Statement of Violation

Kanthak House
Facility I.D. Number: 0037747
724 Second Avenue
Ottawa, Illinois 61350

Date of Survey: 10/24/02

Complaint Investigation

"A" VIOLATION(S):

The facility’s governing body shall exercise general direction of the facility, and shall establish the broad policies and procedures for the facility related to its purpose, objectives, operation, and the welfare of the residents served.

The facility shall have written policies and procedures governing all services provided by the facility which shall be formulated with the involvement of the Administrator. The policies shall be available to the staff, residents, and the public. These written policies shall be followed in operating the facility and shall be reviewed at least annually.

The facility shall notify the Department of any incident or accident which has, or is likely to have, a significant effect on the health, safety, or welfare of a resident or residents. Incidents and accidents requiring the services of a physician, hospital, police or fire department, coroner, or other service provider on an emergency basis shall be reported to the Department.

AN OWNER, LICENSEE, ADMINISTRATOR, EMPLOYEE OR AGENT OF A FACILITY SHALL NOT ABUSE OR NEGLECT A RESIDENT. (Section 2-107 of the Act)

A FACILITY EMPLOYEE OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL IMMEDIATELY REPORT THE MATTER TO THE FACILITY ADMINISTRATOR. (Section 3-610 of the Act)

A FACILITY ADMINISTRATOR, EMPLOYEE, OR AGENT WHO BECOMES AWARE OF ABUSE OR NEGLECT OF A RESIDENT SHALL ALSO REPORT THE MATTER TO THE DEPARTMENT. (Section 3-610 of the Act)

These Regulations were not met.

Based on interview, review of bulk-file records an file verification, the facility neglected to ensure that monitoring systems were adequate to protect an individual (R1) from alleged sexual abuse: 1) by not ensuring that all allegations of sexual abuse were reported to the Administrator immediately. by not ensuring that individuals were protected from potential further abuse by immediately putting protective measures in place. by not immediately initiating an investigation into all allegations of abuse.

by not reporting the allegations of abuse to the Department.

Findings include:

R1 is a 21-year old verbal women whose Individual Program Plan (IPP) dated April 12, 2002, identifies as being a legally competent women who is functioning in the severe range of mental retardation. The clinical record and documents contained in the bulk-file show that allegations made in June and again in September, 2002, identify R1 as having been sexually abused by her father.

The facility neglected to ensure that all allegations of abuse are reported Immediately to the Administrator as required by Illinois Administrative Code 350.3240b)

In a progress note written on September 18, 2002, the day after R1's outing with her father, E4 wrote that R1 stated during a conversation with E4 that someone had hurt her (R1) in the past but not anymore, and that person had been “my dad”. When asked where her dad hurt her, R1 “looked down at her vagina and said, ?down there’.” According to the note written on September 18, 2002, R1 told E4 that a women was present when her father hurt her.

According to Social Service notes for September in R1's clinical record, R1 “went out for supper” with her father and a female cousin on September 17, 2002, and the Activity Participation Form for that date shows that R1 was out of the facility for four hours with her father and female family member.

When asked on October 18, 2002, at 3:50 p.m. in a telephone interview, E4 stated that she recorded the September 18, 2002 conversation with R1 on the Progress note form (P-15) and followed what she understood to be facility procedures by posting the note on a clipboard kept in the locked medicine room where clinical records are stored. E4 stated that she made additional copies of the note and placed them in the daily shift book and the program book in addition to putting on copy in an envelope and sliding the envelope under the Administrator (Qualified Mental Retardation Professional) QMRP’s office door. E4 stated that the Administrator was out of the facility for several days and that E4 did not try to contact him by telephone.

When asked on October 16, 2002 at 9:15 a.m. when he had become aware of the allegation made in the September 18, 2002, progress note, E1 stated that he did not see the progress note until he was in the facility on October 4, 2002 getting ready for a staff meeting. E1 said that the first read the note on October 4, 2002, and that no staff person had called him or brought it to his attention to October 4, 2002. E1 stated on October 16, 2002 at 11:45 a.m. the posting the information on the clipboard “...should have been enough”.

