SPRINGFIELD – The Illinois Department of Veterans Affairs (IDVA) today released an independent report that was requested by the Governor’s Office last fall to fully investigate a COVID-19 outbreak at the LaSalle Veterans home and detailed its progress on corrective actions that the agency began taking last fall.

The report was conducted by the Illinois Department of Human Services’ Office of the Inspector General (OIG) and Armstrong Teasdale, LLP, and it outlines their findings regarding the regulations and protocols at the home, among other data points.

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Starting last fall and now under the leadership of recently appointed Acting Director Terry Prince, IDVA is implementing corrective actions and has already taken steps to meet many of the recommendations prior to receiving the report on Monday. This includes forming new Infection Control Committees at each of the veterans’ homes led by an Infection Control Director, restructuring senior leadership, and streamlining and strengthening department policies and internal communications.

View the complete report here.

On April 1, 2021, Governor JB Pritzker appointed Terry Prince, a 31-year Navy veteran with deep experience in military and veterans’ medical care, to serve as Acting IDVA Director. Prior to this role, Acting Director Prince was Superintendent of the Ohio Veterans Homes and Command Master Chief at Naval Hospital Camp Lejeune and the Walter Reed National Military Medical Center. The new Acting Director is focused on increased visibility and communication for department leadership, improved organizational structure and staff training, and hiring for several new and vacant roles for the agency.

“There is nothing more critical to our department’s mission than ensuring the heroes in our homes are safe and receive the quality care they deserve,” said Acting IDVA Director Terry Prince. “As the acting director of the Illinois Department of Veterans’ Affairs and as a Navy Veteran of more than 30 years, my heart breaks for the families who lost loved ones to COVID-19 in our Veterans’ Homes. In my prior role, I led the Ohio Veterans’ Homes and saw firsthand the enormous challenges this pandemic unleashed on the state facilities that care for our heroes. Lessons learned there and here in Illinois from this unprecedented crisis are already being implemented as we work to make IDVA the department that our veterans deserve. Let me be clear, we will seize any and every opportunity to better ensure the safety of veterans in our care and every single corrective action outlined in this report will be implemented with urgency.”

Prior to the COVID-19 pandemic, IDVA and the LaSalle Veteran’s Home implemented policies and procedures aimed at reducing the risk of outbreaks among staff and residents. At the beginning of the pandemic, all IDVA homes followed recommendations outlined by the Centers for Disease Control and Prevention (CDC) and the Illinois Department of Public Health (IDPH) regarding face masks, social distancing, and handwashing, among other guidelines. In the early days of the pandemic, IDVA restricted visitation to veterans’ homes to protect residents and staff from community spread and prevent COVID-19 from entering the homes.

In the wake of the November 2020 outbreak, the LaSalle Home took additional measures as advised by IDPH to slow the spread of the virus. Those measures included, but were not limited to, daily antigen testing for all staff, additional instruction regarding the use of PPE, and additional vital monitoring for residents who had previously tested positive for COVID-19. The LaSalle home has also established a quality assurance committee to identify and remedy any shortcomings regarding infection control.

Acting Director Terry Prince Bio

Terry Prince is a senior executive leader and 31-year United States Navy veteran. Most recently, Prince served as Superintendent of the Ohio Veterans Homes where he oversaw three facilities, including the nation’s 5th largest skilled nursing home and an independent living community. Previously, he served as Force Master Chief and Director of the United States Navy Hospital Corps. In that role, Prince served as a senior advisor to the Surgeon General of the United States Navy and a member of the Navy Medicine’s Executive Steering Committee. Prior, he served as Senior Enlisted Leader at the Defense Health Agency and at Walter Reed National Military Medical Center. Prince began his military career in 1986, serving in the Dental Technician and Hospital Corpsman ratings. Prince has received a number of awards including the Legion of Merit, the Defense Superior Service Medal, the Joint Meritorious Service Medal and many more. He retired from the military in July 2017. He earned a Bachelor of Arts from Chapman University and is a graduate of the Navy Senior Enlisted Academy, Command Master Chief Program and the National Defense University Keystone Fellowship.

Corrective Actions & IDVA Actions

The Illinois Department of Veterans Affairs accepts all recommendations and corrective action plans. This document provides information regarding each corrective action.

1. Corrective Action: Create centralized policies and develop outbreak drills and stress tests

IDVA fully recognizes the importance of structured, centralized policies, outbreak drills and stress tests. Acting Director Prince has extensive experience developing, testing, and training staff on new policies and has already begun creating and implementing new centralized policies that the department plans to promptly drill and stress test. In his first month, the acting director implemented new policies on overall infection prevention as well as updated COVID-19 policies related to prevention, testing, PPE, masking, cleaning and disinfection, staff health checks, and hand hygiene. The acting director plans to continue a thorough review of all department policies in the coming weeks to determine additional opportunities for improvement.

