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“Criminal inaction”

Thursday, Jun 28, 2012

* This is just incomprehensible to me

The state agency created to prevent neglect and abuse of disabled adults who live at home rejects hundreds of hotline calls for help each year and doesn’t investigate when people die after severe mistreatment. […]

But when the subject of a hotline call is hospitalized and dies soon after, the OIG closes the case without investigating the circumstances surrounding the death because of the agency’s interpretation of state law. According to OIG documents, the agency is prohibited from investigating the moment a death occurs.

The OIG considers such an investigation a “service,” and the dead are “ineligible for services” under the agency’s interpretation of Rule 51 — a legislative directive that governs the Adults with Disabilities Abuse Project, the OIG documents state.

What the Office of Inspector General is saying is just bizarre. If the person surves the alleged abuse, then there will be a full investigation. But if the patient dies, possibly of extreme neglect, then there will be no investigation because the dead person is “ineligible for services.”

That sounds like something right out of Kafka.

What the heck is going on over at the Department of Human Services?

* Kudos to the Belleville News Democrat for unearthing these atrocities

Nurses, doctors, social workers or hospital staff called the state abuse hotline in nearly half of the 53 deaths examined by the News-Democrat. But even demands from medical professionals asking why a disabled adult ended up in their emergency room, often in horrible condition, did not prompt the OIG to investigate.

Those deaths included Barbara Coleman, a 56-year-old Pittsfield woman dying from kidney failure who was taken to a Springfield emergency room on Nov. 18, 2009, with a large abscess on her neck filled with maggots. She died two days later.

“Based on the facts here, we conclude the following: (Coleman) passed away at the hospital and the assessment could not be completed. Therefore, we stopped this assessment process without a finding,” the OIG case file concluded.

Bonnie Matyasik, 51, who was suffering from end-stage cirrhosis, arrived at an emergency room Jan. 26, 2009, near Chicago with dried feces in her hair and under her fingernails. Matyasik was bruised and scraped along one entire side of her body from being dragged across a concrete floor by her mentally impaired caregiver. She died two days later.

On May 6, 2011, authorities responding to a 911 call found Kevin Kage, the 1986 Illinois muscular dystrophy poster child, lying in a bed soiled with feces and urine, unable to move and covered with bedsores that had eaten through flesh to the bone. The 33-year-old Kage died four days later in the intensive care unit of a Wisconsin hospital.


* Some heads really need to roll here

The law in part reads: “This Act shall be liberally construed and applied to promote its underlying purposes, which are to prevent, reduce and eliminate abuse, neglect and exploitation of adults with disabilities.”

“It breaks your heart to see anybody subjected to this kind of abuse and the state not taking appropriate action,” said former state Rep. Lee Daniels, R-Elmhurst, who helped guide passage of the bill. “To allow this to continue is criminal inaction.”

Thomas F. Coleman, the attorney for the Disability and Abuse Project in Los Angeles, a private coalition of medical professionals and volunteers dedicated to assisting the disabled, reviewed the 2000 Illinois statute and Rule 51.

“These laws do not state that an investigation need not be done if the victim is not receiving services. So the ‘no services because they are dead’ excuse is just that — a shallow and meaningless excuse for closing a case. There is no statutory authorization to close an investigation or refuse to initiate one because the victim is dead,” he said. “Whoever came up with that rule should be exposed.”

Go read the whole thing.


- Posted by Rich Miller        

  1. - collar observer - Thursday, Jun 28, 12 @ 9:36 am:

    “To allow this to continue is criminal inaction.”

    First thought I had as I began to read. Wow - I am blown away - no one figured this out until NOW?

  2. - Rob - Thursday, Jun 28, 12 @ 9:40 am:

    Wow…why didn’t they just say they couldn’t do it because they were underfunded and understaffed?

    That would have been a much more acceptable response.

