REPORT
DIGEST

 

ILLINOIS DEPARTMENT OF MENTAL HEALTH AND DEVELOPMENTAL DISABILITIES

 

PROGRAM AUDIT:
OFFICE OF THE INSPECTOR GENERAL

Release Date: December 1996

 

State of Illinois
Office of the Auditor General

JOHN W. KUNZEMAN
DEPUTY
AUDITOR GENERAL

Iles Park Plaza
740 E. Ash Street
Springfield, IL 62703
(217) 782-6046
TDD: (217) 524-4646

 

SYNOPSIS

This is our fourth audit of the Office of the Inspector General's (OIG's) effectiveness in investigating allegations of abuse or neglect at facilities within the Department of Mental Health and Developmental Disabilities (DMHDD). In this audit we reviewed a random sample of 278 OIG investigations closed in Fiscal Year 1996. Several findings have been repeated from our prior audits:

  • While overall timeliness of the investigations has improved since our December 1994 audit, further improvement is warranted. Fifty percent of the investigations reviewed took longer than the 60 days recommended by DMHDD policy.
  • Forty-four percent of the case files reviewed were missing some required documentation. Examples of missing documentation included photos where visible injuries were sustained (46 of 99 cases) and medical examinations (21 of 225 cases).
  • Supervisory review of case files needs to be improved. Of 236 investigations that required a supervisory review form, 19 (8 percent) did not have the form. Also, in some cases, missing documentation was not noted in supervisory case reviews.
  • OIG's database contained inaccurate information due primarily to a lack of an adequate control structure. This database is used to track and record reported incidents of abuse or neglect and to prepare the OIG's statutorily required annual report to the General Assembly.

We also found that the OIG closed cases as "recantations" without conducting thorough investigations. In addition, we found that not all OIG investigators, as well as facility personnel responsible for collecting initial investigatory information, had received all the training required by OIG policy.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Office of the Inspector General was established to investigate alleged abuse or neglect at DMHDD-operated facilities.

 

 

 

Important aspects of an investigation are: thoroughness, timeliness, and whether corrective action is taken.

 

 

 

 

 

 

 

 

 

The overall timeliness of OIG investigations has improved since our December 1994 audit.

 

 

 

 

 

 

 

  

 

 

 

Initial witness statements were not always completed in a timely manner.

 

 

 

 

 

 

 

We recommended that the OIG continue to improve the timeliness of its investigations.

 

 

 

 

Forty-four percent of the case files reviewed were missing one or more pieces of required documentary evidence.

 

FINDINGS, CONCLUSIONS, AND RECOMMENDATIONS

REPORT CONCLUSIONS

The Office of the Inspector General (OIG) closed 1,077 investigations of alleged employee abuse or neglect of DMHDD facility residents in Fiscal Year 1995 and 1,001 in Fiscal Year 1996. The percentage of abuse allegations substantiated declined from 11 percent in Fiscal Year 1995 to 8 percent in Fiscal Year 1996.

While the overall investigation timeliness has improved since our December 1994 audit, further improvement is needed. Fifty percent of the investigations we reviewed took longer than the 60 days recommended by DMHDD policy. In our 1994 audit, 78 percent of the investigations took longer than 60 days to complete.

Case files continued to lack required documentation. In our 1994 audit, 26 percent of the cases reviewed were missing required documentary evidence. In this audit, we found that 44 percent (122 of 278) of the investigations reviewed were missing one or more required documents. Examples of missing documentation included photos where visible injuries were sustained (46 of 99 cases) and medical examinations (21 of 225 cases).

The OIG also improperly closed cases classified as "recantations" (where a person recanted the allegation) without conducting a thorough investigation. In 12 of the 35 recantations reviewed, the victim had a physical injury consistent with the allegation, but the case was closed as a recantation. In some cases closed as a recantation, the victim did not actually recant the allegation.

Many factors may contribute to the above identified problems. OIG investigators were not receiving the training required by OIG policy. Of the 19 OIG investigators, 11 were lacking 5 or more of the required courses. Also, contrary to OIG policy, untrained facility staff collected 14 percent (321 of 2,299) of the written statements we reviewed from the alleged perpetrators, victims, and witnesses. Similarly, in 40 percent (110 of 278) of the investigations examined, the OIG noted a problem with the facilities' collection of preliminary evidence.

