Inside Oversight

Adam Roy
Hello and welcome back to another episode of Inside Oversight, a podcast of the Veteran Affairs Office of Inspector General.
This is your host, Adam Roy. Today, I am speaking with Susan Tostenrude a director within our Office of Healthcare Inspections.
We're going to be talking about the VA OIG 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. This report was published in September 2021.
Susan, how are you doing today?
Susan Tostenrude
I'm doing well. Thank you. Hi, Adam.
Adam Roy
Great. Thank you for being here. Although the report is almost a year old now. It's a good report to revisit, especially given that the pandemic continues to unfortunately influence our personal lives and workspaces. And there has been so many lessons learned over the last couple of years, and I think that we're going to get into that a little bit here. These lessons learned from the pandemic.
Susan, thank you for joining me and sharing the OIG's important oversight work it completed and continues to do related to the pandemic.
Let's start by talking about what prompted this investigation and the subsequent report. How did your team become involved in this?
Susan Tostenrude
Be happy to share that with you. This report was a result of an inspection into several allegations that we received that the facility and the Community Living Center leaders did not implement and adhere to the VHA's COVID-19 guidance for Community Living Centers. We also were concerned that there was a failure to manage a Community Living Center outbreak of COVID-19.
And just one thing, Adam, that it will be important for listeners to know is a little bit about Community Living Centers. We refer to them as the CLCs and they're very much like nursing homes or long-term care facilities in the community. And for the residents living in these facilities, they really consider this their home. The services that the CLCs provide are for individuals with dementia and Alzheimer's disease and also for those who need palliative rehabilitation or extended care. And while residents are residing there, medical professionals provide group therapy and recreational activities.
Adam Roy
That's great. That was exactly what I was going to ask. If you could kind of explain to the listener what a CLC is. That was a great description. Now that we are thinking about older veterans in nursing homes or, you know, in this case CLCs, how did the COVID-19 pandemic affect these residents living in CLCs?
Susan Tostenrude
That's a great question. This was a particularly vulnerable population. And so COVID-19 had a quite significant impact on this population. In October of 2020, our OIG Hotline Division received some complaints saying that there had been an outbreak on a CLC, an outbreak of COVID-19 on the CLC in Danville. That would be a quite significant impact to a population of individuals. The complainants were particularly concerned about a failure to adhere to infection control practices related to respiratory personal protective equipment. The complainants were also concerned about leaders there at the facility and on the CLC, not taking all the steps necessary to minimize the risk of transmission of COVID-19. And then lastly, the complainants were concerned with the COVID-19 testing and test result notification process. During the inspection, we also identified some other impacts to this population in terms of how the CLC responded to the outbreak.
Adam Roy
Sounds like they did have a COVID-19 outbreak. Can you talk a little bit about that and just describe to the listener just the general, the environment at the Community Living Center, you like, the number of patients, you know, what's the physical description of and how many you know, how many patients stay in and so on and so forth?
Susan Tostenrude
So, the Community Living Center there in Danville has 109 beds and it's divided into four units, and the units are referred to as neighborhoods, and these neighborhoods are adjacent to one another. In addition to those four units that are adjacent to one another, there are other CLC units that are freestanding houses located elsewhere on the campus. As I alluded to and as you mentioned, that, yes, there was a COVID-19 outbreak on this CLC. We determined that on October 13, 2020, when the first year of the pandemic, the first person related to this outbreak was diagnosed with the virus. To your point about numbers, we determined that by November 17th, so just a little more than a month later, 23 of 28 residents on two of the CLC neighborhoods tested positive for COVID-19. And 11 of those residents passed away.
Adam Roy
Oh, that's, that's, that's hard. That's hard to hear. In this example, the outbreak, as you said, started around October 2020. And that's, you know, give or take, seven months into the pandemic. Prior to that, had Veterans Health Administration provided any requirements or guidance for handling COVID-19 in a Community Living Center?
Susan Tostenrude
Yes, they had. So early in the pandemic, the Veterans Health Administration identified Community Living Centers as high risk for COVID. They noticed the vulnerability of these particular individuals, and they provided clear guidance to facilities on steps to take to mitigate the risk of transmission of this virus. The guidance that they provided included infection control measures that are known to limit the spread of disease, as well as guidance on items to use such as face masks, as well as more specialized items such as respirators. Throughout our report, we describe the gaps in VA Illiana's adherence to that guidance.