Agency Policy No. 5.24 concerning the Administrative Investigation Committee states under the Procedure Section 1. Any facility employee or agent who witnessed or suspects a violation of resident rights, abuse, or neglect shall immediately report the matter to facility management. The Procedures do not provide further guidance regarding how the report is to be communicated, and E4 and E1 both stated the facility practice was to post this information on a clipboard located in the medication room.

Agency Policy and facility practice failed to ensure that allegations of abuse were reported immediately to the facility Administrator, resulting in a 16-day delay in the Administrator’s receiving the report of an allegation of abuse.

During the 16-day delay from when facility staff documented R1's allegation of sexual abuse until October 4, 2002, when the Administrator/QMRP posted the notice in the medication room that “UNTIL FURTHER NOTICE, (R1) CANNOT LEAVE THE FACILITY UN(A)SCORTED, WITHOUT STAFF” there were not restrictions placed on R1's visits outside the facility, and there were not protections in place to prevent further potential sexual abuse.

When asked on October 16, 2002 at 9:45 a.m., E1 stated that he had considered the facility investigation complete on August 30, 2002, concerning the first allegations that R1's father had sexually abused her and ha told R1's father on September 12, 2002 that R1 could go home with no restrictions on her visits. R1's father took her out of the facility for four hours on September 17, 2002. September progress notes show that R1's mother had her home for overnight visits on September 19 and 20, 2002.

The facility neglected to ensure that individuals were protected immediately after an allegation of abuse was made.

The facility neglected to investigate allegations of abuse immediately.

R1's clinical record contains social service notes stating that R1 “went out for supper” with her father an a female cousin on September 17, 2002. The Activity Participation Form states that R1 was out of the facility for 4 hours with “Dad” and female family member.

In a progress note written on September 18, 2002, the day after R1's outing with her father, E4 wrote that R1 stated that someone had hurt her (R1) in the past but not anymore, and that person had been “my dad”. When asked where her dad hurt her, R1 “looked down at her vagina and said, “down there”. According to the note written on September 18, 2002, R1 told E4 that a woman was present when her father hurt her.

When asked on October 16, 2002 at 11:45 a.m. if the facility had investigated the allegation R1 made on September 18, 2002, E1, the Administrator/QMRP, stated that he was not aware of the allegation until October 4, 2002, and at that time, he viewed R1's statement made on September 18, 2002, to be a statement which “.....speaks of the past when she was a child” and did not see the need to investigate the allegation.

At 9:15 a.m. on October 16, 2002, E1 stated that on August 30, 2002, the facility had completed its investigation of the previous allegations of sexual misconduct by the father and had concluded the “the allegations were not founded”. When asked if the facility had re-opened its investigation in light of the allegation which R1 made on September 18, 2002, E1 stated that the facility had not re-opened it’s investigation which concluded the previous allegations were not founded. When asked if the facility had investigated anything about the unsupervised visit R1 had with her father on September 17, 2002, E1 stated that there had not been anything except R1 was taken to see a therapist in Moline on October 15, 2002, almost four weeks after the original allegation was recorded and posted on September 18, 2002.

When interviewed by telephone on October 23, 2002 at 9:50 a.m., Z1 of the Ottawa police force stated that the status of the June, 2002 police investigation was that the case was not “inactive” but is not closed. Z1 stated that there are no conclusions made from the investigation at this point.

The facility neither re-opened its previous investigation not did it initiate a new investigation in light of the new allegation of sexual abuse which R1 made on September 18, 2002.

The facility neglected to ensure that all allegations of abuse are reported to the Department of Public Health as required by Illinois Administrative Code 350.3240d).

a. The clinical record shows that on June 20, 2002 an officer from the local police department came to the facility and informed the Administrator that there had been an allegation of a sexual nature concerning R1's father and that the police had begun a formal investigation into those allegations. The record shows that the facility did not notify the Department of all allegation of sexual abuse as required.

b. Again on October 4, 2002, when the Administrator/QMRP became aware of the allegations which R1 made on September 18, 2002 and documented by E4, E1 still did not report the allegation to the Department.

