SPRINGFIELD — In the months before the state-run veterans’ home in LaSalle saw a massive COVID-19 outbreak that eventually killed more than a quarter of the facility’s residents, leaders at the state agency that oversees the home obscured its inner workings from Gov. JB Pritzker’s office, a top Pritzker staffer told lawmakers on Thursday.
Thirty-six residents at the LaSalle Veterans’ Home eventually died after testing positive for COVID in an outbreak that began in early November and spread to more than 100 residents and more than 100 staff members. A damning inspector general’s report on the outbreak released late last month faulted absentee leadership, lack of preparedness, lax COVID protocols and poor communication as contributing factors for the crisis at the home.
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In an appearance in front of the Illinois House Veterans’ Affairs Committee Thursday, Deputy Gov. Sol Flores painted the state’s Department of Veterans’ Affairs as a sort of black box, repeatedly telling lawmakers she believed what top officials at the Illinois Department of Veterans’ Affairs was telling her in the months leading up to the LaSalle outbreak.
“I am so sorry,” Flores said, directing her comments to the families of the residents who died. “Every single person involved could have done more to save your loved ones.”
Flores said the entire Pritzker administration grieved the 36 veterans who died during the outbreak, but quickly turned her opening remarks toward placing blame on IDVA officials and shielding the governor’s office from culpability.
“It’s not just grief; I also share your rage at the loss of life that occurred at LaSalle,” Flores said. “What I was told was happening there is a far cry from the circumstances set forth in the [inspector general]’s report.”
As one of Pritzker’s four deputy governors, Flores is in charge of overseeing congregate care, including the state-run veterans’ homes under IDVA. But Flores insinuated the agency’s former director, Linda Chapa LaVia, and three other leaders at IDVA and the LaSalle home itself, misled her about whether COVID protocols were being followed.
“I was told consistently that things were happening on the ground that, in retrospect now when we read this report, were not happening,” Flores said, specifying she was led to believe things were OK by Chapa LaVia and her chief of staff, Tony Kolbeck.
“I was not aware that polices and protocols were not being followed,” Flores said. “We were told that they were being followed.”
The inspector general’s report laid out a litany of reasons the virus spread so quickly through the home, including a sudden stop to a quarantine policy for residents returning from off-site doctor’s visits and staff confusion around how to handle COVID-positive residents. In some cases, COVID-positive residents were commingled with COVID-negative residents, according to the report.
State Rep. Deanne Mazzochi (R-Elmhurst), who immediately called for investigations into possible criminal negligence for those involved in the LaSalle crisis after the report’s release two weeks ago, characterized Flores’ trust in IDVA top brass as complacency.
“To me, a good leader doesn’t assume things are happening, “Mazzochi said. “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.”
But Flores pushed back, saying she didn’t make site visits because public health guidance suggested making unnecessary visits to congregate care facilities put residents at risk. Instead, Flores relied heavily on electronic communication with IDVA and LaSalle home officials, including video calls and email.
Flores also said she trusted Chapa LaVia and her deputies were making progress implementing recommended changes on infection control and other recommendations made in an audit completed at Pritzker’s behest early in his tenure as governor.
During a Jan. 11 hearing on the outbreak just hours before Chapa LaVia’s sudden resignation, the former director was asked about that audit and answered that she and her team had been told to implement everything.
“And did you?” State Rep. David Welter (R-Morris) asked Chapa LaVia at the time.
“Yes, that and more,” Chapa LaVia answered.
But the inspector general’s report said those changes didn’t actually occur.
Many suggestions in that 2019 report stemmed from a deadly outbreak of Legionnaires’ Disease that killed at least 13 residents at the Quincy Veterans’ Home — a crisis Pritzker made into a campaign issue when challenging then-Gov. Bruce Rauner in 2018.
“Look, I’m upset and extraordinarily disappointed that the leadership at the Department of Veterans’ Affairs did not make the corrections that were suggested in that report and others that should have been done,” Pritzker told reporters Wednesday at an unrelated event.
When asked about Chapa LaVia’s resignation that same day in January, Pritzker characterized her exit as a “mutual decision” between himself and the director.
Flores on Thursday revealed that Chapa LaVia was told in late November that she would not be reappointed as acting director of the agency. The pandemic has delayed many official appointments via Senate votes, but Pritzker has reappointed many of his nominees in order to restart the clock on a confirmation vote.
Flores also said a nationwide search for a new IDVA head began in November. After interviewing a dozen candidates, Pritzker announced new IDVA Acting Director Terry Prince on April 1. Prince also testified in front of the committee Thursday, repeating promises he made two weeks ago when the inspector general’s report was published, and assuring lawmakers many changes — including standardized infectious disease protocols — had already been implemented across the four state-run veterans’ homes.
Chapa LaVia and the LaSalle home’s fired administrator, Angela Mehlbrech, declined to sit for interviews for the inspector general’s investigation, but participants who did indicated Chapa LaVia had largely “abdicated” her responsibilities to Kolbeck, her chief of staff.
In addition to performing his own job and covering many of the director’s job duties, the report also said Kolbeck effectively did the job of senior homes administrator, a position vacated by the previous occupant after his retirement in late 2019.
According to the report, one applicant for the job was forwarded to Pritzker’s office for approval, but top staff rejected him. The report provides no further details and goes on to blame the failure to hire a senior homes administrator — a person who ideally would have experience overseeing nursing homes or at least have some medical experience.
But on Thursday, Flores defended the governor’s office’s decision to not move forward with that applicant, saying a review of the candidate’s social media revealed “multiple disparaging remarks” about people on government assistance and also posts “that were viewed as racist.”
“We believed that this was an inappropriate candidate to serve in this leadership role,” Flores said, noting that in the absence of a permanent hire, the Illinois Department of Public Health made staff available to help IDVA oversee its homes.
Lawmakers on the panel, including State Rep. Lance Yednock (D-Ottawa), whose House district includes the LaSalle home, asked Flores why the administration didn’t seem to make further efforts to hire for the position after the candidate was eliminated.
“Did any person at the IDVA or in the governor’s staff bring this up to you or other senior staff of just the emergency or the absolute necessity of getting that position filled?” Yednock asked.
Flores said the position’s importance was recognized, but pointed to the difficulties of competitive hiring for such a specialized position, noting the salary offered for the job “frankly” wasn’t attractive compared with a similar position in the private sector.
But that answer didn’t sit well with State Rep. Dan Swanson (R-Alpha).
“Telling a family their veteran died is too hard,” Swanson said. “Hiring someone is easy, OK?”
Flores said candidates for the position are being vetted and a hire will be made soon.
Welter, meanwhile, questioned why the Illinois Department of Public Health didn’t get involved with the crisis sooner, and told agency Director Ngozi Ezike he felt IDPH “kind of sat on the sidelines.”
But Ezike defended IDPH staff, saying they’d been “stretched to limits that they’ve never been stretched before.”
“Obviously if we could have gone into so many more [long-term care facilities] — if we had the bandwidth, if we had many more people and could go to physically more places — we would have identified some of the things that maybe you can’t tell from [phone and video] conversations,” Ezike said.
Kolbeck finally asked IDPH to make a site visit to the LaSalle home more than a week into the outbreak, and IDPH staff showed up at the facility on Nov. 12. By then, IDVA had already reported 10 residents died after testing positive for COVID, and the number of positive cases for residents and staff were in the 80s for both populations.