IDPH launching external investigation of its nursing home oversight bureau

IDPH launching external investigation of its nursing home oversight bureau

Investigations of abuse, neglect complaints delayed from mid-March through June

Capitol News Illinois

SPRINGFIELD — The Illinois Department of Public Health announced Friday it has initiated an external review of its Bureau of Long-term Care due to delays in investigations of abuse and neglect complaints amid the COVID-19 pandemic.

There have been 7,857 deaths linked to COVID-19 since the pandemic began in Illinois after 24 more were reported Friday. Of those fatalities, 4,319 have occurred in long-term care facilities, according to IDPH.

IDPH said in a news release that while the abuse and neglect investigations were temporarily halted, the department continued conduct virus control efforts, including more than 1,000 infection control inspections at 727 facilities.

According to the IDPH website, the Bureau of Long-term Care is responsible for ensuring nursing homes comply with the state Nursing Home Care Act. In cooperation with the Department of Central Management Services, the Bureau conducts certification surveys to ensure facilities receiving state or federal funds abide by applicable federal regulations.

Surveyors conduct about 10,000 surveys each year, including annual licensure inspections and complaint investigations.

But independent review is needed “in response to IDPH’s recent discovery that the Bureau of Long-Term Care was not properly processing and investigating complaints of abuse and neglect at long-term care facilities from approximately March 15 to June 30, 2020,” according to a news release.

That time period included 272 allegations of abuse and neglect, which, according to IDPH, have since been investigated. The factual circumstances of 17 of those complaints were validated in the ensuing investigations, and IDPH is reviewing those findings to determine the appropriate next steps.

“For example, a surveyor could have confirmed that an incident described in a complaint did occur (e.g. a resident fell or was injured), but that the nursing home was not responsible, acted appropriately, or that the nursing home’s conduct did not violate state or federal regulation,” according to a news release.

The inspections were initially delayed despite the fact that guidelines issued by IDPH to limit the number of people entering long-term care facilities did not suspend the Illinois law that requires abuse and neglect complaints to be reviewed within certain timeframes.

In the most serious cases where complaints of abuse or neglect are made, IDPH must conduct surveys of the facility within 24 hours, while complaints of lesser severity must be surveyed within seven days. IDPH did not meet state deadlines for conducting those surveys, in part because of the “improper classifications of some complaints,” according to a news release.

“As soon as IDPH leadership identified that some abuse and neglect complaints had been improperly classified and not investigated in a timely manner, surveyors were directed to investigate all complaints of abuse and neglect that had not yet been investigated,” according to the release.

The investigations from the affected period were completed with an on-site visit, interviews, review of facility documents, and, where necessary, confirmation that law enforcement had also been notified at the time of the incident.

IDPH said it took immediate action — including “appropriate personnel action” —to ensure completion of the investigations.

IDPH also hired Manatt Health Strategies LLC “to conduct a top to bottom review of the division, with a focus on recommending best practices to ensure proper licensure and oversight activities by the Bureau of Long-Term Care.”

Former U.S. Attorney for the Southern District of Illinois, A. Courtney Cox, was also hired to “take a closer look at specific investigations IDPH conducted into complaints made concerning long-term care facilities during the COVID-19 pandemic.”

“Our top priority as a regulator of long-term care facilities in Illinois is ensuring vulnerable Illinoisans are kept safe by those responsible for their care,” IDPH Director Dr. Ngozi Ezike said in a news release. “Anything short of that is unacceptable, and our entire department is committed to getting this right as we move forward. Working with independent experts, we are simultaneously conducting a full and thorough review of our previous work and revamping our Bureau of Long-Term Care to better serve the people of Illinois.”

IDPH also announced that 20 of the state’s 102 counties are at warning level for COVID-19.

Those counties include Bureau, Cass, Clay, Clinton, Franklin, Greene, Grundy, Hancock, Henderson, Jefferson, Logan, Madison, Monroe, Moultrie, Randolph, St. Clair, Union, White, Will and Williamson.

The counties saw cases or outbreaks associated with weddings, businesses, neighborhood gatherings, parties, long-term care facilities and other congregate settings, travel to neighboring states, bars and sports camps, according to a news release.

IDPH said cases associated with schools were also reported.

The state announced another 2,208 cases of the virus Friday among 51,736 tests completed over the previous 24 hours. That brought the total number of cases to 215,929 since the pandemic began.

That drove the rolling, seven-day positivity rate to 4.3 percent, or one-tenth of a percentage point lower than the day prior. The one-day rate was 4.3 percent as well.

At the end of Thursday, there were 1,526 people in Illinois hospitalized with COVID-19.  Of those, 351 were in intensive care units, and of those ICU patients 121 were on ventilators.


Capitol News Illinois is a nonprofit, nonpartisan news service covering state government and distributed to more than 400 newspapers statewide. It is funded primarily by the Illinois Press Foundation and the Robert R. McCormick Foundation.

Jeff Rogers

Jeff RogersJeff Rogers

Jeff has more than 30 years’ experience working for newspapers as a reporter and editor. He was the editor of daily newspapers in northern Illinois and Wisconsin before joining as Capitol News Illinois’ editor, where he oversees the news service’s development, growth and fundraising. He grew up in Lanark in northwest Illinois and has a journalism degree from Bradley University in Peoria.

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