Improvements in supervisory review are also warranted. Supervisory review is essential in ensuring that OIG investigations are timely and thorough. Eight percent (19 of 236) of the cases reviewed did not have the investigation review form supervisors are required to complete. In some cases, missing documentation was not noted in supervisory case reviews.

In the audit, we also found that:

BACKGROUND

The General Assembly established the Office of the Inspector General (OIG) (Public Act 85-223, effective August 26, 1987) to investigate alleged incidents of abuse or neglect at DMHDD-operated facilities. The Inspector General is appointed by the Governor and confirmed by the Senate for a four-year term. The Inspector General reports to the Director of the Department. The current Inspector General was appointed in October 1995.

The OIG closed 1,077 investigations of employee abuse or neglect in Fiscal Year 1995 and 1,001 in Fiscal Year 1996. The substantiation rate in Fiscal Year 1995 was 11 percent; in Fiscal Year 1996 it was 8 percent. When asked about the decrease in substantiation rates, OIG officials stated that they had not yet had an opportunity to study this question.

There are several aspects to an investigation which can have an impact on whether the investigation is or is not effective. These aspects include: whether the investigation is timely; whether the investigation is thorough (such as whether all relevant evidence is collected and analyzed); and whether corrective action is taken. (pp. 13, 22, & 35)

INVESTIGATION TIMELINESS

While the overall timeliness of OIG investigations of employee abuse or neglect has improved since our December 1994 audit, 50 percent of the investigations we reviewed took longer than the 60 days recommended by DMHDD policy. In our previous audit, 78 percent of investigations exceeded 60 days. In addition, the number of cases that took more than 250 days to complete decreased from 35 percent in our 1994 audit to 3 percent in this audit, as shown in Digest Exhibit 1. (pp. 13-15)

There were certain aspects of investigations where improvements in timeliness were also warranted. Initial written statements were not completed in a timely manner. OIG requires that an initial written statement be taken from each facility staff and resident who may have witnessed the incident within three working days of the reported incident. We reviewed 2,299 initial written statements. As shown in Digest Exhibit 2, 52 percent of the written statements were taken within the required three day period.

The OIG did not always initiate investigations of employee abuse or neglect in a timely manner. In one-third (95 of 278) of investigations reviewed, the first OIG interview was not conducted for more than one month after the incident was reported to the OIG.

The effectiveness of an investigation is diminished if it is not conducted in a timely manner. With the passage of time, injuries heal, memories fade, and witnesses may not be located. We recommended that the OIG continue to improve the timeliness of employee abuse or neglect investigations and ensure that preliminary evidence, such as written witness statements, is collected in a timely manner. (p. 15 - 18)

INVESTIGATION THOROUGHNESS

Collection of all relevant evidence is an essential component of an effective abuse or neglect investigation. Many case files continued to lack required documentary evidence. Of the case files reviewed in this audit, 122 (44 percent) were missing one or more pieces of required documentary evidence. Photographs were missing in 46 cases, diagrams were missing in 30 cases, and medical exams were missing in 21 cases. Digest Exhibit 3 summarizes the missing documentation. In our December 1994 audit, we found that 26 percent of case files reviewed were missing required documentary evidence.

 

Digest Exhibit 3
EXAMPLES OF MISSING
DOCUMENTATION
Document

Percent
Missing

*Number
Missing
Medical Exam

9%

21 of 225
Photos

46%

46 of 99
Diagrams

12%

30 of 255
Time Sheets

13%

33 of 257
Visitor’s Log

15%

32 of 217

Progress Notes

7%

19 of 264
Restraint/Seclusion Monitoring Record

7%

4 of 60
Source: OAG analysis of 278 OIG abuse or neglect investigations closed in FY96

Note: * Total does not equal 278 because documentation was not applicable in all cases.

 

 

 

 

 

 

Cases were improperly closed as "recantations".

 

 

 

 

 

 

 

 

 

We continued to note areas where supervisory review of case files and monitoring of open investigations could be improved.

