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Investigation Of Deadly COVID Outbreak Found State-Run Vets Home ‘Inefficient, Reactive…Chaotic’

Illinois Department of Veterans' Affairs

“Lack of COVID-19 preparation,” paired with “failures in communication” both in and outside of the state-run LaSalle Veterans Home contributed to a major COVID-19 outbreak that killed 36 residents at the facility and infected dozens more, according to a report published by Gov. JB Pritzker’s administration Friday.

Read more: Facing Criticismm Over Scathing Report On Veterans' COVID Deaths, Pritzker Says He Regrets Hire

The investigation revealed missed opportunities and warning signs that could have stemmed the severity of November’s outbreak or even prevented it altogether. The report concluded individuals and policies — or lack thereof — in both the LaSalle home and at the Illinois Department of Veterans’ Affairs, which runs the facility, resulted in a COVID response that was “inefficient, reactive and chaotic,” the report said.

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. 

Read more: As 34th Resident Dies After LaSalle Veterans’ Home COVID-19 Outbreak, Families Prepare To Sue

“There is nothing more critical to our department’s mission than ensuring the heroes in our homes are safe and receive the quality care they deserve,” Acting Director Terry Prince said in a statement accompanying the report’s release Friday.

Organizational failures

The COVID outbreak at LaSalle, and smaller outbreaks at the IDVA’s homes in Manteno and Quincy, present a challenge to Pritzker. In 2018, he waged a campaign against former Republican Gov. Bruce Rauner partially on the message that the venture capitalist-turned-politician failed in his handling of the Legionnaires’ disease outbreak at the Quincy facility in 2015, which killed 13 residents and sickened many more.

Within days of being sworn in, Pritzker requested a “complete review of the health, safety, and security process,” at the state’s four veterans’ homes via executive order. The resulting external audit made nearly two-dozen suggestions for improving health and safety at the facilities. But according to Friday’s report, many recommended fixes, including updating and standardizing infection control policies across the four homes, were never made.

Read more: LaSalle Veterans’ Home Administrator Fired After 32 Residents Dead From COVID-19 Outbreak

Pritzker announced the investigation into the LaSalle home’s COVID crisis in November, the same day IDVA published preliminary reports from the Illinois Department of Public Health and U.S. Department of Veterans Affairs, which both made site visits a couple weeks into the fast-moving outbreak. Those initial findings included attention-grabbing details like the use of alcohol-free hand sanitizer, which is less effective against the coronavirus, and an unsubstantiated claim that staff members allegedly attended a Halloween party together a day before the first four cases among residents and staff were reported at the home.

The investigation, which was conducted by the state’s Department of Human Services’ inspector general with help from St. Louis-based law firm Armstrong Teasdale LLP, found no evidence a Halloween party was a “material contributor” to the outbreak, and could not find a single entity to blame for the hand sanitizer debacle. Instead, the report said the sanitizer issue was “emblematic of larger communication and organizational failures” at the LaSalle Home.

IDVA’s core organizational structure appeared to cause problems from the beginning. Investigators said job responsibilities “are not evenly distributed, and there are few, if any, checks on decision-making.” Nowhere is that more clear than in the upside-down relationship between Chapa LaVia — who served 16 years in the Illinois House before being tapped as Pritzker’s second choice to head the agency — and her chief of staff.

Assistant Director Anthony Vaughn told investigators it seemed as if Chapa LaVia had “abdicated” her authority to Kolbeck, on whom much of the investigation centers. Chapa LaVia declined to sit for an interview for the report, according to a footnote, as she asked to be provided with questions beforehand. Investigators told her they could not treat her differently from the 29 other people who agreed to be interviewed.

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.

For a team fighting a deadly pandemic, investigators noted the IDVA had a dearth of staffers with actual experience in nursing homes, health care or the medical field at large. The report says the vacant senior homes administrator job “would ideally meet that need,” but repeatedly pointed out it had not been filled in two years since the last one retired in the early months of Pritzker’s term.

