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Devastating report released on LaSalle Veterans’ Home

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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.”

* WUIS…

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.

posted by Rich Miller
Friday, Apr 30, 21 @ 9:42 am

Comments

Is it me or does Anthony Kolbeck look like a sacrificial lamb. I feel sorry for the guy, seemed like he wanted to, tried to do the right thing but was in over his head and had no support from the top. I’ve seen this happen time and time again but please tell me if I’m misinterpreting things.

Comment by DTAG Friday, Apr 30, 21 @ 9:47 am
Chapa LaVia’s pension should be revoked. At minimum, taxpayers should NOT pay the higher level that she likely expects for holding a higher paying job she never took seriously. All of this is unforgivable.

Comment by Seal610 Friday, Apr 30, 21 @ 9:50 am
DTAG, sure looks that way to me. The key to a floundering executive’s culpability is their proactiveness in admitting their failings and trying to get help when they know they are in too deep. Some well-meaning leaders try to keep it inside and pretend they can handle things. Some not-so-well meaning leaders try to cover things up and hope it blows over before anything bad happens.

Comment by Six Degrees of Separation Friday, Apr 30, 21 @ 9:53 am
This is what happens when the State manages care, complicates the process to the point common sense is removed and reduces funding compared to other states. Perhaps the state should allow private sector providers to have a chance to make this right?

Comment by Julie Friday, Apr 30, 21 @ 10:00 am
John Anthony stated: “the Director’s position should have been a full-time job, not half-time.”

Comment by Put the fun in unfunded Friday, Apr 30, 21 @ 10:00 am
Many director’s can pull off the absentee role…leaving day-to-day management to skilled deputies and spending time raising awareness of the agency and engaging stakeholders (which is an important function that our agencies struggle with). Unfortunately for Director Chapa LaVia, you can’t pull that off with IDVA…especially after Quincy. I seriously can’t understand what the administration was thinking with that appointment, other than the fact that it would be an easy Senate confirmation.

Comment by NIU Grad Friday, Apr 30, 21 @ 10:00 am
Chapa La Cuomo. NO defending a person who never cared from Jump St. Misplaced trust to the Nth Degree.
JB needs to sincerely apologize for this gallactically poor decision.

Comment by A Guy Friday, Apr 30, 21 @ 10:01 am
=Director Linda Chapa LaVia “abdicated” her responsibilities, leaving things to a nonmedical chief of staff who preferred to let each home manage itself=

Those who died were heroes, these veterans sacrificed to defend our freedoms and deserved to have the best care in their senior years. Makes my blood boil that Chapa LaVia, a political appointee and army veteran, ould be so heartless.

Comment by Donnie Elgin Friday, Apr 30, 21 @ 10:03 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.

All that said…

How can you not be angered, hurt, how can you not feel anguish for those who had to endure such reckless leadership and who failed those most in need of competence for the essential idea of keeping healthy the residents, and the staff too.

I really don’t know what more can be said or gleaned from the report, except for the important details and the necessary recognition that the victims aren’t just names on a list, these were people that should not be forgotten and what happened should not be glossed over in hopes it will be forgotten.

Comment by Oswego Willy Friday, Apr 30, 21 @ 10:04 am
whoever Chapa Latvia reported to should explain the process and what went wrong.

The buck doesn’t stop with her

Comment by Lucky Pierre Friday, Apr 30, 21 @ 10:06 am
The report begs the question of why the state is in the “business” of running these homes itself rather than helping indigent veterans pay for professional nursing care.

Comment by striketoo Friday, Apr 30, 21 @ 10:11 am
In agreement Seal610 with regard to the pension. She was not qualified to run this massive, bureaucratic agency in the first place due to her lack of management, decision-making, and medical experience. Moreover, Mr. Kolbeck shouldn’t have had to run the agency while juggling three roles.

Lastly, it shouldn’t be a question if she
can get the questions beforehand by the IG, it should have been demanded that she participate in the inquiry as she was after all the agency “head.”

