In their gut-wrenching report on the state-run Holyoke Soldiers’ Home, investigators pointed to a clear gap in the facility’s management: Its superintendent was not licensed to run a nursing home, nor was he required to be.
But in detailing several proposals Thursday to overhaul supervision of the facility, Governor Charlie Baker did not recommend rewriting state law to change that standard. Instead, he promised to make licensing a preference — but not a requirement — for the next leader of the home, where investigators say “utterly baffling” medical decisions contributed to a coronavirus outbreak that has killed at least 76 veteran residents.
The decision surprised some union leaders and appeared to cut against a key recommendation of the report Baker himself commissioned.
While there’s no statutory requirement that the superintendent be a licensed nursing home administrator, leaders at private facilities must be. “At a minimum,” the same standard should apply to the Soldiers’ Home, according to the 174-page report, released Wednesday and written by a former federal prosecutor, Mark W. Pearlstein.
“We can think of no reason or explanation why the veterans at the Soldiers’ Home should not receive the same protections as residents at private facilities,” the report states.
”If a license requirement is necessary to ensure a baseline level of care at every other long-term care facility in our state, then why would we compromise that standard when it comes to caring for our veterans?” Attorney General Maura Healey, whose office is conducting its own review of the facility, said in a statement Thursday.
In an e-mail late Thursday, a Baker administration spokeswoman said that requiring the superintendent to have a license would “severely shrink the applicant pool,” and exclude what his administration called appropriate leaders, pointing to Val Liptak, the home’s current acting administrator, as an example.
“The Administration’s reforms require medical and management expertise at several levels both directly at the Home and at the Department of Veterans’ Services, all of which would contribute to experienced, knowledgeable oversight of the facility,” spokeswoman Brooke Karanovich said.
Baker’s newly filed legislation would require annual health inspections at both soldiers’ homes, which Pearlstein’s report called for, and expand the board overseeing the facility to include healthcare professionals. His administration said it also intends to hire an “experienced healthcare leader” for an assistant secretary role to help manage both state Soldiers’ Homes in Holyoke and Chelsea.
Those changes, however, all require legislative approval before going into effect.
Pearlstein’s report concluded that Bennett Walsh, the home’s superintendent, was unqualified to lead the home, whose residents included veterans of World War II, the Vietnam War, and other conflicts. And the Baker administration, which appointed Walsh and his overseers, knew of his shortcomings well before the outbreak, the report found.
Walsh didn’t have a license or “any experience whatsoever” in managing a health care facility, according to the report. Baker said Wednesday that state officials are working to end Walsh’s employment.
“The report says a million times how Walsh was just not qualified, and in that vein, recommends that you have someone with health care administration experience,” said Andrea Fox of the Massachusetts Nurses Association, which represents 40 registered nurses at the 250-bed facility.
“One of the reasons I think passionately that licensing is necessary is that why would we expect a different standard for people in the care of the state versus folks that are in other long-term care facilities that are private sector,” Fox said.
The report acknowledges that Cheryl Poppe, the superintendent at the Chelsea Soldiers’ Home, does not have a license, but is widely considered to be a “highly competent manager.” Poppe on Wednesday was tapped by Baker to be his acting secretary for the Department of Veterans’ Services, replacing Francisco Urena, who resigned Tuesday.
But licensure, as in other professions, “is one way to help ensure a baseline of competence,” the report states.
“I would feel much safer knowing they would have someone with a license there,” said Corey Brombredi of SEIU 888, a union that represents most of the home’s care staff. Given the move to make license only a preference, “if I were a betting man, I would say they have someone in mind.”
Baker on Thursday outlined other legislative proposals designed to increase accountability at the home.
One would require annual inspections of both state facilities and more frequent inspections by the Department of Public Health “if necessary,” his office said. Another aims to expand the boards of both the Holyoke and Chelsea homes to nine members from seven, adding two people who have a health care background “either as a clinician or administrator,” according to his administration.
The secretary of the Department of Veterans’ Services, as well as the secretary of health and human services, would also serve as ex-officio members under his legislation.
The current board of trustees for the Holyoke Home — which has no members with health experience — has remained relatively silent throughout the outbreak and controversy. None of the current trustees have resigned, and when asked Thursday whether their resignations would be warranted, Baker called it “a worthwhile question.”
Other changes Baker laid out do not need legislative approval, including plans to hire a permanent occupational health nurse and a nurse educator position for the Holyoke home.
Baker’s office said it’s also dedicating $6 million to “refresh the units and certain furnishings . . . to address priority infection control,” and it included $2 million in a capital spending plan for an electronic management records system for both soldiers’ homes.
The independent report on the Holyoke home laid out a litany of lapses. The most glaring failure to contain the virus came on March 27, when management merged two locked dementia units. It’s a decision investigators described as a catastrophe, crowding 40 veterans into a space designed to hold 25 and providing the “opposite of infection control.”
How and when lawmakers could pursue Baker’s proposals and any others addressing the Soldiers’ Home is unclear.
State Representative Linda Dean Campbell, House chairwoman of the Joint Committee on Veterans and Federal Affairs, pointed to an array of outstanding investigations into the home being conducted by the state attorney general, the Justice Department, and the state inspector general, and suggested lawmakers should wait until those conclude until moving on legislation.
House Speaker Robert A. DeLeo on Wednesday said he’d also ask the House to approve a special legislative oversight commission to conduct its own probe.
“We’re not going to try and fix a problem before we know the full scope of the problem,” DeLeo said.
Senator Walter F. Timilty, Senate chairman of the veterans committee, said it’s possible lawmakers can pass legislation this year addressing the Soldiers’ Home, but cautioned: “That’s not a guarantee.”
”We owe it to our veterans to get it done right,” the Milton Democrat said.