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A disabled young patient was sent to get treatment. He was abused instead. And he wasn’t the last.

By BETH HUNDSDORFER
Capitol News Illinois
MOLLY PARKER
Lee Enterprises Midwest

This article was produced for ProPublica’s Local Reporting Network in partnership with Capitol News Illinois and Lee Enterprises.

As Blaine Reichard rose from a breakfast table at the Choate Mental Health and Developmental Center in southern Illinois, a worker ordered him to pull up his sagging pants.

A 24-year-old man with developmental disabilities, Reichard was accustomed to workers at the state-run residential facility telling him what to do. But this time he didn’t obey.

“I’m a gangsta! This is how we do it where I am from!” responded Reichard, who, despite his street-tough defiance, still slept with a teddy bear.

Investigators who later came to the scene of the 2014 incident heard various versions of what happened next. But multiple witnesses told the Illinois State Police that shortly after this exchange, Reichard was taken to the floor, held down by four mental health techs and repeatedly punched in the face, according to a 700-page state police investigation obtained under the Freedom of Information Act.

Reichard cursed and spat, trying to fight back. His resistance was met with more blows, according to witness accounts. Reichard, whose diagnoses include autism, would later tell police it felt like he was hit 100 times.

Multiple employees, including a doctor, told investigators that Reichard’s injuries were the worst they’d ever seen. One tech told police she vomited at the sight of his injured face.

Located about 120 miles southeast of St. Louis, Choate serves people with the most profound disabilities in the state. In 2009, the U.S. Department of Justice’s Civil Rights Division had cited Choate for failing to protect residents from physical and psychological abuse and other harm. The federal agency stopped short of suing the state of Illinois — a step it has taken against other states — and closed its investigation in 2013, saying in a report to Congress that Illinois officials had made adequate improvements.

The Reichard beating happened the next year, just before Christmas. While it is one of the most egregious examples of abuse of a Choate resident in a decade, a months-long investigation by Capitol News Illinois, Lee Enterprises and ProPublica has found that the incident is one of many instances of mistreatment at the rural facility managed by the Illinois Department of Human Services.

Reporters from this team filed more than 50 public records requests, reviewing thousands of pages of internal documents from IDHS and its inspector general; the Illinois State Police; officials in Union County, where the facility is located; and other entities.

The documents and interviews with current and former employees and advocates, and with residents and their guardians, revealed a systemic pattern of patient abuse, neglect, humiliation and exploitation.

Over a 10-year period running through 2021, the state police opened at least 40 criminal investigations into alleged employee misconduct at Choate, more than at any of IDHS’s other facilities in southern Illinois.

Using court records and Illinois State Police case files, reporters found that at least 26 Choate employees were arrested on felony charges over roughly the same time period, including four who were connected to the Reichard case. Employees have since been accused of whipping, choking, punching and raping residents.

Among the more recent arrestees are four employees who were accused of choking and beating another Choate patient in 2020, leading to felony battery charges. Two have pleaded guilty to misdemeanor battery charges in exchange for probation sentences and two cases are still pending.

In 2020, an employee was charged with felony battery, for allegedly taking off his belt and using it to repeatedly whip a resident. Then, earlier this year, an employee was charged with criminal sexual assault of an intellectually disabled person who lived at the facility. And in another 2022 case, an employee was charged for allegedly grabbing a non-verbal patient with the mental capacity of a 15-month-old by the neck and punching him in the back of the head as a security officer watched, according to court records. These three cases are still pending.

Over the years, advocates have called for the facility to be closed. “It’s a purely political decision to keep Choate open,” said civil rights attorney Thomas Kennedy, who has provided legal services to Choate patients on and off for decades. “It’s not about helping people. It’s not about habilitating or rehabilitating people. It’s about keeping jobs in the community. Period. They have failed miserably at any other mission.”

