Illinois officials blacked out those details from their investigative report. Nobody else was supposed to learn the man's identity or the location of the state-funded facility where his body was found.
The investigation was closed as it began, with no public disclosure, and the report was filed away, one of thousands that portray a hidden world of misery and harm.
No one would know that Thomas Powers died at 3300 Essington Road in unincorporated Joliet, in a group home managed for adults with developmental and intellectual disabilities.
Or that his caregivers forced a 50-year-old man with the intellect of a small child to sleep on a soiled mattress on the floor in a room used for storage.
Or that the front door bore a building inspection sticker that warned, "Not approved for occupancy."
Not even Powers' grieving family knew the state had looked into his death and found evidence of neglect.
As Illinois steers thousands of low-income adults with disabilities into private group homes, a Tribune investigation found Powers was but one of many casualties in a botched strategy to save money and give some of the state's poorest and most vulnerable residents a better life.
In the first comprehensive accounting of mistreatment inside Illinois' taxpayer-funded group homes and their day programs, the Tribune uncovered a system where caregivers often failed to provide basic care while regulators cloaked harm and death with secrecy and silence.
The Tribune identified 1,311 cases of documented harm since July 2011 — hundreds more cases than publicly reported by the Illinois Department of Human Services.
Confronted with those findings, Human Services officials retracted five years of erroneous reports and said the department had launched reforms to ensure accurate reporting.
To circumvent state secrecy, the Tribune filed more than 100 public records requests with government agencies. But state files were so heavily redacted and unreliable that the newspaper had to build its own databases by mining state investigative files, court records, law enforcement cases, industry reports, federal audits, grant awards and Medicaid data.
The Tribune found at least 42 deaths linked to abuse or neglect in group homes or their day programs over the last seven years. Residents fatally choked on improperly prepared food, succumbed to untreated bed sores and languished in pain from undiagnosed ailments.
Other residents suffered forced indignities and loss of freedom, state records show. Some were mocked for their intellectual limitations, barricaded in rooms, abandoned in soiled clothing and deprived of food.
A male group home resident, accused of stealing cookies, was beaten to death by his caregiver. Employees at one home bound a woman’s hands and ankles with duct tape, covered her head with a blanket and left her for several hours on the kitchen floor. For their own amusement, employees at another home repeatedly ridiculed residents to provoke outbursts, a game the caregivers called "breaking them."
And,
all too often, vulnerable residents' health and safety has been left to
unlicensed, scantly trained employees. Front-line caregivers failed to
promptly call 911, perform CPR or respond to medical emergencies that
resulted in death.
In hundreds of cases, the department allowed employees of group homes to investigate allegations of neglect and mental abuse in their own workplaces, the Tribune discovered. That alliance between group homes and Human Services' investigative arm, the Office of the Inspector General, is not specifically disclosed in state investigative reports.
Citing patient privacy laws, state officials maintain that the addresses of the more than 3,000 state-licensed group homes are secret. Illinois officials refuse to disclose the enforcement history of any home, even in cases of fatal abuse and neglect.
In contrast, Illinois nursing homes must maintain copies of investigative reports and surveys for public inspection. Additionally, state health officials publish a quarterly report detailing violations accompanied by nursing home names and addresses. There are no similar disclosure requirements for group homes.
In this culture of secrecy, even seemingly benign records get shielded from sight. For example, the Tribune requested a state-funded PowerPoint presentation that included a list of needed improvements to community care programs, including group homes.
The state responded. Except for the word "Recommendations," the entire slide was blacked out.
Citing the Tribune investigation, Human Services Secretary James Dimas has ordered widespread reforms to improve public accountability and streamline investigations.
"My
concern is that too often agencies hide behind their confidentiality
statutes, which makes it harder for the public to know what is going
on," said Dimas, who was appointed last year.
Dimas said he will push for legislative changes, if necessary, to allow public disclosure of group home enforcement histories.
The shift in Illinois from large institutional facilities to less costly residential homes reflects the philosophy that these individuals, if supported, will lead fuller lives in the community, and more than 11,400 now live in group homes statewide.
Known as Community Integrated Living Arrangements, or CILAs, these homes accommodate eight or fewer adults in ordinary apartment buildings or houses.
The Arc of Illinois, a statewide advocacy group, reports that hundreds of people with disabilities have successfully transitioned into group homes in recent years. In 2011, a lawsuit brought by individuals who wanted to leave state-funded facilities resulted in a court decree that has forced Illinois to move more people into community settings.
State officials have touted group homes as a preferred option, citing cost savings that can be used to fund more community care. The annual cost of care for an institutionalized resident is about $219,000 compared with $84,000 at a group home, according to state records.
