Gov. Pat Quinn issued an executive order last week that makes immediate changes to the Illinois Department of Human Services and its inspector general’s office.
Why the shake-up?
According to recent stories published in the Belleville News-Democrat, the agency responsible for keeping disabled adults safe failed to investigate 53 deaths since 2003. In each case, a caller had reported suspected abuse or neglect to a state hotline. In each case, the disabled adult ended up hospitalized and died soon after.
Why no DHS investigations to determine whether the deaths resulted from mistreatment?
The newspaper found that DHS Inspector General William Davis had adhered to a strict policy that dead people were not eligible for state services: Once the disabled adults died, his office wiped its hands of them. In cases where Davis’ office said it did notify law enforcement of deaths that followed suspected abuse or neglect, it evidently kept minimal records.
Davis offered his resignation last week.
The people who died were among this state’s most vulnerable citizens — disabled adults who live at home and depend entirely on others’ care, often that of a family member who is paid by the state to do the work. These disabled adults need vigilant guardians. Who knows what happens behind closed doors?
All 53 disabled adults died after someone — neighbors, family members, doctors — had called an agency hotline. Some of them died severely underweight. They died from bedsores that became infected. They died filthy and alone.
Quinn’s executive order triggers a review of each case. The order requires that future deaths of disabled adults who live at home be reported to the local coroner or medical examiner. If the person had been the subject of an abuse allegation, law enforcement must be notified.
What the executive order does not address is the overly bureaucratic culture within DHS, which needs an overhaul. One provider told us the agency primarily pays attention to paperwork: An investigator might look at medical records or a financial audit, but thorough home visits are rarities. There’s not enough face-to-face contact with the disabled.
Here’s the additional rub: Lawmakers passed a bill a year ago to mandate quicker investigations of abuse allegations at group homes and nursing homes where other disabled people live. Sadly, that is, we’ve been here before.
That action came in response to a Tribune investigation into more than 13 child and teen deaths at a state-licensed facility. It came after the closing of Howe Developmental Center in Tinley Park, which had been plagued with a history of patient abuse and neglect. And it came after the death of 42-year-old Paul McCann, a Joliet native who functioned at the level of a 6-year-old. He died at a downstate group home after his caretakers punched, kicked and struck him with a frying pan because he took a cookie without permission.
DHS needs more than a reactive executive order from Quinn. The state’s crisis-of-the-day management style in response to these cases doesn’t supply the focus on patients, not just paperwork, that DHS needs. “If someone gets into a community setting and they’re put in a place where their caretaker becomes their abuser, we need to react to that,” state Rep. Greg Harris, D-Chicago, told us. “If it’s necessary to appoint a guardian and move them out, we need to be able to do that. There are so many things wrong with this picture.”
Illinois often finds itself fixing problems after the damage is done — and, we’d point out, often in reaction to atrocities uncovered by journalists, not the state’s own army of investigators and inspectors general.
Harris will hold a committee hearing on the issue this month. That’s good. Illinoisans deserve answers.
But legislators and the governor need to look beyond DHS and its front-line services. Illinois needs a comprehensive strategy at DHS, the Department of Public Health and the Department on Aging to coordinate their staffs, pool resources and fill systemwide gaps that put fragile lives at risk.
The governor’s executive order doesn’t reach that far. But we agree with the mission it sets forth: “The state has an obligation to protect its most vulnerable citizens from abuse, neglect and exploitation.”