At the Lasalle Home specifically, Acting Home Administrator Anthony Vaughn has worked diligently over the past several months to improve internal communications and ensure understanding and compliance with Home policies. The Acting Director and Home Administrator have also created a separate committee dedicated exclusively to quality assurance in home operations. This committee, which has already begun to meet and recommend improvements in the home, will also provide the foundation for implementing drills and stress tests on new policies.

2. Corrective Action: Educate staff on the importance of quality infection control for any infection

Infection control and prevention are top priorities for the acting director and have been a focus of his first month in the role. The acting director has visited each of the veterans’ homes and met with staff at all levels to hear their suggestions and concerns and understand their needs. Recognizing the challenge infection control has posed for the homes historically, the acting director is forming Infection Control Committees at each home to be led by an Infection Control Director. These committees will focus exclusively on infection control, initially related to COVID-19 before expanding to broader infection control at all Illinois veterans’ homes.

As previously mentioned, this is in addition to a LaSalle Home specific quality assurance committee, which will help identify and remedy any shortcomings regarding infection control.

These efforts must be paired with robust training for all staff on infection control and department policies. Regular training of staff on COVID-related matters has continued, with the most recent in-service training taking place in March of 2021. The acting director plans to expand training for staff on new and existing policies and will implement drills and stress tests on any new policies or programs as appropriate.

3. Corrective Action: Integrate the standards for long-term care facilities, at least in part, into the Veterans’ Home Code

This will require legislation and IDVA welcomes the opportunity to work with legislators to integrate additional long-term care standards into our code.

Throughout the COVID-19 pandemic, IDVA operated under all applicable guidance and regulations issued by the CDC and IDPH for long term care facilities and in its current operations, meets most, if not all, standards for long-term care facilities.

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4. Corrective Action: Develop an infection control task force or committee within the Home

This has been completed by the acting director for both the veterans’ homes as a whole and the Lasalle Home specifically, through the LaSalle Quality Assurance team and the IDVA Infection Control Committee.

5. Corrective Action: Establish and clearly communicate thresholds for when IDPH visits the Home

This has been completed. IDVA has put in place a new policy that will govern how and when employees will notify local and state public health departments of COVID-19 or other outbreak situations. Additionally, IDVA will continue to follow all state rules, regulations, and statutes for notifying local, state, and federal health departments of incidents and outbreaks. Local health departments continue to be the first line of defense and support for our veterans’ homes, pursuant to the public health structure in Illinois.

6. Corrective Action: Provide a suitable independent outlet for escalating internal complaints

Through the labor structure within the state of Illinois, employees have numerous mechanisms for escalating internal complaints in addition to union representatives and supervisors. These include union grievances processes, human resources, EEO officers, and the Office of the Executive Inspector General (OEIG). Additionally, IDVA supports the second amendment to Representative Kifowit’s legislation: HB 359, which would create a Veterans’ Accountability Unit reporting to the OEIG to receive recommendations and complaints from those served by the department.

A key priority for the acting director is ensuring the culture of the department is one in which employees feel empowered to raise suggestions and concerns. The director and the senior team plan to be a consistent presence in all of the homes moving forward and in regular communication with staff at all levels to ensure this is the case.

7. Corrective Action: Create temporary positions or consultancies to ensure essential positions do not remain unfilled

Acting Director Prince has made it a priority to hire qualified experts in essential positions and is moving forward with urgency. The department is working diligently with the Illinois Central Management Services (CMS) to bring people on board as quickly as possible within CMS rules and regulations for hiring. If we experience further delays in filling positions, we are willing to look into personal service contracts.

The department is in the process of creating Infection Preventionist positions at each of the homes as well as an Infection Control Director to fill an essential need for the department to have an expert providing consistent infection control guidance and recommendations.

8. Corrective Action: Require one Veterans Advisory Council member to be appointed by IDPH

We are committed to meeting the goal of this corrective action, which is to have more medical expertise in the centralized operations of IDVA. To best meet this goal, we are developing infection control positions to work alongside the senior homes administrator and within the homes to make sure that all of our Veterans are receiving the same critical care and attention based on updated infection control standards. The acting director is also in the process of creating a “Medical Director” position. Individuals in all of these roles will work closely with IDPH and local health departments to ensure proper care for veterans.


