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Auditor General releases Quincy veterans home report

Monday, Mar 25, 2019

* December 20, 2017

Gov. Bruce Rauner said Wednesday the state is taking “aggressive action” to keep residents safe at the Quincy Veterans’ Home, but declined to say if he bears any moral responsibility after more cases of Legionnaires’ disease were found at the facility following a 2015 outbreak that left a dozen people dead. […]

On Wednesday, Rauner said the state is following all recommended procedures from the CDC and that it was due to increased testing for the bacteria that new cases have been identified, not necessarily because of remediation failures involving some pipes at the facility that are more than a century old.

* Illinois Auditor General’s report issued today

In December 2015, the Centers for Disease Control and Prevention (CDC) recommended point-of-use filter installation on all fixtures fed from the potable hot-water system. Filters were not installed on all fixtures other than the showers until after the February 2018 outbreak, in April 2018.

That would be four months after Rauner claimed that the state was doing everything the CDC said it should do.

* The Auditor General also has a timeline of events

Thursday, August 6, 2015
(1st Case Identified)

9:52 AM 1st confirmed case of legionellosis from the Quincy Veterans’ Home (IVHQ).

Hot water tank number 2 has been out of service since the beginning of July due to a valve issue. The tank is unheated and was cycled back into service on this day.

That’s the hot water tank which pumped a “broth of Legionella” into the facility, but nobody realized it at the time.

A second legionellosis case was identified on August 21st. Officials determined the following day that the two cases weren’t related and they appeared to relax a little

IDPH Director emails the IDVA Director stating: “While this situation is serious because it involves lives, it is not unprecedented or atypical. Legionella is a risk in any situation of this sort. You may have seen that the City of New York has been grappling with a major outbreak. Even in Illinois, we are dealing with another set of cases at a prison facility. Fortunately, Legionella is a disease we know how to diagnose and treat. And from an epidemiology standpoint, we know how to track it down.”

The next day, however, 3 more residents tested positive. And 3 more tested positive the following day. By the morning off August 25th, 10 residents were in the hospital. By early afternoon, 11 residents were in the hospital, with 3 of those in ICU. On August 26th, they finally began to suspect the water heater, with 18 people now in the hospital. But no conclusive evidence is found until September 2nd. By then, 7 people had died and 45 confirmed cases had been identified.

* Back to the audit

IDPH did not go on-site at Quincy Veterans’ Home until midday on Monday, August 24. That was nearly 3 days (approximately 67 hours) after the 2nd case was confirmed late in the afternoon on August 21st. […]

Based on our review of communications between IDPH and the Quincy Veterans’ Home, auditors determined that there was limited communication between IDPH management and the Quincy Veterans’ Home staff. As identified in our timeline in Chapter 2, IDPH officials often did not know the seriousness of the problem at the Quincy Veterans’ Home

* WBEZ

Additionally, more than a week after multiple Legionnaires’ cases were confirmed, former state Public Health Director Nirav Shah concluded that he did not “think it’s necessary right now” to call in the federal Centers for Disease Control and Prevention to assist in the 2015 outbreak, according to the audit.

At that point, Aug. 28, 2015, two people had died from Legionnaires’, and 29 residents and staff had tested positive for Legionella. By the end of the next day, Shah reversed course and recommended that the CDC be brought in to assist the state, the report said.

Since 2015, 66 residents and eight staff members were sickened in rolling Legionnaires’ outbreaks at the facility, with 13 deaths directly attributable to the pneumonia-like illness tied to Legionnaires’. Another resident died in 2018, several months after being sickened by Legionnaires’.

- Posted by Rich Miller        

28 Comments
  1. - 360 Degree TurnAround - Monday, Mar 25, 19 @ 12:06 pm:

    How hard would it have been for Rauner to reach out to people for help? Just realize you are in over your head. Find the right people to fix the problem.


  2. - Huh? - Monday, Mar 25, 19 @ 12:12 pm:

    “Just realize you are in over your head. Find the right people to fix the problem.”

    Wasn’t 1.4% the smartest guy in the room with the BTIA(tm)? /s


  3. - wordslinger - Monday, Mar 25, 19 @ 12:18 pm:

    –That would be four months after Rauner claimed that the state was doing everything the CDC said it should do.–

    And more than two years after the CDC recommendation.

    I wonder if we’ll ever hear anything out of that Adams County grand jury.


  4. - striketoo - Monday, Mar 25, 19 @ 12:19 pm:

    Just get the state out of the veterans housing business. Leave veterans care up to the feds for better or for worse. It can’t be any worse or more expensive.


  5. - Blue Dog Dem - Monday, Mar 25, 19 @ 12:25 pm:

    I think appointing a special prosecutor at this time would be appropriate. I understand one has some free time now.


  6. - wordslinger - Monday, Mar 25, 19 @ 12:29 pm:

    –I think appointing a special prosecutor at this time would be appropriate.–

    Why?


  7. - Anon221 - Monday, Mar 25, 19 @ 12:36 pm:

    Shah’s LinkedIn Profile. Fails to mention anything about Quincy…

    “Former Director of the Illinois Department of Public Health, a large state agency tasked with protecting and promoting the health of all Illinoisans. Reporting directly to the Governor, ‘I focused on a number of public health and healthcare issues, including the opioid crisis, childhood lead poisoning, behavioral health, food safety, and maternal mortality.’”

    https://www.linkedin.com/in/nirav-shah-aa8a091a


  8. - Last Bull Moose - Monday, Mar 25, 19 @ 12:37 pm:

    The lack of urgency by state officials may reach the level of reckless indifference. Doubt we need a special prosecutor, but some legal review is appropriate.


