JEFFERSON CITY — A just-released investigative report on Missouri veterans nursing homes sheds new light on how top government officials first reacted — and didn’t react — to information about the spreading danger of COVID-19 at the state-run facilities.
According to the report, released Thursday evening, Michele Renkemeyer, operational excellence leader with the Department of Social Services, said members of the state’s “Fusion Cell” virus hub were “well aware of positives and deaths as early as mid-August well into the beginning of September.”
Her statement appears to contradict those made by other top state officials coordinating Missouri’s response to the coronavirus. They told investigators they didn’t recognize a problem at the Missouri Veterans Commission’s seven homes until late September at the earliest.
The report, produced by the St. Louis law firm of Armstrong Teasdale, said state Chief Operating Officer Drew Erdmann, Medicaid Director Todd Richardson and consultants with the McChrystal Group, a private firm contracted to help coordinate the state’s virus response, led the state’s Fusion Cell. Dr. Randall Williams, director of the Department of Health and Senior Services, occasionally participated in the group’s meetings. There were general 9 a.m. video meetings with 150-200 participants and 7:30 a.m. “management call” meetings with 60-65 participants, the report said.
Renkemeyer said the Department of Public Safety reported on the status of the commission’s homes “during the 7:30 a.m. management meeting” and said Erdmann and other officials “were on such calls.”
The report says Renkemeyer’s account “contradicted” information provided by Richardson, Office of Administration Commissioner Sarah Steelman and her deputy, Cindy Dixon, and Adam Crumbliss, director of the Division of Community and Public Health, under the Department of Health and Senior Services.
Erdmann declined to be interviewed by the Armstrong Teasdale investigators.
While Tilley worked behind the scenes, the chairman of the veterans commission said he had "no idea" the deal was afoot.
It was only until after Missouri Veterans Commission Executive Director Paul Kirchhoff met with Gov. Mike Parson on Oct. 1 that rapid antigen tests were deployed to the homes, and veterans commission staff began receiving software upgrades and were asked to provide status updates during Fusion Cell meetings.
The veterans commission released the 415-page investigative report on Thursday, minutes before its chairman, Tim Noonan, announced his resignation. Noonan had refused to release the full report but said he relented Thursday following a directive from Attorney General Eric Schmitt.
At least 142 veteran residents have died of complications of COVID-19 from September through early last month; Parson ordered the outside investigation on Oct. 2.
According to the report, Richardson told investigators he received a call from someone on the weekend of Sept. 26 reporting a high number of positive cases and deaths at the Cape Girardeau Veterans Home, but that up to that point, the Fusion Cell wasn’t aware of the severity of the situation.
Richardson then contacted other members of the Fusion Cell, “but it does not appear any significant action was taken at that time,” the report says.
He said “people knew there were positive cases at MVC” but said up until that point, the Fusion Cell was unaware of “the severity and amplitude of the outbreak.”
Still, after the weekend phone call, “there was no discussion of the MVC during the September 28 or September 29 Fusion Meeting,” the report said.
He told investigators he doesn’t have a “line of sight” to facility-specific data.
“When asked who reviews and analyzes the data that MVC and others provided, Richardson stated that the data analyzation ‘falls on each agency’ and that the Fusion Cell does not analyze data provided by the reporting party,” the report said.
The report also said Steelman agreed with Richardson and said that while some agencies scrutinized their own data, she was unaware of any efforts by the veterans commission to analyze its own data.
Steelman and Dixon “became aware of the outbreak sometime in late September” after a call from Erdmann, they told investigators.
They “expressed surprise at the number of positives (and) deaths,” the report said. “Commissioner Steelman also stated that the Fusion Cell would have recognized even one or two positives prior to this point as a trigger to take action.”
The report said Crumbliss was alerted to the situation by Williams — the DHSS director and his boss — in late September.
Crumbliss told investigators he “was unaware of any information up until this point that suggested the Missouri Veterans Homes were experiencing an outbreak.”
Williams told investigators he was alerted on Sept. 29 after receiving a call from Mike O’Connell, spokesman for the State Emergency Management Agency.
The report said Williams “had no situational awareness prior to this call.”
O’Connell asked Williams what was considered a COVID-19-related death, according to the report. He wanted to know whether the primary, secondary or tertiary cause of death influenced a determination. Williams said even if COVID-19 was a tertiary cause, the death would still be logged as COVID-19-related.
Williams wondered why O’Connell was asking. O’Connell said there were eight deaths at one home and 85 cases out of 100 residents (though Williams said he may have misremembered figures).
“Dr. Williams was shocked and asked for the information to be repeated,” the report said. Williams, along with contacting Crumbliss, contacted Richardson and Erdmann, the report said.
Ultimately, the report concludes that the veterans commission was reporting positive test results to the Fusion Cell.
Though officials had access to the data, the failure by top officials to jump on the outbreak in early and mid-September wasn’t because they were ignoring pleas for help from the commission.
Kirchhoff, the commission’s executive director, acknowledged to investigators that prior to an Oct. 1 meeting with Parson, he “had not specifically asked the Fusion Cell for resources.”
Even so, the report notes several early alarm bells.
Though the nursing homes hadn’t experienced any veteran COVID-19 deaths since April, Ryon Richmond, deputy director of the veterans commission, reported all tests conducted and results daily, since May, to the Fusion Cell, according to the report. As part of that process, the commission wasn’t required to report deaths, the report said.
Home administrators said they entered new COVID-19 cases and deaths into a portal managed by DHSS. (Crumbliss said it’s unclear whether this data was traceable to the veterans commission.)
A slide presented at the Sept. 10 Fusion Cell meeting showed 16 staff cases and 17 veteran cases, up from eight staff cases and two veteran cases reported in August.
Richmond said at the time he believed the increase in cases was due to increased transmission in the outside community.
“Someone (Richmond could not tell who among the over 100 participants) remarked they did not think that was the reason for the increase,” the report said. At the time, there had been only one veteran death at the Cape Girardeau home in September, according to the report.
In boldface type, the report said, “According to Richmond, no one during the meeting asked any questions about the information which was provided.”
The report says between Sept. 9 and 11, Department of Public Safety Director Sandra Karsten received several updates “about positives within the Homes” from Kirchhoff and others.
On Sept. 15, Parson visited the Mt. Vernon Veterans Home in southwest Missouri, where he praised the veterans commission for setting a nationwide standard for virus control.
The dementia patient tested positive for COVID-19 on Sept. 19; he wasn’t hospitalized until Oct. 1 after he’d stopped eating and drinking.
The facility reported its first COVID-19 case the next day; Parson tested positive on Sept. 23, though officials haven’t said where they believe he contracted the virus.
On Sept. 17, the report says, the Department of Public Safety reported at the 7:30 a.m. meeting an increase in positive cases among nursing home staff and veterans.
Kirchhoff’s meeting on Oct. 1 with the governor had been scheduled before top officials were alerted to the situation, but after the meeting, the report says the state made available rapid antigen tests and that they were deployed immediately.
Officials began improving data reporting procedures, and Kirchhoff was asked to provide status updates on the situation at Fusion Cell meetings.
Renkemeyer, the Department of Social Services official, said that before the veterans commission staff was provided with software updates, including a tableau dashboard, they “did not have a method to meaningfully analyze the data they were collecting.”
Had they had the ability to spot and analyze trends, “they would have seen in early September that something was ‘not right,’” she told investigators.
Updated to clarify the extent of Williams’ participation in the cell meetings, according to the report, and the report’s description of deaths in homes as of Sept. 10.