But Illinois has not increased reimbursement rates for group home staff wages in nearly nine years, leading to what industry leaders say are catastrophic conditions in which even the best operators are struggling to provide basic care. Illinois ranks among the five worst states for adequately funding community options, according to federal reports and studies by advocacy groups.
In hundreds of cases, the department allowed employees of group homes to investigate allegations of neglect and mental abuse in their own workplaces, the Tribune discovered. That alliance between group homes and Human Services' investigative arm, the Office of the Inspector General, is not specifically disclosed in state investigative reports.
Citing patient privacy laws, state officials maintain that the addresses of the more than 3,000 state-licensed group homes are secret. Illinois officials refuse to disclose the enforcement history of any home, even in cases of fatal abuse and neglect.
In contrast, Illinois nursing homes must maintain copies of investigative reports and surveys for public inspection. Additionally, state health officials publish a quarterly report detailing violations accompanied by nursing home names and addresses. There are no similar disclosure requirements for group homes.
In this culture of secrecy, even seemingly benign records get shielded from sight. For example, the Tribune requested a state-funded PowerPoint presentation that included a list of needed improvements to community care programs, including group homes.
The state responded. Except for the word "Recommendations," the entire slide was blacked out.
Citing the Tribune investigation, Human Services Secretary James Dimas has ordered widespread reforms to improve public accountability and streamline investigations.
Dimas said he will push for legislative changes, if necessary, to allow public disclosure of group home enforcement histories.
The shift in Illinois from large institutional facilities to less costly residential homes reflects the philosophy that these individuals, if supported, will lead fuller lives in the community, and more than 11,400 now live in group homes statewide.
Known as Community Integrated Living Arrangements, or CILAs, these homes accommodate eight or fewer adults in ordinary apartment buildings or houses.
The Arc of Illinois, a statewide advocacy group, reports that hundreds of people with disabilities have successfully transitioned into group homes in recent years. In 2011, a lawsuit brought by individuals who wanted to leave state-funded facilities resulted in a court decree that has forced Illinois to move more people into community settings.
State officials have touted group homes as a preferred option, citing cost savings that can be used to fund more community care. The annual cost of care for an institutionalized resident is about $219,000 compared with $84,000 at a group home, according to state records.
But Illinois has not increased reimbursement rates for group home staff wages in nearly nine years, leading to what industry leaders say are catastrophic conditions in which even the best operators are struggling to provide basic care. Illinois ranks among the five worst states for adequately funding community options, according to federal reports and studies by advocacy groups.
Shirley
Perez, who directs a family advocacy program for the Arc of Illinois,
said: "Some of the phone calls I get from families are that they are
afraid."
Powers, born with a condition that led to brain damage, spent decades inside state institutions, unable to talk, unpredictable in behavior. When state officials promised him a better life in a real home and told his family he'd gain independence, Powers said yes the only way he knew how. He giggled.
But this was not the life that Powers found. Nor did thousands of other adults with developmental and intellectual disabilities, left to the mercy of a system designed to be invisible.
Failures of care
In
one Will County group home, state records show, a caregiver left a
frail woman alone in the bathroom after filling the bathtub with water,
unaware that it was scalding because a maintenance worker forgot to
install a temperature-control valve. The woman tumbled into the tub and
was severely burned. The Trinity Services caregiver put the woman to
bed, later pulled socks over her peeling, bleeding skin and didn't seek
medical help for more than an hour. The woman died days later.
At a Springfield home owned by Sparc, a caregiver forgot to give a man his anti-seizure medication before sending him to a day program in 2013. Rather than deliver the pills, investigators found, the caregiver told a colleague to throw them into the trash. The man suffered a major seizure, turned blue and was treated at a hospital.
A caregiver at a Macomb group home managed by Mosaic allowed a man to sleep with a stuffed snowman even though he had been diagnosed with pica — a disorder that compels people to eat nonfood items — and had a history of consuming stuffing, according to inspector general records. In 2012 the man tore open the snowman, ate the filling and choked to death.
In case after case, group home businesses have delegated frontline care to inexperienced caregivers with negligible training, a cost-cutting combination that has led to harm, the Tribune investigation found.
Indeed, when the newspaper reviewed more than 200 substantiated cases of abuse and neglect, it found the vast majority of injuries and deaths are linked to inadequate staffing levels and failure to closely monitor fragile residents. Records show caregivers trying to cover up mistakes, failing to understand dangers of missed medications and underestimating the complex nature of disabilities.
Powers, born with a condition that led to brain damage, spent decades inside state institutions, unable to talk, unpredictable in behavior. When state officials promised him a better life in a real home and told his family he'd gain independence, Powers said yes the only way he knew how. He giggled.