In a statement to reporters, IDHS spokesperson Marisa Kollias acknowledged the seriousness of the concerns at Choate. She said that the problems are the “result of longstanding, entrenched issues dating back decades” and that the agency has “taken aggressive measures over the past several years to unravel them.” That includes increasing staffing and training and appointing Equip for Equality, an independent legal advocacy organization, to monitor conditions inside the facility, just as IDHS did in response to troubling conditions there nearly 20 years ago.

A spokesperson for the Justice Department provided the news organizations with the congressional report announcing its official exit from Choate, which included a commitment to continuing to monitor conditions there. She declined to answer additional questions.

Strapped to His Bed for Hours

As the beating of Reichard continued, one of the employees shouted for restraints. Reichard was dragged to his room and bound to his bed with black nylon straps around his ankles, wrists and chest.

An IDHS record included in the police report showed that for almost two hours, mental health tech Mark Allen sat just an arm’s length away from Reichard. Allen had been accused of harming residents on seven previous occasions since he started his employment at Choate in 2011 — and had been cleared to return to work each time.

Colleagues would later tell Illinois State Police investigators that Allen was volatile and moody. He told them he was an Iraq War veteran diagnosed with post-traumatic stress disorder.

A fellow resident who walked by the room told police that he saw Allen continue to pummel Reichard’s face even after Reichard was strapped down on his bed. The crime scene photos show blood splattered on the floor and walls of his bedroom.

Allen threatened Reichard with death if he reported that employees had beat him up; made fun of him for not having a girlfriend; and punched him again in the jaw, nose and eyes, Reichard told state police in an interview.

While Reichard was still restrained, Allen sent a text message to a colleague. The text, later obtained by police, read, “we just got done strappin Blaine in… I f***** his world up this morning.” “U guys always do lol…,” she responded.

Fifteen months passed before anyone was arrested. In March 2016, Allen was charged with three felony counts of aggravated battery and intimidation. In October 2016, charges were filed against three other Choate employees, Curt Ellis, Justin Butler and Eric Bittle, who were all accused of helping Allen conceal the abuse and lying to police.

Within a month of being charged, court records showed Ellis cut a deal, agreeing to plead guilty in exchange for a misdemeanor conviction for failing to report the matter to authorities. Bittle and Butler followed suit within three months.

Nearly seven years to the day after Reichard’s assault, Allen pleaded guilty to a felony, but not for beating Reichard. He pleaded guilty to felony obstruction for destroying evidence by throwing away the bloody towel he’d used to mop up Reichard’s blood. He was sentenced to two years of probation.

Until now, the Reichard case has never been covered in the press. It also did not serve as a deterrent to the alleged mistreatment of residents by employees at Choate.

“The Perfect Victim”

People from across Illinois come to live at the 270-bed facility on the outskirts of the small town of Anna, Illinois. It serves people with intellectual and developmental disabilities, mental illnesses or a combination of disorders. Patients can enter voluntarily or be placed there by a guardian, or a judge may order them to Choate for treatment after finding they’re at risk of harming themselves or others. Many end up living at Choate for years.

Nearly 15% of Choate residents with developmental disabilities have diagnoses in the severe or profound range; about 10% are non- verbal.

“In essence, many of these individuals can be ‘the perfect victim’ for a crime because it is easy to cast doubt on someone who has mental challenges or can’t give a statement due to their mental health status,” said Tyler Tripp, the state’s attorney in Union County.

Choate houses the state’s only forensic unit for people with intellectual and developmental disabilities who have been accused of a crime and found either unfit to stand trial or not guilty by reason of insanity. That’s the unit where Reichard, who had been arrested for attacks on his family, police and medical personnel, initially lived; he was moved to the less restrictive “step-down” unit in 2014. Though Choate includes a small psychiatric unit, a review of records shows that most of the alleged mistreatment has involved patients with developmental and intellectual disabilities.

