DHS OIG FY 2014 Annual Report

November 2014

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

In accordance with Section 1-17 of the Illinois Department of Human Services Act (20 ILCS 1305), I am pleased to submit the Fiscal Year (FY) 2014 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 Office of the Inspector General has the statutory mission of investigating and reporting allegations of abuse and neglect of adults who have disabilities and who reside in DHS-operated MH and DD facilities, and in programs operated by local community agencies that are licensed, certified or funded by DHS to provide mental health or developmental disability services.

This annual report provides an overview of OIG's work during FY2014. It covers OIG's training, unannounced facility site visits, investigations, referrals for services, reviews to ensure implementation of corrective actions, and other aspects of OIG's statutory mission.

OIG is committed to preventing and addressing instances of abuse and neglect of Illinois' residents who are facing mental and physical challenges.


Michael J. McCotter

Inspector General

Executive Summary

During FY2014, the Office of the Inspector General (OIG) accomplished the following:

* Presented 90 training sessions on reporting or investigating abuse or neglect, with a total of 1,633 participants.

*  Conducted unannounced site visits to all fourteen DHS facilities providing mental health or developmental disability services, making 48 recommendations to prevent abuse or neglect.

*  Received 3,344 abuse or neglect allegations

 Compared to FY2013, OIG received:

  *  23.8% more allegations at facilities, and

  *  11% more allegations at community agencies.

*  Referred 1,047 complaints that were outside OIG's jurisdiction to the appropriate entity

*  Closed 2,933 investigations into abuse or neglect allegations. OIG substantiated abuse or neglect in 372 of those investigations. Community agency cases accounted for 333 of the 372 substantiated cases (90%) and facility cases for the remaining 39 cases (10%).

*  Received 175 reports of deaths of individuals who were or had been receiving services in facility or community agency programs. OIG closed 192 death cases during FY2014. Of the 192 closed death cases, neglect was substantiated in eight cases and issues were identified in 17 other cases.

*  Recommended administrative action in 994 cases at facilities or community agencies during FY2014. OIG received DHS-approved written responses in 836 of those cases, as well as another 150 completed from prior years, for a total of 986 written responses. A total of 1,218 issues were identified, the most common being substantiated abuse or neglect.

*  Referred to the IDPH Healthcare Worker Registry 57 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.

*  Pursuant to P.A. 98-0049 (HB 948), effective July 1, 2013, OIG's responsibility for investigating domestic cases under 20 ILCS 2435/, (Rule 51), involving adults with disabilities was transferred to the Department on Aging under a new Illinois statute, the Adult Protective Services Act . Under this new statute, the Department on Aging has jurisdiction to investigate allegations of abuse, neglect, and financial exploitation of adults living in their own homes and adults with disabilities aged 18-59 who live in domestic settings in the community.

Table of Contents

Chapter I: Preventing Abuse or Neglect

A. Quality Care Board Page 1

B. Unannounced Site VisitsPage 1

C. TrainingPage 3

D. Facility Staffing Ratios Page 4

E. Investigative Protocols Page 6

Chapter II: Reporting Abuse or Neglect

A. Non-reportable Complaints Page 7

B. FY2014 Reporting Page 8

C. Initial Reporting TimelinessPage13

Chapter III: Investigating Abuse or Neglect

A. Investigative Timeliness Page 14

B. FY2014 Closures Page 14

C. Reconsiderations Page 17

Chapter IV: Stopping Abuse or Neglect

A. Health Care Worker RegistryPage 18

B. Written Responses Page 21

Abuse and Neglect of Adults with Disabilities

Chapter I: Preventing Abuse or 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.

The Quality Care Board Members are:

Susan M. Keegan, Chair, Chicago, Illinois, Appointed 9/28/2012

G. Virginia Conlee, Springfield, Illinois, Appointed 09/28/2012

Thane A. Dykstra, Joliet, Illinois, Re-appointed 08/19/2010

Untress Lamont Quinn, Cahokia, Illinois, Appointed 09/28/2012

Ed Baker, Coal City, Illinois, Resigned 8/22/2013

Neil Posner, Chicago, Illinois, Appointed 11/8/2013

The Board's quarterly meetings in FY2014 were held on: September 11, 2013 (teleconference), November 15, 2013 (teleconference), January 9, 2014 (teleconference) and April 10, 2014 (face to face in Springfield).

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 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.

