An independent report released Friday said the lack of a comprehensive COVID-19 plan at the Illinois Veterans Home in La Salle, including the absence of any operating procedures for an outbreak, was a significant contributing factor to the home’s failure to contain a novel coronavirus outbreak that led to 36 resident deaths beginning in November.
The report — ordered by Gov. JB Pritzker and conducted by the Illinois Department of Human Services’ Office of the Inspector General and the law firm Armstrong Teasdale — said, as a result, some staff members were unaware of certain basic infection control directives, contributing to a culture of non-compliance.
The inspector general’s report said the risks concerning transmission and control of COVID-19 were well known by October; yet, the veterans home lacked any formal preparedness and response plan.
The 50-page report depicts a facility unprepared to handle an infection outbreak, leading to a chaotic and uninformed outbreak response that was exacerbated by disorganized leadership at the department and the home. The IDHS investigation included analyzing COVID-19 data, trends and protocols in the La Salle home and assessing IDVA’s preparation, response and compliance with protocols and regulations. It also included 29 individual interviews and the review of hundreds of documents.
“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,” the report said.
“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.”
Former IDVA Director Linda Chapa La Via, who the report said was not a hands-on or engaged day-to-day director, resigned in January after she was criticized during a legislative committee meeting for her response to the outbreak. La Salle veterans home administrator Angela Mehlbrech was fired in December.
IDVA Chief of Staff Tony Kolbeck said in the report he “was generally making decisions for the IDVA” and handled its day-to-day operations.
State Sen. Sue Rezin (R-Morris) said Monday morning while she was reviewing the report, “it’s clear that the administration has failed these individuals.” Rezin has repeatedly questioned why it took the Illinois Department of Public Health 12 days to visit the veterans home.
“The report reveals a lack of direction from the governor’s office and department directors,” Rezin said. “One notable failure is the fact that the Illinois Department of Veterans’ Affairs didn’t learn from previous outbreaks at facilities and did not implement recommendations that could have helped prevent this tragedy. The lack of action by the department is the reason why I filed legislation in February that would require the state to implement the findings of the Quincy Veterans’ Home audit.”
“The Illinois General Assembly must hold legislative hearings to discuss the findings of (Friday’s) report and we must pass legislation that ensures that we implement potential lifesaving policies.”
State Rep. Lance Yednock (D-Ottawa) said the report sheds more light on the outbreak, “we owe it to those lost and their loved ones to do everything possible to ensure that nothing like it ever occurs again,” by putting proper safeguards in place and ensuring those that failed to take action are held responsible.
“After reviewing this report, my heart breaks again for the families who lost loved ones,” Yednock said. “I feel their pain and share their anger. It’s clear that a failure of proper leadership combined with a series of preventable errors and sheer carelessness led to an unacceptable tragedy.”
The IDVA said Monday it is implementing corrective actions and taking steps to meet recommendations of the report, under its new IDVA Acting Director Terry Prince. The governor’s office did not respond to questions emailed from Shaw Media Local News Network, but the governor did answer questions at an unrelated press conference Friday.
“She seemed like an ideal person to be able to root out the problems in our veterans homes. But I have to admit that, if I knew then what I know now, I would not have hired her,” Pritzker said about Chapa La Via.
“There were challenges of communication, there were challenges of people not following the protocols that were laid out for them. There were challenges of leadership, not providing some of those protocols and so on … We now have a new IDVA director who is going to accelerate our addressing of all of those.”
In response to the report, the IDVA said it has formed new infection control committees at each of the veterans’ homes led by an infection control director, restructured senior leadership, and streamlined and strengthened department policies and internal communications.
Friday’s report said the veterans home didn’t have a COVID-19 task force or committee for managing and monitoring COVID-19. Thus, it was unclear who was responsible for various COVID-19 related tasks within the home leading to important tasks being left unattended, according to the inspector general’s report.
According to the report, IDVA’s executive leadership team also contributed to the home’s failed COVID-19 response by: 1) consolidating too many responsibilities in one individual; 2) failing to delegate and assign clear responsibilities; 3) failing to learn from outbreaks at other long-term care facilities — including another Illinois Veterans’ Home; 4) failing to effectively communicate; and 5) failing to identify, seek, or accept external resources to assist in responding to the outbreak.
The IDHS inspector general’s report outlines seven major failures within the La Salle home that contributed to the outbreak.
The report also cites leadership failures that include “the consolidation of too many responsibilities in one individual, the failure to delegate and assign clear responsibilities, the failure to learn from outbreaks at other long-term care facilities — including other Illinois Veterans’ Homes — the failure to effectively communicate, and the failure to identify, seek or accept external resources.”
It further states the La Salle home did not fill its senior home administrator role, a position which is tasked with overseeing day-to-day operations, serving as a primary IDVA contact, and working toward standardizing policies and procedures. That position has been vacant since 2019.
The seven failures were documented as: no outbreak plans or procedures; a relaxed quarantine policy; inadequate COVID-19 employee screening process; ineffective communication; insufficient training; inadequate education and compliance; and challenges with personal dynamics.
The following summarizes in greater detail some of the reported failures that took place within the home.
