REPORT DIGEST

DHS OVERSIGHT OF THE CILA PROGRAM

PERFORMANCE AUDIT
Performed in Accordance with House
Resolution No. 34

Release Date: July 2018

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, Iles Park
Plaza, 740 E. Ash Street, Springfield, IL
62703
(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

On March 15, 2017, the Illinois House of
Representatives adopted Resolution Number
34 which directs the Auditor General to
conduct a performance audit of the
oversight of the Community Integrated
Living Arrangements (CILA) program at the
Department of Human Services (DHS).

As of May 2017, DHS licensed more than
3,000 CILA locations around the State with
over one-third of all CILAs being located
in Cook County. These CILAs served
approximately 10,000 individuals.

For the period FY12-FY16, DHS:
• expended over $2 billion on CILA services
with the majority for clients with
developmental disabilities;
• additionally expended nearly $6.1 million
for a contractor to provide transition
planning and support, and expended more
than $28 million on 17 Independent Service
Coordinators whose primary role is to
assist with finding individuals appropriate
living arrangements; and
• transitioned 408 individuals to CILA from
State-Operated Developmental Centers
(SODCs).

We found weaknesses in DHS’ licensing
process including failures to:
• publish accurate survey data;
• complete timely annual reviews;
• accurately account for notices of
violation in its database;
• complete all surveys, require plans of
correction, and approve all plans of
correction;
• exercise ability to revoke a CILA
license.

We found weaknesses in DHS oversight and
monitoring of the CILA Program including
failures to:
• conduct all CILA reviews by the Bureau of
Quality Management (BQM);
• monitor CILA residents’ personal funds by
DHS;
• maintain supporting documentation for
community placement interest by individuals
at SODCs;
• share findings from DHS bureaus/offices
with licensing staff; and
• recover funds from CILA providers not
providing services for which they were
paid.

There was a lack of documentation to
support that all required transition visits
were conducted for individuals that
transitioned to CILA from SODCs.

DHS utilized Community Resource Associates
(CRA), on a decision from the Governor’s
Office from the previous administration, to
assist in closing SODCs. We found
weaknesses in the oversight by DHS of CRA
including questionable procurement
strategies and failure to maintain
documentation to support required CRA
contractual deliverables. Additionally, DHS
paid CRA an additional $233,000 for
services already required by the contract.

AUDIT SUMMARY AND RESULTS

On March 15, 2017, the Illinois House of
Representatives adopted Resolution Number
34 which directed the Auditor General to
conduct a performance audit of the
oversight of the Community Integrated
Living Arrangements (CILA) program at the
Department of Human Services (DHS).

A CILA is a living arrangement which
promotes residential stability for an
individual who resides in his or her own
home, in a home shared with others, or in
the natural family home and who is provided
with an array of services to meet his or
her needs. The Community Services Act (405
ILCS 30) directs DHS to assume leadership
in facilitating an array of services for
persons with mental health and/or
developmental disabilities that will
strengthen the individuals’ self-esteem,
participate in and contribute to community
life, and prevent unnecessary
institutionalization. DHS funds CILA
services for persons with developmental
disabilities and for persons with mental
illness. Overall, for the period FY12-FY16:
• DHS expended over $2 billion on the CILA
program, a 36 percent increase during the
period.
• Ninety-seven percent of those
expenditures were for clients that received
CILA services related to developmental
disabilities (DD) issues.
• Mental health (MH) served clients, which
are financed through grants to community
agencies, experienced a drop in overall
expenditures from $11.9 million in FY12 to
$11.2 million in FY16.
• CILA program participation for DD clients
increased during the audit period by 23
percent. MH served clients decreased by 17
percent. Digest Exhibit 1 breaks down CILA
expenditures during the audit period.
(pages 1, 5, 8, 12) Please see the PDF
version of this digest for Exhibit 1.