Adam Roy
Okay, that makes sense. So, can you explain more about what you found? And then also do we know why they did not adhere to the guidance?
Susan Tostenrude
We learned that in the months before the outbreak there was no shortage of personal protective equipment, also known as PPE at VA Illiana. But staff in both the Community Living Center and across the facility were not consistently wearing face masks. Prior to the outbreak, CLC residents were also not wearing face masks regularly, including when they were together.
A little bit more about the compliance with face masks' use. The facility and Community Living Center leaders were aware of this problem, and they took steps to emphasize wearing masks. However, we did not find any evidence of actions taken for staff who remained noncompliant. We also found that CLC providers and nursing staff had not been identified as a group that needed to wear respiratory protection above and beyond the face masks. What we learned was that they had not been added to that list of individuals who needed that, because prior to COVID-19, the CLCs did not have a high rate of contagious disease. This failure resulted in some nursing staff providing care to patients who were eventually confirmed to have COVID-19 without the preferred respiratory protection.
Adam Roy
Okay. Wow. We've all learned that, you know, during the pandemic, face coverings are one part of an overall effort to prevent the spread of COVID. What about testing for COVID? Did your team look into that, too?
Susan Tostenrude
We did. And you're right, the face masks and the high-level respirators are one piece of it. But testing is a very important piece of monitoring COVID-19. We found that in April 2020, shortly after the pandemic started, but six months before the outbreak, the initial COVID testing of all the CLC residents and staff was done. However, ongoing testing, which is critical for knowing if the virus has become present in the environment, it was not consistently done for staff and staff are the individuals who are most likely to bring the virus into the CLC.
Adam Roy
Okay. Yeah, that makes a lot of sense, Susan. We've talked about face coverings and their importance, talked about consistent and regular testing, which wasn't being done, especially with the staff for, you know, testing for COVID-19. Were there any other concerns related to mitigating the spread of COVID-19 that your team looked into?
Susan Tostenrude
Yes, there were there were two. As I mentioned earlier, group therapies are common on Community Living Centers. And this particular Community Living Center offered a wonderful variety of groups for their residents. And that's great. However, in the midst of a pandemic, that is something that you would want to look at. The Veterans Health Administration had sent out guidance to all CLCs, asking them to cancel all groups. However, at this facility, the groups continued, and in many cases the residents were not wearing masks during those groups. We also found that the Veterans Health Administration, as well as the CDC, had issued guidance during the pandemic related to aerosolized generating procedures, which were not adhered to.
Adam Roy
Aerosolized generating procedures. Let's talk about that further and connect it with, you know, the overall the COVID-19 concerns.
Susan Tostenrude
Sure. Let me explain a little bit more. So, an aerosolized generating procedure, an example of that might be a nebulizer. And a nebulizer is a device that provides an extremely fine spray for deep penetration of the lungs. These procedures may spray mist and droplets out into the air, so not just into the person's lungs but out into the air. And that can become a source for respiratory pathogen.
So as many of us remember, COVID-19 is transmitted through respiratory droplets. And the CDC explains that some of the procedures, these aerosolized generating procedures, if done on patients with suspected or known COVID-19, could produce infected aerosols. So, then you have a situation where they're doing a medical procedure that needs to be done but the result is the air in the area of that procedure may have some infected aerosols. When procedures that pose a risk like this cannot be avoided, when the person really needs them to be done, staff should be taking additional infection control measures. Our records, when we reviewed what was going on at this particular facility, showed that aerosolized generating procedures were ordered and completed for two residents and that these procedures were done without those additional infection control measures that were recommended.
Adam Roy
You've just described multiple concerns on how COVID-19 would have spread through the unit. And I know that, you know, it's probably very difficult to determine where it started. But was your team able to determine exactly how the outbreak started?
Susan Tostenrude
Right. That was an important part of our work, was trying to understand what may have started the outbreak or how the virus had been introduced within this vulnerable population. It's impossible to say with certainty how the outbreak started. What we do know is that on October 12, a CLC staff member came to work with a cough, and then later, as that employee was working, the employee found out that a family member had just tested positive for COVID. The employee then asked to be tested and the employee's request for testing was denied. Instead, the employee was told to wear a mask and finish their shift, which the employee did. So then moving forward, the employee goes home, comes back the next day, and is tested at the facility and found to be positive. So of course, that employee then went home and quarantined as required at that particular point in the pandemic. All of the residents on the CLC were then tested and that's in alignment with the requirement that if a staff or resident became positive, everyone had to be tested. So, they were all tested. And five days after that original employee had tested positive, four residents on one of the units tested positive. So those four residents were then transferred off the unit.
