A state Inspector General report issued Friday gives a scathing review of failures of staff at the LaSalle Veterans’ Home and administration at the Illinois Department of Veterans’ Affairs in preventing, and limiting, a COVID-19 outbreak at the facility that led to the death of 36 residents.

Governor JB Pritzker’s administration ordered a review by the Inspector General from the Department of Human Services in the aftermath of the deadly outbreak, which began around November 1 last fall. More than 200 veterans and staff at the home tested positive for the virus in addition to the 36 deaths.

The report blamed former home Administrator Angela Mehlbrech and IDVA Chief of Staff Tony Kolbeck for numerous failures in the facility and with the agency.

“When the outbreak began, [a] lack of preparedness or a detailed plan caused confusion amongst staff,” the report reads. “Several staff members indicated that the Northwest unit was unprepared as a COVID-19 unit and there was insufficient direction and supervision in the transition of positive veterans into the unit and negative veterans out of the unit.”

The report states the facility had no clear plan for infection control, even in October and November, more than 7 months after the pandemic began.

“The risks concerning transmission and control of COVID-19 were well known by October 2020; yet, the home lacked any formal preparedness and response plan,” the report reads. “With no documented COVID-19 specific policies or outbreak plan, the home’s staff was confused on the appropriate course of action during the outbreak, and thus, its operations were inefficient, reactive, and, at times, chaotic.”

While the report twice praised employees for their care and commitment to veterans, it notes many were grossly unprepared for the outbreak.

“The home’s leadership failed to effectively communicate, train, and educate its employees on the dangers of COVID-19 and the precautions required to monitor and control the virus within the home,” it reads. “As a result, some staff members were unaware of certain basic infection control directives, contributing to a culture of non-compliance.”

As a result, many staff members were unaware, or indifferent, about the actual impacts of COVID-19.

“But it appears that many staff at the home continued to treat COVID-19 like the flu and did not comply with more rigorous protocols, like facemasks,” the report states.

Mehlbrech was criticized for a lack of engagement with staff and hands-on action regarding the outbreak.

“Staff was particularly critical of Ms. Mehlbrech’s disengagement throughout the pandemic,” the report indicates. “She was rarely seen at the home and often remained in her office. Ms. Mehlbrech did not hold any meetings with nurses.”

The report asserts the Governor’s staff instructed IDVA to terminate home Administrator Angela Mehlbrech and place Director of Nursing Angela Cook on administrative leave.

The report spends little time on the actions of former IDVA Director Linda Chapa LaVia, claiming she was mostly hands-off throughout the ordeal.

“Several witnesses noted that Ms. Chapa LaVia was not a hands-on or engaged day-to-day Director and that Mr. Kolbeck, [the Chief of Staff], managed the agency. Mr. Kolbeck stated that he “was generally making decisions for the IDVA” and handled its day-to -day operations,” according to the report. “[Deputy Director Anthony] Vaughn confirmed Mr. Kolbeck’s involvement, observing that it was as if Ms. Chapa LaVia had “abdicated” her authority to Mr. Kolbeck. Mr. Kolbeck described his directives as ultimately being on behalf of the Director, which provided him similar control and authority over the homes’ operations.”

The report was critical that a “Senior Home Administrator” position, which a position that requires medical training or long-term care facility experience, was unfilled since the start of the Pritzker administration.

“Mr. Kolbeck stated that the Senior Homes Administrator position requires approval from the Governor’s Office, so while the IDVA conducted several rounds of interviews and selected a candidate in late 2019, Mr. Kolbeck stated the Governor’s Office did not approve that candidate,” the report states.

That left many high-ranking IDVA positions under the watch of Mr. Kolbeck, who has no long-term care experience. But Kolbeck reportedly told investigators the leaders at facilities oversaw their own homes.

“At the end of the day, the Home Administrator is in charge of that home…they’re responsible for their facility,” he stated to investigators. “It’s the Administrator’s license on the wall—not anyone on the leadership team.”

The report states Mehlbrech and Chapa LaVia declined requests to be interviewed by investigators.

Kolbeck admitted IDVA did not ask the Illinois Department of Public Health to inspect the home until November 9, more than a week after the outbreak began and residents were already beginning to die.

“Mr. Kolbeck acknowledged that he did not recognize that the positive results at the home were a real problem until November 9th or 10th, even though the home already had more than 20 cases on November 3.” The report reads. “By November 9th, the Home had more than 60 positive cases. By November 13, 10 Veterans had died. Given this data, Mr. Kolbeck’s delayed reaction was inexcusable and contributed to the prolonged nature of the outbreak.”

According to the report, when IDPH conducted a site visit on November 12, the home still did not have appropriate procedures in place.

“The visiting IDPH nurse observed a staff member moving a veteran’s belongings wearing full PPE and gloves, but then later saw that staff member wearing the same gloves while touching other items,” the report states. “IDPH observed non-compliance with masking and social distancing at the home during its November 12 visit. Indeed, two weeks into the outbreak, IDPH noted laxity in masking and social distancing during break periods resulting in opportunities for transmission among staff. IDPH’s visit was at the height of the outbreak.”

Investigators called staff actions a concerning disregard of safety. But it was also bolstered by direction from the home administration, which did not require staff to change PPE like gowns and gloves when leaving a veteran’s room.

“As a result, staff wore some of the same PPE as they went room by room conducting rapid tests of every veteran,” the report states. “This policy was not corrected until observed by the IDPH during its initial November site visit.”

Kolbeck was found to repeatedly have turned down offers of help from the Illinois Emergency Management Agency and National Guard, while Mehlbrech turned down help from the federal VA.

The Chicago Tribune reports Kolbeck resigned last week, but IDVA has not confirmed his job status to The Illinoize.

UPDATE (2:37 P.M.):

IDVA confirms Kolbeck resigned last week.

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Patrick Pfingsten

@pfingsten1 patrick@theillinoize.com