But this was not the life that Powers found. Nor did thousands of other adults with developmental and intellectual disabilities, left to the mercy of a system designed to be invisible.
At a Springfield home owned by Sparc, a caregiver forgot to give a man his anti-seizure medication before sending him to a day program in 2013. Rather than deliver the pills, investigators found, the caregiver told a colleague to throw them into the trash. The man suffered a major seizure, turned blue and was treated at a hospital.
A caregiver at a Macomb group home managed by Mosaic allowed a man to sleep with a stuffed snowman even though he had been diagnosed with pica — a disorder that compels people to eat nonfood items — and had a history of consuming stuffing, according to inspector general records. In 2012 the man tore open the snowman, ate the filling and choked to death.
In case after case, group home businesses have delegated frontline care to inexperienced caregivers with negligible training, a cost-cutting combination that has led to harm, the Tribune investigation found.
Indeed, when the newspaper reviewed more than 200 substantiated cases of abuse and neglect, it found the vast majority of injuries and deaths are linked to inadequate staffing levels and failure to closely monitor fragile residents. Records show caregivers trying to cover up mistakes, failing to understand dangers of missed medications and underestimating the complex nature of disabilities.
Sparc's
chief operating officer, Ryan Dowd, said his company fired the
caregiver who directed a colleague to throw out anti-convulsant
medicine, added more surveillance cameras in its group homes and
switched from paper to electronic medication records so a nurse can
better catch mistakes.
Nancy Davis, a Mosaic vice president, said her organization dismissed the caregiver who allowed the man to sleep with a stuffed snowman, hired outside behavioral experts to address the needs of residents with pica and retrained caregivers on how to protect those individuals.
Caring for adults with profound intellectual and developmental disabilities can be challenging. Some have the strength of a weightlifter with the impulsiveness of a child. In the blink of an eye, they can find themselves in crisis.
Yet caregivers in group homes earn an average of $9.35 an hour, according to the Illinois Association of Rehabilitation Facilities. That wage is below the federal poverty level for a family of three. Low pay is a contributing factor in high staff turnover — more than 40 percent annually in some homes.
"Staff turnover — it's like a cancer that affects care," said UCP Seguin of Greater Chicago CEO John Voit, who has worked in the industry since the 1970s.
Group home executives complain that inadequate state funding has not allowed the industry to increase entry-level pay or raise existing salaries to retain skilled supervisors. They say caregivers can earn more money in many other industries, citing the experienced employees who recently resigned to take higher-paying jobs at Amazon warehouses.
To fill vacancies, business operators said they have turned to workers whose backgrounds would have disqualified them from jobs in the past.
"You're scraping the barrel," said Little City Executive Director Shawn Jeffers, whose agency's services include group homes for adults with disabilities in the Chicago area. "I have some folks who do some really dumb stuff."
Responding to what group home owners call a staffing crisis, state lawmakers in both houses this summer overwhelmingly approved $330 million in funding to boost pay for caregivers. But Gov. Bruce Rauner vetoed the measure in August, citing a lack of state funds.
The Tribune also found that the group home industry is exempt from basic staffing standards required elsewhere in the state's long-term care system.
Nursing homes, state institutions and other extended-care facilities are required by law to employ on-site registered nurses who can detect and react to sudden changes in patient conditions. Even low-level employees must be state-certified aides who update skills through continuing education.
Group homes are not bound by these requirements. Many group home residents are not examined by a licensed nurse for weeks at a time, sometimes for many months, state enforcement records show. Instead, registered nurses often work from remote locations and supervise dozens of residents over the telephone.
Some unlicensed workers also are allowed to pass out prescription medications — a practice prohibited by law at nursing homes and state-owned facilities.
These and many other relaxed policies place group home residents at greater risk of undetected complications.
Few daily activities underscore the dangers of thin staff or the critical role of competent caregivers like the simple act of eating.
In 2014, a UCP Seguin group home resident attending the company's day program in Cicero choked to death on a marshmallow that a caregiver handed out as a treat. The victim had dysphagia, putting him at high risk of choking, and staff were supposed to give him only pureed or finely chopped foods, the inspector general found. UCP Seguin CEO Voit said his organization, one of the state's largest group home providers, has retrained staff on choking risks and revised safety protocols.
That same year, a man at a Trinity Services group home in Peoria fatally choked on a cheeseburger, carrots and applesauce when a caregiver stepped away. The victim's medical files warned he often swallowed food too fast and needed close supervision, but staff members were not properly trained about his special needs, state records show.