Comment by Pizza Man Friday, Apr 30, 21 @ 10:13 am
So the staff does not follow CDC guidelines about wearing masks and attends events outside the home, then brings the COVID virus to the Vets home and they Exec Director is to blame for everything. I get why the she got some of the blame. How many employees refuse to get vaccinated. I’d put them on unpaid leave. I am so tired of the anti-vax crowd that have government jobs. They want my tax dollars to support their salary, then pension, but refuse to follow the science. Makes me sick.

Comment by Suburban Dad Friday, Apr 30, 21 @ 10:13 am
So tragic. There are some jobs that, even in Illinois, should be filled by credentialed experienced professionals rather than by political appointees who are being rewarded for something. Veterans Affairs and DCFS come to mind. How many lawsuits will this report spawn? The grieving families must be somewhat relieved to know that what they already knew or guessed about their loved ones’ care has finally been made public. Looks like this sorry episode falls at the feet of Chapa LaVia but it is a blot on the governor’s leadership and on the whole state.

Comment by Responsa Friday, Apr 30, 21 @ 10:21 am
Just wondering which JB Dep Gov was assigned to this one? Before or after they blocked the hiring of the assistant director?

Comment by Annonin' Friday, Apr 30, 21 @ 10:24 am
Just because they were elected to office doesn’t mean they know what they’re doing and aren’t lazy.

Comment by Frank talks Friday, Apr 30, 21 @ 10:25 am
Let’s expand state government’s reach and continue to punish the private sector in the name of equity and fairness

Comment by Lucky Pierre Friday, Apr 30, 21 @ 10:33 am
Deputy governors always quiet after bad news but first to attach their name to any success.
Makes the Sullivan resignation even more ridiculous.
In the end Pritzker owns this, but a complete failure on Pritzkers cabinet from top to bottom.

Comment by Almost the weekend Friday, Apr 30, 21 @ 10:37 am
=== Makes the Sullivan resignation even more ridiculous.===

It’s glaring now, the choices, and a real reminder, again, personnel is policy… and the policy between Sullivan and Chapa LaVia… “choices”

Comment by Oswego Willy Friday, Apr 30, 21 @ 10:44 am
“The Buck stops here” as President Truman famously said…this is the governor’s first failure and he/his office delayed for many months the removal of the agency director for either political reasons or to contain the storm.

Comment by Pizza Man Friday, Apr 30, 21 @ 10:45 am
Lucky Pierre nailed it. Seems like the goal is to firewall the political fallout.

If Chapa LaVia was so glaringly bad, why didn’t the Deputy Governor, Chief of Staff or IDPH notice?

I look forward to reading the full report, including the Inspector’s explanation of the role that the Halloween party and the delayed response from IDPH played.

Comment by Juvenal Friday, Apr 30, 21 @ 10:59 am
I just read the report and I think those news stories above are a little too generous about Mr. Kolbeck’s leadership, as it seemed that the excessive responsibilities under his office was a problem of his own making. As the report noted, he could have transferred the Home Administrator position search to the HR director. It seemed like he only trusted himself to take on all of these duties. He also seemed to be late to realizing that there was a problem.

Also, I can’t figure out why the Assistant Director position even exists. The only direct report is a secretary.

Comment by NIU Grad Friday, Apr 30, 21 @ 11:14 am
=== a little too generous about Mr. Kolbeck’s leadership, as it seemed that the excessive responsibilities under his office was a problem of his own making. As the report noted, he could have transferred the Home Administrator position search to the HR director. It seemed like he only trusted himself to take on all of these duties===

No.

Those type of leadership duties and responsibilities fall upon the director of the agency, who seemingly was either grossly inept or not “engaged” in what the job entailed (it can be both)

This idea that Kolbeck lacked leadership… Kolbeck could be in over his head, and has blame on him… the director, Chapa LaVia, at ANY time could’ve stepped in and overrode any and all decisions.

That’s a more fair look, and still not giving Kolbeck any cover or shelter for his decisions

Comment by Oswego Willy Friday, Apr 30, 21 @ 11:19 am
I’m not feeling the sympathy for Kolbeck. He wanted the big job, if he wasn’t getting the support he needed it was his job to make that known to higher ups or resign.

