The office of the Illinois Auditor General released its report on the handling of the Legionnaires Disease outbreak at the Illinois Veterans’ Home in Quincy Monday.

Among the findings in the report released by Auditor General Frank Mautino:

There was limited guidance on procedures provided to nursing staff prior to the first Legionnaires’ outbreak in 2015.

And, there was no documentation that skilled care residents were monitored frequently after the outbreak.

Among the state auditor’s recommendations are that the Department of Veterans’ Affairs and the Department of Public Health provide instruction and guidelines to staff in the case of another outbreak, along with developing monitoring protocols.

From 2015 to 2018, 66 veterans’ home residents and eight employees and volunteers tested positive for Legionnaires’ Disease. Thirteen residents died.