Site Visit Dates

In FY2014, each OIG site visit was conducted by a team of two OIG staff. The dates of the site visits were as follows:

Alton MHC November 13 and 14, 2013

Chester MHC January 22 and 23, 2014

Chicago-Read MHC February 26 and 27, 2014

Choate DC December 4, 2013 and March 7, 2014

Choate MHC December 4, 2013 and March 7, 2014

Elgin MHC February 27 and 28, 2014

Fox DC October 24, 2013

Kiley DC May 27 and 28, 2014

Ludeman DC May 5 and 6, 2014

Mabley DC April 9 and 10, 2014

Madden MHC July 23 and 24, 2013

McFarland MHC April 24, - May 9, 2014

Murray DC April 30 - May 1, 2014

Shapiro DC April 3 and 4, 2014

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 observe processes.

Each site visit 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 60 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 within 60 days of the site visit's closure. Receiving this written plan assists OIG in planning the following year's site visit, as OIG follows up on the facility's actions in response to the recommendations made the prior year. It also greatly reduces repeat recommendations for the upcoming year.

FY2014 Site Visit Topics:

  • Skin Assessments
  • Psychotropic Medication Administration
  • Dental Care
  • Contraband/Visitation
  • Client Observation/Monitoring
  • Drug Free Workplace Directive

In FY2014, OIG made 48 site visit recommendations. Three of the 48 were repeat recommendations from FY2013. Two systemic patterns or findings were identified. Facility Staff willingly participated in the site visits and worked efficiently and professionally with site visitors to address and correct issues that may lead to abuse or neglect. OIG recognizes the support of each division and facility administration as an integral part of this process.

C. Training

OIG is committed to training as a primary means to prevent abuse or neglect and to ensure reporting occurs when abuse or neglect is alleged. OIG continually strives to update its training presentations and to add additional training topics to its schedules to further accomplish this goal. The statute has long mandated basic training of all facility and community agency employees on identifying and reporting abuse and neglect. Rule 50 requires that facilities and community agencies provide basic training to all employees, which includes owners/operators, contractors, subcontractors, and volunteers at least biennially.

Rule 50 additionally requires agencies and facilities to have someone trained to perform the preliminary steps of the investigation that are outlined in Rule 50, Section 50.30(f).

FY2014 Training

According to statute, OIG offers and conducts three primary trainings for agency and facility staff. The first and most attended course is Rule 50 training. This training instructs attendees on the overall function of OIG with emphasis on the definitions and reporting requirements of all agency and facility employees (required reporters). Rule 50 mandates all employees be trained upon hire and at least biennially thereafter. In FY2014, OIG conducted 37 Rule 50 trainings throughout the state with a total attendance of 975.

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 approved to conduct investigations under the auspices of the Community Agency Investigative Protocol program. In FY2014, OIG modified this two day training into two distinct sections, simply identified as Day 1 and Day 2. BIS-Day 1 may be attended by any facility or agency staff and teaches attendees how to conduct the preliminary steps of an investigation, as required by Rule 50, Section 50.30(f). These steps include securing the scene, collecting and preserving evidence, taking appropriate photographs

and taking statements. BIS-Day 2 focuses on the investigative assignment procedures, how to conduct a professional investigative interview, document the investigatory interview, and write an investigative report. Each student learns the interviewing process by participating in multiple role playing exercises. During FY2014, OIG trained 212 staff in Day 1 Basic Investigative Skills and 164 staff in the complete two-day training for a total of 376 staff trained.

The third course, "Investigative Skills Refresher," is a one-day refresher class for staff members who have completed the OIG-conducted Rule 50 class and the two-day Basic Investigative Skills course within the past two years, and are Authorized Investigators in the Community Agency/Facility Investigative Protocol program. It reviews Rule 50 definitions and emphasizes the key points of conducting an investigation. During FY2014, OIG provided Investigative Skills Refresher training to 282 agency and facility staff at 25 training sessions.

The total number of training sessions conducted for the agencies and facilities in FY2014 was 90, with a grand total of 1,633 attendees.

In addition to the three primary trainings, the Training Department provides training to OIG staff in a wide range of topics to meet their required fiscal year goal of five continuing education training classes. OIG staff were able to attend a Statewide Conference in May 2014 and were 100% compliant in meeting their training requirements. Some of the training topics provided during the conference were: Testifying at Health Care Worker Registry hearings, Crisis Prevention Institute (CPI) training, Financial Exploitation investigative training, Rule 50, OIG Report Writing training, Windows 7/Outlook/Word training, Rule 115, Rule 116, and fraud investigation training.

D. Facility Staffing Ratios

By law, OIG's annual report must include facility census figures which includes 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 30th, 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 FY2014. 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 which gives an "unduplicated count." This count is in the first column.

* A more detailed method 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 is census taken on June 30, 2014; that is, the number of individuals actually in the facility on that day.

That census figure taken on June 30, 2014, 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, 2014, is shown in the fourth column of the tables.