 

 

 

 

 

 

 

 

 

 

Facilities decide what action to take, if any, in response to findings from the OIG investigation.

 

 

 

 

 

 

 

 

 

 

 

 

 

OIG investigators lacked required training.

 

 

 

 

 

 

 

 

 

 

In 110 of the 278 cases sampled (40 percent), the OIG noted a problem with the facilities' collection of preliminary evidence.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

There is no policy to ensure that facility investigations of abuse are conducted in a consistent manner.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The OIG has inadequate controls over its investigations database which affects the reliability and accuracy of data.

We also found that in 18 percent (50 of 278) of the cases sampled, not all persons listed on the incident report completed the required initial written statement. In 11 percent of the investigations, the OIG investigator did not interview either the victim, the alleged perpetrator, or other eyewitnesses. We recommended that the Inspector General should ensure that all required documentation is collected during the investigation process. (pp. 22-27)

The OIG closed some cases without conducting a thorough investigation. Forty percent (14 of 35) of investigations sampled which were closed as recantations (where a person recanted the allegation made) did not follow OIG procedures for closing such cases. In some cases, the victim did not actually recant the allegation. In 12 of the 35 cases (34 percent), the victim had an actual physical injury consistent with the initial allegation.

The use of recantations was more prevalent at some facilities than others in the cases we sampled. Kiley Developmental Center accounted for 10 (29 percent) of the 35. Choate Mental Health and Developmental Center had 6 (17 percent), and Howe Developmental Center and Jacksonville Developmental Center each had 5 (14 percent).

According to OIG officials, the policies concerning recantations were discontinued in Fiscal Year 1997, which occurred after our testing period. We plan to follow up on this in our subsequent audit. (pp. 27-30)

CASE REVIEW AND MONITORING

We continued to note areas where supervisory review of case files and monitoring of open investigations could be improved. The reviewer is to complete a standardized case review form for each case indicating irregularities or issues that were noted during the review.

Of the 236 investigations that required a supervisory case review form, 19 (8 percent) did not have the review form. We could therefore not determine to what extent the cases had been reviewed. Also in some cases, missing documentation was not noted in supervisory case reviews.

Fifty-four percent of the cases (74 of 138) that required status reports did not contain all the required reports. These reports are required in all cases over 60 days old in order to document the reason for the investigation delay. We recommended that the Inspector General ensure that adequate supervisory review occurs on OIG investigations, including the completion of supervisory case review forms and status reports which document reasons for investigation delays and require documentation of supervisory review. (pp. 31-33)

CORRECTIVE ACTION

An investigation is far less likely to have an impact if corrective action is warranted, but none is recommended or taken. After an investigation is completed, the OIG sends a recommendation memo to the facility concerning the findings of the case. The OIG does not make specific recommendations to facilities concerning corrective actions. The recommendation memos generally describe the incident and state the finding, but leave it to the facility to determine what, if any, corrective actions are taken. In the 278 cases reviewed, at least 34 employees were either reprimanded, suspended, discharged, or resigned due to findings of abuse, neglect, or other employee misconduct.

Of the 278 cases sampled, OIG substantiated abuse or neglect in 17 cases. In two of the substantiated cases of abuse or neglect, no corrective action was taken against the employees. In some substantiated cases the facilities disagreed with the OIG's position and identified investigative errors, according to the OIG.

We also noted instances where facilities took different actions against staff for similar types of misconduct. We recommended that the Inspector General monitor action taken by facilities for consistency and refer cases to the Director of DMHDD when appropriate corrective action is not taken. (pp. 35-40)

OIG INVESTIGATOR TRAINING

OIG investigators are not receiving the training required by The Abused and Neglected Long Term Care Facility Residents Reporting Act (Act) and OIG policy. The Act requires the OIG to establish a comprehensive program to ensure that every person employed or newly hired to conduct investigations receives training on an on-going basis concerning investigative techniques, communication skills, and the appropriate means of contact with persons admitted or committed to the facilities under the jurisdiction of the Department.