DHS utilizes multiple organizational units
to oversee the CILA program. These units
include: the Bureau of Medicaid Waiver
Programs which oversees the federal waiver
which allows individuals to choose CILA
services; the Bureau of Community Services
which interfaces with providers of the CILA
program on a daily basis; the Bureau of
Quality Management that reviews CILAs for
purposes of ensuring compliance with the
federal home and community based waiver;
the Bureau of Accreditation, Licensure and
Certification licenses CILAs and is
responsible for surveys to ensure
compliance with DHS Rule 115, the CILA
Rule; and the Office of the Inspector
General which investigates allegations of
abuse, neglect and financial exploitation.
Digest Exhibit 2 presents the DHS
organization chart with the units
highlighted that monitor CILA operations.
(pages 6-7) Please see the PDF version of
this digest for Exhibit 2.

CILA Statistics

As of May 2017, there were 3,097 CILA
locations around the State. Over one-third
of all CILAs are located in Cook County.
Ninety-two of the 102 counties in Illinois
have some service level for CILAs. The
sites served approximately 10,000
individuals. Digest Exhibit 3 illustrates
the number of CILA sites in each county.
Please see the PDF version of this digest
for Exhibit 3.

Twenty percent of the CILA sites are
controlled by six provider agencies. Those
providers with the number of sites in
parentheses are:
• Trinity Services (118),
• Illinois Mentor Community Services (108),
• Clearbrook (107),
• UCP Seguin of Greater Chicago (97),
• Association for Individual Development
(91), and
• Individual Advocacy Group (90).

DHS failed to develop a State plan for the
distribution of CILAs around the State.
Nearly 20 percent of the counties around
the State of Illinois had either one CILA
site or no CILA sites. (pages 10-12)

Licensing Issues

During the audit we found a number of
weaknesses in the licensing process for the
CILA program. These findings included:
• DHS failed to provide transparency for
individuals and guardians regarding the
information it published on licensure
survey results for the CILA program. We
found multiple omissions in published data
during FY12-FY16. Additionally, DHS has not
adopted rules regarding posting of
information. (pages 22-25)
• The Bureau of Accreditation, Licensure
and Certification (BALC) utilizes a survey
scoring tool that is inconsistent with
criteria for sanction and license
revocation in administrative rules. The
scoring tool fails to provide scoring for
the lowest level of compliance as defined
in rule. This may have resulted in, for the
period FY12-FY16, BALC only taking action
on four license revocations. (pages 25-26)
• During the period FY12-FY16, DHS failed
to routinely provide BALC with Office of
the Inspector General (OIG) investigative
findings and reports. BALC was not always
aware of and could not follow up on OIG
recommendations to the CILA provider
agencies it licenses. (pages 26-29)
• DHS, in our sample of 25 CILA providers
for the period FY12-FY16, did not complete
five percent (7 of 128) of the CILA
provider agency annual reviews as required
by the administrative rules for CILA. For
the annual reviews that BALC did complete,
26 percent (31 of 121) were not timely.
Additionally, DHS allowed CILA provider
agencies to submit 12 percent (15 of 130)
of renewal applications outside the
timeframe required by the CILA Rule. (pages
29-31)
• BALC used the survey process, including
the issuance of notices of violations
(NOVs) for noncompliance with CILA
standards, to ensure CILA provider agencies
were complying with established standards.
However, we found BALC did not always issue
citations for NOVs as defined in the CILA
Rule. Additionally, BALC allowed CILA
provider agencies to maintain their CILA
licenses despite having repeat violations.
Finally, the NOV database did not represent
the actual number of violations. (pages
31-36)
• BALC survey documentation failed to
indicate immediate corrections had been
completed prior to completing licensing
surveys. This failure is a violation of
policy and can put CILA clients at risk of
injury. Additionally, BALC does not verify
that corrections to all violations of the
CILA Rule are completed by providers,
risking that clients remain in the same
living arrangements for three years prior
to conducting the next license survey.
(pages 36-40)
• Audit testing found that BALC: did not
complete or timely complete all surveys,
did not require all plans of correction
(POCs) to be submitted or be timely
submitted by CILA provider agencies, and
did not approve all POCs it received as
required by the administrative rules.
Additionally, auditors found some
subjectivity and inconsistency in the BALC
survey process. (pages 40-44)
• DHS has failed to adopt rules relative to
establishing a process to determine when to
review a CILA provider. This is a violation
of the CILA Licensure and Certification
Act. Additionally, BALC was not provided
with some of the means to make that
determination for the period FY12-FY16.
(pages 44-46)
• DHS failed to enforce CILA rules by not
seeking revocation of provider licenses in
cases where sections of the rule were
violated. Our examination of a sample of
CILA providers found instances where BALC
cited providers for falsified records,
failure to correct deficiencies and refusal
to participate in or permit the BALC survey
process. Rather than revoke the CILA
licenses, BALC either allowed the providers
to remain in the program or entered into
settlement agreements, agreements which
were not always followed. (pages 46-51)

