REPORT DIGEST

DEPARTMENT OF HUMAN SERVICES

COMPLIANCE EXAMINATION
FOR THE TWO YEARS ENDED JUNE 30, 2023

Release Date:  May 29, 2025

FINDINGS THIS AUDIT: 32

CATEGORY:  NEW -- REPEAT – TOTAL
Category 1:  5 -- 21 -- 26
Category 2:  2 -- 4 -- 6
Category 3:  0 -- 0 -- 0
TOTAL:  7 -- 25 -- 32

FINDINGS LAST AUDIT: 33

State of Illinois, Office of the Auditor
General
FRANK J. MAUTINO, AUDITOR GENERAL

To obtain a copy of the Report contact:
Office of the Auditor General, 400 West
Monroe, Suite 306, Springfield, IL
62704-9849
(217) 782-6046 or TTY (888) 261-2887

This Report Digest and Full Report are also
available on the worldwide web at
www.auditor.illinois.gov

INTRODUCTION

Because of the significance and
pervasiveness of the findings described
within the report, we expressed an adverse
opinion on the Department of Human Services’
(Department) compliance with the assertions
which comprise a State compliance
examination. The Codification of Statements
on Standards for Attestation Engagements
(AT-C § 205.72) states a practitioner
“should express an adverse opinion when the
practitioner, having obtained sufficient
appropriate evidence, concludes that
misstatements, individually or in the
aggregate, are both material and pervasive
to the subject matter.”

Further, the digest covers our Compliance
Examination of the Department for the two
years ended June 30, 2023. A separate
Financial Audit as of and for the year ended
June 30, 2023, was previously released on
December 19, 2024. In total, this report
contains 32 findings, 9 of which were
reported in the Financial Audit.

SYNOPSIS

• (23-10) The Department was unable to
provide adequate records substantiating the
completeness of populations for one or more
laws, regulations, or other requirements
selected for testing, as of the end of
fieldwork.

• (23-11) The Department did not comply with
statutory requirements regarding the use of
restraints.

• (23-12) The Department did not comply with
statutory requirements regarding the
monitoring of facility visitors.

INTRODUCTION

This report presents our Department-wide
compliance attestation examination for the
two years ending June 30, 2023. At June 30,
2023, the Department operated 6
Developmental Centers, 7 Mental Health
Centers, 1 combined Mental Health and
Developmental Center, and 3 Rehabilitation
Services Facilities. The findings are
presented in the report beginning at page
32.

FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS

COMPLETE POPULATIONS NOT PROVIDED

The Department of Human Services
(Department) was unable to provide adequate
records substantiating the completeness of
populations for one or more laws,
regulations, or other requirements selected
for testing, as of the end of fieldwork.
Due to these conditions, we concluded the
Department’s population records were not
sufficiently precise and detailed under the
Attestation Standards promulgated by the
American Institute of Certified Public
Accountants (AT-C §205.36).

Some of the more significant issues noted
were:

• Reporting functions within the
Department’s accounting information system
did not generate accurate populations used
for leases and asset additions and deletions
reported on the Department’s Agency Report
of State Property (C-15 Form).

• While testing compliance with various
Mental Health and Developmental Disabilities
Administrative Acts and other State laws
governing the State-Operated Mental Health
and Developmental Disabilities facilities,
we noted the following:

– For Mental Health and Developmental
Disabilities Code (MH Code) (405 ILCS
5/108(a-e)), the Fox Developmental Center
was not able to provide adequate records
substantiating the population of restraints
issued during the examination period.
Additional information can be found in
Finding 2023-011.

– For MH Code (405 ILCS 5/108(g-h)), the
Ludeman Developmental Center was not able to
provide adequate records substantiating the
population of employees qualified to order
the use of restraints at the facility during
the examination period.  Additional
information can be found in Finding
2023-011.

– For the Mental Health and Developmental
Disabilities Administrative Act (MH
Administrative Act) (20 ILCS 1705/47), the
Jack Mabley Developmental Center was unable
to provide adequate records substantiating
the population of visitor entry logs (for
visitors who visited the facility’s
residents) during the examination period.
Additional information can be found in
Finding 2023-012. (Finding 10, pages 32-33).
This finding has been reported since 2017.

We recommended Department management and
staff strengthen controls over records
maintenance for each area in which a
compliance requirement is present.  We
further recommended that to the extent
possible, population records should be
sequentially numbered.  Lastly, we
recommended the Department strengthen its
internal controls to ensure it maintains
complete and accurate populations.

The Department accepted our recommendation
and stated each Division will work to
strengthen controls to ensure adequate
records are maintained and can be provided
when requested.

