JEFFERSON CITY — The Missouri Veterans Commission on Thursday released the full investigative report into more than 140 COVID-19 deaths at its seven veteran nursing homes statewide since September.
Minutes later, Tim Noonan told the Post-Dispatch in a text message that he had resigned as chairman of the commission.
Noonan, a St. Louis businessman who was appointed chairman of the commission in late 2017 by former Gov. Eric Greitens, had refused to turn over a copy of the results of the independent investigation to the Post-Dispatch following an open-records request.
But officials within Gov. Mike Parson’s administration, and state Sen. Jill Schupp, D-Creve Coeur, pushed back, telling Noonan his interpretation of the Sunshine Law was inaccurate, Post-Dispatch columnist Tony Messenger reported on Tuesday.
Noonan said Thursday evening he released the full report after being directed to by Attorney General Eric Schmitt. Schmitt sent Noonan a letter Wednesday saying he should release the full report.
Noonan pointed to Parson’s comments on Wednesday as the reason he resigned. Parson said, “The veterans will be a priority. I’m not going to worry about everybody’s personal lives that sit on the commission, or the chairman. I’m just going to absolutely worry about the veterans and that’s my whole focus.”
“I can put up with a lot, but this sentiment crosses a fundamental value, so the decision is easy,” Noonan said in a text message to the Post-Dispatch.
“The fundamental issue is not the distraction and misleading statements regarding releasing the closed record, which I believe will do nothing but harm the MVC and indeed should remain closed, but rather this statement,” he said.
The 415-page report, unlike the 53-page summary report issued earlier this month, concludes that Executive Director Paul Kirchhoff, appointed to the post in July, as well as Deputy Director Ryon Richmond, “should have appreciated the presence of a COVID-19 outbreak by Sept. 2, 2020, and acted immediately to attempt to isolate and contain the spread of COVID-19.
“Despite this, even with an increase in cases, leadership failed to appreciate the need to move quickly and aggressively to isolate the positive patients,” the report said. “Failure to do so led to rapid explosion of cases inside the Homes and unnecessary Veteran deaths.”
The full report devotes more than 100 pages to detailing the response at individual homes. Armstrong Teasdale, the St. Louis law firm investigating the commission, dispatched auditors with Pathway Health to conduct site visits at all seven facilities.
At the Mt. Vernon Home, in southwest Missouri, “the lack of formal infection control policies and procedures was apparent during Pathway’s site visit in which a charge nurse indicated that the 3-4 pages of undated COVID-19-specific guidance was the only hard copy of the policies and procedures.
“Moreover, the procedures are not in accordance with the most updated guidance,” the full report said.
While residents and staff awaited test results, they were not quarantined, the summary report said. It said the commission failed to prepare for a “severe and prolonged” outbreak.
The full report devotes several pages to summarizing 75 calls to investigators from veterans’ family members, veterans, volunteers and a nurse.
“One family was not informed by the Home that their father had contracted COVID-19, but only learned about it when their father called and told them a few days later,” the report said.
Since September, at least 142 veterans housed in the facilities have died after contracting COVID-19, the commission reported Dec. 8. More recent death figures were not immediately available.
On Oct. 2, Parson ordered the independent investigation into the veterans homes. The state hired Armstrong Teasdale to conduct the review. The law firm was charged with creating a summary report in addition to the full report.
Parson on Wednesday voiced frustration with the current state of affairs within the Missouri Veterans Commission, an independent agency.
“It’s not about the commissioners, it’s not about the chairman, it’s about the veterans that are in those homes that I care about. And I want to do everything that’s in my powers to make sure they’re taken care of. And if people didn’t do their job, is why I called for an investigation, to expose that, if that is the case. And I will continue to do that.”
The summary report released in early December describes a two-way failure to recognize the severity of the outbreak within the homes, both by the state’s Fusion Cell virus hub and the veterans commission headquarters.
The full report is more explicit as it describes the top staff’s failure to plan for the possibility of an outbreak.
“Our investigation recognizes the novel nature of COVID-19 and the challenges it creates in long-term strategic planning. Even recognizing this acknowledgement, MVC staff demonstrated an absence of leadership in failing to appropriately plan for the COVID-19 outbreak.”
The lack of “a formal preparedness and response plan led to confusion, inefficiencies, and reactive measures,” the report found. And once the infection spread in the homes and “reality had set in,” top staffers were described as “disoriented” and “terrified.”
Meantime, a second point of tension had emerged between Noonan and the Parson administration, this time around the state’s plan to spend $2.5 million in marijuana proceeds on a tiny home village in north St. Louis.
Noonan told the Post-Dispatch that he had “no idea” the deal was afoot and said the veterans commission needed to have more input in how millions of dollars in medical marijuana proceeds are used.
After the Department of Health and Senior Services pays for the cost of running the program, the amendment legalizing medical marijuana says the rest of the money “shall be transferred to the Missouri veterans commission for health and care services for military veterans …”
“The amendment speaks for itself and we all need to work together — the governor’s office, the Legislature and the Missouri Veterans Commission — to develop a process that meets the letter as well as the spirit and intent of that amendment,” Noonan said earlier this month.
On Thursday, in a text message to the Post-Dispatch, Noonan said “the manipulation of the Missouri Veterans Health and Care Fund is not in the best interests of veterans. It also appears that it is not a legal way to spend the monies as (the amendment says) the MVC ‘shall contract with other public agencies for the delivery of services beyond its expertise.’
“The Veterans Community Project is not a public agency and the MVC should have a strong ‘say’ in the allocation of these monies,” Noonan said. “In the time of COVID, it’s hard to imagine building tiny homes as opposed to paying for PPE or overtime for the front-line as the highest and best use of these monies. The process is broken.”
Missouri Attorney General forces chairman of veterans commission to release report.