In response, Trinity Service officials said, they created a training manual for each group home that details how to monitor residents with diet restrictions and choking risks, including pictures that illustrate how to chop or puree food properly.
For Loren Braun, death came from a McDonald's hamburger and an inattentive caregiver who had been hired specifically to watch him.
At 61, Braun had no teeth and couldn't wear dentures. Born with developmental disabilities and diagnosed with schizophrenia, he had lived since 1997 in a North Side group home managed by Anixter Center.
Braun had a history of choking. His food had to be soft and cut into tiny pieces, and someone had to coach him at every meal to eat slowly and drink water between bites.
Braun's sister, Barbara Chyette, tried to protect her younger brother as best she could. (Click to Continue)
Nancy Davis, a Mosaic vice president, said her organization dismissed the caregiver who allowed the man to sleep with a stuffed snowman, hired outside behavioral experts to address the needs of residents with pica and retrained caregivers on how to protect those individuals.
Caring for adults with profound intellectual and developmental disabilities can be challenging. Some have the strength of a weightlifter with the impulsiveness of a child. In the blink of an eye, they can find themselves in crisis.
Yet caregivers in group homes earn an average of $9.35 an hour, according to the Illinois Association of Rehabilitation Facilities. That wage is below the federal poverty level for a family of three. Low pay is a contributing factor in high staff turnover — more than 40 percent annually in some homes.
"Staff turnover — it's like a cancer that affects care," said UCP Seguin of Greater Chicago CEO John Voit, who has worked in the industry since the 1970s.
Group home executives complain that inadequate state funding has not allowed the industry to increase entry-level pay or raise existing salaries to retain skilled supervisors. They say caregivers can earn more money in many other industries, citing the experienced employees who recently resigned to take higher-paying jobs at Amazon warehouses.
To fill vacancies, business operators said they have turned to workers whose backgrounds would have disqualified them from jobs in the past.
"You're scraping the barrel," said Little City Executive Director Shawn Jeffers, whose agency's services include group homes for adults with disabilities in the Chicago area. "I have some folks who do some really dumb stuff."
Responding to what group home owners call a staffing crisis, state lawmakers in both houses this summer overwhelmingly approved $330 million in funding to boost pay for caregivers. But Gov. Bruce Rauner vetoed the measure in August, citing a lack of state funds.
The Tribune also found that the group home industry is exempt from basic staffing standards required elsewhere in the state's long-term care system.
Nursing homes, state institutions and other extended-care facilities are required by law to employ on-site registered nurses who can detect and react to sudden changes in patient conditions. Even low-level employees must be state-certified aides who update skills through continuing education.
Group homes are not bound by these requirements. Many group home residents are not examined by a licensed nurse for weeks at a time, sometimes for many months, state enforcement records show. Instead, registered nurses often work from remote locations and supervise dozens of residents over the telephone.
Some unlicensed workers also are allowed to pass out prescription medications — a practice prohibited by law at nursing homes and state-owned facilities.
These and many other relaxed policies place group home residents at greater risk of undetected complications.
Few daily activities underscore the dangers of thin staff or the critical role of competent caregivers like the simple act of eating.
In 2014, a UCP Seguin group home resident attending the company's day program in Cicero choked to death on a marshmallow that a caregiver handed out as a treat. The victim had dysphagia, putting him at high risk of choking, and staff were supposed to give him only pureed or finely chopped foods, the inspector general found. UCP Seguin CEO Voit said his organization, one of the state's largest group home providers, has retrained staff on choking risks and revised safety protocols.
That same year, a man at a Trinity Services group home in Peoria fatally choked on a cheeseburger, carrots and applesauce when a caregiver stepped away. The victim's medical files warned he often swallowed food too fast and needed close supervision, but staff members were not properly trained about his special needs, state records show.
In response, Trinity Service officials said, they created a training manual for each group home that details how to monitor residents with diet restrictions and choking risks, including pictures that illustrate how to chop or puree food properly.
For Loren Braun, death came from a McDonald's hamburger and an inattentive caregiver who had been hired specifically to watch him.
At 61, Braun had no teeth and couldn't wear dentures. Born with developmental disabilities and diagnosed with schizophrenia, he had lived since 1997 in a North Side group home managed by Anixter Center.
Braun had a history of choking. His food had to be soft and cut into tiny pieces, and someone had to coach him at every meal to eat slowly and drink water between bites.
Braun's sister, Barbara Chyette, tried to protect her younger brother as best she could. (Click to Continue)
Full Article & Source:
Part 1: Illinois hides abuse and neglect of adults with disabilities
Wow, this series should have everyone talking in Illinois and other states reacting as well.
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