People with developmental disabilities living in Illinois’ publicly run institutions have been punched, slapped, hosed down, thrown about and dragged across rooms; in other cases, staff failures contributed to patient harm and death, state police and internal investigative records show.
The Illinois State Police division that looks into alleged criminal wrongdoing by state employees investigates more allegations against workers at these seven residential centers than it does at any other department’s workplaces, including state prisons, which house far more people, according to an analysis of state police data.
It has opened 200 investigations into employee misconduct at these developmental centers since 2012 — most of them outside of Choate.
The state’s seven developmental centers, home to about 1,600 people, are situated from the bottom of the state at the edge of the Shawnee National Forest all the way north to the Wisconsin border. The oldest operating facility opened in 1873 and the newest one in 1987. They house dozens, and in some cases hundreds, of people with developmental disabilities in a hospital-like setting. These residents have a range of conditions: genetic, acquired from a problematic birth, or resulting from exposure to dangerous chemicals or from injury in childhood or adolescence.
As in other states, many of these facilities were built in small towns and rural areas. Today, they are short-staffed and at times chaotic and dangerous, according to a slew of reports and interviews with workers and advocates. This May, the safety concerns inside the developmental centers prompted a court-appointed monitor to urge IDHS to stop placing anyone covered by an expansive consent decree into any of the agency’s developmental centers.
“Too many residents suffer physical injury, sexual assault and death to regard placement in such facilities as safe,” wrote Ronnie Cohn, the monitor and a New-York based expert on disability services, in a report that was prepared at the behest of a federal judge in ongoing proceedings.
Illinois is a stubborn outlier among states, continuing to funnel huge sums of money into institutional care. Many others have entirely shuttered or significantly downsized their state-run institutions. Illinois has about the same number of people living in them as do California, Florida, New York and Ohio combined. In Illinois, the lawsuit that led to the 2011 consent decree argued that the state had violated the civil rights of people with developmental disabilities by failing to offer enough options for community-based care. The next year, the state closed one of its centers and tried to shut another; that effort, to shutter the Murray Developmental Center in southern Illinois, failed in the face of union and community pushback. Now, the state is making space for 60 more residents at Murray, some of which will likely transfer from Choate.
“This is one of the most backwards states in the nation on everything we know how to measure when it comes to the care of people with developmental disabilities,” said Allan Bergman, a consultant from suburban Chicago who advises clients and governments across the U.S. on disability policies and programs.
We asked IDHS about the new reporting on issues within the state’s developmental centers. Agency spokesperson Marisa Kollias pointed out that the state had announced a broader review of every facility that IDHS operates as part of its response to the reporting on Choate. She said in a statement that the state has worked to “identify the root causes of misconduct” and correct them. Among recent improvements, IDHS has appointed a new chief safety officer, held numerous trainings on how to report abuse and neglect and ordered more than 400 security cameras for installation across all of its facilities by the end of the year, she said.
Additionally, IDHS acknowledged shortcomings in the community care settings that operate under the agency’s oversight. Kollias said that the community system had been financially neglected by the prior administration and noted that Pritzker’s administration has successfully advocated for millions of dollars in new spending for these programs. Funding for home- and community-based care has roughly doubled what it was when Pritzker took office to more than $1.7 billion, though advocates contend it’s still not enough after years of steep cuts.
State police investigations of claims against staff at Illinois’ developmental centers are on the rise: Nearly 70% of them over the past decade were initiated since 2019, the year Pritzker took office.
Of the 200 state police investigations into employee misconduct over the past decade, 161 pertained to allegations of physical abuse and criminal battery; 25 to allegations of sexual assault and custodial sexual misconduct; and 10 to alleged criminal neglect of residents. Four were death investigations.
Of those cases, 22 led to convictions, almost all of them for abuse.
A spokesperson for the state police said the agency could not speak to the reasons for the increase or for the disparity in the volume of cases from IDHS facilities that it handled in recent years as compared with Illinois Department of Corrections prisons or other agency workplaces.
But Kollias, the IDHS spokesperson, said the department views the increase in state police investigations “as an improvement in accountability at the facilities.” She also noted that most cases did not lead to convictions.
