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

The VA Office of Inspector General (OIG) conducted an inspection at the VA Illiana Health Care System in Danville, Illinois, to determine the validity of allegations, specific to COVID-19 and the Community Living Center (CLC), of failure to observe infection control practices, failure to minimize risk of exposure to COVID-19, inconsistent ongoing testing, and failure to notify residents, families, and staff of positive test results. During the inspection, the OIG identified concerns related to leaders’ post-outbreak actions. The OIG substantiated a failure to observe general infection control practices. Residents and staff did not consistently wear face coverings prior to and at times, after the outbreak. Prior to the outbreak, one CLC nursing staff member was fit tested for an N95 mask and no CLC nursing staff had been trained about powered air purifying respirators. Leaders failed to minimize the risk of exposure to COVID-19. Leaders did not respond adequately to a staff exposure, have a plan for the transfer and isolation of residents, implement recommended infection control measures when performing aerosol generating procedures, and continued to hold group therapies. The OIG did not substantiate the facility failed to notify residents, their families, and staff of COVID-19 test results, but did substantiate the lack of a post-baseline testing plan and a failure to test CLC staff after potential exposure. The OIG identified actions taken by leaders following the CLC outbreak lacked input from frontline staff to identify corrective actions and opportunities for improvement. The OIG made 14 recommendations related to review of the failure to manage an outbreak; mask wearing; respiratory personal protective equipment; adherence to guidance on COVID-19 exposure; operability of the bed management system; policy management; development of comprehensive testing plans; communicating family notification policy; operational risk management; and frontline staff inclusion in facility review.