Senate committee hears report findings on La Salle Veterans Home COVID outbreak

The Illinois Senate's Veterans Affairs Committee heard findings from a pair of reports on a COVID-19 outbreak at the La Salle Veterans Home released Tuesday, learning an independent investigation to further examine the outbreak that led to 27 deaths could take four to six months to complete.

The veterans home has taken preventative action in discontinuing use of a non-alcohol based hand disinfectant, discontinuing use of a certain type of mask that hadn’t yet been verified and changing the symptom and temperature self-check from self-report to direct screening by another individual, an official said.

The virtual public hearing detailed the timeline that led to a total of 105 residents and 100 staff who tested positive for COVID-19 since the outbreak began. Currently, there are 40 residents and 24 staff who are actively positive for the virus.

Though she was unable to participate in the hearing, state Sen. Sue Rezin (R-Morris) issued a statement Tuesday with concerns.

"The idea that COVID positive staff was allowed to continue working in the home is alarming and unacceptable," Rezin said. "The governor’s Department of Public Health waited 11 days to show up on-site, which caused significant delays in correcting infection control deficiencies leading to this fatal outbreak. Additional legislative hearings must continue to get the full story of what happened."

Tuesday's hearing was attended by members of the committee, Illinois Department of Veterans Affairs Director Linda Chapa LaVia and Illinois Department of Public Health Medical Consultant Dr. Avery Hart.

As noted by Minority Spokesperson Paul Schimpf during the hearing, Rezin was not allowed to participate in the discussion.

Schimpf expressed his disappointment in the committee for denying his request to allow Rezin be given the opportunity awarded previously to state senators when the subject of the hearing involves their district.

“Sen. Rezin is the senator of the La Salle Veterans home, it is in her district,” Schimpf said. “The staff at the facility are her constituents. I’m personally confident that Sen. Rezin knows more about the facts of this tragedy than any of the senators that are participating in the panel today.”

Chapa LaVia said employees at the La Salle Veterans Home have been given full PPE throughout the pandemic, including N-95 mask, surgical masks, show coverings, gowns, face shields, goggles and glasses.

Chapa LaVia said supervisors have corrected improper use of PPE when identified and have tested employees weekly — and residents periodically.

With the increase in positivity throughout La Salle County, the home switched to twice weekly testing for both residents and faculty. Since the outbreak, employees now are tested with a rapid antigen test prior to every shift and each resident is tested daily.

Hart provided a timeline of the outbreak that included the administration first being notified of the first employee and resident positive test on the morning of Nov. 1. The following day the entirety of the residents and staff were tested and residents who tested positive were separated.

The initial widespread test resulted in 59 residents and 64 staff testing positive for the virus as of Nov. 8.

On Nov. 12 a representative from the Illinois Department of Public Health and Department of Veteran’s Affairs made a dual visit to the site. The IDPH then made a second visit to the facility Nov. 17.

During the second visit, identified issues had been resolved, according to the reports from the IDPH.

Schimpf asked Chapa LaVia and Hart to commit both organizations to a policy of complete transparency and both agreed.

Schimpf then questioned the DVA’s outbreak protocols that led to the delayed visit from IDPH after the initial home outbreak. Hart said the local health department tracks the outbreak and acts as the “first line of defense” before support is provided at the state level.

Hart said contact was made during the early period and after the request was made the IDPH responded with a visit the following day.

“I feel that our staff needed as quickly as they could,” Chapa LaVia said. “The tests that were being used initially took 24 hours to get back to us and registered. Then we started going to two tests. The administration was able to receive the rapid tests. I feel that we have tried to move as swiftly as possible.”

Sen. Laura Ellman (D-Naperville) asked about the specific examples in the U.S. VA official’s report of staff violating PPE protocols.

For instance, the report mentions staff were observed in full PPE walking through an administrative area of the home, as well as three staff members being seen in the facility’s kitchen with masks around their chins, eating, and all less than six feet from each other. The report also mentions staff seen wearing gloves to touch patients and multiple surfaces without changing or performing hand hygiene.

“I'm just concerned that for those veterans that are receiving treatment, some of these practices could worsen their condition, which can be quick changes. What are the things that are being done at this facility to ensure that, on the treatment side, they are getting the proper care with the proper protocol?” Ellman asked.

Hart acknowledged breaks in protocol were observed during the site visit, and said staff within the facility now are tasked with monitoring and enforcing proper PPE guidance.

Employees failing to properly wear PPE could increase the likelihood of virus transmission between employees, but Hart said it can be difficult to pin down the precise origin when the virus is rampant in the community.

“Let's say two staff members came down with COVID within a certain period of time. You don't know if one of them is married to a frontline worker, or another one was in a bar downtown or they were just shopping for their groceries and had the bad luck to encounter the virus,” he said.

IDVA Chief of Staff Anthony Kolbeck said five employees at La Salle continued to work at the home after being notified that they tested positive.

“In general, it was notification late at night. They were the only people there for that position. If they went home, it would create another issue and they volunteered to stay,” Kolbeck said during the hearing.

He said the five employees were working with patients who already tested positive.

Schimpf also said the site visit report was given to him around 45 minutes prior to Tuesday's hearing and asked in the future the committee was given ample time to look over the information provided.

The questioning went on for more than an hour as the committee discussed possible areas of improvement and possible causes of the outbreak. The committee discussed COVID-19 treatment, ventilation systems and hospital capacities along with various other topics.

Chapa LaVia said the DVA was asked for independent investigation to help get to the bottom of what has occurred at the La Salle Veterans Home. She believes the timeline of the investigation could take anywhere between four and six months.

Chapa LaVia assured the committee they will be planning on reconvening with them to share the findings of the investigation when the time comes.

Vice Chairperson Cristina Castro urged Illinois residents to follow the rules set forth by Gov. JB Pritzker and state health officials.

“I would hope my colleagues on both sides would reiterate why it’s important to encourage people to follow the rules versus getting on a political pulpit because it’s convenient,” Castro said. “These are people's lives, these are our veterans.”

The committee ended the more than two-hour long meeting with plans to reconvene after more information is acquired and investigations can begin running their course.

“The tragedy of what has unfolded at the veterans’ home cannot be understated," Rezin said in a statement after the hearing. "I’m glad that the director has called for an independent investigation and agree that there are lessons to be learned from this terrible outbreak that has claimed the lives of 27 of our nation’s heroes.”

— Sarah Mansur of Capitol News Illinois contributed to this report.