REPORT DIGEST

ILLINOIS DEPARTMENT OF CHILDREN AND FAMILY
SERVICES INVESTIGATIONS OF ABUSE AND
NEGLECT

PROGRAM AUDIT
FOR THE YEAR ENDED JUNE 30, 2018

Release Date:  May 7, 2019

AUDIT PERFORMED IN ACCORDANCE WITH HOUSE
RESOLUTION NUMBER 418

State of Illinois, Office of the Auditor
General
FRANK J. MAUTINO, AUDITOR GENERAL

To obtain a copy of the Report contact:
Office of the Auditor General, Iles Park
Plaza, 740 E. Ash Street, Springfield, IL
62703
(217) 782-6046 or TTY (888) 261-2887

This Report Digest and Full Report are also
available on the worldwide web at
www.auditor.illinois.gov

House Resolution Number 418 directed the
Auditor General to conduct a performance
audit of the Department of Children and
Family Services to review and assess the
Department’s protocols for investigating
reports of child abuse and neglect.  The
resolution specifically required the audit
to include a review of abuse and neglect
investigations conducted by the Department
in FY15, FY16, and FY17.

In this audit for the three-year period
FY15-FY17, we reported that:
• The number of abuse and neglect
investigations increased significantly,
going from
67,732 in FY15 to 75,037 in FY17 or 10.8
percent.  Within the three-year timeframe
there was a notable spike in FY16 to 78,572
investigations. The increase in
investigations between FY15 and FY16
represents an increase of 16.0 percent.
• The hotline is unable to take calls as
they are received, resulting in call backs.
The number of call backs increased
substantially during FY15-FY17, from 39.6
percent of total calls in FY15 to 55.7
percent in FY17.
• Investigator caseloads were not in
compliance with the B.H. Consent Decree.
For FY15-FY17, 78.7 percent of
investigators (729 of 926) had at least 1
month during the audit period in which they
received more than 15 new assignments.
• Indication rates (the percentage of cases
where there was credible evidence that the
incident occurred) decreased during FY15-
FY17, from 28.3 percent in FY15 to 24.8
percent in FY17.
• The Department did not always follow
procedures in conducting investigations.
• The overall timeliness of completion for
investigations declined significantly over
the three-year period FY15-FY17.  In FY15,
7.6 percent of investigations were not
completed within 60 days.  For FY17, 12.4
percent of investigations were not
completed within 60 days.
• Investigators did not always accurately
document that they assessed the need for
services by completing the Level of
Intervention field in the Department’s
information system known as SACWIS.  Of
indicated investigations sampled, 16
investigations (10.7%) had no Level of
Intervention listed (services recommended).
Further, 39 indicated investigations
(26.0%) had “No Service Needed” as the
Level of Intervention. Additionally, of the
investigations sampled, for 64 (42.7%) we
found that the Level of Intervention was
inaccurate.
• For 65.3 percent of indicated
investigations sampled, there was a lack of
documentation regarding whether any
services were received by the families
involved and the duration of those
services.  The Department could not provide
basic information for Intact Family Service
cases, such as referral forms, to document
that a formal referral for services was
made.

The audit report contains a total of 13
recommendations to the Department.

AUDIT SUMMARY AND RESULTS

House Resolution Number 418 directed the
Auditor General to conduct a performance
audit of the Department of Children and
Family Services

(DCFS or Department) to review and assess
the Department’s protocols for
investigating reports of child abuse and
neglect.  The resolution specifically
required the audit to include a review of
abuse and neglect investigations conducted
by the Department in FY15, FY16, and FY17.