Based on interview, review of Policies and Procedures, and review of clinical records, the facility neglected to develop and/or implement policies and procedures designed to protect individuals from abuse for R1 who is alleged to be the victim of sexual abuse.

Findings include:

Agency Policy concerning the Administrative Investigative Committee (Policy No. 5.24) states that “Any facility employee or agent who witnesses or suspects a violation of resident rights, abuse, or neglect shall immediately report the matter to facility management.” The manner of reporting such allegations is not specified in the procedures, and there was a 16-day delay

between a staff person’s documenting the allegation of sexual abuse which R1 made on September 18, 2002 and October 4, 2002 when E1, the facility Administrator/QMRP (Qualified Mental Retardation Professional) first became aware of the allegation.

R1 is a 21 year-old verbal woman whose Individual Program Plan (IPP) dated April 12, 2002 identifies as a legally competent women who is functioning in the Severe range of mental retardation. A notice posted in the medication room dated October 4 states “UNTIL FURTHER NOTICE, (R1) CANNOT LEAVE THE FACILITY UN(A)SCORTED, WITHOUT STAFF.” When asked on October 16, 2002, at 9:15 a.m., the reason for the notice being posted, E1 stated that it was on October 4, 2002 the he first became aware of the contents of a progress notice written on September 18, 2002 concerning R1.

In a progress note written on September 18, 2002, the day after R1's unsupervised outing with her father and a female family member, E4, direct care staff, wrote that R1 stated during a conversation with E4 that someone had hurt her (R1) in the past but not anymore, and that person had been “my dad”. When asked where her dad had hurt her, R1 “looked down at her vagina and said, ?down there’.” According to the note written on September 18, 2002, R1 told E4 that a woman was present when her father hurt her.

E1 stated that the progress note had hung on the clipboard in the locked medication room from September 18, 2002 until October 4, 2002 without his knowledge. E1 stated that E4 had followed internal procedures by “putting it on the clipboard” but that he (E1) was away from the facility on September 18, 2002 and no one had called him. E1 stated he had not reviewed the contents of the clipboard when he returned to the facility. E1 stated on October 16, 2002, at 11:45 a.m. that the “note on the clipboard should have been enough.”

When interviewed over the telephone on October 18, 2002 at 3:50 p.m., E4 stated that the facility’s system to communicate allegations of abuse or unusual incidents or injuries of unknown origin is to write the details down, “put it on the clipboard and put it in the program book.” E4 stated that she made three copies of the note she had written on September 18, 2002 and that she placed one copy on the clipboard in the medication room, one copy in the daily shift book, and once copy in the program book. E4 stated that because of the nature of the allegation, she made an extra copy of the note, placed it in an envelope and slipped it under the QMRP’s office door so that he wold be sure to see it when he returned to the facility. E4 stated that she though she “had done what was necessary to inform (E1) with posting it and slipping the note under the Q office door.” E4 confirmed that the facility administration has since told staff to call the Administrator/QMRP in addition to documenting incidents.

The agency policy/procedure failed to specify methods for reporting to the Administrator, and the facility’s unwritten internal system of communication using the clipboard did not work, resulting in a 16-day delay between the time the allegation of sexual abuse was made and the Administrator’s becoming aware and setting protections in place.

When asked in a telephone call on October 22, 2002 at 11:35 a.m., for the agency policy covering sexual abuse, E7, Agency Regional Administrator, stated that current agency policy encompassed the problem of sexual abuse. At 2:10 p.m., E7 faxed a copy of the agency Policy No. 5.52, subject of “Individual Rape or Sexual Assault.” A review of that policy shows that the

agency definition for sexual abuse is narrowly defined to be acts of rape or sexual assault and does not include other definitions of sexual abuse.

A review of the clinical record shows that on June 20, 2002 an Ottawa police officer came to the facility and informed the facility that there had been “...an allegation of a sexual nature” concerning R1's father and R1, and that the police had begun a formal investigation into the allegations. In a report dated September 27, 2002, E1 wrote that on July 2, 2002, the facility took R1 to a gynecologist and he “stated that there were no findings. Her (R1) membrane was intact.”