Investigators point the finger at Kolbeck for failing to hire for that job, but mentioned one attempt at hiring was made in late 2019, but Pritzker’s office “did not approve that candidate.” The job was re-posted, but Kolbeck’s hands were too full to conduct interviews at the beginning of the pandemic. 

“Mr. Kolbeck acknowledged that it ‘absolutely’ would have been beneficial to have a Senior Homes Administrator with a clinical background during the pandemic, but it was not a priority to IDVA officials at the time,” the report said. “Ultimately, Mr. Kolbeck could have delegated this hiring process to others, such as the Human Resources Director, but elected not to do so.”

Credit Hannah Meisel/NPR Illinois
While the COVID outbreak at LaSalle didn't officially end until until early March (based on the way new cases are counted as downstream from an official first outbreak), new cases among residents and staff were few and far between after early January, ending in 109 total residents testing positive and 116 employees testing positive since November. No more residents have died since the last death on Jan. 4, where this chart ends.


Communication breakdowns

Failure or inability to delegate or ask for help wasn’t just an issue for Kolbeck. The report detailed unclear communication expectations and responsibilities at many levels in the LaSalle home. For example, the facility’s overworked infection control nurse Adam Mize was also responsible for wound care and staff education, and when contact tracing for COVID was put on his plate, one colleague told investigators Mize was “over his skis” and he “began to neglect certain responsibilities.” 

Mize was also in charge of personal protective equipment training, but could not coordinate schedules so staff could all be fit for N95 masks, which are more effective at blocking coronavirus from airways. Investigators wrote that even at the time the report was finalized, several staff members still hadn’t been fit tested for N95 masks, and some employees have never worn an N95 mask at work. 

Staff also said Mize did not interact with staff or answer questions. The same was said of the home’s former administrator, Angela Mehlbrech, who was fired in December after the death toll reached 32. By then, the outbreak had mostly been contained.

Mehlbrech allegedly holed up in her office and “rarely interacted with frontline staff.” As COVID protocols continued to evolve throughout the pandemic, investigators concluded Mehlbrech’s communication approach contributed to the facility’s “disjointed messaging,” as she preferred to provide guidance by either phone or email.

“One member of the Management Team stated that Ms. Mehlbrech would send out ‘blanket emails’ to every staff member and ‘hope for the best,’” according to the report. 

But most staff either were not provided with a work email account — a problem the new agency director says he’s already fixing — or don’t check their email accounts while on the job.

After Mehlbrech was fired, Vaughn took over the LaSalle home on an interim basis. Mehlbrech declined to sit for an interview, the report said. 

More than a week into the outbreak as veterans began to die, Mehlbeck accepted an offer from the federal department of veterans affairs to perform a site visit, and Kolbeck asked the state’s health department for a visit. But neither communicated with the other about their scheduled visits from outside entities.

The report noted that both declined numerous offers for help to the LaSalle home residents’ detriment.

“Mr. Kolbeck’s failure to appreciate the significance of the circumstances and the resources required prevented the Home from accessing them — even though these needed resources were readily available,” the report said.

Pritzker's office says the IDVA has already implemented a new policy that "will govern how and when employees will notify local and state public health departments of COVID-19 or other outbreak situations."

Read more: National Guard Staff Sent To LaSalle, Quincy Veterans’ Homes After Outbreaks

The report claims the facility had no written policies, and COVID protocols changed frequently, causing confusion — and ultimately “complacency” — among staffers as the pandemic went on.

For example, the facility’s quarantine requirement for residents returning to the home from appointments at the nearby hospital apparently relaxed at some point in the summer, and those residents were put back in their rooms. 

“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 without quarantining,” the report said. 

Lax mask wearing and self-screening were also common, made worse by no consequences, the report said. Before the outbreak, staff was only subjected to COVID tests once per week, and residents were only tested once every two weeks. That changed quickly after the outbreak began, but more than 100 staff members ended up testing positive for the virus.

Hannah covers state government and politics for Capitol News Illinois. She's been dedicated to the statehouse beat since interning at NPR Illinois in 2014, with subsequent stops at WILL-AM/FM, Law360, Capitol Fax and The Daily Line before returning to NPR Illinois in 2020 and moving to CNI in 2023.
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