REPORT CONCLUSIONS

The Office of the Inspector General (OIG) investigates allegations of abuse and neglect that occur in facilities operated by the Department of Human Services (DHS), as well as community agencies licensed, certified, or funded by DHS. In FY 2000, the OIG substantiated abuse or neglect in 490 of 5,095 closed investigations of incidents reported to the OIG. Of the 490 substantiated cases, 450 were related to investigations of 2,365 specific abuse or neglect allegations; the remaining 40 were found in investigations of the 2,730 incidents not classified as abuse or neglect at intake.

Of the 450 substantiated cases, 129 occurred at State facilities and 321 involved community agencies. In FY 2000, State facilities served 12,858 individuals while approximately 15,000 individuals with developmental disabilities and 130,000 individuals with mental illness were served at 535 community agencies in Illinois, according to DHS officials.

While the number of abuse and neglect allegations reported by State facilities has remained fairly consistent over the past four years (fluctuating between 1,114 in FY 1997 and 1,313 in FY 2000), the number of abuse and neglect allegations reported by community agencies has been increasing. In FY 1997, community agencies reported 365 allegations of abuse and neglect; by FY 2000, the number of allegations reported by community agencies increased to 898. OIG officials attributed this increase to an enhanced awareness of the responsibility to report such allegations by community agencies. The overall number of abuse and neglect cases closed by the OIG has increased steadily over the past four years -- from 1,116 in FY 1997 to 2,365 in FY 2000.

Problems cited in prior audits concerning untimely OIG investigations continued in FY 1999 and FY 2000. OIG administrative rules require investigations be completed within 60 days, absent extenuating circumstances. In FY 2000, only 25 percent of OIG investigations were completed within 60 days; 23 percent of the investigations took longer than 200 days to complete. Timeliness has improved slightly from FY 1998 when only 14 percent of investigations were completed within 60 days. An investigation's effectiveness is diminished if it is not conducted in a timely manner. With the passage of time, memories fade and witnesses may become unavailable for interviews.

Interviews with investigative staff and reviews of case files identified numerous factors contributing to cases taking more than 60 days to complete:

• Cases for which State Police conducted a criminal investigation were returned to the OIG approximately 6 months after they had been initially received by the State Police (as compared to 6 days for cases where State Police determined no criminal investigation was necessary).

• Cases referred to DHS Clinical Services for medical review on average took approximately five months longer than investigations not sent to Clinical Services.

• Investigator caseloads varied significantly among the OIG’s four investigative bureaus. The average number of cases assigned annually per investigator varied significantly, with the highest in the South bureau (92 cases annually) and the lowest in the Central bureau (51 cases annually). There are many factors that impact the significance of investigator caseloads such as the nature of the allegation and level of investigator involvement required.

OIG case reports generally were thorough and addressed the allegation. All case files sampled contained a case report. OIG Investigative Guidelines allow investigators to determine what evidence will be collected based on the circumstances of the case. Instances where documentation could be improved included: photographs of injuries and progress notes. While in 70 of 83 (84 percent) injury cases in our sample the case file did not contain required photographs, only 2 percent of injury cases lacked other required documentation of an injury. In addition, progress notes were not collected in 19 of 181 (10 percent) cases sampled.

The required explanations as to why the case took longer than 60 days to complete were missing in 76 of 113 (67 percent) case files reviewed. The timeliness of case file review by OIG management improved from the last audit, with the median number of 19 days for review in FY 2000, down from 33 days in FY 1998.

Of the 1,195 investigations conducted by community agencies in FY 2000, 1,071 were conducted by community agencies without an approved investigative protocol. OIG administrative rules allow the OIG to delegate investigation responsibility in certain cases only to community agencies with an "approved method of investigation." OIG staff stated that until a community agency has an approved protocol, the investigation method approval is granted on a case-by-case basis. The OIG has been working with community agencies to develop protocols to guide the agencies' investigations of abuse or neglect. As of August 4, 2000, the OIG had approved 16 community agency investigation protocols and was reviewing 24 others. In general, community agency conducted investigations were more complete and thorough in our sample of cases from FY 2000 than community agency cases sampled in FY 1998.

