State leaves 3 administrators in charge at Choate despite troubled
history of resident care
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[July 12, 2023]
By BETH HUNDSDORFER
Capitol News Illinois
& MOLLY PARKER
Lee Enterprises Midwest
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
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Allegations of patient abuse, cover-ups and misconduct continue to
proliferate at a beleaguered facility for people with developmental
disabilities, despite promises of reform from Illinois Gov. J.B.
Pritzker and officials in his administration.
In a critical report released last month, the Office of the Inspector
General of the Illinois Department of Human Services said there needs to
be a “fundamental” change at Choate Mental Health and Developmental
Center in the southern town of Anna.
“There are repeated instances of CMHDC staff conspiring to knowingly and
deliberately cover-up misconduct that they either engaged in or
witnessed. In addition, other CMHDC staff, fearing retaliation from
their fellow employees or the loss of their job, have repeatedly failed
to report misconduct or sought to report that misconduct anonymously,”
the report said. “A fundamental overhaul of the system is needed to
establish a new culture where the reporting of abuse is automatic and
not an act of courage.”
Data obtained by Capitol News Illinois, Lee Enterprises Midwest and
ProPublica shows that complaints of abuse and neglect at the facility
have not abated. Since September, when the news organizations began
publishing stories about abuse and neglect of patients at Choate, there
have been 465 new complaints to the inspector general’s hotline for
reporting maltreatment. Nearly half of those were made after the state’s
March 8 announcement that it would begin moving some residents out of
Choate.
Among the new allegations: a report from November of a patient found
lying on a couch bleeding from his right ear. He told a worker that a
technician hit him with a broom, according to a report obtained from the
facility under a Freedom of Information Act request. No criminal charges
were filed. The technician is still employed at the facility.
The inspector general’s report raises new questions about the management
and administration of Choate, as well. Employees at the facility “raised
concerns that CMHDC administration played favorites and was biased in
their decision making,” the report said. “Another CMHDC employee stated
that abuse and neglect occurred at the facility due to the systemic tone
from the administration and nursing staff.”
The report also found “some indication that substandard work performance
is seen and accepted by CMHDC supervisors and management.”
The findings about Choate administrators are particularly notable
because Pritzker’s administration decided to retain the facility’s top
three administrators in March when announcing a plan to reduce the size
of Choate and move some residents to community settings or other
state-run facilities.
All three administrators were previously indicted on felony charges in
connection with their handling of an abuse allegation at the facility.
Facility Director Bryant Davis and Gary Goins, who has served as quality
assurance and improvements director, were both charged with official
misconduct in 2021. Assistant Director Teresa Smith was charged twice
with official misconduct and obstruction of justice, in 2020 and 2021. A
judge dismissed the first case, finding there was not probable cause to
sustain the charge. The prosecutor dismissed the most recent charges
against the three administrators. Smith, Goins and Davis did not respond
to requests for comment.
In explaining her rationale for keeping the administrators, IDHS
Secretary Grace Hou said in March: “We’ve weighed a lot of different
perspectives, but I think we need a leader who knows Choate inside and
out, who has relationships with the residents and the parents and the
staff to lead us through this challenging transition.” Pritzker publicly
backed Hou’s decision at the time.
In her official response to the report, Hou wrote that her agency had
hired new leadership, including Tonya Piephoff, the new director of the
Division of Developmental Disabilities, and a chief resident safety
officer, to oversee patient care at the state’s seven developmental
centers.
“IDHS remains committed to ensuring that there is strong and stable
leadership at Choate Mental Health and Developmental Center,” an agency
spokesperson said in a written statement. “We are always assessing the
strengths and capabilities of members of our leadership team. As the new
Director of DDD, Director Piephoff’s responsibility is to ensure that
every leadership role in that division is appropriately fulfilled,
including those at Choate and of the transformation that is occurring at
that Center.”
Hou’s written response to the OIG report also noted that the department
has implemented new trainings, in partnership with Illinois State
Police, that are “designed to improve reporting, safety, and care,
including training for frontline and direct care staff on abuse
reporting, investigations, retaliation, and code of silence.”
The department is installing cameras at the facility and overhauling
staffing and training protocols, as recommended.
The status-quo approach to facility leadership has drawn criticism,
including from a southern Illinois state senator and longtime proponent
of reforming Choate but also keeping it open. Sen. Terri Bryant, a
Murphysboro Republican, has said keeping the same leadership
demonstrates a lack of commitment to Choate’s long-term success.