The June 30th direct care staff figures are then divided by the June 30th census 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, 2014

DHS Facility


count of





annual totals)


census on

June 30

Direct care





care to



Alton MHC 253 42,476 117 152 1.30
Chester MHC 481 85,683 243 437.8 1.80
Chicago-Read MHC 833 36,298 109 206 1.89
Choate MHC 283 25,101 66 86 1.30
Elgin MHC 1,313 142,853 401 531 1.32
Madden MHC 2,991 48,695 125 116 0.93
McFarland MHC 608 46,293 126 153.65 1.22
Total 6,762 427,399 1,187 1,682.45 1.42

Table 1b: Census and Staffing Ratios, DHS Developmental Centers, June 30, 2014

DHS Facility


count of





 annual totals)


census on

June 30

Direct care





care to



Choate DC 203 61,583 170 245 1.44
Fox DC 117 40,834 112 155 1.38
Kiley DC 210 76,497 199 225 1.13
Ludeman DC 437 153,365 417 516 1.23
Mabley DC 105 36,831 101 137
Murray DC 219 74,909 232 394 1.8
Shapiro DC 563 196,702 531 828 1.55
DD facility totals 1,854 640,721 1,762 2,500 1.42

E. Investigative Protocols

Rule 50, Section 50.30(f), mandates that all facilities and all community agencies take some initial steps in response to allegations of abuse and neglect. 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 when there is credible evidence which supports the allegation.

Beyond these initial steps, the facility or community agency may take administrative actions it deems necessary, but it must request permission from OIG before conducting its own full investigation.

Per Section 50.40(c) of Rule 50, OIG may ask the agency to conduct a full investigation, but only if the agency has voluntarily applied for and adopted OIG's Investigative Protocol after being authorized by OIG. 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.

Prior to being approved as an agency investigator, OIG reviews the employee's position title and job function to rule out any potential or real conflict of interest. OIG verifies that the person has attended OIG-conducted Rule 50 and an investigative skills training course within the past two years and has no substantiated cases against him/her.

Renewal of an approved agency or facility investigative protocol is not automatic and OIG considers the performance of the agency or facility when determining whether to renew the authorization. OIG may rescind an agency's approved protocol if deemed appropriate.

During FY2014, 122 community agencies were authorized by OIG to conduct investigations. A total of 585 agency employees and 81 facility employees were trained, designated, and approved as investigators.

Chapter II: Reporting Abuse or Neglect

OIG maintains a 24-hour Hotline to receive reports of alleged abuse (which includes financial exploitation) and neglect and to respond immediately, if needed. The Hotline allows facilities and community agencies to meet the statutory four-hour time frame for reporting.

The Hotline receives reports of deaths if abuse or neglect is suspected but also in the following circumstances: Any death occurring within 14 days after discharge/transfer, any death occurring within 24 hours after deflection from a residential program or facility, or any death occurring within a residential program or facility or at any department-funded site.

A. Non-Reportable Complaints

The OIG Hotline receives frequent calls about incidents or complaints that do not meet the abuse or neglect definitions or other reporting requirements in Rule 50. The Hotline investigator explains why it is not reportable to OIG and, if applicable, may either refer or directly transfer the caller to the correct reporting entity.


Issues that need follow-up, but are not within OIG's 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 report the allegation.

Frequently, non-reportables are calls from a representative of the community agency or facility, self-reporting an issue or incident that is not reportable. OIG instructs the caller to handle it internally and to call OIG back if any indication of abuse or neglect is suspected. Individuals may also call in non-reportables that can be referred back to the facility or community agency to address. Together, these accounted for 88% of referrals in FY2014. Referrals were made in 1,002 of the 1,047 (96%) non-reportable complaints.

Table 2 below shows the referral locations for non-reportables received this fiscal year.

Table 2: Referrals of Non-Reportable Complaints Received in FY2014

Referral Location
Local community agency or facility 924
Illinois Department of Public Health 7
Department of Healthcare and Family Services 2
Department of Housing and Family Services 2
Local law enforcement authority 25
Department on Aging 1
DHS Division of Rehabilitation Services 1
DHS Division of Developmental Disabilities 14
DHS Division of Mental Health 6
Illinois State Police 0
Other 14
None needed 45
Totals 1,047

B. FY2014 Reporting

During FY2014, OIG received a total of 3,344 allegations of abuse or neglect. The counts by type and location are shown in Table 3 on the following page. Financial exploitation is included in abuse, as defined in Rule 50. Tables 4a and 4b, on the following pages, show a more detailed breakdown by allegation type and location.

Table 3: Summary of Allegations Received by OIG in FY2014

Location Abuse allegations Neglect allegations Total allegations
DHS-operated facilities 759 228 987
Community agencies 1,417 940 2,357
Total 2,176* 1,168 3,344

* Contains 24 financial exploitation allegations from DHS-operated facilities and 100

from community agencies.