Both the numbers and interviews show how difficult it is to pursue charges, even when investigations get underway. In the facilities outside of Choate, between 50% and 99% of residents have disabilities that are diagnosed as “severe and profound”; some of those individuals are nonverbal and unable to communicate in traditional ways. Investigative records show instances of employees failing to report abuse or working together to hide it, or a general reluctance on the part of state employees to share information with investigators. Even when there’s a conviction, state police investigators are not always able to fully determine what happened.
For instance, among the more recent physical abuse cases where a conviction was secured is one from Shapiro Developmental Center in Kankakee, a small industrial city on the outskirts of suburban Chicago. In 2020, a patient was found with U-shaped markings and dark bruising on his chest, back, arms, legs and genitals.
A nurse examined his injuries but dismissed them as a rash from medication. A physician who examined him the next day had a different take: She believed the markings were consistent with someone striking the patient with an object, such as a belt or cord. The U-shaped markings looked like they could have been from a belt buckle, she told investigators.
Police interviewed multiple employees who worked the night shift, but they offered little information. The patient was unable to provide police specific details of the incident. He was only able to tell them a female worker “beat the hell” out of him on the night shift by striking his genitals with an unknown object.
The patient’s treatment plan notes that he needs help managing behaviors that include irritability, agitation and outbursts. One employee admitted to police that she had slapped the patient across the face that evening after she had directed the patient to stop a problematic behavior and he told her to “shut up, bitch.” But the worker denied she was responsible for any of his more serious injuries. No one else came forward with any information.
The worker pleaded guilty last year to misdemeanor battery and received 12 months of court supervision. She was fired from Shapiro, but neither state police nor IDHS’ inspector general were able to determine the cause of the patient’s more extensive injuries.
Peter Neumer, the IDHS inspector general, said his department regularly encounters cover-ups at facilities across the state, which prompted him to push for a new legal measure enhancing the penalty options against those who attempt to stonewall or obfuscate investigators. Pritzker recently signed it into law.
- Red headed step child - Tuesday, Jul 11, 23 @ 9:45 am:
Governors own…4 plus years,maybe not his doing but its jbs problem.
- Frida’s boss - Tuesday, Jul 11, 23 @ 9:49 am:
This is nothing new. Maybe the state should get out of caring for the disabled. They have not been able to ever do it right.
Also the culture from the AFSCME employees hiding and covering up for each other is repugnant.
- Moly Holy - Tuesday, Jul 11, 23 @ 10:03 am:
Molly Parker…when her by-line arrives, you better do more than send out late Friday press release.
- Give Me A Break - Tuesday, Jul 11, 23 @ 10:13 am:
Red Head if you think this issue started with JB you need to educate yourself on the history of DD services in Illinois. Start with the 1960s.
- This - Tuesday, Jul 11, 23 @ 10:16 am:
This is an indictment of all levels - mostly state - failing. Executive actions to fix problems have been sorely lacking during several administrations. Come on, we can do better.
- Anyone Remember - Tuesday, Jul 11, 23 @ 10:18 am:
Many causes for this problem. The inability to close state facilities (i.e., eliminate jobs) is one.
- NIU Grad - Tuesday, Jul 11, 23 @ 10:19 am:
JB’s ongoing neglect of social service agencies and retention of Deputy Governor Flores is an ongoing mystery to me. There’s no more excuses in term two.
AFSCME also needs to step up.
- H-W - Tuesday, Jul 11, 23 @ 10:25 am:
@ Frida’s Boss
No. The state must provide adequate and humane and uplifting care for the disabled. The problem is with how we do so. Institutionalization as a model is archaic. Warehousing citizens is inhumane and immoral. Even our prisons cannot get it right. We must abound on this model that suggests we want to remove people from society; hide them; out of sight, out of mind.
We must create the sort of conditions that integrate the disabled into our communal lives. Group homes, when managed properly and with live as a foundation often accomplish miracles. I have seen this with my our eyes. I worked in one that placed clients into assisted living arrangements routinely.
- H-W - Tuesday, Jul 11, 23 @ 10:26 am:
Above: abound on should be abandon
- Anyone Remember - Tuesday, Jul 11, 23 @ 10:28 am:
“Group homes, when managed properly … .”