Records from the IDHS inspector general’s office — the internal watchdog charged with investigating wrongdoing at the state’s facilities — show the office investigated more than 1,500 reports to its hotline that alleged patient abuse or neglect by employees at Choate over a 10-year period ending in 2021. That’s more than any of the 12 other facilities operated by IDHS, some of which have more patients than Choate. Those reports include roughly 800 claims of physical abuse, 100 of sexual abuse and 600 of mental abuse, financial exploitation or neglect.

Internal investigators found about 5% of the cases to be substantiated, roughly in line with the statewide substantiation rate. But advocates acknowledge that while residents of the state’s facilities sometimes file false reports, Choate in particular has faced repeated criticisms from the inspector general, prosecutors and state police for interfering in their investigations into alleged wrongdoing.

The number of abuse and neglect allegations from Choate reported annually to the agency’s inspector general has been steadily climbing for a decade. There were more than 200 reports in fiscal year 2021, the latest period for which data was available. That was more than double the number from fiscal year 2012.

In addition to the charges of violence, Choate employees have been the subject of hundreds of other allegations, according to reports from IDHS’ Office of the Inspector General and Union County court files. Among the substantiated allegations are instances when staff tortured and humiliated patients, including one who was marched naked in front of peers as punishment for taking too long in the shower, and another who was forced to drink an entire cup of hot sauce.

The substantiated allegations also include incidents of employees using racial and homophobic slurs, sending sexually inappropriate text messages to a patient, and bribing residents with treats to give the employees foot and shoulder massages, according to OIG reports.

In OIG cases brought between fiscal years 2015 and 2022, employees have also been accused of various forms of neglect, including sleeping on the job and failing on multiple occasions to protect clients with pica, a dangerous disorder that causes people to ingest inedible objects.

In one case, a patient was rushed to a hospital after swallowing a razor blade; while there, under the care of a Choate employee, the patient removed two batteries from a heart monitor and swallowed them. Hospital staff reported that the employee’s feet were propped up, his headphones were on and he was playing on his cellphone.

Kollias, the IDHS spokesperson, said the agency is concerned about the volume of reports of abuse and neglect at Choate, but added that the high number of allegations could also be a sign that staff and residents report potential misconduct at a higher rate than people at its other facilities.

Delayed Consequences

For approximately 48 hours, there was no call to a doctor to treat Reichard’s injuries. There was no call to the OIG hotline to report the abuse, a call that the law dictates must be made within four hours of the discovery of an incident. At least three shifts of workers came and went without raising an alarm, the police report showed.

When security arrived on the unit Monday morning to follow up on an anonymous report, Reichard, his face bruised and swollen, greeted the officer with outstretched arms and said, “Look what they did to me,” according to an employee who was on the unit that day but who is not authorized to speak publicly.

In an interview with a reporter, Allen acknowledged that Reichard had been assaulted but maintained he was not the one who did it. He declined to answer further questions. Butler did not respond to calls placed to a phone number provided by a family member, or to messages sent through Facebook. Reporters sent messages to Ellis and Bittle through Facebook and through a union representative seeking comment; the union representative said both men had been made aware of the story and had been provided with contact information for a reporter, though they did not respond.

While the four men were initially charged with felonies, no one was ultimately held criminally responsible for the beating.

The news organizations’ investigation found that this was not the only incident in which consequences were delayed or minimized. The investigation found that employees who abuse residents or engage in other misconduct face few serious consequences. IDHS does not track employee arrests at its mental health and developmental centers.

Court records show that 22 other employees have faced felony charges since the four arrests in the Reichard case. Of those, 11 pleaded guilty in exchange for their charges being reduced to misdemeanors or were sentenced to probation in lieu of charges, seven have cases pending, and four had cases dismissed.

None of those charged have served prison time.

Allen holds the distinction of being the only employee at Choate convicted of a felony related to patient maltreatment in at least a decade.