Effective July 1, 2013, OIG's responsibility for investigating domestic cases under 20 ILCS 2435/, (Rule 51), involving adults with disabilities was transferred to the Department on Aging under a new Illinois Statute, the Adult Protective Services Act. This transfer of jurisdiction of Rule 51 cases caused the total number of allegations to decrease by 19.3%. However, the total number of abuse and neglect allegations in facilities and in community agencies continues to increase each year, increasing by 14.6% since FY2013 and 33% since FY2012.

Total abuse allegations in DHS-operated facilities and community agencies increased by 13% since FY2013 and 24% since FY2012. In these same settings, allegations of financial exploitation (a subset of abuse) increased in FY2014 by 28% from FY2013, and 77% since FY2012.

Total neglect allegations in DHS-operated facilities and community agencies reflected the largest increases, 19% since FY2013 and 57% since FY2012.


During FY2014, OIG received 987 total allegations of abuse and neglect at the DHS-operated facilities, a 23.8% increase in allegations from FY2013. Of the total allegations at facilities in FY2014, there were 759 allegations of abuse which includes 24 allegations of financial exploitation. Abuse allegations accounted for 77% of total allegations at facilities.

OIG also received 228 allegations of neglect at facilities. While the neglect allegations only account for 23% of the total allegations, the number of neglect allegations has been on a steady upward trend. The number of neglect allegations has increased by 30% since FY2013.

Community Agencies

Allegations of abuse or neglect at the community agencies comprise the largest percentage of total allegations of any setting over the past several years. In FY2014, allegations at community agencies accounted for 70% of all allegations OIG received. This high percentage of allegations is reflective of the number of individuals receiving services by community agencies. OIG expects this percentage to increase as rebalancing the provision of services toward community care and away from state-operated facilities remains a high priority.

During FY2014, OIG received 2,357 total allegations at community agencies. This is a 11% increase in allegations from FY2013. Of the total allegations, there were 1,417 allegations of abuse, which includes 100 allegations of financial exploitation. Similar to the facilities, the percentage of abuse allegations to total allegations has slowly declined over the past several years. In FY2014, abuse allegations accounted for 60% of total allegations, in FY2013 62%, and in FY2012 65%.

OIG also received 940 allegations of neglect at community agencies. While the neglect allegations only account for 40% of the total allegations, the number of neglect allegations has been on a steady upward trend. The number of neglect allegations increased by 16% since FY2013, and 55% since FY2012.

Allegation Type

Tables 4a and 4b show the allegations and death cases that OIG received during FY2014 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) from "civil" units (all others).

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


During FY2014, 175 deaths of individuals who were or had been receiving services in facility or community agency programs were reported to OIG. This is a 11% increase in deaths reported from FY2013. OIG closed 192 death cases during FY2014, a 49% increase from FY2013. Of the 192 closed death cases, neglect was substantiated in eight and 17 other cases were unsubstantiated or unfounded with issues identified.

Table 4a: Allegations and Deaths Received in FY2014, Mental Health Services Only










Neglect Total received Death reports
Alton MHC (civil) 1 27 9 17 0 20 73 0
Alton (forensic) 2 8 6 19 0 7 40 0
Chester MHC 77 10 47 3 30 167 0
Chicago-Read MHC 13 1 6 3 12 35 0
Choate MHC 42 4 11 5 19 81 0
Elgin MHC (civil) 18 7 15 1 13 54 0
Elgin (forensic) 16 15 22 8 35 96 1
Madden MHC 17 4 9 3 16 49 2
McFarland MHC (civil) 13 9 10 0 7 39 0
McFarland (forensic) 3 1 8 0 3 15 0
Facility subtotals 234 66 164 23 162 649 3
Community agencies:
Residential 8 9 18 9 22 66 26
Non-Residential 18 21 37 21 10 107 2
Agency subtotals 26 30 55 30 32 173 28
Rule 50 MH totals 260 96 219 53 194 822 31

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

2 Forensic units are for individuals who are criminally court-committed.

Table 4b: Allegations and Deaths Received in FY2014, Developmental Services Only















Choate DC 31 0 18 1 7 57 0
Fox DC 2 0 1 0 2 5 5
Kiley DC 48 7 15 0 17 87 2
Ludeman DC 58 0 2 0 14 74 5
Mabley DC 7 0 0 0 4 11 0
Murray DC 15 0 3 0 11 29 2
Shapiro DC 53 3 8 0 11 75 5
Facility subtotals 214 10 47 1 66 338 19
Community agencies: 542 30 305 64 741 1,682 122
Non-Residential 207 23 99 6 167 502 3
Agency subtotals 749 53 404 70 908 2,184 125
Rule 50 MH totals 963 63 451 71 974 2,522 144

C. Initial Reporting Timeliness

OIG monitors new intakes for timeliness in allegations reported to OIG by staff of the community agency or facility where the alleged abuse or neglect occurred; this is called a "self-report". 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. The final investigative report will cite the agency or facility for late reporting, and the written response will indicate that corrective action is required.

