UPDATED: Auditor General Report Slams Response to Deadly COVID-19 Outbreak at LaSalle Veteran's Home
Governor JB Pritzker Thursday defended the state’s response to a deadly COVID-19 outbreak at the LaSalle Veterans’ Home that killed 36 residents in late 2020. A new Auditor General report slams the administration’s slow response.
A new report from the Illinois Auditor General Thursday slammed Governor JB Pritzker’s administration for its slow response to a deadly COVID-19 outbreak at the LaSalle Veterans’ Home in November 2020 that killed 36 residents.
But Pritzker shot back Thursday morning, blaming Republicans for the spread of the disease because they told people not to wear masks, get vaccinated, or that COVID-19 wasn’t a serious threat.
The Auditor General’s report shows then-Illinois Department of Veterans' Affairs Chief of Staff Tony Kolbeck begged the Department of Public Health for more tests and antibody treatments to stem the spread of the outbreak.
From the report summary:
Although the Illinois Department of Public Health (IDPH) officials were informed of the increasing positive cases almost on a daily basis by the Illinois Department of Veterans’ Affairs (IDVA) Chief of Staff, IDPH did not identify and respond to the seriousness of the outbreak. It was the IDVA Chief of Staff who ultimately had to request assistance. The IDVA Chief of Staff inquired about a site visit and about rapid tests (November 9th), and inquired about getting antibody treatments (November 11th) for LaSalle Veterans’ Home residents. From the documents reviewed, IDPH officials did not offer any advice or assistance as to how to slow the spread at the Home, offer to provide additional rapid COVID-19 tests, and were unsure of the availability of the antibody treatments for long-term care settings prior to being requested by the IDVA Chief of Staff.
The Department of Human Services’ Office of the Inspector General (DHS OIG) investigation reported that the significance of the outbreak was not being meaningfully tracked by the IDVA Chief of Staff. In fact, auditors found the Chief of Staff provided detailed information to IDPH that was used by the Director of IDPH in her daily COVID19 briefings. IDPH and the First Assistant Deputy Governor for Health & Human Services were provided detailed emails of COVID-19 positive cases and related deaths for each of the four State veterans’ homes by IDVA on November 2nd, 3rd, 4th, 5th, 6th, 9th, 10th, 12th, and 13th. The primary finding of the DHS OIG report, which indicated the “absence of any standard operating procedures in the event of a COVID-19 outbreak,” was flawed. Auditors identified hundreds of pages of guidance provided by IDPH and by the Centers for Disease Control. In addition, COVID-19 policies were formulated by IDVA specifically for the LaSalle Veterans’ Home as well as a Continuity of Operations Plan that was reviewed by Illinois Emergency Management Agency and was provided to IDPH back in March 2020.
The full report is here.
Statement from Sen. Sue Rezin (R-Morris), who represents the Home:
“The audit tells the story of a governor who fatally mismanaged the state’s response, abdicated his responsibilities to protect the veterans of this state, and tried to hide it with an investigation he arranged with a predetermined outcome, ensuring his office escaped all accountability. Governor Pritzker and his political appointees intentionally misled legislators during public hearings as we sought answers for the families who lost loved ones but nineteen months after the outbreak began, the truth came out. He must finally accept responsibility for failing to act on the information his office sat on since day one. The Senate must hold legislative hearings to demand answers from the Pritzker Administration.”
Rep. David Welter (R-Morris), who represents part of LaSalle County:
"The Governor's Office previously testified how the IDVA Director duped them regarding the outbreak's severity. Today's report from the Auditor General proves Governor Pritzker was the one who deceived us. His office had information from day one and failed to act. The Governor's investigation into the matter was flawed, too narrowly focused, and purposely removed him and IDPH's leadership team from scrutiny until today's independent findings. The Governor can no longer cover up the truth, and he must be held accountable for his collapse of competence. Legislative hearings must be scheduled to determine how the administration failed so greatly in protecting our state’s heroes.”
In an unrelated news conference Thursday, Governor JB Pritzker blamed Republicans for the outbreak.
“We were working against Republican elected officials who told people to defy mitigation efforts,” Pritzker said. “We told people that they needed to follow those mitigations, but Republicans told them that they need not wear masks. They told people that they didn’t need to get vaccinated. They told people that COVID wasn’t serious. Those lies put people’s lives at risk, especially the most vulnerable. Even as my team and I worked 18 hours a day for 9 months straight to fight them.”
The vaccine was not available in November of 2020.
We’ll have more on this story throughout the day.
