December 8, 2016 - Quality Care Board Meeting - Rescheduled to December 19, 2016


December 19, 2016

2 P.M.




Michael McCotter, Inspector General; William Diggins, Deputy Inspector General; Susan Keegan, Chairperson; Neil Posner; Thane Dykstra; Untress Quinn; Pamela Oller; James Dimas, DHS Secretary


* Quality Care Board Meeting was called to order at 2:02 p.m. with a quorum.

DHS Secretary Dimas Report

Secretary James Dimas expressed his gratitude to members for their service and the invitation to attend the meeting; can only attend briefly due to another commitment. He reiterated the important role of the Quality Care Board members and how members are not held accountable for investigations and the quality of investigations. He is currently working with the Governor's office on filling of board vacancies. He stated the process to fill vacancies on boards is lengthy and takes due diligence.

He reported on the issues that have been brought publicly most recent regarding OIG investigations. He and Inspector General McCotter attended the joint legislative hearing in regards to the issues that were published in the Chicago Tribune. This gave an opportunity to address our work in the past year in response of the article published. The hearing was recorded and able to be viewed on the legislative website. (Inspector General McCotter sent the link of recorded hearing to the board.)

Work In Progress Reforms for DHS/OIG:

  • Agency to become more transparent - which necessitates constructive response from DHS/OIG.
  • A concept of developing transparencies for parents/families that will assist them in making an informed choice of their available options for placement of their family member.
  • Develop an institutional analysis for public availability.
  • Develop a planning model for DSI's.
  • Reviewing the law and may need to possibly amend self-guardianship to allow the OIG temporary guardianship for self-guardians if need be. This would give OIG the authority to self-guard without restricting individuals of their rights as a self-guardian to an extent.

Thane Dykstra stated he thought Secretary Dimas and Inspector General McCotter represented DHS/OIG very well at the hearing. Mentioned to Secretary Dimas' the question that arose regarding his appointment to the board and it being a conflict of interest. Chairperson Keegan stated Thane Dykstra's role is according to statute and believes the conflict of interest question is an optics issue. She suggested possibly amending the statute that governs the board. Secretary Dimas - has reviewed the

Statute and questioned if the board feels this is a conflict. Chairperson Keegan stated Thane Dykstra always removes himself from any discussion that would cause a conflict of interest. He has good insight, diligent in participating in all board activities, and makes a contribution to the board. Secretary Dimas is very aware of this issue and stated he has only heard positive assessments of Thane Dykstra's performance on the board. He stated may need to acknowledge the optics issue but is not sure it is sufficient to make a change. He will revisit the Statute. If there is a change in his view, it will be brought back to the board for discussion.

Chairperson Keegan asked if Mike Berens was in attendance of this teleconference and there was not a response. She had invited him and sent him an agenda for the meeting.


  • Chairperson Keegan asked for a motion to approve the minutes of September 29, 2016.
  • Thane Dykstra had a change to his drafted comments on the last page. Correction made per Thane's recommendation.
  • Chairperson Keegan moved to correct the minutes per Thane Dykstra's recommendation. No further corrections to the minutes.
  • Minutes of September 29, 2016, approved as corrected.


  • Inspector General McCotter reported on 2016 case statistics:
  • More cases were completed than opened, has not seen this in roughly 4-5 years.
  • Total open new investigations - 3,523
  • Total completed cases - 3,017 (increase of 194)
  • Reduction of cases > 60 days old (with attention to Deputy Inspector General Diggins). From January 1, 2016 (996 cases), to current date (412 cases); 58.63% reduction.
  • Active open cases as of 1/1/16 (1,684 cases) and to current date (1,256 cases). Reduction of 428 cases, due to the increase of personnel.
  • The total investigative staff statewide 4 years ago consisted of 15 and today the total investigative staff consists of 32. Goal is to hire more investigative staff and redesign the staff organization to allow a more "hands on" approach. Goal to increase the ITL staff statewide. It would give the senior staff the opportunity to work in the field and/or train the new investigators.
  • Due to retirement staff will be reduced as of December 31, 2016: 3 Bureau Chief's and 1 Policy/Legislative Liaison. Will have staff temporarily assigned into the positions until they are filled permanently. While temporarily assigning current investigators into these vacant positions, it decreases the number of investigators actively working cases. Process has been started to fill the vacancies. Two of the retirees will return on contract with hopes to keep the work flowing smoothly and with the plan of training their replacement.
  • Chairperson Keegan stated it appears OIG is on a successful track with hiring of additional staff and efficient work.