Each month, OIG sends the DHS program divisions a report of each "self-report" determined to be late. This report includes each late report, number of days late and the overall percentage late. The table below provides this information for the past three fiscal years.

Table 5: Late Reporting by Program and Disability Type, FY2012 through FY2014

Fiscal Year Total Self-Reports* DD Agencies MH Agencies DD facilities MH Facilities Total Late Percent late
FY2012 2,144 199 17 25 22 263 12.3
FY2013 2,584 250 24 18 32 324 12.5
FY2014 2,977 276 23 14 28 341 11.5

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

FY2014 showed the highest number of self-reports to date. The number of self-reports increased by 13% from the previous year and the percentage of late reporting decreased by one percent. The Divisions of MH and DD have been very responsive to this issue and it is reflected in the stable percentage of late reporting in spite of the upward trend of self- reports.

Chapter III: Investigating Abuse or Neglect

This OIG has the statutory mission of investigating allegations of abuse and neglect of adults who have disabilities and who reside in DHS-operated MH and DD facilities, and in programs operated by local community agencies that are licensed, certified, or funded by DHS to provide mental health or developmental disability services. 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 there are extenuating circumstances. One such circumstance preventing completion within 60 days is an ongoing criminal investigation. When the Illinois State Police (ISP) or local law enforcement (LLE) accept an allegation for criminal investigation, OIG is prohibited from beginning its administrative investigation until ISP/LLE has completed its criminal investigation. If a criminal investigation results in a referral for prosecution, OIG is often prohibited from beginning until the State's Attorney makes a prosecutorial decision.

For this reason, OIG counts total time and OIG time separately (see Table 6 below). For the first time, the average OIG days for Rule 50 investigations exceeded the regulatory standard of 60 working days.

Table 6: Average Time to Completion for All OIG Investigations, by Fiscal Year

Investigations FY2011 FY2012 FY2013 FY2014**
Number completed 3,070 3,420 3,472 3,037
Average total days* 52.2 48 56.1 79.4
Average OIG days* 50.2 45.9 54.8 78.6

*Average total days includes all time from initial report until case closure; while average OIG days

omits time for delays necessitated by pending Illinois State Police investigations.

**Includes data for Rule 50 cases only. All other years include data for Rule 51 cases.

B. FY2014 Closures

By law, OIG uses three findings for its case reports. For Rule 50 cases, "Substantiated" means there is a preponderance of evidence that supports that the allegation of abuse or neglect occurred is more likely true than not. "Unsubstantiated" means there is not a preponderance of evidence that supports the allegation. "Unfounded" cases have no credible evidence supporting the allegation.

The findings in abuse or neglect allegations and in death cases OIG closed during FY2014 are presented in the two tables that follow. The column entitled "Other issue(s) only" shows cases in which OIG did not substantiate abuse or neglect during an investigation, but identified an issue(s), and recommended that the facility or agency take administrative action to address each issue. These cases are unfounded or unsubstantiated with issues. The column entitled "Not substantiated" shows cases determined to be unfounded or unsubstantiated with no issues.

Table 7a: Cases Closed in FY2014, Mental Health Services Only






Other issue





findings totals


death cases

Alton MHC (civil) 1 1 2 6 60 69 0
Alton (forensic) 2 0 1 2 34 37 0
Chester MHC 6 2 20 127 155 2
Chicago-Read MHC 0 0 4 39 43 0
Choate MHC 0 0 2 64 66 1
Elgin MHC (civil) 1 0 6 62 69 1
Elgin (forensic) 1 0 7 82 90 1
Madden MHC 1 0 2 44 47 0
McFarland MHC (civil) 1 0 0 26 27 1
McFarland (forensic) 0 1 3 15 19 0
Tinley Park MHC 1 0 0 0 1 0
Facility subtotals 12 6 52 553 623 6
Community agencies: 3 1 11 55 70 33
Non-Residential 4 1 14 85 104 1
Agency subtotals 7 2 25 140 174 34
Rule 50 MH Totals 19 8 77 693 797 40
  1. Civil units are for individuals not committed by criminal court order.
  2. Forensic units are for individuals who are committed by criminal court order.

