Report Summary

Title: Comprehensive Healthcare Inspection of Facilities' COVID-19 Pandemic Readiness and Response in Veterans Integrated Service Networks 1 and 8
Report Number: 21-02969-20 Download
Issue Date: 11/18/2021
City/State: Bedford, MA
St. Petersburg, FL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: CHIP
Release Type: Unrestricted

This Office of Inspector General (OIG) Comprehensive Healthcare Inspection Program (CHIP) report provides a focused evaluation of Veterans Integrated Service Network (VISN) 1 and 8 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 1 and 8 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 third in a series, describes findings on COVID-19 practices from healthcare inspections performed at facilities within VISNs 1 and 8 during the second quarter of fiscal year 2021 (January 1 through March 31, 2021). It also provides a more recent snapshot of the pandemic’s demands on these facilities’ operations based on data compiled as of July 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 VISNs were in the midst of VA’s third pandemic peak, which was longer and involved more patients than the previous peaks, and had valuable information to share about their experiences to date.