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Audit blasts Gov. Pritzker admin for failed response to veterans’ home COVID-19 outbreak that killed 36

A staff member with personal protective equipment looks out from the front entry door of the Illinois Veterans'­ Home. (Antonio Perez/ Chicago Tribune/TNS)

An Illinois state auditor general review of the COVID-19 outbreak that killed 36 elderly military veterans at the LaSalle Veterans’ Home in 2020 blames Gov. J.B. Pritzker’s Public Health department for failing to “identify and respond to the seriousness of the outbreak.”

Department of Public Health officials didn’t show up at the LaSalle home until 11 days after the outbreak began on Nov. 1, 2020, even though department leaders had been receiving near daily updates on the deteriorating situation at the home, according to Auditor General Frank Mautino’s review, which was released Thursday.

Auditor General Frank Mautino, center, at the Illinois State Capitol in Springfield. (E. Jason Wambsgans/ Chicago Tribune/TNS)

The public health department’s visit came only after top agency staff members were told that Pritzker was “very concerned” and wanted them to go to the facility, the report said.

The  health department’s failure to intervene quickly at the home after the outbreak had been detected was notable, the audit said, because “all but four” of the 36 “residents who died were positive prior to” the agency’s first site visit on Nov. 12, 2020.

Mautino’s review, requested by the General Assembly, also said an inspector general’s report ordered by Pritzker and released in April of last year that blamed management failures at both the Illinois Department of Veterans Affairs and the LaSalle home was too narrowly focused on the VA and largely excluded the public health department’s role in the crisis.

That report, from the Department of Human Services inspector general, contended the significance of the outbreak was not being meaningfully tracked by the chief of staff for Veterans Affairs when, “in fact, auditors found the chief of staff provided detailed information” that was used by former state Public Health Director Ngozi Ezike in her daily COVID-19 briefings, the auditor general report said.

The inspector general investigation also wrongly concluded that an “absence of any standard operating procedures in the event of a COVID-19 outbreak” was a significant factor in why the coronavirus was not contained at the LaSalle home when, in fact, hundreds of pages of guidelines existed, the state audit said.

Overall, the state audit points to a massive bureaucratic failure involving the administration’s response to the pandemic and the LaSalle deaths.

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Auditors recommended that the VA work with the public health department and the governor’s office during COVID-19 outbreaks “to advocate for the health, safety, and welfare of the veterans who reside in the homes under IDVA’s care.” The state agencies accepted the auditors’ findings and recommendations.

The report represents a major embarrassment for the Democratic governor as he seeks reelection in November. Pritzker won office in 2018 in part by attacking his predecessor, one-term Republican Gov. Bruce Rauner, for his failure to take quick action after a series of Legionnaires’ disease outbreaks at the Quincy Veterans Home led to the deaths of 14 veterans.

Republicans had been critical that the inspector general’s report was not wider in scope, and central Illinois lawmakers who represent the LaSalle region said the auditor general’s review vindicated their criticisms, while also calling for legislative hearings on the matter.

“The governor’s investigation into the matter was flawed, too narrowly focused, and purposely removed him and IDPH’s leadership team from scrutiny until today’s independent findings,” said state Rep. David Welter of Morris, a sponsor of the legislation that led to the auditor general’s review. “The governor can no longer cover up the truth and he must be held accountable for his collapse of competence.”

State Sen. Sue Rezin, also a Morris Republican, said the latest findings show Pritzker “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.”

Criticism also came from the governor’s own party, as Democratic state Rep. Lance Yednock of Ottawa said he was “frustrated and disappointed there wasn’t better coordination between state agencies to recognize and address the increasingly serious infection rate at LaSalle as it was happening.”

Pritzker, at an unrelated Springfield news conference Thursday, said the LaSalle outbreak occurred at the “dawn of the worst surge” of the pandemic and that public health officials at that time were not making in-person visits to long-term congregate care facilities “because the threat of unintentionally spreading COVID was significantly greater than the potential benefit of a visit.”

But Pritzker also sought to blame LaSalle-area Republicans who opposed his coronavirus mandates for contributing to the spread of the virus in the surrounding community and into the VA home.

“We were working against Republican elected officials who told people to defy mitigation efforts. We told people that they needed to follow those mitigations. But Republicans told them that they need not wear masks. They told people that they didn’t need to get vaccinated. They told people that COVID wasn’t serious. Those lies put people’s lives at risk, especially the most vulnerable,” Pritzker said.