Table 7b: Cases Closed in FY2014, Developmental Services Only







issue only




findings totals


death cases

Choate DC 2 1 8 44 55 0
Fox DC 0 0 1 3 4 0
Kiley DC 3 5 6 67 81 0
Ludeman DC 0 2 17 37 56 1
Mabley DC 1 3 3 6 13 0
Murray DC 1 2 5 17 25 3
Shapiro DC 1 0 2 41 44 3
Facility totals 8 13 42 215 278 7
Community agencies: 86 150 308 857 1401 139
Non-Residential 39 49 108 261 457 6
Agency totals 125 199 416 1,118 1,858 145
Rule 50 DD Totals 133 212 458 1,333 2,136 152

Trends in Closures

During FY2014, OIG closed 2,933 investigative cases of abuse or neglect. Including 192 closed death cases, OIG closed a total of 3,125 cases. Total allegations and death reports received in FY2014 totaled 3,519 which is 13% more allegations received than cases completed.

While investigative caseloads are increasing, OIG has experienced a reduction in staffing over the past several years. Although the Auditor General in the last several audits has noted that OIG needs additional investigative staff to meet goals, several investigative bureaus have not been at full investigative contingent for past three years. Over past several years, the hiring process for filling vacant investigative positions has taken in excess of five months. OIG continues to improve efficiencies, streamline internal processes, redistrict bureau boundaries, and reposition staff into high volume areas to meet this challenge.

Trends in Investigative Findings

OIG substantiated abuse or neglect in 372 investigations. The substantiation rate or the percentage of allegations that are substantiated is shown in Table 8. The rates of substantiations at facilities and agencies have fluctuated slightly over time with no trends noted.

Table 8: Substantiation Rates by Location and Fiscal Year,

FY2011 through FY2014

Location FY11 FY12 FY13 FY14
DHS facilities 4.20% 6.70% 6.30% 4.30%
Community agencies 15.50% 16.10% 14.00% 16.40%
Overall total 11.60% 13.20% 11.70% 12.70%

C. Reconsiderations

During FY2014, OIG received 152 requests to reconsider the findings of 137 Rule 50 investigations, which is a reconsideration request on 37% of the substantiated cases. Of the 152 requests, OIG granted 20 (involving 19 cases); the remaining 132 requests were denied because no new information was provided, which is a requirement of Rule 50. Of the 19 cases with granted reconsiderations, OIG revised 13 (3.5%) case reports. Of the 13 revised case reports, eight (2.2%) had changes in findings or issues. The reconsideration process continues to show that OIG investigative findings are largely accurate and that OIG is responsive to new information.

Chapter IV: Stopping Abuse or Neglect

OIG's statutory mission reaches beyond investigating. As noted at the outset of this report, OIG has been given the responsibility of acting to prevent abuse and neglect from occurring. Further, OIG is required to stop abuse and neglect as it occurs. This role is evident in the identification of site visit issues each year; in recommendations to eliminate problems that may lead to recurrent abuse and/or neglect; and in tracking and ensuring compliance with actions taken in response to those recommendations.

A. Health Care Worker Registry

Since January 1, 2002, OIG has been required to notify the Illinois Department of Public Health's Health Care Worker Registry of the identity of any person with an OIG substantiated finding of physical abuse, sexual abuse, or egregious neglect in a Rule 50 setting. The statutory definition of employees has been expanded and now includes, but is not limited to: owners, operators, payroll personnel, contractors, subcontractors, and volunteers. It also includes someone who is no longer working for an agency or facility, but is the subject of an ongoing OIG investigation.

Data and Trends in Registry Referrals

During FY2014, 57 employees were referred to the Registry. Eleven referrals involved facility employees and 46 involved agency employees. Nine of the facility employees referred to the Registry were direct care staff. The other two were professional staff- a registered nurse and a clinical psychologist- both of whom were referred for sexual abuse. Five of the 46 agency staff referred were administrative (cashier, house manager, assistant manager, residential support supervisor, and agency employee support supervisor). The other 41 agency staff were direct care staff. One employee was referred for both physical and sexual abuse, which is counted in both categories.

Type of Referrals

Physical Abuse: Physical abuse is defined as staff's non-accidental and inappropriate contact with an individual that causes bodily harm. It also includes actions that cause bodily harm as a result of an employee directing an individual or person to physically abuse another individual.

Substantiated physical abuse accounted for 46 of the 57 referrals (81%) this fiscal year - eight facility staff (five MH and three DD) and 38 DD agency staff.

Among referrals for physical abuse in FY2014 were the following:

* An employee struck an individual several times in the face and kneed him in the back while attempting to adjust a restraint on his arm, after his other arm and both feet were already secured to the restraint bed. Injuries included prominent, deep purple bruising to the left jaw, behind the left ear to his neck and throat area, and left rib cage area.

* An individual with a history of refusing his medications would not comply and take his medication from an employee trainee. An employee came up, said "Here, this is the easiest way to get him to take his pills", pinched his nose closed, and forced applesauce and medicine into his throat. When asked by one of the other employees if this was how staff always gave him his medications, she said, "No, but sometimes he just doesn't want to open his mouth for pills." Later the same evening, the same employee placed her hand over the mouth of another individual to get her to stop screaming.