Adam Roy
Did you get an understanding of why the request for testing was denied or why that employee was told to remain at work for the rest of the shift?
Susan Tostenrude
Adam, we didn't. We did try to determine that, but we were unable to determine why that instruction was given because the information that we received from the individuals that we spoke to was conflicting, and we just couldn't sort that out.
Adam Roy
So, at first you had the four residents and the one staff member diagnosed with COVID. Did any other residents test positive for COVID-19 as well?
Susan Tostenrude
They did. Not long after the first four residents tested positive, two residents on another CLC unit did as well, including one who shared a room. When this resident tested positive, his roommate was still testing negative.
Adam, I think it's worthwhile right now to note that while they were testing the residents consistently, they were testing all of the residents, only 67 percent of the employees on the first unit and 22 percent of the employees on the second unit were tested on their next shift back to work. In fact, when we looked at the data, some staff worked multiple shifts before testing occurred and those individuals ultimately tested positive.
Adam Roy
Oh yeah, that is interesting, also concerning. So, there could be a situation where an employee had COVID but was never tested in the first or second unit during this time period.
Susan Tostenrude
Right
Adam Roy
Now, thinking, like you mentioned, the resident tested positive and then his roommate was testing negative. Obviously, they're sharing a space together in close quarters. So how did the Community Living Center manage the situation with roommates in this regard?
Susan Tostenrude
That's a good question. You're right. It is concerning to have a resident who becomes positive for COVID-19 staying in a room with a roommate. Veterans Health Administration provided guidance in March 2020, so right when the pandemic was really taking off, that facility should have a plan to isolate any resident who is suspected of having COVID-19. Unfortunately, the OIG learned that likely due to a lack of plan for the scenario, both residents with COVID-19 on that second CLC unit remained on the unit overnight.
Adam Roy
And so why weren't the infected residents moved?
Susan Tostenrude
What we know is that it was in the evening and so there was not a provider on the unit, but there was an on-call provider and so that individual was consulted about the situation with the roommates and the provider considered the roommate exposed to COVID-19 already. Therefore, staff did not transfer the roommate who already had COVID-19 off the unit or to another room. So, the resident who had been exposed to COVID-19 but not diagnosed with it, was not isolated and was actually permitted to wander on the unit while waiting for the ill resident to be transferred and for his room to be cleaned. We were able to determine that in total, those two residents who had recently tested positive for COVID-19 remained on their unit for 20 hours before they were transferred.
Adam Roy
Okay. So, the plan to, you know, isolate a resident who was suspected having COVID-19, you indicated that there was a lack of a plan for a scenario like this. Can you talk about that a little bit more?
Susan Tostenrude
We looked into what plans were in place to handle an outbreak on the CLC at this facility and found that up to the point in time of the outbreak, the facility did not have a really solid plan for this possibility. There was a plan to manage a limited number of individuals with COVID-19 at the facility, but it was not specific to CLC residents. The beds that the facility had identified in their COVID-19 plan ended up being full when these two individuals became positive, and in fact, they were filled. You know, once you transferred those first four COVID-19 positive residents off of the unit, all of the facility's identified beds were full.
Adam Roy
Okay.
Susan Tostenrude
So, they just didn't have a plan to go beyond that.
Adam Roy
So, if all the beds allocated for patients with COVID-19 were full, where did those two residents you just mentioned, where did they go?
Susan Tostenrude
So, this started a conversation at the level of leadership about what to do and how to handle this. And what leadership decided to do was to use a vacant CLC unit for residents who became positive with the virus and that final plan was finalized four days after the first CLC resident tested positive. Eventually to allow for thorough cleaning and to disrupt further transmission of the virus, all the residents from the two impacted units were transferred off of their units with those who were COVID positive going into one unit and all others going into another.

Adam Roy
Okay. It seems a little odd that they didn't they wouldn't have a plan specific to the Community Living Center, since you mentioned that VA had issued guidance to the facilities regarding the vulnerability of this population back in March, you know, more than six months earlier. Did anyone tell you why they didn't plan specifically for this scenario?
