton (forensic**) 0 0 3 102 105 0
Chester MHC (forensic) 1 2 8 117 128 0
Chicago-Read MHC 1 1 3 21 26 2
Choate MHC 0 1 3 17 21 0
Elgin MHC (civil) 1 0 7 16 24 0
Elgin (forensic) 0 0 3 27 30 2
Madden MHC 0 0 3 46 49 0
McFarland MHC (civil) 0 0 1 22 23 1
McFarland (forensic) 0 0 0 11 11 0
Singer MHC 2 0 4 16 22 1
Tinley Park MHC 1 1 2 11 15 2
Facility subtotals 6 5 37 425 473 8
Community agencies
Residential sites 4 1 14 47 66 15
Non-residential sites 2 2 5 48 57 0
Agency subtotals 6 3 19 95 123 15
Rule 50 MH Totals 12 8 56 520 596 23

*Civil units are for individuals who are not committed to the facility by the judicial system.

**Forensic units are for individuals who are court-committed or who have aggressive behaviors.

Table 7b: Cases Closed in FY2011, Developmental Services Only

Location Abuse substan -tiated Neglect substan -tiated Other issue only Not substan -tiated Alleg. findings totals Closed death cases
DHS Facilities
Choate DC 1 2 2 34 39 2
Fox DC 0 1 3 3 7 4
Howe DC 0 3 3 6 12 2
Jacksonville DC 5 2 10 60 77 3
Kiley DC 0 1 10 14 25 2
Ludeman DC 1 0 9 21 31 6
Mabley DC 0 1 2 9 12 1
Murray DC 1 0 6 20 27 4
Shapiro DC 1 2 4 37 44 8
Facility totals 9 12 49 204 274 32
Community agencies
Residential sites*  86 92 257 607 1042 78
Non-residential sites 44 25 91 218 378 2
Agency totals 130 117 348 825 1420 80
Rule 50 DD Totals 139 129 397 1029 1694 112

*OIG also substantiated neglect in five deaths in agency residences.

Table 7c: Cases Closed in FY2011, Domestic Settings Only

Disability type Abuse substan -tiated Neglect substan -tiated Exploit'n substan -tiated Refused consent Not substan -tiated Findings totals
Developmental disability 67 34 2 102 271 476
Mental health 3 2 0 41 49 95
Physical disability 6 9 1 92 100 208
Rule 51 Totals 76 45 3 235 420 779

The statute governing OIG's investigations in domestic settings allows an alleged victim to refuse consent for the investigation. That is, in the 235 domestic cases above, the alleged victim did not consent to OIG conducting an investigation into the alleged abuse or neglect.

Trends in closures

OIG continues to keep up with the increase in allegations received. During FY2011, OIG closed 3,065 allegations compared to the 3,010 new allegations received. Counting the 135 closed death cases, OIG closed a total of 3,200 cases.

The continuing increase in allegations closed has been significant. During FY2011, OIG closed 6.0% more allegations than in FY2009 (2,896) and 21.9% more than in FY2007 (2,517). While investigative caseloads are increasing, OIG has sought out efficiencies and streamlined internal processes. With decreases in headcount, further improvement may become difficult.

Trends in investigative findings

The substantiation rates - the percentage of allegations that are substantiated - over the past seven years are shown in Table 8 below. The rate of substantiations has fluctuated over time but remained similar. Recently, it has been trending downward in domestic cases, but was higher this past year than the prior one.

Table 8: Substantiation Rates by Location and Fiscal Year, FY2005-FY2011

Location FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
DHS facilities 4.5% 6.3% 5.9% 5.9% 4.1% 5.0% 4.2%
Community agencies 18.4% 17.5% 16.2% 16.4% 16.0% 15.3% 15.5%
Domestic settings 21.9% 19.9% 19.3% 26.2% 19.7% 13.0% 15.9%
Overall total 13.5% 14.4% 14.0% 15.9% 13.1% 11.7% 12.8%

C. Reconsiderations

During FY2011, OIG received 135 requests to reconsider the findings of an OIG investigation under Rule 50, although these requests were of the findings of 130 investigations. As awareness of the reconsideration process has increased, so have requests for reconsiderations. OIG had received only 84 requests for reconsiderations in FY2007 and 107 in FY2009.

Of the 135 requests during FY2011, OIG granted 41 (covering 30 cases); the remaining 94 requests were denied because they provided no new information. Of the 30 cases with granted reconsiderations, OIG revised 20 case reports but changed the findings in only one case. The reconsideration process continues to show that OIG investigative findings are largely accurate and that OIG is responsive to new information that can change the finding.