Yet neither he nor the other three Choate employees convicted in the Reichard case have been fired. Ellis and Butler were almost immediately placed on leave, as was Bittle when the charges were filed. After pleading guilty, the three returned to work at Choate, mowing lawns, cooking or doing laundry. About three years ago, their status returned to administrative leave. They no longer do any work at Choate, but they still receive a state paycheck today. Since the incident, taxpayers have paid the trio more than $1 million combined. Their annual salaries range between $50,000 and $54,000, IDHS records show.

The three are also receiving their scheduled raises, health insurance benefits, vacation time and service credit toward their pensions. Per their plea deals, their court fees amounted to $807 each, $350 of which was a fine.

John “Mike” Dickerson, the unit supervisor on duty the day of the assault, participated in restraining Reichard, according to police records. Though he was not charged in the Reichard beating, Dickerson was reassigned to mow grass at the facility two years later, records show.

Between when the incident occurred in 2014 and when he retired in December 2017, he received $168,000 in salary, plus insurance and credit toward his pension. He receives $39,000 a year in state pension benefits. Dickerson, reached at home, declined to comment.

IDHS senior officials told reporters in an interview that Allen’s coworkers and supervisor were outliers in terms of the amount of time they spent on paid administrative leave. But agency records obtained via the Freedom of Information Act show 26 Choate employees were on paid leave as of the end June, the last month of the state fiscal year. Eleven have been on paid leave for more than a year. Some of these cases involve employees who were charged with crimes or are under criminal investigation.

IDHS’ spokesperson said administrative reviews by its inspector general typically do not proceed until any criminal investigation is concluded.

“Regrettably, some investigations, which can be conducted by the Illinois State Police, the IDHS OIG, or both, and the prosecutorial decision whether to charge an individual have taken years to complete,” IDHS’ statement read.

A supervisor with the OIG’s office wrote in a May 2020 email to Inspector General Peter Neumer that the internal investigation will rule that the abuse charge against Allen is substantiated, as are the charges against the other three for egregious neglect for “not stopping the abuse, colluding and failing to report,” according to emails obtained by the news organizations. His email from more than two years ago asked if it would be possible to proceed with closing out the case because “it has gone on too long already.”

Senior officials within IDHS and its OIG who spoke to reporters declined to elaborate further on the details of the investigation. With Allen’s guilty plea this past December, the investigation is nearing completion, and depending on the results, IDHS will either pursue discipline or return Butler, Bittle and Ellis to work, the agency’s spokesperson said in a statement.

State police said in a statement that abuse cases are challenging to investigate due to a lack of witness cooperation and corroborating evidence.

While Allen was suspended without pay when he was charged in 2016, he remained on the state payroll during the 15-month period between the time of the incident and the time he was charged, collecting nearly $56,000 while on administrative leave, IDHS records show. He received nearly $2,000 in three additional payments between 2016 and 2019. As a part of his plea deal, Allen agreed to pay fines and court fees of $2,874.

Reichard was discharged from Choate after the assault, but he was readmitted three years ago after he attacked his mother. Deemed by a judge to be unfit to stand trial, he lives in the Sycamore Unit, the same building where the assault occurred.

HEADLINE OPTIONS

  1. At a remote mental health facility, a culture of cruelty persists despite decades of warnings
  2. Culture of cruelty persists at state-run mental health facility despite decades of warnings
  3. Culture of Cruelty: Few consequences after abuse reports at Illinois-run Choate center

Subhead options

  1. Federal and state officials have urged reforms at the rural facility for people with mental and developmental disabilities. But the state-run center still has more allegations of abuse and neglect than any other in Illinois.
  2. Officials have urged reforms at the facility for people with mental and developmental disabilities. But the state-run center still has more allegations of abuse and neglect than any in Illinois. 

By MOLLY PARKER
Lee Enterprises Midwest
BETH HUNDSDORFER
Capitol News Illinois

This article was produced for ProPublica’s Local Reporting Network in partnership with Lee Enterprises, along with Capitol News Illinois.

