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* I’m still going through the full Performance Audit of the State’s Response to the COVID-19 Outbreak at the LaSalle Veterans’ Home, but this is from the summary…
• Although the Illinois Department of Public Health (IDPH) officials were informed of the increasing positive cases almost on a daily basis by the Illinois Department of Veterans’ Affairs (IDVA) Chief of Staff, IDPH did not identify and respond to the seriousness of the outbreak. It was the IDVA Chief of Staff who ultimately had to request assistance. The IDVA Chief of Staff inquired about a site visit and about rapid tests (November 9th), and inquired about getting antibody treatments (November 11th) for LaSalle Veterans’ Home residents. From the documents reviewed, IDPH officials did not offer any advice or assistance as to how to slow the spread at the Home, offer to provide additional rapid COVID-19 tests, and were unsure of the availability of the antibody treatments for long-term care settings prior to being requested by the IDVA Chief of Staff.
• The outbreak at the LaSalle Veterans’ Home occurred at a time when COVID-19 cases were trending up statewide. Positive cases in Region 2 (where the LaSalle Home is located) increased from 12,108 in October 2020 to 37,825 in November 2020, an increase of 212.4 percent. Also, the outbreak occurred prior to the COVID-19 vaccine. Prior to the outbreak that began at the end of October 2020, only six staff members had tested positive for COVID-19. Even though the LaSalle Home had designated areas for isolation and quarantine, once the virus entered the Home, it spread very rapidly.
The administration threw IDVA chief of staff Tony Kolbeck under the bus. He appears to have gotten a bad rap on at least some of this.
* Tribune coverage…
Department of Public Health officials didn’t show up at the Lasalle home until 11 days after the outbreak began on Nov. 1, 2020, even though department leaders had been receiving near daily updates on the deteriorating situation at the home, according to Auditor General Frank Mautino’s review, which was released Thursday.
The public health department’s visit came only after top agency staff members were told that Pritzker was “very concerned” and wanted them to go to the facility, the report said.
The public health department’s failure to intervene early at the LaSalle home after the outbreak had been detected was notable, the audit said, because “all but four” of the 36 “residents who died were positive prior to” the agency’s first site visit on Nov. 12, 2020.
Mautino’s review, requested by the General Assembly, also said an inspector general’s report ordered by Pritzker and released in April of last year that blamed management failures at the Illinois Department of Veterans Affairs and the LaSalle home was too narrowly focused on that VA and was flawed because it largely excluded the public health department’s role in the crisis.
That report, from the Department of Human Services inspector general, contended the significance of the outbreak was not being meaningfully tracked by Veterans Affairs chief of staff when, “in fact, auditors found the chief of staff provided detailed information” that was used by former state Public Health Director Ngozi Ezike in her daily COVID-19 briefings, the auditor general report said. […]
Overall, the state audit points to a massive bureaucratic failure involving the administration’s response to the pandemic and the LaSalle deaths.
* From the audit…
The virus hit the Home very quickly with a large number of residents and staff positive within a few days. As a result, it was unclear whether non-adherence to policy caused the virus to spread so quickly or whether the rapid spread was due to other factors. These factors include: a rumored outside gathering of employees; a Halloween parade at the LaSalle Home; or possibly the high positivity rate during that time in the community. Auditors obtained pictures of the parade and Halloween activities from October 30, 2020, where residents and some staff were unmasked. Since the virus is invisible, and several days may pass after exposure before symptoms develop, the origin of the virus at the Home may never be determined. It is likely that the high positivity rate in the community during that time period was a significant contributor.
Emphasis added because we’re going to hear from outraged GOP legislators today who were pushing back hard against the administration’s mitigations at the time of the outbreak and up to this day.
