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

In FY 2002 46 percent of OIG investigations were completed within 60 days.

The number of cases taking more than 200 days to complete decreased from 547 in FY 2000 to 41 in FY2002.

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

The Inspector General has made two policy changes related to community agency investigations.

OIG substantiated abuse or neglect in 253 of 1,503 allegations of abuse or neglect in FY 2002.

We again recommended that the OIG establish a process to insure that all written responses are completed and received.

The Abused and Neglected Long Term Care Facility Residents Reporting Act (Act) requires the Office of the Inspector General (OIG) to investigate 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 Fiscal Year 2002, DHS operated 19 State facilities and licensed, certified, or funded over 400 community agencies. Additionally, the Act requires the Office of the Auditor General to conduct a biennial program audit of the Inspector General's compliance with the Act. This is the seventh audit conducted of the OIG since 1990.

Timeliness of investigations has improved significantly since our last audit. In Fiscal Year 2002, 46 percent of cases were completed within 60 calendar days while in Fiscal Year 2000 only 25 percent were completed within the 60-day requirement. In addition, the number of cases taking more than 200 days to complete has also decreased from 547 in Fiscal Year 2000 to 41 in Fiscal Year 2002. Although progress has been made, additional work is needed. Untimely investigations have been an issue in all seven OIG audits conducted by the Office of the Auditor General.

OIG case reports generally were thorough, comprehensive, and addressed the allegation. All case files in our sample contained a case report and a library sheet. Progress notes were obtained in cases where they were pertinent.

The Inspector General and State Police need an interagency agreement that stipulates responsibilities for investigations. The OIG and Illinois State Police's relationship has been guided by Administrative Order 1999-3 to investigate all criminal allegations of State employees who work at any agency under the control of the Governor. The Administrative Order provides guidance related to allegations involving State employees but not other allegations against non-State employees where evidence indicates a possible criminal act.

Alleged incidents of abuse or neglect are not being reported to the OIG by facilities and community agencies in the time frames required by OIG administrative rule. During the second half of Fiscal Year 2002, 16 percent of facility cases and 50 percent of community agency cases were not reported within the OIG's reporting requirement.

We found that various changes in investigative guidance and administrative rules may have left investigative staff unclear on appropriate definitions and investigative requirements. During Fiscal Year 2002, the Inspector General's Office operated under three versions of administrative rule 50. In addition, the OIG had memos, Directives, and Guidelines that were all in effect during portions of this audit period.

The Deputy Inspector General did not review all substantiated cases of abuse or neglect as required by OIG's investigative guidance. Our fieldwork sample contained 18 substantiated cases of abuse or neglect. Twelve of the 18 substantiated investigations were completed by community agencies. None of these 12 cases were reviewed by the Inspector General, the Deputy Inspector General, or a designee.

Although training of OIG investigators had improved in our last OIG audit, there were again problems in this audit period. In our previous OIG audits, we have had seven total recommendations on training in four of the audits. We again recommended that the Inspector General should ensure that all OIG investigators meet training requirements as set forth by OIG investigative guidance.

The Quality Care Board did not meet statutory requirements for meeting quarterly. In Fiscal Year 2001, the Board only met twice and in Fiscal Year 2002, the Board met three times. This is the first OIG audit where the Board has not met as required by the Act. However, it appeared that the Board was following other requirements established by the statutes.

The Office of the Inspector General (OIG) was established by Public Act 85-223 in 1987 which amended the Abused and Neglected Long Term Care Facility Residents Reporting Act (210 ILCS 30/et seq.). The Act required the Inspector General to investigate allegations of abuse and neglect within State-operated facilities serving the mentally ill and developmentally disabled. In 1995, the role of the Office of the Inspector General expanded to include the authority to investigate reports of abuse or neglect at facilities or programs not only operated by the Department of Human Services (State facilities), but also those licensed, certified, or funded by DHS (community agencies).

As of April 2002, the OIG had 68 staff. This represents an increase of nine positions over staffing levels reported in our 2000 OIG audit. However, investigative staff for abuse or neglect investigations have decreased from 39 in FY 2000 to 27 in FY 2002. The largest organizational unit within the OIG is the Bureau of Investigation. The Bureau of Investigation is responsible for conducting investigations of allegations of abuse or neglect. Each region has a Bureau Chief, an Investigative Team Leader who is responsible primarily for case file review, and additional investigatory staff.

In FY 2002, the Department of Human Services operated 19 facilities Statewide which served 13,680 individuals. Nine facilities served the developmentally disabled, eight facilities served the mentally ill, and two facilities served both. In FY 2003 two facilities and half of a third were closed. In addition, DHS licenses, certifies, or provides funding for over 400 community agency programs that provided services to approximately 24,500 individuals with developmental disabilities and approximately 160,000 individuals with mental illness in FY 2002.

