Quebec's college of physicians and orders representing nurses describe the catastrophe that unfolded at a private long-term care home in the West Island as a by-product of inexperienced staff and mismanagement.
But they also say it's up to the Quebec government to make sure it never happens again.
Last spring, dozens of residents at the CHSLD Herron died within a matter of weeks, and many others were found to have been neglected and malnourished.
The joint report pushes for the province to equip itself legally to step in more quickly when the situation in a private, non-subsidized long-term care home deteriorates.
They even say the province should "seriously consider rescinding" those homes' permits, and integrating them within the province's network of subsidized private homes.
The report's findings are the latest that have been released in recent months in hopes of shedding light on why so many CHSLD residents have died during the pandemic.
"There was a lack of knowledge on the part of operators about the laws and regulations surrounding the management of a CHSLD," said Luc Mathieu, the president of the Quebec Order of Nurses.
A public inquiry into deaths in long-term care homes was set to begin last month, but was delayed until September.
Not much training, not much experience
In recent years, CHSLD Herron was often without a director of nursing services, and that was the case in the weeks leading up to the start of the COVID-19 pandemic, according to the report.
"Many times, the executive director was managing the delivery of services alone," the report stated. "Furthermore, management had no nursing training."
The joint committee issued 30 recommendations, including having the Health Ministry put in place "regulatory mechanisms" to make the presence of a nursing services director mandatory in private, non-subsidized long-term care homes.
It's also calling on the province to make it more difficult to get a permit to operate a CHSLD.
Most of the 12 nurses at Herron had their permits for four years or less, and only two of them had a university degree in nursing sciences, which would qualify them as beginners, the joint committee said, especially considering that their experience in caring for the elderly was gained almost exclusively at the West Island long-term care home.
Most of the 15 licensed practical nurses were just starting out their careers, and many of the 45 patient attendants, or PABs, had no professional training or diploma.
The committee recommends mandatory training for PABs in private, non-subsidized long-term care homes, and says the province should make sure more nurses have university degrees.
Despite the lack of training and experience, the report made it clear that health-care staff was not to be blamed for what transpired at Herron.
"Contrary to what has been conveyed, employees at the CHSLD did not abandon residents and the home," the report stated. "They were asked to leave because they had symptoms of the disease, or because they had been in contact with someone who tested positive, and management did not make any plans to replace them."
Sounding the alarm since 2017
The report also analyzed the failings at Montreal Geriatric Institute, where many residents died during the first wave.
In a joint statement, Quebec Health Minister Christian Dubé and the minister responsible for seniors, Marguerite Blais said they intend to follow up on the report's recommendations.
"We will do everything to put in place conditions to avoid that such situations don't repeat themselves," Blais said in reference to the heavy death toll in long-term care homes.
This isn't the first time the professional orders have looked into what was going on at Herron.
The order representing licensed practical nurses issued a report in 2017, lamenting the lack of infection control in the home.
In 2018, the Quebec Order of Nurses followed up and found many of the home's shortcomings had to do with a high turnover rate and inexperience among staff.
"Our reports weren't really taken seriously," said Mathieu.