Chambana Sun

The Covid response at the VA Illiana Health Care System facility in Danville was mismanaged according to the Veteran Affairs Office of the Inspector report released Oct. 21.

The Covid infection killed 11 veterans. The report said leaders at the nursing home did not follow appropriate Covid guidelines during the outbreak and that staff were warned about pouting elderly veterans in danger. 

Read the full report below: 

Office of Healthcare Inspections 

VETERANS HEALTH ADMINISTRATION Failure to Mitigate Risk of  and Manage a COVID-19  Outbreak at a Community  Living Center at VA Illiana  Health Care System in  Danville, Illinois

HEALTHCARE INSPECTION REPORT #21-00553-285 SEPTEMBER 28, 2021 

In addition to general privacy laws that govern release of medical  

information, disclosure of certain veteran health or other private  

information may be prohibited by various federal statutes including, but  

not limited to, 38 U.S.C. §§ 5701, 5705, and 7332, absent an exemption or  other specified circumstances. As mandated by law, the OIG adheres to  

privacy and confidentiality laws and regulations protecting veteran health  or other private information in this report. 

Report suspected wrongdoing in VA programs and operations  to the VA OIG Hotline: 

www.va.gov/oig/hotline 

1-800-488-8244

Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  

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Community Living Center at the VA Illiana HCS in Danville, IL 

Executive Summary 

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess  allegations that facility leaders failed to mitigate risk of and manage a community living center  (CLC) COVID-19 outbreak (CLC outbreak) at the VA Illiana Health Care System (facility) in  Danville, Illinois.1In the fall of 2020, 11 residents died of COVID-19, and 239 patients and 92  staff were diagnosed with the virus. The allegations stated that a COVID-19 outbreak occurred in  two CLC neighborhoods—Unity and Victory—and there was a failure to observe general  infection control practices specifically related to respiratory personal protective equipment (PPE)  use, issuance, and training; failure to minimize risk of exposure to COVID-19 for CLC residents  and staff; and inconsistent ongoing testing and failure to notify residents, their families, and staff  of positive COVID-19 test results. The OIG identified concerns related to facility and CLC  leaders’ actions following the CLC outbreak.2 

Infection control measures limit the spread of transmissible diseases and include wearing basic  PPE, such as face masks, and more specialized items such as respirators. The OIG substantiated  that facility leaders and staff failed to observe general infection control practices specifically  related to respiratory PPE including face coverings, face masks, N95s, and powered air purifying  respirators (PAPRs). 

Facility and CLC leaders took steps to emphasize and reinforce the importance of staff wearing  face masks properly. The Facility Director stated support of facility supervisors taking disciplinary action for staff who were noncompliant. However, the OIG found that CLC  residents did not consistently wear face coverings prior to the CLC outbreak and a few CLC staff  did not comply with infection control measures related to face masks both prior to, and after, the 

1 The underlined terms are hyperlinks to a glossary. To return from the glossary, press and hold the “alt” and “left  arrow” keys together. 

2 On March 11, 2020, due to the “alarming levels of spread and severity” of COVID-19, the World Health  Organization declared a pandemic. For the purposes of this review, the OIG defined the duration of the CLC  outbreak to be from the date the first CLC employee tested positive through the date of death of the last resident  diagnosed with COVID-19 (October 13–November 17, 2020).

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

CLC outbreak.3 Moreover, the OIG did not identify any disciplinary actions brought against staff  for noncompliance with infection control practices. 

The OIG substantiated that at the time of the CLC outbreak, the facility’s Environmental and  Safety Section did not identify CLC providers and nursing staff as requiring respiratory  protection.4 The facility’s Safety Manager justified this decision by noting that prior to the CLC  outbreak, there was a lack of contagious diseases in the CLC units. Although not identified by  the facility’s Environmental and Safety Section, the OIG found some CLC providers and one  CLC nursing staff member on the impacted units were N95 mask fit tested prior to the CLC  outbreak. According to facility records, none of the nursing staff on Unity and Victory had  PAPR training prior to the outbreak. This failure resulted in CLC nursing staff providing direct  care to residents with suspected and confirmed diagnoses of COVID-19 without the preferred  respiratory protection.5 

The OIG substantiated that CLC and facility leaders failed to minimize the risk of CLC residents  and staff exposure to COVID-19. Facility leaders did not follow Centers for Disease Control and  Prevention (CDC) guidance when responding to a CLC staff member’s reported cough and  COVID-19 community close contact exposure, and did not remove the employee from direct  patient care. Information as to why this occurred was conflicting. A few interviewees stated that  the notification went through the chain of command and ultimately the Acting Associate Director  of Patient Care Services was contacted and gave instructions that the CLC staff member would  not be tested and should wear a mask and remain at work. However, the Acting Associate  Director of Patient Care Services reported having no knowledge of this event. The Chief of  Geriatrics and Rehabilitation Service arranged for the staff member to be tested the day after  reporting the close contact exposure. The test result was positive for COVID-19. The failure to  

3“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19) Pandemic,” Centers for Disease Control and Prevention (CDC), accessed on January 21,  2021, https://stacks.cdc.gov/view/cdc/90582. Face coverings are most often cloth and are not considered PPE.  “Personal Protective Equipment: Questions and Answers,” CDC, accessed on June 7, 2021.  http://web.archive.org/web/20201001160417/https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use faq.html. Face masks refer to non-FDA regulated procedure masks as well as surgical masks and provide barrier  protection against droplets, including large respiratory particles, and are intended to prevent contamination of the  surrounding area when the wearer coughs or sneezes. Face masks do not require fit testing. Proper wearing of face masks is demonstrated when each loop is around the ears, the bendable edge of the mask is around the bridge of the  nose, the mask covers the nose and mouth, and the lower edge of the mask is under the chin.  4 For this report, the OIG considers providers to include physicians, nurse practitioners, and physician assistants. Facility MCM 001ESS-11, Respiratory Protection Program, December 2017. The facility’s Respiratory Protection  Program is specific to respiratory protection provided by N95s and PAPRs. 

5“Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed  Coronavirus Disease 2019 (COVID-19) in Healthcare Settings,” CDC, accessed on April 22, 2021.  https://stacks.cdc.gov/view/cdc/86043. Preferred respiratory protection for CLC staff providing care to COVID-19  infected residents include fit tested N95s or PAPRs.

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

remove the staff member, who tested positive for COVID-19, resulted in the employee providing  direct patient care and potentially exposing CLC residents and staff to COVID-19. 

Veterans Health Administration (VHA) guidance for CLCs dated March 17, 2020, stated, “the  facility should have a plan to isolate a resident that is suspected of having COVID-19.” VHA  guidance defers to each facility to determine the specifics related to managing the transfer and  isolation of residents suspected of having, or diagnosed with, COVID-19.6 The OIG found the  

facility did not have a comprehensive plan that specified operational details such as roles,  actions, and targeted time frames for transfer and isolation of CLC residents suspected of, or  diagnosed with, COVID-19. The lack of a plan was likely a contributory factor for two COVID 19 positive residents remaining at the CLC for 20 hours after a CLC physician was notified of  the positive diagnoses. One of the residents diagnosed with COVID-19 stayed overnight in a  room with a roommate who was COVID-19 negative. Once the resident was transferred, the  shared room was cleaned. However, due to an inoperable bed management system and the lack  of an alternative system of record keeping, the OIG was unable to determine when the cleaning  occurred. 

The OIG determined that due to a lack of knowledge of infection control requirements, facility  and CLC leaders did not implement additional measures recommended by the CDC when administering aerosol-generating procedures such as nebulizers, that produce spray and droplets  and run the risk of introducing the virus into the air. The failure of CLC leaders to disseminate  this information resulted in two residents receiving aerosol-generating procedures without the  proper infection control measures in place. 

In response to the risks associated with transmission of COVID-19, VHA guidance stated that facilities with CLCs should immediately initiate procedures to cancel all group activities.7 The  OIG team found CLC leaders permitted group therapy sessions to continue throughout the  pandemic and that facility leaders were unaware that group therapy sessions were taking place. The OIG identified that two Unity residents tested positive for COVID-19 the same day after  they attended separate group therapy sessions with five other residents. Similarly, three of the  first four Victory residents diagnosed with COVID-19 attended a group therapy session three  days earlier with six other residents. Continuation of group therapy sessions during the pandemic  increased the risk of exposure to COVID-19 for CLC residents and staff. 

Concerns regarding the separation of nurses working with residents diagnosed with COVID-19  from residents without the diagnosis during the same shift led the OIG team to review nurse  staffing assignments. The OIG found that CLC leaders minimized the risk of cross 

6 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers – Revised 03/17/2020. 7 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers – Revised 03/17/2020.

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

contamination by ensuring staff did not work on both the COVID-19 and non-COVID-19  designated units during the same shift. 

Testing for COVID-19 provides facility staff with information regarding disease activity among  CLC residents and staff.8 The OIG found the facility lacked a plan for post-baseline testing of  residents and staff and that ongoing testing following the CLC outbreak was inconsistent. The  absence of a post-baseline plan resulted in the lack of a standardized process to address ongoing  disease screening, monitoring, and testing of CLC residents and staff for the prevalence of  COVID-19. In addition, the OIG learned that there was no formalized process for tracking  weekly COVID-19 testing of residents and staff. The failure to test represents a missed  opportunity to promptly identify and isolate residents and staff diagnosed with COVID-19 to  reduce further transmission of the virus and may have led to staff members working while  having COVID-19. The OIG did not substantiate that the facility failed to notify residents, their  families, and staff about COVID-19 test results. 

The OIG team identified a failure by facility leaders to proactively develop and implement plans  to prepare for, and respond to, a potential COVID-19 outbreak at the CLC following VHA’s  identification of CLCs as a high-risk environment.9 The OIG found the facility’s initial action  plan, prepared prior to the official recognition of the pandemic, lacked planning specific to CLC  preparedness for mitigating or responding to COVID-19. Rather, facility leaders focused on  planning for an influx of VHA patients from other geographic regions or non-VHA patients from  the community who may have needed to be quarantined at the facility due to a lack of beds  elsewhere. Facility leaders did not initiate CLC-specific planning until the CLC outbreak  occurred, seven months into the pandemic. Analysis by the OIG team identified the lack of CLC specific planning as a contributory factor that led to a failure to identify CLC staff as: requiring  respiratory protection, being fit tested and issued N95 masks, and trained in the use of PAPRs;  developing thorough processes to minimize exposure; and ensuring consistent testing for  residents and staff. The failure to proactively develop and implement plans was a missed  opportunity to ensure that facility and CLC staff were in a state of ongoing readiness should a  CLC resident or staff member become diagnosed with COVID-19. 

Facility leaders developed a post-COVID-19 outbreak action plan following the CLC outbreak.  This plan was based on concerns identified by administrative nurses who provided direct patient  care during the CLC outbreak and led to six teams focusing on the concerns. While the input of  

the administrative nurses was considered, CLC direct care staffs’ input was not included. The  OIG determined that, while the plan was a step in the right direction, actions taken by facility  and CLC leaders following the CLC outbreak lacked input of frontline staff to identify corrective  

8 VHA Memorandum, COVID-19 Guidance on COVID-19 Testing for Community Living Centers and Spinal Cord,  June 11, 2020. 

9 VA Response to COVID-19, Guidance for VA Community Living Centers, March 6, 2020. 

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

actions and opportunities for improvement. A review of vaccination data showed the facility had  made significant progress toward mitigation of the spread of COVID-19 through vaccines; all CLC residents were fully vaccinated as of March 9, 2021. 

The OIG made one recommendation to the Veterans Integrated Service Network Director related  to administrative actions and 14 recommendations to the Facility Director related to face mask  compliance, staff training on and access to respiratory PPE, limiting exposure to COVID-19 for  residents and staff, tracking the completion of room cleaning, following CDC guidelines for  aerosol-generating procedures, disseminating new or updated VHA policies, maintaining  oversight of CLC implementation of VHA guidance, completing a post-baseline testing plan, reviewing facility procedures for the timely management of individuals with positive COVID-19  test results, performing ongoing testing of residents and staff, notifying family members of a resident’s change in condition, identifying and planning for high-risk scenarios, and including frontline staff in after-action reviews of the CLC outbreak. 

Comments 

The Veterans Integrated Service Network and Facility Directors concurred with the findings and  recommendations 1–14 and concurred in principle with recommendation 15. Acceptable action  plans were provided (see appendixes D and E for the Directors’ comments). The OIG considers  all recommendations open and will follow up on the planned actions until they are completed. 

JOHN D. DAIGH, JR., M.D. 

Assistant Inspector General 

for Healthcare Inspections

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

Contents 

Executive Summary......................................................................................................................... i Abbreviations............................................................................................................................... viii Introduction......................................................................................................................................1 Scope and Methodology ..................................................................................................................3 Timeline of Events...........................................................................................................................4 Inspection Results............................................................................................................................9 

Allegation: Failure to Observe General Infection Control Practices Specific to Respiratory  PPE......................................................................................................................9 

Allegation: Failure to Minimize Risk of Exposure to COVID-19............................................13 

Allegation: Inconsistent Ongoing Testing and Failure to Notify of Positive COVID-19 Test  Results...............................................................................................................22 

Contributory Factors .................................................................................................................27 Concern: Facility and CLC Leaders’ Post-CLC Outbreak Actions..........................................29 Conclusion .....................................................................................................................................31 Recommendations 1–15.................................................................................................................33 Appendix A: Facility Campus Map ...............................................................................................35 Appendix B: Facility Inpatient Surge Plan ....................................................................................36 Appendix C: CLC Upsurge Action Plan........................................................................................37 Appendix D: VISN Director Memorandum ..................................................................................39

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

Appendix E: Facility Director Memorandum................................................................................41 Glossary .........................................................................................................................................49 OIG Contact and Staff Acknowledgments ....................................................................................53 Report Distribution ........................................................................................................................54

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

Abbreviations 

ADPCS Associate Director of Patient Care Services CDC Centers for Disease Control and Prevention CLC Community Living Center 

CPAP continuous positive airway pressure EHR electronic health record 

NOD Nurse Officer on Duty 

OIG Office of Inspector General 

PAPR powered air purifying respirator PPE personal protective equipment SOP standard operating procedure VHA Veterans Health Administration VISN Veterans Integrated Service Network

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  

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Community Living Center at the VA Illiana HCS in Danville, IL 

Introduction 

The VA Office of Inspector General (OIG) conducted a healthcare inspection to assess allegations that facility leaders failed to mitigate risk of and manage a community living center  (CLC) COVID-19 outbreak (CLC outbreak) at the VA Illiana Health Care System (facility) in  Danville, Illinois.1 

Background 

The facility, part of Veterans Integrated Service Network (VISN) 12, consists of an acute care  medical center, primary care and mental health clinics, and a CLC. The facility is designated as  Level 3, low complexity, and has 38 inpatient beds for internal medicine and psychiatry, and a  109 bed CLC.2 The facility does not have an intensive care unit or an emergency department.  The main CLC, located in Building 101, is divided into four neighborhoods and provides  services in “rehabilitation, dementia and Alzheimers care, geri-psychiatric care, palliative care  and extended care.”3 Additionally, the CLC includes four smaller, free-standing homes on the  facility campus called Green Houses, which provide the same services found at the main CLC (see appendix A).4 

COVID-19 Impact on Residents of Nursing Homes and CLCs 

As of February 25, 2021, nursing home resident deaths accounted for 35 percent of all United  States deaths due to COVID-19, even though fewer than 1 percent of the population reside in  nursing homes.5 This highlights the risk of death from COVID-19 in residents who are older,  may have complex medical conditions, and may be immunocompromised.6“Older adults and  people who have severe underlying medical conditions like heart disease or lung disease or  

1 Underlined terms are hyperlinks to a glossary. To return from the glossary, press and hold the “alt” and “left  arrow” keys together. 

