News from the Abuse Investigation Unit

EFE Again Calls on the State to Close Choate Developmental Center

After a joint federal-state survey cited Choate Developmental Center for previously documented violations, Equip for Equality has again called for its closure. Choate Developmental Center is Illinois' southernmost state-run institution. The survey, by the Department of Public Health (DPH) and the Centers for Medicaid and Medicare Services (CMS), cited Choate for the same serious violations documented by Equip for Equality in its February 2005 report, which detailed a longstanding pattern of profound mistreatment of people with disabilities.

That report, entitled Clyde Choate Developmental Center: How an archaic system results in tragic consequences for people with disabilities, resulted from an extensive investigation that discovered significant problems in existence at the center since at least 2002, including death due to inadequate healthcare; abuse, neglect and sexual assault; excessive use of restraints; absence of adequate treatment, programs or supervision; failure to ensure individuals' dignity; and failure to thoroughly investigate injuries.

In response to Equip for Equality's findings, the Illinois Department of Human Services (DHS) instituted measures to "fix" Choate, utilizing consultants, technical assistance from other state-operated facilities, staff training and document review and analysis. DPH placed monitors in the facility and brought in the Illinois Foundation for Quality Health Care to encourage a culture change.

Despite the increased oversight and infusion of substantial resources, which should have presented Choate at its very best, the CMS/DPH survey revealed that more individuals have died, programs and treatment continue to be scarce, individuals' rights are being arbitrarily restricted, and the simplest forms of human dignity and choice are being denied. The additional resources did not prevent an individual with profound mental retardation from leaving her group room unnoticed by staff, finding an unlocked office, locking herself in and using scissors to cut her hair and genitals.

While Choate has developed a plan to address the most serious deficiencies, its history of repeated failures to meet even the most basic standards of care and safety indicates that any improvements are highly unlikely to be sustained. Even Lincoln Developmental Center, prior to its closure, had prepared and received approval for corrective measures, that ultimately failed, to address the ongoing problems and ensure the safety and well-being of the residents. Choate and Lincoln share a common profile of violations and tragedies, and these ultimately closed Lincoln. The serious problems documented by Equip for Equality and revealed in the most recent CMS/DPH survey demonstrate that, like Lincoln, Choate needs to be closed.

Equip for Equality's report, entitled Choate Developmental Center: A second call for closure, is available online.

State Resumes Facility Funding Despite Findings of Mistreatment

Despite evidence of serious mistreatment of people with disabilities, the State continues to fund Southwest Disabilities Services and Support (SWDSS), a privately run facility that operates four residential sites and one developmental day training program for people with developmental disabilities.

In April 2005, in conjunction with the Centers for Medicare and Medicaid Services, the Illinois Departments of Public Aid and Human Services conducted an unannounced investigation of SWDSS, formerly named These Are God's People Too, and found substantial violations of state licensing standards. The unannounced investigation found SWDSS in significant noncompliance with state regulations, including human rights violations, dangerous living conditions, the use of dangerous restraint practices and insufficient food for residents.

The joint federal/state investigation also documented that SWDSS failed to report, investigate or address issues of abuse and neglect, failed to provide appropriate programming or services, failed to ensure safeguards in the administration of psychotropic medications, failed to ensure that its staff members are not identified abusers and do not have criminal backgrounds, failed to provide evidence of staff training and failed to provide individuals with opportunities to go into the community.

Following each of the Equip for Equality's investigations and reports, it called upon the state to terminate SWDSS' funding, revoke its licenses and reexamine the system by which service providers are reviewed and sanctioned. Each time, the state announced that it would terminate its contract with SWDSS, but shortly thereafter reversed its position as a result of pressure from SWDSS and its supporters.

Following the federal/state investigation this year, Equip for Equality called on Gov. Blagojevich to terminate state funding of SWDSS and revoke its licenses. The state again terminated its contract with SWDSS and again reversed its position, reinstating the contract for a third time following pressure from SWDSS. Despite removing its own wards because of unsafe and deplorable conditions, the State has yet to shut down the agency's facilities or terminate funding. The federal/state investigative findings may threaten SWDSS' eligibility for participation in the federal Medicaid program. Abuse Investigation Unit reports are available online.