…Adding… Rep. Welter…
Illinois House Republican Conference Chair Rep. David Welter, R-Morris, issued the following statement today in reaction to the Auditor General’s findings on the Pritzker Administration’s response to the deadly COVID-19 outbreak at the LaSalle Veterans Home in the fall of 2020 that claimed the lives of 36 of our state’s heroes:
“The Governor’s Office previously testified how the IDVA Director duped them regarding the outbreak’s severity. Today’s report from the Auditor General proves Governor Pritzker was the one who deceived us. His office had information from day one and failed to act. The Governor’s investigation into the matter was flawed, too narrowly focused, and purposely removed him and IDPH’s leadership team from scrutiny until today’s independent findings. The Governor can no longer cover up the truth, and he must be held accountable for his collapse of competence. Legislative hearings must be scheduled to determine how the administration failed so greatly in protecting our state’s heroes.”
…Adding… Irvin campaign…
Aurora Mayor Richard Irvin released the following statement in response to the Illinois Auditor General’s report published today showing that J.B. Pritzker’s team and senior leadership at the Illinois Department of Public Health were well aware, in real time, of the Covid-19 epidemic at the LaSalle Veterans Home and failed to take quick action to address the outbreak that ultimately took the lives of 36 heroes:
“As an Army veteran, it is disheartening and beyond disturbing that J.B. Pritzker and his Department of Public Health were aware of the outbreak at LaSalle and neglected to respond quickly to save the lives of 36 veterans. The governor owes the families of these American heroes an explanation and needs to be held accountable for his administration’s failure to prevent this needless tragedy.”
The outbreak occurred several months into the Covid-19 pandemic in Illinois, where safety protocols and preventative measures were to be in place at all nursing homes, hospitals and community living facilities. An initial investigation by the Office of the Inspector General found that this tragedy could have been prevented if the safety protocols were followed. Today’s Auditor General Report found that the OIG report did not go far enough in thoroughly investigating the Governor’s Office and IDPH, and only lightly touched the surface in its determination of their actions or lack thereof.
…Adding… Irvin mentions “safety protocols” in his response, but check out his answer to this newspaper question…
What is your position on mask- mandates and vaccination requirements at workplaces?
Again, I oppose such state mandates.
Not good.
* Rep. Yednock…
State Rep. Lance Yednock, D-Ottawa, who led the Legislature to request a special state audit in the aftermath of the deadly La Salle Veterans Home COVID-19 outbreak in late 2020, today issued the following statement in response to the release of the audit:
“The devastating and deadly outbreak at the La Salle Veterans Home raised so many questions, and we needed to know more. Today’s audit reveals some disappointing breakdowns in communications and protocols that very likely led to more sickness and deaths. It also underscores the terrifying speed of infection we saw at COVID-19’s peak and acknowledges even the best preparation and planning might not have been enough to prevent more infection.
I want to thank Auditor General Frank Mautino and his dedicated staff for reviewing thousands of documents and spending the time needed to talk with everyone involved and paint a clear picture of what went wrong and how we can make sure it never happens again at the La Salle Veterans Home.
I’m frustrated and disappointed there wasn’t better coordination between state agencies to recognize and address the increasingly serious infection rate at La Salle as it was happening. As the audit found, staff should have been tested more regularly, and the Illinois Department of Public Health should have moved more quickly to visit the home.
I also want to acknowledge those in charge of the home and at the Illinois Department of Veterans Affairs who, despite previous reports, did take proper precautions and sound the alarm for help repeatedly as infections grew.
Our goal with this audit was to produce positive change, not settle political vendettas. I am encouraged that significant improvements have been made to prevent this from happening again. I would ask the Auditor General’s team and all of the involved agencies to meet with us in an upcoming legislative hearing to discuss these findings in more detail. With COVID-19 still in our communities, we owe this continued work to every veteran counting on us to protect them and keep them safe.”
…Adding… Leader Rezin…
llinois Senate Deputy Minority Leader Sue Rezin (R-Morris) issued the following statement after the Illinois Auditor General released their report on the Pritzker Administration’s handling of the COVID-19 outbreak at the LaSalle Veterans’ Home that resulted in the death of 36 residents:
“The audit tells the story of a governor who fatally mismanaged the state’s response, abdicated his responsibilities to protect the veterans of this state, and tried to hide it with an investigation he arranged with a predetermined outcome, ensuring his office escaped all accountability.