2 VHA Office of Productivity, Efficiency, and Staffing, The Facility Complexity Model classifies VHA facilities at  levels 1a, 1b,1c, 2, or 3, with level 1a being the most complex and level 3 being the least complex. A level 3 facility  has low volume, low risk patients; few, or no complex clinical programs; and small or no research and teaching  programs. 

3“VA Illiana Health Care System,” VA Intranet, Facilities Locator and Leadership Directory, accessed November  13, 2020. The four neighborhoods are known as Unity, Victory, Abe Lincoln Boulevard, and Stars and Stripes. Two  other units that were vacant pre-pandemic were also located in Building 101. The two vacant units were not  designated as neighborhoods with specific names and were known as 101-1 and 101-2. 

4 The four Green Houses are known as Freedom, Honor, Liberty, and Valor. 

5 VHA Handbook 1142.01, Criteria and Standards for VA Community Living Centers (CLC), August 13, 2008. The  handbook announced VA’s decision to replace the term nursing home care unit with community living center. For  the purpose of this review, the OIG refers to CLC patients as residents. 

6 Orestis A. Panagiotou et al., “Risk Factors Associated With All-Cause 30-Day Mortality in Nursing Home  Residents With COVID-19,” JAMA Internal Medicine, (January 4, 2021): 2.

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

diabetes seem to be at higher risk for developing more serious complications from COVID-19  illness.”7 Additionally, nursing home residents live in close proximity to one another requiring significant hands-on care from staff, thus increasing transmission risks for certain infections  including COVID-19. Further, residents with cognitive or mental disorders may be noncompliant  with wearing personal protective equipment (PPE) and may wander, promoting the spread of  COVID-19 and limiting mitigation efforts in an outbreak. A recent study of nursing home  residents also recognized increased age, masculine gender, and impaired cognitive and physical  function as risk factors for COVID-19 mortality.8 These demographics in mortality risks are  comparable to those residents who live in VA CLCs.9 

Prior OIG Reports 

In March 2020, the OIG conducted an inspection to evaluate Veterans Health Administration’s (VHA) COVID-19 screening processes and pandemic readiness at selected VA medical  facilities. The OIG observed staff conducting screenings at acute care facilities and CLCs, and  interviewed VHA leaders on their facilities’ readiness capabilities.10 The facility at issue in this  report was included in the review and the OIG found (1) the facility reported adequate supplies  and equipment, and (2) access to the CLC was limited, per VHA policy.11 

Allegations and Concerns 

On October 21 and 22, 2020, the OIG received two separate complaints alleging that facility leaders failed to mitigate risk of and manage a COVID-19 outbreak at two CLC neighborhoods,  Unity and Victory. Due to the nature of the allegations and the impact of COVID-19 on the  vulnerable CLC population, the OIG opened a hotline inspection on November 6, 2020, to  review the care of the residents, implementation of and adherence to VHA guidance for CLCs  related to COVID-19, and facility leaders’ management of the CLC outbreak. 

7“Symptoms of Coronavirus,” Center for Disease Control and Prevention, accessed on November 19, 2020.  https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html.  

8 Panagiotou, “Risk Factors,”  

9 VA OIG, Review of VHA Community Living Centers and Corresponding Star Ratings, Report No. 18-05113-81,  February 12, 2020. VHA Handbook 1142.01. 

10 VA OIG, OIG Inspection of Veterans Health Administration COVID-19 Screening and Pandemic Readiness,  Report No. 20-02221-120, March 26, 2020. 

11 VA OIG, Report No. 20-02221-120, March 26, 2020. “VA announces safeguards to protect nursing home and  spinal cord injury patients,” Office of Public and Intergovernmental Affairs, accessed February 9, 2021  https://www.va.gov/opa/pressrel/pressrelease.cfm?id=5400. On March 10, 2020, VA instituted a “no visitors stance” at CLCs and spinal cord injury units. 

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

The complainants alleged 

∙ failure to observe general infection control practices specifically related to respiratory PPE use, issuance, and training, 

∙ failure to minimize risk of exposure to COVID-19 for CLC residents and staff, and 

∙ inconsistent ongoing testing and failure to notify residents, their families, and  staff of positive COVID-19 test results. 

During the inspection, the OIG identified concerns related to facility and CLC leaders’ post outbreak actions. Additionally, the OIG learned of a concern that facility leaders failed to address  the emotional well-being of CLC staff after the CLC outbreak. This was discussed with OIG  leaders and is under review through other ongoing OIG work. As such, it is not addressed in this  report. 

Scope and Methodology 

The OIG initiated the inspection on November 6, 2020, and conducted a virtual site visit  December 14–17, 2020. Additionally, an unannounced site visit was completed on February 17,  2021. The OIG defined the duration of the CLC outbreak to be from the date the first CLC  employee tested positive through the date of death of the last resident diagnosed with COVID-19  (October 13–November 17, 2020). 

The OIG interviewed staff familiar with the CLC outbreak and actions taken following the outbreak. Interviewees included the Facility Director, Acting Chief of Staff, Acting Associate  Director of Patient Care Services (ADPCS), Chief of Geriatrics and Rehabilitation Service,  Acting Chief Nurse of Geriatrics, and CLC nursing staff. 

The OIG team reviewed the electronic health records (EHR) of CLC residents, employee health records of staff, VHA and facility policies, VHA operational memorandums, facility standard  operating procedures (SOPs) and statements of work, Centers for Disease Control and  Prevention (CDC) COVID-19 guidance, Geriatric and Rehabilitation Service meeting minutes,  facility town hall COVID-19 meeting minutes, Employee Health testing data, N95 fit testing and  powered air-purifying respirator (PAPR) training records, nursing staff schedules, and facility COVID-19 action plans from March 2020 through February 2021. 

In the absence of current VA or VHA policy, the OIG considered previous guidance to be in  effect until superseded by an updated or recertified directive, handbook, or other policy  document on the same or similar issue(s). 

The OIG substantiates an allegation when the available evidence indicates that the alleged event  or action more likely than not took place. The OIG does not substantiate an allegation when the  available evidence indicates that the alleged event or action more likely than not did not take 

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place. The OIG is unable to determine whether an alleged event or action took place when there  is insufficient evidence. 

Oversight authority to review the programs and operations of VA medical facilities is authorized  by the Inspector General Act of 1978, Pub. L. No. 95-452, 92 Stat. 1101, as amended (codified at  5 U.S.C. App. 3). The OIG reviews available evidence to determine whether reported concerns  or allegations are valid within a specified scope and methodology of a healthcare inspection and,  if so, to make recommendations to VA leaders on patient care issues. Findings and  recommendations do not define a standard of care or establish legal liability. 

The OIG conducted the inspection in accordance with Quality Standards for Inspection and  Evaluation published by the Council of the Inspectors General on Integrity and Efficiency. 

Timeline of Events 

Prevalence of COVID-19 

On March 11, 2020, due to the “alarming levels of spread and severity” of COVID-19, the World  Health Organization declared a pandemic.12 

Danville, Illinois, has a population of 30,000 people and is located in Vermilion County, roughly  1.5 hours west of Indianapolis, Indiana, and 2.5 hours south of Chicago, Illinois. Figure 1 depicts  the number of persons diagnosed with COVID-19 for Vermilion County from March 15 through November 30, 2020.13 

Figure 1. The number of new and total number of COVID-19 cases in Vermilion County, Illinois, from March 15, 2020, through November 30, 2020. 

Source: The data represented in this chart are sourced from Johns Hopkins University’s Center for Systems Science  and Engineering. 

12 World Health Organization, WHO Director-General’s opening remarks at the media briefing on COVID-19,  March 11, 2020, accessed on November 19, 2020, https://www.who.int/dg/speeches/detail/who-director-general-s opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020. 

13“COVID-19 United States Cases by County,” Johns Hopkins University, accessed March 9, 2021,  https://github.com/CSSEGISandData/COVID-19. 

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The facility employs roughly 1500 people. Figure 2 depicts the number of facility staff  diagnosed with COVID-19 from March 15, 2020, through November 30, 2020.14 

Figure 2. The number of new COVID-19 staff cases from March 15, 2020, to November 30, 2020. Source: Department of Veterans Affairs COVID-19 National Surveillance Tool: COVID-19  National Summary. 

The facility served over 29,000 veterans from October 1, 2019, through September 30, 2020.  Figure 3 depicts the number of veterans, both inpatient and outpatient, newly diagnosed with  COVID-19 at the facility from March 15, 2020, through November 30, 2020.15 

14 VA National Surveillance Data, accessed March 8, 2021. 

15 VA National Surveillance Data, accessed March 8, 2021.

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Community Living Center at the VA Illiana Health Care System in Danville, IL 

Figure 3. The number of new COVID-19 veteran cases within the facility, both inpatient and  outpatient, from March 15, 2020, through November 30, 2020. 

Source: VA COVID-19 National Surveillance Tool: COVID-19 National Summary. 

COVID-19-Related Facility Actions and Occurrences 

Consistent with VHA guidance, the facility developed a pandemic action plan in January 2020,  that included 46 items addressing topics such as screening processes for staff and visitors,  COVID-19 staff education, signage, documentation templates, and PPE inventory. Target dates  for completion of the items ranged from January 27 to March 21, 2020. The action plan assessed the need for respiratory PPE for staff working in some facility locations and services. However,  it did not include actions to minimize or address a potential outbreak at the facility’s CLC.16 

The Facility Director held daily virtual town hall meetings to communicate COVID-19-related  updates to staff from March 12–31, 2020, after which the frequency was reduced to three times  per week. Additionally, the facility had a COVID-19 information SharePoint site available for  

staff reference. The facility linked its website to VHA’s COVID-19 SharePoint site available for  staff. 

A facility pandemic incident command center (command center) opened on March 23, 2020, to manage COVID-19 related information and decisions. The command center had a dedicated  phone line and email address that staff could use to ask COVID-19 associated questions. At the  same time, facility leaders started planning for an influx of patients from the community. 

16 The information provided in this section is based on a review of documents and interviews with the facility  Director, Acting ADPCS, Chief of Facilities Management, and the infection control coordinator.

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Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at the VA Illiana Health Care System in Danville, IL 

As noted in figures 1, 2, and 3, the county and facility experienced a low number of newly  diagnosed COVID-19 cases through the spring and summer of calendar year 2020. 

Low rates of COVID-19 at the county level resulted in the facility experiencing minimal impact  from the pandemic in the initial months. Therefore, the Facility Director reduced the frequency  of the virtual town halls to once a week on May 18, 2020; the command center was “stood  down” on June 25, 2020.17 With the command center no longer staffed, command center members met virtually as needed and the email and phone number remain active for staff to use  for COVID-19-related concerns. 

In July 2020, the number of individuals testing positive for COVID-19 started to increase in the  community. The Valor House, a Green House with a maximum capacity of 10 residents, was  closed due to low census and repurposed as a potential quarantine space. Table 1 is a timeline of  events that occurred in the facility and CLC planning, decision-making, and outcomes specific to  COVID-19. 

Table 1. Timeline of Notable Events Related to the CLC COVID-19 Outbreak 

Location

Freedom House

Valor House

Freedom House

Victory

Victory

Unity

Victory

Victory

Unity

Date Event 

August 2020 Residents transferred to Valor  House from Freedom House  

because of the need for repairs. 

August 29–September 5, 2020 Two staff and three residents  tested positive for COVID-19. 

End of September 2020 All residents who had  temporarily relocated to Valor  

House returned to Freedom  

House. 

October 13, 2020 One staff member tested  positive for COVID-19. 

October 13, 2020 All residents tested negative for  COVID-19. 

October 14, 2020 All residents tested negative for  COVID-19. 

October 17, 2020 One staff member tested  positive for COVID-19. 

October 18, 2020 Two staff and four residents  tested positive for COVID-19. 

October 19, 2020 Four staff tested positive for  COVID-19. 

17 Merriam-Webster, “Definition of Stand down, or when used as a verb, stood down,” accessed April 16, 2021,  https://www.merriam-webster.com/dictionary/stand-down. A term that indicates going off duty or ending  operations.

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Location

Liberty House

Valor House

Unity

101-2

101-2

Facility

Facility

Facility

Unity and Victory

101-1

Date Event 

October 19, 2020 One resident tested positive for  COVID-19. 

October 19, 2020 Five COVID-19 positive  residents from Victory and  

Liberty House transferred to  

Valor House. 

October 20, 2020 All residents retested; two tested  positive for COVID-19. 

October 21, 2020 Facility leaders opened 101-2  for COVID-positive residents  

due to limited capacity in the  

Valor House. 

October 21, 2020 CLC staff transferred nine  COVID-19 positive residents to  

101-2; two from Unity, two from  

Victory, and five from Valor  

House. 

October 22, 2020 Facility leaders finalized  inpatient surge plan (see  

Appendix B). 

October 22, 2020 CLC leaders finalized CLC  Upsurge Plan (see Appendix C). 

October 23, 2020 Facility leaders opened a  second unused unit, 101-1, and  

approved moving all COVID-19 

negative CLC residents from  

Unity and Victory to allow  

cleaning of the space. 

October 23, 2020 All remaining residents retested;  two from Unity and two from  

Victory tested positive for  

COVID-19 and were transferred  

to 101-2. 

October 24, 2020 CLC staff transfer the12  remaining residents on Unity  

and Victory to 101-1. 

Source: OIG analysis of timeline using EHRs and facility documents. 

In October, following the CLC outbreak, command center meetings resumed with a frequency of  once a week. From the date the first resident tested positive for COVID-19 at the CLC, to the  date of the last death of a resident diagnosed with COVID-19, approximately one month, 11 residents died after having tested positive for COVID-19. Seven of the 11 residents had  documentation in their EHR stating their death was from COVID-19-related respiratory  complications, and four of the 11 residents had other causes noted as the primary cause of death  but accelerated by COVID-19.