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Credit: Alex Bandoni/ProPublica. Source
images: Whitney Curtis for ProPublica.
“This is a no-brainer. How do you change the culture of the facility
and leave the people in place who allowed the culture to grow and
flourish?” Bryant said in an interview. “This plan is a setup for
failure. I don’t care how much money you are going to put into the
buildings, you will change nothing without removing the leadership.”
The Retained Administrators
As facility director and assistant director, Davis and Smith are
responsible for staffing, employee evaluations, responding to
critical incidents and discipline at Choate, according to job
descriptions; Goins is tasked with assessing patient care,
developing corrective actions plans and staff training.
Davis, who has served as the facility director since 2014, is paid
an annual salary of $133,000; Smith, who has served as assistant
director since 2019, earns $111,000; and Goins, who has served as
quality assurance and improvements director since 2019, is paid
$106,000. Each has risen through the ranks at Choate over decades.
Goins and Smith started at Choate as nurses, while Davis joined
Choate staff in 2000 as a social worker.
Though the three were in charge and part of their job description
included recommending discipline for workers found to have
mistreated patients, the news organizations’ investigation showed
employees often escaped serious consequences for abusing or
neglecting patients.
Capitol News Illinois, Lee Enterprises Midwest and ProPublica
reported in September that at least 26 Choate employees were
arrested on felony charges related to patient maltreatment over a
10-year period concluding in 2021. Davis and Smith were in
leadership while all 26 arrests took place; 16 of them occurred
after Goins was promoted to leadership.
According to the agency’s records, in 25 of the 45 substantiated
abuse or neglect incidents since 2016, IDHS responded with
“retraining,” specifically providing employees with the written
policy and having them sign to say they had read it. Almost no
employees were fired for mistreating patients.
OIG investigations found workers who witnessed abuse but chose not
to report it because they feared for their jobs and their safety.
IDHS stated last month in response to reporters’ questions that no
one has lost their job for properly reporting abuse or neglect.
The OIG report also laid out how staff, including supervisors, were
involved in concealing abuse at the facility. In one particularly
disturbing account in the report, workers told the OIG that abusers
found ways to inflict pain on patients with developmental
disabilities without leaving any marks or evidence. The methods,
which they referred to as “DD Love,” included forcibly spreading
patients’ legs wider and wider while they were in a seated position
and, in at least one case, forcing a patient to stand with their
arms above their head for long periods.
To change the status quo, the OIG report said, “the administration
must be open to all ideas as to how to improve the level of care
provided at the facility.”
Another former employee who was in leadership when several
allegations of employee misconduct were leveled also returned to
Choate on a temporary basis this spring. Steve Hartline, the
longtime security chief who is also the mayor of Anna, where Choate
is located, resumed his former position on a 45-day personal service
contract that ended in May. From 2004 to 2019 — during Hartline’s
tenure as security chief — patients were charged with dozens of
felonies for scuffles with staff. The practice of charging patients
ended in 2020 under Hartline’s successor, Barry Smoot.
Hartline did not respond to requests for comment.
The department defended the temporary hiring. “Mr. Hartline provides
assistance in areas where he has significant experience. He is not
serving in a policymaking capacity,” a department spokesperson said
before Hartline’s contract ended in May.
Complaints Continue
Of the 465 new complaints of mistreatment at Choate to the inspector
general since September, the office has accepted roughly half for
investigation. To date, 51 did not include enough evidence to
sustain them and 119 are still open. The OIG has brought on a number
of full-time and temporary investigators to help process the
complaints quickly.
Despite those numbers, in its report the OIG also found barriers to
reporting abuse and neglect. Patients told investigators that they
had to ask staff to use the phone and to identify who they were
calling. They said that phones in the units were broken and that
posters carrying the OIG abuse hotline number were removed. Patients
also said they lost access to trust accounts, family visits and
other privileges after reporting abuse by staff.
While there have been no criminal charges issued against Choate
employees since March 2022, one employee pleaded guilty in February
to a felony for abusing a patient. The patient was nonverbal and had
the mental capacity of an infant.
Bradley Cross, a former mental health tech at Choate, is now seeking
to withdraw that guilty plea, an effort that is still pending. In
his motion filed in Union County court, Cross said the felony
conviction had cost him a $60,000-per-year state job and thousands
in legal fees.
He blamed news coverage for the punishment that included his firing.
“I agree(d) to a plea that, until this media explosion, could have
been dealt with by a retraining or relocating me to another place to
work,” Cross wrote in his motion.
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