Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Network 19

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 19 facilities’ COVID-19 pandemic readiness and response. This evaluation focused on emergency preparedness; supplies, equipment, and infrastructure; staffing; access to care; community living center patient care and operations; facility staff feedback; and VA and VISN 19 vaccination efforts. The OIG has aggregated findings on COVID-19 preparedness and responsiveness from routine inspections to ensure prompt dissemination of information given the quickly changing landscape as infection rates and demands on facilities continually shift. Findings of inspected medical facilities are grouped by VISN, which are regional offices that provide oversight of medical centers in their area. This report, the second in a series, describes findings on COVID-19 practices from healthcare inspections performed within VISN 19 during the weeks of November 30 and December 7, 2020. It also provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of April 2021. Interviews and survey results provide additional context on lessons learned and perceptions of both preparedness and response. This report also provides data that illustrates the tremendous COVID-19-related demands on VA healthcare services. It describes leader and staff experiences, assessments, shared sentiments, and best practices to help improve operations and clinical care during public health crises. At the time of the inspections, the Veterans Health Administration and the VISN were experiencing the highest number of cases since the beginning of the pandemic and had valuable information to share about their experiences.