SPRINGFIELD — A new report from the state auditor general found more fault in the Illinois Department of Public Health in its response to a deadly outbreak of COVID-19 at a state-run veterans home than what had been found by a previous monitoring report investigating the matter.
A November 2020 COVID-19 outbreak at the LaSalle Veterans’ Home resulted in the deaths of 36 residents, leading the Illinois House to pass a resolution in April 2021 requesting an audit of the outbreak from the Office of Auditor General Frank Mautino.
The outbreak also led to the firing or resignation of LaSalle home administrator Angela Mehlbrech, then Illinois Department of Veterans Affairs director Linda Chapa LaVia, and IDVA chief of staff, Tony Kolbeck.
The Auditor General’s report released Thursday found that the IDVA had in fact had infection control guidelines in place at the time of the outbreak, contradicting an April 26, 2021 report from the Department of Health‘s Office of Inspector General. social services and an outside law firm.
The 2021 OIG report, which was commissioned by Governor JB Pritzker, revealed leadership shortcomings at the IDVA that led the director to “abdicate” her responsibilities to her subordinates. He also said the house “has not developed comprehensive COVID-19 policies.”
While both reports pointed to staff attending a Halloween party and not social distancing as potential causes of the outbreak, the Auditor General found that “there was no evidence to support that a lack of policies and procedures resulted in a failure to contain the virus.”
“The virus hit the house very quickly with a large number of residents and staff positive within days,” the Auditor General’s report said. “As a result, it was unclear whether the non-compliance with the policy had caused such a rapid spread of the virus or whether the rapid spread was due to other factors.”
Other factors may have included community spread, which led to a 212% increase in COVID-19 cases in the region compared to the previous month, or the fact that guidelines at the time did not require testing. COVID-19 rapids before entering the home, allowing asymptomatic spread.
The Auditor General’s report describes the OIG’s report as “flawed” because it relies on interviews rather than documents.
At an independent press conference in his office on Thursday, Pritzker faulted Republicans for questioning the mitigation guidelines at the time and said the audit failed to indicate that the IDPH was “the central agency responsible for the entire pandemic”.
“So just when this veterans home had its outbreak, they were happening all over the state, in schools, in other nursing homes, in other congregate care facilities,” a- he declared.
Pritzker said IDPH was following U.S. Centers for Disease Control and Prevention guidelines not to visit a crowded facility and risk the spread of disease when a phone call would suffice. He said he held IDVA officials accountable and credited new director Terry Prince who took office in April 2021 following the OIG report.
The Auditor General’s report largely focused on a 13-day period in early November 2020, when the number of cases rose from four to more than 170 at the LaSalle home between residents and staff.
It was November 1, 2020 when Kolbeck, the IDVA’s chief of staff, reported four cases to the governor’s office and the Illinois Department of Public Health, among others. Eleven days later, IDPH conducted an on-site visit to the home. The following day, IDVA reported 83 residents and 93 staff positive, all but six of whom were current, along with 11 resident deaths and four hospitalizations.
The report says Sol Flores, deputy governor of health and human services under Pritzker, and an aide “may not have realized the significance of the outbreak at the LaSalle veterans’ home as the virus continued to progress in the household”.
Flores told listeners that his office believed that IDVA and House leaders were “communicating and taking action regarding employees under their responsibility to ensure things were done.”
The audit further noted that an assistant to Flores emailed Kolbeck on November 2, 2020 asking if further support was needed from IDPH and if he had been in contact with the state physician.
Kolbeck replied the next day: “I don’t see anything specific we need in LaSalle. You’ll soon see, it doesn’t get any better though. I have emailed the Chief Medical Officer of the State to receive a call with the administrators and his team, but we have not set a date/time yet.
According to the audit, Kolbeck first inquired about a possible site visit on Nov. 9. A response did not come until November 11, and that was after the doctor spoke to IDPH’s chief of staff, who relayed that Pritzker “was very concerned and wanted IDPH to visit the house.
The email citing Pritzker’s concern came 22 minutes after an IDPH infection control consultant determined “ongoing processes are healthy” at LaSalle’s home, relaying that a nurse in home infection control ‘feels they’re doing well and doesn’t feel the need for someone to visit.
The audit postulated that an on-site visit could have taken even longer without the involvement of Pritzker.
The audit also found that IDPH failed to act during the first week of November, “even though it was the largest outbreak in any of the state’s congregate care facilities. “.
It was Kolbeck who contacted IDPH about the home receiving rapid tests on November 9 and monoclonal antibody treatments on November 11. By the time the rapid tests arrived, more than two-thirds of residents at the home had tested positive.
“Based on the documents reviewed, IDPH management offered no advice or assistance on how to slow the spread at home, offered to provide additional rapid COVID-19 testing, and were unsure of the availability of antibody treatments,” the report said.
The auditor recommended that IDPH “clearly define its role” in monitoring COVID-19 outbreaks in veterans’ homes and develop policies and procedures that “clearly identify the criteria that mandate the intervention of IDPH” in homes.
IDPH accepted the recommendation, but the department noted that antibody treatments were not available for distribution at the time of the LaSalle outbreak and that an infection preventer assigned to IDVA died so unexpected two weeks before the outbreak.
IDPH said its monitoring task included communicating with 97 local health departments and preparing for the distribution of the vaccine which arrived a month later.
The audit also recommended that the IDVA develop policies that mandate timely testing of residents and staff during outbreaks. It described testing periods that spanned three days, extending the time it takes to send results to labs, compounding processing delays.
The audit also recommended that the Director of IDVA work with IDPH and the Governor’s Office during COVID-19 outbreaks. IDVA accepted the recommendations.
The report also noted that the IDVA and IDPH implemented new policies in April 2021 to “establish a comprehensive and integrated infection prevention and control program at all Illinois veterans’ homes.” which included new training requirements.
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