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Inspection Results 

Allegation: Failure to Observe General Infection Control Practices  Specific to Respiratory PPE 

The OIG substantiated that facility leaders and staff failed to observe general infection control  practices specifically related to respiratory PPE.18 

Infection control measures limit the spread of transmissible diseases and include wearing basic  PPE, such as face masks, and more specialized items such as respirators. A 2017 VHA directive  outlined policy that medical facilities would apply a combination of safe work practices,  employee training, and PPE to prevent injury and illness.19 In April and May 2020, VHA issued  guidance related to PPE specific to reducing transmission of COVID-19 on certain inpatient and  residential units. On April 7, 2020, VHA issued a memorandum that stated “Facemasks should be used by employees working in the Community Living Center, Spinal Cord Injury units and  inpatient Mental Health.”20 Face masks, when worn properly, assist in limiting the potential  transmission of airborne illness.21 Nine days later, in response to concerns regarding PPE supply  levels, VHA provided additional guidance stating that staff directly involved with care on CLCs  will be provided one face mask or surgical mask a day to protect the residents.22 A May 1, 2020, VHA memorandum stated that “VHA staff that require additional respiratory protection to  provide direct patient care (enter a room, interact within six feet) and/or evaluate any suspected  or confirmed COVID-19 infected patients will receive appropriate PPE including surgical masks  and/or N95 respirators or PAPRS.” Additionally, this memorandum implemented source control measures requiring the use of a face covering by all individuals entering a VHA facility and  states that…“source control face coverings are to be provided to inpatients who move outside of  their room.” The memorandum also notes that face coverings, most often cloth, “must cover the  mouth and nose, fit snugly, and allow for breathing without restriction” and are not considered  

18 The OIG considers the term respiratory PPE to refer to face coverings, face masks, N95s, and PAPRs. 19 VHA Directive 7701, Comprehensive Occupational Safety and Health Program, May 5, 2017.  20 VHA Memorandum, Updated: Coronavirus (COVID-19) Facemask and N95 Respirator Use, April 7, 2020. 21“COVID-19 Considerations for Wearing Masks,” CDC, accessed March 23, 2021,  

https://web.archive.org/web/20201006013358/https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting sick/cloth-face-cover-guidance.html. 

22 VHA Memorandum, Update: Coronavirus COVID-19 Return to a Contingency strategy for Facemask and N95  Respirator Use, April 16, 2020.

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PPE.23 Respirators, such as N95s or PAPRs are preferred when entering the room of a resident  with known or suspected COVID-19.24 

Face Coverings and Face Masks 

The OIG substantiated that CLC residents did not consistently wear face coverings prior to the  CLC outbreak and a few CLC staff did not comply with infection control measures related to  face masks both prior to and after the CLC outbreak.25 

CLC leaders and staff stated that Unity and Victory, the CLC neighborhoods that experienced  the CLC outbreak in October 2020, are geri-psychiatric neighborhoods with residents who have  impaired cognitive diagnoses. They also described challenges with residents wearing face coverings prior to the CLC outbreak noting compliance was complicated by the cognitive and  mental disorders of CLC residents. The requirement for veterans to wear face coverings was  stressed by facility and Geriatrics and Rehabilitation Service leaders during service-line meetings  and town halls. At the time of the OIG’s virtual site visit in December 2020, CLC staff reported  that since the CLC outbreak, compliance by residents wearing face coverings when out of their  rooms had improved. During the February 2021 unannounced site visit, the residents whom OIG  staff observed wore face coverings or masks when out of their rooms. 

In interviews, facility and CLC leaders, the infection control coordinator, and CLC staff acknowledged that employees, including some CLC staff, did not consistently wear face masks properly. Reminders of the need to wear face masks properly were provided to staff through  multiple mechanisms: CLC staff meetings and emails, facility town halls, facility-wide emails to  staff, and verbally by co-workers. During the unannounced site visit, the OIG observed two  employees working on a quarantined COVID-19 CLC neighborhood and wearing unapproved  face coverings, or failing to cover their nose and mouth with their face mask. 

The OIG team found that facility and CLC leaders took steps to emphasize and reinforce the  importance of staff wearing face masks properly. The Facility Director reported supporting 

23 VHA Memorandum, Update: Coronavirus (COVID-19) Mask Use in Veterans Health Administration (VHA)  Facilities, May 1, 2020. 

24 “Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed  Coronavirus Disease 2019 (COVID-19) in Healthcare Settings,” CDC, accessed on April 22, 2021.  https://stacks.cdc.gov/view/cdc/86043. 

25“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19) Pandemic.” Face coverings are most often cloth and are not considered PPE. “Personal  Protective Equipment: Questions and Answers,” CDC, accessed on June 7, 2021.  

http://web.archive.org/web/20201001160417/https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirator-use faq.html. Face masks refer to non-FDA regulated procedure masks as well as surgical masks and provide barrier  protection against droplets, including large respiratory particles, and are intended to prevent contamination of the  surrounding area when the wearer coughs or sneezes. Fit testing is not required for face masks. Proper wearing of  face masks is demonstrated when each loop is around the ears, the bendable edge of the mask is around the bridge of  the nose, the mask covers the nose and mouth, and the lower edge of the mask is under the chin.

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facility supervisors taking disciplinary action for staff who were noncompliant; however, no  incidents of noncompliance warranting disciplinary actions were brought to the OIG’s attention. 

Respirators 

The OIG substantiated that, at the time of the CLC outbreak, the facility’s Environmental and  Safety Section did not identify CLC providers and nursing staff as requiring respiratory  protection.26 Although not identified by the facility’s Environmental and Safety Section, the OIG  found some CLC providers and one CLC nursing staff member, assigned to the impacted units,  were N95fit tested.27 

When caring for individuals with suspected or known cases of COVID-19, wearing respiratory  protection, such as a fit tested N95 or PAPR, is key to mitigating the transmission of the virus to  direct patient care providers. 28 The facility’s Environmental and Safety Section (Safety Section) is responsible for all facets of the respiratory protection program, including the development and  provision of respirator training programs for N95s and PAPRs. Facility policy states that a  respirator will be provided to each employee based on the need for and type of respiratory  protection.29 Annually, the Safety Manager, Infection Control Coordinator, and Employee Health  provider identify employees required to wear respiratory protection and then sends the list of  employee names to the infection control and environment of care committees for approval. Employees must be fit tested and provided with the same make, model, style, and size of the  respirator that will be used and annual testing must occur thereafter. Employees not able to wear  respirators with tight fitting face-pieces will use PAPRs. Training is to consist of contaminant  information, types of respiratory protection available, hands-on experience with respirators,  cleaning, maintenance, and fit testing. 

N95s 

The Safety Manager described fit testing for N95s as a two-step process involving medical  clearance from Employee Health and the fit testing session with Safety Section staff. In October  2019, staff from the Safety Section, Infection Control, and Employee Health created a memo  listing the identified employees that should be included in the respiratory protection program. Although neither CLC providers or CLC nursing staff were included on the list, the Chief of  Geriatrics and Rehabilitation Service discussed with the OIG about ensuring CLC providers were  fit tested prior to the CLC outbreak. The OIG learned through interviews that Valor House  

26 For this report the OIG considers providers to include physicians, nurse practitioners, and physician assistants. 27 Facility MCM 001ESS-11, Respiratory Protection Program, December 2017. The facility’s Respiratory  Protection Program is specific to respiratory protection provided by N95s and PAPRs. 

28“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19) Pandemic.” 

29 Facility 001ESS-11, December 2017.

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nursing staff were later identified and fit tested for N95’s in response to the possibility that the  facility would use the Valor House to provide post-acute care for “stable minimally ill COVID 19 positive patients” in need of rehabilitation or as an overflow COVID-19 positive unit if the  facility acute care beds were full. 

The OIG learned through interviews that Unity and Victory staff did not have access to or  training about respirators prior to caring for residents that tested positive for COVID-19. Therefore, staff provided direct patient care wearing surgical masks and face shields to both initial residents diagnosed with COVID-19. CLC leaders and staff confirmed that N95 fit testing for staff on Unity and Victory did not occur prior to the CLC outbreak. A revised list for fit  testing was issued in December 2020, after the CLC outbreak, and included CLC providers and  nursing staff. When asked about the rationale for not including CLC providers and staff on  earlier lists, the Safety Manager noted the prior lack of contagious diseases in the CLC units. 

During the CLC outbreak, the Safety Section was contacted by the Infection Control Coordinator  and the Acting Chief Nurse of Geriatrics to request fit testing for CLC staff. The Safety Manager confirmed that after CLC providers and nursing staff were identified as requiring respiratory  protection, they were to be fit tested before working with residents that tested COVID-19  positive. According to Safety Section records, none of the Unity nursing staff and one Victory  nursing staff member were fit tested prior to the CLC outbreak. While CLC staff reported efforts  to increase fit testing began during the CLC outbreak, the OIG learned from nursing leaders that  at least three CLC nursing staff later assigned to work 101-2 were not fit tested prior to working  in the unit. Safety Section records indicated 52 percent of the CLC nursing staff were fit tested as  of November 23, 2020. 

PAPRs 

PAPRs are used to provide respiratory protection when staff are unable to tolerate N95s or when  fit testing has not been completed. According to the Safety Manager, PAPRs are typically housed  in the facility equipment storage warehouse and issued to the person in charge of the unit or  service making the request. Reportedly, “a couple” of PAPRs were kept in the Safety Section office. A Nurse Officer on Duty (NOD) stated that part of the NOD’s duties on evenings and  weekends, when the warehouse and Safety Section were closed, was to provide PAPRs for those  staff who had not been fit tested for an N95. On October 19, 2020, the facility had 40 PAPRs. The Safety Manager did not know the number of PAPRs on the CLC at the time of the CLC  outbreak but reported that as of December 2020, the CLC had 10. 

Similar to the lack of N95 fit testing, CLC staff told the OIG that PAPR training was not  provided prior to October 20, 2020, and CLC staff lacked access to PAPRs prior to CLC residents testing positive for COVID-19. Contrary to staff reports to the OIG, the NOD reported  seeing PAPRs on the CLC the day the first resident tested positive for COVID-19.

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According to Safety Section records, none of the CLC nursing staff had PAPR training prior to  the CLC outbreak; 6.9 percent were trained as of November 23, 2020. CLC nurse leaders told the  OIG that just-in-time training about the use of PAPRs was provided to staff. However, the  training was not documented and therefore, the OIG was unable to determine the extent of the training. 

The OIG found the facility was compliant in 2019 and 2020 with their own policy requiring an  annual review of the staff included in the respiratory protection program. However, the 2020  review was not completed until December 2020, nine months into the pandemic. 

The OIG concluded that nursing leaders and the Chief of Geriatrics and Rehabilitation Service  identified the need to fit test Valor House staff and CLC providers but failed to reassess the need  for fit testing of other CLC nursing staff. Therefore, CLC nursing staff were not fit tested and  provided N95s or trained in the use of PAPRs prior to the CLC outbreak. This failure resulted in  CLC nursing staff providing direct patient care to residents with suspected and confirmed  diagnoses of COVID-19 without the preferred respiratory protection.30 

Allegation: Failure to Minimize Risk of Exposure to COVID-19 

The OIG substantiated that CLC and facility leaders failed to minimize the risk of CLC residents  and staff exposure to COVID-19. The OIG found facility leaders did not adequately respond to a  CLC staff member’s reported cough and COVID-19 community close contact exposure, and did  

not remove the employee from direct patient care. Additionally, the facility did not have a  comprehensive plan that specified operational details such as roles, actions, and targeted time frames for the transfer and isolation of CLC residents suspected of having, or diagnosed with  COVID-19. The OIG confirmed the room of a COVID-19 negative resident was cleaned after  the transfer of the resident’s COVID-19 positive roommate. However, due to the non-functional  bed management system and the absence of a substitute record keeping system, the OIG was  unable to determine when the room was cleaned. 

While not specifically referenced in the allegation, the OIG also assessed facility actions related  to 

∙ administering aerosol-generating procedures without infection control measures, ∙ continuing group therapy sessions, and 

∙ identifying dedicated staff for the units reserved for residents with and without COVID 19. 

30“Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed  Coronavirus Disease 2019 (COVID-19) in Healthcare Settings.” Preferred respiratory protection for CLC staff  providing care to COVID-19 infected residents include fit tested N95s or PAPRs.

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Managing Positive Staff Exposures 

The OIG found facility leaders did not minimize CLC residents and staff exposure to COVID-19  when they failed to abide by VHA instructions to follow CDC guidelines. A CLC staff member  reported a cough and COVID-19 community close contact exposure and was not removed from  direct patient care per the guidelines. 

The actions taken when an individual reports symptoms of, significant exposure to, or a  diagnosis of COVID-19 are critical to limiting potential exposure to others.31 On March 6, 2020,  VHA indicated that it would follow CDC guidelines.32 At the time of this event, CDC guidance  stated that healthcare personnel with a known COVID-19 community close contact exposure of  greater than 15 minutes should be tested and stay home until 14 days after the last exposure.33 

During interviews, the OIG learned that on a morning in fall 2020, that was a federal holiday, a  CLC staff member assigned to Victory had a cough and was notified, while at work, that a close  family member had tested positive for COVID-19. The CLC staff member then notified a  colleague about the exposure. Information as to what occurred next was conflicting. A few  interviewees reported that the notification went through the chain of command and ultimately the  Acting ADPCS was contacted and gave instructions that the CLC staff member would not be  tested, should wear a mask, and continue to work, providing direct patient care for the remaining  six hours of the shift. Contrary to these reports, the Acting ADPCS stated having no knowledge  of this event. The staff member recalled being told no when asking for a COVID-19 test and to  put a mask on and continue working. 

The CLC staff member stated that the following day, the Chief of Geriatrics and Rehabilitation  Service arranged for testing and was called at home by co-workers and told to come into the  facility.34 The staff member reported not working that day, being tested at the facility’s urgent  care at approximately 8:30 a.m., and being notified of a positive test result around 1:00 p.m.  Employee Health contacted the CLC staff member and advised to quarantine based on CDC  guidelines. 

CLC nurse managers stated that Employee Health would be contacted if there was concern that a  staff member was exposed or had COVID-19 symptoms. However, since the day was a federal  holiday, Employee Health staff were not available for consultation and the Acting ADPCS was 

31“Public Health Guidance for Community-Related Exposure,” CDC, accessed on December 30, 2020,  https://www.cdc.gov/coronavirus/2019-ncov/php/public-health.recommendations.html. 

32 VHA, COVID-19 Communications Toolkit, March 6, 2020. 

33 “Public Health Guidance for Community-Related Exposure;” “Interim Guidance on Testing Healthcare Personnel  for SARS-CoV-2,” CDC, accessed on October 2, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/testing healthcare-personnel.html. On March 10, 2021, CDC updated guidance states that asymptomatic healthcare  personnel who are fully vaccinated do not have to be restricted from work.  

34 The CLC staff member stated being unsuccessful when attempting to receive a COVID-19 test in the community.

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called for guidance.35 CLC nurse managers stated although they did not think the CLC staff  member should stay on duty, they followed the guidance of the Acting ADPCS. 