“Governor Pritzker and his political appointees intentionally misled legislators during public hearings as we sought answers for the families who lost loved ones but nineteen months after the outbreak began, the truth came out. He must finally accept responsibility for failing to act on the information his office sat on since day one. The Senate must hold legislative hearings to demand answers from the Pritzker Administration.”
…Adding… HGOP Leader Durkin…
House Republican Leader Jim Durkin offered the following comments after Illinois Auditor General Frank Mautino released the findings of a performance audit into the fatal mismanagement that led to the tragic deaths of 36 of our nation’s heroes at the LaSalle Veterans’ Home.
“The Auditor General’s report today shows again that when it comes to protecting our state’s most vulnerable, like children in DCFS or Veterans in the care of IDVA, Governor Pritzker is a failure. Our heroes deserved better than Pritzker’s fatal mismanagement at the LaSalle Veteran’s Home.”
…Adding… Jesse Sullivan…
Following today’s release of an audit of the Pritzker administration’s failed response at the LaSalle Veterans Home, Jesse Sullivan is calling for an immediate criminal investigation into the Pritzker administration – starting at the top with J.B. Pritzker himself.
Sullivan said:
“What happened at LaSalle was a shameful tragedy. When our heroes cried out for help, they were met with deafening silence from the Pritzker administration. Thirty-six veterans died as a result. Illinois veterans deserve better. The families who lost loved ones deserve better.
“Four years ago, J.B. Pritzker called the 13 deaths at the Quincy Veterans Home from Legionnaires’ disease a ‘shameful neglect of our veterans’ and an ‘unconscionable moral failing.’ ‘[T]his is incompetence,’ Pritzker said. ‘This is gross mismanagement.’ Attorney General Lisa Madigan quickly launched a criminal probe into the Rauner administration.
“J.B. Pritzker needs to be held accountable for his failures, and to take responsibility for the lives lost and the damage done. Time and time again, Pritzker has blamed others. He scapegoated IDVA Chief of Staff Tony Kolbeck for not disclosing the severity of the outbreak, but now we are learning that it was IDPH that didn’t act. The bottom line is that by his own definition four years ago, Pritzker is unfit to serve as governor.”
“As governor, I will always stand up for our veterans, and ensure they receive the highest quality of care.”
…Adding… Rep. Kifowit…
State Representative Stephanie Kifowit (D-Oswego), a United States Marine Corps Veteran and Chair of the IL House Veterans Affairs Committee, was the Chief Co-Sponsor of House Resolution Number 62 (HR62), which passed the Illinois House unanimously on April 28, 2021. As Chair of the Illinois House Veterans Affairs Committee, she issued the following statement following the Auditor General’s Report issued today pursuant to HR62:
“The Veterans in all our Veterans’ homes trust and depend on the state of Illinois to give them the best care we can in honor for their service to our great Country. As a Veteran myself, I stand by this standard and strive to ensure our Veterans are properly taken care of every day”, stated Kifowit. “The heart-breaking loss of our decorated Veterans at the LaSalle Home showed us just how deadly COVID-19 was, and still is.
“The members of the Veterans Affairs committee have been diligent on ensuring that all the information regarding the COVID-19 outbreak at the LaSalle Veterans affairs has been fully vetted, and as Chair of the Veterans Affairs Committee, you have my word that this report will be fully vetted as well in an upcoming subject matter hearing that I have already requested to be scheduled before the end of May.
“Through the hard work of the committee, and already law in Illinois, the soon to be established Veterans Accountability Unit is expected to address some of the issues that we are seeing in the Auditor General’s report and will provide an avenue for concerns and complaints to be readily addressed in a timely manner. It is unfortunate that so many lives were lost in a complete breakdown in communication during the largest public health crisis in our history. We must make certain that tragedy like this will never happen again to our most vulnerable Veterans under the care of the State of Illinois.