Not all community agencies are reporting incidents of abuse and neglect to the Department of Public Health as required by the Abused and Neglected Long Term Care Facility Residents Reporting Act (Act). In addition, 64 of 99 (65 percent) of the alleged incidents of abuse or neglect in sampled cases were not reported by community agencies within one hour of discovery as required by OIG administrative rules. At State facilities, 21 of 63 (33 percent) abuse or neglect allegations in our sample were not reported to the OIG within the one-hour requirement.

State facilities and community agencies took administrative action, such as suspension or termination, against employees in 366 (75 percent) of the 490 substantiated cases closed in FY 2000. Other actions taken against employees included: staff retraining, policy/procedure issues, treatment/program change, structural change, and legal review.

The OIG closed 53 of the 490 substantiated cases even though facilities or community agencies had not yet provided a response, such as a corrective action plan, to the OIG's finding of substantiated abuse or neglect. The OIG’s Investigative Log did not contain information regarding what, if any, corrective action facilities or community agencies took in these cases. Statutorily, it is the Secretary of the Department of Human Services' responsibility to accept or reject the facility or community agency response to OIG reports. DHS currently monitors the approval of written responses and the actions taken. However, since corrective action taken to address issues identified in substantiated cases of abuse or neglect is a critical element of an effective investigatory process, the OIG should also track all actions taken in response to its investigations.

As recommended in past audits, the OIG established a protocol in December 1999 that defines when sanctions should be recommended to the Department of Public Health and the Department of Human Services. OIG officials stated they found it unnecessary to recommend any sanctions against State-operated facilities during FY 2000. In FY 2000 the OIG also conducted unannounced site visits at all of the State-operated facilities as required by statute.

Training of OIG investigators has improved since our last audit. Our review of the training database noted that only one of the OIG investigators had not obtained all of the required investigation-related courses.

The current Inspector General was appointed by the Governor in July 2000.

In FY 1997, abuse and neglect allegations involving community agencies totaled 365; by FY 2000, the number of incidents reported for community agencies

This is the sixth audit related to the Office of the Inspector General

The number of cases taking more than 200 days to complete increased from 13 in FY 1997 to 211 in FY 1998 and to 547 in FY 2000.

In FY 2000 only 25% of OIG investigations were completed within 60 days.

BACKGROUND

The Abused and Neglected Long Term Care Facility Residents Reporting Act (Act) established the Office of the Inspector General within the Department of Human Services. The Act requires the OIG to investigate allegations of abuse or neglect within State-operated facilities and community agencies (funded, certified, or licensed by DHS) that serve the mentally ill and developmentally disabled. The Inspector General is appointed by the Governor and confirmed by the Senate for a four-year term. The current Inspector General was appointed in July 2000.

As of June 30, 2000, the OIG had 59 staff. This represents an increase of seven investigatory positions over staffing levels reported in our 1998 OIG audit. The largest organizational unit within the OIG is the Bureau of Investigations. The Bureau of Investigations is responsible for conducting investigations of allegations of abuse and neglect and is divided into four regional bureaus of investigations. Each regional bureau has a Bureau Chief, a Network Team Leader who is responsible primarily for case file review, and additional investigatory staff.

In FY 2000, the Department of Human Services operated 19 facilities Statewide which served 12,858 individuals. In addition, DHS licenses, certifies, or provides funding for approximately 535 separate community agency programs that provided services to 15,000 individuals with developmental disabilities and 130,000 individuals with mental illness in community settings within Illinois in FY 2000.

In FY 2000, a total of 2,211 allegations of abuse or neglect were reported to OIG (1,313 from State facilities and 898 from community agencies). As shown in Digest Exhibit 1, the number of abuse or neglect allegations at State facilities remained fairly consistent over the past four years (fluctuating between 1,114 in FY 1997 and 1,313 in FY 2000). However, the number of abuse and neglect allegations reported at community agencies has increased each year since FY 1997. In FY 1997, abuse and neglect allegations involving community agencies totaled 365; by FY 2000, the number of incidents reported for community agencies increased to 898. OIG officials stated that this increase is attributable to increased awareness of the responsibility to report such allegations by community agencies.