You mean, among other things, a Rauner-free world …
- TheInvisibleMan - Tuesday, Jul 11, 23 @ 10:33 am:
We are a broken culture. We’ve decided abuse is something to not talk about, because it is unpleasant and/or ‘brings negative attention to a town and its institutions’.
The abusers have run full speed ahead with that, and gravitate to areas where they can abuse. Caregiver has always been one of the categories this happens with, in addition to school coaches, and youth pastors.
We can try to point fingers of blame all day long, but a mirror will lead to the quickest way to find the ultimate cause.
There are terrible people in this world who will abuse people. Right up there with them are the people who feel exposing and publicly handling the abuse they know is happening, is worse than the abuse itself. There are a lot of this second group of people in charge right now. In these circumstances many times the attempt from the outside to resolve and bring accountability to ongoing abuse is not resolution, but retaliation.
Covering up abuse knowingly, should be punished in the same way being a driver in a drive-by shooting is punished. The driver gets the same charges as the shooter.
But that will rely on local State’s Attorneys to initiate prosecution and bring those charges, and they are a large part of the reason the current situation exists.
—the IDHS inspector general, said his department regularly encounters cover-ups at facilities across the state—
I’m glad to see the new law has been signed, but it still depends on the local SAs using it.
Just look to the hazing stories yesterday for how that will likely play out. “Did not meet the requirements for hazing(because it was covered up internally), so we didn’t prosecute” local SAs were using to brush off the abuse they obviously knew was happening. They never even bothered prosecuting for the obvious assault charge. It just goes away quietly, and all that ‘negative attention’ is spared for that towns institutions.
Getting out of this entrenched mess is going to take an Elliot Ness type person. But I’m not sure we have a George Johnson type at the state level who understands why such an appointment is desperately needed.
- Give Me A Break - Tuesday, Jul 11, 23 @ 10:45 am:
For far too long, Illinois has tried to run dual systems, one a State Op Model and the other a community provider systems.
Both sides have been and continue to be underfunded. AFSCME has opposed any move to downsize and close state ops. There is a small percentage of people who need care at the institutional level, but too many remain in State Ops when a community level placement is appropriate.
- Friendly Bob Adams - Tuesday, Jul 11, 23 @ 10:54 am:
The policy in Illinois for at least 30 years has been to shrink, but not close, state operated developmental centers. The number of residents keeps going down but never gets to zero.
This is the case not just with Pritzker or Rauner but a long history of governors. No one has taken the position that the state should just close them all down.
Of course, moving all the residents to private group homes presents its own challenges for monitoring their safety.
- DuPage Saint - Tuesday, Jul 11, 23 @ 10:55 am:
So you have this article the one yesterday about no proper medical care for prisoners and the article above about the juvenile system, maybe we should spend some more money hire or get a “czar” for social service and start doing something for the institutionalized people that are out of sight and out of mind. Maybe you can blame Rauner but by now it is J B fault
- SpiDem - Tuesday, Jul 11, 23 @ 11:04 am:
This report is especially galling when you consider that the ID/DD community had to blow up this last session budget just to get an additional $0.50 per hour — which is peanuts; and the new medicaid health care expansion for immigrants got over $500M.
The original $4.00 increase ID/DD advocated for was an $88M fiscal impact by comparison — and it garners federal matching funds.
The state could be doing so much more. They just choose not to.
- sulla - Tuesday, Jul 11, 23 @ 11:07 am:
Why on earth does Illinois continue to provide direct services for the DD population? Outsource to the private sector. Fund and monitor providers.
Is AFSCME really so powerful that we must adhere to this abusive and wasteful status quo? Is the state-run system anything other than a perpetual bad headline machine for whomever is in the governor’s office?
- Rich Miller - Tuesday, Jul 11, 23 @ 11:19 am:
===Is AFSCME really so powerful===
If it was just AFSCME, that would maybe be manageable. But the state also has to deal with parents, activists and community leaders/legislators.
- Excitable Boy - Tuesday, Jul 11, 23 @ 12:03 pm:
- state also has to deal with parents, activists and community leaders/legislators. -
Given that the current administration gets negligible support from any of these parties in downstate Illinois I think it’s time to impose some reality on them. Get our disabled out of these places, their misery shouldn’t be a jobs program.