  9. - Perrid - Monday, Mar 25, 19 @ 12:47 pm:

    word, I imagine Blue is making a joke about a special prosecutor given the weekend’s news. But I do think this puts the grand jury/investigation in Adams County in the spotlight again. What, if anything, has happened since the election?


  10. - Annonin' - Monday, Mar 25, 19 @ 12:51 pm:

    Yup someone might want to check in on GovJunk’s grand jury in Adams County. If we can pull ourselves away from the coverage of wardrobe notes and noisy weddings


  11. - wordslinger - Monday, Mar 25, 19 @ 12:52 pm:

    –word, I imagine Blue is making a joke about a special prosecutor given the weekend’s news.–

    Jokes about dead vets?


  12. - JoanP - Monday, Mar 25, 19 @ 12:57 pm:

    =Fortunately, Legionella is a disease we know how to diagnose and treat.=

    Yeah, well, I just looked at the CDC website:

    “For those who get Legionnaires’ disease during a stay in a healthcare facility, about 1 out of every 4 will die.”


  13. - The Dude - Monday, Mar 25, 19 @ 1:19 pm:

    Rauner will never admit he did a poor job with Quincy. He will never admit any of the damage he did to the state.


  14. - Groundhog Day - Monday, Mar 25, 19 @ 1:31 pm:

    And this is why it matters who is the governor and how they govern. Incompetency can be fatal, esp for the vulnerable. I do think it is governing malpractice, at the very least. Of course, no criminal or civil penalties, so who really cares.


  15. - DuPage - Monday, Mar 25, 19 @ 1:47 pm:

    Rauner had problems with patients safety in his nursing homes back before he became governor. He said he was going to run the state like his business, and he did. Tragic results followed.


  16. - cover - Monday, Mar 25, 19 @ 1:55 pm:

    = Just get the state out of the veterans housing business. Leave veterans care up to the feds for better or for worse. It can’t be any worse or more expensive. =

    The federal VA operates hospitals, not nursing homes.


  17. - Honeybear - Monday, Mar 25, 19 @ 1:59 pm:

    Although Mike Hoffman must have done something right for Rauner. He’s now the COO of Ounce of Prevention.


  18. - Anon221 - Monday, Mar 25, 19 @ 2:03 pm:

    “Adams County State’s Attorney Gary Farha said no outside group has requested any time with the grand jury since the three attorneys went before the grand jury Oct. 25. Farha said outside groups, such as a special prosecutor or the attorney general’s office, would typically call the state’s attorney’s office to request time before the grand jury, which meets every three weeks.”

    https://www.whig.com/20190322/vets-home-investigation-continues-months-after-ag-staff-went-before-grand-jury#


  19. - Lester Holt’s Mustache - Monday, Mar 25, 19 @ 2:10 pm:

    ==Shah’s LinkedIn Profile. Fails to mention anything about Quincy…==

    You expect it to? What should it say, “Responsible for bureaucratic screw-up that resulted in numerous deaths and illnesses?” You’re talking about the employment version of Eharmony profiles here.


  20. - NeverPoliticallyCorrect - Monday, Mar 25, 19 @ 2:23 pm:

    Just tragic. Once again state run services prove incompetence. If it were my relative an attorney would have been contacted already.


  21. - Bourbon Street - Monday, Mar 25, 19 @ 2:42 pm:

    =Even in Illinois, we are dealing with another set of cases at a prison facility.=

    What happened at the prison? Did anyone die there? How did IDPH “deal” with the outbreak? This story seems to have not gotten much publicity (or maybe I just missed it). IDPH’s response to the Legionnaires’ outbreak at the prison would tell us a lot about IDPH.


  22. - Groundhog Day - Monday, Mar 25, 19 @ 2:45 pm:

    And for the record: The Federal VA does operate nursing homes, over 100 beds at Hines VA and Lovell FHC, and Jesse Brown VA in Chicago even has 22 beds. But the state system is actually co-funded by the feds and the state. The feds pay one-third of the daily cost, at least, and has oversight as well.


  23. - JS Mill - Monday, Mar 25, 19 @ 3:36 pm:

    =–word, I imagine Blue is making a joke about a special prosecutor given the weekend’s news.–

    Jokes about dead vets?=

    That BDD person is just a laugh riot. /s

    I hope the appropriate people forgo all of the show pony stuff and get down to some real investigating and prosecuting here. This was criminal behavior.


  24. - Blue Dog Dem - Monday, Mar 25, 19 @ 5:12 pm:

    Wait a second. My comment was in regards to negligence for political gain by the ex governor. A $50k water heater looks cheap in hindsight. Not insinuating the ex had anything to do with this, but would love to find the guilty party.


  25. - wordslinger - Monday, Mar 25, 19 @ 7:03 pm:

    –My comment was in regards to negligence for political gain by the ex governor…..Not insinuating the ex had anything to do with this….–

    Is there a third voice in your head that can serve as tie-breaker on this?

    Your original comment was:

    –I think appointing a special prosecutor at this time would be appropriate. I understand one has some free time now.–

    Why would a special prosecutor be needed?

    If you got a laugh out of using the Quincy vets to make a Mueller joke, I guess that’s all that matters.


  26. - m4a - Monday, Mar 25, 19 @ 7:08 pm:

    Deplorables


  27. - FormerParatrooper - Monday, Mar 25, 19 @ 7:27 pm:

    It took 3 years to install the CDC recommended filters on the shower fixtures. If Mr Shah believes this is quick, coordinated and decisive, I would hate to think what slow, chaotic and indifference is to him.


  28. - Rich M - Tuesday, Mar 26, 19 @ 3:15 am:

    The water hygiene centre has published a bog on Legionnaires disease in care homes which some of you may find interesting
    https://resources.waterhygienecentre.com/blog/the-control-of-legionella-in-care-homes


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