Susan Tostenrude
Yeah, you're right, Adam. We found this unusual and concerning as well. And so, we had a discussion with the facility director about this. And the facility director acknowledged that up to that point in the outbreak, this facility in Danville was really focused on taking an overflow of patients from the greater VA health care system. In their particular region, they had health care systems in the Chicago area that were being hit hard with COVID-19 and needed to open up some of their beds to care for individuals with COVID-19, meaning they needed to move or may need to move individuals who didn't have COVID-19 out of their facility to free up those beds. To do that, they thought that they would need to transfer some of those patients who are not so, so very ill or who did not have COVID to a facility like Danville. The facility director really acknowledged that their planning up to that point had been focused on that type of scenario rather than an outbreak at their particular facility.
Adam Roy
That makes that make sense. Thinking back to what you said earlier about staff on the CLC not being fitted for the respirators they needed, were they ever fitted?
Susan Tostenrude
Yes and no. Thank you for circling back to that. During the outbreak, the nursing staff on the CLC, without fitted respirators and what we mean by that is the N95s. They had to be trained in the moment, in the use of something called a power air purifying respirator and we just call that a PAPR. They had to be trained on how to use those very quickly until fit testing could be done for those N95s. By the end of the outbreak, we know that just over half of the CLC staff had been fitted for N95s. And while waiting for that fitting, they were using these PAPRs.
Adam Roy
Okay. And then what about the concern with the staff being tested frequently? Did that change?
Susan Tostenrude
Unfortunately, it didn't. The required weekly testing of staff averaged about 44 percent compliance throughout the outbreak. This failure to test them really represented a missed opportunity to promptly identify staff with the virus, which would clearly then have potential to reduce further transmission of the virus on the CLCs.
Adam Roy
Well, Susan, it sounds, you know, from your description of your findings, that there was just issues across different areas. Would also venture to say that there were some failures with leadership as well. Is that accurate?
Susan Tostenrude
Yes, Adam, it is. There were failures at different levels of leadership. To start with, despite clear communication from Veterans Health Administration that really emphasized very early on the need to pay particular attention to CLCs and to this very vulnerable population, the leaders at this facility did not initiate that CLC-specific planning in any real depth until the outbreak occurred, nearly seven months into the pandemic. Now, as we just mentioned, instead, leaders were focusing on the potential for an incoming influx of patients from other VAs and weren't really considering an internal outbreak. And then if you go to the CLC level, CLC leaders made the decision to continue groups despite the recommendation from VHA that they not do so, and also to continue offering these aerosolized procedures without all of the infection control measures in place.
There have been a number of leadership changes since we conducted this work. The Facility Director and the Associate Director of Patient Care Services are no longer at the facility. Leadership was one of the things that we determined was a key vulnerability in this particular situation. In the end, we ended up making 15 recommendations. And of those 15, we made one of them to the regional leadership, so what we call the Veterans Integrated Service Network Leader. We also made 14 directly to the facility and as I mentioned, the Facility Director is no longer there. However, the acting and now new Facility Director are aware of these recommendations and acting on them.
Adam Roy
Okay. And where is the facility today?
Susan Tostenrude
The facility created a post outbreak action plan, and that was definitely a step in the right direction. Unfortunately, that plan lacked input from frontline staff. Since that time, the facility has really looked at a lot of their processes and what occurred during this outbreak, and I'm pleased to share that they've made significant progress toward the mitigation of any further COVID-19 spread, and that progress that they have made has been primarily through vaccinations, just as is the case and in many other populations and facilities. Having individuals vaccinated is taking a great step to limit the spread or the severity of this particular virus.
Adam Roy
That's encouraging news, and I appreciate you sharing that. Is there anything you want to add before we wrap up today?
Susan Tostenrude
I don't think there is. I just want to thank you for having us on your podcast to discuss this very important inspection that we were able to conduct.
Adam Roy
Absolutely. And I appreciate you taking time to do that as well and explain the work we do here in the VA OIG, and how that helps improve veterans' lives and those that are currently in our Community Living Centers around the country. So, thank you again for being here.
Susan Tostenrude
Thank you.
Adam Roy
All right.
Susan Tostenrude
My pleasure.
Adam Roy
All right. Well, thank you, Susan. I encourage those listening to visit the VA OIG's website and read a summary of this report or download the full report. There you can also find many more reports by the VA OIG related to the pandemic across a variety of topics. That is it for this episode of Inside Oversight. So, I encourage you to check out other episodes wherever you listen to podcasts. Thanks for tuning in.
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