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It is naive to think the pandemic that devastated so many nursing homes would not also find its way into Missouri's seven homes for veterans, but a 415-page investigation makes clear things wouldn't have gotten as bad as they did but for a failure of leadership from the Missouri Veterans Commission.

The unsparing reports should be required reading for every lawmaker and elected official, particularly as they gather Wednesday in Jefferson City for the legislative session.

In a period of about two months, more than 100 veterans in Missouri died because of COVID-19 at seven state veterans homes, and the investigation reached three conclusions:

• The Missouri Veterans Commission "failed to recognize and appreciate the impact of even one positive case of COVID-19. ... This meant MVC leadership did not change tactics to aggressively contain the first positive cases ... even as cases increased MVC headquarters failed to appreciate the need to move quickly to isolate positive patients."

• "MVC headquarters demonstrated an absence of leadership in failing to appropriately plan for a severe and prolonged COVID-19 outbreak. ... Despite several months to prepare for a predicted fall surge in COVID-19 cases, MVC Headquarters did not develop any comprehensive outbreak plan. ... The lack of a comprehensive outbreak plan led to confusion and inefficiencies and it almost certainly contributed to the inability to contain the spread of COVID-19 once it was introduced into the homes."

• "MVC's response to the outbreak was inadequate," and the report also noted that individual homes, including the one in Mount Vernon, had problems preventing and then containing the spread, were out of compliance with Centers for Disease Control and Prevention guidelines and that problems were compounded by staffing issues.

The report then breaks down problems at individual homes, including Mount Vernon, where nine veterans died. Those problems included:

• Because of MVC policies, punishing noncompliant staff with regard to the use of personal protective equipment was difficult. The report concluded: "Overall, the Mount Vernon home seemingly struggles with balancing compliance and discipline due to the fear that discipline may create staffing shortages."

• In one instance, a staff member who self-reported COVID-19 symptoms in September was asked to continue working and two days later tested positive.

There's more. There are things the veterans homes did right, too, offerings lessons that can be passed on to other homes.

The investigation and its recommendations must not be the end but a beginning, and its authors hope that the commission and "external" organizations — which we take to mean lawmakers and statewide elected leaders, up to and including Gov. Mike Parson — should take whatever steps are necessary to make sure the commission has effective leadership and that our veterans are protected.

The ball has been passed to them at the beginning of this legislation session.

As the report itself notes: "It is our hope that these findings and recommendations will serve as a launching point for positive change for those who deserve it most."

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