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Executive Summary
This document contains the Department of Veteran’s Affairs mission assessment of the
Yukio Okutsu State Veterans Home in Hilo, Hawaii and Avalon Health Care’s response,
which you will see noted in bold and green text throughout.
Avalon Health Care, the manager of the Yukio Okutsu State Veterans Home, thanks the
Department of Veterans Affairs for its support and collaboration. We welcome their
collaborative efforts and expertise. There is a State VA Liaison Officer whose office is at
the Facility and who is in daily contact with Facility administration. We are very thankful
for his support as well. The nation’s nursing homes have been the hardest hit by the
COVID-19 pandemic. Our number one priority is, and has always been, the health,
safety, and wellbeing of our veterans and residents. We are honored to care for them and
take that responsibility very seriously. We are thankful to have such an amazing team of
healthcare heroes that work for us day in and day out to provide outstanding care.
Since the early days of the pandemic, Avalon and the Facility have consistently followed
the rules and guidance of the Centers for Disease Control and Prevention (CDC), Centers
for Medicaid and Medicare Services (CMS), and the Hawaii State Health Department to
the very best of our abilities. Those rules and recommendations changed frequently as
the pandemic progressed, but the Facility studied and implemented the many changes.
Upon receiving the Department of Veterans Affairs Onsite Assessment Team Briefing on
September 13, 2020, the Facility leadership immediately began to prioritize and
implement the recommendations. Many of the recommendations contained in the
Assessment are above and beyond CDC, CMS, and State COVID-19 rules and guidance
and are not common practice in long term care facilities, even during a COVID-19
outbreak. Likewise, some of the recommendations are hospital level (and above)
interventions that a very, very small number of nursing homes nationwide would have
implemented – or had the capability to implement. Notwithstanding, the Facility had
already had more than 60% of the recommendations in place at the time of the 9/11/20
visit from the Department of Veterans Affairs. The VA team was in the Facility for four
hours and did not review the Facility’s Pandemic Plan or training records. Thus, while the
VA may not have seen evidence of certain of their noted observations, many of them had
already been operationalized.
Avalon and the Facility are committed to working side-by-side by with the Department of
Veterans Affairs in this fight against COVID-19.
Katherine Kalama
Chief, Safety and Security Services
Pacific Islands Health Care System
Tyler Furukawa
Chief, Facilities Management Engineering Service
Pacific Islands Health Care System
Background
The Department of Veterans Affairs (VA) commenced support to the state of Hawaii on
September 10, 2020 at 21:34 via Mission Assignment 1509-330043. The mission
supports the formulation of recommendations for interventions, processes, and
procedures to assist and support outbreak control of COVID-19. Additionally, the team
will provide education and training on infection control, processes, protocols, and best
practices.
On September 11, 2020, the VA team traveled to the Yukio Okutsu State Veterans
Home on the Island of Hawaii to conduct a one-day onsite assessment. The team
consisted of a Nurse Executive Team Leader, Chief Safety and Security Services,
Infectious Disease Specialist, and Chief Facilities Management Engineering Service.
The visit began with a brief introductory meeting including the team listed above, the
Facility Information
• 95 licensed beds
• 67 current in house census
• 4 absent sick in hospital (COVID positive)
• 35 residents currently COVID positive
• 17 residents currently recovered
• 8 persons under investigation (PUI)
• 63 cumulative residents COVID positive
• 10 deaths related to COVID
• 143 total staff members
• 24 staff members COVID positive
• 5 staff members recovered
• 8/22/20 first SVH employee tests COVID positive
• 8/27/20 first SVH resident tests COVID positive
• 8/29/20 first SVH COVID positive resident expires
• Report certified Nursing Assistant staffing ratio as 1:8 or 9 (unable to confirm)
• Report current nurse staffing as 2 nurses and 1 supervisor (unable to confirm)
• Staff work 8-hour shifts
Promising/Best Practices
• Touchless door entry in several areas throughout the facility.
• Entry points with extensive active screening and documentation on first both
levels to distance assigned employees. Clean mask issued prior to entry.
Screeners utilized proper PPE.
• Hand washing sinks at both entrances and as part of active screening process.
• Reuse of face shields. Clean face shields were placed in one container and
made available to staff entering. Used container for face shields supplied at the
exit. Staff placed used face shields in the used container and housekeeping
sanitizes the face shields each day using a submersion method with a bleach
solution.