EFE Issues Report on Psychiatric Day Programs

This June, Equip for Equality's Abuse Investigation Unit issued a report on psychiatric day programs that serve individuals with mental illness living in intermediate care facilities (ICF). The report was issued to Illinois' Departments of Public Health and Public Aid and details the Unit's review of several agencies providing services allegedly in compliance with Subpart S of the federal nursing home regulations. Over an 11-month period, the Unit conducted unannounced site visits to several agencies, interviewed staff, reviewed case records, observed programs and collected policies related to abuse, neglect and restraint.

As a result of the Unit's review, Equip for Equality has identified significant problems regarding the quality of services and the safety of individuals receiving those services. The review also found problems with the programs' documentation systems that are supposed to interface with Medicaid and Medicare billing, and the lack of a state authority responsible for overseeing and investigating allegations of abuse and neglect, as well as licensing and monitoring psychiatric day programs.

Individuals with mental illness warehoused in large institutional like settings do not receive coordinated services based on their individual interests and needs. Rather, most programs expect individuals to attend only one "therapy" group a day for either 45 minutes or one hour, with the remainder of the programming day filled with cigarette breaks, lunch and large-group activities such as bingo, puzzles, television, movies, hangman, and arts and crafts. As an incentive for coming to the program, individuals receive lunch and either cigarettes or, if a nonsmoker, money (a dollar a day). At one program, a participant received one dollar a day for cleaning the restroom.

Many of the programs operate as for-profit entities and secure funding by billing Medicaid and Medicare for services allegedly provided by doctors who "supervise" staff-run groups. Actual case records, however, reveal limited involvement by physicians or psychiatrists.

The review revealed that nursing homes routinely fail to support individuals in their rehabilitation efforts. Homes often fail to share pertinent information with day programs or collaborate with them in establishing care plans, treatment strategies or coordination of services. Staff at one nursing home could not identify where the home was sending individuals for "services" and had to ask a driver from the transport company for the program location. The nursing home staff was also unaware that the day program is open only four days a week.

The review revealed that day program treatment plans were frequently standardized based on broad diagnoses rather than individualized for specific needs. At one program, two individuals had identical "bipolar" care plans, and two other individuals had identical "schizophrenia" plans.

Most day programs provide people under their care only limited access to the community. Outings are often unavailable. One facility staff member indicated that, in their opinion, outings are "too risky," given the acute conditions of the individuals and the fact that the program does not have its own means of transportation.

Though most programs receive complaints of abuse and neglect from participants, they more often than not have no policies or procedures to address alleged incidents. Most programs indicated that they dealt with the issues internally without reporting to outside regulatory or investigatory entities. In response to an Investigation Unit inquiry regarding the frequency of behavioral incidents at one day program, professional staff indicated that they have to deal with aggression from time to time, adding, "They get mad at us just like little kids." Although restraints reportedly are not used, staff indicated that they occasionally have to "tussle" with participants and use an unlocked quiet room for "belligerent" individuals.

The review also found that psychiatric day programs fail to ensure the safety of their environments. Programs did not have fire alarm pull boxes within program areas and did not routinely inspect fire extinguishers or schedule fire drills. Program doors are frequently locked, requiring staff to provide exit from the facilities. Drivers used to transport individuals to and from day programs have no established safety protocol or training, and yet are allowed to transport medications between nursing homes and day programs.

Psychiatric day programs were established to provide psychiatric rehabilitation to individuals with mental illnesses to help them acquire skills related to improved functioning and independence. Unfortunately, these programs only illustrate significant systemic problems and demonstrate the need for improvements in the current oversight system. Given the lack of oversight and the seeming ease with which these programs are established, Equip for Equality suspects that numerous other programs have already opened or will open in the near future.

In its report, Equip for Equality expresses serious concerns about the quality of services and the lack of oversight surrounding psychiatric day programs. The report raises concerns over the absence of any state authority designated to monitor and evaluate the quality of programming and services, monitor nursing home compliance with standards and ensure the safety of individuals with disabilities through timely reporting and investigation of allegations of abuse and neglect.

Equip for Equality has recommended that more stringent criteria need to be implemented and enforced for community-based programs serving individuals with serious mental illnesses who reside in nursing homes. These criteria should include the certification, re-certification and periodic review of programs to ensure compliance with local state and safety codes and Subpart S of the federal nursing home regulations. Equip for Equality also recommends the designation of a state agency authorized to investigate allegations of abuse and neglect and to establish standards for psychiatric day programs related to abuse and neglect. Equip for Equality has proposed in its report to work with state agencies to develop a plan to remedy the lack of oversight in the state system.

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