UPDATE (2:38 P.M.):
Statement from Rep. Lance Yednock (D-Ottawa), who represents the LaSalle home:
“The devastating and deadly outbreak at the La Salle Veterans Home raised so many questions, and we needed to know more. Today’s audit reveals some disappointing breakdowns in communications and protocols that very likely led to more sickness and deaths. It also underscores the terrifying speed of infection we saw at COVID-19’s peak and acknowledges even the best preparation and planning might not have been enough to prevent more infection.
I want to thank Auditor General Frank Mautino and his dedicated staff for reviewing thousands of documents and spending the time needed to talk with everyone involved and paint a clear picture of what went wrong and how we can make sure it never happens again at the La Salle Veterans Home.
I’m frustrated and disappointed there wasn’t better coordination between state agencies to recognize and address the increasingly serious infection rate at La Salle as it was happening. As the audit found, staff should have been tested more regularly, and the Illinois Department of Public Health should have moved more quickly to visit the home.
I also want to acknowledge those in charge of the home and at the Illinois Department of Veterans Affairs who, despite previous reports, did take proper precautions and sound the alarm for help repeatedly as infections grew.
Our goal with this audit was to produce positive change, not settle political vendettas. I am encouraged that significant improvements have been made to prevent this from happening again. I would ask the Auditor General’s team and all of the involved agencies to meet with us in an upcoming legislative hearing to discuss these findings in more detail. With COVID-19 still in our communities, we owe this continued work to every veteran counting on us to protect them and keep them safe.”
Statement from the Illinois Department of Veterans’ Affairs:
“IDVA is deeply committed to the health and safety of the veterans in our care and continue to grieve the loss of the 36 veterans who passed away from the effects of this horrible virus. As the report clearly indicates, IDVA had strong COVID-19 mitigation policies and training in place that guided our work to protect residents and staff from the exponential spread of COVID-19 that was happening in the communities surrounding our veterans’ homes. Since joining the department, IDVA Director Terry Prince has further strengthened these policies and training while continuing the efforts that resulted in nearly 98 percent of our residents receiving their COVID vaccines. IDVA has already implemented the recommendations in the Auditor General’s report and will continue to use every resource at our disposal to keep our veterans safe.”
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UPDATE (3:00 P.M.):
Statement from House Veterans’ Affairs Committee Chair Rep. Stephanie Kifowit (D-Oswego):
“The Veterans in all our Veterans' homes trust and depend on the state of Illinois to give them the best care we can in honor for their service to our great Country. As a Veteran myself, I stand by this standard and strive to ensure our Veterans are properly taken care of every day”, stated Kifowit. “The heart-breaking loss of our decorated Veterans at the LaSalle Home showed us just how deadly COVID-19 was, and still is.
The members of the Veterans Affairs committee have been diligent on ensuring that all the information regarding the COVID-19 outbreak at the LaSalle Veterans affairs has been fully vetted, and as Chair of the Veterans Affairs Committee, you have my word that this report will be fully vetted as well in an upcoming subject matter hearing that I have already requested to be scheduled before the end of May.
Through the hard work of the committee, and already law in Illinois, the soon to be established Veterans Accountability Unit is expected to address some of the issues that we are seeing in the Auditor General’s report and will provide an avenue for concerns and complaints to be readily addressed in a timely manner. It is unfortunate that so many lives were lost in a complete breakdown in communication during the largest public health crisis in our history. We must make certain that tragedy like this will never happen again to our most vulnerable Veterans under the care of the State of Illinois.
In the end, this is about our Veterans. I am encouraged by the leadership of newly confirmed IDVA Director Prince and his team, the hard work of all the employees that care deeply for our Veterans in all our Veterans’ Homes, and the dedication of the Veterans Affairs Committee members to bring about positive change for our highly decorated Veterans under the care of the state of Illinois."
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UPDATE (3:25 P.M.):
GOP gubernatorial candidate Richard Irvin:
“As an Army veteran, it is disheartening and beyond disturbing that J.B. Pritzker and his Department of Public Health were aware of the outbreak at LaSalle and neglected to respond quickly to save the lives of 36 veterans. The governor owes the families of these American heroes an explanation and needs to be held accountable for his administration’s failure to prevent this needless tragedy.”
GOP gubernatorial candidate Jesse Sullivan:
“What happened at LaSalle was a shameful tragedy. When our heroes cried out for help, they were met with deafening silence from the Pritzker administration. Thirty-six veterans died as a result. Illinois veterans deserve better. The families who lost loved ones deserve better.