According to data provided by the
Department, for FY15-FY17 the number of
abuse and neglect investigations increased
significantly, going from 67,732 in FY15 to
75,037 in FY17 or 10.8 percent.  Within the
three-year timeframe, there was a notable
spike in FY16 to 78,572 investigations.
The increase in investigations between FY15
and FY16 represents an increase of 16.0
percent. As is shown in Digest Exhibit 1,
indication rates (the percentage of cases
where there was credible evidence that the
incident occurred) decreased during FY15-
FY17, from 28.3 percent in FY15 to 24.8
percent in FY17. (pages 5-13)

INVESTIGATION PROTOCOL

The Department has established
administrative rules and extensive policies
and procedures that delineate the
investigations process and protocol to be
followed during investigations.  The
protocol includes timelines to be followed,
interviews to be conducted, forms to be
completed, and documentation to be
collected in completing investigations of
child abuse and neglect.  However, we found
that the Department did not always follow
procedures in conducting investigations.

For the audit period, the Department did
not comply with investigator assignment
requirements delineated in the B.H. Consent
Decree.  The B.H. Consent Decree requires
that each child protective services
investigator be assigned no more than 12
new abuse or neglect investigations per
month during nine months of a calendar year
and during the other three months of the
calendar year, no more than 15 new
investigations per month.  Our analysis of
primary assignments for FY15-FY17 showed
that 78.7 percent of investigators (729 of
926) had at least 1 month during the audit
period in which they received more than 15
new assignments.  Further, our analysis
showed that 32 investigators averaged more
than 15 case assignments per month for the
entire three-year period.  In addition,
there were 114 investigators who did not
receive assignments for all 36 months and
averaged more than 15 assignments per month
for the months worked during the period.
Digest Exhibit 2 shows that as the total
number of investigators decreased during
FY16, the higher the percent of
investigators who were out of compliance
with the B.H. Consent Decree’s maximum
allowable new assignments of 15 new
assignments.  The exhibit also shows that
for February through April 2016 over half
of all investigators were out of
compliance.

We could not document that the Department
had evaluated the reliability and validity
of the Child Endangerment Risk Assessment
Protocol (CERAP) as required by the
Children and Family Services Act (20 ILCS
505/21(e)).  The CERAP is a six-page safety
assessment protocol designed to provide
investigators with a mechanism for quickly
assessing the potential for moderate to
severe harm to children in the immediate or
near future and for taking quick action to
protect them.  The Department also could
not provide specific CERAP training
procedures required by statute. (pages
16-25)

STATUS AND FINAL DETERMINATION

Our analysis for the three-year period
FY15-FY17, as of July 27, 2018, showed that
the status for a majority of cases, 142,766
of 221,341 investigations or 64.5 percent,
was classified as expunged. Expunged
investigations for the period were
unfounded investigations in which most
information, including the name of the
alleged perpetrator, had been hidden or
removed from the investigation information.
An additional 78,520 (35.5%) investigations
were classified as closed.  For the
remaining 55 investigations:
• 22 were undetermined (3 cases were FY16
and 19 cases were
FY17);
• 18 were in appeal (15 cases were FY15, 1
case was FY16, and 2
cases were FY17);
• 9 were purged or concealed (all were FY15
cases);
• 3 were in review (one from each fiscal
year);
• 2 were in a 20-day hold (both were FY17
cases); and
• 1 was pending approval (an FY17 case).

According to data provided by the
Department, 25.5 percent of investigations
(56,457 of 221,341) for the three-year
period FY15-FY17 had a final determination
or finding of indicated, meaning there was
credible evidence that the allegation
occurred. For 74.5 percent of all
investigations the status was unfounded
(164,864 of 221,341 investigations). As of
July 2018, there were 20 investigations for
FY16 and FY17 that were listed as pending.
(pages 25-27)

INVESTIGATION TIMEFRAMES

We found that the Department needs to
improve timeliness in several areas. The
Department is not timely in completing
intakes from callers reporting allegations
of abuse and neglect. The hotline is unable
to take calls as they are received,
resulting in call backs. The hotline did
not meet targets, and call backs increased
substantially during FY15-FY17, from 39.6
percent in FY15 to 55.7 percent of total
calls in FY17.  The Department also does
not have written procedures regarding the
process for calling back individuals who
report allegations of abuse or neglect that
do not complete the intake process at the
time of their initial call.  Further, the
Department does not maintain call back
information electronically in its
information system, known as SACWIS, for
more than 90 days, which makes any long-
term analysis of call back timeliness
difficult.

