CARBONDALE — An audit of the Illinois Department of Veterans' Affairs that Illinois Gov. J.B. Pritzker requested shortly after taking office has been delivered to the agency.
The auditor, engineering services firm Tetra Tech, reviewed more than 250 policies and procedures, surveyed employees and residents, and did onsite inspections at each of the IDVA’s four veterans homes, according to an executive summary of the audit, obtained by The Southern Illinoisan via Freedom of Information Act request.
The homes at Anna, Quincy, Manteno and LaSalle care for about 1,000 veterans, in a mix of independent and assisted living.
Since 2015, 15 veterans’ home residents at Quincy and Manteno have died of Legionnaires’ disease, a severe form of pneumonia contracted by inhaling infected water vapor.
The deaths led the state to update sinks, showerheads, plumbing and water treatment infrastructure at its homes, removing old fixtures containing legionella bacteria.
The deaths also brought sharp criticism on the Rauner administration for its failure to immediately publicize the initial outbreak, in 2015, and its delay in seeking help from the federal Centers for Disease Control and Prevention to control the disease.
Shortly after the 15th IDVA Legionnaires’ death in January, Pritzker requested a “complete review of the health, safety, and security process,” at all four homes, via executive order.
In its summary of the audit, Tetra Tech praises the four homes as clean, inviting, and “resident-centric” environments, where both staff and residents feel safe.
All four homes, auditors noted, are developing water management plans to minimize public health risks like Legionnaires’.
But they’re not always working together.
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Among its 22 recommendations, Tetra Tech repeatedly describes a need for shared policies and best practices across the four homes, in areas from water management, to facilities maintenance, to housekeeping and new employee orientation.
The report also recommends providing more training to employees in “health and safety, fire safety and CPR,” adding staff on overworked maintenance crews and prioritizing several urgent facilities improvements.
Two work areas at Quincy, the state’s biggest home, have non-functioning sprinkler or fire-alarm systems, auditors found, and multiple sidewalks need to be demolished and rebuilt.
At Manteno, roads are riddled with cracks and potholes that could slow down emergency vehicles. Across the facilities, “numerous ceiling tiles were stained, missing or broken,” presenting disease control and mold exposure risks, Tetra Tech found.
Going forward, centralized electronic tracking of maintenance needs, auditors recommended, could ensure aging facilities are addressed promptly.
Developing common quality standards across homes in other areas, like housekeeping, is also key to improving conditions, auditors added.
The IDVA received the Tetra Tech report in late May, and will work to implement all of its recommendations as quickly as possible, said Evan Fazio, the department’s public information officer.
“The audit carried out based on Governor Pritzker’s executive order provides our department with an important framework to move forward,” Fazio said. “We will be working hand in hand with the governor’s office to implement the governor’s significant investments in our veterans’ homes and ensure that all of our state’s heroes get the care they deserve.”
Among the investments Pritzker plans are $20.6 million for a new Chicago veterans’ home and $230 million to build a new, state of the art facility at Quincy, the IDVA’s oldest home.
Both expenditures were included in the governor’s $41.5 billion capital plan, passed by legislators last week.
Requests for comment on the audit from Tetra Tech went unanswered. Multiple requests for comment to Pritzker Spokesperson Jordan Abudayyeh went unreturned.