Four years ago, J.B. Pritzker called the 13 deaths at the Quincy Veterans Home from Legionnaires’ disease a ‘shameful neglect of our veterans’ and an ‘unconscionable moral failing.’ ‘[T]his is incompetence,’ Pritzker said. ‘This is gross mismanagement.’ Attorney General Lisa Madigan quickly launched a criminal probe into the Rauner administration.
“J.B. Pritzker needs to be held accountable for his failures, and to take responsibility for the lives lost and the damage done. Time and time again, Pritzker has blamed others. He scapegoated IDVA Chief of Staff Tony Kolbeck for not disclosing the severity of the outbreak, but now we are learning that it was IDPH that didn’t act. The bottom line is that by his own definition four years ago, Pritzker is unfit to serve as governor.”
As governor, I will always stand up for our veterans, and ensure they receive the highest quality of care.”
I just got a notice from Blueroom Stream that Darren Bailey is holding a news conference on the topic. His campaign never sent me a notice of that news conference, so we’ll try to get a quote up as soon as we’re able.
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(UPDATE 3:45 P.M.):
Some additional notes from the report:
-The Department of Human Services’ Office of the Inspector General (DHS OIG) investigation reported that the significance of the outbreak was not being meaningfully tracked by the IDVA Chief of Staff. In fact, auditors found the Chief of Staff provided detailed information to IDPH that was used by the Director of IDPH in her daily COVID- 19 briefings. IDPH and the First Assistant Deputy Governor for Health & Human Services were provided detailed emails of COVID-19 positive cases and related deaths for each of the four State veterans’ homes by IDVA on November 2nd, 3rd, 4th, 5th, 6th, 9th, 10th, 12th, and 13th. The primary finding of the DHS OIG report, which indicated the “absence of any standard operating procedures in the event of a COVID-19 outbreak,” was flawed.
Auditors identified hundreds of pages of guidance provided by IDPH and by the Centers for Disease Control. In addition, COVID-19 policies were formulated by IDVA specifically for the LaSalle Veterans’ Home as well as a Continuity of Operations Plan that was reviewed by Illinois Emergency Management Agency and was provided to IDPH back in March 2020.
-The outbreak at the LaSalle Veterans’ Home occurred at a time when COVID-19 cases were trending up statewide. Also, the outbreak occurred prior to the COVID-19 vaccine. Prior to the outbreak that began at the end of October 2020, only six staff members had tested positive for COVID-19.
Even though the LaSalle Home had designated areas for isolation and quarantine, once the virus entered the Home, it spread very rapidly. According to documentation provided by the LaSalle Veterans’ Home, the first resident was positive on October 23, 2020. This was followed by another resident and two staff on October 27, 2020. Based on tests administered prior to the end of October 2020, 13 residents and staff (8 residents and 5 staff) tested positive. Clearly there was a verified outbreak and by November 4, 2020, according to IDPH, 57 residents and staff (46 residents and 11 staff) had tested positive for COVID-19. By the end of November 2020, 203 total positive cases had been identified at the LaSalle Veterans’ Home. According to IDPH, in total, between October 23, 2020 and December 9, 2020, 109 of the Home’s 128 residents (85%) and 88 of the Home’s 231 staff (38%) had tested positive for COVID-19.
-In total, 36 residents of the LaSalle Veterans’ Home died due to COVID-19. The deaths occurred between November 7, 2020 and January 1, 2021. Positive cases increased rapidly during the first week of November 2020. By November 15, 2020, 17 residents had lost their lives from COVID-19 at the LaSalle Home.
Auditors compared the deaths to the date these 36 residents tested positive for COVID-19. Four residents that lost their lives from COVID-19 were positive before November 2, 2020. We determined that of the 35 residents that tested positive for COVID-19 on November 2, 2020, 15 died from the virus. Additionally, all but four residents who died were positive prior to the date of the IDPH site visit on November 12, 2020.
-The time it took to receive staff COVID-19 testing results from the IDPH lab was lengthened by the collection method used by the LaSalle Home. The Home tested staff over a three day period. As a result, new tests of staff collected on November 3rd, 4th, and 5th were not delivered to the IDPH lab until Thursday, November 5th, even though the first two staff members from the outbreak were found to be positive by Sunday, November 1st. The IDPH lab published the majority of the test results on either Friday or Saturday. Therefore, the delay in getting testing results was primarily due to the collection method used by the LaSalle Home. Additionally, the testing method, collecting tests over three days, was not in compliance with the facility’s policy, which allowed for testing over two days.