Over a year ago, the security chief at Choate Mental Health and Developmental Center in southern Illinois sent an email to the head of the state agency that operates the facility, warning her of dangerous conditions inside.

“What I am presently seeing occur at Choate and hearing occur at other facilities concerns me more than it has my entire career,” Barry Smoot, a decades-long IDHS employee, wrote to Illinois Department of Human Services Secretary Grace Hou on May 26, 2021. Among the recommendations he wanted to make: that cameras be installed inside the facility.

Hou responded that same day, agreeing to meet.

But no meeting took place. Instead, Hou suggested Smoot start by sharing his concerns with her chief of staff, Ryan Croke, and the director of the Division of Developmental Disabilities, Allison Stark, according to records of the exchange. But those meetings never happened, either. (Stark left the agency in July.)

It would take more than a year, and some high-profile arrests related to abuse at the facility, before the agency unveiled a plan to address poor conditions at Choate. This June, Hou sent a letter addressed to “stakeholders” in which she publicly acknowledged safety concerns at Choate for the first time. The agency, she said, would be rolling out a series of reforms in response to “serious allegations about resident abuse and neglect” at the facility located at the edge of the small town of Anna.

The reform plan, she wrote, includes hiring four additional security officers, installing 10 surveillance cameras on the facility grounds, having staff undergo new training and increasing the presence of senior IDHS officials inside the residential units. Her letter referenced safety issues that arose “in the last year” but offered no other specifics.

At least 26 Choate employees have been arrested on felony charges over the past decade, according to reporting published today by Capitol News Illinois, Lee Enterprises and ProPublica. Of those, the local state’s attorney has filed charges against more than a dozen, including three administrators, since 2019, when Hou was appointed IDHS secretary by Gov. J.B. Pritzker. (Charges have been dropped against two of the administrators charged with official misconduct and obstruction of justice.)

Marisa Kollias, a spokesperson for the agency, said the facility is working expediently to implement these reforms, but she cautioned that it will take time to implement all aspects of the plan. Senior IDHS officials told reporters in an interview last week that the enhanced training and monitoring have been underway for months and, to date, the department has hired one of the four new security officers. The department ordered the cameras this summer, but they are on backorder and no date has been set for installation, the department officials said.

In a statement, Kollias said that the agency determined, “based on information gathered” after the secretary’s initial response to Smoot, “that it was inadvisable for IDHS management staff to communicate with him any further.” The department did not provide further details.

Camera Controversy

Smoot was not the first to raise alarms. The inspector general’s office at IDHS has repeatedly cited the facility for failing to adhere to rules regarding reporting and investigating abuse and neglect allegations.

IDHS’ inspector general recommended the installation of cameras in the course of 21 investigations into abuse and neglect allegations at Choate between fiscal years 2015 and 2021, according to a review of internal records by the news organizations. Each time, Choate officials responded to the inspector general that it was “not an option due to budget concerns.”

This summer, advocates and insiders praised Hou’s announcement that IDHS would finally install cameras.

But in response to reporters’ questions, Kollias, the agency spokesperson, clarified that the cameras would go outside the facility.

One former investigator with the inspector general’s office, when told of the plan to put cameras outside, called it “a waste of money and time.” Almost all abuse and neglect allegations stem from incidents that occur inside.

“This is all being done for show,” said former Office of the Inspector General Supervisor and Choate Unit Director Charles Bingaman, who retired from IDHS in 2013. “I predict that it will have no real impact on patient safety.”

Senior IDHS officials acknowledged to reporters in an interview last week that the inspector general had previously recommended interior cameras.

But placing cameras in interior common areas on a residential unit requires the consent of every resident who lives in that unit, or their guardian, per guidelines from the federal Centers for Medicare & Medicaid Services, which partially funds Choate. Placing them outside does not require consent.

Kollias said that officials met virtually this month with organizations led by parents of residents in IDHS’ developmental centers, including Choate, who informed the agency they do not want cameras inside the facilities.

