Watchdog report details large-scale mismanagement of COVID-19 outbreak at LaSalle VA home where 36 veterans died

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."

Some staff members were left to learn of the outbreak only from their co-workers, while others learned it from the news. In addition, workers were not required to wear masks until after they entered the facility, veterans who tested positive shared space with those who tested negative and temperature checks of workers were sporadic, the report found.

"It appears that many staff at the home continued to treat COVID-19 like the flu and did not comply with more rigorous protocols, like face masks," the report said, citing more stringent public health and federal Centers for Disease Control and Prevention guidance in the pandemic's earlier stages.

"The home's leadership failed to effectively communicate, train and educate its employees on the dangers of COVID-19 and the precautions required to monitor and control the virus within the home," it said. "As a result, some staff members were unaware of general infection control directives, contributing to a culture of noncompliance."

At issue is the state's response to an outbreak that began Nov. 1, when the state VA was notified that two veterans and two employees at LaSalle had tested positive for COVID-19. Within a week, 60 veterans and 43 staff members tested positive. Eventually, a total of 36 veterans died.

The report was ordered by Gov. J.B. Pritzker, who had been critical of Republican Gov. Bruce Rauner's handling of what had been annual Legionnaires' disease outbreaks at the Quincy Veterans Home that led to the deaths of 14 veterans.

On April 1, Pritzker appointed Terry Prince, a 31-year Navy veteran who was superintendent of the Ohio Veterans Homes, as acting Veterans Affairs director to replace Chapa LaVia.

Lawmakers have asked the state's auditor general's office to look into the LaSalle Veterans Home outbreak, as it did following the Quincy Legionnaires' outbreaks.

Republicans have been critical that it took more than 10 days for the state Department of Public Health to visit the LaSalle home after the outbreak began. The report also notes that no one in the VA's top leadership went to LaSalle until December, when Kolbeck he delivered the news Mehlbrech, the home's administrator, had been terminated.

The March 2019 Quincy audit recommended the public health department develop a policy for when on-site visits should occur, and the inspector general's report cites a May 2019 consultant's recommendation for a standardized infection control management program at veterans homes that was not adopted at LaSalle.

The report twice praises the LaSalle home's staff for their "dedication and care for veterans amid the pandemic's demanding conditions," but it faults "inadequate leadership and structure" within the home and the Veterans Affairs agency.

The report notes that the lack of infections at the LaSalle home from March through October of last year provided plenty of time for its management to develop plans, protocols and training to deal with the pandemic, particularly knowing COVID-19 s effects on the elderly in congregate settings. Nonetheless, "the management team and staff did not anticipate and were not prepared for an outbreak."

"The lack of a comprehensive COVID-19 plan, including the absence of any standard operating procedures in the event of an outbreak within the home, was a significant contributing factor to the home's failure to contain the virus," the report said.

"The risks concerning transmission and control of COVID-19 were well known by October 2020, yet the home lacked any formal preparedness and response plan. Moreover, the rising positivity rates within LaSalle County should have alerted the (home's) management team to the emerging urgency for infection control at the home," it said.

"Despite this forewarning in the community, the home was complacent and did not develop comprehensive COVID-19 policies," it said. "With no documented COVID-19 specific policies or outbreak plan, the home's staff were confused on the appropriate course of action throughout the outbreak, and thus, its operations were inefficient, reactive, and chaotic."

The report said the LaSalle home initially instituted a 14-day quarantine policy for veterans who left the home for nearby hospitals visits, but that rule had been relaxed because such visits were determined to be low risk.

"Several nurses noted that the first positive tests within the home were veterans and accompanying staff members who had recently returned from a visit to St. Margaret's Hospital (near LaSalle) without quarantining," the report said.

Prince, the acting Veterans Affairs director, said steps had been taken to improve management, training and communication at the veterans homes before he accepted the post earlier this month, including plans to restructure the agency's senior leadership and the hiring of more people to keep workers from trying to fill multiple roles.

Vowing to adopt a more hands-on style than his predecessor, Prince said he would prioritize infection control, including the establishment of an infection control committee and an "infection preventionist" at each home, as well as an infection control director to oversee those positions. Prince also said he would be establishing quality of care committees to review veterans care at the homes.

Prince said he wants those looking at the LaSalle report to note changes that have already taken place in management and practices while the inspector general's investigation was going on.

"The good news is we don't have to start from scratch. I was brought into this position, I feel, to accelerate the progress," he said. "The state, the governor and his team have done a lot to get these things in place."

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