In the past, the Office of the Auditor General has conducted five audits of the OIG to assess the effectiveness of their investigations into allegations of abuse and neglect, as directed under 210 ILCS 30/6.8. These audits were released in 1990, 1993, 1994, 1996, and 1998. (Pages 4-6, 9, 14)

INVESTIGATION TIMELINESS

The OIG continued to have problems completing investigations in a timely manner. OIG administrative rules require that, absent extenuating circumstances, investigations be completed within 60 days. Digest Exhibit 2 shows the number of investigations completed in terms of ranges of the number of days to completion. In FY 2000, only 25 percent of OIG investigations were completed within 60 days. While this is an improvement from FY 1998 and FY 1999, when only 14 percent and 21 percent of cases, respectively, were completed within 60 days, additional improvement is necessary.

The number of cases taking more than 200 days to complete has also increased the past four years. In FY 1997, only 13 cases took longer than 200 days to complete. By FY 2000, that number had increased to 547. An investigation's effectiveness is diminished if it is not conducted in a timely manner because with the passage of time, memories fade and witnesses may become unavailable for interviews.

There are many factors that impact the significance of investigator caseloads. However, investigator caseloads varied significantly among the four investigative bureaus.

OIG case reports generally were thorough, comprehensive, and addressed the allegation.

Interviews with investigative staff and reviews of case files identified numerous possible factors contributing to cases taking more than 60 days to complete:

• Cases for which State Police conducted a criminal investigation were returned to the OIG approximately 6 months after they had been initially received by the State Police (as compared to 6 days for cases where State Police determined no criminal investigation was necessary).

• Cases referred to DHS Clinical Services for medical review on average took approximately five months longer than investigations not sent to Clinical Services.

• Investigator caseloads varied significantly among the four investigative bureaus. The average number of cases assigned annually per investigator varied significantly, with the highest in the South bureau (92 cases annually) and the lowest in the Central bureau (51 cases annually). There are many factors that impact the significance of investigator caseloads, such as the nature of the allegation or level of investigator involvement required. Digest Exhibit 3 shows that the average number of cases assigned per investigator and the average time to complete those cases varied by OIG bureau for FY 2000.

We recommended that the OIG continue to improve the timeliness of investigations. We recommended that efforts be directed in the areas of case referrals to Illinois State Police and Clinical Services, investigator caseloads, and interview and case review timeliness. (Pages 17 – 24)

INVESTIGATION THOROUGHNESS

OIG case reports generally were thorough, comprehensive, and addressed the allegation. All case files in our sample contained a case report. We did identify instances where documentation could be improved. While in 70 of 83 (84 percent) injury cases in our sample the case file did not contain required photographs, only 2 percent of injury cases lacked other required documentation of an injury. In 19 of 181 OIG cases sampled (10 percent), progress notes were not collected.

For cases that take over 60 days to complete, OIG Investigative Guidelines require the Network Team Leader (case reviewer) to document in the investigation case file a "barrier to completion." The barrier to completion notation is to document the extenuating circumstances that caused the case to exceed the 60-day requirement.

Of 113 cases reviewed that exceeded the 60-day completion timeline, 76 (67 percent) case files did not contain the required notation. Digest Exhibit 4 shows the reasons for delay cited for cases exceeding the 60-day completion requirement.

In 76 of 113 investigations sampled, the case file did not contain the required "barrier to completion" notation.

In 65% of cases sampled at community agencies and 33% of cases at State facilities, allegations of abuse or neglect were not reported within one hour.

OIG substantiated abuse or neglect in 450 of 2,365 allegations of abuse or neglect in FY 2000.

OIG should track the actions taken in all substantiated cases.

Community Agency Investigations

In general, community agency conducted investigations were more complete and thorough in our sample of cases from FY 2000 than the community agency investigations sampled in FY 1998.

OIG administrative rules allow the OIG to delegate investigation responsibility in certain cases only to community agencies with an "approved method of investigation." The rules require community investigations to meet the same investigation standards and methodologies as used in OIG investigations. The OIG has been working with community agencies to develop protocols to guide the agencies' investigations of abuse or neglect. As of August 4, 2000, the OIG approved 16 community agency investigation protocols and was reviewing 24 others.