- MyTwoCents - Tuesday, Jul 11, 23 @ 3:29 pm:
I would be curious about the statistics on the number of criminal investigations in CILAs and if they’re similar to state facilities. Since they would be the responsibility of the local law enforcement agencies unless DHS OIG tracks this I can only imagine how challenging it would to be to individually compile that across all of Illinois.
If IL transitions more & more residents to CILAs maybe the State Police should be given jurisdiction to investigate all allegations of abuse against residents in the care of the State, whether in a state facility or not.
- Rufus T. Firefly - Tuesday, Jul 11, 23 @ 3:36 pm:
If you think DD system bad, wait until you hear about the child welfare system in this state. Both have been in a state of complete and utter meltdown for decades. Under multiple governors, both parties. I’ve never understood why a candidate for governor doesn’t run on these issues.
- Rich Miller - Tuesday, Jul 11, 23 @ 4:15 pm:
===I’ve never understood why a candidate for governor doesn’t run on these issues. ===
They have. A lot. And then when they’re elected they find out that it’s an almost impossible situation.
What I’d like to know is if there is a state out there that is doing things right. I’ve looked on occasion, and haven’t found one.
- Oswego Willy - Tuesday, Jul 11, 23 @ 4:30 pm:
===And then when they’re elected they find out that it’s an almost impossible situation.
What I’d like to know is if there is a state out there that is doing things right. I’ve looked on occasion, and haven’t found one.===
I think this is a significant reason I don’t comment on this issue.
It’s such a tough issue that hasn’t found an answer, it’s not something that has the time or patience of drive by uselessness.
It’s also why I only agree to the truth of “Governors own” in these instances, but where are the answers and paths these past governors, or this current governor, haven’t found?
It’s not that I give up or have no answer, it is specifically that typing words that aren’t helping towards that righting seems defeating.
- Former State Employee - Tuesday, Jul 11, 23 @ 5:10 pm:
People from the outside believe there is some magic answer.
Rich said it best. If there is A state this handling this, someone needs to step up and name it.
- Grateful Gail - Tuesday, Jul 11, 23 @ 5:35 pm:
The CILA (group home) system is equally as disturbing, but DHS tries to hide those incidents of abuse/neglect. In the past five years the vast majority of individuals moving to SODCs are individuals who have been abused, raped, sodomized, and starved in community placements. DHS just ignores it, until it becomes so bad that someone forces them to deal with the bad CILA providers.
There ARE good SODCS, just like there are good CILAs, but DHS needs to demand quality care where ever a disabled person chooses to live. A good friend of mine’s loved one was starving to death in a CILA; is recovering well now, eating again, and once again walking. This young man lived in a CILA, DHS knew what was going on, and ignored it, until finally someone saw the abuse/neglect and moved the individual to an SODC to recover.
- Northsider - Wednesday, Jul 12, 23 @ 8:44 am:
The prevailing issue is the lack of investment in the State for human/social services. This is a bipartisan, decades long issue. The recent annual report found Illinois still ranked 49th in servicing people with developmental disabilities. This is a largely voiceless body that lacks the power of utility lobbyists and such, so concerns largely get ignored. The establishment with laud that Illinois has significantly increased funding for disability services since JBP has been in office, but that has been under court order and monitorship, and Ilinois still slow-walked the proposed 6 year funding escalation. To make matters worse, much of the gains from this ramp up were cancelled by minimum wage increases, and obliterated by inflation, so we are stalled out with entry level wages similar to 7-11 employees. If we pay 10-15% over minimum wages for this very demanding, specialized field, we are going to staff the field with those that got paid more to move boxes at Target, so what do we expect will happen? LAstly, this is by far NOT just a SODC problem. We have very little knowledge of how pervasive abuse and neglect might be int he community system, were staff have exceedingly little contact with management and supervision, alone with people with disabilities in neighborhood homes or apartments. These placements are blanketly applauded as success because people are “integrated in the community”. but how much work is being done by the community advocates to evaluate the potential for abuse side of this story? I’m not saying that community-based services are bad, nor am I promoting SODCs as an answer, but the field has to spend less time on chasing silly rules produced by academia-tied advocates, that don’t actually do the work, and let the field concentrate on the care that matters