“In the end, this is about our Veterans. I am encouraged by the leadership of newly confirmed IDVA Director Prince and his team, the hard work of all the employees that care deeply for our Veterans in all our Veterans’ Homes, and the dedication of the Veterans Affairs Committee members to bring about positive change for our highly decorated Veterans under the care of the state of Illinois.”
posted by Rich Miller
Thursday, May 5, 22 @ 10:21 am
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The Legislative Audit Commission is going to have a real political hot potato on its hands. The GOP will try to turn this into a political show and call for hearings and subpoenas like they did in 2014 with the audit of Quinn’s Neighborhood Recovery Initiative. There are major differences between the two which will give the Dems some cover. The administration and agencies were all flying blind at the beginning of COVID.
Comment by exhausted Thursday, May 5, 22 @ 10:34 am
What does the Kevin Cavanaugh case from 2014 linked to above have to do with the COVID situation?
Comment by Dutch Thursday, May 5, 22 @ 10:39 am
Personnel is policy.
The blame can be “put” on a chord of staff if an agency, you can even put “half” of the blame on Chapa LaVia…
… but personnel *is* policy.
This report is damaging as a harsh reminder of the tragic things that occurred, and that the administration stuck by Chapa LaVia at full force until the end.
Comment by Oswego Willy Thursday, May 5, 22 @ 10:46 am
JB has political vulnerability in his leadership of state agencies. The AG’s ransomware/hack cost taxpayer’s over $2.5 Million and the mandated OMA portal was down for 8 months, the tragedy of the IDPH veteran home deaths, and the Costly IDES fraud issues that languished for over a year.
Comment by Donnie Elgin Thursday, May 5, 22 @ 10:56 am
===JB has political vulnerability in his leadership of state agencies. The AG’s ransomware/hack===
LOL
You do know that the AG is elected independently of the governor, right?
Try sticking with the very real and very important topic at hand instead of bloviating off script.
Comment by Rich Miller Thursday, May 5, 22 @ 10:58 am
” Legislative hearings must be scheduled to determine how the administration failed so greatly in protecting our state’s heroes.”
Sure thing, Mr. Welter. You can even have Senator Rezin lead the investigative panel - now that she is done telling people to ignore mask mandates in this same district.
Comment by TheInvisibleMan Thursday, May 5, 22 @ 11:09 am
I know it doesn’t work this way. But the GOP “owns” this as much as Gov. Pritzker does. They downplayed the virus and all but encouraged people to ignore them and act like it was just the flu.
Comment by Cool Papa Bell Thursday, May 5, 22 @ 11:18 am
TheInvisibleMan,can you point to a single incident when Senator Rezin told people to not wear masks? I do remember her questioning why restaurants were still closed at the time of the outbreak, but I’ve never seen her tell people not to wear masks.
Comment by Illiana Thursday, May 5, 22 @ 11:22 am
===I know it doesn’t work this way. But the GOP “owns” this as much as Gov. Pritzker does.===
It does NOT work that way. Nope.
Governors own.
What Republican could fire Chapa LaVia for her half hearted running of the agency, including the agency’s chief of staff?
Like Rauner and Quincy, and that was not a global pandemic but a crisis they had those like Diana Rauner more focused on messaging and not the crisis… governors own, they always do.
Right or wrong, they own.
Comment by Oswego Willy Thursday, May 5, 22 @ 11:23 am
==The administration threw IDVA chief of staff Tony Kolbeck under the bus.== Yup-the administration stood by Chapa well past the time that it became obvious that she had to go.
Comment by SAP Thursday, May 5, 22 @ 11:32 am
=== Personnel is policy ===
Was that meant to be ironic?
You were leading the charge to pin the blame on Chapa LaVia and Kolbeck without all of the facts.
The independent investigation more than suggests this was a case of “Round up the Usual Suspects” and pin the blame on someone as quickly as possible to so we can fire them and make the story disappear.