An Employee Health provider told the OIG that in addition to all-employee emails and  availability via telephone, a decision tree following CDC guidelines was developed to serve as the main source of guidance for staff questions related to exposure and symptoms for COVID 19. The OIG reviewed the decision tree and found that it was not created until December 8,  2020. 

The OIG concluded facility and CLC leaders did not adhere to VHA instructions to follow CDC guidance for removing a CLC staff member with a cough and a known COVID-19 community  close contact exposure from duty.36 This failure resulted in an employee, who later tested  positive for COVID-19, providing direct patient care and potentially exposing CLC residents and  staff to COVID-19. 

Resident Transfers and Isolation 

The OIG determined that the facility did not have a comprehensive plan to address the transfer  and isolation of CLC residents suspected of having, or diagnosed with, COVID-19. While the  facility did develop a surge plan, it was not finalized until after CLC residents were diagnosed  with COVID-19 and lacked specific operational details such as roles, actions, and targeted time frames. 

At the beginning of the CLC outbreak, two CLC residents (resident A and resident B) were diagnosed with COVID-19, one of whom (resident B) lived in a shared room. The OIG found  that resident B’s non-infected roommate (resident C) was not isolated. 

Isolating individuals with known exposure to, or a confirmed diagnosis of, COVID-19 reduces  the likelihood of transmission to others. VHA guidance for CLCs dated March 17, 2020, stated, “the facility should have a plan to isolate a resident that is suspected of having COVID-19.” The  guidance further stated, “Facilities with multiple suspected or confirmed cases should have plans  to isolate residents to one area (neighborhood) in the CLC or at another location at the medical  center if space does not allow to isolate in the CLC.”37 The VHA guidance was not prescriptive  regarding time frames for relocating residents with suspected or confirmed COVID-19.38 

35 Employee Health hours of operation are Monday–Friday, 8:00 a.m. to 4:30 p.m. 

36 In February 2021 during a follow-up interview, the OIG informed the Facility Director about the CLC staff  member’s exposure. The Facility Director was not aware of the exposure and subsequently initiated a fact-finding;  however, the fact-finding was inconclusive due to conflicting testimony and the Facility Director is evaluating next  steps.  

37 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers-Revised 03/17/2020. 38 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers-Revised 03/17/2020.

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VHA guidance defers to each facility to determine the specifics related to managing the transfer  and isolation of residents suspected of having, or diagnosed with, COVID-19.39 The plan  developed by the facility was finalized after the CLC outbreak started and did not provide staff  with the necessary specifications to carry out the task. The OIG was unable to determine if  facility leaders had requested clarification on the VHA guidance regarding the required time frame to transfer a patient after notification of a positive COVID-19 test result to assist them with development of the plan. 

For further clarification on the expected time frame to relocate a resident suspected of having, or  diagnosed with, COVID-19 and how to manage a roommate who is COVID-19 negative, the  OIG contacted VHA’s Office of Patient Care Services. The response, approved by the VHA  Acting Principal Deputy Under Secretary for Health, stated, “Veteran is cohorted from the  COVID negative Veteran to prevent cross-transmission…The time frame to relocate the CLC  resident to the designated COVID area should occur upon identification of the resident’s COVID  status. The COVID negative resident will continue to be monitored as required.” 

During interviews, the OIG learned that on the date at issue, resident A lived in a private room  and resident B shared a room with resident C, who was known by CLC staff to walk around the  neighborhood. The EHR reflected that at 9:10 p.m., the lab notified the after-hours physician of  positive COVID-19 results for resident A and resident B. Between 9:25 p.m. and 10:02 p.m., the  physician notified a CLC nurse of the lab results. The OIG learned through EHR documentation  and an interview with a nursing staff member, that the nurse informed the NOD of the positive  lab results, discussed concerns regarding the cohabitation of resident B and resident C, and  awaited further instruction from the NOD regarding resident B. Later that evening, the off-tour  CLC physician and NOD came to the unit to assess the status of both residents. In the absence of  local guidance, the off-tour CLC physician determined that resident A could remain in the  private room. Resident B was approved to stay overnight in the room with resident C, the  COVID-19 negative roommate, since resident C had already been exposed. 

EHR documentation and interviews with CLC staff indicated both nursing and medical staff  anticipated transferring residents A and B to Valor House around 7:45 a.m. the day following the  positive COVID-19 results. A CLC staff member told the OIG that around 7:30 a.m., the transfer  was postponed until 1:30 p.m. citing transportation issues. The staff member also reported a lack  of direction regarding which staff should care for the residents diagnosed with COVID-19 and  which isolation protocols to use for the COVID-19 positive resident sharing a room. Staff told  the OIG that during this period, resident C paced the neighborhood, including communal areas  where other residents were congregated. Staff also gave conflicting information on whether  resident C was wearing a face covering while walking around the neighborhood. 

39 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers - Revised 03/17/2020.

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The transfers for residents A and B were further delayed due to a change in the transfer location.  Per the Acting ADPCS, the residents would move to unit 101-2 later that day because Valor  House was nearing capacity. At 5:45 p.m., CLC staff received authorization and moved both  residents to unit 101-2. The transfer occurred 20 hours after the physician first became aware of  both residents’ positive COVID-19 tests. Of note, after several COVID-19 negative test results,  resident C tested positive for COVID-19 (14 days after the roommate’s positive result) and was  transferred to 101-2 without delay. Although the OIG could not determine that resident C contracting COVID-19 was a consequence of being left in a room with the COVID-19 positive  roommate, the lack of a plan to isolate residents was likely a contributory factor. 

Room Disinfection 

The OIG confirmed that resident C’s room was cleaned after the transfer of the COVID-19  positive roommate; however, due to a lack of record keeping, the OIG was unable to determine  the time of the cleaning. The OIG did not assess the cleaning status of the single occupant room  of resident A because the timing of the cleaning did not impact a roommate. 

Cleaning spaces occupied by individuals with COVID-19 prevents potential transmission of the  disease, through contaminated surfaces, to future occupants of the space.40 VHA guidance  indicates that the bed management system should be updated as part of the discharge or transfer  cleaning process for a patient’s room to ensure proper bed flow data.41 A March 2020 facility  SOP outlined the proper and safe cleaning techniques to disinfect a room that has housed an  individual with suspected or confirmed COVID-19.42 

A CLC staff member reported to the OIG that prior to the transfer of residents A and B, Environmental Management Service staff brought cleaning supplies to the unit at 1:30 p.m. but  were unable to clean the room at that time because the transfer of resident A and B had been  further delayed. Once the two residents transferred, a CLC staff member requested cleaning of  the rooms. The staff member conveyed that at 5:45 p.m. the Environmental Management Service  supervisor on duty was notified that the shared room had not been cleaned to allow resident C to  continue residing in the room. The same CLC staff member did not know when the room was  cleaned, but reported receiving a text while at home from a colleague on duty indicating the room was cleaned. The OIG learned there were no complaints elevated to Environmental  Management Service leaders by CLC staff regarding room cleaning delays on October 21, the  day the cleaning occurred. 

40“Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes,” CDC,  accessed March 23, 2021, https://www.cdc.gov/coronavirus/2019- 

ncov/community/pdf/REopening_America_Guidance.pdf.  

41 VHA, Environmental Management Services, Sanitation Procedural Guide, 2016. 

42 Facility Environmental Management Service, Standard Operating Procedure No 47-137, March 2020. 

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According to the Chief of Environmental Management Service, a housekeeper is assigned to the  CLC during the first shift but not the second or third shift.43 Per the Chief of Environmental  Management Service and an Environmental Management Service staff member, the response  time for cleaning at the CLC is 30 minutes or less. When the OIG inquired about mechanisms to  track room cleaning, the Environmental Management Chief reported that the bed management  system used to track discharge cleanings was not operational and an alternative system of record  keeping was not in place. A verbal hand-off between staff was used to communicate bed cleaning status despite the procedural guide directing staff to document room cleaning in the bed  management system.44 

Due to an inoperable bed management system and the lack of an alternative system of record  keeping, the OIG was unable to determine when the cleaning of the room was initiated and  completed following the transfer of resident B. 

Aerosol-Generating Procedures 

The OIG determined that facility and CLC leaders did not implement the additional infection  control measures recommended by the CDC when administering aerosol-generating procedures. 

COVID-19 is a virus transmitted through respiratory droplets.45 The CDC explains that some  procedures performed on patients with suspected or diagnosed COVID-19 could produce  infected aerosols. When procedures that pose such risk cannot be avoided, staff should perform  procedures cautiously with additional infection control measures including 

∙ wearing an N95 or PAPR, a face shield or goggles, gloves, and a gown, ∙ limiting the number of staff present during the procedure, 

∙ administering the procedure in a negative pressure room whenever possible, 

∙ keeping doors closed except when entering or leaving the room, which should be  minimized and, 

∙ disinfecting a room soon after completion of the procedure.46 

VHA guidance confirms that nebulizer treatments and continuous positive airway pressure (CPAP) are classified as aerosol-generating procedures. The guidance further states that when a  patient has not been COVID-19 tested in the past 72 hours, or has results pending, they should be  

43 The facility provided the following for shift descriptions: 7:00 a.m.-3:30 p.m. (first shift), 3:30 p.m.–12:00 a.m.  (second shift), and 10:00 p.m.–6:30 a.m. (third shift). 

44 VHA, Environmental Management Services, Sanitation Procedural Guide, 2016. 

45“How Coronavirus Spreads,” CDC, accessed April 12, 2021, https://www.cdc.gov/coronavirus/2019- ncov/prevent-getting-sick/how-covid-spreads.html.  

46“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19) Pandemic.”

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treated as COVID-19-positive when performing procedures that have a high risk of  transmission.47 

The OIG conducted an EHR review of residents residing in the CLC who were prescribed an  aerosol-generating procedure (nebulizer or CPAP) during the time frame of the CLC outbreak. The OIG found two residents that were receiving aerosol-generated procedures and reviewed  

their care. Neither resident was being tested for COVID-19 every 72 hours, therefore, additional  infection control measures should have been used during administration. Both residents became  COVID-19 positive during the CLC outbreak. 

In an interview with the OIG, the Chief of Geriatrics and Rehabilitation Service reported being  unaware of nebulizer use at the CLC during the COVID-19 pandemic and stated that if a resident  needed a nebulizer, they would be transferred to the acute inpatient unit to have it administered  in a negative pressure room. The OIG learned that facility leaders had not discussed additional  infection control measures, recommended for aerosol-generating procedures, until early  December 2020 after a respiratory therapist brought concerns of nebulizer and CPAP use without  proper infection control precautions to the attention of facility leaders and the infection control  coordinator. As a result, a nurse who provided nebulizer treatments reported being unaware of  special precautions related to aerosol-generating procedures for residents who were not recently  tested, were suspected to have, or known to have, a COVID-19 positive diagnosis. The nurse  reported administering the nebulizer in the resident’s room wearing a gown, gloves, and a  surgical mask prior to the December discussion. Had staff been familiar with the precautions,  there were still impediments; none of the CLC nursing staff had been trained on the use of a  PAPR, and only 5 percent had been N95 fit tested at the start of the CLC outbreak. 

The OIG determined that the failure of CLC leaders to disseminate information regarding the  implementation of additional infection control measures to limit CLC residents and staff  exposure to COVID-19 during aerosol-generating procedures throughout the pandemic resulted  in noncompliance with VHA and CDC guidance. 

Group Therapies 

The OIG team found CLC leaders permitted group therapy sessions to continue throughout the  pandemic thereby increasing residents and staff risk of exposure to COVID-19. 

CLCs are residents’ home. As such, the availability of purposeful activity is an important part of  the environment. To increase socialization and reduce isolation, activities are often provided in  group settings. In response to the risks associated with transmission of COVID-19, a March 17,  2020, VHA memorandum stated that facilities with CLCs should immediately initiate procedures  

47 VHA, Moving Forward Together, Guidance for Resumption of Procedures for Non-Urgent and Elective  Indications, ver 2.0, August 19, 2020.

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to cancel all group activities.48 In an interview with the National Program Director of Recreation  Therapy, the OIG learned that while there was some flexibility to vary from the guidance  provided to the field, the expectation was that a facility director be involved with making that  decision. 

Through a review of EHR records, the OIG found CLC residents attended group therapy sessions  during the CLC outbreak. Facility documents show that CLC residents attended multiple group  sessions prior to, during, and after the main CLC outbreak. In reviewing these documents, along  with EHR records, the OIG identified that two Unity residents tested positive for COVID-19 the  same day after they attended separate group therapy sessions with five other residents. Similarly,  three of the first four Victory residents diagnosed with COVID-19 attended a group therapy  session three days earlier with six other residents. When speaking with CLC staff, the OIG was  told that prior to the CLC outbreak, the facilitator wore a face mask during these group sessions; however, the residents did not. 

The Facility Director, Acting Chief of Staff, and Acting ADPCS reported awareness of the VHA  guidance to stop all group activities. The Acting Chief of Staff and Acting ADPCS indicated that  they were not aware of CLC group therapy sessions taking place throughout the pandemic. The  Chief of Geriatrics and Rehabilitation Service sent an email on April 3, 2020, to service line and recreation therapy staff with the March 17, 2020, memo attached. The email stated, “regarding  groups, there is no clear-cut guidance whether “groups” can occur…it is my understanding that  we should not have more than 10 people, including staff, in one area at once and all should be at  least 6 feet apart.” Additionally, the Chief of Geriatrics and Rehabilitation Service reported in an  email to the OIG that all CLC group activities were suspended after the March 17, 2020, VHA  guidance was released.49 In interviews with the OIG, recreation therapists and a CLC leader  indicated that they had not been made aware of the VHA guidance to stop all group therapies. A  recreation therapist stated that guidance and information on COVID-19 would come from the  service chief, in this case the Chief of Geriatrics and Rehabilitation Service. Recreation  therapists described their concern for both the physical and emotional well-being of the CLC  residents and shared they wanted to do the best they could with the information that they had. 

The OIG concluded that facility leaders were aware of VHA guidance to stop all group activities  at the CLC. However, facility leaders were not involved in the decision-making to continue the  group activities and were not aware they were occurring. The statement from the Chief of  Geriatrics and Rehabilitation Service that group activities were not taking place in the CLC  during the COVID-19 pandemic is inconsistent with evidence obtained by the OIG. Continuation  of group therapy sessions during the pandemic increased the risk of exposure to COVID-19 for  

48 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers – Revised 03/17/2020. 49 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers – Revised 03/17/2020.

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CLC residents and staff and is indicative of a failure by CLC leaders to understand,  communicate, and implement VHA guidance. 

Nurse Staffing Assignments 

The OIG determined facility leaders minimized the risk of cross-contamination by ensuring staff  did not work on both the non-COVID-19 and COVID-19 units during the same work shift. 