Observations
• Facility reports 3 residents with current/active nebulizing treatments (1-3
times/day, 2 as needed).
o Facility Response and Actions #1
o Since March 2020, the Facility has repeatedly approached residents
to discontinue aerosol generating procedures (AGP) and repeatedly
Yukio Okutsu State Veterans Home Onsite Assessment Team Briefing
September 2020
5
• Isolation gowns are plastic and do not fit over face shields.
o Facility Response and Actions #7
o All gowns the Facility has utilized are CDC compliant. The Facility used
the plastic gowns for one week only when it was awaiting additional cloth
gowns. Plastic gowns are no longer in use. Facility utilizing all cloth
disposable gowns that close in the back.
• Gowns donned upon entrance to unit and worn until staff have a break.
Example, one gown worn for all resident care and then continued in same gown
while working at nurse’s station.
o Facility Response and Actions #8
o Facility has been following CDC extended wear guidelines on the
COVID Unit. This also reduces the repeated donning/doffing of gowns
which can promote cross contamination.
o The first floor COVID unit only houses COVID positive residents and
the donning and doffing of gowns followed established practice and
CDC guidance for a COVID unit.
o Per the VA’s recommendation, the COVID Unit has been reconfigured
into three sub units, each with a zipper barrier and ante chamber;
nurses don and doff gowns prior to entry and exit of each sub unit.
However, the Facility is concerned that having 3 separate sub units
with 3 additional zipper walls could increase cross contamination.
• Staff crossing from wing to wing wearing the same PPE (except gloves).
o Facility Response and Actions #9
o This process was not occurring in the non-COVID areas of the facility.
o The entire downstairs was designated a COVID unit in accordance with
CDC guidelines.
o All three wings were in the COVID unit (downstairs); thus, this practice
was in accord with CDC guidelines because all three wings are COVID
positive.
o The COVID unit has been separated into 3 sub units with dedicated
staffing in compliance with the VA recommendation.
• Signage on bedroom doors not clear, not consistent with practice or no
sign designating isolation status.
o Facility Response and Actions #10
o Facility had clear signage posted at the entrance to COVID
unit and on all isolation room doors per CDC guidance.
o The Facility discussed this with Dr. Yazawa who directed the
Facility to post signage on zipper wall entry into COVID sub
units and that there’s no need to post individual signage on
each resident's door inside COVID Units.
• Cloth chairs in hallways of PUI or positive areas (unable to properly clean).
o Facility Response and Actions #11
o The Facility has removed all cloth chairs from Facility’s common areas of
PUI unit and positive areas.
o Resident room cloth chairs have not been removed as they are only
Yukio Okutsu State Veterans Home Onsite Assessment Team Briefing
September 2020
7
being used by individual residents. Chairs have been part of the facility’s
terminal cleaning procedure.
• Resident room curtains—DON unable to articulate how often or if
process for cleaning.
o Facility Response and Actions #12
o Privacy curtains had been cleaned periodically.
o Additional routine and terminal cleaning of curtains has been
implemented. The Facility has also purchased additional
curtains.
• Refreshment cart with juice and coffee in large containers. CNA pours,
enters rooms, coming back out and prepares for next room. Creates
possible cross contamination.
o Facility Response and Actions #13
o Safe and sanitary process has been in place using bulk
containers of refreshments with appropriate disinfecting and hand
hygiene between residents.
o The Facility has ordered individual portions to replace bulk
containers. The Facility switched to disposable dinnerware for
the entire facility at the beginning of the outbreak.
• Corrugated boxes on floor and on sink in medication room. Large stacks of
papers on shelf in medication room.
o Facility Response and Actions #14
o The Facility has removed excess PPE supplies to another area.
• Staff not consistently caring for residents only on one hall. Floating among
two or more halls.
o Facility Response and Actions #15
o There has been no floating of staff between the COVID and non-
COVID units per CDC guidance. The COVID unit staff did float
within the COVID unit as all residents are COVID positive. This is
in accordance with CDC guidelines. In the upstairs non-COVID
area, staff donned and doffed PPE and practiced hand hygiene
each time they went into an isolation/PUI room pursuant to CDC
guidelines.
o Per VA guidance, the PUI unit has been cohorted into individual
lanes using the same donning and doffing procedures as before
(for each individual patient).
o Three sub COVID units have been created with the COVID unit,
each with dedicated staff.
o On the upstairs non-COVID floor, per VA recommendations, three
zippered walled lanes have been created: PUI, recovered,
remaining negatives. This process is beyond CDC guidance and
we believe creates more touchpoints and possible cross-
contamination for staff getting in and out of zipper walls.
