A scathing independent report on last fall’s COVID-19 outbreak at the LaSalle Veterans Home that led to 36 deaths details systemic mismanagement from the top of the Illinois Veterans Affairs department down to the home’s leadership, which created an “inefficient, reactive and chaotic” response to controlling the virus.
The 50-page report from the Illinois Department of Human Services’ Office of the Inspector General and the law firm of Armstrong Teasdale, released Friday, says then-VA Director Linda Chapa LaVia “abdicated” her responsibilities, leaving things to a nonmedical chief of staff who preferred to let each home manage itself while issuing rules contradictory to health guidelines and failing to seek outside help as the outbreak grew.
Chapa LaVia, a former Democratic state representative from Aurora, resigned as state VA director in January and did not agree to be interviewed for the report. Her chief of staff, Anthony Kolbeck, submitted his resignation last week.
The report also portrays the home’s former administrator, Angela Mehlbrech, who the governor fired in December, as detached from her staff, and the home’s infectious control nurse as overburdened and “over his skis.”
It cites a lack of planning, training and communications at the home that resulted in the failure of contact tracing among COVID-19-positive employees, improper use of protective gear and a screening desk that was “frequently left vacated.”
Former IDVA Director Linda Chapa LaVia, who resigned in January after making a “mutual decision” with Pritzker, is characterized as a largely absentee agency head in the report. According to interviews cited by investigators, Chapa LaVia “was not a hands-on or engaged day-to-day Director.” Instead, Chapa LaVia’s chief of staff Tony Kolbeck essentially ran the department — a notion Kolbeck himself acknowledged, according to the report.
Pritzker’s office and IDVA’s new acting director, appointed April 1, stressed Friday that many of the suggested fixes contained in the report have already been implemented even before receiving the final report Monday, or are in the process of remedying. Earlier this month, the family of a 90-year-old Korean War veteran who died in November sued the state for $2 million.
While the report places blame on Kolbeck’s shoulders for many decisions, it also notes several times that he was attempting to do the jobs of three people: his own chief of staff role, Chapa LaVia’s director role and a job overseeing the state’s four veterans homes — a position that has been vacant since 2019.
The report’s release roughly coincides with Kolbeck’s resignation, Pritzker’s office confirmed, though he’ll stay on for a two-week transition period.
* ABC 7…
Consistent statewide procedures and ongoing drills that target infection response and other emergencies will be routine at Illinois veterans’ homes after COVID-19 caught the LaSalle Veterans’ Home unprepared and claimed 36 lives last fall, the state’s newly appointed director said.
Terry Prince, a 31-year Navy veteran and former senior adviser to the U.S. Surgeon General, has issued a six-point plan for improving readiness at the state’s veterans’ homes in Anna, Manteno, Quincy and LaSalle. The plan follows a blistering investigative report that laid out a string of miscommunications, lax policy and missed opportunities when the pandemic hit the home in LaSalle, 94 miles west of Chicago.
The report by the inspector general of the Illinois Department of Human Services, released Friday, noted that despite escaping all traces of the deadly respiratory illness for eight months after it entered Illinois, there was little done to devise protocols for preventing or managing infections. After the first four cases were reported Nov. 1, the virus spread to 60 residents and 43 employees as confused staff operated in an environment that was “inefficient, reactive and chaotic,” the report said.
“We need to train as if it’s always happening,” said Prince, who arrived in Illinois on April 1 from his post as superintendent of the Ohio Veterans Homes, where he administered three facilities. “When there is an absence of the virus we train even harder, so that when something does come to fruition, our people know exactly what to do and how to do it.”
The report is here. The IDVA press release is here. The IDVA acting director’s path forward is here. Subscribers have more.
…Adding… Sen. Sue Rezin represents LaSalle County…
This morning the Office of the Inspector General (OIG) for the Illinois Department of Human Services released their investigation report on the COVID-19 outbreak at the LaSalle Veterans’ Home. State Senator Sue Rezin (R-Morris) releases the following statement about the report:
“The veterans who died as well as many of the family members who were directly impacted by the deadliest outbreak at a state facility in Illinois are my constituents. While I am still reviewing the OIG report in detail, it’s clear that the Administration has failed these individuals.
“The report reveals a lack of direction from the Governor’s office and department directors. 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 today’s report and we must pass legislation that ensures that we implement potential lifesaving policies.”