Given minimal movement of residents off the CLC, employees posed the greatest risk to  residents for exposure to COVID-19. The March 17, 2020, VHA memorandum stated, “if the  need to isolate in a neighborhood setting is required, consistent staff should be assigned to those  residents and not be assigned to go between COVID-19 infected and negative residents to  provide care.”50 The OIG reached out to VHA’s Office of Patient Care Services for clarification whether staff movement between COVID-19 positive and negative units should be limited to  within a shift or day to day. The written response stated, “staff movement (assignment) is to be  limited within a shift to prevent cross-transmission from COVID-19 positive to negative  residents….”51 

During interviews with the OIG, CLC nursing staff expressed concern with nurses working on  both 101-1 (non-COVID-19) and 101-2 (COVID-19), and sharing a common hallway and  restroom. A review conducted by the OIG of CLC nursing staff assignments on 101-1 and 101-2  from October 25 through November 13, 2020, found 11 nursing staff members were assigned to  work shifts on both units, but on different days. There were three occurrences of nursing staff  members assigned to work shifts on both units on the same day; however, there were no  instances of nursing staff assigned to work both units during the same shift. 

During the virtual tour of units 101-1 and 101-2 and the on-site visit, the OIG saw the common  hallway with two restrooms. The OIG observed signage on each restroom designating the use for  either 101-1 or 101-2 staff, respectively. 

Ancillary service staff not solely assigned to a single CLC unit reported a combination of  approaches to mitigate risk of COVID-19 exposure while providing care on multiple units  throughout a shift. Approaches to mitigating risk included: using PPE, social distancing, and  scheduling non-COVID-19 care prior to seeing residents diagnosed with COVID-19. 

The OIG found that CLC leaders minimized the risk of cross-contamination by ensuring staff did  not work on both the non-COVID-19 and COVID-19 designated units during the same shift. 

50 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers - Revised 03/17/2020.  51 VHA Memorandum, Coronavirus (COVID-19) Community Living Centers - Revised 03/17/2020.

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Allegation: Inconsistent Ongoing Testing and Failure to Notify of  Positive COVID-19 Test Results 

The OIG found the facility lacked a plan for post-baseline testing of residents and staff. Additionally, the OIG substantiated that ongoing testing for residents and staff was inconsistent  following the CLC outbreak. The OIG did not substantiate that the facility failed to notify  residents, their families, and staff of COVID-19 test results. 

Inadequate Post-Baseline Testing Plan 

While reviewing the facility process to test residents and staff for COVID-19, the OIG  determined that the facility plan for COVID-19 post-baseline testing for the CLC was not in  accordance with VHA guidance. 

Testing for COVID-19 provides facility staff with information regarding disease activity among  CLC residents and staff.52 In April 2020, VHA released specific testing guidance for CLCs and  Spinal Cord Injury and Disorder units that stated each facility director “should develop a plan for  ongoing COVID-19 disease screening, monitoring, and testing for Veterans/residents and  employees in CLCs and SCI/D [Spinal Cord Injury and Disorder] units once baseline testing is  completed.”53 Similarly, the CDC guided facilities to put a testing plan in place to identify (1)  triggers for when to perform testing, (2) the process that will be taken to perform testing on all  residents and staff, and (3) how residents and staff who refuse or are unable to be tested will be  addressed.54 

When the OIG requested the required COVID-19 testing plan, a facility staff member provided a  facility SOP outlining the step-by-step process for performing CLC resident and staff testing, and  actions to take based on test results. The SOP lacked a plan for ongoing screening, monitoring,  and the frequency of testing.55 The staff member also provided the March 2020 guidance from  VHA as evidence of a plan for screening and monitoring.56 This document was released more  than a month before VHA required facilities to create a post-baseline testing plan and provided  guidance on multiple topics but was not a plan for screening, monitoring, or testing. The OIG  noted that the facility SOP dated April 2020 did not follow the March 2020 VHA guidance  encouraging facilities to have CLC nursing staff perform all duties within their scope of practice  

52 VHA Memorandum, COVID-19 Guidance on COVID-19 Testing for Community Living Centers and Spinal Cord  Injury and Disorder Units, June 11, 2020. 

53 VHA Memorandum, Coronavirus (COVID-19) Community Living Center (CLC) and Spinal Cord Injury and  Disorder Unit (SCI/D) Veteran and Staff Testing, April 14, 2020. 

54“Preparing for COVID-19 in Nursing Homes,” CDC, accessed February 11, 2021  

https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html.  

55 Facility Community Living Center Standard Operating Procedure, COVID-19 Testing Residents/Staff, April 4,  2020. 

56 VA Response to COVID-19, Guidance for VA Community Living Centers, March 6, 2020.

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in an attempt to limit the number of staff entering the CLC. Instead, the facility SOP relied on  urgent care and acute nursing staff to administer the COVID-19 tests.57 

The importance of COVID-19 testing cannot be understated, without it, silent transmission can  occur due to the risk of an infected person being asymptomatic.58 An Employee Health provider,  the infection control coordinator, nursing leaders, and staff reported that before the CLC  outbreak, residents and staff were to be tested monthly; however, staff reported that they were  not tested consistently. An Employee Health provider and the infection control coordinator told  the OIG that the determination to test residents and staff monthly was made at the command  center level and shared with staff. However, the OIG did not find evidence to support that the command center team made the decision or communicated the information to staff. 

The OIG found facility leaders did not create an adequate COVID-19 post-baseline testing plan; this resulted in the lack of a standardized process to address ongoing disease screening,  monitoring, and testing of CLC residents and staff for the prevalence of COVID-19. 

Inconsistent Ongoing Testing Following a COVID-19 Outbreak 

The OIG substantiated that although CLC residents were tested, facility leaders failed to ensure  testing of all CLC staff after an individual at the CLC was diagnosed with COVID-19. 

When outbreaks of COVID-19 occur, routine testing to identify individuals with the virus is  critical to limit the spread of the disease. A June 11, 2020, VHA memorandum states all CLC  residents and staff should be tested as soon as a newly confirmed case of COVID-19 is identified. The same memorandum further instructs facilities to, “continue to test residents and  staff who initially test negative weekly until no new cases are identified and at least 14 days have  passed since the most recent positive test in the unit.”59 

Following the CLC staff member’s positive COVID-19 test on October 13, 2020, per VHA  guidance, all CLC residents and staff should have been tested for COVID-19 as soon as  possible.60 The OIG reviewed the EHR and facility databases for COVID-19 testing of CLC  residents and staff for the week after the CLC staff member tested positive. The OIG found that  67 percent of Victory and 22 percent of Unity staff were tested on their next shift back to work.  Three Victory and two Unity staff worked multiple shifts between October 13–19, 2020, before  testing occurred and ultimately tested positive. The OIG found that by October 14, 2020, COVID-19 testing was complete for all residents on CLC neighborhoods Victory and Unity. 

57 Facility Community Living Center, COVID-19 Testing, April 4, 2020. 

58“Why COVID-19 is The Key to Getting Back to Normal,” National Institute of Health, September 04, 2020 https://www.nia.nih.gov/news/why-covid-19-testing-key-getting-back-normal. 

59 VHA Memorandum, COVID-19 Guidance on COVID-19 Testing for Community Living Centers and Spinal Cord. 60 VHA Memorandum, COVID-19 Guidance on COVID-19 Testing for Community Living Centers and Spinal Cord.

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In addition to the immediate testing for COVID-19, CLC residents and staff who initially tested  negative should have been retested weekly and until 14 days had passed after the most recent positive test. The OIG learned through interviews with CLC staff that resident and staff testing for COVID-19 increased following the identification of residents and staff diagnosed with  COVID-19; however, the frequency was inconsistent. The OIG verified the frequency of resident  and staff testing for the duration of the CLC outbreak through a review of documentation  provided by the facility and in the EHR. Table 2 shows the weekly testing compliance rates for  CLC residents and staff on Unity and Victory for the duration of the CLC outbreak. 61 

Table 2. Weekly Testing Completion Rates for Residents and Staff on Unity and  Victory for the Duration of the CLC Outbreak 

Week 1	Week 2	Week 3	Week 4
100%	100%	100%	100%
100%	100%	100%	33%
41%	74%	37%	71%
100%	35%	31%	20%

Testing Group Week 5 Unity Residents 100% Victory Residents 67% Unity Staff 7% Victory Staff 27% Source: OIG analysis of EHRs and data provided by Employee Health. 

The OIG found through interviews with Employee Health, nursing leaders, and staff, that there  was no formalized process for tracking weekly COVID-19 testing of residents and staff. The  Chief of Geriatric and Rehabilitation Service reported that residents were tested weekly and an  administrative staff member maintained a grid that tracked resident testing. Employee Health and  nurse leaders told the OIG that nurse supervisors were responsible for ensuring 100 percent  compliance with staff testing. A CLC nurse leader described a process in which paper lab  requisition forms would be printed and staff would be marked off once they were tested by one  of three CLC nurses identified as unit COVID-19 champions. These forms were shredded when  no longer in use. While the OIG learned of this process through interviews, this process was not  included in the CLC testing SOP.62 The SOP outlined the process for testing residents and staff  as well as actions to take depending on results. However, the SOP did not state the frequency to  conduct testing or specify roles and responsibilities regarding processes and accountability for  ensuring all staff were tested. CLC nurse leaders recognized that 100 percent COVID-19 testing  compliance did not occur and attributed it to staff schedules, leave status, and confusion over  whether the testing was mandatory. 

61 The OIG did not include staff members and residents who had already tested positive for COVID-19 in  subsequent weekly data as the CDC recommends that diagnostic testing for COVID-19 does not resume for three  months after the date of initial symptom onset. The OIG did not include staff in a leave status in data for time  periods because they were not available for testing. 

62 Facility Community Living Center SOP, COVID-19 Testing Residents/Staff.

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The OIG found that the failure to test all CLC staff during their first shift after a known positive  test result may have led to staff members working while having COVID-19. Additionally, the  OIG found that facility leaders did not implement a reliable method of tracking weekly testing  for CLC residents and staff during the CLC outbreak. A lack of clear roles and responsibilities  outlined in an SOP likely led to confusion as to who was responsible for ensuring testing  occurred and the failure to test all residents and staff as required. Missed testing represents a missed opportunity to promptly identify and isolate residents and staff diagnosed with COVID 19 to reduce further transmission of the virus. 

Notification of COVID-19 Test Results 

The OIG did not substantiate a failure to notify residents, their families, and staff of positive  COVID-19 test results. The OIG found that the facility had a process in place to manage  communication of staff members’ positive COVID-19 test results within the supervisory  structure. Additionally, although staff could not articulate the individual responsible for notifying  residents or their family of a residents positive COVID-19 test result, documentation in the EHR  showed notification occurred. 

Contact tracing is the process of notifying individuals who have been in contact with someone  who tests positive for COVID-19; it is an infection control practice intended to stop or slow the  spread of further transmission. The act of quarantining keeps individuals exposed to the virus  away from others.63 

Resident 

The OIG found that CLC staff were unable to verbalize who was responsible for notifying a  resident or point of contact (POC) when a resident had a positive COVID-19 test result. This was despite evidence that notification of a resident’s COVID-19 diagnosis, and subsequent change of  room location occurred and was made by nursing staff. 

The CLC COVID-19 SOP on testing residents and staff specifies, “Resident POC [Point of  Contact] will be notified of the testing if deemed incompetent to make medical decisions” and  “If the test comes back positive Resident (POC) will be informed of the positive test results.”64 However, the SOP does not state who is responsible for notifying the resident or the POC of a  positive test result. 

63“Isolate if You are Sick,” CDC, accessed on March 23, 2021, https://www.cdc.gov/coronavirus/2019-ncov/if-you are-sick/isolation.html.  

64 Facility Community Living Center SOP, COVID-19 Testing Residents/Staff. This SOP uses the acronym POC,  which stands for point of contact.

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According to a July 2018 facility nursing SOP, nursing staff are to document patient transfers  using the NUR/TRANSFER NOTE in the EHR. The note should include the reason for transfer,  notification of next of kin, and by whom.65 

The OIG interviewed facility and CLC leaders and CLC staff regarding who was responsible for  notifying the resident and or their POC of a resident’s testing and positive COVID-19 test result.  The responses were inconsistent but commonly attributed the responsibility to physicians, nurse  

practitioners, and nursing staff. The OIG reviewed the EHRs of 23 Unity and Victory residents  diagnosed with COVID-19 and found that all 23 POCs were notified of the resident’s COVID-19  positive test result and relocation to the designated treatment unit. Additionally, the OIG found  that nursing staff provided the notification to POCs. 

The OIG concluded that although CLC staff were unable to verbalize the person responsible for notifying the resident and or their POC of a resident’s positive COVID-19 test result, nursing  staff completed the notifications to residents or their POC. 

Staff 

The facility had a process to inform supervisors of an employee’s positive COVID-19 test result and to alert staff of possible exposure in a manner that protected the affected individual’s confidentiality. 

An April 3, 2020, VHA memorandum explains that contact tracing and risk-assessment of all  potentially exposed health care personnel is costly to resources and impractical in areas with  community transmission, citing that when community transmission is high, healthcare workers  are assumed to be at high risk of exposure. Therefore, because the use of formal contact tracing may place an undue demand on the system and unnecessarily pull resources from elsewhere, VHA recommends that healthcare workers report significant exposures, self-monitor, and stay  home if ill.66 On June 18, 2020, the CDC issued guidance that stated when informing individuals  of exposure to COVID-19, notification should “be carried out in a way that protects the  confidentiality of affected individuals and is consistent with applicable laws and regulations.”67 

Through interviews and a review of the facility’s COVID-19 employee databases, the OIG  learned of a facility process to notify supervisors of a staff member’s positive COVID-19 test  result and alert staff of a possible workplace-related exposure. Employee Health maintains a  database of persons under investigation, defined by an Employee Health provider as a staff  member falling into one of three categories: tested at the facility, tested in the community, or 

65 Facility SOP 118-6, Nursing Documentation, July 2018. 

66 VHA Memorandum, Guidance for Notification Surrounding Exposure to Health Care Personnel (HCP) with  Confirmed 2019 Novel Coronavirus (COVID-19) Illness, April 3, 2020. 

67“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19) Pandemic.” 

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self-isolated at home due to a positive family member. At the time of the inspection, persons  under investigation could receive a COVID-19 test either at the facility or within the community.  The OIG was told that regardless of test location, staff were advised to inform their supervisor  about the potential exposure, plan for testing, and need to quarantine until the final test results  were known. Information including the name of the COVID-19 positive staff member, duration  of quarantine, and the return to work date was maintained within the database. When results  were known, Employee Health sent an email to the supervisor regarding the COVID-19 positive  staff member to inform them that one of their staff tested positive. Additionally, Employee  Health sent a separate email for supervisors to forward to staff telling them someone had tested  positive in their work area while protecting the identity of the positive staff member, in  accordance with CDC guidance. As a staff member reached the end of their quarantine period,  Employee Health contacted them to check on their condition and discuss release from  quarantine. Once ready to return to work, the staff member was asked to contact their supervisor  to finalize the date of return.68 Employee Health provided a daily report on the number of individuals who had tested positive or who were under investigation to the command center and  the Chief Nurse of Operations. 