• Residents not cohorted based on COVID status.
o Facility Response and Actions #16
o The Facility established the COVID unit within 24 hours of the first
resident testing positive. All positive patients have been moved there
and it was expanded with the additional positive residents.
o Symptomatic residents were put on droplet contact precautions per CDC
guidelines in private rooms whenever possible pending test results.
o Per VA recommendations, the COVID unit has been separated into three
sub units. The Facility also created separate units for recovered and
negative residents. This process is beyond CDC guidance and we
believe creates more touchpoints and possible cross-contamination for
staff getting in and out of zipper walls.
• Some residents wandering throughout unit/floor into other hallways.
o Facility Response and Actions #17
o Staff have consistently tried to re-direct wandering residents and have
been providing diversional activities. Several residents have PTSD and
behavioral diagnoses, which make it very difficult to re-direct and these
residents are not always compliant with re-direction and mask use.
o The Social Worker has re-evaluated all care plans and diversional
activities and care plans remain appropriate.
• Residents wearing masks outside of bedrooms not consistent.
o Facility Response and Actions #18
o See above Facility Response and Actions #17 above. Staff continues to
work with residents on these issues. This is a big challenge, especially
after 6+ months of residents being asked to stay in their rooms.
• Fire doors were closed between the main nursing station and the halls of the
unit, but resident bedroom doors were open.
o Facility Response and Actions #19
o From outset of outbreak, the facility has closed hallway doors to
limit/curtail movement of residents and staff through the facility. The
staff did not close residents’ doors when residents expressed a
desire for the door to be open as this could be a physical restraint.
o Facility has closed all resident doors on the PUI unit except for
residents who require frequent visual checks for safety for these
residents and clear plastic zipper walls were installed in the
doorways.
• Fit test kit was available for N95 respirator fit testing. N95 respirators were
available in various models but sizes were limited. Select staff were trained in
July 2020 by National Guard Medical Task Force to conduct fit tests. Most of the
records reviewed for staff respirator program were dated in May and June of
2020. Medical clearance documents were not reviewed.
o Facility Response and Actions #20
o There has been an ongoing and inconsistent supply chain of PPE,
especially respirators like N95s. Small masks have had intermittent
supply chain issues and facility procured through HI-EMA.
o This continues to be in process.
• Powered Air Purifying Respirator (PAPRs) are not used and have not
been requested.
o Facility Response and Actions #21
o A discussion with Dr.Yazawa and Hilo Medical Center led to
direction to not pursue PAPRs for the PA/LTC setting.
• Ultraviolet sanitation boxes for handheld items not available in the facility.
o Facility Response and Actions #22
o This exceeds CDC guidance.
o The Facility has ordered four devices and will setup processes to
implement.
• HVAC system (Petra system) contains two main Air Handling Units (AHU). One
AHU services each floor. Individual rooms on each floor would “share” some of
the recirculated air by design. Each dual occupancy room has two supply ducts
and one exhaust/return air vent. Each single occupancy room has one supply
duct and one exhaust/return air vent.
o Facility Response and Actions #23
o This is a traditional system for PA/LTC setting. All maintenance is
current.
• Random air flow readings were taken. At the time of readings, the resident rooms
were positive pressure in relation to the adjoining hallway.
o See Facility Response and Actions #23
• There were no anterooms, negative pressure rooms or isolations rooms present
(as designed nor temporary/make-shift).
o Facility Response and Actions #24
o The Facility initially used temporary barriers prior to the growth of the
outbreak. Once the outbreak enlarged to encompass the units on the
lower level, the entire lower level has been treated as a COVID unit.
This was in place during the recent Infection Control survey and was
not cited as deficient practice upon exit of survey on 9/10/20.
o Negative air pressure is not a usual configuration in PA/LTC and would
require extensive retrofitting to install.