According to investigations data provided,
the Department was timely in initiating
investigations for approximately 99 percent
of investigations. However, required
interviews with the alleged victim and
perpetrator were not always completed in a
timely manner.  With data provided by the
Department, we reviewed the timeliness of
interviews with the alleged victim(s) based
on whether actual contact was made and
found that the alleged victim was not
interviewed within 24 hours in 29.1 percent
of cases for the audit period FY15-FY17.
The alleged perpetrator was not interviewed
within 7 days in 24.5 percent of cases for
the audit period.

The overall timeliness of completion for
investigations declined significantly over
the three-year period FY15-FY17.  In FY15,
7.6 percent of investigations were not
completed within 60 days.  For FY16, the
percentage of investigations not completed
within 60 days increased to 16.0 percent.
It remained elevated in FY17 at 12.4
percent of investigations not completed
within 60 days.

We reviewed the timeliness of submission of
the completed investigation to the
supervisor and found that for the audit
period FY15-FY17, 44.2 percent of all
reports without extensions were not
submitted within 55 days.  The highest rate
of noncompliance was for FY16, in which
51.2 percent of reports did not meet the 55
day requirement for submission to the
supervisor, according to data provided by
the Department.

The Department’s difficulty in completing
investigations in a timely manner during
the audit period is further demonstrated by
the number and percentage of investigations
that received a 30-day extension.  The
percentage of cases receiving one or more
extensions increased from 7.5 percent in
FY15 to 16.1 percent in FY16 and 12.7
percent in FY17.  Further, the number of
investigations receiving multiple
extensions also increased significantly.
For instance, the number of investigations
that received three extensions (an
additional 90 days) increased from 274
investigations in FY15 to 1,263
investigations in FY16 and 719
investigations in FY17.  In our review of
cases involving an extension, it was also
not always clear what the cause for the
extension was or whether it rose to the
level of “good cause.” (pages 30-40)

SERVICES

Conducting an analysis of all
recommendations for services and services
provided by the Department was not possible
for the audit period because of inherent
limitations in the data provided by the
Department as well as other data
reliability and consistency issues.  In
order to assess the services recommended
and services provided, we selected a sample
of 150 indicated investigations (50 each
year for FY15, FY16, and FY17) and reviewed
the investigations for recommended services
and any services received. (pages 42-44)

Recommendations for Services

The Department’s policies and procedures
require that during an investigation the
need for services for the family involved
in the investigation be assessed by the
Child Protection Specialist (investigator)
and the Child Protection Supervisor.  Our
review of 150 indicated investigations
found that investigators did not always
document that they assessed the need for
services by completing the Level of
Intervention field in the Department’s
information system (SACWIS).  Of the 150
indicated investigations sampled, 16
investigations (10.7%) had no Level of
Intervention listed.  Further, 39
investigations (26.0%) had “No Service
Needed” as the Level of Intervention.  For
most of these cases there was no rationale
regarding why no services were being
recommended even though the case had been
indicated. Additionally, of the
investigations sampled, for 64 (42.7%) we
found that the Level of Intervention was
inaccurate.

