This article was produced for ProPublica’s Local Reporting Network in partnership with Lee Enterprises, along with Capitol News Illinois. Sign up for Dispatches to get stories like this one as soon as they are published.
Illinois Gov. J.B. Pritzker signed a bill into law on Friday that strengthens the range of penalties that a state watchdog can mete out for health care employees who conspire to hide abuse or interfere with investigations by the state police or internal oversight bodies.
The legislation was introduced following an investigative series by Capitol News Illinois, Lee Enterprises Midwest and ProPublica into rampant abuses and cover-ups at Choate Mental Health and Developmental Center, a state-run institution in southern Illinois that houses people with intellectual and developmental disabilities and mental illnesses. The new law applies to employees at state-run institutions and at privately operated community agencies for people with developmental disabilities and mental illnesses that operate under the oversight of the Illinois Department of Human Services and its Office of the Inspector General.
The news organizations detailed how employees had lied to investigators, leaked sensitive investigative details, retaliated against people who reported abuse and sought to indoctrinate new workers into the cover-up culture. Employees who engaged in such actions made it difficult to pursue cases of patient abuse, yet they rarely faced serious consequences. IDHS Inspector General Peter Neumer suggested the change in law last year.
The new law allows the OIG to report workers who engage in such misconduct to Illinois’ existing Health Care Worker Registry, which would bar them from working in any health care setting in the state.
The registry identifies any health care worker who has been barred from working with vulnerable populations in any long-term care setting, such as state-operated developmental centers or group homes. Under prior law, workers could be barred because they had been found to have engaged in financial exploitation; neglect that is considered “egregious”; or physical or sexual abuse. The new law adds “material obstruction” of an investigation to the list of findings that can be reported to the registry, which is maintained by the Illinois Department of Public Health.
Pritzker signed the bill on the same day the IDHS inspector general released a 34-page report that recommended a “top to bottom analysis” of all processes related to the reporting of abuse and neglect at Choate “because at the present time there appear to be fundamental problems with all aspects of that system.”
The OIG report referenced the beating of a patient with a developmental disability by Choate staff in December 2014 that was covered by the news outlets. Four mental health technicians were charged with felonies in connection to the beating. Three of them pleaded guilty to failing to comply with abuse reporting laws for state employees, and one — Mark Allen, a mental health technician who had been originally charged with felony aggravated battery — pleaded guilty to felony obstruction of justice.
The report noted that at least eight people colluded to obstruct the state police and OIG investigation. Few staff members were forthcoming with details, even though they later told investigators it was the worst case of abuse they had ever seen.
“This was a textbook example of a code of silence, in which staff seek to protect each other from the consequences of their misconduct by remaining silent about what they witnessed or lying to protect their fellow employees,” the new OIG report stated. While Allen was ultimately reported to the registry after the inspector general found him responsible for the abuse, the other three were not. Even though they were criminally convicted of failing to report what they’d witnessed, and the inspector general found that they had engaged in the cover-up, prior law did not include obstruction as a reportable offense.
The new law is a “necessary reform that will provide additional protection for residents and hold accountable any bad actors who violate the trust of a resident or patient,” Alex Gough, a spokesperson for Pritzker, said in a statement.
“Governor Pritzker continues to take the longstanding problems at Choate very seriously, and he remains committed to providing a healthy, safe living environment for every single person residing in the state’s care.”
On Monday, Neumer said in a statement that he was pleased that the governor and legislators supported the measure, which passed both chambers unanimously, because it “serves as a strong deterrent to those who would engage in ‘code of silence’-type conduct, where employees lie or omit key facts to investigators in an effort to protect themselves and/or their fellow employees.”
“When employees fully and completely cooperate with OIG’s investigations, that also enhances OIG’s ability to fact-find, which serves as an additional deterrent to misconduct,” he said.
IDHS Secretary Grace Hou noted in a letter to Neumer, which was included in the inspector general’s report, that she also had backed the legislative change. That is one of several steps her department has taken to address conditions at Choate and in the agency’s 12 other developmental centers and psychiatric hospitals, the letter said.
In a statement, Marisa Kollias, a spokesperson for IDHS, said that a “system-wide transformation” of the agency’s facilities is already underway.
In March, Pritzker and Hou announced that more than 120 residents of Choate — about half of the facility’s population — would have to move out for their safety. The residents and their guardians were given up to three years to find an alternative placement, such as in a community group home or another state-run facility.
In addition to the relocation of some of Choate’s residents, the department has also hired a chief resident safety officer and is implementing other safety enhancements.
Kollias noted that Hou asked the inspector general to conduct the review of Choate last September, the same month the news organizations published their first in a series of reports about Choate.
“IDHS leadership continues to be deeply concerned by the events investigated and reported on by the OIG,” Kollias said. “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.”
The inspector general has repeatedly called for the installation of security cameras at Choate and in other IDHS facilities, but the department had previously said that doing so was complicated by federal regulations. The department said late last week that the Centers for Medicare and Medicaid Services, which partially funds its institutional care, has provided new guidance that will allow for the installation of cameras in indoor, common area locations. The department, the statement said, “will be installing those expeditiously.”