-An initial site visit was conducted by the U. S. Department of Veterans Affairs in collaboration with IDPH on November 12, 2020…The November 12th initial site visit identified issues in the following areas: insufficient staff and visitor screening; the timeliness of receiving testing results; limited housekeeping which included use of the wrong hand sanitizer; negative pressure rooms which failed qualitative tissue testing; and improper PPE usage.
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UPDATE (5:20P.M.):
Sen. Darren Bailey (R-Xenia), earlier today:
“JB Pritzker campaigned on Bruce Rauner’s fatal mismanagement that lead to deaths from Legionnaires Disease in Quincy’s Veterans’ Home. I’ll agree that Rauner’s administration failed those veterans, because when you’re governor, the buck stops with you.
My heart is breaking for these veterans and their families and my blood boils when I see excuses coming from our governor. It’s downright embarrassing that we have a governor who blames everyone but himself. Excuses won’t bring our veterans back and excuses won’t provide solutions or assurances that this won’t happen again.
But, sadly, the Pritzker administration is full of excuses and has already proven that they can’t handle health care. The tragic deaths at the LaSalle Veterans’ Home under his watch simply prove that.”
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UPDATE (9:15P.M.):
More from the report:
-The DHS OIG concluded that the lack of policies and procedures “was a significant contributing factor to the Home’s failure to contain the virus. ”Therefore, there was no evidence to support that a lack of policies and procedures resulted in a failure to contain the virus. The virus hit the Home very quickly with a large number of residents and staff positive within a few days. As a result, it was unclear whether non-adherence to policy caused the virus to spread so quickly or whether the rapid spread was due to other factors. These factors include: a rumored outside gathering of employees; a Halloween parade at the LaSalle Home; or possibly the high positivity rate during that time in the community. An additional potential cause may have been that guidelines during that time did not require rapid COVID-19 testing prior to entering the Home; therefore, asymptomatic staff possibly carried the virus into the Home from the community unknowingly.
-”…A review was conducted and determined that seven employees worked on certain days between November 6, 2020, and November 13, 2020, after testing positive for COVID-19. According to IDVA, all seven employees were asymptomatic when they worked. IDVA noted that the LaSalle Veterans’ Home followed Centers for Disease Control (CDC) guidelines to ensure that the seven employees maintained safety precautions including wearing PPE, working only in COVID-19 positive units, using separate entrances and exits to avoid contact with others, and using separate bathrooms and break areas.
IL OSHA sent a letter to IDVA on December 15, 2020, informing the agency that based on the response and information provided the case would be officially closed.
-[A report] during the first week of November 2020 and determined that there were COVID-19 outbreaks at the Homes in LaSalle, Quincy, and Manteno. The outbreak at LaSalle was much larger than in the other two Homes. Auditors then compared the outbreak at the LaSalle Veterans’ Home with the long-term care facilities throughout Illinois. According to IDPH data, for the week ending November 8, 2020, the LaSalle Veterans’ Home had the highest number of total COVID-19 cases (including both residents and staff) in all of Illinois’ long-term care facilities at the time. Of the 710 long-term care facilities in Illinois, 645 (91%) had 10 cases or fewer, with 284 (40%) of the facilities having zero cases. Five of the facilities had greater than 50 cases, with the LaSalle Veterans’ Home being the only facility with greater than 100 cases, with 134 total cases.
-According to IDPH, in total, between October 23, 2020, and December 9, 2020, 109 of the Home’s 128 residents (85%) and 88 of the Home’s 231 staff (38%) had tested positive for COVID-19.
-Additionally, all but four residents who died were positive prior to the date of the IDPH site visit on November 12, 2020.
-At other veterans’ homes, Manteno had 19 deaths, Quincy had 7 deaths, and Anna had no deaths.
-In the weeks just prior to the outbreak, the Home said it was testing residents weekly in response to isolated employee positive tests, which is even more frequently than is required by IDVA policy. However, the Home did not test residents the last week of October, which was the week the outbreak began. After the outbreak began, documentation shows the Home tested employees and residents at least every seven days according to IDVA policy.
-The Deputy Governor for Health & Human Services (Sol Flores) and First Assistant Deputy Governor may not have realized the significance of the outbreak at the LaSalle Veterans’ Home as the virus continued to progress through the Home. It wasn’t until the Governor requested that someone go on site, more than 10 days after the outbreak began, that significant action was taken.
-According to the Deputy Governor for Health & Human Services, the response to the outbreak was her responsibility. It was also overseen by her assistant, the First Assistant Deputy Governor. Auditors interviewed the Deputy Governor and she stated that her office thought that the leadership at IDVA and the Home were communicating and taking actions regarding the employees under their responsibility to ensure things were being done.