Of the 1,195 investigations conducted by community agencies in FY 2000, 1,071 were conducted by community agencies without an approved investigative protocol. OIG officials stated that until a community agency has an approved protocol, the investigation method approval is granted on a case-by-case basis.

Reporting of Abuse or Neglect Allegations

Not all community agencies are reporting incidents of abuse and neglect to the Department of Public Health (DPH) as required by the Abused and Neglected Long Term Care Facility Residents Reporting Act (Act). In addition, 64 of 99 (65 percent) of the alleged incidents of abuse or neglect in sampled cases were not reported by community agencies within one hour of discovery as required by OIG administrative rules. At State facilities, 21 of 63 (33 percent) abuse or neglect allegations in our sample were not reported to the OIG within the one-hour requirement.

According to DPH staff, community agencies who call the DPH hotline with an allegation of abuse or neglect are told that in the future they should call the OIG hotline if they are funded by the Department of Human Services (DHS), and have eight or less Medicaid certified beds. Such a practice is not consistent with the requirements of the Abused and Neglect Long Term Care Facility Residents Reporting Act. The Act requires that all allegations of abuse or neglect be reported to a central registry established and operated by DPH. We recommended that the OIG and DPH work with community agencies to ensure they are reporting allegations of abuse or neglect as required by statutes. (Pages 27, 30, 32 – 35)

ACTIONS, SANCTIONS, AND RECOMMENDATIONS

In FY 2000, the OIG substantiated abuse or neglect in 490 of 5,095 closed investigations of incidents reported to the OIG. Of the 490 substantiated cases, 450 were related to investigations of 2,365 specific abuse or neglect allegations; the remaining 40 were found in investigations of the 2,730 incidents not classified as abuse or neglect at intake. Of the 450 substantiated cases, 129 occurred at State facilities and 321 involved community agencies.

In FY 2000, the OIG closed 53 cases for which State facilities or community agencies had not yet provided a written response to the Inspector General's finding of substantiated abuse or neglect. State law requires that the Secretary of the Department of Human Services accept or reject community agency and State facility written responses. The Divisions of Mental Health and Developmental Disabilities within DHS monitor the approval of written responses and the actions taken. They also follow-up with facilities and community agencies which do not respond to OIG timely. OIG does not always update its Investigative Log to reflect the actions taken as stated in the written response. Closing these cases while lacking a system to ensure that appropriate responses are received and recorded can limit the effectiveness of OIG investigations.

Digest Exhibit 5 shows the 490 substantiated cases by the type of action taken and the investigating agency. There are 4 cases where an action was recommended but no action was taken. In these cases, no

As recommended in past audits, the OIG developed a protocol that defines when sanctions should be recommended to DPH and DHS.

All but one OIG investigator had received required investigation-related training.

Sanctions and Site Visits

As recommended in past audits, the OIG established a protocol that defined when sanctions should be recommended to the Department of Public Health and the Department of Human Services. OIG officials stated they found it unnecessary to recommend any sanctions against State-operated facilities during FY 2000. Over the past five years, the OIG has not recommended any sanctions against facilities. In FY 2000 the OIG also conducted unannounced site visits at all of the State-operated facilities.

The OIG has not conducted any unannounced site visits at community agencies. OIG officials stated they do not have statutory authority to conduct site visits at community agencies. (Pages 39 - 48)

OTHER ISSUES

To conduct an effective investigation, OIG investigators must be adequately trained. The criteria for OIG investigator training are clearly defined in OIG’s policies and procedures.

Training of OIG investigators has improved since our last audit. Our review of the training database noted that all but one of the OIG investigators had obtained all of the required investigation-related courses. Our last audit noted that 12 employees were lacking one or more of the required courses. OIG also began maintaining data on training provided to community agency employees who attend OIG sponsored courses. (Page 47)

RECOMMENDATIONS

The audit report contains seven recommendations related to the Office of the Inspector General and one recommendation to both the Office of the Inspector General and the Department of Public Health. The OIG and Public Health agreed with all of the recommendations. Appendix F to the audit report contains the Inspector General’s and Public Health’s complete responses.

__________________________________

WilliamG.Holland

AuditorGeneral

 

WGH:KJM

December 2000