Another must-read from the Trib
Monday, Nov 21, 2016 - Posted by Rich Miller
* Part 2 of the Tribune’s investigation…
On her last night at a Lockport group home, Tina Marie Douglas tossed her few possessions in the trash and warned caregivers that she planned to run away in the morning.
It was not an idle threat. In the last three months, the 48-year-old state ward diagnosed with psychiatric and intellectual disabilities had slipped out of the home eight times and repeatedly run into the street. Her caregivers were considering moving her to a different home, one on a block with less traffic.
But that never happened. Shortly before dawn in October 2013, she broke away again, sprinted down a four-lane state road and was fatally struck by a car.
The Illinois Department of Human Services, which licensed the group home, assigned its inspector general’s office to conduct a comprehensive review.
But a Tribune investigation found the inspector general’s staffers never interviewed a witness, never visited the group home, never left their desks. Instead, they relied on group home employees to help investigate their own business and, based on those findings, determined the home was not at fault.
The Douglas investigation is one of hundreds in which self-policing played a role in determining whether neglect had occurred, including many where group home employees played an even more significant role — not only gathering evidence but drafting the state’s final investigative reports.
These group home employees — dubbed “buddy investigators” by the Office of the Inspector General — handled at least 550 cases, the Tribune determined. And in the vast majority of instances, employees helped clear their own group homes of wrongdoing. […]
The inspector general’s practice of relying on so-called buddy investigators goes back more than a decade, but by the time of Douglas’ death their use was growing, mostly out of desperation by the state.
By 2013, staffing levels had fallen to historic lows at the inspector general’s office. With just 18 investigators statewide, some carried up to 90 open cases, leaving just minutes a day to spend on each, state files show. Some cases languished without action for up to five years.
The “buddy investigations” have now been stopped, thanks to the Tribune. But more resources are most definitely needed.
As before, go read the whole thing.
- Anonymous - Monday, Nov 21, 16 @ 2:50 pm:
–The Illinois Department of Human Services, which licensed the group home, assigned its inspector general’s office to conduct a comprehensive review.
But a Tribune investigation found the inspector general’s staffers never interviewed a witness, never visited the group home, never left their desks–
As in the previous story on hundreds of “erroneous reports,” only discovered after the state forced the Trib to file more than 100 FOIA requests, the “buddy system” could reasonably be suspected to be part of a systematic coverup.
Bring on the federales. The state has proven it can’t be trusted on this matter.
- wordslinger - Monday, Nov 21, 16 @ 2:51 pm:
Pardon, 2:50 was me.
- Honeybear - Monday, Nov 21, 16 @ 2:55 pm:
Staffing levels at historic lows. Hmmmm I wonder how our new contract will effect that? Maybe it will get better but I don’t think so. We don’t like state workers. Maybe there’s somebody who could volunteer?
- Dome Gnome - Monday, Nov 21, 16 @ 3:02 pm:
I’ve waited most of my adult life for Illinois to gain a conscience. The problem cuts across party lines and also spans various economic peaks and troughs, through the years. The issue is that we lack the drive to solve this particular brand of problem. This should be weighing on all of our minds.
- Truthteller - Monday, Nov 21, 16 @ 3:05 pm:
The problem didn’t start with Rauner, but how long has he been governor? Where is the turnaround?
Is busting unions really more important than the lives of these individuals? Sadly, in Rauner’s world ,the answer is ” yes”.
- Ghost - Monday, Nov 21, 16 @ 3:11 pm:
we need fewer employees, that saves money. We should eliminate all inspectors and just use volunteer investigators; maybe scooby and shaggy are free….. /s
Same situatiin with workers comp fraud and all the other fraud investigators. When budgets get cut investigators get gutted.
Perhaps a critical work comp reform is more then like 6 investigators, or whatever they have left state wide.
- scott aster - Monday, Nov 21, 16 @ 3:16 pm:
Rich Just another lazy state employee that takes the easy way. This is a management problem….nobody is inspecting or keeping track of there investigations.
- Earnest - Monday, Nov 21, 16 @ 3:19 pm:
Kudos for some great reporting from the Tribune. Heartbreaking stuff.
Illinois’ human service system has been crumbling for decades. Sadly, the only thing that seems to get the state to do anything about it are lawsuits and consent decrees. Hopefully this will have an impact.
Lots of little, related issues I’ve noticed–at one point, OIG investigators weren’t getting reimbursed for mileage and many hotels would not let the state charge rooms due to late payment. This made it more difficult to get out.
I know of an instance (n=1, I know) where OIG conducted a six month investigation of a person who died in their 80s after a history of aging-related health issues that were well-documented as having been addressed over the years. They are required to investigate every death, but perhaps there are some clear cases where they could spend less time.
The state’s quality assurance system is a mess. As noted, investigations and complaints results don’t always make it over to the Bureau of Accreditation and Licensure. Different parts of DHS do surveys, which are sometimes duplicative and time- and resource-intensive for both agencies and the state.
Under Governor Rauner, DHS has begun to implement some system change, particularly with the Medicaid Waiver, which funds these CILA group homes. As I think we’ve discussed before, he’s done some good things at DCFS. One place that seems especially ripe for improvement in IT infrastructure…the information coming into the state should be summarized and analyzed for patterns and built into follow ups via the survey/licensure system. The state also needs a stronger ability to eliminate “bad” providers. I honestly don’t think there are a ton of them, but the state needs better tools to deal with them.