Chapter IV: Stopping Abuse/Neglect

OIG's statutory mission goes beyond investigating. As noted at the outset of this report, OIG has been given responsibilities to act to prevent abuse and neglect from occurring. Further, the statutes require that OIG act to help stop abuse and neglect when it is happening. This role is evident: in emergency interventions in domestic abuse/neglect; in recommendations to eliminate problems that may lead to recurrent abuse/neglect, and in tracking and ensuring compliance with actions taken in response to those recommendations.

A. Domestic abuse intervention

OIG continues to have separate statutory authority to take immediate actions to intervene in domestic situations where abuse, neglect, or financial exploitation is being substantiated or will be substantiated (20 ILCS 2435/). The statute describes three primary interventions in domestic cases: emergency placement in a different residence; a formal order of protection, obtained through a local law enforcement agency; and a change of guardianship, either to a different family member or the Office of State Guardian.

Emergency placement

The most common type of emergency intervention is the removal of the individual from a situation where there is risk of injury or death. Upon investigating an allegation, OIG may find an individual in imminent risk - i.e., a serious, life-threatening medical condition, which requires emergency transport to a hospital or other medical facility.

When the individual's immediate medical condition is not life-threatening but OIG finds a risk of ongoing abuse or neglect, OIG may ask the individual if he/she would like to move. If the individual agrees, OIG may facilitate his/her move to a different residence on an emergency basis. This may be done after some initial investigation into the situation reveals significant risks not immediately known.

Order of protection

OIG may instead find that the problem is the alleged perpetrator, not the individual's home. If the alleged perpetrator does not live in the home but is a family member or other person with access to the home, OIG may help the individual pursue an Order of Protection against the alleged perpetrator. Since this intervention is time-limited, it is used infrequently.


If the alleged perpetrator is also the individual's guardian, OIG may help get the guardianship changed. OIG first tries to find a suitable family member to assume guardianship. If that fails, OIG uses its statutory authority to go to court and get the Illinois Guardianship and Advocacy Commission's Office of State Guardian to take guardianship of the individual. This intervention has long-term benefits for care and treatment decisions, so it is much more frequently used.

Table 9 below shows the break-out of emergency interventions during FY2011 and the prior five fiscal years. While variations from year to year can be significant, no long-term trends in these interventions are apparent.

Table 9: Emergency Interventions by Fiscal Year, FY2006-FY2011

Intervention FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
Emergency placement 33 29 25 32 24 29
Orders of protection 8 4 3 3 6 4
Guardianship pursued 16 18 14 18 17 11
-Guardianship by OIG* 3 6 6 10 7 4

*Guardianship pursued by OIG is a subset of all cases where guardianship is pursued.

FY2011 service plan referrals

When OIG substantiates a domestic case, the statute requires that OIG refer the individual to the appropriate DHS program division to develop a plan for providing needed services. Individuals referred may already be receiving services provided by DHS either directly or through a community agency. Table 10 shows the program divisions to which OIG referred individuals in substantiated cases during FY2011 and the five prior fiscal years.

Table 10: Service Plan Referrals by Fiscal Year, FY2006-FY2011

DHS Division FY2006 FY2007 FY2008 FY2009 FY2010 FY2011
Developmental Disabilities 61 76 107 96 68 92
Rehabilitation Services 42 35 74 23 22 29
Mental Health 7 8 12 5 7 0
Totals 110 119 193 124 97 121

Most service plan referrals continue to be to the Division of Developmental Disabilities. In addition to service plan referrals, OIG may make a secondary referral to another division or external entity. Counting the secondary referrals, OIG made 215 referrals in substantiated domestic cases.

B. Health Care Worker Registry

The Illinois Department of Public Health maintains Illinois' Health Care Worker Registry (formerly "Nurse Aide Registry"), which is a listing of health care workers in Illinois. The Registry is also used to show any adverse findings against these health care workers. Since January 1, 2002, OIG has been required to notify the Registry of the identity of any person substantiated to have committed physical abuse, sexual abuse or egregious neglect.

FY2011 Registry referrals

During FY2011, OIG made 45 referrals to the Registry: six facility employees and 39 community agency employees. While the total number of referrals has varied only slightly over time, DD agency employees have constituted an increasingly large majority of names referred. Table 11 below shows the breakout by disability type and location over the past four years.

Table 11: Registry Referrals by Disability and Location, FY2008-FY2011

Disab. Type FY2008 count FY2008 percent FY2009 count FY2009 percent FY2010 count FY2010 percent FY2011 count FY2011 percent
DD 9 12 8 13 3 4 4 9
MH 5 7 0 0 0 0 2 4
DD 56 77 50 78 61 90 39 87
MH 3 4 6 9 4 6 0 0
DD 65 89 58 91 64 94 43 96
MH 8 11 6 9 4 6 2 4

Most referred persons are direct care staff - that is, employees who are not clinically licensed and whose primary job is helping individuals directly. In FY2011, these staff accounted for 38 of 39 community agency employees referred and five of six facility employees referred.