The OIG found processes in place at the facility that adhered with guidance for informing supervisors and staff of positive COVID-19 results in a manner that protected confidentiality. 

Contributory Factors 

The OIG team identified a failure by facility leaders to proactively develop and implement plans  to prepare for, and respond to, a potential COVID-19 outbreak at the CLC following VHA’s  identification of the CLC as a high-risk environment.69 The OIG found the facility’s initial action  plan, prepared prior to the official recognition of the pandemic and inception of the command  center, lacked planning specific to CLC preparedness for mitigating or responding to COVID-19.  Rather, the Facility Director stated focusing on planning for an influx of VHA patients from  other geographic regions or non-VHA patients from the community who may have needed to be  quarantined at the facility due to a lack of beds elsewhere. 

Early in the pandemic, due to their high-risk population, VHA identified CLCs as locations that  warranted special precautions to mitigate exposure to and transmission of COVID-19.70 The  Chief of Quality Management reported the facility created an action plan in response to  pandemic-related actions assigned to medical centers by VHA’s Deputy Under Secretary for  Health for Operations and Management. Later, facility leaders contributed to the development of  the plan. In total the plan included 46 items, only two were specific to the CLC. The first was a  

68“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19 Pandemic.” 

69 VA Response to COVID-19, Guidance for VA Community Living Centers. 

70 VA Response to COVID-19, Guidance for VA Community Living Centers.

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response to queries regarding the availability of space to provide a mobile hospital and staff to  provide training. The second focused on screening individuals entering the CLC. The plan lacked  items specific to a potential outbreak at the CLC. 

The OIG learned through interviews that staffing of the command center, that opened on March  23, 2020, included facility leaders, the Chiefs of Quality Management and Environmental  Management Service, the emergency manager, and the infection control coordinator. CLC  leaders were not members of the command center. Command center members met together at  least weekly from March 23, 2020, until the command center transitioned to virtual meetings in  June 2020. 

The Facility Director stated plans were initiated in March 2020 to address how the facility would  manage VHA patients from other geographic regions or non-VHA patients from the community who may have needed to be quarantined. Units 101-1 and 101-2 were designated for the  anticipated quarantined patients. The Facility Director acknowledged that an internal outbreak  was not part of the considerations. 

The Facility Director told the OIG that after a neighborhood-wide testing occurred on October  20, 2020, two residents at the main CLC tested positive and that the Director met with the Associate Director, Chief of Staff, and ADPCS to determine next steps; at that time, two CLC  neighborhoods, 101-1 and 101-2, and Valor House were vacant. The Director stated that “in an  attempt to move out with a sense of urgency to mitigate this on a wider scale” a decision was  made to separate the residents and use 101-1 for residents who were not diagnosed with COVID 19 and 101-2 for residents diagnosed with COVID-19. The decision was shared with  representatives from the CLC and other service lines. The OIG confirmed 101-2 opened on  October 21, 2020, and the two residents diagnosed with COVID-19 were moved to the unit the  same day. 

The CLC outbreak led to completion of a facility inpatient surge plan on October 22, 2020. The  surge plan addressed bed management and had three stages specific to the placement of patients  diagnosed with COVID-19 (see appendix B): 

∙ Utilize the two negative pressure rooms on an inpatient medical unit, 

∙ Activate Valor House when the census reaches three, and 

∙ Activate 101-2 when the census reaches 10. 

The remaining residents were retested on October 23, 2020. On October 24, 2020, unit 101-1  opened; CLC residents who remained negative for COVID-19 transferred to the unit. From late  March until October 2020, when community spread was at low levels, facility leaders had the  opportunity to put processes and plans in place to mitigate and manage a potential COVID- 19  outbreak at the CLC. The initial focus of facility leaders on plans to receive and care for patients  from the community and other VHA facilities, coupled with the initial level of community 

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spread, may have contributed to a lack of urgency and lack of planning for the possible need to  provide care to significant numbers of CLC residents diagnosed with COVID-19 at the facility. 

The OIG team identified the lack of CLC-specific planning as a contributory factor that led to a  failure to: identify CLC staff as requiring respiratory protection, being fit tested and issued N95s, and trained in the use of PAPRs; develop thorough processes to minimize exposure; and ensure  consistent testing for residents and staff. Despite clear communication from VHA emphasizing  the need to pay particular attention to CLCs, facility leaders did not initiate CLC-specific  planning until the CLC outbreak occurred, seven months into the pandemic. This failure to  proactively develop and implement plans was a missed opportunity to ensure that facility and  CLC staff were in a state of ongoing readiness should a CLC resident or staff member become  diagnosed with COVID-19. 

Concern: Facility and CLC Leaders’ Post-CLC Outbreak Actions 

The OIG determined that actions taken by facility and CLC leaders following the CLC outbreak lacked input from frontline staff to identify corrective actions and opportunities for improvement. However, the facility has made significant progress toward mitigation of the  spread through vaccines. 

The OIG team asked facility and CLC leaders, as well as staff, to reflect on the CLC outbreak and the level of readiness for a similar event, were one to occur. The OIG heard starkly different  responses. One facility leader described the time frame during the CLC outbreak as difficult, not  because the information about COVID-19 was still changing but because they were having to  apply it for the first time, months after the pandemic started. Overall, facility leaders reported  pride in the facility’s response, felt confident in their readiness to handle possible future  outbreaks, and that staff understood actions to take were that to occur. CLC managers and direct  care staff reported feeling they could have been better prepared for the CLC outbreak and lacked  confidence in their readiness to respond to subsequent COVID-19-related challenges. Direct care  staff described chaos and a lack of awareness of what to do once the CLC outbreak occurred.  They reported doing their best with little recent training or experience to draw upon. 

On October 22, 2020, in response to the CLC outbreak, CLC leaders finalized an upsurge action  plan. The action items focused on CLC staff education about PPE and auditing of correct PPE  use. The plan addressed proper face mask wearing education, both face-to-face and computerized  training modules, weekly audits of five staff members to monitor compliance, monitoring  transfer times for residents diagnosed with COVID-19, and tracking that residents who were  transferred for COVID-19 care returned to their original neighborhood (see appendix C). The  action plan was completed on February 28, 2021. 

The Acting ADPCS conveyed that following the OIG’s virtual site visit in December 2020,  concerns previously identified by administrative nurses who provided direct resident care during  the CLC outbreak were provided to a Patient Clinical Support Workgroup and translated into a 

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facility post-COVID-19 CLC outbreak action plan with recommendations and actions to address  the concerns. A review of documentation provided showed the concerns were organized into the categories of communication, resources and assets, safety and security, staff responsibilities,  utilities management, and patient clinical support. Each category had a team assigned to address  the action items. An email to the OIG confirmed the teams were comprised of members from  quality management, service chiefs, as well as executive and CLC leaders, and that direct care  staff from the CLC were not included as members. The action items were discussed and monitored during updates provided to members of the command center. Representatives from the  CLC were invited guests at a February 2021 command center meeting where CLC testing was  discussed and reports from the workgroups were presented. Facility leaders’ post-COVID-19  outbreak action plan had several recommendations centered around communication; however, in  only having the action plan presented to the command center team, an opportunity was missed to  educate staff on actions being taken to prepare for a future outbreak. While the action plan was a  step in the right direction, the plan was reliant on the observations from a limited number of staff  and did not include direct care staff from the CLC. 

In addition to the CLC COVID-19 upsurge action plan and facility post-COVID-19 outbreak  action plan, the OIG learned the facility updated COVID-19 processes since the CLC outbreak  focusing on screening, testing, isolation, and vaccination. Employee Health created a staff  decision tree that provides situation-based guidance related to staff reports of exposure or  symptoms. In December 2020, a facility document was created that states each CLC direct care  staff member will be tested twice a week for COVID-19. The Geriatrics and Rehabilitation  Service Chief issued a CLC SOP on February 18, 2021, outlining that residents would be tested  twice a month. Additionally, the SOP outlined that when a resident tested positive, the resident  would be isolated, and the service line chief would make a decision on the transfer of the resident  based upon the resident’s condition. The SOP is silent on the time frame in which the isolation or  decision to transfer will be made. 

The facility made significant progress toward mitigation of the spread of COVID-19 with all CLC residents fully vaccinated as of March 9, 2021. The facility did not have the same success  with facility staff vaccination rates. As of March 9, 2021, for the 1500 facility staff, the overall  vaccination rate was 57 percent. 

The OIG conducted a follow up interview with the Facility Director concerning post-CLC  outbreak challenges and actions taken. The Director acknowledged challenges. The Director  expressed concerns with both the facility culture and unit level accountability for actions. The  Director and the executive team have taken action to work with consultants to assist with  changing the organizational culture, and improving psychological safety and communication.  The Director also shared that facility leaders were working with VHA to launch a program on  leadership to be presented to all managers in the facility.

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As evidenced by the creation of action plans, facility and CLC leaders recognized the  opportunity to make improvements following the CLC outbreak. The OIG noted the action  planning process lacked involvement of ancillary and frontline staff to assist in identifying  necessary corrective actions and opportunities for improvement. 

Conclusion 

The OIG substantiated that facility leaders and staff failed to observe general infection control  practices specifically related to respiratory PPE. The OIG found CLC residents did not  consistently wear face coverings prior to the CLC outbreak and some CLC staff did not comply  with infection control measures related to face masks both prior to and after the CLC outbreak. 

At the time of the CLC outbreak, the facility’s Environmental and Safety Section did not identify  CLC providers and nursing staff as requiring respiratory protection. The OIG found that prior to  the CLC outbreak some CLC providers, but none of the CLC nursing staff on the impacted units, were fit tested or trained. Additionally, a small percentage of nursing staff on Unity and Victory  

were fit tested and none had PAPR training prior to the outbreak. The OIG concluded that  nursing leaders and the Chief of Geriatrics and Rehabilitation Service failed to reassess the need  for fit testing of CLC nursing staff. This failure resulted in CLC nursing staff providing direct  patient care to residents with suspected and confirmed diagnoses of COVID-19 without the  preferred respiratory protection. 

The OIG substantiated that CLC and facility leaders failed to minimize the risk of CLC  residents’ and staff exposure to COVID-19. The OIG found facility leaders did not follow CDC  guidelines when responding to a CLC staff member’s reported cough and COVID-19 community  close contact exposure and did not remove the employee from direct patient care. The facility did  not have a comprehensive plan that specified operational details such as roles, actions, and  targeted time frames for the transfer and isolation of CLC residents suspected of having or diagnosed with COVID-19. At the start of the CLC outbreak, two CLC residents were diagnosed with COVID-19, one of whom lived in a shared room. The OIG found that for the resident who  shared a room, the resident’s roommate, who was not diagnosed with COVID-19 but was  exposed, was not isolated. The transfer of the two CLC residents diagnosed with COVID-19  occurred 20 hours after the physician first became aware of both residents’ positive COVID-19  tests. The OIG confirmed the shared room of the non-infected resident was cleaned after the  transfer of the roommate diagnosed with COVID-19; however, due to the non-functional bed  management system and the absence of a substitute record keeping system, the OIG was unable  to determine what time the room was cleaned. 

The OIG determined that facility and CLC leaders did not implement the additional infection  control measures recommended by the CDC when administering aerosol-generating procedures.  CLC leaders also permitted group therapy sessions to continue throughout the pandemic thereby  increasing residents and staff risk of exposure to COVID-19. However, CLC leaders minimized 

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the risk of cross-contamination by ensuring staff did not work on both the COVID-19 and non COVID-19 designated units during the same shift. 

The OIG found the facility lacked a plan for post-baseline testing of residents and staff.  Additionally, the OIG substantiated that ongoing testing for residents and staff was inconsistent  following the CLC outbreak. The OIG did not substantiate that facility staff failed to notify  residents or their POCs, and staff of COVID-19 test results. 

The OIG team identified a failure by facility leaders to proactively develop and implement plans  to prepare for, and respond to, a potential COVID-19 outbreak at the CLC following VHA’s  identification of the CLC as a high-risk environment. The OIG found the facility’s initial action plan, prepared prior to the official recognition of the pandemic and inception of the command  center, lacked planning specific to CLC preparedness for mitigating or responding to COVID-19.  Rather, facility leaders focused on planning for an influx of VHA patients from other geographic  regions or non-VHA patients from the community who may have needed to be quarantined at the  facility due to a lack of beds elsewhere. Facility leaders did not initiate CLC-specific planning  until the CLC outbreak occurred, seven months into the pandemic. This failure to proactively  develop and implement plans was a missed opportunity to ensure that facility and CLC staff  were in a state of ongoing readiness should a CLC resident or staff member become diagnosed  with COVID-19. 

As evidenced by the creation of action plans, facility and CLC leaders recognized the  opportunity to make improvements following the CLC outbreak. The OIG determined that the  action planning process lacked involvement of ancillary and frontline staff to assist in identifying  necessary corrective actions and opportunities for improvement. 

The facility made significant progress toward mitigation of the spread of COVID-19 with all CLC residents fully vaccinated as of March 9, 2021. The facility did not have the same success  with facility staff vaccination rates. As of March 9, 2021, for the 1500 facility staff, the overall  vaccination rate was 57 percent.

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Recommendations 1–15 

1. The VA Great Lakes Health Care System Director evaluates whether administrative action is  warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at  the VA Illiana Health Care System, and takes action, as appropriate. 

2. The VA Illiana Health Care System Director ensures the plan to monitor and track face mask  wearing by staff at the community living center adheres to current Centers for Disease Control  and Prevention guidance, is ongoing, results are monitored, and action plans are implemented as  warranted. 

3. The VA Illiana Health Care System Director confirms that all community living center staff  identified as requiring respiratory protection are fit tested, trained, and have ready access to  respiratory devices. 

4. The VA Illiana Health Care System Director ensures a plan is in place that adheres to current  Centers for Disease Control and Prevention guidance regarding staff with known community  exposure to COVID-19, and monitors for compliance. 

5. The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that adheres to current Centers for Disease Control and Prevention guidance regarding  community living center residents with known exposure to individuals diagnosed with COVID 19, and monitors compliance. 

6. The VA Illiana Health Care System Director ensures operability and use of the bed  management system for tracking completion of room cleaning. 

7. The VA Illiana Health Care System Director oversees the completion and implementation of a  policy for administering aerosol-generating procedures during the COVID-19 pandemic that  adheres to Centers for Disease Control and Prevention guidance, and monitors compliance. 

8. The VA Illiana Health Care System Director evaluates the organizational approach for  notifying managers of updated Veterans Health Administration policies and guidance for  monitoring actions taken to ensure compliance with new requirements. 

9. The VA Illiana Health Care System Director reinforces facility staff understanding of  Veterans Health Administration guidance related to community living center practices, including  group activities, disseminated during emergent events such as a pandemic and maintains  oversight of community living center leaders’ implementation of such guidance. 

