Report finds infection control policy deficiencies at Illinois veterans homes

Report finds infection control policy deficiencies at Illinois veterans homes

Release comes amid announcement of new IDVA director

Capitol News Illinois

SPRINGFIELD — A joint report from two state agencies and the U.S. Department of Veterans Affairs found Illinois’ four state-run veterans homes lack standardized infection prevention policies despite previous audits suggesting they be implemented.

The report from the Interagency Infection Prevention Project, or IIPP, calls for the facilities to create a new infection control position and increase staffing and training.

The goal of the IIPP is to “support an integrated and comprehensive response to COVID-19” at the state’s veterans homes, according to the joint report of the Illinois Department of Public Health, Illinois Department of Veterans Affairs and USDVA.

While the report is dated March 9, it was only made public Friday, according to an IDVA spokesperson.

The report references the May 2019 audit issued after the outbreak of Legionnaires’ disease at the Quincy Veterans Home that made similar findings about the lack of uniform policies across facilities and the need to create them.

But, when the pandemic hit Illinois in March 2020, those policies had not been enacted.

“Following the audit in 2019, the Senior Home Administrator retired. The task of creating an integrated Infection Control Program was deferred while that position remained open. Some of the Veterans’ Homes have updated their infection prevention policies, independently of one another, since then,” according to the joint report.

“Standardized policies and procedures, as recommended in the 2019 audit, are needed as one part of an infection prevention program,” the report continued.

The public release of the report came the same day as Gov. JB Pritzker’s announcement on Friday that his administration appointed Terry Prince, a 31-year U.S. Navy veteran, as new Illinois Department of Veterans Affairs director.

Prince will serve as acting director pending a confirmation vote of the state Senate, replacing former director Linda Chapa LaVia, who resigned in January following calls for her to step down due to the department’s handling of the outbreak at LaSalle. Peter Nezamis has been acting director since Chapa LaVia’s January resignation.

The formation of the IIPP was prompted after all three agencies — IDVA, IDPH and USDVA — jointly conducted a site visit together on Nov. 12 at the LaSalle Veterans Home in response to a COVID-19 outbreak there.

Members of the team consisted of an infection control manager at the USDVA, two infection prevention consultants with IDPH and a medical consultant with IDPH.

The LaSalle home has reported 36 resident deaths due to COVID-19 since November. The homes at Quincy and Manteno have also experienced coronavirus outbreaks that have resulted in 24 and 19 resident deaths, respectively. The home in Anna did not report any resident deaths resulting from COVID-19 related illnesses, according to the report.

Outbreaks at the three homes have waned since they were initially reported.

According to the report, March 1 was the last new positive resident test at LaSalle; Jan. 1 was the last new positive resident test at Quincy; Nov. 25 was the last new positive resident test at Anna; and six residents who tested positive between Feb. 1 and Feb. 13 at Manteno were the latest cluster of positive tests there.

The project team conducted a total of 15 on-site, in-person visits across all four homes, including five total visits to LaSalle, between Nov. 12 and Feb. 11. They also held weekly 45-minute videoconferences and daily communications between the homes and agencies.

A report from first on-site visit to LaSalle on Nov. 12 documented multiple inappropriate uses of personal protective equipment, violations of social distancing requirements and the use of less effective nonalcohol based hand sanitizer.

The IIPP report makes six broad recommendations for improving the response to COVID-19 and other potential viral outbreaks at the four veterans’ homes.

First, the report recommends the facilities “develop and implement system-wide policies, procedures, and practices for infection prevention,” and “create a position for a Senior Infection Preventionist and establish a new, system-wide Infection Prevention Committee.”

The second recommendation is for facilities to “expand system capacity for infection prevention.”

This recommendation includes providing staffing levels based on U.S. Centers for Disease Control and Prevention guidance, such as at least one full-time position for each facility with more than 100 beds.

The third and fourth recommendations advise that the facilities “broaden and deepen the perspective of the infection preventionists,” and “strengthen staff-wide training.”

Lastly, the report recommends facilities closely monitor compliance with the infection policy, including compliance with PPE guidelines and hand hygiene, and establish collaboration among top management and frontline staff to problem solve and develop strategies for infection prevention.

Chairpersons of the House and Senate Veterans Affairs committees, Rep. Stephanie Kifowit and Sen. Tom Cullerton, did not immediately respond to requests for comment about the report.


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


Sarah MansurSarah Mansur

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