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2    WHEREAS, The Quincy Veterans' Home, founded in 1886, is the
3largest and oldest of the Illinois Veteran Homes; and
4    WHEREAS, The Quincy Home has approximately 400 residents
5and employs over 500 full-time staff; and
6    WHEREAS, Legionnaires' disease is a severe, often lethal,
7form of pneumonia caused by a bacterium found in both potable
8and nonpotable water systems; and
9    WHEREAS, In July 2015, the first cases of Legionnaires'
10disease were discovered at the Quincy Veterans' Home and would
11shortly claim the lives of twelve residents; and
12    WHEREAS, In 2016, more than fifty residents and staff
13contracted Legionnaires' disease, leading to the death of
14another resident veteran; and
15    WHEREAS, The Centers for Disease Control conducted a study
16of the Legionnaires' disease outbreak at the Quincy Veterans'
17Home in 2015 and had an extensive list of recommendations for
18the Home; and
19    WHEREAS, In 2016, the Quincy Veterans' Home followed the



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1recommendations of the CDC and completed renovations of parts
2of its plumbing system, which included the construction of a
3water treatment plant capable of providing higher quality
4water; and
5    WHEREAS, In Fall 2017, an additional three residents
6contracted Legionnaires' disease after infrastructure updates
7were made; therefore, be it
9ASSEMBLY OF THE STATE OF ILLINOIS, that the Auditor General is
10directed to conduct a performance audit of the Illinois
11Department of Veterans' Affairs' management of Legionnaires'
12disease outbreaks; and be it further
13    RESOLVED, That this performance audit include, but not be
14limited to, the following determinations:
15        (1) The responses of the Department of Veterans'
16    Affairs to the outbreaks of Legionnaires' disease in 2015,
17    2016, and 2017, including the recommendations made in the
18    2015 study by the Centers for Disease Control and the
19    Department's actions to address those recommendations;
20        (2) The type, cost, and timing of any infrastructure or
21    other building improvements intended to contain the
22    further spread of Legionnaires' disease or prevent its
23    reoccurrence;



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1        (3) The nature of changes made by the Department in
2    operating protocols and staff training thereon, intended
3    to contain the further spread of Legionnaires' disease or
4    prevent its reoccurrence;
5        (4) The nature and extent of monitoring conducted by
6    the Department to determine whether the improvements and
7    protocols put in place are effective to ensure the safety
8    of residents and staff at the Quincy Veterans' Home;
9        (5) The amount of State moneys received and the amount
10    of state moneys expended by the Department or any other
11    State agency during State fiscal years 2015, 2016, 2017,
12    and 2018 for infrastructure improvements, monitoring, and
13    other measures taken to address the Legionnaires' disease
14    outbreaks; and
15        (6) To the extent information is available, whether the
16    Quincy Veterans' Home has been the subject of any reviews
17    since 2015 to determine its compliance with applicable laws
18    and regulations with regard to the care of its residents
19    and, if so, the results of those reviews; and be it further
20    RESOLVED, That the Illinois Department of Veterans'
21Affairs and any other State agency or other entity or person
22that may have information relevant to this audit cooperate
23fully and promptly with the Auditor General's Office in its
24audit; and be it further



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1    RESOLVED, That the Auditor General commence this audit as
2soon as practical and report its findings and recommendations
3upon completion in accordance with the provisions of Section
43-14 of the Illinois State Auditing Act; and be it further
5    RESOLVED, That a suitable copy of this resolution be
6presented to the Auditor General.