-After our interview and our review of email documentation provided by the Department of Innovation and Technology (DoIT), auditors could not document when the Deputy Governor was notified of the outbreak or when the she had meetings or discussions with IDVA and IDPH officials regarding the outbreak at the LaSalle Veterans’ Home. The first email we saw from the Deputy Governor from the information provided to auditors was on November 9th.
-As the IDVA Chief of Staff continued to report the increasing number of cases, auditors could not identify any further communications from the Governor’s office until November 9th, when the Deputy Governor responded to the IDVA Chief of Staff in response to media questions following the first resident deaths. By this time, there were 67 staff and 64 residents positive with COVID-19. There also had been 3 resident deaths.
-In an email on November 11, 2020, the IDPH State Medical Officer noted to the IDVA Chief of Staff and the Infection Control Consultant that she spoke to the IDPH Chief of Staff who told her the Governor was very concerned and wanted IDPH to visit the LaSalle Home. This was 22 minutes after a decision was made by the Infection Control Consultant for IDPH that the “processes being done are sound” and that the infection specialist at the LaSalle Home will reach out with any questions, and “at this time feels they are doing okay and doesn’t feel the need for someone to visit.” The Consultant stated: “Just feels like it came on quickly and hoping it will calm down just as quick. I will reach out in a day or two and see if he has additional needs.” Therefore, it appears that without intervention by Governor Pritzker, a site visit would not have been conducted for several more days. (emphasis added)
-The Illinois Department of Public Health did not act on the significant outbreak at the LaSalle Veterans’ Home during the first week of November, even though it was the largest outbreak in any of the State’s congregate care facilities. Although IDPH officials were informed of the increasing positive cases almost on a daily basis, there was no action taken. The number of cases increased rapidly from 4 on November 1st to 53 on November 5th. By November 9th, there had been no effort by IDPH to reach out to the Home to provide assistance, solutions, or to determine the cause of the large outbreak, even though there were now 64 residents and 67 staff positive with COVID-19.
-From the documents reviewed, management at IDPH did not offer any advice or assistance as to how to slow the spread at the Home, offer to provide additional rapid COVID-19 tests, and were unsure of the availability of the antibody treatments for long-term care settings prior to being requested by the IDVA Chief of Staff, even though the State had been allocated 6,380 vials of monoclonal antibodies, which could have been used to treat positive residents.
-Auditors found evidence that the LaSalle Veterans’ Home Administrator emailed supervisory staff every few days during the outbreak. The email noted that there were 2 residents and 2 employees who had tested positive for COVID-19. It requested that staff “continue to be diligent with infection control precautions” and stated that “everyone needs to take breaks responsibly – maintain social distancing.” The email also stated “We must stop this outbreak in its tracks! Please take this seriously – it is important to keeping our Veterans safe and healthy!”
-Based on our review of emails during the span of the outbreak, there was very little if any communication from the IDVA Director [Linda Chapa LaVia] to anyone related to the outbreak. There was no evidence provided that showed the Director had any communications or involvement related to the LaSalle outbreak. This includes communication with the Administrator of the LaSalle Home, the IDVA Chief of Staff, officials from IDPH, or the Governor’s office, including the First Assistant Deputy Governor or Deputy Governor who oversees the Health and Human Service agencies in Illinois. There was no documentation to support the Director was monitoring the situation or advocating for the health, safety, and welfare of the veterans who reside in the Homes under her care with IDPH and the Governor’s office.
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Auditor General recommendations:
-The Illinois Department of Veterans’ Affairs should ensure each of its Veterans' Homes have policies and procedures in place that mandate timely testing of its residents and employees during COVID-19 outbreaks, and should ensure that residents and employees are tested according to the policy.
-The Illinois Department of Public Health should:
⚫ clearly define its role in relation to monitoring COVID-19 outbreaks at Illinois Veterans’ Homes; and
⚫ develop policies and procedures that clearly identify criteria which mandate IDPH intervention at Veterans’ Homes during an outbreak of COVID-19.
- The Illinois Department of Veterans’ Affairs should ensure that:
⚫ the IDVA Director works with the Department of Public Health and the Governor’s office during COVID-19 outbreaks to advocate for the health, safety, and welfare of the veterans who reside in the Homes under IDVA’s care; and
⚫ the Senior Home Administrator position is filled and the duties of the position include monitoring and providing guidance to the Veterans’ Homes during COVID-19 outbreaks