No outbreak policies or procedures
The home’s lack of a comprehensive COVID-19 plan, which includes any operating protocols in the event of an outbreak, was reported as a significant contributing factor to the failure to contain the virus at the LaSalle home.
This led to confusion among staff at the facility, and contributed to an “inefficient, reactive and chaotic” response to the outbreak, according to the report.
The lack of preparedness was evident in the movement of veterans to different areas of the home before and during the outbreak, the report states, and resulted in cross-contamination of positive and negative veterans.
For example, the home decided a month before the outbreak to relocate 10 of the 20 veterans housed in the future quarantine unit into a different area of the home. The relocation stopped in early October, leaving 10 veterans living in the future quarantine unit. When the outbreak happened weeks later, those veterans were relocated, “again causing avoidable movement and interaction amongst positive and negative Veterans,” the report states.
“The home’s decision to leave half of the veterans regularly housed in the future quarantine hall demonstrates the lack of foresight that contributed to the prolonged outbreak in the home,” according to the report
Relaxed quarantine policy
Several nurses interviewed for the report said that the first positive COVID-19 tests came after the LaSalle home changed its quarantine policy. Initially, at the beginning of the outbreak, the home required all veterans who left the home for any reason to quarantine for 14 days upon return.
At some point, veterans returning from a local hospital, St. Margaret’s Hospital, no longer were required to quarantine because it was determined that these visits were “low-risk.”
According to the report, it’s not clear who issued this relaxed quarantine policy, in part because there was no written quarantine policy at the home until Jan. 21, 2021.
Insufficient training, inadequate education and compliance
The report states that active instruction and in-service training were not a priority for the leadership team at the LaSalle facility.
For example, initially during the outbreak, staff at the home were not required to change PPE, such as gloves and gowns, after exiting a veteran’s room.
“The obvious risks associated with unchanged PPE and interacting with colleagues in any portion of the Home without a mask were either not appreciated by leadership or not properly conveyed to or enforced with the staff,” the report states.
The report found that lack of proper training was evident by the management team’s failure to create “a workplace culture that valued safety and personal responsibility.”
This culture, according to the report, was due in part to the management team’s failure to create a COVID-19 committee or task force to address infection prevention education, training for PPE, and other compliance issues.
IDVA releases response
Pritzker appointed Prince, a 31-year Navy veteran with experience in military and veterans’ medical care, to serve as acting IDVA director on April 1. Prior to this role, Prince was superintendent of the Ohio veterans homes and command master chief at Naval Hospital Camp Lejeune and the Walter Reed National Military Medical Center.
“There is nothing more critical to our department’s mission than ensuring the heroes in our homes are safe and receive the quality care they deserve,” Prince said. “As the acting director of the Illinois Department of Veterans’ Affairs and as a navy veteran of more than 30 years, my heart breaks for the families who lost loved ones to COVID-19 in our veterans’ homes. In my prior role, I led the Ohio veterans’ homes and saw firsthand the enormous challenges this pandemic unleashed on the state facilities that care for our heroes. Lessons learned there and here in Illinois from this unprecedented crisis are already being implemented as we work to make IDVA the department that our veterans deserve. Let me be clear, we will seize any and every opportunity to better ensure the safety of veterans in our care and every single corrective action outlined in this report will be implemented with urgency.”
Prior to the COVID-19 pandemic, IDVA and the La Salle veterans home implemented policies and procedures aimed at reducing the risk of outbreaks among staff and residents. At the beginning of the pandemic, all IDVA homes followed recommendations outlined by the CDC and the Illinois Department of Public Health regarding face masks, social distancing and handwashing, among other guidelines. In the early days of the pandemic, IDVA restricted visitation to veterans’ homes to protect residents and staff from community spread and prevent COVID-19 from entering the homes.
In the wake of the November 2020 outbreak, the La Salle facility took additional measures as advised by IDPH to slow the spread of the virus. Those measures included, but were not limited to, daily antigen testing for all staff, additional instruction regarding the use of PPE, and additional vital monitoring for residents who had previously tested positive for COVID-19. The La Salle home established a quality assurance committee to identify and remedy any shortcomings regarding infection control.
The state spelled out nine corrective actions: create centralized policies and develop outbreak drills and stress tests, educate staff on the importance of quality infection control for any infection, integrate the standards for long-term care facilities, at least in part, into the Veterans’ Home Code, develop an infection control task force or committee within the home, establish and clearly communicate thresholds for when IDPH visits the home, provide a suitable independent outlet for escalating internal complaints, create temporary positions or consultancies to ensure essential positions do not remain unfilled, require one Veterans Advisory Council member to be appointed by IDPH and adopt the recommendations of the audit and succeeding interagency memo as soon as possible.
The IDVA said it is adopting all corrective actions included in the report and have either completed or are in the process of completing all recommendations.
After consultation with the IDPH infection control expert assigned to the department, IDVA-wide procedures on infection prevention, COVID-19 testing, COVID-19 response, vaccines, hand hygiene, PPE, and cleaning were formalized on April 23. These procedures built upon many of the practices and procedures that had been in place at the La Salle home, the IDVA said.