WOODLAND PARK, N.J. — Oversight of state-run nursing homes for military veterans in New Jersey should be removed from the military and be turned over to a newly created agency that focuses on health care, according to a new report released Tuesday by an independent fact-finding agency.

The recommendation by the New Jersey State Commission of Investigation (SCI) is the first and most drastic offered in its 16-page report, which centers on how "massive absenteeism" by front-line staff at the beginning of the COVID-19 pandemic, poor communication and faulty building designs helped exacerbate health risks among residents.

The pandemic "presented a perfect storm of circumstances that exposed systemic and, in some cases, enduring problems in the administration and supervision of the veterans homes,” SCI Chair Tiffany Williams Brewer said in a statement.

The administration of New Jersey Gov. Phil Murphy has been intensely scrutinized for its management of these homes, where more than 200 residents died during the pandemic due to "systemic and persistent problems."

The report comes less than a month after the publication of a more in-depth investigation by the U.S. Department of Justice, which found that a lack of preparation, deficient infection control practices, a growing distrust between managers and staff, and policies against mask-wearing helped the virus spread at two nursing homes.

The widespread dysfunction and inadequate care at these homes left residents unprepared for the pandemic, causing them to be at high risk for serious infections and illness. The Justice Department's report also noted that poor conditions in the homes continue to persist today.

New Jersey's state-run veterans homes in Paramus and Menlo Park had among the highest death tolls nationally during the pandemic for nursing homes. But multiple states faced similar issues and mismanaged nursing homes killed tens of thousands of people while hundreds of veterans succumbed to the virus.

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New Jersey State Commission of Investigation's recommendations

The primary recommendation of the SCI's report echoes similar calls from others, including Dave Ofshinsky, a former executive at the Paramus facility and a whistleblower: Move the homes away from the Department of Military and Veterans Affairs, whose primary responsibility is to oversee the New Jersey Army and Air National Guard.

"Most leadership within DMAVA has traditionally been current or retired military members without medical backgrounds or the necessary knowledge of nursing homes," the report states.

The commission recommended that a new Cabinet-level agency take control of the homes and be staffed by health care professionals with experience in skilled nursing, institutional care and other skills necessary to operate the nursing homes.

Other recommendations include:

  • Expedite the conversion of all rooms from double-bed to single-bed. Menlo Park is scheduled to be completed by 2025, but Paramus has no target date.
  • Make sure all medical and front-line staffers know they are considered "essential employees" and must report for their shifts during a public health emergency.
  • Offer competitive pay for replacement staff.
  • Upgrade technological capabilities at the homes, including electronic medical records and Wi-Fi capability, to allow better communication, including telehealth consultations.

'Deficient basic medical care' persists:DOJ slams New Jersey over COVID deaths at veterans homes, residents still at high risk

'Residents did not, and still do not, receive the level of care they are entitled to,' report says

The report also focused on staff members' not reporting to work from March to late-April 2020. Paramus had a 100% increase in call-out rates, and Menlo Park’s rate spiked to a 480% increase.

Morale had plummeted at the homes, with constant distrust between workers and management. Staffers feared for their lives and were afraid of bringing COVID home to their families. Not only did staffers not have access to face masks and other personal protective equipment, but some were being disciplined for wearing masks from home because managers thought it would scare residents.

Lawyers, including those in Gov. Phil Murphy's office, began devising penalties for staffers who took masks from the homes' supplies without approval. One Menlo Park employee told commission investigators that some workers wore plastic bags over their heads at the beginning of the pandemic. At least two staff members died from COVID — one in Paramus and another at Menlo Park.

Six months after the pandemic began, Murphy fired four top Department of Military and Veterans Affairs officials, including the commissioner and the CEOs of both homes. He replaced the head of the agency with a physician, Brig. Gen. Lisa Hou, and hired consultants to run the top managerial spots of the homes.

The Justice Department report from last month said the homes have not improved despite calls for reforms and that they continue to provide "deficient basic medical care" in areas such as preventing falls and treating wounds properly.

While the latest report does not address current conditions at the home, it states that its findings bolster the Justice Department's conclusions that "residents did not, and still do not, receive the level of care they are entitled to from the State of New Jersey."

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