In FY 2002, a total of 1,636 allegations of abuse or neglect were reported to the OIG (948 from State facilities and 688 from community agencies). Digest Exhibit 1 summarizes abuse or neglect allegations reported to the OIG from the two sources for FY 1997 to FY 2002. For perspective, a note to the exhibit contains DHS statistics on the numbers of individuals served in State facilities and by community agencies.

In the past, the Office of the Auditor General has conducted six 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, 1998, and 2000. (pages 2, 4, 12, 13)

Changes in Investigative Guidance

Various changes in investigative guidance may have left investigative staff unclear on appropriate definitions and investigative requirements. In past audits of the Inspector General's Office we have reviewed a number of different versions of guidance that investigators are to follow. In this audit, we did our testing from cases closed in Fiscal Year 2002. During that time period the old version of administrative rule 50 was in effect from July to December; then an emergency rule was in effect from January through part of May; and finally a new version of rule 50 was in effect for part of May through June.

In addition, the OIG had memos, Directives, and Guidelines that were all in effect during portions of this audit period. Investigative Guidelines were a portion of the investigative guidance that was in effect during our last OIG audit which was released in December of 2000. But by January of 2001 several memos were issued to change investigative guidance. Then, in January to March 2002 a number of Directives came out to change investigative guidance. Some Directives followed similar memos. For example, a memo on a case management system was issued in January of 2001 and was followed with a Directive in February of 2002. Directives sometimes rescinded or amended portions of the Guidelines, but portions of the Guidelines were still in effect when we were completing our fieldwork. We recommended that the Inspector General assure that clear and consistent investigative guidance is available for investigators which allows investigative effectiveness to be judged over time. (pages 7-9)

OTHER STATE AGENCIES

Neither the OIG nor State Police are fulfilling statutory responsibilities established under the Abused and Neglected Long Term Care Facility Residents Reporting Act. The Inspector General and State Police need an interagency agreement that stipulates responsibilities for investigations. The OIG and Illinois State Police's relationship has been guided by Administrative Order 1999-3 to investigate all criminal allegations of State employees who work at any agency under the control of the Governor. The Administrative Order provides guidance related to allegations involving State employees but not other allegations against non-State employees where evidence indicates a possible criminal act. The OIG should assure that allegations at community agencies, where a possible criminal act has been committed, are referred as required. (pages 10-11)

INVESTIGATION TIMELINESS

While overall timeliness of investigations has been an issue in the previous six OIG audits, there has been noteworthy improvement in FY 2001 and 2002. One of the clearest indicators of this improvement is that in FY 2002, 46 percent of investigations were completed in 60 days while in FY 2000 only 25 percent were completed within 60 days. Although improvement is still needed, significant progress was made. Digest Exhibit 2 shows timeliness data for OIG investigations for the last six fiscal years.

The number of cases taking more than 200 days to complete has also decreased significantly from FY 2000. In FY 2000, 547 cases took longer than 200 days to complete. By FY 2002, the cases taking longer than 200 days to complete decreased to 41. Investigations at State facilities completed during FY 2002 accounted for 46 percent (19 of 41) of the cases that took longer than 200 days to complete and community agency investigations accounted for 54 percent (22 of 41).

Although timeliness has improved since our last audit, the OIG does not have a good method to document for all cases what is preventing completion of cases that go over the 60-day completion requirement and to assure that cases continue to have investigative progress. In January 2001, the Inspector General issued a memo saying that a case management system would be implemented February 1, 2001. In February 2002, an OIG Directive was issued that established the policy for the case management system along with the authority, responsibilities and related procedures. The system is not electronic but a paper based system where each investigator submits one form for each case if it is not completed within 30 days and within 45 days of assignment. Team leaders review the investigators’ reports, sign off on them and submit a monthly report on them to their supervisor, the Bureau Chief. Bureau Chiefs then submit a monthly report to the Deputy Inspector General which shows all cases more than 45 days old. This report should include the reason for the delay, the actions needed to complete the investigation, and the expected date of completion.

Our analysis showed that, February 2002 reports that Bureau Chiefs prepared did not contain all of the cases over 45 days old. Less than 30 percent of cases over 45 days old were included on the case management reports. When the reports are incomplete, Bureau Chiefs cannot rely on them to adequately monitor timeliness. We recommended that the Inspector General continue to work to improve the timeliness in investigations of abuse and neglect. (pages 15-21)

Alleged incidents of abuse and neglect are not being reported to the OIG by facilities and community agencies in the time frames required by OIG administrative rule. Improvement in time to report incidents was not realized until the second half of FY 2002 when the OIG revised the reporting requirement from one to four hours after discovery of the incident. In the first half of FY 2002, the reporting times by facilities and community agencies were almost identical to the times from the 2000 OIG audit. We recommended that the Inspector General work with State facilities and community agencies to ensure that allegations of abuse or neglect are reported within the time frame specified in State law and OIG administrative rules. (pages 22, 23)

INVESTIGATION THOROUGHNESS

OIG case reports generally were thorough, comprehensive, and addressed the allegation. All case files in our sample contained a case report and a library sheet. Additionally, progress notes were obtained in cases where they were pertinent. We did find that photographs were not taken in 5 of 11 cases where an injury report indicated that an injury was sustained.