Most referred persons are for substantiated physical abuse. Of the 45 referrals this fiscal year, 35 were for physical abuse, while three were for sexual abuse and seven for egregious neglect. Compared to prior years, the number for physical abuse was slightly lower and the number for egregious neglect was slightly higher.

Referral appeals

Fifty-five appeals were either filed in FY2011 or had been filed before and yet remained undecided. Of these 55 filings, 44 were finalized during the fiscal year. In fourteen instances, the employee was referred to the Registry: in ten appeals, the employee withdrew the appeal; and in four appeals, the decision was to refer the employee. In the remaining 34 instances, the employee was not referred to the Registry: eleven of these were stipulations agreed to prior to the hearing; in nineteen appeals, the decision was to not refer the employee to the Registry.

Removal appeals

After being referred to the Registry, a person may appeal to have the finding removed from the Registry - although the person may file only one such appeal each year. A total of seven such appeals were filed either in FY2011 or remained unresolved from prior years. Of these seven appeals, only one remained open at the end of FY2011. The six decided appeals resulted in three removed and three not removed.

C. Written Responses

When OIG substantiates abuse/neglect or makes a recommendation regarding other administrative issues during an investigation, the facility or agency is required to respond in writing. This "Written Response" must indicate the action(s) that have been taken or planned to protect the individual from future occurrences of abuse/neglect and eliminate the problem(s) identified during the investigation.

The facility or agency has 30 calendar days from the date the investigative report is received to submit a Written Response to the appropriate program division in DHS. The program division then reviews and approves the Written Response listing the proposed actions, sending the approved Written Response to OIG.

During FY2011, OIG sent to the facilities or community agencies an initial Written Response in 765 cases; that is, OIG made a finding and/or at least one recommendation in 765 cases during the fiscal year. This is 3.5% more than the 739 required during FY2010 and nine percent fewer than the 843 required during cases FY2009.

FY2011 issues

During FY2011, OIG received the approved Written Response in 714 of those 765 cases. OIG also received 97 that had been required during a prior fiscal year, totaling to 811 approved Written Responses received during FY2011. Those 811 Written Responses identified a combined total of 1,183 issues. Table 12 below compares the number of issues cited across the prior three fiscal years.

Table 12: Issues Cited in Approved Written Responses Received, FY2008-FY2011

Issues FY2008 count FY2008 percent FY2009 count FY2009 percent FY2010 count FY2010 percent FY2011 count FY2011 percent
Substantiations 244 24.7 329 21.7 282 24.0 287 24.2
Late reporting 175 17.7 305 20.0 190 16.0 181 15.3
Nursing practices 28 2.8 200 13.1 189 16.0 180 15.2
Investigative error 78 7.9 127 8.4 62 5.0 42 3.5
Service plan 47 4.8 115 7.6 74 6.0 81 6.8
Inappr. interaction 63 6.4 99 6.5 92 8.0 80 6.7
Failure to report 98 10.0 98 6.5 69 6.0 83 7.0
Monitoring/staffing 49 5.0 68 4.5 48 4.0 65 5.5
All other issues 204 20.7 177 11.7 174 15.0 187 15.8
Total issues 986 100 986 100 1180 100 1186 100

This table shows that the counts of total issues OIG cited and of total substantiations by OIG were slightly higher during FY2011 than in the approved Written Responses received the previous year. In FY2011, substantiations still accounted for 24% of the issues cited.

Late reporting has been identified and cited fewer times this year than the prior two years, but it was still cited 181 times. Failure to report rebounded from last year's low, but it is still identified and cited fewer times than in FY2008 and FY2009.

Issues with nursing practices, including failures in clinical documentation and unclear policies, were cited 180 times, habilitation or treatment plan concerns were cited 81 times, and monitoring or staffing problems were cited 65 times.

Investigative errors by facility or community agency staff after an allegation is made - such as in a failure to obtain an immediate medical examination or to take a photograph of an injury site - are decreasing. OIG attributes the decrease to its mandated biennial investigative training required of facility and agency investigators.

FY2011 timeliness

During FY2011, slightly more of the approved Written Responses that OIG received were late compared to last year. The statute expects the agencies and facilities to submit Written Responses to the program division within 30 days of the case completion date. OIG then gives the division another 30 days to review and approve the Written Response.

For several prior years, over half of all approved Written Responses had been later than those 60 days. During FY2009, however, 69% of approved Written Responses received were timely. During FY2010, the percent on time dropped to 66%, and during FY2011, it rose slightly to 67%. This delay in getting Written Responses approved was cited again by the Illinois Auditor General in its December 2010 program audit.