…Adding… Rep. Stephanie Kifowit…
The Illinois Department of Veterans’ Affairs (IDVA) today released an independent report that was requested to fully investigate the COVID-19 outbreak at the LaSalle Veterans home that resulted in more than 200 Veterans and staff at the Home testing positive for the virus, and 36 Veteran deaths. State Representative Stephanie Kifowit (D-Oswego), who is also a Veteran and Chair of the IL House Veterans’ Affairs Committee released the following statement:
“As an Honorably discharged Veteran of the US Marine Corps, I am beyond disgusted by the findings in this report. It confirms the suspicions of not only myself, but other members of the committee, of the failure in leadership of the IL Department of Veterans Affairs that we witnessed in over four hours of hearings that were held in 2020,” stated Representative Kifowit.
“Throughout the outbreak at the LaSalle Veterans Home, dedicated staff were reaching out to me directly with serious concerns and fear for the safety of our decorated Veterans who trust Illinois with their welfare. The genuine care of the rank-and-file staff was always shown to me of their devotion and sincerity for our Veterans, but the lack of protocols, leadership and structure on the department level let down our Veterans and the staff that care for them,” stated Kifowit.
The nearly 50-page report, released early Friday morning, details the multitude of failures by IDVA management staff and executive leadership. The report found “inadequate leadership and structure within the Home and IDVA resulted in the Home’s failure to adequately meet the increased expectations caused by the pandemic”. The report, link to the full report is here, found the following contributing factors:
• Lack of a comprehensive COVID-19 plan at the Home
• Leadership failed to effectively communicate, train and educate its employees on the dangers of COVID-19 and necessary precautions
• No established COVID-19 task force or committee for managing and monitoring COVID-19
• IDVA’s executive leadership team also contributed to the Home’s failed COVID-19 response.
“The past failures of IDVA, from the outbreak at Quincy, computer malfunctions for months affecting Veteran’s claims, an assistant Director being accused of sexual harassment and racism and now the deadly outbreak of COVID-19 at LaSalle are the reasons I passed HB359, creating the Veterans Accountability Unit for Veterans and their families that is independent of IDVA and will hold the department accountable.
“I look forward to working with Acting IDVA Director Terry Prince, a 31-year Navy Veteran with the experience in military and Veterans’ medical care that the department needs to ensure that the state of Illinois has a department that not only our Veterans and their families, but all Illinoisans can be proud of.”
State Representative Stephanie Kifowit is an honorably discharged Veteran of the United States Marine Corps and has served as the Chair of Veterans Affairs since 2019. She was first elected to the Illinois House of Representatives in 2013 and is currently also the Chair of State Government Administration, Vice Chair of General Services Appropriations and a member of the Public Utilities and Revenue and Finance Committees.
* Rep. Yednock…
State Rep. Lance Yednock, D-Ottawa, issued the following statement on Friday in regard to the release of the Illinois Department of Human Services’ Office of the Inspector General and the law firm of Armstrong Teasdale’s report on last fall’s COVID-19 outbreak at the LaSalle Veterans’ Home:
“After reviewing this report, my heart breaks again for the families who lost loved ones. 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.”
“While this report sheds more light on how this tragedy happened, we owe it to those lost and their loved ones to do everything possible to ensure that nothing like it ever occurs again. This starts with putting the proper safeguards and plans in place for all veterans’ homes and ensuring those that failed to take action are held responsible.”
* Sen. Cullerton…
Following the release of a report from the Office of the Inspector General on the COVID-19 outbreak at the state-run LaSalle Veterans Home in November 2020, State Senator Tom Cullerton (D- Villa Park) called for hearings to further investigate the issue, discuss the obvious mistakes that occurred and how to move forward.
“It breaks my heart and I can’t imagine what the loved ones of those lost during this outbreak must be feeling,” said Cullerton, chair of the Senate Veterans Affairs Committee. “This report will give me, my colleagues and our veterans’ families an opportunity to seek understanding of what occurred plus offer clarity on what can be done to prevent this situation in the future.”
From late October to December 2020, more than 200 veterans and staff at the LaSalle Veterans Home tested positive for COVID-19, resulting in 36 deaths. When the state learned of the outbreak, the Veterans Affairs Committee held multiple hearings with witnesses from the Illinois Department of Veterans’ Affairs (IDVA) and the Illinois Department of Public Health (IDPH) to determine what went wrong.
Following the outbreak, IDVA director Linda Chapa LaVia stepped down and was replaced by Terry Prince, a 31-year Navy veteran who was also superintendent of the Ohio Veterans’ Homes, as acting IDVA director.
“Now that this report is out, we will hold hearings with the Veterans Affairs Committee to discuss these findings,” Cullerton said. “It is incredibly important that legislators have the opportunity to ask questions on this report. I spoke with the Governor this morning plus IDVA Director Prince late last night and was assured their teams would be helpful and responsive during these hearings. We can never bring these veterans back, but we can find answers. We owe it to their families and the veteran community to provide transparency and assurances that we cannot let this happen again.