Oversight and Monitoring Issues
During the audit we found a number of
weaknesses in the oversight and monitoring
of the CILA program by DHS. These findings
included:
• The Bureau of Quality Management (BQM)
failed to conduct CILA reviews on 50
providers of CILA services during the
period FY12-FY16. Twenty-three of the
providers were in the CILA program for at
least three years during the audit period.
These 23 providers received $47,508,399
from DHS for CILA services. (pages 54-57)
• BQM does not routinely share the results
of its oversight activities with the Bureau
of Accreditation, Licensing and
Certification (BALC). The sharing of this
information could be beneficial to BALC in
decisions to conduct well-being checks or
modify its survey schedule of CILA
providers. (pages 57-59)
• DHS does not monitor CILA residents’
personal funds maintained by the CILA
providers. Even though questions concerning
client funds were discovered by the OIG and
the Office of Contract Administration (OCA)
during the audit period it does not appear
that the unit tasked with licensing of
CILAs, BALC, conducted any follow-up or was
aware of problem CILA providers. (pages
59-64)
• DHS failed to maintain supporting
documentation for community placement
interest by individuals that reside in
SODCs. Due to this lack of documentation we
were unable to determine whether Community
Resource Associates (CRA) was conducting
activities only on individuals that were
actively pursuing transition to CILA. CRA
was paid almost $6.1 million by DHS for the
period FY12-FY16. (pages 64-68)
• DHS does not require organizational units
that have oversight of the CILA program to
always share information that could be
beneficial to monitoring efforts. OCA does
not provide the results of its fiscal/
administrative reviews with the DHS unit
that has authority to revoke the license of
a non-performing CILA provider, BALC.
(pages 68-70)
• DHS failed to revise administrative rules
for changes made to the CILA program. These
changes were effective July 1, 2017. The
failure by DHS resulted in community
providers and Independent Service
Coordinators (ISCs) operating under rules
that were not consistent with federal
guidelines. (pages 70-73)
• DHS did not seek recoupment from CILA
providers when documentation appeared to
show that individuals did not receive the
services for which the provider was being
paid. Evidence from DHS’ own documentation
showed that housekeeping, a service which
is part of the rate, was lacking in some
instances yet the provider was still paid
the full rate. Recovery was also not
conducted even when DHS documentation
showed that providers had not been able to
document that services were being
implemented for individuals. (pages 73-78)

Transition Follow-Up Issues

During the period FY12-FY16, DHS
transitioned 408 individuals from the eight
SODCs to CILAs. The responsibility for
providing follow-up service visits to
individuals who transition from an SODC to
the community is performed by several
entities. These entities are the ISCs, the
Bureau of Transitional Services (BTS)
within DHS, SODC staff, and a vendor
(Community Resource Associates (CRA)) that
DHS contracted with for SODC closure
activities. (pages 80-81)

DHS contracted with 17 ISCs whose primary
role is to work with the individual,
family, and/or guardian to identify the
most appropriate living arrangement, be it
State-operated facility or CILA. The 17
ISCs received over $28 million for these
services during the audit period. (pages
81-82)

During the audit we found a number of
weaknesses in whether individuals that
transitioned from State-Operated
Developmental Centers (SODCs) to the
community had the required transition
follow-up services. These findings
included:

• DHS failed to ensure that Independent
Service Coordinators (ISCs) maintained
documentation on all required visits to
individuals that transitioned from an SODC
to a CILA. ISCs only conducted 62 percent
of the required weekly visits to the
individuals in CILAs. Additionally, ISCs
only conducted 82 percent of the required
monthly visits to the individuals in CILAs.
However, ISCs did conduct 91 percent of the
required quarterly visits to the
individuals in CILAs. (pages 83-85)
• DHS, through its Bureau of Transitional
Services, failed to conduct follow-up
visits with individuals that transitioned
from SODCs to CILAs. Our sample testing
found that BTS only conducted 45 percent of
the required weekly visits to the
individuals in CILAs. Additionally, BTS
only conducted 51 percent of the required
monthly visits to the individuals in CILAs.
(pages 85-88)
• DHS failed to maintain documentation
showing that CRA conducted all transition
follow-up visits with individuals that
transitioned from SODCs during its
contracts with DHS. Auditors requested
documentation from DHS concerning all CRA
activities, including transition follow-up
visits conducted by CRA. However,
information provided to the auditors by DHS
did not document all of CRA’s required
transition follow–up visits. For instance,
DHS’ documentation of CRA’s follow-up
visits accounted for 56 percent (860 of
1,527) of the required weekly visits, and
11 percent (171 of 1,576) of the required
monthly visits. CRA initially indicated to
auditors that it had turned all of its
documentation over to DHS. Upon further
auditor inquiry, CRA did locate some
documentation; however, that documentation
also was not complete. (pages 88-91)
• DHS failed to ensure that ISCs maintained
all required consents for individuals
selecting CILA as a living option. Our
testing of 50 individuals that transitioned
to a CILA during the audit period found two
instances where the ISC did not have the
consent for CILA services. Additionally,
the consents we did review were often not
timely. Some consents occurred after the
individual transitioned, some consents were
signed the day of transition, and others
were dated well in advance of the
transition date. Based on our testing we
concluded only 20 percent of the consents
were timely. (pages 91-93)
• DHS failed to ensure that either the
individual in a CILA setting, or a
guardian, participated in the development
of all individual services plans (ISPs).
This lack of oversight contributed to
nearly 27 percent of our sample where the
plans were developed without input from the
individual or guardian. (pages 94-97)

Transition Planner Issues

DHS officials indicated that there was only
one contractor that provided transition
planning and support for the CILA program,
Community Resource Associates (CRA).
Officials also told auditors that the
decision to contract, and renew, with CRA
was not made by DHS. Instead, an official
from the Governor’s Office made that
decision. During the period FY12-FY15, CRA
was paid almost $6.1 million for services
to DHS. Digest Exhibit 4 breaks out the CRA
payments. (pages 99, 106) Please see PDF
version of this digest for Exhibit 4.

During the audit we found a number of
weaknesses in the oversight of the CRA
contract work. These findings included:
• DHS secured the services of Community
Resource Associates (CRA) under
questionable procurement strategies, first
as an emergency then as a purchase of care
contract. These strategies kept the
services from being competitively procured
and made it impossible to tell whether the
State received the best deal for the funds
paid. CRA was paid over $6 million by DHS
over the life of the contracts. (pages
101-106)
• DHS was unable to provide auditors
documentation to support its decision to
close any SODCs during the period FY13-
FY15. These decisions were needed for CRA
to conduct activities under two contracts
with DHS for transition services. DHS paid
CRA $3.9 million for these two contracts
even though it had no documentation to
support the need for the services. (pages
106-109)
• From 2012-2015, CRA received full
contractual payment, $6.1 million, from DHS
for services under three contracts. The
three contracts between DHS and CRA
contained deliverables sections. However,
DHS could not provide support for a number
of deliverables that were outlined in those
contracts. (pages 109-111)
• DHS provided CRA over $233,000 for
services more than 180 days after the
contract term ended for the contract to
assist in the closure of the Jacksonville
Developmental Center (JDC). The funds were
for follow-up services related to on-site
visits for the closure of JDC. However,
these services were already built into the
original contract, a contract that paid CRA
all $1,950,000 of the contract value.
(pages 111-113)

RECOMMENDATIONS

This audit report contains 26
recommendations directed to the Department
of Human Services. The Department accepted
6 recommendations, agreed with 5
recommendations, partially agreed with 6
recommendations and disagreed with 9
recommendations. Appendix H to the audit
report contains the agency responses.

This performance audit was conducted by
staff of the Office of the Auditor General.

MIKE MAZIARZ
Audit Manager

This report is transmitted in accordance
with Sections 3-14 and 3-15 of the Illinois
State Auditing Act.

FRANK J. MAUTINO
Auditor General

FJM:MJM