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Investigations by both EFE and Public Health reveal serious problems
Pine Lawn Manor, an intermediate care facility for individuals with developmental disabilities, located in Sumner, Illinois, has closed its doors, following extensive investigations by both the Illinois Department of Public Health (DPH) and Equip for Equality's Abuse Investigation Unit (AIU). Those investigations revealed substantial problems, which led DPH to place monitors in the facility and its action to revoke the facility's license, and terminate it from the Medicaid program. Pine Lawn Manor, owned by Saint Simon Health Care LLC, a Georgia company, is licensed as a 68-bed facility, although its population steadily declined to 27 individuals as a result of the ongoing and serious problems revealed by DPH and Equip for Equality's Abuse Investigation Unit.
AIU became aware of the problems at Pine Lawn Manor in late 2003 after receiving information suggesting that the health and safety of the individuals residing there were at substantial risk. After AIU conducted a three-day unannounced site visit to the facility in February and March 2004 and reviewed numerous treatment records and state investigative reports, Equip for Equality strongly recommended that DPH place a receiver in the facility and institute the process necessary to promptly close Pine Lawn Manor. These recommendations included the transfer of individuals living there to providers that could meet their needs in the least restrictive environment.
Following AIU's initial visit, its staff members continued to monitor conditions at Pine Lawn Manor through periodic unannounced site visits and interviews with residents and facility staff, as well as through review of treatment records and charts, incident and investigative reports, and surveys and complaints. AIU's investigation revealed serious ongoing problems related to inadequate health and nursing care, poor monitoring of individuals' needs, medication errors, medical treatment errors, lack of critical documentation, lack of adequate programming, lack of adequately trained staff and abysmal environmental conditions, all of which presented a significant risk of serious harm or death to those living at the facility. AIU communicated its concerns to DPH and both public and private guardians. In response to identified problems, the Office of State Guardian removed all of its wards from Pine Lawn Manor.
Independent monitors placed in the facility by DPH since February 2004 continued to document the same serious and pervasive problems at the facility that AIU identified. Pine Lawn Manor's failure to implement acceptable responses to those problems in order to prevent other similar incidents illustrated the facility's inability to establish or sustain improvements that would ensure resident safety and provide appropriate services to meet the needs and desires of the individuals living there.
In June 2004, DPH initiated legal action to revoke Pine Lawn Manor's license and fined the facility $95,000. Pine Lawn Manor contested the DPH's licensure revocation action and fine. A hearing on its objection to DPH's actions remained pending at the time Pine Lawn Manor made its announcement to close.
Throughout the investigation collaborative efforts were undertaken by AIU and DPH. "This case highlights how effective such collaboration can be to better ensure the safety and well-being of people with disabilities," said Deborah Kennedy, director of the Abuse Investigation Unit. "We commend the Department of Public Health for taking swift and appropriate action to address the problems revealed through the work of our agencies and for the Department's collaborative efforts with us."
Several individuals residing at Pine Lawn Manor sought assistance from Equip for Equality's Legal Advocacy Program to find other providers that can offer residential and programmatic services that would meet their wants and needs in safe and more integrated settings. Three of these individuals are also named plaintiffs in a class action lawsuit brought against state officials to expand community options for people with developmental disabilities.
About the Abuse Investigation Unit
Equip for Equality's Abuse Investigation Unit conducts unannounced visits and monitors public and private facilities and programs to uncover dangerous conditions and practices. The Unit issues recommendations and alerts.