9. Corrective Action: Adopt the recommendations of the audit and succeeding interagency memo as soon as possible.

We are committed to adopting all corrective actions included in this report and have either completed or are in the process of completing all recommendations.

IDVA and the Governor’s Office received the report Monday and reviewed its findings to update the public on progress.

The Department is also providing additional context and documents that were not given full consideration by the inspector general’s report:

Prior to the COVID-19 pandemic, the department had nearly 40 general infection control policies in place to address issues such as the use of personal protective equipment, handwashing, administering vaccines, and using masks. At the start of the pandemic, both the Illinois Department of Veterans Affairs and the Illinois Veterans’ Home at LaSalle developed plans for the Continuity of Operations (COOP Plans). The purpose of the plans was to ensure that there would be a minimal disruption to IDVA and the Home during an emergency that may impact staffing levels, service availability, or the safety of residents and staff.

After the pandemic began in March 2020, the senior staff of the LaSalle Home received regular updates from IDPH on the evolving best practices to combat the spread of COVID-19. As IDPH issued updated recommendations regarding the use of masks, social distancing, testing, visitation, and other COVID-related matters, senior LaSalle Home staff would issue directives to all staff to abide by the new guidance. These recommendations were updated frequently as experts learned more about this novel virus and the Home worked to immediately implement any and all new guidance. The home was also in regular communication with the LaSalle local health department, our first line of support as issues arise.

The Home instituted a number of policies prior to the start of the November 2020 outbreak to formalize some of these rules as the scientific community’s understanding of COVID-19 developed. The Home developed policies and procedures regarding family visitation, COVID-19 testing of staff and residents, and identifying and responding to suspected or confirmed exposure to COVID-19. Given the evolving nature of knowledge in this field, the Home’s procedure on identifying and responding to suspected or confirmed exposure to COVID-19 was modified in September 2020. After receiving guidance from the Illinois Department of Central Management Services, IDVA was able to institute an agency-wide procedure that made testing a requirement for staff on November 2, 2020. The IDVA testing program was also reviewed and approved by IDPH per their guidance at the time. Masks were and are required and this was repeatedly emphasized to staff in addition to standard trainings. By this point in the pandemic, it’s unrealistic that anyone in the general public would not be aware of the importance of wearing masks, let alone staff at the veterans’ homes.

In the wake of the November 2020 outbreak, the LaSalle Home acted immediately on recommendations from the IDPH and USDVA site visits and reports. These included mandating daily antigen testing for staff, ordering staff to only use the free-standing hand sanitizer bottles until the wall hand sanitizers were replaced in late-November 2020, assigning staff to monitor employee compliance with facility entrance requirements, increased staff and resident PCR testing, weekly weighing of residents, and additional vital monitoring for residents who had previously tested positive for COVID-19. Additional in-service trainings were held to refresh staff on COVID-19-related rules. Also, senior staff instituted patrols to ensure that employees complied with expectations regarding PPE, temperature checks, and social distancing. Employees who were noncompliant were subject to counseling and oral reprimands.

After extensive consultation with the IDPH infection control expert assigned to the department, IDVA-wide procedures on infection prevention, COVID-19 testing, COVID-19 response, vaccines, hand hygiene, PPE, and cleaning were formalized on April 23, 2021. These procedures built upon many of the practices and procedures that had been in place at the LaSalle Home. Novel elements of these procedures had begun to be implemented at LaSalle prior to their formalization in April 2021. Some of these policies were modified by the IDPH infection control expert in March of 2021 due to the updated CDC guidance.

Provided in the appendix of this document you will find:

• The COOP (Continuity of Operations) plans that show the initial COVID-19 response plan - 1 – Outbreak Plans
• The policies, directives and communications for staff to prevent the introduction and spread of COVID in the facility - 2a – Policies; 2b – Directives and Communications
• The communications regarding IDPH/CDC/CMS guidance to the department - 4b – IDPH, CMS, and other Guidance
• Trainings for staff - 5 – Training

Read More:

Nov 25, 2020 | Durbin, Duckworth Discuss Covid-19 Outbreak At Lasalle State Veterans Home With Idva Director, Call For Investigation Nov 25, 2020

Dec 8, 2020 | LaSalle Veterans Home Leader Terminated After 32 Die in COVID-19 Outbreak   Dec 8, 2020

May 3, 2021 | Durbin, Duckworth Statement On State IG Report On LaSalle State Veterans' Home May 3, 2021

Dec 7, 2020 | IDVA Announces Assistant Director Anthony Vaughn to Serve as Interim Administrator of LaSalle Veterans’ Home Dec 7, 2020

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