* An individual grabbed a donut off a table and ran from staff members. As staff were chasing him, one of the employees grabbed him from behind as he approached his bedroom door and purposely pushed him forward by the back of the head, making no attempt to slow down his pursuit. This caused the individual to stumble forward and strike his head against a steel door frame, causing a one inch laceration which required four sutures.

* An individual at a facility refused to get out of her bed after she was instructed to leave her bedroom during a security procedure. As an employee approached her, the individual waved at staff to leave her alone, at which time the employee struck her on the face multiple times. The individual sustained abrasions, swelling and bruising to her face, lips, right and left eyes, and scratches on her right temple and left upper forehead.

* After an individual engaged in maladaptive behaviors, an employee tied her left arm to a metal chair with a white, 11/4-inch elastic-type cloth, despite the fact that another employee in the same room told her not to do so. The individual remained there approximately ten minutes while the employee sat by her, until a third employee discovered the situation and reported it to a supervisor. The supervisor had to use both hands to remove it because it was so tight and it had been wrapped around her arm approximately three times.

* An employee woke up an individual during the early morning hours to take him to the restroom. After he refused to use the facilities, the employee began yelling at him, pushed his head back, and splashed water on his face to keep him awake so he would go. He told her, "Stop, I am getting all wet and I'm going to get sick." He was forced to sit on the toilet for an hour and staff threatened to keep him in the restroom indefinitely until he used the restroom.

* An employee dragged and lifted an individual by her arm and pants with enough force to cause her pants and adult undergarment to rise between her buttocks because she was not walking fast enough to the dinner table. He then forced her to sit in her own feces while she ate dinner, despite being told she had soiled herself. The employee refused to continue to feed her dinner. He then showered her using an incorrect shower chair, which allowed her to slide out, and left her on the floor to finish her shower on her own.

* After an individual had maladaptive behaviors in a classroom, an employee directed another individual to hit her in the head. While in the employee's presence, the male individual struck her on the head with an open hand with enough force to knock her glasses askew. The male individual who struck the female individual was on a strict maladaptive behavior reduction plan for physical aggression. He was to be rewarded with diet pop at specific times of the day for good behavior, and lose rewards for behavior including physical aggression. After the incident, he asked the employee, "Did I do good? Do I still get my pop?" The employee hugged him and replied, "Yes." The employee then attempted to obstruct the investigation by communicating via text message with another employee, asking that she "not tell them anything" about the incident.

Sexual Abuse: Sexual abuse is defined as any sexual behavior, sexual contact, or intimate physical contact between an employee and an individual, including an employee's coercion or encouragement of an individual to engage in sexual activity that results in sexual contact, intimate physical contact, sexual behavior, or intimate physical behavior.

In FY2014, ten employees (17%) were referred to the Registry for sexual abuse. Three were DD agency employees, four were MH agency employees, one was a DD facility employee, and two were MH facility employees.

Among this year's referrals for sexual abuse were the following:

* The supervisor of an individual took her to a local motel, where he forced her to have sexual relations with him. When she attempted to resist his assaults, he struck her in the face and threw her across the room into a dresser. When he allowed her to leave, he threatened her by telling her not to say anything to anyone.

* A facility employee unlocked a unit laundry room door to allow an individual, who was under the age of 18, to elope. The employee picked him up, took him to her home, and had sexual relations with him. When he refused to return to the facility, the employee put him in her trunk, drove him to a local store, and dropped him off. He stole a car and was apprehended by police. The employee was charged with Criminal Sexual Assault and pled guilty to a lesser charge of Assault. She received a $1,500.00 fine and 12 months court supervision.

* While receiving services at an agency, an individual and an employee entered into a sexual relationship. After the employee became concerned that the agency would find out, she convinced the individual to stop services because she could get fired. After the relationship soured, the individual suffered a serious deterioration of his mental condition and attempted suicide. He was hospitalized as a result, but ultimately refused any services from the agency because he did not trust the staff.

Egregious Neglect: Egregious neglect is a finding of neglect as determined by the Inspector General that represents a gross failure to adequately provide for, or a callous indifference to, the health, safety, or medical needs of an individual and results in an individual's death or other serious deterioration of an individual's physical condition or mental condition.

In FY2014, two names (3%) were referred to the Registry for egregious neglect. The cases were:

* An individual who was on 1:1 special observation kicked out the screen to his bedroom window and walked away from his CILA home while the staff assigned to him sat on the couch playing with her cell phone. She told him she was "giving him his space" so she was only checking on him every fifteen minutes. The employee had completed her 1:1 training only eleven days prior to the incident. The individual was found 1.78 miles from the home and had taken a bottle of Advil. He suffered a serious deterioration to his mental condition following the incident and required involuntary psychiatric hospitalization.