- Give Me A Break - Monday, Nov 21, 16 @ 3:21 pm:
For way too long, Illinois has tried to run parallel human services systems and they have been underfunding both the state operated and community level systems for 30 years. You can’t have it both ways, Illinois needs to either go back to a state-operated system or move to a system where all but the most disabled live in the community.
Trying to have it both ways is the root cause of the perpetual underfunding of both systems of care which in neither case produces a quality product.
Both parties and both chambers talk a good game when it comes to funding DD and MH services, but when it comes time to swing the budget axe, this is one of the areas they go to first given the amount of GRF it takes to run these systems.
How may more consent decrees is it going to take before Illinois decides to have the moral courage to stand up to either the human services providers or AFSCME and move to one system of care? We can’t have it both ways and these stories prove it.
Lawmakers need to pick one system, then fund it and stop holding hearings to drag in DHS staff to go under the bus to explain another series of media stories. You get what you pay for lawmakers and lawmakers, you own this as much as prior PQ staff and current Rauner staff.
- Wilson - Monday, Nov 21, 16 @ 3:30 pm:
Strange - I thought closing JDC was going to solve this.
- illini - Monday, Nov 21, 16 @ 4:05 pm:
This was as disturbing as the first part of the investigation that Rich shared with us last week.
I wrote ( and forwarded a link to the article ) to my 2 downstate members of the GA, added my comments and asked for a reply or comment. As of now I have not heard nor had any acknowledgment from either.
I also sent basically the same letter to a retiring member ( not currently representing me ) that I have known for may years. He was the only one who had the courtesy to respond and we spoke at great length, and honestly, about this first report as well as other pressing issues in Illinois.
I understand, and appreciate, that many issues are complex and the dynamics of decision making are often times nuanced by concerns about the next election.
Yet, we are talking about the most vulnerable of our neighbors who are being impacted by this lack of oversight. And it continues.
Absolutely NO ONE in the GA or any of the responsible agencies are exempt from criticism for what happens on their watch. And this includes BVR.
- Beaten down but almost done - Monday, Nov 21, 16 @ 4:25 pm:
A hearing notice for Human Services in the Senate has been posted for November 30 at 9:00 am. “Subject Matter On: The abuse and neglect taking place at group homes for individuals with developmental disabilities.”
- formerpro - Monday, Nov 21, 16 @ 4:48 pm:
I’ll channel Ralph: if you don’t adequately fund human services, which we don’t, then you get lousy human services. Or my mother: “you get what you pay for…” Or James Carville: “It’s the revenue, stupid.”
- just me - Monday, Nov 21, 16 @ 5:02 pm:
This article has even less depth than the first one in the series. The real issues are systemic and have little to do with individual providers or “transparency,” as these reporters would have you believe. OIG is not a law enforcement agency, and cases are not matters of public record. If a crime has been committed, the local or state police do the investigation and the former employees are charged, which happened in some of the cases in the first article. Why are the reporters cherry-picking the facts they share in this series? Is it because they had a conclusion drawn before they started?
- anon - Monday, Nov 21, 16 @ 7:10 pm:
So when group homes investigate themselves they find no blame. Given human nature, that should be predictable. On the other hand, when OIG is so severely shorthanded, dangerous shortcuts are tempting.
- Anonymous - Monday, Nov 21, 16 @ 7:13 pm:
Also Give Me a Break. States that have gone to an all “community” system with no state centers as a backup (which Olmstead says must be done) are now contacting other states to take their most difficult individuals. Under Olmstead it says there will always be a need for state institutions for some individuals. One size does not fit all as some so-called advocates believe.
- Eye on 2 - Monday, Nov 21, 16 @ 9:19 pm:
Bring in an independent investigator. I am sure it won’t take long to see a pattern of where the ball drops on not reporting all of this.The problem I see is that there will be so many within DHS if they fire them, there won’t be anyone left. lol
- Rayne of Terror - Tuesday, Nov 22, 16 @ 3:47 pm:
I was surprised to see my friend’s face on the Tribune. I want to tell you a little more since I’m a regular reader here. JoAnna and her family are the kind of people who make a small town run. JoAnna took over our small town’s floral shop when the mayor retired. She does elder care, and she works at the hospital. She volunteers her time for everything sports and school related. Concession stand, school fundraisers, you name it JoAnna and her husband do it. Her oldest son delivered mulch to my retired neighbor before the garden parade of homes this summer in 95 degree heat and saw that she needed help so he called the floral shop and told his mom he’d be back once he spread the mulch for Cathy. These are the kind of people who make Illinois great.
- Anonymous - Tuesday, Nov 22, 16 @ 6:51 pm:
It’s too bad Michael Berens and Patricia Callahan haven’t spent anytime interacting with the difficult people community providers serve. Have they spent anytime at Trinity meeting the people no one else will serve?
- VC1 - Wednesday, Nov 23, 16 @ 6:39 am:
I bet there would be more funding for people with disabilities if legislators or the governor and their staff just worked a mere eight hours with people who ran away, hit them, pulled their hair, or had to be fed with tubes.