Following the results of an investigation into the St. Louis Veterans Home that revealed serious issues, Governor Eric Greitens took action to protect Missouri veterans. The Governor replaced all five of the previous administration's appointees to the Missouri Veterans Commission, called on Larry Kay to be replaced as the Executive Director of the Missouri Veterans Commission and for Rolando Carter, the administrator of the home, to be fired.
Larry Kay has been replaced, with Col. Grace Link of the Missouri Air National Guard serving as interim Executive Director and Rolando Carter has been fired. Governor Greitens also launched independent investigations into all of Missouri’s other Veterans Homes. Today, he released the results of those investigations.
The results show that there is much more work to be done to continue improving Missouri’s Veterans Homes. Some staff reported that they fear retaliation for speaking out about problems with care or veteran safety. Some homes also received tremendous support from veterans, staff, and the community. The report contains a series of recommendations for continued improvements in Missouri’s Veterans Homes. The executive summary of the report can be read here.
Statement from Governor Eric Greitens:
“Big government was failing Missouri veterans. We aren’t accepting excuses; we’re demanding accountability.
Last year, after we concluded our independent investigation into mistreatment in the St. Louis Veterans Home, we took action. Our investigation showed that serious problems—including triggers for immediate jeopardy: “serious injury, harm, impairment, or death”—were being missed or ignored by the Missouri Veterans Commission and the VA. We were told by people at the home and the Commission that everything was fine. Those people are now gone.
We’ve brought in new leaders to clean things up and they’ve already started to get results. Families and staff in the home report that while things aren’t perfect, they are quickly getting better and that they no longer feel ignored.
We also launched investigations into every other veterans home to ensure our veterans are getting the quality care they deserve everywhere in the state. These investigations showed that there are many things that must be done to improve care for our veterans. Some of these homes have serious issues to address. It also showed that many of the staff in these homes are capable, caring, and love the veterans they work with every day.
Unlike in the past, the problems that exist in these homes won’t be swept away or ignored. We’re doing the tough work to root out the problems in our government and to fix them. Our new leaders are holding open houses at each of these homes to talk with the community about what we can do to serve them better. They’ll continue doing spot inspections. They’re asking tough questions, and supporting staff on the front lines. They’re putting veterans first, not shirking responsibility. They’re driving change and not accepting excuses. We’re going to get results.
These brave men and women put their lives on the line to keep American safe. They shouldn’t have to fear for their safety and dignity in one of these homes. We are doing the tough work to ensure that each of these veterans are treated with the respect and honor that they have earned. That’s what these veterans deserve.”
In July 2017, the Governor's office received reports of mistreatment and inadequate care at the St. Louis Veterans Home. The Missouri Veterans Commission (MVC) oversees and runs these homes. The Governor told the MVC that he expected answers—an immediate investigation and response. The MVC reported that they were unable to find evidence confirming the allegations.
The Governor then instructed the Department of Public Safety to follow up, looking for any criminal misconduct. At the conclusion of their work, the Department of Public Safety advised the Governor to call in the US Department of Veterans Affairs to conduct another full and complete investigation.
The Governor then requested an investigation from the VA. They published a 57-page report that examined the quality of the home against 158 different standards. The VA said that, for all 158 standards, the St. Louis Veterans Home met all quality thresholds.
Based on the serious concerns expressed by the family members of veterans in the home, the Governor determined that he would launch an independent investigation into these homes to continue demanding answers. That investigation was commissioned by Missouri's Department of Public Safety and conducted by Harmony Healthcare International.
Their investigative team visited the St. Louis Veterans Home nine times over the course of one month. They conducted 144 interviews with staff, family members, and veterans. They also looked directly at the care veterans were getting and did a full review of the home's policies and procedures. They examined patient charts and collected and reviewed data about patient care.
