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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.

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Yukio Okutsu State Veterans Home
1180 Waianuenue Avenue
Hilo, HI 96720
Mission Assignment 1509-330043
Onsite Assessment Team Briefing

Department of Veterans Affairs

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Onsite Assessment Team
Dorene Sommers, Team Leader
Associate Director, Patient Care Services/Nurse Executive
Erie Veterans Affairs Medical Center
Katherine Kalama
Chief, Safety and Security Services
Pacific Islands Health Care System
Mary Lynn Ricardo-Dukelow, MD
Infectious Disease Specialist
Pacific Islands Health Care System
Tyler Furukawa
Chief, Facilities Management Engineering Service
Pacific Islands Health Care System
K. Albert Yazawa, MD (Observer)
Long Term Care Facility Unit Lead
Hawaii Emergency Support Function 8
Ka’ohimanu Dang Akiona, MD (Observer)
Medical Director, Big Island Clinical Services
Premiere Medical Group
Juan Babiak (Observer)
Liaison
Hilo Medical Center
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

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SVH Administrator, Director of Nursing, and Avalon Health Group corporate
representative. The meeting was followed by a tour of the facility led by the Director of
Nursing. Real time education and mitigation recommendations were presented with
each observation/finding. At the conclusion of the visit, a meeting was held with Mayor
Harry Kim that included the VA Onsite Assessment Team, K. Albert Yazawa, MD, and
Juan Babiak.
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
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approached the physician to assess and reassess need for AGPs.
Facility worked with residents to keep doors to rooms closed.
o Facility has worked with residents’ physicians who have been able to
convince veterans to alter pulmonary regimens, including
discontinuing AGPs; all AGPs have been discontinued
Hand sanitizers not readily accessible in all areas throughout.
o Response and Actions #2
o Hand Sanitizers are and have been available throughout the facility since
March 2020 and prior. Additional hand sanitizers were added in April as
hand sanitizer became available. Facility has ordered 25 additional
dispensers
Breakrooms are small with chairs spaced for social distancing.
o Facility Response and Actions #3
o Since March 2020, the Facility has provided repeated education to staff
on social distancing, hand hygiene and use of PPE while at work and
when not at work. During the outbreak, additional break rooms, both
indoors and outdoors, have been made available to staff.
Disinfecting high touch surfaces—unable to define exact surfaces expected,
unable to verify completion, no visual cues that cleaned every 2 hours as
verbalized (ex: timeclock)
o Facility Response and Actions #4
o Per CDC guidance, Facility has implemented repeated cleaning of
high touch surfaces throughout the facility since March 2020. This
increased in frequency at onset of outbreak.
o A mobile hand sanitizing station has been present at the time clock
prior to the outbreak; it had been temporarily removed from the area
for refill at the time this was inspected.
Paper copies of information attached to high touch items making impossible to
clean correctly (resident room doors, time clock, walls).
o Facility Response and Actions #5
o Since March 2020 and prior, the Facility has been diligent in posting
signage to remind employees of proper infection control practices and
transmission-based precautions. The signage in the COVID and
isolation areas has mostly been laminated.
o The Facility is in the process of laminating signage throughout the
facility.
Scrubs currently worn home after working an entire shift.
o Facility Response and Actions #6
o The Facility outsources its laundry and the company could not launder
the scrubs and have them returned by the next day. Hilo Medical Center
could not launder the scrubs because they would not withstand
commercial laundering.
o The Facility has implemented a scrub exchange program with Hilo
Medical Center.

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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

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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 nonCOVID 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 crosscontamination for staff getting in and out of zipper walls.
Residents not cohorted based on COVID status.
o Facility Response and Actions #16

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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

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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

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used (ECOLAB Multi-surface cleaner) is on the List N – EPA COVID
Disinfectants list. The SVH switched to this product about a week and a half ago
from a product that required a 10-min wet time.
o Facility Response and Actions #26
o The Facility has used locally available, N-listed disinfectant and
switched to the Ecolab product due to shorter dwell time.
Administrator not aware of specific housekeeping procedures (especially for
terminal cleaning). Provided a guide VA developed to provide to housekeeping
staff.
o Facility Response and Actions #27
o Throughout the outbreak there have been housekeepers in all units and
terminal cleanings have been conducted.
o The Facility is hiring two additional housekeepers and has also
requested three housekeepers from HI-EMA.
Administrator stated there were no current processes in place to limit
housekeeping staff or maintenance personnel from intermixing from the COVID
unit to other areas.
o Facility Response and Actions #28
o There was a dedicated housekeeper for the COVID unit from the start
of the unit. Recently, the maintenance department was instructed to
complete COVID unit maintenance tasks at the end of the day so that
they did not have to re-enter non-COVID areas prior to leaving.
o The Facility is hiring two additional housekeepers and has also
requested three housekeepers from HI-EMA.
Social Worker expressed exhaustion with working extended hours and covering
for maintenance, feeding, and other duties due to shortage of staff. Stated the
shortage was not only due to staff being out due to being positive, but also due
to staff “quitting”. The leadership did not appear to share the same feeling of a
staff shortage or need for additional staffing.
o Facility Response and Actions #29
o Since early in the pandemic, the Facility has had an emergency staffing
plan to address staffing shortages as a result of the COVID pandemic.
The Facility has utilized leadership and managers to supplement floor
staff to make sure needs of the residents were met at all times.
o The Facility continues to carefully review its staffing model and plan to
ensure adequate staffing to meet residents’ needs. Avalon has
deployed additional direct line staff and consulting staff to assist for the
duration of the outbreak. Avalon’s regional team leaders have assumed
administrative and clinical leadership for the facility while partnering
closely with existing facility leadership to provide all available resources
to care for the veterans.
There was very little evidence of proactive preparation/planning for COVID.
Many practices observed seemed as if they were a result of recent changes.
Even though these are improvements, these are things that should have been in
place from the pandemic onset and a major contributing factor towards the rapid
spread. A basic understanding of segregation and workflow seemed to be