The clinical record and the report dated September 27, 2002 show between June 20 and July 3, 2002, when the Department had begun investigating a complaint, the facility had not identified R1 as being a potential victim of sexual abuse in need of facility protection. The facility had no restrictions on R1's having unsupervised out-of-facility visits with her father, who was the alleged perpetrator. The facility did not initiate any interventions for R1 as a potential victim of sexual abuse.

Also, the facility had not linked R1's injuries of unknown origin identified in June, 2002 as potentially linked abuse or to abuse of a sexual nature. The clinical record states in a progress note written on June 12, 2002, that R1 had bruises on her outer thigh and one on her inner thigh “by her vagina” that on June 18, 2002, R1 had a small red mark on her left pelvic area and on her right pelvic area. These injuries of unknown origin were discovered after visits with the father but were not linked with possible sexual abuse, and, as stated in the September 27, 2002 document, were not investigated or reported until the Department initiated a complaint investigation on July 2, 2002.

The agency’s current Policy 5.52 deals only with cases of rape or sexual assault and do not provide facility staff with enough information and guidance to protect individuals from other kinds of sexual abuse. The agency’s policies state that individuals shall be free of abuse, but do not define the terms of verbal or physical abuse or address all injuries of unknown origin.

Based on interview, review of facility incident reports, review of facility policies and procedures, and review of the clinical record and bulk-file, the facility did not ensure that allegations of sexual abuse wee reported for R1 either to the Administrator or to the Department as required.

Findings include:

R1 is a 21-year old verbal women whose Individual Program Plan (IPP) dated April 12, 2002, identifies as being a legally competent women who is functioning in the severe range of mental retardation.

The clinical record shows that on June 20, 2002 an officer from the local police department came to the facility and informed the Administrator that there had been an allegation of a sexual nature concerning R1's father, and that the police had begun a formal investigation into those allegations. When asked on October 16, 2002 at 9:15 a.m, E1 stated that the facility’s investigation was completed on August 30, 2002 and that “the allegations were not founded”. E1 stated that when R1's father called on September 12, 2002, and asked for an outing, the facility made arrangements for R1 to go out with her father.

According to Social Service notes for September, 2002 in R1's clinical record, R1 “went out for supper” with her father and a female cousin on September 17, 2002. The Activity Participation Form for that date shows that R1 was out of the facility for four hours with her father and female family member.

The facility did not ensure that allegations of abuse were reported to the facility Administrator as required by the Illinois Administrative Code 350.3240b).

When asked on October 18, 2002 at 3:50 p.m., in a telephone interview, E4 stated that she recorded the September 18, 2002 conversation with R1 on the Progress Note Form (P-15) and followed what she understood to be facility procedures by posting the note on a clipboard kept in the locked closet where clinical records are stored. E4 stated that she made additional copies of the note and placed them in the daily shift book and the program book, in additional to putting one copy in an envelope and sliding the envelope under the Administrator (Qualified Mental Retardation Professional) QMRP’s office door. E4 stated that the Administrator was out of the facility for several days and that E4 did not try to contact him by telephone.

When asked on October 16, 2002 at 9:15 a.m. when he had become aware of the allegation made in the September 18, 2002 progress note, E1 stated that he did not see the progress note until he was in the facility on October 4, 2002 getting ready for a staff meeting. E1 said that he first read the note on October 4, 2002 and that no staff personal had called him or brought it to his attention prior to October 4.

The facility failed to ensure that allegations of abuse were reported to the Department of Public Health as required by the Illinois Administrative Code, 350.3240d).

When asked on October 15, 2002 at 4:55 p.m. if he had reported the allegation contained in the September 18, 2002 progress note to the Department of Public Health, E1 stated that he has not contacted the Department because he felt that the allegation R1 made on September 18, 2002 was not a present allegation but was an allegation which “.....speaks of the past when she was a child.” When asked if the facility had investigated anything about the unsupervised visit R1 had with her father on September 17, 2002, E1 stated that there had not been anything except R1 was taken to see a therapist in Moline on October 15, 2002.

E1 confirmed that he had not reported the allegation to the Department.