MISSOURI - Following the release of an independent, external review of Missouri's seven veterans homes, the Missouri Veterans Commission Chairman called the report fair and thorough.
The review found the homes failed to recognize COVID-19 outbreaks, failed to plan for an extensive outbreak and failed to respond promptly.
"I think the report was fair," MVC Chairman Tim Noonan said. "It was fact based, it was thorough."
Armstrong Teasdale, a national law firm headquartered in St. Louis, conducted the review. It was presented to the chairman in November.
"I think that they did a very strong job getting to the root cause and a series of corrective actions that are going to make us stronger and allow us to drive strong reforms of the Missouri Veterans Commission," Noonan said.
He said as soon as Armstrong Teasdale launched the review, the firm made four recommendations that MVC implemented very quickly.
"The first was to test everybody, every day. The next was to ensure that we had appropriate PPE supply chain. The third recommendation was to ensure that we had a contingency plan if we found ourselves in the situation that we did where we kind of overran our quarantine capacity. And the fourth was that we opened up a hotline for families to ensure that families could have their voice heard in this process," Noonan said.
He said veterans homes were able to hold the virus at bay up until September, when cases began overwhelming homes.
"It overwhelmed us, as the review was very clear. We were slow to react to the data. We were slow to react to the positive cases that were happening," Noonan said.
He added that asymptomatic cases drove an escalation that MVC did not deal with properly.
The report noted that while awaiting test results, infectious staff and veterans interacted with one another; some without any PPE. When asked why this was happening seven months into the pandemic, Noonan said: "In a home where the infection rate of veterans at some point was north of 60, 70%, the realization was, and the report was very clear on this, is that we did not have a contingency plan in place."
He added that homes did not have enough quarantine space.
"We did our best to isolate veterans in their rooms. Now, we've taken steps to dedicate entire wings to our quarantine facilities," Noonan said.
Noonan said when MVC saw the data coming out of the homes in late September and early October, they realized a different plan needed to be put in place.
"It really starts with testing - testing everybody, every day," he said. "Making sure that we've got the right culture and climate for teammates as frontline workers to help us be successful. That means taking care of themselves outside of the homes when they're in their communities. That's following all the CDC guidance relative to masking when they're not working in our homes. We've been implementing that as soon as we saw the outbreak get away from us."
Noonan said the commission will be completely transparent and drive reforms based upon the findings.
"In terms of accountability, we are going to review up and down to make sure that we have the right people in the right jobs," he said. "We're going to make sure that we have the team in place not only to enact the recommendations but also make sure that we exit this crisis stronger."
For a full look at the independent review, click here.