Chairperson Keegan - discussion of the questions composed by Thane Dykstra and brainstorm ideas that will improve the board and its oversite function.

  1. Do procedures need to be implemented to ensure that investigations are thorough such that it is not necessary to re-open cases?
    • Chairperson Keegan believes this question came about due to the fact of reopening cases.
  2. Does there need to be a change to minimize such activity? (Chairperson Keegan)
    • Inspector General McCotter- The few cases that were brought up in the Chicago Tribune article were found to be unsubstantiated which are completed at the Bureau Chief level. However, with the FOIA and article of the Tribune, the cases were reviewed at the administrative level and reopened. One case involved lack of notifying the family of the investigation outcome (this was a clerical error). An apology letter has since been sent to the family. The office is working to revise the review procedure; which included reestablishing an internal audit team. If the internal audit team suggests reopening a case, it will be brought to the attention of Inspector General McCotter and Deputy Inspector General Diggins. Cases are reopened cases due to the fact of further investigation is needed.
  1. What is an example of why a case would be reopened? (Neil Posner)
    • Inspector General McCotter - If an investigation was not thorough due to the need of further interviews, additional documentation, or additional evidence; among other aspects.
  1. If the finding of a case is substantiated but not egregious, does this raise the issue to possibly re-open the case? (Neil Posner)
    • Deputy Inspector General Diggins -Rule 50 outlines protocol of investigation criteria and definitions. When a finding is substantiated, it is sent for a review to Inspector General/Deputy Inspector General to determine the final decision.
    • Neil Posner - In reviewing the recent reports received, agreed with findings of being substantiated but didn't necessarily agree with conclusion of neglect not being egregious. Inquired if such findings were cause for a review. Noticed that some reports discussed such findings and some reports did not.
    • Deputy Inspector General Diggins - Egregious is specifically tied to neglect. Rule 50 has a definition of and criteria for egregious neglect. Egregious neglect cases are received as an allegation of neglect, investigated, and when substantiated is sent for review. Usually the determination of egregiousness is made at the administrative level. The decision is based on how evidence applies to the definition. Egregiousness' does not apply to any other type of allegation. If something is seen in other types of cases that increase the culpability of the individual accused, there would be aggravated factors.
    • Neil Posner - questioned how objective the aggravating factors. Would like understanding of the distinction made whether or not a case is aggravating or not. Had a lot of questions regarding the determination process when reviewing the cases. Feels the recommendations he reviewed were benign relative to the incident being reported.
    • Deputy Inspector General Diggins - Will forward egregious and aggravating definitions from Rule 50 to members clarifying the process of deciding a finding. Aggravating has to be something that takes it above and beyond the of physical abuse definition (i.e. use of a weapon, striking to the head, something that makes it worse). The definitions are followed diligently. The recommendations are not necessarily directly related to the incident itself. They are seen as a problem and require correction in order to prevent further abuse. There is a difference of recommendations in relation to the finding.
    • Neil Posner - Agrees with the encouraging of better care and training for employees that work with the residents. However, when reading through the individual cases with specific incidents he would consider to be significant danger, the finding was not considered egregious.
    • Deputy Inspector General Diggins - Need to look at the definition of egregious neglect and we have to determine that it is 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 serious deterioration of an individual's physical condition. or mental condition. As in the scenario presented by Neil Posner of the unsupervised individuals who walked to a park and according to their profile was not capable to do this alone; the individuals were not harmed. Therefore, the definition of egregious neglect did not apply due to the fact of nothing very serious happened to the individuals.
    • Neil Posner - In an attorney's perspective doesn't necessarily agree. There may be a standard in the Administrative Code, but there is the standard of care. Inquired if a statement addressing the below levels of standard care in such situations should be added to the reports. If the report does not have such a statement, the general interpretation could be perceived the behavior did not have consequences.
    • Deputy Inspector General Diggins - The OIG's responsibility is to complete an investigation and conclude a finding. It is up to the Agency and Department of Human Services to determine what happens to the staff in such scenarios.
    • Neil Posner - questioned consequences of staff in such situations.
    • Deputy Inspector General Diggins - Yes, the outcome could lead to the employee being fired, suspended, and re-trained. The Department requires a written response from the agency to ensure they corrected all policies and procedures that lead to such an allegation and make changes. After OIG completes their investigation it proceeds through the proper protocol to ensure oversight that the OIG recommendations were complete. The OIG begins the process and is the fact finding entity, and the division follows up and ensures that appropriate action is taken to prevent future occurrences.
    • Neil Posner - Does OIG receive the decision made by the Division?
    • Deputy Inspector General Diggins - OIG receives a copy of every written response sent to the Division. OIG completes an audit (approximately 10%) quarterly, to ensure the agencies are completing the follow-up they indicated they would perform.
    • Inspector General McCotter reported the percentage of audits has been increased to 15% quarterly.
    • Neil Posner - When the audits are performed, where is it found?
    • Deputy Inspector General Diggins - The purpose of the audit is to follow-up to ensure the entities actually did what they stated would be done. If OIG does not agree with the written response, it will be directed back to the Division with recommendations of further follow-up and requirements to be completed by the entity in order to meet the OIG's request. The OIG is the investigative arm and the Division follows up on the allegations. OIG and the Division communicate regularly regarding cases. If a finding is registry reportable and placed on the registry, they are banned from obtaining employment in the field while they are listed.
    • Thane Dykstra - Believes the Bureau of Quality Management at one point followed up on every substantiated case in terms of following up on the recommendations.
    • Neil Posner -Inquired if Bureau of Quality Management continues to follow-up on substantiated cases.
    • Deputy Inspector General Diggins and Thane Dykstra - answered yes, BQM is continuing to follow-up on cases.
    • Thane Dykstra - When Bureau of Quality Management was performing surveys on providers, it seemed they were following up on every one of the substantiated cases.

