An investigation of a state agency responsible for protecting disabled adults who live at home found that case investigators had weak investigative and report-writing skills, a lack of supervision, were understaffed and failed to involve law enforcement in abuse calls.

The report involves the Office of the Inspector General for the Department of Human Services, a 54-employee agency based in Springfield with a $5 million annual budget and six employees who investigate complaints concerning homebound adults.

The findings of former Chicago Police Chief of Detectives Michael McCotter were announced Friday by Gov. Pat Quinn, who in July ordered a "top to bottom" review of the OIG's office in response to investigative stories in the Belleville News-Democrat.

The newspaper reported that 53 deaths of disabled persons since 2003 were not investigated because of a policy that stated the dead are "ineligible for services."

In his review of 72 cases -- 19 more than the newspaper examined -- McCotter found:

* Errors and omissions on the part of investigators for failing to notify law enforcement or coroners or failing to investigate at all. McCotter found errors or omissions in 20 of the 72 cases -- or 28 percent.

In many cases, McCotter deemed that the OIG acted properly and turned a case over to police, according to his report.

"I do believe that in these types of cases, if there was even the slightest hint of abuse, neglect or financial exploitation of these victims, the investigator should have erred on the side of the victim and notified the proper investigative agency for additional follow-up," McCotter wrote.

However, a criminal conviction resulted in only one of the 53 cases examined by the newspaper.

* The bureau chief responsible for reviewing all cases was overwhelmed and had no administrative help. McCotter found stacks of cases to be reviewed by the bureau chief, who could only give the files a cursory review because of the caseload. This lead to a failure to critically review investigative cases.

* The investigators had no training in basic investigative practices and report writing. McCotter found they were "relying on their common sense for adjudication of these cases." He further found the case reports failed to document the details of the investigations.

"It was painfully apparent during this review that the investigators assigned to this unit were lacking in the area of training regarding basic investigative practices," McCotter wrote.

In the 36 death cases that McCotter reviewed that were among the 53 that made up the BND's investigative report, 16, or 44 percent, were deemed to have been handled improperly.

But in the remaining BND cases that McCotter said were handled properly by an OIG investigator, only one, the death from neglect of Margie Wade in 2003 in Montgomery County, resulted in a criminal conviction. Her husband, Leonard Wade, was sentenced to a conditional discharge and community service for a misdemeanor conviction for neglecting his diabetic wife for more than four months.

Another of the cases previously investigated by the News-Democrat was handled properly, McCotter said. In that case, the home health-care worker who poured scalding water on Rejubhai Desai's feet, causing burns that required surgery, was arrested. McCotter stated the worker was arrested.

The newspaper reported that Midloathian Police, who investigated Desai's death, never questioned the worker, who continues to hold a health-care license.

McCotter's report did not address the 534 reports in fiscal year 2011 to the OIG hotline that were deemed "non-reportable" and not referred for investigation, as the newspaper reported.

"We will immediately review the findings and work with members of the General Assembly and advocates to implement a comprehensive solution that reforms this office and ensures all people are treated with dignity and respect," Quinn said.

McCotter recommended that the OIG:

* Establish a death review team composed of coroners, legal and law enforcement officials and an OIG member to review investigations involving deaths that were due to abuse, neglect or financial exploitation of the home-bound disabled.

* Expand the role of its Quality Care Board, a volunteer citizens group that recently received four new members appointed by Quinn, to act as a "fresh set of eyes" to review the OIG's investigative practices.

* Utilize the Illinois State Police's Medicaid Fraud Unit to investigate allegations of financial exploitation, abuse or neglect.

* Interact more with law enforcement, including appointing a liaison between these agencies to establish policies and protocols in investigating abuse and neglect allegations.

The report stated that "many of the cases reviewed by the special investigator (McCotter) were extremely hard to follow with regard to facts, dates individuals, etc."