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   [open pdf - 2MB]

From the Executive Summary: "The VA [Department of Veterans Affairs] 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 [coronavirus disease 2019] outbreak (CLC outbreak) at the VA Illiana Health Care System (facility) in Danville, Illinois. In 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 [Office of the Inspector General] identified concerns related to facility and CLC leaders' actions following the CLC outbreak."

Report Number:
Department of Veterans Affairs, Office of the Inspector General, Healthcare Inspection Report No. 21-00553-285
Public Domain
Retrieved From:
Oversight.gov: https://www.oversight.gov/
Media Type:
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