A performance audit of the Illinois Department of Veterans' Affairs management of the deadly Legionnaires' disease outbreaks at the Illinois Veterans Home in Quincy, Illinois, found that after the second case of the respiratory illness was discovered in 2015, public health officials did not visit the campus until three days later and nursing staff did not receive sufficient instructions to protect other residents for six days.

The findings of the audit conducted by Illinois Auditor General Frank J. Mautino reflect research into the numerous outbreaks of legionella at the Illinois Veterans' Home in Quincy dating back to Aug. 21, 2015.

Since the 2015 outbreak, 13 people died and dozens were sickened from Legionnaires’ disease. Although the majority of the cases occurred in 2015, there were reported outbreaks in 2016, 2017 and 2018.

The audit pinpointed the cause of the initial outbreak to water that sat unused in a disabled water heater for a month in July 2015. When the water heater began operating again, it was not drained. The water in it was heated to 120 degrees before it was released into the water system – well below the 140 degrees required to kill legionella bacteria.

Key points highlighted in this audit include:

• Although Quincy Veterans Home officials stated skilled care residents were monitored every four hours and independent care residents were monitored twice daily beginning on Aug. 22, 2015, there was no documentation to support that a directive was provided to the nursing staff or whether it was followed.
• In December of 2015, the Centers for Disease Control and Prevention recommended a point-of-use filter installation on all fixtures fed from the potable ho-water system. Filters were not installed on all fixtures other than the showers until after the February 2018 outbreak in April 2018.
• As of June 30, 2018 The State has spent $9.6 million for legionella remediation at the Quincy Veterans Home since the initial outbreak in August 2015.
• According to documentation provided by the Illinois Department of Veterans Affairs, there were no legionella policies in place and there had been no training on legionella prior to the 2015 outbreak at the Quincy Veterans home.
• According to the CDC, many of the optimal conditions for legionella growth were found at the Quincy Veterans' Home, including the presence of bio film, scale, and sediment.

Mautino made four recommendations for the Veterans' Affairs and Public Health departments, including sufficient and timely instructions to nursing staff and caregivers after a Legionnaires' outbreak is confirmed to protect other residents from water vapor exposure.

More details here.

Read the complete report here.