OFFICE OF THE INSPECTOR GENERAL
WILLIAM G. HOLLAND AUDITOR GENERAL
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The Inspector General's Office became part of DHS July 1, 1997
This is the fifth audit related to the Office of the Inspector General
Overall timeliness of case completion deteriorated in FY 98
The number of cases taking more than 200 days to complete increased from 13 in FY 97 to 211 in FY 98
Documentary evidence collection in OIG investigations has improved since the last audit
Documentary evidence collection in investigations conducted by facilities and community agencies needs improvement
We continue to find problems with supervisory review n both OIG and facility and community agency investigated cases
The facilities and community agencies took some kind of action in 95 percent of FY 98 cases substantiated by the OIG
The OIG has not recommended sanctions against facilities nor have they developed criteria for when a recommendation should be made
Not all OIG investigators have received required training
The OIG does not monitor the training of facility staff who conduct investigations and conduct the initial steps in OIG investigations
|FINDINGS, CONCLUSIONS, AND
The Office of the Inspector General closed 1,470 investigations of alleged employee abuse or neglect of DHS facility residents and community agency residents in Fiscal Year 1998 and 1,124 in Fiscal Year 1997.Of these investigations closed in Fiscal Year 1998, 279 abuse or neglect allegations were substantiated. This increased the allegation substantiation rate from 16 percent in Fiscal Year 1997 to 19 percent in Fiscal Year 1998. The OIG also substantiated abuse or neglect in an additional 26 other incidents which were not alleged to be abuse or neglect at intake, for a total of 305 substantiated cases.
Overall the quality of OIG investigations has improved since our last audit. Case file documentation is more thorough, and final case reports are generally comprehensive, follow Investigation Guidelines, and address the allegation of abuse or neglect. There are, however, still areas for improvement.
Timeliness of cases closed has deteriorated in Fiscal Year 1998 with 86 percent of cases not completed within the 60 days allowed by DHS Policy. In Fiscal Year 1996 and 1997, 50 percent and 59 percent of cases respectively were not completed timely.
There was also a significant increase in the number of cases not completed within 200 days of being reported-- 211 in Fiscal Year 1998 and 13 in Fiscal Year 1997. Many of these cases in our sample lacked documentation of substantive reasons for delay.
Further, OIG Investigation Guidelines in effect during this audit eliminated many of the incremental case investigation timeliness requirements applicable in the last audit. For example, our sample of cases noted a median of 33 days for case review. Previous requirements allowed 3 days for case review.
Case file documentation has improved since the last audit. However, we found that 18 percent (34 of 186) of OIG investigations were missing one or more required documents. In our prior audit, 44 percent of case files were missing required case file documentation.
We continued to find problems with documentation of supervisory review. Of the cases requiring a supervisory case review form and status reports in our sample, 16 percent (30 of 186) did not have the review form and 48 percent (51 of 106) did not contain status reports.
New requirements established in statutes have not been fully implemented by the OIG. Statutes now require facilities and community agencies to submit a written response to the OIG in substantiated cases. In addition, the OIG is required to establish an appeals process to resolve differences between the OIG and the facilities and community agencies, and to report all substantiated cases to the Secretary of the Department of Human Services within ten days of a case becoming final.
Again in Fiscal Year 1998, the OIG has not imposed or defined sanctions against facilities although the OIG has had statutory authority since January 1990.
The number of OIG investigators who received all required training has improved. However, 12 of the 30 investigators (40%) were still lacking one or more of the 15 required courses. Our prior audit noted that 17 of 19 (89%) investigators were lacking one or more courses. In addition, the OIG has not monitored the training received by facility investigators who conduct facility investigations and the preliminary investigative steps in OIG investigations. Facility staff training should be monitored to ensure thorough and effective investigations.
OIG and other DHS employees are not reporting to the Department of Professional Regulation (DPR) as required in statutes. We found one instance in our sample of community cases where a private physician misdiagnosed a patients condition, but we found no evidence that the instance was ever reported to DPR as required.
The OIG closed investigations conducted by facilities and community agencies which did not meet the standards the OIG uses in their investigations. OIG Investigation Guidelines contain criteria for approving community agency investigation protocols. OIG will begin approving community agency protocols when draft administrative rules are adopted.
Of the 15 audit recommendations made in the last audit, the OIG has either corrected the problem (4), not addressed the problem (3), eliminated requirements in procedures (2), or improved their performance (6). The following report addresses these issues and others that affect the thoroughness and effectiveness of OIG investigations of abuse and neglect.
