From State Rep. Dan Ugaste:

Audit slams Pritzker Administration for failed response to deadly COVID outbreak at LaSalle Veterans Home.  In total, 36 residents of the LaSalle Veterans’ Home died due to COVID-19. The deaths occurred between November 7, 2020, and January 1, 2021. By November 15, 2020, 17 residents had lost their lives from COVID-19 at the LaSalle Home.

Multiple legislative hearings in response to the deaths at the LaSalle Veterans’ Home uncovered lack of management and health protocols to keep veterans safe in the Home and a lack of response from the Governor and his Administration. In response to the unanswered questions about the tragic deaths and the lack of response by Governor Pritzker’s Administration, House Republicans filed HR 62 (Welter). The resolution directed the Auditor General to conduct a performance audit of the State’s response to the management of the COVID-19 outbreak at the LaSalle Veterans’ Home. On April 28, 2021, the House adopted HR 62.

On May 5, 2022, the Office of the Auditor General released the report of its Performance Audit of the State’s response to the COVID-19 Outbreak at the LaSalle Veterans’ Home. The audit report contains seven key findings and three recommendations. Two recommendations were directed to the Department of Veterans’ Affairs and one was directed to the Department of Public Health. The Departments agreed with the recommendations.

Key Findings:

Although the Illinois Department of Public Health (IDPH) officials were informed of the increasing positive cases almost on a daily basis by the Illinois Department of Veterans’ Affairs (IDVA) Chief of Staff, IDPH did not identify and respond to the seriousness of the outbreak. It was the IDVA Chief of Staff who ultimately had to request assistance. The IDVA Chief of Staff inquired about a site visit and about rapid tests (November 9th), and inquired about getting antibody treatments (November 11th) for LaSalle Veterans’ Home residents. 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 the IDVA Chief of Staff.

• The outbreak at the LaSalle Veterans’ Home occurred at a time when COVID-19 cases were trending up statewide. Positive cases in Region 2 (where the LaSalle Home is located) increased from 12,108 in October 2020 to 37,825 in November 2020, an increase of 212.4 percent. Also, the outbreak occurred prior to the COVID-19 vaccine. Prior to the 3 outbreak that began at the end of October 2020, only six staff members 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.
• The time it took to receive staff COVID-19 testing results from the IDPH lab was lengthened by the collection method used by the LaSalle Home. The Home tested staff over a three day period. As a result, new tests of staff collected on November 3rd, 4th, and 5th were not delivered to the IDPH lab until Thursday, November 5th, even though the first two staff members from the outbreak were found to be positive by Sunday, November 1st. The IDPH lab published the majority of the test results on either Friday or Saturday. Therefore, the delay in getting testing results was primarily due to the collection method used by the LaSalle Home. Additionally, the testing method, collecting tests over three days, was not in compliance with the facility’s policy, which allowed for testing over two days.
• IDVA provided auditors with new infection prevention policies on June 17, 2021, which were drafted with the assistance of IDPH, which were officially implemented on April 23, 2021. The purpose of these policies was to establish a comprehensive and integrated infection prevention and control program at all Illinois veterans’ homes. A system-level Infection Prevention and Control Committee was tasked with standardizing policies and procedures and was required to oversee infection prevention at the Illinois veterans’ homes. These policies also updated infection prevention training requirements for staff at Illinois veterans’ homes.
• The LaSalle Veterans’ Home implemented several infrastructure improvements during FY20 and FY21 as a result of the COVID-19 pandemic and outbreak at the Home. Prior to the outbreak, external firms were commissioned to design and build airborne infection isolation rooms at IDVA Homes, including the LaSalle Home. The construction of the isolation rooms was initiated in March of 2020 and operational by May 23, 2020. Payments made for the construction of the isolation rooms totaled $1,057,470. In total, the cost for all infrastructure improvements from March 2020 through June 2021 totaled $1,162,719.
• The State expended approximately $3.4 million between FY20 and FY21 as a result of the COVID-19 pandemic at the LaSalle Veterans’ Home. According to documentation provided by IDPH and IDVA, expenditures included PPE, infrastructure improvements, and COVID-19 testing for both the COVID-19 pandemic as a whole and the outbreak at the LaSalle Home that began in late October 2020. Auditors concluded that the outbreak did not significantly add to the Home’s overall COVID-19-related costs during FY20 and FY21.
• The Department of Human Services’ Office of the Inspector General (DHS OIG) investigation reported that the significance of the outbreak was not being meaningfully tracked by the IDVA Chief of Staff. In fact, auditors found the Chief of Staff provided detailed information to IDPH that was used by the Director of IDPH in her daily COVID19 briefings. IDPH and the First Assistant Deputy Governor for Health & Human 4 Services were provided detailed emails of COVID-19 positive cases and related deaths for each of the four State veterans’ homes by IDVA on November 2nd, 3rd, 4th, 5th, 6th, 9th, 10th, 12th, and 13th. The primary finding of the DHS OIG report, which indicated the “absence of any standard operating procedures in the event of a COVID-19 outbreak,” was flawed. Auditors identified hundreds of pages of guidance provided by IDPH and by the Centers for Disease Control. In addition, COVID-19 policies were formulated by IDVA specifically for the LaSalle Veterans’ Home as well as a Continuity of Operations Plan that was reviewed by Illinois Emergency Management Agency and was provided to IDPH back in March 2020.

Key Recommendations:

• IDVA should ensure each of its Veterans’ Homes have policies and procedures in place that mandate timely testing of its residents and employees during COVID-19 outbreaks, and should ensure that residents and employees are tested according to the policy.
• IDPH should: (1) clearly define its role in relation to monitoring COVID-19 outbreaks at Illinois Veterans’ Homes; and (2) develop policies and procedures that clearly identify criteria which mandate IDPH intervention at Veterans’ Homes during an outbreak of COVID-19.
• IDVA should ensure that: (1) the IDVA Director works with the Department of Public Health 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; and (2) the Senior Home Administrator position is filled and the duties of the position include monitoring and providing guidance to the Veterans’ Homes during COVID-19 outbreaks.

Illinois House Republican Conference Chair Rep. David Welter issued the following statement in reaction to the Auditor General’s findings on the Pritzker Administration’s response to the deadly COVID-19 outbreak at the LaSalle Veterans Home in the fall of 2020 that claimed the lives of 36 of our state’s heroes:

“The Governor’s Office previously testified how the IDVA Director duped them regarding the outbreak’s severity. Today’s report from the Auditor General proves Governor Pritzker was the one who deceived us. His office had information from day one and failed to act. 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. 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.”