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A maddening story of incompetence and chaos at every level

Monday, May 3, 2021

* My weekly syndicated newspaper column

An inspector general’s report on the deadly COVID-19 outbreak at the Illinois Department of Veterans’ Affairs LaSalle Veterans’ Home is a maddening story of incompetence and chaos at every level.

The IG report, released Friday, tells the story of an allegedly AWOL agency director; an in-over-his-head chief of staff; a crucial failure to fill an important upper management position; an unconscionably delayed IDVA management response at all levels to a clearly and rapidly deteriorating situation both in the surrounding communities outside the home and when the virus inevitably spread inside the facility; an unprepared and woefully uninformed management on multiple issues, including basics about personal protection equipment; an abject failure to properly train and equip staff; multiple failures to ask for outside help and accept it when offered; and staff infighting and managerial timidity.

Thirty-six veterans died during the LaSalle catastrophe last year, a quarter of the facility’s population. Frankly, after reading the report, I was surprised more people didn’t die. It’s that bad.

The trouble started with Gov. J.B. Pritzker’s hasty appointment of a state legislator to fill the IDVA director job after his initial appointee abruptly dropped out — a mystery that he has not explained to this day.

According to the report, after state Rep. Linda Chapa LaVia became IDVA director, she apparently “abdicated” her responsibilities to her chief of staff, Tony Kolbeck. Kolbeck’s heart was in the right place but he should not have been given that job, partly because he didn’t have the requisite knowledge and experience, but also because the administration never appointed a Senior Homes Administrator for the agency. That administrator would’ve had the “medical understanding to provide meaningful leadership,” according to the IG report.

Kolbeck essentially served as the director, the chief of staff and the Senior Homes Administrator all at once, a near impossibility during “normal” times, let alone during a deadly crisis.

After Director Chapa LaVia finally quit under pressure, Pritzker brought in a new acting director.

Terry Prince is a buttoned-down 31-year Navy man with an abundance of healthcare management experience in the Navy and in his last job running Ohio’s veterans homes. One of those homes, the fifth largest in the country, had an outbreak last year, but it was contained and the fatality rate was a fraction of what it was at LaSalle and at many private nursing homes in the country. Like everyone in that sector, he’s not unblemished, but he’s never been accused of incompetence that I could find.

Prince’s extensive management experience is something the IDVA has lacked for years. But he is also a student of management theory and mentioned several management training models he admires.

I asked Prince about an item in the IG report that the LaSalle home managers refrained from disciplining workers out of fear of retaliation. I pointed out that this is prevalent in state government here because upper management too often won’t back up lower management in personnel disputes. Prince said he created a program in Ohio called “I got your six” to address that very issue. “The management team has to know that their director, assistant director has their backs,” he rightly said.

Prince wants to subject the veterans’ homes to accreditation and the federal government’s Medicaid rating system. “I want evaluations from anybody who will come and evaluate our buildings because I believe that the more inspections we have, the better,” he said.

He’s a military veteran and these are veterans’ homes, and Prince says he intends to put employees through regular training drills to make sure they are up to dealing with emergencies.

But he also talked about trying to work more cooperatively with AFSCME, something he claimed to have had success with in Ohio. Prince said Illinois Department of Human Services Secretary Grace Hou recommended that he make himself “crazy available” to union personnel, which he says he’s doing. Hou has had significant success in dealing with AFSCME. The IDVA, on the other hand, has been notable for its hostility toward the union.

“I want our veterans in our veterans’ homes to live their best possible life,” Prince said. “I want their star to shine bright in our facilities. I know we have the teams to do it. We just have to make sure that we’re training them and holding them accountable and saying, ‘Here’s our expectations.’”

Prince is no doubt an impressive person, but there is no longer any room for failure at that agency. He gets zero slack. To put it bluntly, if we can’t stop killing our veterans, then we as a state need to get out of this business.

