* Background is here if you need it. From the Illinois Department of Human Services…

Secretary Hou requested a review of resident safety reporting practices in September 2022 to provide additional context and recommendations related to abuse and neglect cases at Choate Mental Health and Developmental Center (Choate) over the past decade. The Illinois Department of Human Services (IDHS) is grateful to the IDHS Office of the Inspector General for their diligence in putting together this report. IDHS leadership continues to be deeply concerned by the events investigated and reported on by the OIG. The report underscores the importance of actions that IDHS has taken since the beginning of the administration, including substantially expanding training, hiring new staff, and installing security cameras. IDHS has also received guidance from the federal Centers for Medicare and Medicaid Services to be able to install additional cameras in indoor, common area locations and will be installing those expeditiously.

Most importantly, the report affirms IDHS’ plan for a system-wide transformation aimed at providing better care for individuals with intellectual and developmental disabilities in Illinois. This transformation is already underway with a focus on moving residents from Choate to community-based settings and other State centers and repurposing the existing campus. System-wide the department has hired a chief resident safety officer, implemented additional safety enhancements, and continued to invest in the community-based system, with funding nearly doubled under this administration. As we move forward, our top priority at IDHS is ensuring the safety of all our residents as they live and receive support in the setting of their choice that best meets their needs.

* As mentioned above, the OIG’s report recommends installing cameras to catch and perhaps prevent wrongdoing. But it also includes this recommendation…

OIG recommends that CMHDC conduct a top to bottom analysis of all processes related to the reporting of abuse and neglect, including training, because at the present time there appear to be fundamental problems with all aspects of that system, including: (1) repeated instances of CMHDC staff deliberately covering up misconduct—sometimes in coordination with other staff—that they either engaged in or witnessed; (2) repeated instances of CMHDC staff failing to report misconduct, or seeking to report that misconduct anonymously, in fear of possible retaliation from their fellow employees; (3) individuals experiencing retaliation after making reports or being threatened with potential harm for making reports; and (4) a lack of accuracy and thoroughness regarding the allegations that are reported to OIG or documented through CMHDC’s incident reporting system

* Enforcing the code of silence and resisting change…

CMHDC employees noted multiple obstacles to individuals [defined as people receiving services] reporting allegations, including that individuals must ask staff to use the phone and tell staff who they are calling and that OIG hotline posters—which include the number to call to report an allegation—are sometimes removed. […]

Another individual similarly stated that they had reported things and nothing was done. After reporting, staff come back to work and are even worse. The individual asked why individuals would put themselves out there and risk getting staff madder at them. […]

Retaliation was also identified as a concern for reporters of abuse and neglect. According to ISP- DII, people at CMHDC believe they are going to be punished for speaking the truth. Even security officers do not want to speak up. […]

A CMHDC employee related that an RN was reported for neglect because the RN had turned in the lower ranking staff for neglect. According to this CMHDC employee, lower ranking staff retaliate against individuals and higher-ranking staff. […]

A different CMHDC employee stated that as a trainee, you did not speak up for fear of losing your job. … The employee said that they regularly went home and cried over the way individuals were treated.

According to a CMHDC employee, by the time some allegations get to OIG, the paperwork or story has already changed. […]

Although changing a facility’s culture is by no means a simple task, the first step in that process is recognizing that there is indeed a problem. Stated plainly, the status quo at CMHDC is not acceptable. Every CMHDC employee has to understand that the reporting of misconduct is one of their fundamental responsibilities and that not reporting misconduct is what could lead to their discharge. That message is clearly not getting through right now. CMHDC must take steps to identify how it is that certain CMHDC staff are so effectively able to indoctrinate and intimidate new staff and counteract the training that is being provided regarding reporting.

* One of the report’s last lines…

Preventing and eliminating abuse and neglect should be considered the floor, not the ceiling, regarding individual care.

…Adding… AFSCME Council 31…

“AFSCME-represented Choate employees are dedicated, compassionate and deeply committed to the individuals they serve. The well-being of Choate residents is employees’ top priority, which is why the AFSCME local union at Choate has called repeatedly for more staff, better training and the installation of security cameras throughout the facility—the same recommendations now found in this report.”