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.
No other state has bestowed full-fledged investigative powers on caregivers at group homes serving people with intellectual and developmental disabilities, according to federal regulators.
The Tribune investigation, the first comprehensive examination of the
state's secretive network of 3,000 group homes, also found that Human
Services officials routinely obscured evidence of harm from the public.
The
inspector general's office sealed 3,239 cases in which they found some
evidence of abuse or neglect, a Tribune analysis of previously
undisclosed state records from the last six years found.
Neither the public nor family members — not even group home residents — are allowed to know the nature of those investigations, the strength of the evidence or what reforms, if any, were mandated or made.
It's a flawed system that conceals the silent victims of abuse and neglect — some, literally voiceless — while allowing investigators to close as many cases as possible with the fewest consequences.
In one such case, the Tribune found, the inspector general's own investigators overlooked obvious clues pointing to neglect and were easily misled by a group home employee who later admitted she made up her story about what had transpired.
As a result of the Tribune's investigation, Human Services Secretary James Dimas said this month that he will seek to make public the records of all unsubstantiated cases. "We're working hard to push the envelope to become more transparent," he said. "And we're prepared to seek a change to the legislation if we decide that becomes necessary."
Additionally, Human Services Inspector General Michael McCotter has reopened both the investigation of Douglas' death and the neglect case involving the employee who gave false information.
McCotter credited the Tribune for sparking an agencywide audit and reform of investigative practices.
Human Services' oversight of group homes is fragmented, and McCotter acknowledged that his staff routinely didn't send its case reports to the division that licenses the homes — even when his investigators cited a business or its employees for abuse or neglect. He vowed to change that.
McCotter also said group home employees are no longer leading state investigations. In a policy change from the beginning of the year, McCotter began ordering his staff to visit group homes, conduct their own interviews and write all final reports.
As for state practices that have prohibited the public from knowing where abuse and neglect have occurred, he said, "It doesn't seem right, does it?" (Continue Reading)
Neither the public nor family members — not even group home residents — are allowed to know the nature of those investigations, the strength of the evidence or what reforms, if any, were mandated or made.
It's a flawed system that conceals the silent victims of abuse and neglect — some, literally voiceless — while allowing investigators to close as many cases as possible with the fewest consequences.
In one such case, the Tribune found, the inspector general's own investigators overlooked obvious clues pointing to neglect and were easily misled by a group home employee who later admitted she made up her story about what had transpired.
As a result of the Tribune's investigation, Human Services Secretary James Dimas said this month that he will seek to make public the records of all unsubstantiated cases. "We're working hard to push the envelope to become more transparent," he said. "And we're prepared to seek a change to the legislation if we decide that becomes necessary."
Additionally, Human Services Inspector General Michael McCotter has reopened both the investigation of Douglas' death and the neglect case involving the employee who gave false information.
McCotter credited the Tribune for sparking an agencywide audit and reform of investigative practices.
Human Services' oversight of group homes is fragmented, and McCotter acknowledged that his staff routinely didn't send its case reports to the division that licenses the homes — even when his investigators cited a business or its employees for abuse or neglect. He vowed to change that.
McCotter also said group home employees are no longer leading state investigations. In a policy change from the beginning of the year, McCotter began ordering his staff to visit group homes, conduct their own interviews and write all final reports.
As for state practices that have prohibited the public from knowing where abuse and neglect have occurred, he said, "It doesn't seem right, does it?" (Continue Reading)
Full Article & Source:
SUFFERING IN SECRET: Flawed investigations ignore victims of neglect
See Also:
Part 1: Illinois hides abuse and neglect of adults with disabilities
4 comments:
This is a great series and it's also horrifying. You know it's going on in every state. So sad.
It just breaks my heart.
There is just no excuse. It's a national shame.
Thank you for this investigation. There needs to be more attention to the most vulnerable population of society. We must all do better.
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