An internal watchdog report blamed “inadequate leadership” in Gov. JB Pritzker’s administration, including a former agency director who “abdicated” her duties, for a COVID-19 outbreak last fall at the state-run LaSalle Veterans’ Home that killed dozens of residents.

The long-awaited report by the acting inspector general of the Illinois Department of Human Services, Peter Neumer, revealed a lack of preparation, poor communication and training and an ignorance of proper infectious-disease protocols that combined to create one of the deadliest COVID-19 outbreaks in the state.

“The lack of a comprehensive COVID-19 plan, including the absence of any standard operating procedures in the event of an outbreak within the Home, was a significant contributing factor to the home’s failure to contain the virus,” Neumer wrote in his report. “The risks concerning transmission and control of COVID-19 were well known by October 2020, yet the home lacked any formal preparedness and response plan.”

All told, the November COVID-19 outbreak at LaSalle claimed 36 veterans’ lives and resulted in 109 other veterans and 116 staff members testing positive for the virus.

As the situation roared out of control at LaSalle, conditions inside the home were described with such superlatives as a “whirlwind,” “frantic” and “chaotic,” with one nurse telling Neumer that “nobody seemed to know what to do.”

His report, obtained by WBEZ, was commissioned by the governor.

Pritzker ran in 2018, in part, on a platform of cleaning up the “fatal mismanagement” of multiple Legionnaires’ disease outbreaks at the Quincy Veterans’ Home by his predecessor, Republican Bruce Rauner.

The revelations in this response to a bigger and far more fatal public-health catastrophe at LaSalle threaten serious political blowback for Pritzker as he mulls a potential 2022 re-election bid. Republicans have already ramped up criticism of the administration response.

The new report presents a broad case of malfeasance at the home and within the Illinois Department of Veterans’ Affairs and poses troublesome questions about whom Pritzker appointed to run the state agency overseeing the facility, which is about 95 miles southwest of Chicago.

“We understand that this is going to be heartbreaking for some people to read,” Pritzker’s new acting IDVA Director, Terry Prince, said in an interview with WBEZ. “We were working on policies long before I got here. Putting things in place, moving people into new positions, ultimately relieving some individuals from their jobs to make sure that we had the right people in place to ensure this type of outbreak — and more importantly this result of the outbreak — wouldn’t happen again.”

Failure of oversight

Neumer’s report paints an unflattering picture of former IDVA Director Linda Chapa LaVia, a former member of the Illinois House who co-chaired hearings into how the Rauner administration fumbled fatal Legionnaires’ outbreaks at Quincy between 2015 and 2018.

Chapa LaVia resigned from her post last January in a departure that coincided with a general Pritzker administration housecleaning within her agency following the calamity at LaSalle. A month earlier, the governor ousted the LaSalle administrator and the facility’s director of nursing because of their handling of the outbreak.

As the pandemic was ravaging, Chapa LaVia appeared to have relegated key duties to a top aide, enough so that key administrators in her agency questioned whether she was properly engaged in overseeing the department, Neumer’s report said.

“Several witnesses noted that Ms. Chapa LaVia was not a hands-on or engaged day-to-day director and that [her chief of staff] managed the agency,” the report said, with one agency administrator “observing that it was as if Ms. Chapa LaVia had ‘abdicated’ her authority” to the agency chief of staff.

Neumer noted in his report that Chapa LaVia was not cooperative in his investigation. Through a lawyer, she agreed to answer questions only if investigators were willing to submit them ahead of an interview, a courtesy not extended to dozens of other agency officials and staff who were spoken to as part of the report. Investigators wouldn’t, and she was not interviewed, the report stated.

State law requires that current state employees cooperate with any inspector general investigation. The same standard does not apply to ex-state employees under existing law.

Failure to prepare

During Chapa LaVia’s watch, the LaSalle facility had done little serious preparation for a COVID-19 outbreak, the report said, even though the disease was sweeping through the state.

By Nov. 1, the date of the first confirmed cases of COVID-19 at LaSalle, nearly 9,800 Illinoisans had died from the virus and another 417,000-plus had been sickened, and case counts in the facility’s home county, LaSalle County, had been surging.

“Despite this forewarning in the community, the home was complacent and did not develop comprehensive COVID-19 policies,” the report said. “With no documented COVID-19 specific policies or outbreak plan, the home’s staff were confused on the appropriate course of action throughout the outbreak, and thus, its operations were inefficient, reactive, and chaotic.”

The lack of preparation and structure meant healthy residents at the home were inadvertently being placed alongside residents known to have tested positive for COVID-19.

One instance cited in the report involved two sets of roommates who were tested, with each set containing one COVID-positive veteran and one COVID-negative veteran. Those veterans who had tested negative but had recently been exposed were moved to a non-infected wing of the home without any quarantine period. The next day, in that supposedly safe environment, both negative veterans tested positive.

“A detailed outbreak plan was necessary based on the known risks and rising community positivity rates at that time. The absence of such a plan resulted in unnecessary and unsafe movement of positive and potentially positive veterans throughout the home, contributing to the outbreak’s rapid spread,” the report said.

Meanwhile, as the home was aflame with disease, the situation was being monitored within Chapa LaVia’s office by her chief of staff, who had no background in long-term medical care. The report said that Chapa LaVia aide was slow to react to the growing body count, taking nine to 10 days to “recognize that the positive results at the home were a real problem.”

By Nov. 9, the home had more than 60 positive cases and by Nov. 13, 10 veterans were dead.

“Given this data, [the chief of staff’s] delayed reaction was inexcusable and contributed to the prolonged nature of the outbreak,” the report said.

Death lead to lawsuit

Whether the problems identified at LaSalle rise to the level of criminality is an unknown. A criminal investigation into the Rauner administration’s mishandling of the Legionnaires’ outbreaks at Quincy was closed by Attorney General Kwame Raoul without any charges.

But there already are civil ramifications. One family has sued the state over the death of their loved one at LaSalle.

Raoul settled negligent death cases with 12 families whose loved ones died in the Legionnaires’ disease outbreaks at the Quincy home. The cost to taxpayers was $6.4 million.

Illinois lawmakers instituted a new limit of $2 million on cases before the Court of Claims, the quasi-judicial body that handles lawsuits against the state, after WBEZ reported that each Quincy family was capped at awards no greater than $100,000 — the lowest such award in the country.

Dave McKinney and Tony Arnold cover Illinois politics for WBEZ. Follow them @davemckinney and @tonyjarnold.