As of June 30, 1996, only two of the nineteen investigators had received all the training required by OIG policy. The other 17 investigators were missing between 1 and 12 of the required courses. We recommended that the Inspector General ensure that every person employed or newly hired to conduct investigations receive the required investigatory training courses established by OIG policy. (pp. 44-45)

TRAINING OF FACILITY STAFF

Untrained facility staff are collecting preliminary investigation evidence, contrary to OIG policy. OIG policy requires that at the scene of an alleged incident of abuse or neglect, a trained facility designee should secure the scene and collect relevant physical evidence and take initial written statements. If staff have not been trained in basic investigations, OIG field investigators are responsible for ensuring that initial written statements are obtained.

In our review of 2,299 written statements, we found that 321, or 14 percent, were taken by facility staff not trained in the Basic Investigations Course. The remaining statements were taken by either OIG investigators, trained facility staff, or it could not be determined who took the statements. Furthermore, in 110 of the 278 cases sampled (40 percent), the OIG noted a problem with the facilities' collection of preliminary evidence. Our April 1996 audit of facilities' reporting of abuse or neglect also concluded that additional training of facility staff on the reporting of abuse or neglect was needed.

The proper collection of evidence is a critical component of an abuse investigation. Having facility staff who are untrained in the proper methods of evidence collection could impair the overall effectiveness of the OIG investigation. We recommended that the Inspector General ensure that all facility employees involved in reporting and collecting initial evidence of resident abuse or neglect receive required training. (pp. 45-47)

FACILITY ABUSE INVESTIGATIONS

The OIG is not ensuring that all investigations of abuse or neglect are being conducted in a thorough and consistent manner. The OIG investigates allegations of abuse of residents by employees. Investigations of other types of abuse, as defined by the Abused and Neglected Long Term Care Facility Residents Reporting Act, such as injuries caused by another resident, are conducted by facility staff. The OIG reviews these facility investigations.

There is no policy or control to ensure that facility investigations of abuse are conducted in a consistent manner. DMHDD policy does not specify how facility investigations should be conducted and there were no uniform training requirements for facility investigators.

Our review of 25 facility investigations found a wide variance in the content of the case files submitted to the OIG for review at the conclusion of the investigation. Some case files contained only the incident report and injury report; others had additional documentation.

The Act gives the OIG the responsibility to conduct investigations of all abuse allegations. Without ensuring that all investigations of abuse are conducted by appropriately trained staff and meet basic investigation requirements, the OIG cannot assure that it is meeting its statutory mandate. We recommended that the Inspector General ensure that all investigations of abuse or neglect allegations: are conducted by trained investigators, follow established investigation protocols, adequately document the investigation procedures used and conclusions reached, and are adequately reviewed by supervisory personnel. (pp. 47-49)

OIG INVESTIGATIONS LOG COMPUTER SYSTEM

The OIG Investigations Log computer system contains inaccurate information. This condition was primarily due to a lack of an adequate control structure. These control weaknesses affect the reliability and accuracy of the information used to record and track reported incidents of abuse or neglect.

In several instances, information concerning number and types of allegations, case findings, and closed cases requested and received from the OIG was inconsistent with prior information received from the OIG or that which is contained in the OIG's Annual Reports. The changes to the data are not documented and it is often unclear why and how the data changed. Documentation of changes made to the database would allow for a clear audit trail.

Incorrect data was input into OIG's database in over a third of the cases in our sample. In 104 of the 278 (37 percent) OIG investigations reviewed, at least one piece of information in the Investigations Log database did not agree with that in the case file. Errors ranged from differences in times or dates to incorrect investigation finding codes.

This finding is expanded and repeated from our 1994 audit report in which we also found a lack of controls related to the OIG's Investigations Log computer system. We recommended that the OIG strengthen its controls over its database and ensure that data is consistent and valid from year to year. (pp. 52-57)

AGENCY RECOMMENDATIONS

The audit report contains 15 recommendations related to the Office of the Inspector General. The Inspector General provided responses to the recommendations, as well as other comments to the report. Appendix E to the audit report contains the Inspector General's complete response.

 

_____________________________
JOHN W. KUNZEMAN
Deputy Auditor General

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December 1996