Compared to FY2010, Written Responses approved by the Division of Developmental Disabilities from agencies improved from 67% to 69% timely and from facilities improved from 38% to 45% timely. Comparing the two years for Written Responses approved by the Division of Mental Health, those from agencies fell from 89% to 59% timely but from facilities increased from 90% to 94% timely. OIG continues to send the divisions a monthly listing of Written Responses that have not been received as approved.

FY2011 actions taken

OIG may identify multiple issues in a single case, and each issue may require multiple actions. Any single action may involve many people (e.g., a re-training of ten employees) or many documents (e.g., a revision of three related forms). For consistency of reporting, OIG counts actions taken.

During FY2011, the facilities and agencies took 1,524 actions to address the 1,186 issues identified in the 811 cases with an approved Written Response. This is similar to FY2010, when facilities and agencies took 1,560 actions to address the 1,187 issues identified in 795 cases with an approved Written Response.

OIG categorizes the actions taken into 22 types. During FY 2011, the most common action taken continues to be retraining of the involved employee(s), which was done in 328 issues that were raised in approved Written Responses. Related to this is general retraining, which may involve a single unit, a job function, a range of job titles, or the entire staff of the facility or agency, which was done in a total of 176 issues.

After training, the most common action is disciplinary action against at least one employee: i.e., discharge (204); suspension (55), written reprimand (107); and oral reprimand (20). In addition, 32 times at least one employee had been fired for other reasons, 29 times at least one was reassigned, and 67 times at least one employee resigned in lieu of disciplinary action. Counseling (79), increased supervision (20), and performance evaluation objectives (3) were other actions taken against employees.

Policy or procedural revisions were made in 176 issues, modifications were made to habilitation or treatment plans in 67 issues, administrative changes were made in 36 issues, and some repairs/upgrades to buildings and other structures were done in 15 issues.

FY2011 implementation status reports

As noted, OIG investigations continue to cite administrative issues, resulting in significant actions by the facilities and community agencies to prevent recurrence and to eliminate problems. While the DHS program divisions are required to review and approve those actions, the statute gives OIG the responsibility to ensure that those actions are implemented. OIG does this two ways.

One way is that the facility or community agency must list on the Written Response the date that all actions were implemented. If all actions were not implemented by the time the Written Response was approved, the facility or community agency must send an implementation status report to OIG every 60 days until every listed action is implemented. On a monthly basis, OIG sends the facility or community agency a reminder letter about any implementation status reports that are overdue. The letter also indicates what is needed on the case(s).

FY2011 Compliance Reviews

The other way that OIG ensures that the actions are implemented is through getting actual documentation proving that implementation. These "Compliance Reviews" are discussed in Rule 50.80.

OIG conducts Compliance Reviews on two types of Written Responses. First, each month, OIG selects a random sample of all approved Written Responses received during the prior month - Rule 50 requires a minimum of 10%; OIG chooses 20%. Second, each month, OIG adds to that sample every approved Written Response that has been approved for longer than 120 days, but the actions listed on it have not yet been implemented.

For FY2011 Compliance Reviews, OIG randomly selected 162 (21%) of the 773 required Written Responses approved from May 1, 2010 through April 30, 2011, and then added the remaining 21 unselected Written Responses that were over 120 days. Table 13 below shows the break-out of all 183 Compliance Reviews by disability type and location.

Table 13: FY2011 Compliance Reviews on Approved Written Responses

Location DD Programs MH Programs Totals
DHS facilities 21 16 37
Community agencies 140 6 46
Totals 161 22 183

OIG's Compliance Reviews seek documentation that the actions listed in the approved Written Response were actually taken. For example, in the cases of retraining for late reporting, the Compliance Reviewers first obtain training sign-in sheets or some other document proving completion of the training and, then, interview the employee to ensure that he or she knows the definitions of abuse and neglect and knows the process and time frames for reporting allegations. The Compliance Reviewers may also review the curriculum for the training and recommend using the OIG Rule 50 training module that was distributed in April 2010.

During FY2011, OIG sent four "out of compliance" letters - that is, in four compliance reviews, the facility or community agency did not provide documentation that all actions listed on the approved Written Response had been implemented. Two were at DD community agencies, and two were at facilities (Elgin and Jacksonville).

OIG's randomly selected compliance reviews help ensure that problems and unsafe practices identified during an investigation have been corrected by the facility or agency. Ensuring that corrective action has been taken helps the facility and agency to effectively address the underlying issues and allows the individuals to avoid suffering a recurrence of the abuse/neglect. It also brings OIG full-circle in preventing abuse/neglect of people in Illinois with receiving mental health or developmental disability services.