For Intact Family Services (IFS) provided
through the Department, investigators have
the responsibility to discuss and offer
these services if the final investigation
finding of indicated has been recommended.
The Department did not document that Intact
Family Services were discussed and offered
to all families with indicated
investigation findings as is required by
Department procedures.  Only 20 of 150
(13.3%) indicated investigations reviewed
contained documentation of a recommendation
for Intact Family Services (IFS).  An
additional 3 investigations had
recommendations for multiple services,
which included IFS; therefore, 23 of 150
indicated investigations had a
recommendation of IFS.  For 33 of 150
investigations (22.0%), community services
were recommended.  We could not determine
whether any services were recommended or
what the specific services were for 67 of
150 (44.7%) indicated investigations
reviewed.  The remaining 27 investigations
included recommendations for placement,
already receiving services, no services
needed, multiple services, Intact Family
Recovery, and Norman Cash Assistance.
(pages 44-48)

Services Provided

We sampled 150 indicated cases for the
audit period and found that for 98 cases
(65.3%), there was a lack of documentation
regarding whether any services were
received by the families involved and the
duration of those services.  The Department
could not provide basic information for
Intact Family Service cases, such as
referral forms, to document that a formal
referral for services was made.  The
Department also could not provide auditors
with the number of families served by each
IFS contractor each year for the audit
period. For investigations involving the
Norman Cash Assistance program, the
Department could not provide all approval
forms. For community services, there are no
formal forms for referrals to community
based services, and the Department is not
documenting these services as required by
procedures.  Therefore, it is difficult to
determine if the families actually received
services from community providers. (pages
48-56)

VICTIM DEMOGRAPHICS

During the audit period, the number of
indicated children decreased every year
while the total number of alleged victims
increased.  According to data provided by
the Department as of July 27, 2018, for the
three-year period FY15-FY17 there were
221,341 investigations involving a total of
358,545 children, 96,576 of whom had at
least one indicated allegation.

Auditors could not obtain a reliable count
of the number of unique victims because of
limitations with the data provided by the
Department.  Each person in the SACWIS
system is assigned a unique PersonID.
However, auditors found that there were
over 8,000 instances where the same child
had been assigned multiple PersonIDs.
Therefore, auditors could not obtain a
reliable count of the number of unique
child victims over the audit period because
of data limitations.

For the 221,341 investigations for FY15-
FY17, there were 450,483 total allegations,
with an overall indication rate of 25.5
percent.  The most common allegations were
“Substantial Risk of Physical Injury/
Environment Injurious to Health and Welfare
by Neglect” and “Inadequate Supervision.” A
total of 52,502 children were the alleged
victims of sexual abuse during FY15-FY17,
and 32,439 children were the alleged
victims of serious harm.

Age

Children under the age of one were the most
frequent alleged victims of abuse or
neglect (8.1% of all victims) and also the
most likely to be indicated victims (13.3%
of all indicated victims).  After the age
of one, the number of indicated allegations
of abuse or neglect trends downward.

Race and Ethnicity

For race, children who were identified as
White or Black/African-American made up
96.4 percent of all alleged victims (62.5%
White and 33.9% Black/African-American) and
97.1 percent of all indicated victims
(62.4% White and 34.7% Black/African-
American).  Data provided by the Department
showed that 2.3 percent of alleged victims
did not have a race recorded.  For
ethnicity, children with a Hispanic
ethnicity comprised 15.6 percent of all
alleged victims and 16.7 percent of
indicated victims.

Gender

For gender, there was an even split between
male and female victims. Males accounted
for 49.7 percent of all alleged victims and
females were 49.6 percent.  For indicated
victims, males accounted for 49.4 percent
and females were 50.3 percent.

Geographic Location

Auditors found that 25.6 percent of all
investigations occurred in Cook County,
followed by Lake County with 4.1 percent.
There were investigations of alleged abuse
or neglect in all 102 counties in Illinois.
(pages 58-67)

RECOMMENDATIONS

The audit report contains a total of 13
recommendations to the Department of
Children and Family Services. The
Department generally agreed with the
recommendations in the report. Appendix H
to the audit report contains the agency
responses.

This performance audit was conducted by
staff of the Office of the Auditor General.

JOE BUTCHER
Division Director

This report is transmitted in accordance
with Sections 3-14 and 3-15 of the Illinois
State Auditing Act.

FRANK J. MAUTINO
Auditor General

FJM:MSP