A plane reading of the DHS IG report at the time made it pretty clear the goal was to insulate IDPH from any accountability.
My question is who finally got through directly to Governor to raise the alarm to finally get IDPH to act? If it turns out it was Chapa LaVia, we collectively look pretty foolish.
Comment by Juvenal Thursday, May 5, 22 @ 11:32 am
===Was that meant to be ironic?===
When isn’t personnel… policy?
So I’m clear… you think Chapa LaVia shoulda stayed on?
Did you read or digest her last “performances” in front of committees on the crisis?
===A plane reading of the DHS IG report at the time made it pretty clear the goal was to insulate IDPH from any accountability.===
Then that means personnel blame is blame placed on an administration, no?
=== If it turns out it was Chapa LaVia, we collectively look pretty foolish.===
… and yet the administration looked continually foolish every day Chapa LaVia stayed on.
The administration was done looking foolish, Chapa LaVia was gone.
So I’m clear… I asked again, you think Chapa LaVia shoulda stayed on?
Comment by Oswego Willy Thursday, May 5, 22 @ 11:47 am
===The administration threw IDVA chief of staff Tony Kolbeck under the bus.===
If the Director of an agency isn’t really coming to work I’m pretty confident it’s the responsibility of the Chief of Staff to inform the Governor’s Office instead of facilitating a no-show job. If the Chief of Staff remained employed in any capacity, for that alone, they should be thankful.
=== abdicated his responsibilities to protect the veterans of this state===
Bold words from an elected official who repeatedly and consistently advocated against public health safety measures and encouraged others to flout them while refusing to follow them herself in public.
Sen Rezin may not work for the IDVA, but she’s a contributing factor to the spread of COVID-19 in her district with her decision to actively and publicly work against mitigation efforts.
Comment by Candy Dogood Thursday, May 5, 22 @ 11:49 am
Illiana,
I clearly remember her attendance at an event was specifically to remove the mask requirement from restaurants - while everyone in attendance was flaunting the mandate at the event - in the very same district as the veterans home.
Leadership positions mean exactly that. If you use a position to advocate for the opposite of a mask mandate, and openly ignore it, you are telling your constituents that masks mandates should be ignored.
That’s the opposite message of what was needed at the time, and she fully participated in it.
The opposition was clearly warning that this would lead to an increase in infections and deaths in the region. The response back from the circle she aligned herself with was “If you are afraid just stay home”.
Republicans own these consequences, as they were quite vocal at the time that such consequences were the ‘cost of keeping business open’.
There’s no escape from what they’ve done. The time for them to have cared about this was in 2020 and 2021, and they made their choice at that time.
Comment by TheInvisibleMan Thursday, May 5, 22 @ 11:55 am
===Republicans own these consequences, as they were quite vocal at the time that such consequences were the ‘cost of keeping business open’.===
That won’t happen. Nope. Not how it works.
Governors own. Same as Rauner in Quincy, the realty is the agency’s failure is not going to be dismissed by voters (if this blame is to punish, politically) as a GOP failure, it will be something voters may weigh when grading the Pritzker Administration on Covid.
Is it fair? Maybe. Maybe not.
Comment by Oswego Willy Thursday, May 5, 22 @ 12:08 pm
TheInvisibleMan,
Thank you for the example. I wasn’t at the event or know that it occurred, and didn’t see it promoted/advertised when I searched her social media. I did see she prompted the IL Restaurant Association campaign questioning why IL was the only state that had an indoor ban the same week as the outbreak, which probably wasn’t a great move.
If she did attend that event, which I have no reason not to believe you, then that shows some poor judgement.
Comment by Illiana Thursday, May 5, 22 @ 12:22 pm
I have read your article from top to bottom. It appears that there were a series of mistakes made in the beginning of this situation. We must remember that this was the beginning of an outbreak in that area and that no one realized how serious it would become. But the “buck” must ultimately stop on someone’s desk. I just hope that everyone will remember that the VA Chief is a new player. She has been working very hard ever since she came aboard to make sure all Veterans are cared for to the best of her ability.
