Audit finds IDPH failed to intervene in early days of LaSalle Veterans' Home outbreak

Audit finds IDPH failed to intervene in early days of LaSalle Veterans' Home outbreak

36 died in the November 2020 outbreak at state-run facility

Capitol News Illinois

SPRINGFIELD – A new report from the state’s auditor general found more fault with the Illinois Department of Public Health in its response to a deadly COVID-19 outbreak at a state-run veterans home than was found by a previous watchdog report that investigated the matter.

A November 2020 COVID-19 outbreak at the LaSalle Veterans’ Home resulted in 36 resident deaths, leading the Illinois House to pass a resolution in April 2021 requesting an audit of the outbreak from Auditor General Frank Mautino’s office.

The outbreak also led to the firing or resignations of LaSalle home administrator Angela Mehlbrech, then-director of the Illinois Department of Veterans Affairs Linda Chapa LaVia and IDVA chief of staff Tony Kolbeck.

The report released Thursday by the auditor general found IDVA did in fact have infection control guidance in place at the time of the outbreak, contradicting an April 26, 2021 report from the Department of Human Services Office of the Inspector General and an outside law firm.

The 2021 OIG report, which was conducted at the request of Gov. JB Pritzker, found leadership deficiencies at IDVA which led to the director “abdicating” her responsibilities to subordinates. It also stated the home “did not develop comprehensive COVID-19 policies.”

While both reports pointed to staff attending a Halloween party and failing to socially distance as potential causes for the outbreak, the auditor general found “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 home very quickly with a large number of residents and staff positive within a few days,” the auditor general report stated. “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.”

Other factors may have included community spread, which led to a 212 percent increase in COVID-19 cases in the region from the month prior, or the fact that guidelines at the time did not require rapid COVID-19 testing prior to entering the home, allowing for asymptomatic spread.

The auditor general’s report described the OIG report as “flawed” for its reliance on interviews rather than documentation.

At an unrelated news conference in his office Thursday, Pritzker faulted Republicans for questioning mitigation guidance at the time and said the audit failed to convey that IDPH was the “central responsible agency for the entire pandemic.”

“So, just while this veterans home was having its outbreak, they were occurring all over the state, in schools, in other nursing homes, in other congregate care settings,” he said.

Pritzker said IDPH was following U.S. Centers for Disease Control and Prevention guidance not to visit a congregate facility and risk disease spread when a phone call would suffice. He said he held officials at IDVA accountable and credited new director Terry Prince who took over the job in April 2021 in the wake of the OIG report.

The auditor general report largely focused on a 13-day span at the beginning of November 2020, when the case count grew from four to over 170 at the LaSalle home between residents and staff.

It was Nov. 1, 2020 when Kolbeck, the IDVA chief of staff, reported four cases to the governor’s office and the Illinois Department of Public Health among others. Eleven days later, IDPH performed a site visit at the home. By the next day, IDVA reported 83 residents and 93 staff positives, all but six of which were current, along with 11 resident deaths and four hospitalizations.

The report stated that Sol Flores, deputy governor for health and human services under Pritzker, and an assistant “may not have realized the significance of the outbreak at the LaSalle Veterans’ Home as the virus continued to progress through the home.”

Flores told auditors that her office thought leadership at IDVA and the home were “communicating and taking actions regarding the employees under their responsibility to ensure things were being done.”

The audit further noted that an assistant to Flores emailed Kolbeck on Nov. 2, 2020, to ask if more support was needed from IDPH and if he’d been in contact with the state medical officer.

Kolbeck replied the next day, “I can’t think of anything specific we need at LaSalle. You’ll see shortly, it’s not improving though. I have traded emails with the state medical officer on getting a call with the administrators and her team but we haven’t locked in on a date/time yet.”

According to the audit, Kolbeck first inquired about a potential site visit on Nov. 9. A response didn’t come until Nov. 11, and that was after the medical officer spoke to IDPH’s chief of staff, who relayed that Pritzker “was very concerned and wanted IDPH to visit the home.”

The email citing Pritzker’s concern came 22 minutes after an IDPH infection control consultant determined that the “processes being done are sound” at the LaSalle home, relaying that an infection control nurse at the home “feels they are doing okay and doesn’t feel the need for someone to visit.”

The audit postulated that a site visit might have taken even longer without Pritzker’s intervention.

The audit also found that IDPH failed to act in 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 reached out to IDPH about the home receiving rapid tests on Nov. 9 and monoclonal antibody treatments on Nov. 11. By the time rapid tests arrived, more than two-thirds of the home’s residents had tested positive.

“From the documents reviewed, management at IDPH 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,” the report stated.

The auditor recommended that IDPH should “clearly define its role” in monitoring COVID-19 outbreaks at veterans homes and develop policies and procedures that “clearly identify criteria which mandate IDPH intervention” at the homes.

IDPH accepted the recommendation, but the department noted antibody treatments were not available for distribution at the time of the LaSalle outbreak and an infection preventionist assigned to IDVA died unexpectedly two weeks prior to the outbreak.

IDPH said its oversight task included communicating with 97 local health departments and preparing for distribution of the vaccine which arrived one month later.

The audit also recommended IDVA develop policies that mandate timely testing of residents and staff during outbreaks. It outlined testing periods that occurred over three days, extending the time when results would be sent to labs, compounding processing delays.

The audit also recommended that the IDVA director work with IDPH and the governor’s office during COVID-19 outbreaks. IDVA agreed with the recommendations.

The report also noted IDVA and IDPH put new policies in place in April 2021 to “establish a comprehensive and integrated infection prevention and control program at all Illinois veterans homes” that included new training requirements. 


Capitol News Illinois is a nonprofit, nonpartisan news service covering state government that is distributed to more than 400 newspapers statewide. It is funded primarily by the Illinois Press Foundation and the Robert R. McCormick Foundation.

Jerry Nowicki

Jerry NowickiJerry Nowicki

Jerry has more than five years of experience in and around state government and nearly 10 years of experience in news. He grew up in south suburban Evergreen Park and received a bachelor’s degree from Illinois State University and a master’s degree online from Purdue University.

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