10. The VA Illiana Health Care System Director directs community living center leaders to  complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing. 

11. The VA Illiana Health Care System Director evaluates the community living center  standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” 

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to ensure that it provides guidance with specific actions for staff to take when a resident  tests positive for COVID-19. 

12. The VA Illiana Health Care System Director verifies that COVID-19 testing for community  living center residents and staff occurs as required for both routine surveillance and in response  to confirmed cases of COVID-19. 

13. The VA Illiana Health Care System Director confirms that the community living center  COVID-19 standard operating procedure clearly communicates the process, including roles and  responsibilities, for notification of a resident’s change in condition or room assignment and  communicates the plan to all community living staff. 

14. The VA Illiana Health Care System Director executes a process to ensure that the  facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the  community living center, and when identified, creates a plan to mitigate and manage risk. 

15. The VA Illiana Health Care System Director directs those conducting the facility’s  after-action review of the community living center outbreak to include input from frontline community living center staff and takes action as necessary.

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Appendix A: Facility Campus Map 

Green  

Houses

Figure A.1. VA Illiana Health Care System Campus Map. 

Source: Facility Public Internet Website. 

Table A.1. Neighborhood Call Names and Physical Locations 

CLC Neighborhood Call Name	Physical Location
101-1 (unnamed)	Building 101 (CLC unit not in use prior to the outbreak)
101-2 (unnamed)	Building 101 (CLC unit not in use prior to the outbreak)
Abe Lincoln	Building 101, unit 3 (101-3)
Stars and Stripes	Building 101, unit 4 (101-4)
Unity	Building 101, unit 7 (101-7)
Victory	Building 101, unit 8 (101-8)
Valor House	Building 131, Green House
Freedom House	Building 128, Green House
Honor House	Building 130, Green House
Liberty House	Building 129, Green House

Source: OIG interviews with staff and facility provided internal documents. 

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Appendix B: Facility Inpatient Surge Plan 

October 22, 2020 

Illiana Comprehensive Inpatient COVID-19 Surge Plan 

Plan A: 58-2 2 Acute Care beds 

1. Use two negative pressure beds 244, 246 

2. Admit COVID positive/all levels of care (Acute, CLC, Mental Health) 

3. Two additional rooms maybe used utilizing hepa-filters inside room 

Plan B: Valor House CLC for non-Acute Veterans and continue with 58-2 for Acute Veterans  (Acute, Mental Health) 

1. Activate when COVID census reaches 3 

2. Use available rooms 105, 109, 110, 114, 115, 117, 118, 122,123, 124 

3. Provides a total of 10 COVID beds Valor and 2 Negative Pressure COVID beds on 58-2 4. These 10 rooms in Valor are private rooms and private bathrooms would NOT be negative  pressure. 

5. Notify VISN assessment of current conditions and staffing issues if applicable Plan C: Activate 101-2 Beds non-Acute 24 COVID beds. Continue to have available 2 Acute beds  58-2 

1. Activate when COVID census reaches 10 

2. Use 101-2 for COVID non-acute 102b (beds 2,3,4), 103b (beds 2,3,4), 104b (beds 1,2,3), 109b  (2,3,4), 110b (beds 2,3,4), 111b (beds 2,3,4), 118b, 119b,120b,121b,122b,123b 3. Provides a total of 24 non-Acute COVID beds utilizing hepa-filters in hallways with two  additional 58-2 Acute COVID negative pressure rooms 

4. Assess staffing needs. Activate/continue Surge Staffing/Staff Mobilization plan if appropriate.  Request VISN support if staffing is low. 

Plan D: Consider decreasing services. 

1. Curtail Services at recommendation of QUAD 

2. Discuss mobilization of Veterans

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Appendix C: CLC Upsurge Action Plan Table C.1. October 22, 2020 CLC Upsurge Action Plan

State the /Issue Resolution/Actions  to Be Taken 

(include action words  

and target dates) 

Responsible  Party/Parties 

How Will this be  Monitored 

Status/Completion Date 

Patients within  the CLC are  

testing positive  for COVID19,  presumably from  staff exposure. 

Educate staff: 

1.Face to face  

education by  

Neighborhood Nurse  Manager to be  

provided regarding  appropriate mask wearing. 

1. Nurse Manager 1. Shift Nurse Manager will request staff  

signature after face-to 

face education, To  

capture more  

employees this will be  

done two times in one  

week per  

neighborhood. 

1.Goal date 11/6/2020 100% 11/24/2020

2.Provide hand out of  an article for Correct  Donning & Doffing of  PPE:  

https://www.cdc.gov/c oronavirus/2019- 

ncov/downloads/A_F S_HCP_COVID19_P PE.pdf 

3.Clinical staff will  complete TMS,  

“COVID19 Clinical  Staff” TMS 41327 

4.Complete TMS  “COVID-19 PPE  

Donning and Doffing  Simulation” VA  

41571. 

Observation: 

5.Neighborhood  

Provider will audit five  staff per week for  appropriate mask  wearing. 

2. Neighborhood MAS &  Nurse Manager 

3. Nurse Managers &  Neighborhood MAS 

4. Nurse Managers &  Neighborhood MAS 

5. Neighborhood  

Providers 

2. Educational Read &  Sign Notebook 

3. TMS Completion  Report 

4. TMS Completion  Report 

5. Percentage of  

compliant staff will be  reported to Geriatrics  and Rehabilitation  Service Secretary  weekly until three  consecutive weeks at  100% or better are  achieved. 

2.Goal date 11/12/2020  100% 11/24/2020 

3. Goal date 0/30/2020 11/30/2020: 120/149 81%  12/31/20: 140/145 97%  1/22/21: 145/145=100% 

4.Goal date 11/12/2020 11/30/2020: 28/44 64% 12/31/20: 41/42 98%  1/21/21: 42/42=100% 

5.100% compliance with  correct mask wearing for 3  consecutive weeks.  

October through December 100% COMPLETED

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State the /Issue Resolution/Actions  to Be Taken 

(include action words  

and target dates) 

Mitigation  

Measures: 

6.When testing  

positive, Veterans will  

be moved to the  

appropriate  

Neighborhood, such  

as Valor, within the  

shift; including after 

hours, holidays and  

weekends. This is to  

reduce further staff  

and Vet exposure. 

7.Vets will return to  

their usual  

Neighborhood when  

they are at minimum  

meeting CDC criteria,  

when clinically and  

institutionally  

appropriate. 

Responsible  

Party/Parties 

6.Neighborhood Provider  or Hospitalist On Call 

7.COVID Neighborhood  Provider 

How Will this be  

Monitored 

6. QM RN CLC Liaison  will audit transfer time  of COVID19 positive  Veterans. 

7. COVID  

Neighborhood Provider  will observe symptoms  and testing when  

indicated 

Status/Completion Date 

6.100% for 3 consecutive  months, November 2020  4/4 100%, December 2020  1/1 100%, January 2021  2/2 100% COMPLETED 

7.100% for 3 consecutive  months, November 2020:  18/20 90%, December  2020: 1/1 100%, January  2021: 0/0, February 2021:  3/3 100% 

COMPLETED

Source: Facility CLC completed action plan on October 22, 2020.

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Appendix D: VISN Director Memorandum 

Department of Veterans Affairs Memorandum 

Date: September 9, 2021 

From: Director, VA Great Lakes Health Care System (10N12) 

Subj: Healthcare Inspection—Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at VA Illiana Health Care System in Danville, Illinois 

To: Director, Office of Healthcare Inspections, (54HL05) 

Director, GAO/OIG Accountability Liaison Office (VHA 10BGOAL Action) 

1. Thank you for the opportunity to view the draft report of the VA Illiana Health Care System inspection. I  would like to thank the OIG Inspection team for a thorough review. 

2. I concur with recommendations 1-14 and support the facility response for 15. 

3. Should you have additional questions, please contact the Quality Management Officer (QMO), VISN  12: VA Great Lakes Health Care System. 

(Original signed by: Victoria P. Brahm, MSN, RN, VHA-CM)

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VISN Director Response 

Recommendation 1 

The VA Great Lakes Health Care System Director evaluates whether administrative action is  warranted for individuals regarding failures to mitigate risk and manage a COVID-19 outbreak at  the VA Illiana Health Care System, and takes action, as appropriate. 

Concur. 

Target date for completion: March 31, 2022 

Director Comments 

The VA Great Lakes Health Care System Director has initiated a Fact Finding to determine if  administrative action is warranted for individuals who failed to mitigate risk and manage the  COVID-19 outbreak at VA Illiana Health Care System. The Fact Finding team is charged to also  make recommendations based on the findings.

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Appendix E: Facility Director Memorandum 

Department of Veterans Affairs Memorandum 

Date: September 9, 2021 

From: Acting Director, VA Illiana Health Care System (550/00) 

Subj: Healthcare Inspection—Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a  Community Living Center at VA Illiana Health Care System in Danville, Illinois 

To: Network Director, Great Lakes VA Health Care Network (10N12) 

1. Thank you for the opportunity to review the Office of the Inspector General (OIG) draft report  “Failure to Mitigate Risk of and Manage a COVID-19 Outbreak at a Community Living Center at VA  Illiana Health Care System in Danville, Illinois.” 

2. We extend our condolences to the family and friends of our patients and are deeply saddened by  their loss. The cases in our Community Living Center impacted our entire staff and reinforced our  commitment to learning and improving from the experience. As health care professionals, we find it  difficult to accept the loss, especially as our staff were heavily invested in providing quality care and  maintaining patient and staff safety throughout this pandemic. 

3. We thank the OIG team for their recommendations which identified areas for improvement. We  have been actively working to improve care for our Community Living Center Veterans and staff  during the COVID-19 pandemic since the completion of our internal reviews. We concur with  recommendations 2-14 and concur in principle with recommendation 15. The leadership team at  VA Illiana Health Care System is committed to implementing corrective actions and will diligently  pursue all measures to ensure safe, high-quality care for the Veterans that we serve. 

(Original signed by:) 

Staci M. Williams, Pharm D, RPh 

Acting Medical Center Director

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Facility Director Response 

Recommendation 2 

The VA Illiana Health Care System Director ensures the plan to monitor and track face mask  wearing by staff at the community living center adheres to current Centers for Disease Control  guidance, is ongoing, results are monitored, and action plans are implemented as warranted. 

Concur. 

Target date for completion: March 31, 2022 

Director Comments 

The Acting VA Illiana Health Care System Director will ensure that the plan to monitor and  track face mask wearing by staff in the Community Living Center adheres to current Centers for  Disease Control guidance, is ongoing, results are monitored, and action plans are implemented as  warranted. Statistics from personal protective equipment (PPE) rounding/tracers will be tracked  and reported to Oversight Response Committee, of which the Acting Medical Center Director is  the Chair, on a monthly basis until 6 months of 90% compliance are documented. Compliance is  measured by number of staff compliant with PPE (numerator) as compared to total number of  staff observed (denominator). 

Recommendation 3 

The VA Illiana Health Care System Director confirms that all community living center staff  identified as requiring respiratory protection are fit tested, trained, and have ready access to  respiratory devices. 

Concur. 

Target date for completion: October 31, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director will confirm that all Community Living  Center staff identified as requiring respiratory protection are fit tested, trained, and have ready  access to respiratory devices. On February 23, 2021, the facility formally expanded the  respiratory protection program to Community Living Center staff and fit testing and training was  initiated for the staff members. Confirmation of compliance will be reported through the  Oversight Response Committee, of which the Acting Medical Center Director is the Chair, at the  October 2021 meeting. Compliance will be demonstrated by providing a list of names of the staff  in two (2) representative CLC neighborhoods who require testing per policy and their testing and 

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training dates. Since staff may change across the year, this item shall be considered closed once  100% of applicable staff onboard during the month of review have been tested and trained. 

Recommendation 4 

The VA Illiana Health Care System Director ensures a plan is in place that adheres to current  Centers for Disease Control guidance regarding staff with known community exposure to  COVID-19, and monitors for compliance. 

Concur. 

Target date for completion: October 31, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director validated that a plan with ongoing  monitoring is currently in place that adheres to current Centers for Disease Control guidance  regarding staff with known community exposure to COVID-19. The facility developed a  “COVID-19 Employee Decision Tree” that addresses staff with known exposure to COVID-19.  Confirmation of compliance will be reported through Oversight Response Committee, of which  the Acting Medical Center Director is the Chair, at the October 2021 meeting. Compliance will  be measured by incorporating and communicating updates over six months of monitoring.  Months with no cases will be counted as compliant with the intent of closing the finding within  six months. 

Recommendation 5 

The VA Illiana Health Care System Director confirms that a comprehensive plan is in place that  adheres to current Centers for Disease Control guidance regarding community living center  residents with known exposure to individuals diagnosed with COVID-19, and monitors  compliance. 

Concur. 

Target date for completion: September 30, 2021 

Director Comments 

On March 3, 2021, the facility revised its Standard Operating Procedure (SOP 11-83) “Outbreak  Identification Control Management and Investigation” to ensure adherence to Centers for  Disease Control guidance regarding Community Living Center residents with known exposure to  individuals diagnosed with COVID-19. Confirmation of compliance will be reported through  Oversight Response Committee, of which the Acting Medical Center Director is the chair, at the  September 2021 meeting. Compliance will be measured by incorporating and communicating 

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updates over six months of monitoring. Months with no modifications will be counted as  compliant with the intent of closing the finding within six months. 

Recommendation 6 

The VA Illiana Health Care System Director ensures operability and use of the bed management  system for tracking completion of room cleaning. 

Concur. 

Target date for completion: October 31, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director ensures operability and use of the bed  management system for tracking completion of room cleaning. The facility created a workgroup  tasked with ensuring functionality and use of the bed management system. Confirmation of  compliance will be reported through Oversight Response Committee, of which the Acting  Medical Center Director is the chair, at the October 2021 meeting. 

Recommendation 7 

The VA Illiana Health Care System Director oversees the completion and implementation of a  policy for administering aerosol-generating procedures during the COVID-19 pandemic that  adheres to Centers for Disease Control guidance, and monitors compliance. 

Concur. 

Target date for completion: December 31, 2021 

Director Comments 

The facility has adopted VHA Guidance on Aerosol Generating Procedures During COVID-19  Outbreak. Confirmation of compliance will be reported monthly through Oversight Response  Committee, of which the Acting Medical Center Director is the chair, until 6 months of 90%  compliance is achieved. Compliance is measured by number of Veterans not receiving Aerosol  Generating Procedures in the CLC (numerator) as compared to total number of Veteran charts  traced per month in the CLC (denominator).

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Recommendation 8 

The VA Illiana Health Care System Director evaluates the organizational approach for notifying  managers of updated Veterans Health Administration policies and guidance for monitoring  actions taken to ensure compliance with new requirements. 

Concur. 