That investigation revealed serious failures in the home. Investigators found “substandard qualities of care” and “triggers for immediate jeopardy.” Immediate jeopardy is defined as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”
The report also investigated the home's policies and found many of them to be inadequate. For example, they found that the Cardio-Pulmonary Resuscitation policy did not specify which members of the staff are CPR certified. They found a problem with the policy on Catheterization, which “does not meet current evidence-based practice.” They found a problem in the home's Psychotropic Drug Protocol. The investigators found that the policy is “not consistent with current evidence-based and recommended practice for obtaining informed consent from veterans prior to initiating treatment with psychotropic medications.”
On December 11th, 2017, the Governor announced that he has launched full investigations into each of Missouri's other six veterans homes and replaced all five of the previous administration's appointees to the Missouri Veterans Commission.
The results of those investigations include a series of recommendations for improving these homes and better serving Missouri’s veterans.
The Governor also called for Larry Kay, the Executive Director of the Missouri Veterans Commission, to be replaced and for Rolando Carter, the administrator of the St. Louis Veterans Home, to be fired. Larry Kay has been replaced, with Col. Grace Link of the Missouri Air National Guard serving as interim Executive Director and Rolando Carter has been fired.
The Governor has appointed Dr. John “Bucky” Buckner, Dr. José Dominguez, Meredith Knopp, Tim Noonan, and Tim Smith to the Missouri Veterans' Commission. Those appointments have been confirmed by the Missouri Senate.
Dr. John Buckner is a Colonel (Ret.) in the United States Army. He is a member of The American Legion, the Veterans of Foreign Wars, the Reserve Officers Association, and the Association of Military Surgeons of the United States. Dr. Buckner has received numerous military awards from his service, including the Meritorious Service Medal and the Combat Medic Badge. He is a general surgeon at the Ferrell-Duncan Clinic at CoxHealth in Springfield. Dr. Buckner holds a medical degree from the University of Missouri-Kansas City School of Medicine and is a fellow of the American College of Surgeons.
Dr. José Dominguez is a retired Lieutenant Colonel, with service in the Missouri National Guard and the United States Army Reserves. He is a member of the Veterans of Foreign Wars, and the Reserve Officers Association. Dr. Dominguez received the Meritorious Service Medal, the Iraq Campaign Medal, the Kosovo Campaign Medal, and the Combat Medic Badge. He is a surgeon at the Ferrell-Duncan Clinic at CoxHealth in Springfield and serves as a reserve deputy for the Greene County Sheriff’s Office. Dominguez holds a medical degree from the University of Missouri-Kansas City School of Medicine.
Meredith Knopp served as a Captain in the United States Army. She is a member of the Women’s Army Corps Veterans’ Association and the Association of the United States Army. She is a co-founder of HEROES Care, a non-profit that provides support for veterans and their families, and she is the Senior Vice President of Programs and Operations at The Mission Continues. She holds a bachelor’s degree in international relations from Michigan State University and has studied at Cambridge University.
Tim Noonan served as a Captain in the United States Marine Corps and is the founding board member of the Friends of Soldiers Memorial. He is the Founder and Chief Executive Officer at NICE Holdings. Previously, Noonan was the Vice President of Training Systems and Government Services at The Boeing Company in the Defense, Space, and Security division. Noonan graduated from the United States Naval Academy and holds a master’s degree in business administration from the Wharton School of the University of Pennsylvania.
Tim Smith served as a Sergeant in the United States Army. He is the owner and founder of Patriot Commercial Cleaning. He has been recognized as the Veteran Business Owner of the Year in Missouri and has hired over forty veteran employees. Smith holds a bachelor’s degree in social work from the University of Missouri-St. Louis and a master’s degree in social work from the Brown School of Social Work at Washington University in St. Louis.
The Missouri Veterans Commission is a state agency, established by statute in 1989, and governed by nine commissioners. The MVC oversees seven Veterans Homes, in St. Louis, Cape Girardeau, Mexico, Warrensburg, St. James, Mount Vernon, and Cameron. More than 1,200 Missouri veterans currently reside in these homes.