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Gov. J.B. Pritzker on Friday acknowledged a failure of leadership in hiring a former legislator as director of the state’s Veterans’ Affairs Department following this week’s blistering report that found widespread mismanagement of last fall’s COVID-19 outbreak at the LaSalle Veterans’ Home where 36 veterans died.
Pritzker said he believed Linda Chapa LaVia, a veteran and former state lawmaker from Aurora, was “an ideal person to root out the problems in our veterans homes” following her role on legislative panels investigating outbreaks of Legionnaires’ disease at the Quincy VA home where 14 veterans died.
“But,” Pritzker said, “I have to admit that if I knew then what I know now, I would not have hired her.”
The independent report from the Illinois Department of Human Services’ Office of the Inspector General and the law firm of Armstrong Teasdale detailed systemic mismanagement from top VA officials down to administrators at the LaSalle home, creating an “inefficient, reactive and chaotic” response to controlling the outbreak that began Nov. 1.
Chapa LaVia, who resigned in January and did not agree to be interviewed for the report, was cited in the report for her hands-off management style. The report found that she left her responsibilities to a nonmedical chief of staff who allowed local administrators to run their own homes, gave inaccurate guidance on the pandemic and refused to enlist outside help in the early stages of the outbreak.
The governor’s stark admission of failure in hiring Chapa LaVia comes in the lead-up to an expected bid for a second term. In winning the office in 2018, he accused Republican Gov. Bruce Rauner of “fatal mismanagement” for the Legionnaire’s deaths at the Quincy VA home that began in 2015.
Pritzker said amid the 22,000 pandemic deaths in Illinois, “nothing is more devastating to me than knowing 36 of our veterans, our heroes, died of COVID in a single veterans home.”
“We all needed to know what went wrong here and I asked for this investigation so that we would all know what happened, and we would all know how to fix it,” he said.
He said the state VA began changes months ago, prior to his appointment of new director Terry Prince earlier this month. Prince, a 31-year Navy veteran with a medical background, previously oversaw veterans homes in Ohio.
The report on LaSalle noted that in the months before the outbreak, when no cases had been reported at the home, there was a lack of planning, training and communications between the agency, home administrators and staff — despite the knowledge of the deadly dangers COVID-19 presented for older people living in congregate settings.
The report said there was a failure to conduct contact tracing among COVID-19-positive employees, improper use of protective gear, employees gathering for work who were not required to wear a mask until inside the facility and a screening desk that was “frequently left vacated.”
It also found veterans who tested positive shared space with those who tested negative and sporadic temperature checks of workers. It said some employees treated the virus “like the flu” and some learned of the outbreak from the local news.
Democratic and Republican lawmakers on Friday used terms such as “horrible” and “beyond disgusting” to describe the events that took place at the home — and questioned whether nothing had been learned from the Quincy Legionnaire’s outbreak.
House Republican Leader Jim Durkin of Western Springs, a former prosecutor, went further, saying that beyond the “damning and heartbreaking report,” an investigation into whether anyone should face criminal negligence charges in connection with the deaths needs to be launched.
“The administration just can’t say that we’re going to do a better job next time,” Durkin said. “There has to be accountability for the loss of 36 of our valued heroes.”
In 2018, then-Attorney General Lisa Madigan launched a criminal investigation into the Quincy Legionnaire’s deaths. Her successor, Attorney General Kwame Raoul, closed the investigation last year, saying there was not sufficient evidence to bring charges.
Republicans also blasted Pritzker for appointing a former legislator to run the state VA, and for leaving another key agency position, senior homes administrator, unfilled.
“The governor likes to say he’s following the science, but what actually happened is he put a political person with no experience in charge of this critical agency,” GOP Rep. Deanne Mazzochi of Elmhurst said.
House lawmakers previously approved a resolution requiring the auditor general to conduct a review of the LaSalle outbreak, as was done for Quincy.
Republican State Sen. Sue Rezin of Morris, whose district includes the LaSalle home, said the veterans who died were “my constituents, and I’m incredibly disappointed.”
Rezin faulted the Pritzker administration and the VA for not following the recommendations of the auditor general following a review of the handling of the Quincy Legionnaire’s outbreak., Those recommendations included an immediate on-site review by state public health officials when an outbreak occurs.
Instead, public health officials didn’t show up at the LaSalle home for 10 days, after two residents and two staff members tested positive for COVID-19 on Nov. 1. Within a week of the first positive tests, 60 veterans and 43 staff members tested positive.
“This would have prevented the tragedy at the LaSalle Veterans Home, period. So that’s my frustration, you know, just the lack of action by the department,” Rezin said.
“This report just shows a complete and utter breakdown from the governor’s administration to the Department of Veterans’ Affairs, the Department of Public Health and then the executive administration of the LaSalle veterans home,” Rezin said.
State Sen. Tom Cullerton, the Villa Park Democrat who chairs the Senate’s Veterans Affairs panel, said he expected to call hearings within two weeks on the report.
“There was constant lack of communication, lack of urgency, lack of direction. I mean, just everything was lacking in the way in this response occurred and that ended up being horrific for these veterans and horrific for these families,” said Cullerton, himself a veteran.
Cullerton gave Pritzker credit for initiating the report and seeking to be more transparent than the Rauner administration was with Quincy.
But, he said the LaSalle outbreak provides a “painful reminder” that “when we start trying to save pennies, then we’re not doing a service to our veterans, to our seniors.”
State Rep. Stephanie Kifowit, an Oswego Democrat and Marine Corps veteran who chairs the House Veterans Affairs Committee, said the report “confirms the suspicions of not only myself but other members of the committee of the failure in leadership” at the agency that arose during a series of legislative hearings last fall and winter.
“Throughout the outbreak at the LaSalle Veterans’ Home, dedicated staff were reaching out to me directly with serious concerns and fear for the safety of our decorated veterans who trust Illinois with their welfare,” said Kifowit, pinning the blame on a “lack of protocols, leadership and structure on the department level.”
She said her committee plans to hold hearings on the report and will put together comprehensive legislation to address issues at the Department of Veterans’ Affairs, to be introduced next year.
As a first step, Kifowit sponsored a bill, approved in the House without opposition, that would create an independent Veterans’ Accountability Unit to receive complaints and recommendations from veterans, including residents of the state homes, and others and refer problems to the inspector general.
Another area for improvement would be developing minimum qualifications for the agency’s director, a “professionalizing” of the position, Kifowit said.