Gov. JB Pritzker on Friday expressed regret over hiring former Illinois Department of Veterans Affairs Director Linda Chapa LaVia as critics lash out after a scathing report examining what led to the massive COVID-19 outbreak at the LaSalle Veterans Home last fall, which left 36 residents dead.
The investigation, which Pritzker ordered a few weeks into the deadly outbreak in November, found systemic organizational problems and failures to communicate in both the LaSalle Home and the state’s Department of Veteran Affairs, which runs the facility and three other veterans homes in Illinois.
Along with inconsistent and confusing COVID protocols that led to lax enforcement among staff, the report also found former agency Director Linda Chapa LaVia “abdicated” her responsibilities to her chief of staff, who in essence performed three jobs. The failure to fill crucial vacant jobs inevitably left the chief of staff and other managers in IDVA and at the LaSalle home “with too many responsibilities to effectively lead.”
The governor on Friday told reporters he picked Chapa LaVia, who had spent 16 years as a Democratic member of the Illinois House before getting tapped to lead the IDVA, because she led an investigation into a deadly Legionnaires' Disease outbreak at the Quincy Veterans' Home in 2015.
“She seemed like an ideal person to be able to root out our problems in our veterans’ homes,” Pritzker said “But I have to admit if I knew then what I know now, I would not have hired her.”
Pritzker’s new pick for IDVA head, Acting Director Terry Prince, made assurances Friday that many of the suggested changes included in the report have either already been made or are in the process of being fixed. But both stakeholders and political rivals piled on.
Republicans predictably pointed to Pritzker’s 2018 campaign against Gov. Bruce Rauner, in which Pritzker harped on the Republican governor’s handling of a the Legionnaires’ outbreak at Quincy, in which 13 residents died and dozens more were sickened.
“Governor, when you made a political issue out of our veterans deaths at Quincy, I gave you the benefit of the doubt that it was about protecting our heroes and not scoring political points on dead veterans," State Rep. Dan Swanson (R-Alpha) said at a virtual news conference Friday.
Other Republican House members called for further investigations into possible criminal negligence by those involved in the LaSalle outbreak. State Rep. Deanne Mazzochi (R-Elmhurst) challenged Democratic Attorney General Kwame Raoul to investigate, and during Republicans' news conference, referenced Illinois laws governing criminal negligence at nursing homes.
After being sworn in as attorney general in 2019, Raoul opened an investigation into the Rauner's handling of the Quincy Legionnaires' outbreak, but earlier this year the office said no charges would be brought.
"This report does give us — I wouldn't say we're at the level of probable cause, but it certainly does warrant further investigation on whether or not criminal negligence did take place, because not only were [the veteran residents] injured, became ill, but we did have deaths at that facility," House GOP Leader Jim Durkin (R-Western Springs) said.
Durkin, a former prosecutor, said he "will not accept anything less than another set of eyes to look at the facts of this case to determine whether or not any section of the criminal code was violated."
"The administration just can't say that 'we're going to do a better job next time," Durkin said. "There has to be more accountability for the loss of 36 of our valued heroes who were entrusted in this home."
State Sen. Sue Rezin (R-Morris), whose district includes the LaSalle home, characterized the findings of the report as an "absolute complete disaster" in handling the outbreak by Pritzker's administration.
"This outbreak absolutely could have been avoided," Rezin said.
The report details lack of communication from Chapa LaVia's chief of staff, Tony Kolbeck, who was also working as de facto senior homes supervisor overseeing the state's four veterans' homes, and the former LaSalle home administrator, Angela Mehlbrech. It took a week before both Kolbeck and Mehlbrech asked for site visits from the Illinois Department of Public Health and the U.S. Department of Veterans' Affairs.
But neither knew the other one had done so.
Both entities conducted site visits and cursory investigations a few days later, when the home's COVID outbreak was in full force, and noted basic failures of protocol, including staff not wearing masks in the home's employee area and the use of non-alcoholic hand sanitizer in wall dispensers.
Rezin notes an Auditor General report from 2019 examining the Quincy Legionnaires' outbreak recommended the IDVA adopt protocols for how soon IDPH should make a site visit after an outbreak of a disease at a home.
But a bill she filed earlier this year that would compel IDPH to make a site visit soon after an outbreak started, just like the audit's recommendation, has been held up in the Senate's Committee on Assignments.
"This should be a bipartisan bill that everybody who supports veterans should be not only supporting, but co-sponsoring the bill," Rezin said Friday. "And the fact that I can't get the bill heard and debated is telling me that somebody's put the brick on the bill."
The The Illinois Association of County Veterans Assistance Commissions, which advocates for veterans in the state, said the community was “in utter shock and disbelief” after reading the report. IACVAC President Michael Brooks pointed to a litany of issues in the Department of Veterans Affairs over the last decade, claiming that Illinois had “gone from one of the best states in the Union for veterans to dead last.”
“For far too long, there has been empty rhetoric and broken promises to our nation’s heroes,” Brooks said in a statement Friday. “Just in the last six years almost 100 veterans have died at our state’s veteran homes because of breakdowns in procedure, antiquated policy, and lax accountability.”
The association is calling for the creation of an inspector general’s office within the IDVA, but Pritzker is backing an alternative approach — a Veterans’ Accountability Unit within the department, which would report to the Office of the Executive Inspector General.
Both of those ideas are contained in separate amendments to legislation filed by State Rep. Stephanie Kifowit (D-Oswego), chair of the House Veterans’ Affairs Committee.
Acting Director Prince, who was recently appointed to head the agency after overseeing Ohio’s veterans’ homes, did not directly comment Friday on the merits of an inspector general solely responsible for IDVA versus an accountability unit.
“When and if that bill comes to fruition, we will utilize that service as well,” Prince said in an interview.
Prince also said he would invite more oversight of Illinois’ veterans facilities, including seeking ratings by the federal Centers for Medicare and Medicaid services, which monitors traditional nursing homes.
“I welcome anyone who wants to come in and walk through our homes and inspect us because I want them to see the incredible work that our staff does every day at these facilities to support Illinois’ heroes,” Prince said.
Kifowit on Friday said she was “beyond disgusted” by the report’s findings.
“It confirms the suspicions of not only myself, but other members of the committee, of the failure in leadership of the IL Department of Veterans Affairs that we witnessed in over four hours of hearings that were held in 2020,” Kifowit said in a statement.