NONCOMPLIANCE WITH STATUTORY REQUIREMENTS
REGARDING THE USE OF RESTRAINTS AND
SECLUSION

The Department did not comply with statutory
requirements regarding the use of
restraints.

During fieldwork, we performed on-site
testing regarding the use of restraints at
five of the Department’s State-operated
facilities.  Although we were unable to
obtain complete populations across all five
facilities, we performed testing on the
information provided.

Some of the more significant exceptions
noted were:

Chester Mental Health Center
• For 2 of 12 (17%) residents tested, prior
authorization was not obtained before
applying the same restraint within a 48-hour
period.
• For 5 of 12 (42%) residents tested, we
were unable to determine if the Facility
Director reviewed the ordered restraints.
• For 13 of 59 (22%) restraints tested,
employee restraint certifications were not
valid upon application of restraint date.

Elgin Mental Health Facility
• For 2 of 12 (17%) restraints tested, the
Facility was unable to provide documentation
to support the certifications for the
employees who applied the restraints were up
to date on the date of restraint
application.

Ludeman Developmental Center
• For 4 of 12 (33%) residents tested, we
were unable to determine the person applying
the restraint had completed the proper
training.
• For 11 of 12 (92%) residents tested, the
Facility was unable to provide documentation
to support the certifications for the
employees who applied the restraints were up
to date on the date of restraint
application.  (Finding 11, pages 34-36).
This finding has been reported since 2011.

We recommended Department management re-
train staff on compliance with statutory
requirements when restraints are ordered.
We also recommended Department management
establish a process to monitor compliance
with annual training requirements.

The Department accepted our recommendation
and stated it will re-train staff on
compliance with statutory requirements
regarding the use of restraints.  The
Department further stated this training will
include documentation requirements when
restraints are ordered.  Lastly, the
Department stated procedures to monitor
compliance will be developed.

NONCOMPLIANCE WITH STATUTORY REQUIREMENTS
REGARDING THE MONITORING OF FACILITY
VISITORS

The Department did not comply with statutory
requirements regarding the monitoring of
facility visitors.

As part of our testing at eight of the
Department’s State-operated facilities, we
reviewed facility visitor logs and tested
facility procedures regarding the monitoring
of visitors.

Some of the more significant exceptions
noted were:

• The facility visitor logs appeared to be
incomplete for the following facilities:
Elgin Mental Health Center, Shapiro Mental
Health Center, Chester Mental Health Center,
Murray Developmental Center, Fox
Developmental Center, Jack Mabley
Developmental Center, Illinois Center for
Rehabilitation and Education – Wood, Ludeman
Developmental Center, and the Treatment and
Detention Facility.  Missing information
included name, time-in, time-out,
organization or address of the individual,
purpose, and/or area of visit.

• In addition, at the Chester Mental Health
Center, we noted the facility’s policy for
visitors was not being adequately followed.

• At the Jack Mabley Developmental Center,
we noted inconsistencies between different
copies of the same visitor logs provided.

• At the Ludeman Developmental Center, for 6
of 8 (75%) months selected, the facility was
unable to provide copies of the completed
visitor logs, and the facility did not
maintain adequate physical safeguards
regarding building access and monitoring.
(Finding 12, pages 37-39).  This finding has
been reported since 2017.

We recommended Department management enforce
policies and procedures to ensure compliance
with the Mental Health and Developmental
Disabilities Administrative Act regarding
visitors to facilities and employees.  The
policies and procedures should include
training personnel on compliance
requirements and implementing management
oversight over compliance requirements.  We
also recommended each Facility retain
visitor entry logs as required.  Further, we
recommended the Department improve controls
over building access and monitoring.

The Department accepted our recommendation
and stated it will work to ensure compliance
with statutory requirements regarding
monitoring of facility visitors and
employees.  The Department further stated
staff will be trained regarding the
requirements when processing visitors
signing in at the facilities and procedures
will be developed to monitor compliance.

OTHER FINDINGS

The remaining findings are reportedly being
given attention by the Department.  We will
review the Department’s progress towards the
implementation of our recommendations in our
next State compliance examination.

AUDITOR’S OPINION

The auditors stated the financial statements
of the Department as of and for the year
ended June 30, 2023, are fairly stated in
all material respects.

ACCOUNTANT’S OPINION

The accountants conducted a State compliance
examination of the Department for the two
years ended June 30, 2023, as required by
the Illinois State Auditing Act.  Because of
the effect of the noncompliance described in
Findings 2023-001 through 2023-032, the
accountants stated the Department did not
materially comply with the requirements
described in the report.

This State compliance examination was
conducted by RSM US LLP.

COURTNEY DZIERWA
Division Director

This report is transmitted in accordance
with Section 3-14 of the Illinois State
Auditing Act.

FRANK J. MAUTINO
Auditor General

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