Deputy Inspector General Diggins - The Rule 50 definitions are imperative. The power point will be sent to the board for reference. In reviewing the Rule 50 power point presentation, it should answer some of the questions regarding definitions of standards in terms of how a case is considered to be substantiated.

Chairperson Keegan - in reviewing the power point will inform OIG if the board feels something may need to be revised in the presentation.

  1. Does the use of contract employees result in inferior investigations?
    • Thane Dykstra - Mike Berens (Chicago Tribune Reporter) asked him specifically about this and his response was he only knew of nurses being hired on contract.
    • Inspector General McCotter - This is correct and OIG also brings retirees back on contract in order to complete duties of their previous position. This is done on an interim basis until the position is filled and/or to provide training to their replacement.
    • Chairperson Keegan - inquired if OIG experiences any issues with employees coming back on contract; are the returning employees in the same capacity before retirement.
    • Inspector General McCotter - The process works well and retirees return on contract in their former capacity, until the position can be permanently filled.
  1. On what basis is under-performing agencies and institutions identified; is there or should there be a "watch list"; is there a list of agencies that seem suspicious due to their lack of activity?
    • Secretary Dimas - reported at the beginning of the meeting: a list is maintained. It is being reviewed for possible revisions to ensure it is useful toward specific concerns.
    • Thane Dykstra - stated with his experiences in reviewing cases, he believes interviews are being completed.
    • Deputy Inspector General Diggins - Stated Mike Berens was referring to death reviews. The nurses review every death that occurs. The initial review is done with paper reviews; which are not an investigation. If they are open for a full investigation, in depth interviews are performed.
    • Chairperson Keegan inquired if the review included medical records, etc. Deputy Inspector General Diggins confirmed all medical records, fire department records, and information needed to conclude if there was abuse and/or neglect. If abuse and/or neglect are found, it is opened for a full investigation.
    • Chairperson Keegan inquired whether all death cases are reviewed by the panel. Deputy Inspector General Diggins reported DHS has a committee that reviews all death related cases.
    • Thane Dykstra- stated in the time he has served on the committee he does not recall a lot of discussion about agencies. There was an agency 6 or 7 years ago, seems that OIG alerted the DD Division of the problems and ultimately that agency was closed. This was one of the agencies mentioned in the Chicago Tribune article.
  1. How are patterns and trends of substantiated findings reported to the Developmental Disability & Mental Health Divisions? Does the follow-up seem appropriate?
    • Secretary Dimas - reported at beginning of the meeting on this issue: stating the information is "silo" within DHS and not contrary to the article of the Chicago Tribune. It is not meant to conceal information from other entities. Each agency has its own business functions; each organization has worked independently to this point, and currently working on changing such practice. Data is now shared amongst the agencies/organizations which will create a full view of providers and challenges. By meeting and sharing data this will ensure everyone is informed and will result in a better system.
    • Inspector General McCotter - Mike Berens was provided with the data from OIG and DD. The difference in the data received from both entities was OIG reported a full year and DD reported a quarter of the year. The Tribune was contacted and informed of the correct data. The data that was provided to the Tribune per their FOIA request was pursuant to the Illinois HIPPA laws.
    • Thane Dykstra - Inquired if the DD Division will now report the same way OIG reports data. Deputy Inspector General Diggins - OIG and DD have been working with the Secretary's innovation office and there is a monthly reconciliation of data and DD has the correct data when they are posted.
    • Chairperson Keegan - inquired about a FOIA from Mike Berens regarding a specific death allegation and why the members don't have this information. Deputy Inspector General Diggins stated it is due to the fact the cases are not complete and only substantiated case information can be released. One of the cases in question will be going to trial next month. The other case will be completed as unsubstantiated because the death was found to be of natural causes and does not constitute abuse and/or neglect.
