FILE - PA Southeastern Veterans Center

The Southeastern Veterans Center in Spring City, Pennsylvania.

(The Center Square) – Leadership failures, poor internal and external communication and inadequate social distancing protocol were among the deficiencies an outside firm pinpointed in its investigation into deaths in the early months of COVID-19 at the Southeastern Veterans Center.

The Pennsylvania Department of Military and Veterans Affairs, within Gov. Tom Wolf’s administration, recently released an independent audit of the 292-bed SEVC in Spring City, which was under scrutiny throughout 2020 for a disproportionately high number of deaths compared to other facilities within the organization’s oversight.

The law firm Morgan, Lewis and Bockius LLP completed the audit Oct. 15, and the Department of Military and Veterans Affairs released it publicly Dec. 29.

In the 142-page report, law firm representatives laid out an 11-point list of problems that resulted in at least 42 SEVC residents dying of the coronavirus when 2020 came to a close.

“(The front line workers) should be recognized and lauded. This report commends their efforts,” the auditors wrote in the report. “Nevertheless, their leadership failed them, and much went wrong at SEVC that could have been avoided.

A number of the nearly dozen issues outlined in the report took aim at procedural failures that exposed residents to the virus. Communal dining, for instance, continued through early April, even though there was a call to cease such activities in mid-March.

Other procedural failures early in the pandemic at the SEVC included little to no infection control planning, even as the virus was spreading in the facility, and an inadequate job of isolating residents from one another.

The DMVA issued a statement in response to the report, asserting proactive measures have and will continue to be implemented within the SEVC and other facilities across Pennsylvania.

“The DMVA has implemented most of the recommendations in this report that could be implemented immediately and is now in the process of reviewing and implementing additional recommendations, to include a review of its organizational structure, crisis management, communications and infection control procedures,” the statement, in part, reads.

The state agency’s release of the audit coincides with a number of other late-year developments related to the SEVC, including a Dec. 21 lawsuit filed on behalf of five resident veterans who died from COVID-19. The DMVA is named in the complaint, as is Rohan Blackwood, SEVC’s former commandant, and Deborah Mullane, SEVC’s former director of nursing.

Ian Horowitz, whose 81-year-old father, Edward, is among the residents who died from the virus, is among the parties involved in the lawsuit.

Reached for comment, Horowitz said he was gratified with the findings within the report.

“I read through the report for a couple of hours,” Horowitz said in an interview with The Center Square. “I looked at it as a gift and a small victory. It reflects what I’ve been saying and others have been saying.”

As 2021 unfolds, Horowitz said he hopes the coronavirus-fueled deaths at the SEVC and other facilities shine a spotlight on the importance of having strict protocols in place.

“My word for 2021 is accountability,” Horowitz said. “I see state legislators finding it more important to try and pass laws to try and protect these nursing homes with immunity and protect these managers from prosecution. Where’s the protection of our senior citizens, our veterans and other vulnerable populations?”

Early in December, state Auditor Gen. Eugene DePasquale also issued a 12-page report, “Protecting Our Protectors: A Review of State Veterans Homes.” The document, DePasquale said, was a follow-up to a similar analysis he conducted in 2016.

“Given the disproportionate impact of COVID-19 on residents of long-term care facilities and nursing homes across the state this year, a review solely of the 2016 audit recommendations would not present a full picture of how the DMVA is serving our aging veterans,” DePasquale wrote.

In his updated report, DePasquale issued a number of recommendations to all statewide veterans centers, including training on proper use of personal protective equipment, or PPE, and improving management-workforce communication.