Correction: This story has been corrected and clarified. Veterans were unable to get immediate access to donated name-brand toiletries due to a process that has since been changed, but the Illinois Department of Veterans' Affairs says residents never went without basic personal care supplies if they ran out.
The Coronavirus outbreak at the state-run LaSalle Veterans’ Home claimed a 36th life earlier this week, though the spread within the home has been in control for weeks after infecting 90% of residents and killing more than a quarter of the facility’s population.
But during the deadliest days of the outbreak in November, some residents were not able to get access to donated toiletries due to an antiquated policy that’s been changed in recent weeks. The old policy meant that residents at the facility would have to wait up to a week for access to donated supplies of name-brand shampoo, toothpaste or other personal care items ran out.
While veterans never went without basic supplies as the facility buys personal care items in bulk, most residents have preferred brands of various toiletries. While the home had a stock of donated name-brand items for veterans, not all veterans were eligible to receive them.
In late December, the home changed its policy after pressure from the local Veterans’ Assistance Commission, which had organized a toiletry drive in November during the height of the outbreak. But the group later found out that the personal care items that had been donated were not being distributed to everyone.
The old policy predated Illinois Department of Veterans’ Affairs Director Linda Chapa LaVia, but local VAC Superintendent Steven Kreitzer says she should have stepped in to change it sooner, especially as his and other VACs organized a massive toiletry drive as the COVID-19 outbreak raged through the home.
“[Nursing staff] were trying to take care of [residents] as best as possible but these policies kept happening even though we were trying to sound the alarm,” Kreitzer said.
Kreitzer said that he and the VAC were told by nursing staff that they were personally buying toiletry items for veterans in order to get around the process. The old policy mandated that when a veteran ran out of a personal care item like toothpaste or shampoo, nursing staff would have to fill out a request form and send it to the facility’s social services division. That staff would then have to contact the veteran’s family to ask if they were willing to buy the resident what was needed. Only if the family was unable to do so would a resident be able to receive one of the donated toiletry items.
IDVA spokeswoman Bridget Dooley said the issue has been resolved, and acknowledged the previous policy “was problematic and didn’t do what it was supposed to do.” In an open letter from Kreitzer dated Dec. 21, he said nursing staff indicated the policy was to deter theft of the toiletries by those working at the home.
"At no point during the pandemic or any other time has a veteran in one of our homes not had access to soap, toothpaste, or any other basic hygiene product," Dooley said. "Those items are provided to all veterans in our homes, free of charge, on a regular basis, 24 hours a day. The donation process is used for specialty items that veterans request beyond the standard products they are provided."
But the bureaucratic process meant accessing the donated supplies could take days. An email provided to NPR Illinois from the nursing staff's union representative dated Dec. 16 said the union rep — who is not a nurse but represents the bargaining unit for the home — understood from his nursing colleagues that the process took "days to a week when they really need the supplies at the moment they request them."
"If we have the donated supplies on hand then there should be no need for the veterans to have to wait or possibly go without during their time of need," the union representative wrote. "As I also understand it, if the need is realized on an off shift (2nd or 3rd) they may have wait till the next day for their request to be received, and unlikely to get items on the weekends."
Renewed call for IDVA director's resignation
The LaSalle VAC joined 14 other county VACs earlier this week calling on Chapa LaVia to resign after 35 residents at the LaSalle facility had died. On Friday, the facility reported a 36th death.
Lake County VAC Supervisor Andrew Tangen sent the letter Monday to high-level staff in Gov. JB Pritzker’s office. Though the Pritzker administration fired the home’s former administrator in early December and put its head of nursing on leave, each time the governor has been asked about Chapa LaVia’s future with the agency, Pritzker has said he’s waiting on the conclusion of an investigation by the Department of Human Services’ inspector general, which was launched in November.
But Tangen said there’s enough evidence to ask Chapa LaVia to resign, given both preliminary reports made public before the first Senate hearing on the matter in November, and what’s been uncovered since.