The Office of State Guardian — which handles the personal, financial and legal affairs of people who require a guardian because they are developmentally disabled, elderly or mentally ill — represents 22 patients at Choate. An office spokesperson said the department did not object to cameras inside the facility and continues to have conversations with IDHS regarding their installation. A senior IDHS official, who spoke to reporters on condition that her name not be used, said that the installation of cameras outside Choate is a “pilot program” to try to help with the issue of residents leaving the facility without authorization and improve security on facility grounds.

A Long History of Problems

States across the nation have closed dozens of large facilities like Choate in the past 20 years, following a 1999 U.S. Supreme Court decision that ruled it is unconstitutional to segregate people with disabilities from the rest of society. But Illinois has been a holdout. It houses more people with developmental disabilities in large institutions, and spends more to operate those institutions relative to statewide personal income, than almost every other state in the nation, according to a review of data compiled by researchers with the University of Kansas.

For years, the state has also failed to intervene when serious abuse patterns are found inside its institutions. Since the late 1990s, state and federal overseers have told Choate to do more to protect and serve its residents.

In 1992, the American Civil Liberties Union sued the state of Illinois on behalf of patients, alleging that poor conditions at state-run psychiatric hospitals violated patients’ rights to safety and medical care. Five years later, a report commissioned by the ACLU found that Choate had a culture of staff intimidating and abusing patients. In one case, a patient who had a colostomy as the result of a gang rape was repeatedly punished by staff for urinary and fecal incontinence, according to the report. That same year, the parties settled the case with the state of Illinois, which agreed to enhance staffing and training.

In 2005, after two patients died from neglect at Choate, Equip for Equality, a federally designated legal advocacy organization for people with disabilities, found numerous unsafe conditions and poor treatment of residents. The advocacy group — which had been appointed by the state to monitor conditions at the facility — cited issues such as the way Choate staff used restraints to control residents, tactics that Equip for Equality called “extraordinarily excessive” and said were in violation of state and federal law. In its report, the organization called Choate’s practices “archaic.”

In response to Equip for Equality’s findings, the U.S. Department of Justice’s Civil Rights Division launched an investigation and warned the state in 2009 that the Choate staff’s failures to help residents successfully transfer out of the facility into community living arrangements violated the Americans with Disabilities Act. The facility had further failed to protect them from harm and provide adequate health and psychiatric care, the DOJ found.

Stacey Aschemann, a vice president with Equip for Equality, expressed disappointment that so little has changed since her organization’s and the Department of Justice’s investigations.

Equip for Equality began once again monitoring conditions inside Choate in early 2021. Those monitoring activities included stationing employees inside the facility; interviewing staff, residents and their guardians; and reviewing records.

Based on that monitoring, Aschemann said, the abuse and neglect of residents by staff continues to be a “serious concern.” Equip for Equality will continue to monitor the facility to determine whether the changes Hou announced in mid-June adequately address the safety and quality concerns raised by the organization, Aschemann said.

Smoot said leadership’s slow response to the serious issue he encountered left him deeply troubled. But it was not the first time he had sought to bring problems within IDHS to the attention of senior leadership.

Prior to his role at Choate, Smoot worked as an investigator for the IDHS inspector general, probing allegations of abuse and neglect of disabled adults who lived in their homes.

After leaving the OIG, Smoot worked security at IDHS facilities, ending his career at Choate.

Earlier this year, he self-published a book, “Failure to Protect,” outlining many of his concerns about the inspector general office’s weak oversight authority and how he felt the agency had failed the residents at state-run facilities like Choate.

In December, on the last day of his 20-year career with IDHS, he sent Hou an email to let her know that no one had followed up with him.

This time, there wasn’t a response, according to records of the email exchange obtained by reporters. Smoot said he wasn’t expecting one, but he hoped someone would heed his warning and take his advice. “Without any time left, it was a Hail Mary pass,” Smoot said in an interview.

 

 

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