Big titles and paychecks are always fun until your incompetence gets people killed. He needs to go.

Comment by Excitable Boy Friday, Apr 30, 21 @ 11:19 am
Sadly “inefficient, reactive and chaotic” pretty much sums up Team Pritzker’s term in office.
Time for fewer press conferences, stop passing the buck and blaming other people.
These veterans, people waiting on unemployment benefits and seniors in nursing homes deserve an efficient, well managed and thoughtful administration in our Governor’s office.

Comment by Back to the Future Friday, Apr 30, 21 @ 11:26 am
I worked with Tony Kolbeck and I’ve worked with Chapa LaVia. Tony is an honest broker who does his best in all matters. Far from perfect, but a decent man. Chapa is an empty suit, unfocused, lazy and unserious. Its pretty clear who should wear the jacket here.

Comment by High Socks Friday, Apr 30, 21 @ 11:57 am
This is what happens when you put a realestate agent in charge of a major health care bureaucracy.

Why in this world or any other would you put a person who sold houses (before she was elected to the legislature) to run the IDVA? I will never understand that or peoples support for Chapa-LaVia. Interacted with her on a number of occasions professionally and always left with the feeling that she was just a bad salesperson. No substance. And now it cost people their lives.

Comment by JS Mill Friday, Apr 30, 21 @ 12:38 pm
Very tragic and preventable. I hope the State will reimburse these families and the governor issues an apology as well.

Comment by Pizza Man Friday, Apr 30, 21 @ 12:45 pm
Seems that people understand the reality. Everyone except our states leaders, who will expect Chief of Staff Kolbeck to resign and disappear without acknowledgement of his 18 years of service to the State of Illinois and unmatched military career. If IDVA is supposed to take care of those that served it seems using Kolbeck as a scape goat is a disrespect to his service and sacrifice.

Comment by WhereDoesItStop Friday, Apr 30, 21 @ 12:54 pm
I agree with a number of others familia with the situation; Kolbek doesn’t deserve to be scapegoated.

Kolbeck was one of a few at IDVA who had to step forward to fill a void left by LCL, who went MIA at the agency’s largest challenge in recent memory.

LCL should be the focus, not those that actually were left to pick up the pieces from her desertion.

Comment by Animus Friday, Apr 30, 21 @ 1:17 pm
Having read the report, I agree with Rich, it is devasting.

A few things stand out. First, the IDHS OIG did the investigation/report and hired an outside law firm, Armstrong Teasdale LLP. I thought this odd because IDVA falls under the Executive Inspector General for the Agencies of the Illinois Governor. One would reasonably think that the DHSOIG would have the expertise to investigate, but they hired a law firm to do it.

Second, CoS Kolbeck was flying blind here. He has no medical background. A key position has been vacant for nearly two years–the Senior Homes Administrator. On page 32, the report states that,

>>>”Mr. Kolbeck stated that the Senior Homes Administrator position requires approval from the Governor’s Office, so while the IDVA conducted several rounds of interviews and selected a candidate in late 2019, Mr. Kolbeck stated the Governor’s Office did not approve that candidate.”

Comment by Fmr Accountant Friday, Apr 30, 21 @ 1:54 pm
- honest broker who does his best in all matters. -

Honesty and work ethic are commendable, but they aren’t substitutes for competency.

Comment by Excitable Boy Friday, Apr 30, 21 @ 2:03 pm
My question is, how much is this going to cost the state? It seems that with this report, IDVA would be liable for the residents, staff and families of the staff that contracted Covid.

Comment by Realist Friday, Apr 30, 21 @ 2:22 pm
The COS was nothing but a micro manager that was puppetering the director. As he has with the whole upper echelon. His tyrannical rule is over. I applaud his service, but despise his managerial skills. He is not a scapegoat, what is being done fits the bill… he had every opportunity to correct the issues, but he was so busy trying to be the king of his domain that it came crashing down on him, because of him.

No remorse for him resigning.

Comment by Anon1sthand Friday, Apr 30, 21 @ 3:27 pm