BACKGROUNDThe Office of the Inspector General was initially created by Public Act 85-223 within the Department of Mental Health and Developmental Disabilities (DMHDD). 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 October 1995.
The OIG continued to operate as part of DMHDD through Fiscal Year 1997. Effective July 1, 1997 the Departments of Mental Health and Developmental Disabilities, Alcoholism and Substance Abuse, and Rehabilitation Services were merged into the newly formed Department of Human Services.
In Fiscal Year 1998, the Department of Human Services (as successor to DMHDD) operated 19 facilities Statewide. In addition, DHS licenses, certifies, or provides funding for over 350 separate organizations that provide services to the developmentally disabled and the mentally ill in community settings within Illinois.
In the past, the Office of the Auditor General has conducted four 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 this audit in 1998. Digest Exhibit 1 indicates the categories that findings fell into for each of these audits.
In 1995, statutes clarified the role of the Office of the Inspector General expanding it to include the authority to investigate reports of abuse or neglect at facilities or programs not only operated by DHS, but also those licensed, certified or funded by DHS. This gives the OIG the authority to conduct investigations at community agencies. The amendment does not require the community agencies to report all allegations of abuse and neglect to the OIG; therefore, there are likely incidents that go unreported.
During our audit, the OIG formally established a mission statement and goals. OIG administrative rules that were in draft form during this audit were finalized in October.
The OIG closed 1,470 investigations of alleged employee abuse or neglect of the Department of Human Services facility residents and community agency residents in Fiscal Year 1998 and 1,124 in Fiscal Year 1997. Of these investigations closed in Fiscal Year 1998, 279 abuse or neglect allegations were substantiated. The OIG also substantiated abuse or neglect in an additional 26 other incidents which were not alleged to be abuse or neglect at intake, for a total of 305 substantiated cases. (pp.1-5)
There are certain important components of an investigation into abuse and neglect. They include: whether the investigation is timely, whether the investigation is thorough, and whether corrective action is taken.
INVESTIGATION TIMELINESSThe effectiveness of an investigation is diminished if it is not conducted in a timely manner. Timely completion of investigations is critical for an effective investigation, because as time passes, injuries heal, memories fade, or witnesses may not be located. DHS policy requires that investigations be completed as expeditiously as possible and should not exceed 60 days absent exceptional circumstances.
In Fiscal Year 1998, the overall timeliness of case completion deteriorated. Approximately 86 percent of cases closed in Fiscal Year 1998 took more than the 60 days allowed in DHS Policy to complete. In Fiscal Year 1997, 59 percent of cases exceeded the 60 day time requirement.
In addition, the number of cases taking more than 200 days to complete increased to 211 (16%) in Fiscal Year 1998 from 13 (1%) cases in Fiscal Year 1997. Our measurement of the time to complete an investigation was taken from the time an incident was reported to the OIG until the OIG completion date. Overall it took an average of 130 days to complete an investigation of employee abuse or neglect in Fiscal Year 1998 and an average of 76 days in Fiscal Year 1997. Digest Exhibit 2 shows the number of days to investigate cases.
OIG Investigation Guidelines in effect during our audit eliminated many of the incremental case investigation timeliness requirements applicable in the last audit. One requirement involved supervisory review.
We recommend that the OIG develop a process to ensure the timeliness in investigations and to ensure that case reports are reviewed in a timely manner. (pp.15-19)
INVESTIGATION THOROUGHNESSEssential components of an abuse or neglect investigation include thoroughness in the collection of evidence, adequate supervisory review, and a clear and comprehensive final case report. The investigators primary responsibility is to collect facts and information in order to accurately determine the manner in which the incident occurred.
Documentary evidence collection has improved since the last audit. However, improvement in overall case file thoroughness is still needed as was also cited in our four previous audits. In our sample of Fiscal Year 1998 cases, we found that 18 percent (34 of 186) of investigations conducted by OIG were missing one or more required documents. In our prior audit, 44 percent of case files were missing required case file documentation. Digest Exhibit 3 shows the percent of documents missing in Fiscal Year 1996 and Fiscal Year 1998. The OIG has improved in many areas.
The Abused and Neglected Long Term Care Facility Residents Reporting Act (Act) requires the OIG to investigate all allegations of abuse and neglect at State-operated facilities and complaints of abuse and neglect at community agencies. Other incidents and self-reported allegations of abuse and neglect at community agencies are investigated by the community agency.
We sampled incidents that were delegated to State operated facilities and community agencies. In our sample, we noted a significant difference in the documentation in these case files to those investigations conducted by the OIG. Eleven percent (2 of 19) of the facility investigations and 22 percent (19 of 87) of the community agency investigations in our sample were missing at least one of the documents the OIG requires in their investigations.