* Meanwhile, here’s a press release…

U.S. Senate Majority Whip Dick Durbin (D-IL) and U.S. Senator Tammy Duckworth (D-IL), a combat Veteran and former Director of the Illinois Department of Veterans’ Affairs (IDVA), today urged the U.S. Department of Veterans Affairs (VA) to assist the IDVA following a Illinois Department of Human Services Office of Inspector General’s (OIG) report released last week, which documents a number of failures within IDVA leadership in addressing and preventing a fatal COVID-19 outbreak at the Illinois Veterans Home (IVH) LaSalle. In a letter to VA Secretary McDonough, Durbin and Duckworth asked the VA to ensure that IDVA has the appropriate protocols in place, as well as training and support it needs in order to continue to protect Illinois Veterans from COVID-19 or any future infectious disease outbreaks.

* The letter

Dear Secretary McDonough:

We write to request urgent assistance for the Illinois Department of Veterans’ Affairs (IDVA) in light of an Illinois Department of Human Services Office of Inspector General’s (OIG) report released last week, which documents a number of failures within IDVA leadership in addressing and preventing a fatal COVID-19 outbreak at the Illinois Veterans Home (IVH) LaSalle. During the time of the outbreak last fall, the Department of Veterans Affairs (VA) participated in inspections alongside the Illinois Department of Public Health (IDPH), helping to identify a myriad of problems and detailing a full-time VA staffer to provide technical assistance to the State on pandemic concerns and protocols. We urge the VA to return to Illinois once again to ensure that IDVA has the appropriate protocols in place, as well as training and support it needs in order to continue to protect Illinois Veterans from COVID-19 or any future infectious disease outbreaks.

We understand that the risks associated with the deadly coronavirus are only increased in long-term care facilities. However, as the OIG report indicates, the proper implementation and execution of infectious disease protocols can help control outbreaks. By fall 2020, the potential effect of COVID-19 on such facilities was well-documented, and as the pandemic surged across the State, including in LaSalle County, more than 200 Veterans and staff at IVH LaSalle had tested positive for COVID-19, resulting in 36 Veteran deaths.

The OIG report ultimately found a lack of preparation, poor communication and training, and a serious lapse in infectious-disease protocols. The report also noted that IDVA failed to implement a number of basic Centers for Disease Control and Prevention (CDC) recommendations, including formalizing a COVID-19 preparedness and response plan, resulting in actions that were “inefficient, reactive, and, at times, chaotic.” The report also notes that IVH Manteno and IVH Quincy faced related, fatal outbreaks. While the death tolls were smaller at these two facilities, the urgency to take corrective action remains the same.

We appreciate that the VA has provided technical assistance to the State of Illinois over the years, including during a deadly Legionnaires’ outbreak that took place at IVH Quincy between 2015 and 2018. Today, while we recognize that Governor Pritzker has taken a number of proactive steps—including personnel changes to replace the IDVA Director and oversight efforts such as requiring this OIG investigation—we remain worried about IDVA’s future preparedness against both the ongoing COVID-19 pandemic and other infectious disease outbreaks.

Countless families have entrusted the care of their loved ones—Veterans who have served and scarified for this country with honor, and deserve the highest standards—to the State of Illinois. We urge the VA to help ensure that our State is up to the task in the face of challenges such as the COVID-19 pandemic.

* And from the ILGOP…

“The Governor ran for office in 2018 blaming his predecessor for the Legionnaires outbreak at the Quincy Veterans’ Home that tragically took the life of 14 American heroes. Pritzker said the incident revealed a callous regard for human life and a fatal lack of leadership,” reminded ILGOP spokesman Joe Hackler. “36 dead veterans later at LaSalle and the Governor is on record as now saying ‘these things can happen’ and has refused to take full responsibility for this tragedy on his watch. The IG report makes clear that candidate Pritzker in 2018 would think Governor Pritzker’s administration is fatally incompetent and responsible for the deaths of 36 American heroes.”

- Posted by Rich Miller        

  1. - Red Ketcher - Monday, May 3, 21 @ 12:03 pm:

    Weekly Column - Outstanding - On Target

  2. - SSL - Monday, May 3, 21 @ 12:09 pm:

    I hope Mr. Prince is wildly successful. Our Veterans deserve it.