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lacking even approximately three weeks after first positive case.
o Facility Response and Actions #30
o The Facility has been actively engaged in pandemic preparation since
the identification of a global pandemic. This is evidenced by the
ongoing pandemic committee, the emphasis on education relative to
COVID-19, basic Infection Control practices, transmission based
precautions, prevention of COVID by screening of employees and
essential visitors/ daily or more frequent monitoring of residents for
signs and symptoms of COVID-19. There were also periodic "drills" for
setting up the COVID unit as well as ongoing monitoring of infection
control practices.
o Facility wide testing was conducted in June with all negative results.
The facility conducted weekly testing of high-risk dialysis patients. The
facility implemented prevalence/random testing in August, which
identified the first asymptomatic staff positive. All of this testing was
above any testing requirements of state or federal agencies in place at
the time.
o Since the beginning of the pandemic, the Facility has been using
COVID focused survey critical element pathway to assess infection
control processes.
Recommendations/Opportunities for SVH
• Work with physician/provider to discontinue nebulizing treatments and
explore alternatives.
o See Facility Response and Actions #1. All nebulizing
treatments have been discontinued.
• Place additional hand sanitizers throughout the units to ensure readily accessible
from all locations.
o See Facility Response and Actions #2. Twenty-five additional
hand sanitizer dispensers have been ordered to supplement
current supply.
• Encourage staff to take breaks outdoors when possible to decrease
exposure. Ensure gatherings are not occurring in the breakrooms.
o See Facility Response and Actions #3. Additional staff
education has been provided and compliance will be monitored.
• Determine “high use areas” list. Assign specific staff to clean high use areas.
Do not designate clinical staff to have additional task of wiping including their
daily obligation. Create visual que to ensure accountability and safety.
o See Facility Response and Actions #4. This has been in place
since the beginning of the pandemic and will be monitored.
• Remove paper signage in areas that must be cleaned/disinfected regularly.
o See Facility Response and Actions #5. All remaining paper signage
has been removed and is being laminated.
• Issue scrubs that are used only in the building. Explore scrub exchange
program with Hilo Medical Center.
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o See Facility Response and Actions #6. The Facility has
implemented a scrub exchange program with Hilo Medical Center.
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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

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physician notification and/or admission to hospital.
o Facility Response: This has been in place since March 2020.
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Cohort residents according to COVID status not based on resident preference.
o See Facility Response and Actions #16. The COVID unit has been
separated into three sub units and the Facility has created separate units
for recovered and COVID-19 negative residents.
Re-evaluate staffing to ensure time for proper use of PPE, COVID and
other infection control processes.
o See Facility Response and Actions #29. Avalon has
deployed many front line and consulting staff from the mainland
to supplement current staff.
Consider creation of negative pressure wings/bedrooms on COVID floor.
o See Facility Response and Actions #24. Negative pressure is not a
usual configuration in PA/LTC and would require extensive retrofitting. It
will be analyzed for possible future implementation after the outbreak has
resolved.
Consider purchase of ultraviolet sanitation boxes.
o See Facility Response and Actions #22. Four have been ordered.
Place higher emphasis on administrative controls and engineering controls.
Close doors to bedrooms and create physical barriers entering each ward to
create negative pressure areas.
o See Facility Response and Actions #8, #15, and 19. Facility has
closed resident doors and will consistently reeducate residents on
why doors cannot remain open. COVID unit has been reconfigured
into three sub units, each with a zipper barrier. On the non-COVID
floor, each with a zipper wall: three separate lanes have been
created: PUI, recovered, and remaining negative residents
Reduce the amount of traffic entering the COVID unit including (housekeeping
and maintenance).
o Response: The Facility has periodically reviewed the process of
servicing COVID Unit with an emphasis on minimizing traffic as part
of its pandemic planning and COVID Unit Table-Top exercises. The
Facility will continue to educate staff regarding workflow of current
configurations of COVID unit. Maintenance will continue to hold all
non-urgent COVID unit work orders until the end of the day.
Conduct regular risk mitigation training for all staff. Request a dedicated staff
member (IH (preferred) or Safety) to assist with employee exposure risk
assessments, audits of PPE and training. This person can also look at PPE being
brought in through logistics or supply for NIOSH/OSHA/FDA compliance.
o Response: The Staff Development Coordinator is responsible
for training staff. The Staff Development Coordinator and
Infection Preventionist collaborate on risk assessments and
audits of PPE, etc.
Continue to fit test and train staff on multiple respirators to anticipate

