Review of Environment of Care, Infection Control Practices, Provider Availability, and Leadership, VA Loma Linda Healthcare System, California

The OIG conducted an inspection at the request of Congressmen Pete Aguilar and Mark Takano to review concerns related to environment of care (EOC), infection control practices including Legionella testing, provider availability, leadership responsiveness, and allegations in the dental clinic at the VA Loma Linda Healthcare System, California. The EOC was unclean and furnishings needed repair and housekeeping staff did not receive standardized training in cleaning procedures. In addition, staff were deficient in the required bloodborne pathogen training. While the OIG found no specific instance of inappropriate Legionella testing, there was no standardized process for notifying clinical staff of testing results. Water temperatures were not consistently sustained to discourage Legionella growth. The room where clean equipment and sterile supplies were stored was not consistently within parameters for temperature and humidity. Corrective actions were not documented after a positive biological spore test result. Facility healthcare associated infection rates were generally underperforming Veterans Health Administration’s national averages and leaders implemented specific corrective programs with limited impact. Veterans Integrated Service Network (VISN) and facility leaders were aware of EOC concerns and did not effectively implement actions to address the concerns. Inpatient provider availability was limited due to hospitalist staffing shortages and scheduling for nocturnists. Mental health staffing levels and measures to improve access to services were improved; however, staffing issues persisted related to vacancy rates and filling vacant positions. The OIG substantiated that staff were not routinely cleaning the inpatient dental clinic but was unable to determine exposure to biohazard residue. The OIG made 12 recommendations related to EOC, infection control practices, Legionella, training, staffing, and documentation, and two VISN recommendations to implement actions from previous reviews and development of a comprehensive EOC policy.