“This is absolutely not something that we wanted to do,” Tangen said. “We didn’t call for her resignation on Nov. 15, we didn’t call for it Dec. 1, we didn’t call for it right before Christmas. It took two months…we have said over and over and over again, ‘Whatever you need, whatever help you need — tell us.’ And nothing.’”
Tangen cited the IDVA’s failure to hire a senior homes administrator after the last one retired in the fall of 2019. That person is supposed to oversee the homes, and while IDVA’s spokeswoman said the previous administrator has stayed on in a contract position, Tangen said it’s baffling why the agency would not have moved to hire a person with a medical background into the empty position sooner, especially given IDVA’s historic mishandling of the Legionnaires’ Outbreak at the Quincy Veterans’ Home in 2015 that killed 13 residents.
“Knowing what happened with Quincy, the moment the pandemic started I would’ve filled that position to make sure that all five of those homes were adequately supervised and the chief of staff, who was put in charge of the homes, could actually do the chief of staff job.”
Quincy has suffered its own smaller COVID-19 outbreak beginning in November. On Friday, IDVA reported 17 veterans have died — five more than its most recent prior report on Wednesday.
The retired senior homes administrator did not have a medical background either, but Dooley confirmed the agency is searching for a candidate with a medical background. An email obtained through the Freedom of Information Act shows Chapa LaVia asking the director of the Hines VA Hospital in Chicago for recommendations for the job on Nov. 22 in response to an email from Hines VA Hospital Director James Doelling.’
Doelling wrote to Chapa LaVia that he had just learned the future state-run veterans’ homes in Chicago “may be assigned,” which he noted would make Hines “the only VA with three [state veterans’ homes] to provide oversight to.”
Doelling said he believed it would “be a great partnership, but was also checking to see” if Chapa LaVia could forward him information about the senior homes administrator position. At that point during the LaSalle outbreak, 27 residents had already died.
During the first public hearing on the LaSalle outbreak in November, committee members were outraged over reports from both the Illinois Department of Public Health and the U.S. Department of Veterans’ Affairs based on site visits to the LaSalle home. Among other findings, the agency found employees not wearing masks or social distancing in staff areas of the home, and reported non-alcoholic hand sanitizer was being used — which has not been approved to kill the COVID virus.
Tangen said the hand sanitizer issue — along with the donated toiletry debacle — is emblematic of the mismanagement of the home, and said as a fellow military veteran, Chapa LaVia should have both controlled the situation sooner and have taken more responsibility and been willing to appear publicly in front of reporters.
“We are taught [in the military] how to lead and take charge of situation that is going sideways,” Tangen said. “No incident command was set up or appears to have been set up. Director Chapa LaVia has not once held a press conference…the only appliances she has made is has been the Senate committee and the House committee. To us, that feels like a failure to lead. And it feels like there is a leadership failure at the IDVA that caused this outbreak to happen.”
House judiciary committee to hear from IDVA
The House Judiciary - Civil Committee will hold its own hearing on the LaSalle outbreak on Monday. In early December, that committee's chairman, State Rep. Andre Thapedi (D-Chicago) opened a rare judicary investigation into the matter, requesting internal documents from IDVA about the outbreak. Thapedi said the agency "has not been very forthcoming" with the information.
"The only reason why we teed up a hearing — I was really hoping that I would not have to tee up a hearing," Thapedi said. I was hoping that they would be forthcoming with the information.”
Thapedi expressed shock when told that veterans had trouble accessing basic personal care items during the outbreak, and said he hoped to investigate the matter in committee. But the committee is organized under the 101st General Assembly, which will end on Wednesday when the 102nd General Assembly is sworn in.
With embattled House Speaker Mike Madigan (D-Chicago) unable to put together the necessary 60 votes to be re-elected speaker for a historic 19th term, the House cannot conduct any other business until another speaker is chosen, which could take days or even weeks.
But Thapedi said he hoped to continue the investigation into the 102nd General Assembly.