Pritzker administration slammed in audit for its handling of La Salle veterans home COVID-19 outbreak

The Illinois Department of Public Health, which is under the jurisdiction of Gov. JB Pritzker’s office, “did not identify and respond to the seriousness” of a COVID-19 outbreak that resulted in 36 resident deaths at the Illinois Veterans Home in La Salle, according to a report released Thursday by the Auditor General’s Office.

The House of Representatives directed the auditor general’s office to conduct a performance audit of the state’s response to the COVID-19 outbreak at the La Salle veterans home.

In November 2020, the veterans home had 203 positive cases among staff and residents at the home.

The outbreak brought scrutiny to the veterans home from committees within the General Assembly. The head of the state’s veterans administration Linda Chapa LaVia resigned amid the fallout, and the administrator of the La Salle facility also was removed from her post. Also there is pending wrongful death lawsuits filed among some of the residents’ families.

State auditors reviewed emails and documentation and conducted meetings and determined 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, the Auditor General’s report said.

The report released Thursday by the auditor general found IDVA did in fact have infection control guidance in place at the time of the outbreak, contradicting an April 26, 2021 report from the Department of Human Services Office of the Inspector General and an outside law firm.

The 2021 OIG report, which was conducted at the request of Gov. JB Pritzker, found leadership deficiencies at IDVA which led to the director “abdicating” her responsibilities to subordinates. It also stated the home “did not develop comprehensive COVID-19 policies.”

While both reports pointed to staff attending a Halloween party and failing to socially distance as potential causes for the outbreak, the auditor general found “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,” the auditor general report stated. “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.”

Other factors may have included community spread, which led to a 212% increase in COVID-19 cases in the region from the month prior, or the fact that guidelines at the time did not require rapid COVID-19 testing prior to entering the home, allowing for asymptomatic spread.

The auditor general’s report described the OIG report as “flawed” for its reliance on interviews rather than documentation.

The auditor general report largely focused on a 13-day span at the beginning of November 2020, when the case count grew from four to over 170 at the LaSalle home between residents and staff.

It was Nov. 1, 2020, when Kolbeck, the IDVA chief of staff, reported four cases to the governor’s office and the Illinois Department of Public Health among others. Eleven days later, IDPH performed a site visit at the home. By the next day, IDVA reported 83 residents and 93 staff positives, all but six of which were current, along with 11 resident deaths and four hospitalizations.

The report said Sol Flores, deputy governor for health and human services under Pritzker, and an assistant “may not have realized the significance of the outbreak at the La Salle Veterans’ Home as the virus continued to progress through the home.”

Flores told auditors her office thought leadership at IDVA and the home were “communicating and taking actions regarding the employees under their responsibility to ensure things were being done.”

The audit further noted an assistant to Flores emailed Kolbeck on Nov. 2, 2020, to ask if more support was needed from IDPH and if he’d been in contact with the state medical officer.

Kolbeck replied the next day, “I can’t think of anything specific we need at La Salle. You’ll see shortly, it’s not improving though. I have traded emails with the state medical officer on getting a call with the administrators and her team but we haven’t locked in on a date/time yet.”

According to the audit, Kolbeck first inquired about a potential site visit on Nov. 9. A response didn’t come until Nov. 11, and that was after the medical officer spoke to IDPH’s chief of staff, who relayed that Pritzker “was very concerned and wanted IDPH to visit the home.”

The email citing Pritzker’s concern came 22 minutes after an IDPH infection control consultant determined that the “processes being done are sound” at the La Salle home, relaying that an infection control nurse at the home “feels they are doing okay and doesn’t feel the need for someone to visit.”

The audit postulated a site visit might have taken even longer without Pritzker’s intervention.

The audit also found IDPH failed to act in the first week of November, “even though it was the largest outbreak in any of the state’s congregate care facilities.”

It was Kolbeck who reached out to IDPH about the home receiving rapid tests on Nov. 9 and monoclonal antibody treatments on Nov. 11. By the time rapid tests arrived, more than two-thirds of the home’s residents had tested positive.

“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,” the report stated.

The auditor recommended IDPH should “clearly define its role” in monitoring COVID-19 outbreaks at veterans homes and develop policies and procedures that “clearly identify criteria which mandate IDPH intervention” at the homes.

IDPH accepted the recommendation, but the department noted antibody treatments were not available for distribution at the time of the La Salle outbreak and an infection preventionist assigned to IDVA died unexpectedly two weeks prior to the outbreak.

IDPH said its oversight task included communicating with 97 local health departments and preparing for distribution of the vaccine which arrived one month later.

The audit also recommended IDVA develop policies that mandate timely testing of residents and staff during outbreaks. It outlined testing periods that occurred over three days, extending the time when results would be sent to labs, compounding processing delays.

The audit also recommended the IDVA director work with IDPH and the governor’s office during COVID-19 outbreaks. IDVA agreed with the recommendations.

The report also noted IDVA and IDPH put new policies in place in April 2021 to “establish a comprehensive and integrated infection prevention and control program at all Illinois veterans homes” that included new training requirements.

The audit’s release set off a flurry of responses.

IDPH spokesman Mike Claffey said the agency “has worked tirelessly” to implement precautions and protocols against a swift-acting virus.

“The La Salle outbreak occurred during one of the worst surges of the pandemic, leading to rapid community spread in La Salle County and as a result, in many of its congregate facilities,” Claffey said. “As the outbreak unfolded, IDPH was in daily communication with IDVA leadership to ensure they had the guidance and resources they needed to respond. While federal guidance at the time advised against in-person visits to congregate facilities to protect residents, IDPH sent a team to the facility as soon as that was requested, with strict safety precautions.”

Nevertheless, IDPH “welcomes the recommendations of the Auditor General and has implemented many of them since the outbreak.”

Veterans Affairs issued a statement citing portions of the audit showing full compliance with the Auditor General’s Office and the implementation of new protocols. Despite the swiftness of the virus (an increase of 212.4% in a month), vaccination rates among residents and staff are more than 90%.

“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,” the release said.

“Since joining the department, IDVA Director Terry Prince has further strengthened these policies and training while continuing the efforts that resulted in nearly 98% 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.”

But some lawmakers were singing a different tune. State Sen. Sue Rezin (R-Morris) renewed her criticism of Pritzker for the state’s handling of the crisis.

“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,” Rezin said, alleging Pritzker and his appointees “intentionally misled legislators” during public hearings.

“He must finally accept responsibility for failing to act on the information his office sat on since day one,” Rezin said. “The Senate must hold legislative hearings to demand answers from the Pritzker Administration.”

State Rep. Lance Yednock (D-Ottawa) said the outbreak “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.”

Yednock said he was “frustrated and disappointed” there wasn’t better coordination between state agencies. “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.”

While Yednock said “significant improvements” were made to prevent future deadly outbreaks, he asked the Auditor General’s Office and all involved agencies to participate in an upcoming legislative hearing to discuss these findings in more detail.

State Rep. David Welter (R-Morris), whose district includes La Salle County, said the governor’s investigation into the matter was flawed, too narrowly focused and “purposely removed him and IDPH’s leadership team” from scrutiny. Welter called for legislative hearings to further examine the administration’s response.

“The governor’s office previously testified how the IDVA director duped them regarding the outbreak’s severity,” Welter said in a statement Thursday. “(Thursday’s) report from the auditor general proves Gov. Pritzker was the one who deceived us. ... 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.”