* An employee left an individual alone and unsupervised in the bathroom with the shower running, in direct violation of his program. The individual sustained second degree water burns to his thighs, scrotum, penis, ankle and foot. When she returned to the shower area, she took him out, dried him off, and placed him into bed. She failed to notify nursing staff and management of the full extent of his injuries, substantially delaying treatment for his injuries.

 B. Written Responses

 When OIG substantiates abuse or 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 are

 planned to protect the individual from future occurrences of abuse or 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.

 FY2014 Issues

In FY2014, OIG sent an initial written response to facilities or community agencies in 994 cases. OIG received the approved written responses in 836 of those 994 cases. OIG also received 150 written responses that had been required during a prior fiscal year, totaling 986 approved written responses received during FY2014. In the 986 written responses received, there was a combined total of 1,218 issues identified.

 Table 9: Issues Cited in Approved Written Responses Received, FY2012 through FY2014

FY2012 FY2013 FY14
Issues Count Percent Count Percent Count Percent
Substantiations 399 30.1 325 32.7 407 33.5
Late reporting 196 14.8 146 14.6 194 15.9
Nursing practices 103 7.8 92 9.2 45 3.7
Investigative error 22 1.7 28 2.8 32 2.6
Service plan 116 8.7 99 9.9 118 9.7
Inappr. interaction 89 6.7 70 7 80 6.6
Failure to report 177 13.3 47 4.7 66 5.4
Monitoring/staffing 96 7.2 36 3.6 37 3
All other issues 128 9.7 155 15.5 239 19.6
Total issues 1,326 100 998 100 1,218 100

   This table shows that the count of total issues OIG cited in FY2014 was 22% more than in FY2013. Substantiations by OIG remain the highest percentage of cited issues. Nursing practice issues continue on a steady downward trend, decreasing by 49% since FY2013.

 FY2014 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 group training of ten employees) or many documents (e.g., a revision of three related forms). For consistency of reporting, OIG counts actions taken.

 During FY2014, the facilities and agencies performed 1,857 actions (a 22% increase from FY2013) to address the 1,218 issues (a 22% increase from FY2013) identified in the 986 cases with an approved Written Response.

 OIG categorizes the actions taken into 22 types. During FY2014, the most common action taken continues to be retraining of the involved employee(s), which was completed in 345 issues involving approved Written Responses. Related to this is general group 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 completed in a total of 225 issues.

 After training, the most common action is disciplinary action involving at least one employee: Discharge (262); written reprimand (103); suspension (44); oral reprimand (32), and Fired other cause (19). In addition, in 32 instances at least one employee was reassigned; and in 68 instances an employee resigned in lieu of disciplinary action. Other action taken with

 employees were: Counseling (73); increased supervision (18); and performance evaluation objectives (one).

 Policy or procedural revisions were made in 135 issues; modifications were made to habilitation or treatment plans in 99 issues; administrative changes were made in 36 issues; and some repairs/upgrades to buildings and other structures were completed in ten issues.

 FY2014 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 in two ways.

 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 to complete the actions on the case(s).

 FY2014 Compliance Reviews

 The other way that OIG ensures that the actions are implemented is through obtaining actual documentation proving that implementation occurred. These compliance reviews are outlined in Section 50.80(d) of Rule 50.

 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 sample of 10%. OIG chooses 15%. Second, each month OIG adds to that sample every approved written response that has been approved for longer than 120 days, but for which the actions listed on it have not yet been implemented.

 For FY2014 compliance reviews, OIG randomly selected 157 of the written responses approved, and then added the 23 written responses that were pending over 120 days for a total of 180 compliance reviews. Table 10 below shows the breakdown of all 180 compliance reviews by disability type and location.

 Table 10: FY2014 Compliance Reviews on Approved Written Responses 

Location DD Programs MH Programs Totals
DHS facilities 16 27 43
Community agencies 130 7 137
Totals 146 34 180

 OIG's compliance reviews seek documentation that the actions listed in the approved written response were actually completed. 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. The reviewers must also obtain a signed acknowledgment of understanding from the employee, a successfully completed test, or interview the employee to ensure that he/she understands the definitions and timely reporting of abuse and neglect.

 During FY2014, OIG issued two "out of compliance" letters to two DD community agencies which did not provide documentation that all actions listed on the approved Written Response had been implemented. OIG worked with both of these agencies and outstanding actions were later completed. The status of both compliance reviews was changed to compliant.

 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 or neglect. It also brings OIG full-circle in preventing abuse or neglect of individuals in Illinois who are receiving mental health or developmental disability services.