  3. - Candy Dogood - Monday, May 3, 21 @ 12:09 pm:

    === she apparently “abdicated” her responsibilities to her chief of staff===

    I think it is important for the administration to be aware that if this is the only instance of that happening at the state under the Pritzker Administration, I would be shocked. I could speculate a handful of agencies right now where the director isn’t taking an active role in the administration of their agency or performing a work load I would think is consistent with their salary.

  4. - Oswego Willy - Monday, May 3, 21 @ 12:09 pm:

    Great read, Rich. Thank you for that column.

    It’s important and critical to have a pointed look at such a tragedy as 30+ deaths, and how Chapa LaVia and her own ineptness and passing on work to others set a dangerous table and it had tragic results.

    Also this… Governor Pritzker…quoting…

    ===And so she seemed like an ideal person to be able to root out the problems in our veterans’ homes. But I have to admit that if I knew then what I know now I would not have hired her.===

    If Mr. Hackler can’t read or can’t read for comprehension, I could understand his silly words. The governor is owning Chapa LaVia, frankly admitting he made a mistake and knowing now, he, the governor, wouldn’t have hired her.

    ===… has refused to take full responsibility for this tragedy on his watch.===

    Willful ignorance on Hackler’s part.

    Hackler is well aware what he (Hackler) is trying to do.

  5. - Perrid - Monday, May 3, 21 @ 12:15 pm:

    Great piece Rich. Picking LaVia was clearly a huge mistake, and probably one that should have been foreseen. Since the GOP made the inevitable comparison to Quincy, I just want to say that the cover up of the Quincy outbreak is what really made ,e mad. The governors office telling staff at the home not to tell families about the outbreak was the really inexcusable part. You can learn from mistakes and do better, it’s hard to get past a simple disregard for life. Rauner’ s administration simply didn’t care, they were just worried about how it looked.

  6. - Lucky Pierre - Monday, May 3, 21 @ 12:20 pm:

    The failure was not just hiring her, it was also a failure to over see her, especially given JB’s partisan rhetoric about the deaths at the Quincy home being the previous Governor’s fault

  7. - Oswego Willy - Monday, May 3, 21 @ 12:28 pm:

    === given JB’s partisan rhetoric about the deaths at the Quincy home being the previous Governor’s fault===

    That’s an odd take for you.

    You’re *now* saying the Legionaries deaths are now Rauner’s fault?

  8. - Hahaha - Monday, May 3, 21 @ 12:52 pm:

    Oswego Willy - if you read today’s subscriber post, you would understand that Rich also thinks he hasn’t taken full responsibility. Would you like to take your reading comprehension jab at Mr. Miller too?

  9. - Lucky Pierre - Monday, May 3, 21 @ 12:54 pm:

    The odd take is JB’s not mine especially with 36 deaths on his watch at the Veteran’s home.

    Twitter is forever

    “After fatally mismanaging the Quincy Veterans’ Home, @BruceRauner is letting persistent health issues jeopardize the wellbeing of our nation’s heroes,” Pritzker said in a March 30 tweet. “This is a shameful display of failed leadership.”

    JB blamed the previous Governor for 13 deaths Quincy and an outbreak of a stomach virus

    Fact-Check: Facts Bug New Pritzker Attack Line on Quincy Veterans’ Home
    Democrat JB Pritzker is quick to blame rival Gov. Bruce Rauner for new health problems at the state facility for retired veterans. But the stomach virus is very different and harder to prevent than Legionnaires’ disease, which has killed 13 residents since 2015.

  10. - PublicServant - Monday, May 3, 21 @ 12:57 pm:

    Agree with Perrid, and Hackler is appropriately named. Pritzker owned up to it, while Rauner was busy sweeping his bungle under the rug, but then that was his style in the nursing home industry too, so no surprise there.

