Illinois health officials say state VA misled them
They make claim in testimony over LaSalle outbreak
Illinois’ public health director and Gov. J.B. Pritzker’s deputy in charge of health care said Thursday they were misled by top state veterans affairs officials when told COVID-19 procedures were being followed that could have slowed or prevented a deadly outbreak at the LaSalle Veterans Home in November.
“We believed the home was following all the recommended protocols and that the appropriate steps were being taken to address the cases,” Illinois public health Director Dr. Ngozi Ezike said during an Illinois House hearing over a scathing inspector general’s report on the outbreak.
“These tragic deaths, they are extremely frustrating to accept because there were some basic steps that, if taken, could have made a difference,” Ezike said.
Deputy Gov. Sol Flores said VA officials showed no urgency in selecting a senior administrator to oversee health care practices at the state’s veterans homes — a post that has been vacant since the fall of 2019, a year before the outbreak.
The highly critical April 30 report from the Illinois Department of Human Services’ Office of the Inspector General cited management lapses from the top of the state Department of Veterans Affairs down to staff at the LaSalle home.
In all, 36 residents died of COVID-19, and hundreds of residents and staff were sickened. Relatives of the dead veterans have filed lawsuits against the state as a result of the report’s findings.
“I was not aware that polices and protocols were not being followed. We were told that they were being followed,” Flores said at Thursday’s hearing.
To families affected by the outbreak, Flores said, “I also share your rage at the loss of life at LaSalle. What I was told was happening there is a far cry from the circumstances set forth in the IG’s report.”
The responses from Ezike and Flores were in line with findings from the inspector general’s report, which was critical of former state VA
Director Linda Chapa LaVia, who resigned in December, for delegating her job duties to subordinates.
Chapa Lavia’s chief of staff, Anthony Kolbeck, who had no medical background, provided the home with inconsistent advice, let homes run their own management and did not seek outside assistance to deal with the outbreak, the IG found. He resigned following the release of the report.
“IDVA leadership routinely assured me of their compliance with (Centers for Disease Control and Prevention) and (Illinois Department of Public Health) policies and guidelines,” Flores said. “To say the least, the IG report shows that this was not always the case.”
The hearing represented some Republican payback to criticism leveled by Democrats, including Pritzker during his run for governor, over the bungled handling of repeated outbreaks of Legionnaires’ disease at the Quincy Veterans Home, where 14 veterans died, under former GOP Gov. Bruce Rauner.
Republicans contended the interagency agreement that led to the inspector general’s report showed it was less than a full examination of the LaSalle incident because it exempted questioning of Pritzker’s office and its knowledge or involvement in dealing with the outbreak.
Asked by Republicans what grade Flores would give Pritzker and his administration’s handling of the LaSalle outbreak, she said she would give management of the home an “F,” but would not grade herself or the administration.
“I can’t speak to that right now,” Flores said. “What I can speak to is that we are working to correct and fix everything that went wrong at LaSalle.”
That prompted Republican
state Rep. Deanne Mazzochi of Elmhurst to say, “To me, a good leader doesn’t assume things are happening. A good leader actually checks to make sure that things are happening. For you to just sit there and say, ‘Oh, well, I just assumed things were happening,’ that’s a failure of leadership. I’m sorry.”
Mazzochi also noted that on Nov. 11, Pritzker appeared at a ribbon-cutting for a new veterans home in Chicago where he touted the success of the agency in combating COVID-19 in veterans homes despite what was happening at LaSalle.
“We’ve worked very hard. Our veterans homes really have done an outstanding job of keeping our veterans safe. But you can’t 100% keep everybody safe in this environment” when local officials aren’t enforcing mitigations, Pritzker said at the ribbon-cutting.
That was a day before the state public health department and the federal Veterans Affairs sent an on-site team to LaSalle, where they found lapses in protocols and the use of non-alcohol based hand sanitizer as well as staff congregating without masks.
By Nov. 9, two days before Pritzker’s statement, the home had more than 60 positive cases, and by Nov. 13, two days after his statement, 10 veterans had died.
“How could you let him make that statement with a straight face … given the nature of the briefing that you gave him internally on Nov. 9?” Mazzochi asked after Flores said she briefed Pritzker of the intensifying outbreak.
“We didn’t understand the full scope of what was happening until after Nov. 10,” Flores replied.
But she also said Pritzker had ordered the public health agency be “immediately” deployed to LaSalle on Nov. 9. They arrived three days later.
Much of the initial questioning focused on the report’s findings that the veterans agency lacked a senior administrator with health care oversight over the veterans homes, particularly during a pandemic.
Flores said one person who met the qualifications was later rejected by the governor’s office after a review of social media found “disparaging remarks” about people receiving welfare benefits and “remarks that were viewed as racist.”
“We counted on our director and the chief of staff to work with Central Management
Services (the state’s personnel agency) to identify candidates and bring them forward,” Flores said.
The inspector general’s report also touched on a lack of action by the state’s public health department, despite having agreed with a March 2019 auditor general’s recommendation to establish time frames “adequate to conduct on-site monitoring visits in response to a confirmed disease outbreak.”
The LaSalle outbreak began Nov. 1, when two residents and two staff were confirmed positive for COVID-19. Though it was receiving regular updates on the outbreak, IDPH didn’t enter the facility until Nov. 12, joined by the federal VA officials.
Kolbeck, the chief of staff at the state’s veterans agency, acknowledged he didn’t recognize the problem until Nov. 9 or Nov. 10, the report said.
Though Kolbeck reported numbers of cases to the health department, “he assumed that IDPH would reach out if it thought there was a problem. IDPH, on the other hand, expected the IDVA to identify if it had a problem and to use IDPH as a resource,” the report said.
Rep. David Welter, a Republican from Morris, noted that the public health department was being updated regularly by the VA on the growing outbreak, but “IDPH, it’d be fair to say, just from what I’m seeing here, kind of sat on the sidelines.”
“They’re watching the situation. They’re seeing what’s going on, but they’re not taking direct action at that time as the situation was growing more and more,” he said.
Ezike defended the public health staff, saying “my team has been stretched to limits that they’ve never been stretched before.”
As for a delay in sending a public health team on site to LaSalle, Ezike said the health guidance at the time for congregate settings with elderly residents was to limit exposure from outside people.
She said in hindsight, “We would have wanted to do more if we knew that the information that we were getting and the protocols that we were told were being adhered to were not being fully followed.”
“These tragic deaths, they are extremely frustrating to accept because there were some basic steps that, if taken, could have made a difference.” — Illinois public health Director Dr. Ngozi Ezike