Target date for completion: September 30, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director has evaluated the organizational approach  for notifying managers of updated Veterans Health Administration policies and guidance for  monitoring actions taken to ensure compliance with new requirements. Opportunities for  improvement were noted and new processes were implemented. Confirmation of completion will  be reported through Oversight Response Committee, of which the Acting Medical Center  Director is the chair, at the September 2021 meeting. 

Recommendation 9 

The VA Illiana Health Care System Director reinforces facility staff understanding of Veterans  Health Administration guidance related to community living center practices, including group  activities, disseminated during emergent events such as a pandemic and maintains oversight of  community living center leaders’ implementation of such guidance. 

Concur. 

Target date for completion: October 31, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director will utilize the same communication process  referenced in the response to Recommendation 8 to reinforce facility staff understanding of VHA  guidance related to Community Living Center practices, including group activities, disseminated  during emergent events such as a pandemic and maintain oversight of Community Living Center  

leaders’ implementation of such guidance. Ten random end user audits will be completed to  ensure the information is being conveyed and that guidance is being followed. Confirmation of  completion will be reported through Oversight Response Committee, of which the Acting  Medical Center Director is the chair, at the October 2021 meeting.

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Recommendation 10 

The VA Illiana Health Care System Director directs community living center leaders to complete  a post-baseline plan for the COVID-19 disease that includes the required elements of screening,  monitoring, and testing. 

Concur. 

Target date for completion: September 30, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director will direct community living center leaders  to complete a post-baseline plan for the COVID-19 disease that includes the required elements of screening, monitoring, and testing. The facility standard operating procedure “COVID-19  Testing Residents/Staff” was reviewed and opportunities for improvement were identified.  Confirmation of compliance will be reported through Oversight Response Committee, of which  the Acting Medical Center Director is the chair, at the September 2021 meeting. 

Recommendation 11 

The VA Illiana Health Care System Director evaluates the community living center standard  operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to ensure  that it provides guidance with specific actions for staff to take when a resident tests positive  for COVID-19. 

Concur. 

Target date for completion: September 30, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director will evaluate the Community Living Center  standard operating procedure titled “COVID-19 Bi-Monthly Resident Surveillance Testing” to  ensure that it provides guidance with specific actions for staff to take when a resident tests  positive for COVID-19. Confirmation of compliance will be reported through Oversight  Response Committee, of which the Acting Medical Center Director is the chair, at the September  2021 meeting.

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Recommendation 12 

The VA Illiana Health Care System Director verifies that COVID-19 testing for community  living center residents and staff occurs as required for both routine surveillance and in response  to confirmed cases of COVID-19. 

Concur. 

Target date for completion: December 31, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director will verify that COVID-19 testing for  community living center residents and staff occurs as required for both routine surveillance and  in response to confirmed cases of COVID-19. The facility has an established tracking system to  ensure testing occurs as required. Confirmation of compliance will be reported monthly through  Oversight Response Committee, of which the Acting Medical Center Director is the chair, until 6  months of 90% compliance is achieved. Compliance is measured by number of community  living center residents and staff receiving testing in compliance with policy (numerator) as  compared to total number of residents and staff (denominator). 

Recommendation 13 

The VA Illiana Health Care System Director confirms that the community living center COVID 19 standard operating procedure clearly communicates the process, including roles and  responsibilities, for notification of a resident’s change in condition or room assignment and  communicates the plan to all community living staff. 

Concur. 

Target date for completion: October 31, 2021 

Director Comments 

Community Living Center standard operating procedure #11-83, Outbreak Identification Control  Management and Investigation, was reviewed and opportunities for improvement identified.  Confirmation of compliance will be reported through Oversight Response Committee, of which  the Acting Medical Center Director is the chair, at the September 2021 meeting.

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Recommendation 14 

The VA Illiana Health Care System Director executes a process to ensure that the facility  identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the Community  Living Center, and when identified, creates a plan to mitigate and manage risk. 

Concur. 

Target date for completion: October 31, 2021 

Director Comments 

The Acting VA Illiana Health Care System Director will execute a process to ensure that the  facility identifies potential high-risk scenarios, such as an outbreak of COVID-19 at the  Community Living Center, and when identified, creates a plan to mitigate and manage risk. The  Emergency Operations Plan, SOP 001ESS-05, will be reviewed and modified to include a  process to identify potential risks and mitigation/management strategies. The current facility  process upon identification of an issue is to convene a team of subject matter experts to conduct  a risk assessment based on the type of event, intervene to mitigate the risks, and monitor  compliance will be added to the Emergency Operations Plan. Confirmation of completion will be  reported through Oversight Response Committee, of which the Acting Medical Center Director  is the chair, at the October 2021 meeting. 

Recommendation 15 

The VA Illiana Health Care System Director directs those conducting the facility’s after action review of the Community Living Center outbreak to include input from frontline community living center staff and takes action as necessary. 

Concur in principle. 

Target date for completion: September 30, 2021 

Director Comments 

The facility had developed six core workgroups following the October/November Community  Living Center outbreak. Each workgroup consulted and/or included frontline staff members  when developing facility action plans. In addition, listening sessions were held on February 1,  2021 following the outbreak to obtain feedback from frontline staff. Actions identified by the  workgroups or through listening sessions have been completed. Confirmation of compliance will  be reported through Oversight Response Committee, of which the Acting Medical Center  Director is the chair, at the September 2021 meeting.

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Glossary 

aerosol-generating procedure. Procedures that are believed to spray mist and droplets as a  source of respiratory pathogen and can include “positive pressure ventilation (BiPaP and CPAP),  endotracheal intubation, airway suction, high frequency oscillatory ventilation, tracheostomy,  chest physiotherapy, nebulizer treatment, sputum induction, and bronchoscopy.”71 

baseline testing. Initial viral testing of a resident or individual “who is not known to have  previously been diagnosed with COVID-19.”72 

close contact. “Someone who has been within 6 feet of an infected person…for a cumulative  total of 15 minutes or more over a 24-hour period…. An infected person can spread SARS-CoV 2 [COVID-19] starting from 2 days before they have any symptoms (or, for asymptomatic  patients, 2 days before the positive specimen collection date) until they meet criteria for  discontinuing home isolation.”73 

contact tracing. The practice of identifying, notifying, and monitoring individuals who may have  had close contact with a person having a confirmed or probable case of an infectious disease as a  means of controlling the spread of infection.74 

continuous positive airway pressure. “A treatment that uses mild air pressure to keep your  breathing airways open.” It involves using a “machine that includes a mask or other device that  fits over your nose or your nose and mouth, straps to position the mask, a tube that connects the  mask to the machine’s motor, and a motor that blows air into the tube.”75 

COVID-19. “Coronavirus disease 2019 (COVID-19) is caused by a new coronavirus first  identified in Wuhan, China, in December 2019. Because it is a new virus, scientists are learning  more each day. Although most people who have COVID-19 have mild symptoms, COVID-19  

71 Tran, Khai et al., “Aerosol Generating Procedures and Risk of Transmission of Acute Respiratory Infections to  Healthcare Workers: A Systematic Review.” PLoS ONE vol. 7,4 (2012): e35797. doi:  

10.1371/journal.pone.0035797 

72“Testing Guidelines for Nursing Homes: Interim SARS-CoV-2 Testing Guidelines for Nursing Home Residents  and Healthcare Personnel,” CDC, accessed February 24, 2021, https://www.cdc.gov/coronavirus/2019- ncov/hcp/nursing-homes-testing.html. 

73“COVID-19, Appendices,” CDC, accessed on April 29, 2021, https://www.cdc.gov/coronavirus/2019- ncov/php/contact-tracing/contact-tracing-plan/appendix.html.  

74 Merriam Webster ”Definition of contact tracing” accessed March 25, 2021, https://www.merriam webster.com/dictionary/contacttracing 

75 “CPAP,” National Heart, Lung, and Blood Institute, accessed February 25, 2021,  

https://www.nhlbi.nih.gov/health-topics/cpap.

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can also cause severe illness and even death. Some groups, including older adults and people  who have certain underlying medical conditions, are at increased risk of severe illness.”76 

fit testing. “The use of a protocol to qualitatively or quantitatively evaluate the fit of a respirator  on an individual.”77 

geri-psychiatric. “Geriatric psychiatry emphasizes the biological and psychological aspects of normal aging, the psychiatric effect of acute and chronic physical illness, and the biological and  psychosocial aspects of the pathology of primary psychiatric disturbances of older age.”78 

n95. A type of National Institute for Occupational Safety and Health (NIOSH)-approved filtering  facepiece respirator (FFP). N95s are air purifying respirators that protects by filtering particles  out of the air while the user is breathing. N95s filter at least 95% of airborne particles and is not  resistant to oil.79 

nebulizer. An atomizer equipped to produce an extremely fine spray for deep penetration of the  lungs.80 

negative pressure room. A form of hospital isolation room that “prevents airborne disease (such  as tuberculosis or flu) from escaping the room.” “A machine pulls air into the room. Then it filters the air before moving it outside.”81 

outbreak. “A recommended definition is a situation that is consistent with either of two sets of  criteria: During (and because of) a case investigation and contact tracing, two or more contacts  are identified as having active COVID-19, regardless of their assigned priority. OR Two or more  patients with COVID-19 are discovered to be linked, and the linkage is established outside of a  case investigation and contact tracing (e.g., two patients who received a diagnosis of COVID-19  

76 CDC, About COVID-19, accessed April 29, 2021, https://www.cdc.gov/coronavirus/2019- ncov/cdcresponse/about-COVID-19.html. 

77 National Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory.  Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators, May 2015,  Publication Number 2015-117. 

78 “Geriatric Psychiatry,” American Psychiatric Association, accessed on February 24, 2021,  https://www.psychiatry.org/psychiatrists/practice/professional 

interests/geriatric#:~:text=Geriatric%20Psychiatry%20Geriatric%20psychiatry%20emphasizes%20the%20biologica l%20and,pathology%20of%20primary%20psychiatric%20disturbances%20of%20older%20age.  79 “NIOSH Guide to the Selection and Use of Particulate Respirators,” Centers for Disease Control and Prevention,  accessed on February 23, 2021, https://www.cdc.gov/niosh/npptl/topics/respirators/disp_part/default.html.  80 Merriam Webster, “Definition of nebulizer,” accessed February 25, 2021, https://www.merriam webster.com/medical/nebulizer.  

81 “Hospital Isolation Rooms,” Michigan Medicine, accessed on February 24, 2021,  

https://www.uofmhealth.org/health-library/abo4381.

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are found to work in the same office, and only one or neither of the them was listed as a contact  to the other).”82 

palliative. “Specialized medical care for people living with a serious illness” that focuses on  providing “relief from the symptoms and stress of the illness. The goal is to improve quality of  life for both the patient and family.”83 

pandemic. “An outbreak of a disease that occurs over a wide geographic area (such as multiple  countries or continents) and typically affects a significant proportion of the population: a  pandemic outbreak of a disease.”84 

personal protective equipment. “Specialized clothing or equipment worn by an employee to  protect the respiratory tract, mucous membranes, skin, and clothing from infectious agents or  other hazards. Examples of PPE include gloves, respirators, goggles, facemasks, surgical masks,  face shields, footwear, and gowns.”85 

powered air purifying respirator. “An air purifying respirator that uses a blower to force air through filters or cartridges and into the breathing zone of the wearer. This creates a positive  pressure inside the facepiece or hood, providing more protection than a non-powered or negative pressure half mask APR [air purifying respirator].”86 

prevalence. “The degree to which something is prevalent especially: the percentage of a  population that is affected with a particular disease at a given time.”87 

respirator. “A mask or device worn over the mouth and nose to protect the respiratory system  by filtering out dangerous substances (such as dusts, fumes, or bacteria) from inhaled air. NOTE:  Particulate respirator masks are only able to filter out particles and are not effective against gases  or vapors. A numerical rating (such as 95 or 99) is sometimes assigned to such a respirator to  indicate the percentage of airborne particles filtered. A letter may also be assigned to indicate  

82 “Managing Investigation During an Outbreak,” CDC, accessed February 24, 2021,  

https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/outbreaks.html.  83 “About Palliative Care,” Center to Advance Palliative Care, accessed February 23, 2021,  https://www.capc.org/about/palliative-care/.  

84 Merriam Webster, “Definition of pandemic,” accessed July 20, 2021, https://www.merriam webster.com/dictionary/pandemic 

85 National Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory.  Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators, May 2015,  Publication Number 2015-117. 

86 National Institute for Occupational Safety and Health, National Personal Protective Technology Laboratory.  Hospital Respiratory Protection Program Toolkit: Resources for Respirator Program Administrators, May 2015,  Publication Number 2015-117. 

87 Merriam Webster, “Definition of prevalence,” accessed August 9, 2021, https://www.merriam webster.com/dictionary/prevalence

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whether it is somewhat resistant (R), not resistant (NR), or strongly resistant (P) to the degrading  effects of oil on proper respirator function.”88 

source control. “Use of well-fitting cloth masks, facemasks, or respirators to cover a person’s  mouth and nose to prevent spread of respiratory secretions when they are breathing, talking,  sneezing, or coughing. Cloth masks, facemasks, and respirators should not be placed on children  under age 2, anyone who cannot wear one safely, such as someone who has a disability or an  underlying medical condition that precludes wearing a cloth mask, facemask, or respirator safely,  or anyone who is unconscious, incapacitated, or otherwise unable to remove their cloth mask,  facemask, or respirator without assistance. Face shields alone are not recommended for source  control.”89 

88 Merriam Webster, “Definition of respirator,” accessed July 20, 2021, https://www.merriam webster.com/dictionary/respirator. 

89“Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus  Disease 2019 (COVID-19) Pandemic.”

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OIG Contact and Staff Acknowledgments 

Contact For more information about this report, please contact the  Office of Inspector General at (202) 461-4720. 

Inspection Team Susan Tostenrude, MS, Director 

Kevin Arnhold, FACHE 

Leakie Bell-Wilson, MSN, RN 

Tabitha Eden, MSN, RN 

Nancy Short, LCSW 

Thomas Wong, DO 

Other Contributors Alicia Castillo-Flores, MBA, MPH 

Christopher Dong, JD 

Christopher Hoffman, LCSW, MBA 

Carol Lukasewicz, BSN, RN 

Sarah Mainzer, JD, BSN 

Natalie Sadow, MBA 

Robyn Stober, JD, MBA 

Robert Wallace, MPH, ScD

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Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, VA Great Lakes Health Care System (10N12) 

Director, VA Iliana Health Care System (550) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and  Related Agencies 

House Committee on Oversight and Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate 

Illinois: Tammy Duckworth, Richard J. Durbin  

Indiana: Mike Braun, Todd Young 

U.S. House of Representatives 

Illinois: Mike Bost, Cheri Bustos, Rodney Davis, Bill Foster, Robin Kelly,  Adam Kinzinger, Darin LaHood, Mary Miller 

Indiana: Jim Baird, Larry Bucshon, Frank Mrvan 

OIG reports are available at www.va.gov/oig

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