The governor said the inspector general report he ordered was intended specifically to look at the LaSalle home, its management, and the management of the state VA in light of the outbreak.

The Department of Public Health, he said, “was the central responsible agency for the entire pandemic. So just while this veterans’ home was having its outbreak, (outbreaks also) were occurring all over the state, in schools in other nursing homes, in other congregate care settings.”

In fact, auditors reported that as of Nov. 8, seven days after the LaSalle outbreak began and four days before the site visit, data showed that of the 710 long-term care facilities in the state, LaSalle was the only one that had more than 100 cases of COVID-19. All but four others had 50 or fewer cases, if any at all.

Republicans running for governor noted Pritzker’s 2018 campaign criticism of “fatal mismanagement” by Rauner over the Quincy Legionnaire’s outbreaks.

“The bottom line is that by his own definition four years ago, Pritzker is unfit to serve as governor,” said cryptocurrency venture capitalist Jesse Sullivan of Petersburg, one of the five major GOP contenders for governor.

The GOP contenders have opposed Pritzker’s COVID-19 mitigation mandates in favor of local control.

The auditor general’s report recounted the failure of the state health department to respond to constant updates of growing infections and deaths due to coronavirus at the LaSalle home provided by the VA’s chief of staff, Anthony Kolbeck.

Kolbeck resigned a year ago, before the release of the inspector general’s report that faulted mismanagement at the VA for the outbreak.

Criticisms of the VA’s handling of the LaSalle outbreak led to the resignation of the agency’s director, Linda Chapa LaVia, who was accused by the inspector general of abdicating her responsibilities to Kolbeck, a nonmedical chief of staff who was also criticized in that report. Officials at the home also were fired by Pritzker, including the home’s administrator, Angela Mehlbrech, in December 2020.

“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 failed to identify and respond to the seriousness of the outbreak,” Mautino’s audit said, using the acronym for the Illinois Department of Public Health.

“From the documents reviewed, IDPH officials 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” Kolbeck, the audit said.

Four positive COVID-19 cases were identified at the LaSalle home on Nov. 1, the initial indication of the outbreak, and Kolbeck reported them to the state medical officer at public health and the governor’s office that day, the audit said.

By Nov. 4, a total of 46 residents and 11 staffers had tested positive for COVID-19 and by Nov. 13 Kolbeck reported in an email that 83 residents and 93 staffers were positive and that there had been 11 resident deaths and three residents and one employee were hospitalized, auditors said.

It was Kolbeck, the audit said, “who ultimately had to request assistance” by inquiring about a site visit by public health, the availability of rapid tests and antibody treatments.

It wasn’t until Nov. 11, 10 days after the outbreak began, that anyone from the public health department scheduled a visit, and then only after officials noted “the governor was very concerned” and wanted them to visit the home. The site visit was conducted the following day.

The audit said that while the inspector general investigation concluded a lack of policies and procedures “was a significant contributing factor to the home’s failure to contain the virus,” those policies existed and “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. 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.”

Those factors included a Halloween gathering at the LaSalle home, “the high positivity rate during that time in the community” and guidelines that at the time did not require rapid testing before entering the facility.

While the inspector general “relied heavily on interviews to support its findings” auditors said they collected documentation that was “contrary to many of the statements” the IG used to reach its conclusions.

The audit acknowledged some of the findings of the inspector general report, which noted that the initial site visit by the public health department found insufficient staff and visitor screening, lack of timely testing results, the use of a non-alcohol based hand sanitizer and improper usage of protective gear.

But public health officials said a follow-up visit five days later, on Nov. 17, found improvements in a number of areas, including staffing strategies, removal of the improper sanitizer, proper use of gowns, masks and face shields, and screening and testing for symptoms.

In March, families and the estates of 26 of the home’s veterans who died of COVID-19 or coronavirus-related illnesses began filing lawsuits in LaSalle County. The suits, which allege negligence and wrongful death, could cost the state millions of dollars.

Steve Levin of Levin and Perconti, the law firm handling the suits, said in a statement that the audit outlined “the state’s extreme negligence” in what was “a preventable tragedy.”

“It is time for the governor to be accountable to the families and settle the lawsuits with them. The evidence is overwhelming and it is wrong to make the families endure the added trauma of a lengthy legal battle,” he said.


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