  3. - western illinois - Thursday, Jun 28, 12 @ 9:41 am:

    I was just at a DHS offcie the other day. There was almost no one ther I saw a stack of cases for one persona mile high
    We have cut government

  4. - Cassiopeia - Thursday, Jun 28, 12 @ 9:43 am:

    Nothing will happen at DHS since the Secretary there is one of the “protected” ones that cannot be disciplined no matter how bad they manage. If the heat gets too much or they have confirmation problems they get a new department to run.

    Mismanage GOMB and relationships with the legislature and you get to run DCEO.

    Be found unqualified at State Police and you get moved to IEMA.

    The Quinn beat goes on for 928 more days.

  5. - Crime Fighter (fka Honestly) - Thursday, Jun 28, 12 @ 9:51 am:

    One reason this type thing may continue is beacause the OIG/OEIG refuses to protect whistle-blowers who are fired. The inspectors refuse to follow-up on whistleblower retaliation based on its claim that they do not pursue cases where there may be other statutory violations. Geesh!

    The important thing to remember is that our state has an ethical focus that can catch a SERS employee eating lunch at their desk.

  6. - Rich Miller - Thursday, Jun 28, 12 @ 9:55 am:

    ===The important thing to remember is that our state has an ethical focus that can catch a SERS employee eating lunch at their desk. ===

    Exactly. What a joke the OIG system has become.

  7. - Secret Square - Thursday, Jun 28, 12 @ 10:06 am:

    What is Rule 51? What is a “legislative directive” anyway? Whose, ahem, brilliant idea was it (I’d better not say what I think of them after reading these stories, I’d surely be banned for life), and where can we find a copy of it?

  8. - soccermom - Thursday, Jun 28, 12 @ 10:06 am:

    Having been questioned by the OIG brain trust, I think we need to find people with brains, experience, and good judgment to investigate these cases — i.e., people who are NOT OIG investigators.

  9. - soccermom - Thursday, Jun 28, 12 @ 10:07 am:

    The Governor should hire the BND’s investigative reporters to look into this kind of thing. I’m serious — they’re world-class.

  10. - Secret Square - Thursday, Jun 28, 12 @ 10:26 am:

    OK, I think I’ve found the “Rule 51″ referred to in the story. It apparently refers to Title 59, Part 51 of the Illinois Administrative Code, containing the DHS OIG rules for the Adults with Disabilities Abuse Project. You can read the various sections here:

    I’ve perused these rules a couple of times in the last few minutes and unless I’m missing something, there is absolutely NOTHING in these rules that says an investigation must be terminated if the abuse victim dies because dead people can’t receive “services”. Nor does it define “services” in a manner that would lend itself to such an interpretation.

    If anyone can tell me where the DHS OIG came up with that interpretation, I’d sure like to know.

  11. - Yellow Dog Democrat - Thursday, Jun 28, 12 @ 10:30 am:

    In retrospect, the OIG probably shouldn’t be performing this investigatory function.

    OIG is primarily designed for internal investigations.

    And FIVE investigators? No wonder they dropped the ball.

    With all due respect to Leader Daniels, I’d recommend retooling the program to model it based on the Elder Abuse and Neglect Act, administered by the Department of Aging. Through 45 local agencies — primarily nonprofits that are morally committed to protecting the elderly — EANA has proven highly effective at investigating and preventing abuse and neglect in the community. Cases occurring within licensed facilities are investigated by the Illinois Department of Public Health, which oversees licensure.

    BTW, I would like to know if — and if not why not — any of these cases were referred to local state’s attorneys. Rich?

  12. - Leave a Light on George - Thursday, Jun 28, 12 @ 10:31 am:

    This is a result, in part due to corruption. This is an agency that was led by incompetent Blago hacks. Governor Quinn failed in his promiise to “fumigate”

  13. - G'Kar - Thursday, Jun 28, 12 @ 10:39 am:

    First, I agree wholeheartedly that this is wrong and something needs to be done to fix it at the state level. But, and I may be showing my ignorance here, would the three examples given be criminal cases that should be investigated by the local police and local state’s attorney’s office?

  14. - Rayne of Terror - Thursday, Jun 28, 12 @ 10:46 am:

    Could it be that investigations end at death because the appropriate state’s attorney office takes over?

