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Missouri's Public Safety Department last week launched its investigation of the St. Louis Veterans Home, which Gov. Eric Greitens ordered Oct. 31.

"After a thorough search, the department has contracted with Harmony Healthcare International, which is already on-scene at the home in Bellefontaine Neighbors in north St. Louis County," the department announced in a news release.

"HHI is a health care consulting firm whose services include nursing home audits, compliance reviews and monitoring to ensure quality patient care."

Greitens' order for a new investigation came after Missouri Veterans Commissioners — at their Oct. 30 meeting — supported the commission staff's operations at the St. Louis home.

Lt. Gov. Mike Parson — whose office serves as an advocate for veterans and senior citizens — on Oct. 31 also called for a new, independent investigation of the state-owned St. Louis facility, noting his office had "conducted numerous interviews with family members, as well as current and former staff members of the facility, to document their experiences in the hope of enacting needed change."

The News Tribune on Friday obtained a copy of the lieutenant governor's report, which previously had not been made public.

William Bellomy, Parson's Veterans Affairs director, on Friday confirmed the report's authenticity but declined to discuss any of its findings on-the-record.

The report says Parson's investigation began last Feb. 21 when the lieutenant governor's office "was approached by a medical professional about issues" at the St. Louis Veterans Home.

The report details five issues to be addressed, including:

1. Medication problems — As-needed use of anti-psychotics and medications prescribed without informing primary care doctors or neurologists and recommended "there should be an immediate review of (prescription) use by an MD, not affiliated with the Missouri Veterans Commission."

Hunt told commissioners Oct. 30 "an independent pharmacy does an independent review" each month of the home's handling of residents' prescriptions, and it hasn't shown any major problems.

2. Complaint procedures give the perception of being less than honest and "designed to hide problems." The report recommends an immediate review of procedures and future changes in state law.

3. Complete lack of transparency for veterans and their families. The finding included relatives' complaints they can't get official reports on a veteran's death, even if they have the power of attorney. So, the report recommends, "immediately develop(ing) procedures to ensure copies of reports, as they relate to the death or complaint, can be redacted (as needed) and released to a family member with a valid Medical Power of Attorney."

4. Administration is unable to hire and retain quality personnel.

5. Complete loss of faith among veterans, their families and Veterans Home staff with the leadership of the home and the commission staff, with the recommendation "a change in the leadership of both the Missouri Veterans Home, St. Louis, and the Missouri Veterans Commission" is needed.

When veterans, family members and staff complained either to the home's administration or to the commission, the Parson report says, "nothing was done (and) if anything, there seems to be a closing of ranks, threatened employees and making veiled threats to have veterans removed from the Veterans Home or further medicated."

The report said "anything less than a new group of leaders will only display more of the same."

And Parson's report said: "It should also be noted that there are six additional Veterans Homes in the state, (but they) have not reported the type of issues covered in this investigation."

The commission was told Oct. 30 its staff wasn't contacted until July when Greitens' office was contacted by family members and friends of veterans living in the home.

Director Larry Kay and Deputy Director Bryan Hunt reported investigations by the commission staff, the Public Safety Department and the federal Veterans Administration all found no major problems.

Hunt told commissioners Oct. 30 the VA's inspection found the St. Louis home to be in full compliance with all 158 VA standards.

In its news release last week, the Public Safety Department said: "Since July 21, Gov. Greitens has taken the following actions related to care at the St. Louis County Veterans Home:"

Directed the Missouri Veterans Commission administration to investigate and take corrective actions after concerns were raised about conditions at the home.

Directed the Department of Public Safety to conduct a follow-up investigation, including an unannounced inspection of the home.

The department didn't comment on a request for a copy of any report made about that DPS investigation.

Requested an investigation by the Veterans Administration.

The Veterans Commission is a part of the Public Safety Department, and the news release said, "DPS has directed the Missouri Veterans Commission staff to cooperate fully with the investigation, including providing full access upon demand to the facility, records, employees and residents."

In a statement, DPS Director Drew Juden said: "We take this matter extremely seriously because the health, safety and wellbeing of veterans in the state's care are absolutely essential.

"We are committed to ensuring the investigation is independent, thorough and completed expeditiously, because that's what Missouri veterans and their families deserve."

Juden noted, when Greitens "directed me to initiate this investigation, he told me our mission is to make Missouri the best state in America for all veterans, every single day. We intend to make sure that directive is carried out."

The department didn't say whether its investigation would include the issues raised in the nine-page Parson report.

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