REPORT HIGHLIGHTS

STATE’S RESPONSE TO THE COVID-19
OUTBREAK AT THE LASALLE VETERANS’ HOME

PERFORMANCE AUDIT

Release Date:  May 5, 2022

State of Illinois, Office of the
Auditor General
FRANK J. MAUTINO, AUDITOR GENERAL

To obtain a copy of the Report
contact:
Office of the Auditor General, Iles
Park Plaza, 740 E. Ash Street,
Springfield, IL 62703
(217) 782-6046 or TTY (888) 261-2887

This Report Digest and Full Report are
also available on the worldwide web at
www.auditor.illinois.gov

REPORT HIGHLIGHTS

BACKGROUND:

On April 28, 2021, the Illinois House
of Representatives adopted House
Resolution Number 62, which directed
the Office of the Auditor General to
conduct a performance audit of the
State's response to the management of
the COVID-19 outbreak at the LaSalle
Veterans' Home (see Appendix A). The
outbreak at the LaSalle Veterans’ Home
occurred in late October 2020, when
COVID-19 cases were trending up
statewide. Also, the outbreak occurred
prior to the COVID-19 vaccine. Based
on tests administered prior to the end
of October 2020, 13 residents and
staff (8 residents and 5 staff) tested
positive. According to the Department
of Public Health (IDPH), by November
4, 2020, 57 residents and staff (46
residents and 11 staff) had tested
positive for COVID-19. By the end of
November 2020, 203 total positive
cases had been identified at the
LaSalle Home. According to IDPH, in
total, between October 23, 2020 and
December 9, 2020, 109 of the Home’s
128 residents (85%) and 88 of the
Home’s 231 staff (38%) had tested
positive for COVID-19.

Key Findings:

• Although the Illinois Department of
Public Health (IDPH) officials were
informed of the increasing positive
cases almost on a daily basis by the
Illinois Department of Veterans’
Affairs (IDVA) Chief of Staff, IDPH
did not identify and respond to the
seriousness of the outbreak. It was
the IDVA Chief of Staff who ultimately
had to request assistance. The IDVA
Chief of Staff inquired about a site
visit and about rapid tests (November
9th), and inquired about getting
antibody treatments (November 11th)
for LaSalle Veterans’ Home residents.
From the documents reviewed, IDPH
officials 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 for long-term care
settings prior to being requested by
the IDVA Chief of Staff.

• The outbreak at the LaSalle
Veterans’ Home occurred at a time when
COVID-19 cases were trending up
statewide. Positive cases in Region 2
(where the LaSalle Home is located)
increased from 12,108 in October 2020
to 37,825 in November 2020, an
increase of 212.4 percent. Also, the
outbreak occurred prior to the
COVID-19 vaccine. Prior to the
outbreak that began at the end of
October 2020, only six staff members
had tested positive for COVID-19. Even
though the LaSalle Home had designated
areas for isolation and quarantine,
once the virus entered the Home, it
spread very rapidly.

• The time it took to receive staff
COVID-19 testing results from the IDPH
lab was lengthened by the collection
method used by the LaSalle Home. The
Home tested staff over a three day
period. As a result, new tests of
staff collected on November 3rd, 4th,
and 5th were not delivered to the IDPH
lab until Thursday, November 5th, even
though the first two staff members
from the outbreak were found to be
positive by Sunday, November 1st. The
IDPH lab published the majority of the
test results on either Friday or
Saturday. Therefore, the delay in
getting testing results was primarily
due to the collection method used by
the LaSalle Home. Additionally, the
testing method, collecting tests over
three days, was not in compliance with
the facility’s policy, which allowed
for testing over two days.

• IDVA provided auditors with new
infection prevention policies on June
17, 2021, which were drafted with the
assistance of IDPH, which were
officially implemented on April 23,
2021. The purpose of these policies
was to establish a comprehensive and
integrated infection prevention and
control program at all Illinois
veterans’ homes. A system-level
Infection Prevention and Control
Committee was tasked with
standardizing policies and procedures
and was required to oversee infection
prevention at the Illinois veterans’
homes. These policies also updated
infection prevention training
requirements for staff at Illinois
veterans’ homes.

• The LaSalle Veterans’ Home
implemented several infrastructure
improvements during FY20 and FY21 as a
result of the COVID-19 pandemic and
outbreak at the Home. Prior to the
outbreak, external firms were
commissioned to design and build
airborne infection isolation rooms at
IDVA Homes, including the LaSalle
Home. The construction of the
isolation rooms was initiated in March
of 2020 and operational by May 23,
2020. Payments made for the
construction of the isolation rooms
totaled $1,057,470. In total, the cost
for all infrastructure improvements
from March 2020 through June 2021
totaled $1,162,719.

• The State expended approximately
$3.4 million between FY20 and FY21 as
a result of the COVID-19 pandemic at
the LaSalle Veterans’ Home. According
to documentation provided by IDPH and
IDVA, expenditures included PPE,
infrastructure improvements, and
COVID-19 testing for both the COVID-19
pandemic as a whole and the outbreak
at the LaSalle Home that began in late
October 2020. Auditors concluded that
the outbreak did not significantly add
to the Home’s overall COVID-19-related
costs during FY20 and FY21.

• The Department of Human Services’
Office of the Inspector General (DHS
OIG) investigation reported that the
significance of the outbreak was not
being meaningfully tracked by the IDVA
Chief of Staff. In fact, auditors
found the Chief of Staff provided
detailed information to IDPH that was
used by the Director of IDPH in her
daily COVID-19 briefings. IDPH and the
First Assistant Deputy Governor for
Health & Human Services were provided
detailed emails of COVID-19 positive
cases and related deaths for each of
the four State veterans’ homes by IDVA
on November 2nd, 3rd, 4th, 5th, 6th,
9th, 10th, 12th, and 13th. The primary
finding of the DHS OIG report, which
indicated the “absence of any standard
operating procedures in the event of a
COVID-19 outbreak,” was flawed.
Auditors identified hundreds of pages
of guidance provided by IDPH and by
the Centers for Disease Control. In
addition, COVID-19 policies were
formulated by IDVA specifically for
the LaSalle Veterans’ Home as well as
a Continuity of Operations Plan that
was reviewed by Illinois Emergency
Management Agency and was provided to
IDPH back in March 2020.

Key Recommendations:

The audit report contains three
recommendations:

• IDVA should ensure each of its
Veterans' Homes have policies and
procedures in place that mandate
timely testing of its residents and
employees during COVID-19 outbreaks,
and should ensure that residents and
employees are tested according to the
policy.

• IDPH should:
– clearly define its role in relation
to monitoring COVID-19 outbreaks at
Illinois Veterans’ Homes; and
– develop policies and procedures that
clearly identify criteria which
mandate IDPH intervention at Veterans’
Homes during an outbreak of COVID-19.

• IDVA should ensure that:
– the IDVA Director works with the
Department of Public Health and the
Governor’s office during COVID-19
outbreaks to advocate for the health,
safety, and welfare of the veterans
who reside in the Homes under IDVA’s
care; and
– the Senior Home Administrator
position is filled and the duties of
the position include monitoring and
providing guidance to the Veterans’
Homes during COVID-19 outbreaks.

This performance audit was conducted
by the staff of the Office of the
Auditor General.