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shifts in respirator type availability.
o See Facility Response and Actions #20. This continues to be
in process.
Consider use of PAPR which will require funding procurement, frequent
education, maintenance, storage and sanitation. Request PAPRs (2x number
of personnel on shift in COVID unit) and associated accessories (hoods, tubes,
filters, spare batteries).
o See Facility Response and Actions #21.
Replace existing filters with the highest MERV rating that the system can
handle. MERV 13 or higher is recommended for Health Care inpatient.
o See Facility Response and Actions #23 and #25. There are no
MERV 13 or higher in the islands. MERV 11s have been located
and are being installed.
Adjust HVAC settings to intake as much “outside air” as possible. Too much
outside air will introduce condensation and moisture issues so this needs to be
monitored closely.
o Response: Routine maintenance is conducted on HVAC system.
Most recent routine maintenance and filter change occurred 07/2020.
Instill a process to assign housekeeping and maintenance staff to certain
areas. If not possible, have personnel enter the COVID positive area at the end
of their shift so they don’t have to enter the other areas of the facility after that.
o See Facility Response and Actions #27 and #28. The Facility is
hiring two additional housekeepers and has also requested three
housekeepers from HI-EMA.
Provide education to both leadership and staff on basic infection control
practices and COVID/CDC practices.
o Response: Education on Infection Control practices and specifics
for COVID-19, including PPE/Hand Hygiene competencies, and
importance of social distancing has been provided repeatedly to
leadership and staff since March 2020. Additional education will be
provided to leadership and staff by Avalon consultants being
deployed to the Facility.
Have a physician on site or on call 2-3 days/week preferably someone of
GREC training or at least understanding in care of residents.
o Response: Dr. Belcher and Dr. Jung visiting regularly (2-3 days
per week). Exploring options for additional physician support.
Review DNR and end of life care
o Response: All Advance Directives and DNR orders were reviewed with
the Medical Director prior to the outbreak.
Review or create procedures regarding:
o PUI residents: quarantine practices
o COVID residents: Isolation practices
o Emergent/Urgent transfer to hospital
o Universal COVID testing and notification process
o Reeducate team on relevant Clinical Policies and Guidance

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o See Response and Actions #15 and #16.
Conduct leadership rounding during all shifts to ensure/verify
compliance, accountability, to identify risk, issues, barriers, and to
provide education.
o Response: The Clinical leadership is rounding regularly to
provide supervision and engage with employees.
Conduct socially distanced staff meetings and/or huddles in all areas on all
shifts to ensure open communication.
o Response: Facility has had access to tools to guide beginning of shift
huddle to include proper use of PPE.
o Facility will re-educate and monitor use of Shift huddles/PPE review
process.
Ensure regular and transparent communication with residents, as well as
family members, to inform of changes that ensure the safety of the staff and
residents.
o Response: Prior to and throughout the outbreak, the Nursing
Home Administrator and Social Worker have been communicating
regularly with the veterans, families and staff, consistent with CMS
regulations, to include calls, emails, letters, and website postings.
This process will continue.
Recognize deaths and consider offering Employee Assistance Program (EAP)
and compassion fatigue sessions for staff.
o Response: The Facility’s Social Worker has been working closely
with staff members to assist in the bereavement process. Facility has
a salute ceremony for each veteran who passes away. Avalon has
an EAP available to employees. Facility exploring options to have onsite or telehealth counselors available to staff in addition to the EAP
program.

Recommendations for the State of Hawaii
• Immediately provide a “Tiger Team” to help implement recommendations,
provide training and oversight, and to provide needed staffing support and
respite.
o Nurse Leader—Team Lead (1)
o Infection Control RN (1)
o Nurse RN (1)
o Nurse Educator RN (1)
o Employee Health RN (1)
o Safety and/or Industrial Hygiene (1)
o Housekeeping Supervisor (1)
o Logistics Supervisor (1)
o Maintenance Worker (2)
o Food Service Worker (1)
o Licensed Practical Nurses (5)
o Nursing Assistants (4)
Yukio Okutsu State Veterans Home Onsite Assessment Team Briefing
September 2020

 16

•

*Individual position time requirements/needs will vary.
Consider a revisit of this Onsite Assessment Team within the week, while
obtaining Tiger Team, to assess progress toward implementation of
recommendations.

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

Yukio Okutsu State Veterans Home Onsite Assessment Team Briefing
September 2020