Supervisory ReviewThe second element of an effective investigation is case review and monitoring. We continued to find problems with supervisory review of case files and monitoring of open investigations similar to those noted in our prior audits. In our sample of allegations investigated by OIG, 16 percent (30 of 186) did not contain the required review form.
In addition, there was not any evidence of review in some of the facility and community agency investigated cases because they did not contain any of the review forms required in OIG case files. Eighty-nine percent (77 of 87) of community and 32 percent (6 of 19) of facility cases did not contain the appropriate case review documentation.
Case ReportsA third element of an effective investigation is a clear and convincing case report. In our sample of OIG cases closed in Fiscal Year 1998, we noted that all of the cases contained a case report of some kind.
Case reports in our sample of non-OIG investigated cases were significantly different from those conducted by the OIG investigators. Community agency case reports of abuse and neglect were missing in 4 of 26 cases (15%) in our sample and only 2 of 26 contained all elements of an OIG case report.
Only 11 of 19 facility and 14 of 61 community agency investigations of other incidents in our sample contained case reports. None of these reports from facilities and community agencies included all of the elements required in OIG case reports. (pp. 4,7, 23-31)
ACTIONS, SANCTIONS, AND RECOMMENDATIONSOf the 1,470 abuse and neglect cases closed in Fiscal Year 1998, the OIG substantiated abuse or neglect in 279 cases.The OIG also substantiated abuse or neglect in an additional 26 other incidents which were not alleged to be abuse or neglect at intake, for a total of 305 substantiated cases. In Fiscal Year 1998, facilities or agencies took some kind of action in 95 percent of cases substantiated by the OIG.
Administrative action, such as suspension or termination, against employees was used in 251 (82%) of these cases. Digest Exhibit 4 shows actions taken in cases substantiated by the OIG and who investigated the case.
Amendments to the Act established new requirements for the OIG which have not been fully implemented. Statutes now:
Written response had been submitted in 56 of 182 substantiated cases investigated by OIG. Of the 56 substantiated cases with written responses, 45 were facility cases and 11 were community agency cases. Only 3 of 123 substantiated cases investigated by community agencies had written responses.
In Fiscal Year 1998, there were 3 of the 305 cases where the allegation of abuse or neglect was substantiated but the facility/agency did not accept the recommendation of the OIG. However, there were no cases where the facility or community agency used either the new formal appeals process required in statutes or reported to the Secretary ofthe Department of Human Services to reconcile the difference of opinion.
SanctionsThe OIG enabling statute (210 ILCS 30/6.2) allows the OIG to recommend sanctions to be imposed against the facilities for the protection of residents including appointment of on-site monitors, transfers or relocation of residents, and closure of units.
The OIG has not issued sanctions against any facility during the last three years. The OIG has also not developed formal written criteria to determine when sanctions should be recommended.
In Fiscal Year 1998, the OIG did, however, conduct annual unannounced site visits of all State operated facilities as required by 210 ILCS 30/6.2. The OIG developed a site visit protocol using input from consumers, advocates, family members, facility and Department administrators, other Department staff, and OIG investigators. (pp. 33-39)
OTHER ISSUESDuring the course of our audit we identified other issues that may affect the conduct and effectiveness of investigations at the OIG.
To conduct an effective investigation, OIG investigators must be adequately trained. The criteria for OIG investigator training are clearly defined in OIGs policies and procedures.
Training has improved since the last audit, however, not all OIG investigators are receiving the training that is required by OIG policy and the Act. Of the 30 investigators, 12 (40%) were lacking one or more of the 15 required courses. Digest Exhibit 5 shows the number of missing courses by investigator.
The OIG does not monitor the training received by staff that conduct investigations at the facilities unless training is provided or sponsored by the OIG. Facility staff should also receive appropriate training since they routinely conduct the initial steps of the investigation such as taking initial statements. Facility staff may also conduct investigations of other incidents at the facilities.
Another issue that may affect OIG operations concerns the OIG Investigations Log. The OIG has not yet ensured that the Investigations Log is Year 2000 compliant.
Finally, the OIG and DHS employees have not been reporting to the Department of Professional Regulation (DPR) as required in statute. We found one instance in our sample of community agency cases where a private physician misdiagnosed a patients condition but we could find no evidence that the instance was ever reported to DPR as required. (pp. 41-46)
The audit report contains 11 recommendations related to the Office of the Inspector General. The OIG agreedwith all of the recommendations. Appendix E to the audit report contains the Inspector Generals complete responses.
William G. Holland