    • Chairperson Keegan - questioned the statements from the OIG that were reported in the Tribune in regards to not having a finding on death cases. Understanding there is a current case going to trial for prosecution. Deputy Inspector General Diggins - clarified OIG did not make such a statement. This inquiry was responded to by DHS General Counsel stating there was no death that met the criteria of his request which was of substantiated for the last 5 years. Chairperson Keegan thought possibly further information should have been produced. Inspector General McCotter - stated FOIA requests are handled through the agency FOIA officer and pursuant to the Freedom of Information Act. Untress Quinn - agrees fully the agency can only provide information that is allowed legally. Chairperson Keegan - is concerned about the death being recorded publicly with individual names etc., and recommends it be released. She offered to express her opinion with the FOIA officer. Untress Quinn - stated in the perspective of an attorney he believes the response should simply reiterate the law and the information they are receiving is pursuant to such laws. Neil Posner - reiterated they are attorneys in their personal life, but not the attorney for DHS/OIG. Untress Quinn - stated his understanding and agreement with the stance of DHS legal counsel in this instance.
    • Chairperson Keegan inquired if the follow-up seem appropriate. Deputy Inspector General Diggins - stated it does and if an issue is found with their follow-up a response is sent requesting more to be done. In the last few years the follow-up has been more robust. If they find issues during the OIG investigation, they have been reporting them to the OIG. The reforms that were put in place by Inspector General McCotter and DHS Secretary Dimas, there is a closer collaboration between OIG, Bureau of Quality Management, Licensure and the Division to ensure the follow-up is timely, stringent, and adequate.
    • Thane Dykstra - in reviewing the recent cases received he noticed a good protocol from the DD Division: One of their staff went out to check on an individual and they had their own recommendations.
  1. Do investigations rely too much on paper audits vs. personal interviews?
    • Inspector General McCotter - the investigations are handled in an appropriate manner, whether done via paper or personal interviews.
  1. Statistics are available related to incidence of substantiated findings per agency. Does this tracking/ reporting need to be refined to specific sites (i.e. CILA location within an agency)?
    • Inspector General McCotter - stated this was covered by Secretary Dimas at the beginning of the meeting. This is not something that is under the OIG's jurisdiction. The OIG keeps track of only their findings, not specific CILA sites. DD Division tracks the CILA findings.
    • Secretary Dimas - reported this is currently being constructed (report card - using this phrase "report card" until an official name of scoring system is agreed upon) and is not only complex but also, multi-statutory. There will be a scoring system in place that will compare entities within their pair group which will be available to family members etc., in order to make an informed decision of placement.
    • Thane Dykstra - in regards to the web based reporting where an agency could be researched - there should be some "good" discussion regarding whether or not unsubstantiated cases data be used in the "report card" scoring. Not stating they should not be tracked, only concerned it will create a climate where agencies are not reporting. This was discussed when the topic of making information public by agency. Inspector General McCotter - feels it would be an unfair rating to the agency if unsubstantiated cases were not included in the "report card".
    • Chairperson Keegan inquired of the direction of current reporting. Thane Dykstra - Currently there is not a "report card" per say, but information can be found on the web regarding substantiated cases. This actually takes into account the number of people served by an agency. It is based on the number of beds the agency has and is more a less an "equalizer". Otherwise, other agencies would be punished for being large and seems to work well.
  1. What has been done to ensure that there are not discrepancies between OIG's statistics and those reported by the DD division?
    • Inspector General McCotter - the OIG and DD Division are meeting regularly and sharing information to ensure the correct numbers are being reported. (This was thoroughly discussed previously in meeting)
  1. Does the criteria for Quality Care Board membership need to be revisited?
    • Chairperson Keegan - Stated the statute and criteria for the board members should be reviewed and possibly revised. Currently the board is in violation due to not meeting the criteria of board membership. Feels very strong about having the specific members on the board, per the criteria.
    • Neil Posner - there are candidates listed that meet the criteria to serve on the board. Will need to reach out to them again to confirm their interest of becoming a board member.
    • Thane Dykstra - suggested a few organizations to reach out to for possible board members that meet the criteria. (ARC of Illinois which would represent a parent of people with intellectual disabilities; NAMI would represent the mental health criteria).
    • Neil Posner - possibly the board should be proactive with the appointments until the current Tribune propaganda settles.
    • Chairperson Keegan - suggested forming a committee to compile a list of possible board candidates with Neil Posner chairing such committee. A compiled list will be reviewed by OIG and then forwarded to Secretary Dimas. Neil Posner accepted the position of chairing committee. Inspector General McCotter in agreement with this idea.