  11. - Oswego Willy - Monday, May 3, 21 @ 1:05 pm:

    === JB blamed the previous Governor for 13 deaths Quincy and an outbreak of a stomach virus

    Fact-Check: Facts Bug New Pritzker Attack Line on Quincy Veterans’ Home===

    Governors own. They always do.

    Again, Bruce Rauner all but quit, couldn’t find a soul to run in his place and *still* you defend Bruce Rauner compared to any ownership governors have.

    Like I said.

    So odd.

    Partisan odd.

    Governors own.

  12. - Oswego Willy - Monday, May 3, 21 @ 1:08 pm:

    - Hahaha -

    Sharing subscriber information is a real no-no.

    Can’t I not disagree?

    Further, the Chapa LaVia ownership as a real mistake and the release of the report, its scathing and points directly at the administration.

    Has the governor disavowed the report?

  13. - Jibba - Monday, May 3, 21 @ 1:09 pm:

    JB was never a politician nor an administrator of a large organization. Sometimes it is costly to learn on the job, but he better learn from this.

  14. - Oswego Willy - Monday, May 3, 21 @ 1:14 pm:

    - Hahaha -

    Last point I forgot;

    I don’t recall absolving the governor, or in any way fine with the tragedy.

    I specifically wrote..,

    === - Oswego Willy - Friday, Apr 30, 21 @ 10:04 am

    Personnel IS policy.

    Choosing an inept legislator after, arguably, the worst “to date” case of incompetence at Quincy’s Home, the lingering and how long Chapa La Via was *still* in her role, that is devastating to those families and those veterans.

    To the CoS who seemed to be saddled with so much because of a lazy and purposely aloof Director, the reality is simple; if personnel is policy, and I believe that to my “political core”, I look at both Chapa LaVia and others who had to have known of Chapa LaVia’s dereliction of duty AND that the people attempting to make up for it were also grossly inadequate. That’s it.

    If governors own, and I believe that too to my “political core”, then Chapa LaVia and her continued presence while not being anything close to a leader or competent, it can’t be brushed aside that the buck stops with Chapa LaVia===

    I can wholly agree with Rich, in fact anyone, or I can see recent quotes stronger or weaker than others too.

    But… this governor owns this, his choices of personnel, mea culpa accepted or acceptable… that’s not changing in my eyes.

  15. - Publius - Monday, May 3, 21 @ 1:22 pm:

    Going forward we all have to be carefull of what Jibba just said. Running a goverment is something that requires a lot of experience. That is something that Rauner, Pritzker, and Trump didn’t have. We will see what happends with Pritzker. So far as President Biden has done well based on this test but he has had lots of experience. This just goes to show it can’t all be about personality and scoring points. You actually have something to run and be able to pick good administrators/managers.

  16. - Dutch - Monday, May 3, 21 @ 1:33 pm:

    I don’t understand why the Chief of Staff Kolbeck is being forced to resign now?

  17. - Merica - Monday, May 3, 21 @ 1:49 pm:

    This is very interesting and a very good dive into these circumstances. i am sure that these decisions had a large impact on bad policy making at a high level.

    Also of note:

    Since the EEC implemented the electronic procurement system, BidBuy, agencies have been unable to purchase the goods and services they need to operate. the primary problem is that this electronic procurement system is very difficult for state users and vendors, to use. it is extremely complicated and will often take a year or even two to learn.

    CMS personnel and the Special Master have brought hiring to a halt. Exempt positions must now go through the full rutan process and may take 6mo or a year to fill. CMS compliance has stopped agencies from doing PSC’s, so valuable employees who retire are now gone after 75 days, their knowledge is never replaced.

    This is not to give a pass to bad decisions at the top, only to say that just because the lights are on doesn’t mean things are working. In fact, the light are on and always on because the state didn’t build a switch to turn them off

  18. - Lucky Pierre - Monday, May 3, 21 @ 1:56 pm:

    There are some other similarities too

    Governing is harder than an administration self promoting through twitter

  19. - The Dude - Tuesday, May 4, 21 @ 5:48 am:

    The actual investigation left so much out.

    Like state agencies that should have been involved but because they were moving office locations were very hands off.

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