  15. - OneMan - Thursday, Jun 28, 12 @ 10:49 am:

    At some point, someone is state government thought this was a good idea and so did their boss. These people need to be identified and no long working for the state. If I was Pat Quinn, that would become my mission in life.

    We have time to investigate with a frakin stake out a dudes lunch habits but we can’t investigate deaths because they in fact died?

    Good golly what is wrong with this state.

  16. - Kerfuffle - Thursday, Jun 28, 12 @ 10:57 am:

    They must have come up with this interpretation after a screening of the old movie “Catch 22″. How pathetic!

  17. - Original Rambler - Thursday, Jun 28, 12 @ 11:11 am:

    I’m thinking there must be more to this story since I think I’ve seen investigations in death cases, certainly by the DCFS OIG. Also, remember that the OIG is not the OEIG. Wholly different enabling statutes.

  18. - Rich Miller - Thursday, Jun 28, 12 @ 11:15 am:

    ===certainly by the DCFS OIG.===

    Different agency.

  19. - wordslinger - Thursday, Jun 28, 12 @ 11:17 am:

    Time for Quinn to clean house at the OIG. If he won’t do it, I believe the GA can just put them out of business, correct?

    The story doesn’t say, but did no one refer reports to the local state’s attorneys or police? How could that be?

    I’m with Soccermom on the BND, another homerun.

  20. - Just a Citizen - Thursday, Jun 28, 12 @ 11:43 am:

    My only wish is the spotlight stays on DCFS until action is taken to clean this atrocity up!!!!

  21. - Truthteller - Thursday, Jun 28, 12 @ 11:49 am:

    Where have Equipped for Equality and the other advocates who spend all their time trying to close down state facilities been?
    Aren’t they funded to protect the rights of all the disabled, not just those in SODC’s?

    And is this why Quinn is forging ahead to move residents out of Jacksonville? Out of sight,out of mind.

  22. - Jeff Park Mom - Thursday, Jun 28, 12 @ 11:58 am:

    So those family members from Jacksonville Developmental Center who have been telling the Governor they want the place to stay open seem to be right about their concerns about safeguards in the community.

  23. - Eugene - Thursday, Jun 28, 12 @ 12:03 pm:

    A couple of thoughts here. This is likely an issue of incompetence, but it also certainly an issue of resources. All of the oversight and regulatory functions of state government are reduced to skeleton staffing if even that.

    Also, the Quinn Administration is caught between the rhetoric and the reality of community-based services. These can be great in a system that is adequately funded and has effective oversight. In Illinois we have neither.

    Consider the HBSS program, which pays a stipend to families who are caring for a developmentally disabled individual. Most families do their best. However, consider that the person with DD is often defenseless, is a source of income to others, is often very difficult to handle, and may be living with a family with other problems/issues. This is a recipe for abuse and neglect, yet the state is pushing to expand this service delivery model without investing in any means to ensure accountability. Why? Because it’s cheap.

  24. - Yellow Dog Democrat - Thursday, Jun 28, 12 @ 12:09 pm:

    === the Quinn Administration is caught between the rhetoric and the reality of community-based services. ===

    To a degree. Although community-based care providers are likely mandated reporters.

    My guess is that many of the victims here were not enrolled in any community-based care programs, for much the same reason that many choose to not enroll their kids in schools and home school them instead.

    If you’re abusing your child or a disabled adult, the last thing you want to do is send them into a facility every day where professionals are trained, and required to report, suspected abuse.

  25. - Freeman - Thursday, Jun 28, 12 @ 12:27 pm:

    This is Kafka-esque combined with the Twilight zone. I had to stop reading the BND piece at one point while considering that this is the very system of care Gov. Quinn wants to expand. It’s too much.

    A manpower shortage does not excuse utter failure to lift a single finger in this instance. Not for one flippin’ second. Willfully turning a blind eye to such blatant and disturbing red flags borders on negligence, if not worse.

    Nice of them to threaten the reporters for possessing this information as well. Real classy move.