Comment by Oldster Thursday, May 5, 22 @ 1:03 pm
It’s easy to react to the summary and blame agency ineptness. What would really be helpful would be for folks to do an in-depth review. Read the agency responses. IDPH’s was especially enlightening in highlighting staffing issues. Interesting note was that the communicable disease staffer working with vets passed away during the process. Public health funding has been a habitual problem and COVID was just another among many crises that bring the problem to the forefront. To me the Audit recommendations are pretty much a joke. Write policy for this, that and the other thing …
The frustrating thing is that the GOP has become so insanely opposed to science we can expect nothing but resistance to efforts to revamp our public health system. Because of the GOP, we are not going to fair well against future pandemics.
Comment by Norseman Thursday, May 5, 22 @ 1:15 pm
Illiana - all through the covid pandemic, any and all wearers of the LaSalle County republican’t badge were denigrating mask mandates. The local republican’t officials were openly refusing to enforce the governor’s mask mandates. People were proudly flouting any efforts to enforce wearing masks.
Your fingers can press the Google key to look for rezin quotes about masks.
Comment by Huh? Thursday, May 5, 22 @ 1:21 pm
“ I just hope that everyone will remember that the VA Chief is a new player. She has been working very hard ever since she came aboard to make sure all Veterans are cared for to the best of her ability.”
Who are you referring to? Former COS, he took all the hits —new COS…not in the picture.
Comment by RadLife Thursday, May 5, 22 @ 1:42 pm
It’s sad that voters can’t and won’t connect the dots on anti-mask, anti-vax and 1M deaths across the country. It’s obvious yet, there is no acceptance of responsibility. As for LaSalle - the Director owns the responsibility ultimately. Rezin is a hypocrite for trying to have it both ways… but the voters won’t notice, sadly.
Comment by Lincoln Lad Thursday, May 5, 22 @ 2:06 pm
Up and down the blog today are a lot of stories that look negative for the Governor but then I read the comments and realize the super minority is to blame. Seems legit.
Comment by Franklin Thursday, May 5, 22 @ 2:25 pm
Huh?, ==Your fingers can press the Google key to look for rezin quotes about masks.==
I did and didn’t find any quotes from her telling people not to wear masks during that time or anytime. There was some stuff about her being opposed to businesses being fined for customers not wearing masks and this year’s JCAR vote blocking IDPH from reissuing the school mask mandate right after the Sangamon County judge incorrectly ruled masks were a type of quarantine.
I’m not here to defend anyone who was preaching not wearing masks so if you have a quote that would be helpful. I do find it too common for people to make claims without any proof, which is why I truly appreciated TheInvisibleMan providing an example.
Comment by Illiana Thursday, May 5, 22 @ 3:13 pm
This audit is great, do DCFS next.
Comment by Kyle Hillman Thursday, May 5, 22 @ 3:15 pm
When does the audit on Sullivan’s emails come out?
It’s embarrassing how Sullivan was treated when CLV is responsible for multiple unnecessary deaths. This could be in an episide of The Wire for such a colossal bureaucratic failure this was.
Comment by Almost the Weekend Thursday, May 5, 22 @ 6:03 pm
Rezin was a frequent complainer on the Gov’s mitigation efforts… restaurant and bar closures in particular before the LaSalle story broke. Masks in schools later in the game… after the LaSalle deaths unfortunately occurred.
Comment by Lincoln Lad Thursday, May 5, 22 @ 8:17 pm
Please excuse my picky petty point; but I can’t forget the picture of Gov JBP falling all over himself heaping praise on IDPH Director Ngozi Ezike about how great she was - all while Vets were suffering. As has been said: Gov’s own, and this dichotomy is hard to explain.
Comment by joe Thursday, May 5, 22 @ 10:27 pm
IDPH Director and Chief of Staff both left their positions in the days leading up to the release of this report…
Comment by Max Friday, May 6, 22 @ 4:37 pm