The Deputy Inspector General did not review all substantiated cases of abuse or neglect as required by OIG’s investigative guidance. Our fieldwork sample contained 18 substantiated cases of abuse or neglect. Twelve of the 18 substantiated investigations were completed by community agencies. None of these 12 cases were reviewed by the Inspector General, the Deputy Inspector General, or a designee. We recommended that the Inspector General assure that all cases requiring review by the Inspector General, the Deputy Inspector General, or a designee receive that review.

Community Agency Investigations

In general, investigations by the community agencies were complete and thorough in our sample of cases from FY 2002. However, the Inspector General has made two policy changes related to community agency investigations.

• Community agencies now must accept the community agency protocol developed by the OIG and be properly trained or they will not be allowed to conduct any investigations for the OIG.
• As of January 1, 2002, OIG administrative rules were changed so that community agencies can investigate only abuse cases that allege mental injury.

In addition, facilities and community agencies may still investigate reportable incidents that do not meet the definition of abuse and neglect.

There were 304 cases reported in FY 2002 that were investigated by community agencies. In the first half of the fiscal year (between July 1, 2001 and December 31, 2001), 279 cases were investigated by community agencies. The second half of the fiscal year (between January 1, 2002 and June 30, 2002) only 25 cases were investigated by community agencies. The significant decrease in community agency investigations is likely due to policy changes noted above.

We reviewed the 25 cases that were investigated by community agencies from the second half of FY 2002 to see if the community agencies had adopted OIG investigative protocols. We found one community agency that investigated 3 of the 25 cases but had not adopted the OIG Investigative protocol as required by OIG administrative rule. (pages 25-29)

SUBSTANTIATED ABUSE AND NEGLECT CASES

In FY 2002, the OIG closed a total of 1,503 investigations of allegations of abuse or neglect. The OIG substantiated 253 of the abuse or neglect allegations, resulting in a 17 percent substantiation rate. Digest Exhibit 3 shows the past seven years’ closed cases and substantiation rates for allegations classified as abuse and neglect. The exhibit breaks out both facility and community agency allegations and substantiated cases of abuse and neglect. The data includes substantiated cases investigated by OIG that were classified as abuse or neglect at intake. (pages 31-33)

ACTIONS, SANCTIONS, AND RECOMMENDATIONS

Although the Office of the Inspector General is statutorily responsible for requiring facilities and community agencies to submit written responses for substantiated cases, they have not established a process to insure that all written responses are completed and received. In our 2000 OIG audit and in this audit, we recommended that the OIG establish a process to track and follow-up on cases that did not provide a written response.

Over the past nine fiscal years (1994 to 2002) the Inspector General has not used sanctions against facilities. The Act (210 ILCS 30/6.2) gives the Inspector General broad authority to recommend sanctions. In our 2000 OIG audit, the OIG’s Guidelines included criteria for sanctions. At the close of this audit, the Inspector General was working to develop a new Directive that specifies criteria when sanctions could be recommended.

Digest Exhibit 4 shows the 260 substantiated cases by the type of action taken and by the investigating agency. Administrative action was taken in 78 percent of the cases (202 of 260) and was the most frequently used action in both OIG and community agency investigations.

Administrative actions include, but are not limited to suspension, termination, reprimand, and retraining. (pages 34-38)

OTHER ISSUES

Although training of OIG investigators had improved in our last OIG audit, there were again issues noted in this audit period. In our previous OIG audits, we have had seven total recommendations on training in four of the audits. We again recommended that the Inspector General should ensure that all OIG investigators meet training requirements as set forth by OIG investigative guidance.

During Fiscal Years 2001 and 2002, the Quality Care Board did not meet statutory requirements for meeting quarterly. In Fiscal Year 2001, the Board only met twice and in Fiscal Year 2002, the Board met three times. This is the first OIG audit where the Board has not met as required by the Act. However, it appeared that the Board was following other requirements established by the statutes. We recommended that the Inspector General work with the Quality Care Board to assure that the Board meets quarterly as required by statute. (pages 41-44)

RECOMMENDATIONS

The audit report contains eight total recommendations, seven related to the Office of the Inspector General and one recommendation to both the Office of the Inspector General and the Illinois State Police. The OIG and State Police generally agreed with the recommendations. Appendix E to the audit report contains the Inspector General’s and the State Police’s complete responses.

________________________________  William G. Holland
Auditor General

 

WGH\EKW
December 2002