* Chairperson Keegan asked for a motion to form a committee that will compile the list of board candidates for submission to the Governor's office and will be chaired by Neil Posner.

Motion to create a committee to compile a list of potential board members with Neil Posner being the chairperson of the committee - Untress Quinn

Motion Seconded - Susan Keegan

All in Favor

Motion Carried to form the committee

* Discussion of current member status and the position of continuing to serve after said term have expired. The wish list is to have a total of 7 quality care board members.

  1. In the legislative hearing yesterday, Secretary Dimas suggested a report card for community providers. I presume a component would be rate of substantiated findings. What other information might we include from an OIG perspective?
    • Chairperson Keegan - This issue was discussed in length at beginning of the meeting by Secretary Dimas. Agrees with the idea of having the capability to research data on agencies/facilities.
  1. Do we now have a contact in the Governor's office that will assist in confirming unfilled QC Board positions?
    • Chairperson Keegan - at this time, we do not have a contact person. Feels confident with Secretary Dimas' effort to move forward with the appointments.


  • Chairperson Keegan - would like for the board to receive a training video utilized for investigators.
  • Deputy Inspector General Diggins - currently creating a web-based video for facility staff purposes. The video is not as in depth as the actual training provided to new investigators. The board will be informed as soon as the video is ready for distribution. Rule 50 PowerPoint that is currently utilized for training will be sent to board members.


Chairperson Keegan - expressed appreciation of receiving the reports. Pleased with the quality of the cases she reviewed for the meeting. The discussion was opened for any specific cases.

