The Illinois Department of Public Health “did not identify and respond to the seriousness” of an outbreak at the LaSalle Veterans Home in November 2020 that killed nine veterans in just 10 days, the state’s auditor general concluded in a painstakingly detailed report released on Thursday.
The outbreak — which ultimately killed 36 veterans from November 2020 through January 2021 — was the largest in any of the state’s congregate care facilities. And the warnings were well-documented as two resident cases of COVID-19 on Nov. 1, 2020 quickly turned into 82 positive resident cases and nine resident deaths by Nov. 12, 2020, according to the report by Illinois Auditor General Frank Mautino.
Illinois Republicans and GOP gubernatorial primary candidates were anxiously awaiting the 154-page report, which squarely places the blame on Gov. J.B. Pritzker’s public health department and staffers in the home.
Pritzker, at an unrelated bill signing in Springfield on Thursday, pinned some of the blame on the outbreak on “stressed” agencies, rampant COVID-19 outbreaks at the time, people ignoring mitigation efforts and bringing the virus into the home and “management faults.”
“As you know I did hold people accountable and I did fire people who are in those positions,” Pritzker said.
The report puts a narrow focus on the role of the Illinois Department of Public Health in the crisis that hadn’t previously been reported.
Another report issued last year that Pritzker had requested from the inspector general of the Illinois Department of Human Services laid the blame on former state veterans’ affairs chief Linda Chapa LaVia and her department’s handling of the crisis.
At the time, Pritzker said that he wouldn’t have hired the former Democratic state representative had he known she would “abdicate” her responsibilities. LaVia had already stepped down before that report came out.
But the latest report spreads blame to Pritzker’s public health department.
“Auditors reviewed emails and documentation and conducted meetings and determined that although IDPH officials were informed of the increasing positive cases almost on a daily basis, IDPH did not identify and respond to the seriousness of the outbreak,” Mautino wrote in the report.
Thursday’s report, which was requested by an Illinois House resolution last year, reveals veterans’ affairs chief of staff Tony Kolbeck had been properly notifying the public health department almost daily to no avail. Kolbeck had also been viewed as a fall guy in the earlier report.
Mautino’s report found it took 11 days for an Illinois Department of Public Health site visit that would have recognized numerous problems, including incorrect masks, hand sanitizer without alcohol and “staff complacency.”
And it was Kolbeck who ultimately had to request assistance from the public health department, inquiring about a site visit and about rapid tests on Nov. 9, 2020 and about antibody treatments on Nov. 11.
An infections control consultant for the public health department on Nov. 11 told state authorities that “processes being done are sound,” 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 report notes that Pritzker expressed concern about the home that same day, prompting a site visit on Nov. 12.
The state’s medical officer on Nov. 12, 2020 told public health leaders the “source of the outbreak appears to be staff complacency.” She noted staff had not been wearing masks or social distancing and had been gathering in the parking lot and in the lunchroom socializing, according to the report.
The site visit also revealed insufficient staff and visitor screenings for COVID-19, limited housekeeping, the use of the wrong hand sanitizer and improper use of personal protective equipment.
Thursday’s report also notes a lag in communication between the governor’s office and the Illinois Department of Veterans Affairs from Nov. 2 until Nov. 9. The report notes the chief of staff in the veterans’ department sent out daily “home reports” to the first assistant deputy governor from Nov. 2 through Nov. 13, missing just one day on Nov. 11.
“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,” the report concludes.
Veterans at the home are among the most vulnerable in the state, having served the country and many already suffering illness from combat or other military duties. The report notes that there were veterans at the home that didn’t want to be sent to hospitals for further treatment due to the wishes of “Power of Attorney” documents they signed and families.
The audit found that between October and December 2020, 85% of the veterans and 38% of the staff 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.
Asked whether he bears responsibility for the outbreak, Pritzker said as governor, “I understand that these agencies are my responsibility.”
“My appointments to lead those agencies are my responsibility. The policies and procedures are done by the agency themselves. The management of the individuals who work at a particular veterans home are handled by people at those homes,” Pritzker said. “Look, I appoint people to office. I also take them out of office when they’ve not done the job.”
Illinois House Republican Leader Jim Durkin said the report “shows again that when it comes to protecting our state’s most vulnerable, like children in DCFS or Veterans in the care of IDVA, Governor Pritzker is a failure.”
Republican primary gubernatorial candidate Richard Irvin said 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.”
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