    And, as Crime Fighter duly notes above, we’re apparently too busy looking for guys eating baloney sandwiches in front of their desk. Meanwhile, this merits… nothing?

    Bizarre. Twisted priorities. Tragic. And unacceptable.

  26. - buck - Thursday, Jun 28, 12 @ 12:39 pm:

    If there is abuse why can’t the state police step in and investigate?

  27. - downstate commissioner - Thursday, Jun 28, 12 @ 12:39 pm:

    Rich writes the rules and I have been deleted for language, so I can add little to what has already been said, other than since capitol punishment has been banned, maybe we need to bring back the cat-o-nine tails for certain state employees…

  28. - Jimbo - Thursday, Jun 28, 12 @ 12:41 pm:

    Is there any difference between these terrible incidents and the DCFS cases of bureaucrat blunder leading death in children.Possibly DHS needs more than a review

  29. - Anonymous - Thursday, Jun 28, 12 @ 12:53 pm:

    If there is abuse why can’t the state police step in and investigate?
    If there is abuse why can’t the state police step in and investigate?
    No resources…ISP is at about 2/3 of the manpower it had a decade ago.

  30. - Yellow Dog Democrat - Thursday, Jun 28, 12 @ 1:12 pm:

    @Buck -

    For criminal investigations, this is a job for local police and state’s attorneys, not the State Police or Attorney General.

  31. - Yellow Dog Democrat - Thursday, Jun 28, 12 @ 1:26 pm:

    …but according to the article, reporters could only confirm that OIG referred 5 of the 53 death cases to criminal law enforcement.

    Rich, thanks for sharing. A depressing story on the one-hand about a 100% dysfunctional state agency. On the other hand, a reminder of exactly why we need a functioning government to begin with.

  32. - Skirmisher - Thursday, Jun 28, 12 @ 2:10 pm:

    I don’t think there is anyone in Springfield who has not been long aware that DHS is a cesspool of incompetence and Demo patronage. This bizarre way of looking at things reduces the backlog of work that no one wants to do anyhow and at the same time comveniently reduces demands for more budget. So what did you expect?

  33. - Michelle Flaherty - Thursday, Jun 28, 12 @ 3:21 pm:

    sorry, the OIGs are too busy busting people for eating lunch at their desks, or typing blog comments like this one.

  34. - Anna - Thursday, Jun 28, 12 @ 3:25 pm:

    Rule 51 covers individuals living in the community with alone or with someone (family, friend, etc.). Rule 50 covers community based agencies, who are mandated reporters and OIG does look into deaths that occur in community based agency programs.

  35. - soccermom - Thursday, Jun 28, 12 @ 4:01 pm:

    Rich, you’re right — I got emotional and thought it was OEIG that was involved.

  36. - Ain't No Justice - Thursday, Jun 28, 12 @ 6:07 pm:

    I can’t say what I know or how I really feel, but if you think this is bad…it is only the tip of the iceberg folks.

  37. - Susie - Thursday, Jun 28, 12 @ 7:51 pm:

    State employees became aware early on that the OIG is just a political cover-up agent for state agencies. They investigate the employees but will never fault management actions for creating the mess that exists. OIG is completely political. I was investigated for wrongdoing because I failed to perform the duties of another state position worker because I simply did not have time to do it. I already had too much work to complete and had to prioritize how to be the most effective at my actual job. OIG completely faulted me for the failure of completing the work. It did not fault management for doing away with one position and assigning all their work to workers of another position and expecting us to complete the work without time or overtime or any other means to do so. OIG acted as if we state employees carry the contractual obligation to federal agencies to complete this work when in fact the responsibility is on the state to ensure that there is a sufficient plan in place to handle and complete the work. The above does not surprise me at all.

  38. - Just the Facts - Thursday, Jun 28, 12 @ 9:48 pm:

    OIG appears to be a landing pot for retired state police administrators to come and pad their pensions. Davis is a retired trooper drawing a pension and now heads OIG making another big salary? Give me a break! OIG administration needs to be sanitized from the incompetent political hacks heading it. Problems exposed in this article have to start at the top.

Sorry, comments for this post are now closed.

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