  • Deputy Inspector General Diggins - the reports that are sent to board members for review shows the number of cases that are completed by the OIG and there are more. Chairperson Keegan - agreed it does show the number of cases done.
  • Thane Dykstra - Impressed by the quality of the reports and felt the investigations are thorough. Tries to pay attention to trends and did not feel there were as many in relation to supervision. Surprised by the number of cases in relation to medical concerns, the findings against nurses, and the level of an individual's medical complexity.
  • Neil Posner - one of the cases that involved death brought forth some questions to him in regards to a facility had changed from an ICF/DD to a CILA and had all of the same residents.
  • Deputy Inspector General Diggins - OIG is noticing a trend right now and believes it is due to the LIGAS Decree. The LIGAS Decree gives individuals the choice to move into the least restrictive environment they could live in. This is resulting in a lot of ICF's closing and converting into a CILA. Also, some of the agencies that oversee the ICF/DD fall under the Department of Public Health. When an ICF/DD closes and converts into a CILA they would then fall under Department of Human Services. Example: Community ICF/DD's have the same amount of people as the state-operated facilities. In one area one ICF/DD shut down (approximately 300 individuals living in the home) and it was converted into CILA's. This resulted in the area going from 5 CILA's to 35 CILA's in a matter of 6 months. This created a larger area of operation for OIG because of the increase of cases within such a short period.
  • Neil Posner - in reviewing the cases noticed some repeat claims of negligence and lack of training against direct service providers; which states they are not receiving enough support and/or training. Globally, is there prevention of such allegations? Is the training and support needed for individuals with direct contact of residents being monitored and by whom? Understands it is not the obligation of the OIG per statute, but it is the duty of the OIG to investigate allegations of abuse, neglect, financial exploitation and so forth.
  • Deputy Inspector General Diggins - in such scenarios within an investigation the OIG will have recommendations. If during an investigation it is found a staff member was not trained, the agency is held accountable (substantiated neglect against the agency). In terms of following up from OIG's reports and recommendations, it is the responsibility of the Bureau of Quality Management; they follow up on the training. A classroom training of 40 hours and 80 hours on-the-job training is required by the Department.
  • Thane Dykstra - Suggesting in addition to the required training mentioned, possibly include specialized needs training; which would highlight some of the learned materials in the classroom that applies to that particular CILA. Neil Posner - is in agreement.
  • Neil Posner - if there was additional oversight at the front end rather than the back end, it may result in fewer allegations of this nature.
  • Deputy Inspector General Diggins - Due to the nature of the questions from the board about the Division responses, it would be best to have the Bureau Chief of the Bureau of Quality Management give a presentation at a board meeting. Inspector General McCotter agrees with the idea of the Bureau Chief of BQM giving a presentation. Neil Posner - agrees with this suggestion and understands the OIG cannot answer some of his questions as they pertain to the duties/responsibilities outside of the OIG's jurisdiction. His point is to ensure work is not being done due to lack of oversight on the front end. Deputy Inspector General Diggins will contact the Bureau Chief of Bureau of Quality Management.
  • Chairperson Keegan - requested cases continue to be sent to members as they have been as it assists the board members in understanding the process of the investigations. Neil Posner in agreement. Inspector General McCotter and Deputy Inspector General Diggins agreed to keep sending the cases per the criteria requested by the board members.


Chairperson Keegan suggested the following tentative meeting dates:

(Untress Quinn left the meeting)

  • February 9, 2017 at 2:00 p.m.
  • May 11, 2017 at 2:00 p.m.
  • September 14, 2017 at 2:00 p.m.
  • December 14, 2017 at 2:00 p.m.

Chairperson Keegan asked for a motion for tentative 2017 meeting schedule subject to everyone's approval.

Motion to approve the tentative 2017 meeting schedule subject to everyone's approval - Neil Posner

Motion Seconded - Chairperson Keegan

All in Favor

Motion carried to approve the tentative 2017 meeting schedule subject to everyone's approval.

Chairperson Keegan - without a quorum not sure this vote can carry. Neil Posner - reiterated if there is a quorum at the beginning of the meeting and if someone leaves prior to the end of the meeting, it does not break the quorum.

Chairperson Keegan - inquired if there were any other FOIA requests received and not sent to the board. Deputy Inspector General Diggins - the board is up-to-date on all FOIA's at this time.


Chairperson Keegan asked for a motion to adjourn.

Motion to Adjourn - Neil Posner

Motion Seconded - Chairperson Keegan

All in favor

Motion Carried

Meeting Adjourned - 4:04 p.m.