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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.
“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.
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 misdemeanor 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 misdemeanor 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.
Editor's note: This story was corrected on July 11, 2023. It originally misidentified the plea entered by Bradley Cross; he pleaded guilty to a misdemeanor, not a felony.