• The AHU filter minimum efficiency reporting value (MERV) ratings could not
be visually confirmed and no maintenance personnel was present. Two new
filters XTREME +Plus 24x24x2 Self Supported Pleated Filters were seen,
however, no marking of actual MERV rating was discovered. SVH
Administrator provided information stating that the filters were MERV 8. That
brand of filters in that size comes in MERV 6, 8, 11, and 13.
o Facility Response and Actions #25
o There are no MERV 13 on the islands. MERV 11s have been
located and are being installed. MERV 13s have been located on
the mainland and shipped to the Facility.
• The overall condition of HVAC system seemed to be in good operational
condition with no visible deficiencies. Unable to determine automated control
system settings or monitoring as no HVAC or maintenance personnel available.
• One housekeeper was observed cleaning a resident room (COVID Negative).
Wearing adequate PPE including face shield. The general cleaner/disinfectant
Yukio Okutsu State Veterans Home Onsite Assessment Team Briefing
September 2020
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• Explore options and obtain isolation gowns that are breathable (no plastic) and
allow donning and doffing without removing reusable PPE such as face shield or
mask.
o See Facility Response and Action #7. The Facility is utilizing
disposable cloth gowns that fully close in the back.
• Create ante room outside of each hallway and establishing nurse’s station as
clean area with assigned seats to eliminate cross contamination. Remove PPE
when leaving the hallway/wing. Improve segregation of the individual wards by
installing physical barriers (non-flammable plastic with zipper entries) at each
entrance to the hallways.
o See Facility Response and Actions #8. The COVID unit has been
reconfigured into three sub units, each with a zipper wall and an ante
chamber; nurses don and doff gowns prior to entry and exit of each
sub unit.
• Consistent staff assignments to hallway/wing to reduce cross contamination.
o See Facility Response and Actions #9. The COVID unit has been
reconfigured into three sub units, each with a zipper wall and an ante
chamber; nurses don and doff gowns prior to entry and exit of each sub
unit.
• Ensure isolation signage is clear, consistent, and maintained. Create and
consistently post proper signage at each bedroom door (not paper). Clearly
identify what PPE to wear upon entering rooms.
o See Facility Response and Actions #10.
• Remove cloth chairs or any furniture that cannot be properly cleaned
and disinfected.
o See Facility Response and Actions #11. The Facility has
removed all cloth chairs from common areas, including
hallways.
• Clean all bedroom curtains. Establish a reoccurring cycle that is easily
understood and implemented.
o See Facility Response and Actions #12. Routine and terminal
cleaning of curtains has been implemented. The Facility has also
purchased additional curtains.
• Recommend individual containers or pre-made individual portions for drinks
before going to unit.
o See Facility Response and Actions #13. The Facility has ordered
individual portions to replace bulk containers.
• Create and implement diversional activities for wandering residents.
o See Facility Response and Actions #17. The Facility’s Social Services
Director has re-evaluated all care plans and diversional activities for
wandering residents and has updated care plans as indicated.
• Ensure daily screening of residents (vital signs) and create triggers for
Yukio Okutsu State Veterans Home Onsite Assessment Team Briefing
September 2020
13
Conclusion
This mission was successfully completed with an onsite visit as charged. The above
recommendations are listed for immediate action by both the State Veterans Home and
the State of Hawaii. Thank you for this opportunity to assist the State of Hawaii and to
continue to serve our Veterans.
o Facility Response: We appreciate the support and collaboration of the
Department of Veterans Affairs. As you can see, the Facility had already
implemented a large number of the recommendations. For those not already
in place, the Facility immediately began prioritizing and implementing many
of the remaining recommendations as set forth above, in advance of the
arrival of the Tiger Team. Some of the recommendations are not feasible in a
long term setting to be implemented during the current outbreak in a short
time frame given the restrictions of the physical plant. Additionally, the
Hawaii Office of Health Care Assurances conducted an infection control
survey on Thursday, 9/10/20 – the day before the VA team conducted its
inspection on Friday, 9/11/20. Upon exit of the survey, the surveyor informed
the facility that she found only one D level citation (no harm, not widespread)
that involved a contractor exiting the Facility and going to the parking lot prior
to doffing his PPE and performing hand hygiene. OHCA also conducted an
infection control survey on 6/20/20 that resulted in no deficiencies and praise
from the surveyor on the Facility’s infection control processes.
Report prepared by
Dorene Sommers, Team Leader
Associate Director, Patient Care Services/Nurse Executive
Erie Veterans Affairs Medical Center
September 12, 2020