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In May, a special committee formed by the Massachusetts Legislature released the report on its investigation of the COVID-19 outbreak at the Holyoke Soldiers’ Home that resulted in 77 deaths. The report by the Special Joint Oversight Committee, which we chair, is most notable for taking the opposite approach of an investigation conducted by Mark Pearlstein and commissioned by Governor Charlie Baker. We acknowledge that important questions have been raised regarding the independence and depth of the Pearlstein investigation and report. Our committee’s investigation and report focus on the underlying governance failures that created a perfect storm for the preventable tragedy that occurred at the Soldiers’ Home.

The Pearlstein report provided a good chronological picture of what happened in those fateful few days when the two locked dementia units at the Soldiers’ Home were combined and suspected COVID-19 patients and likely non-COVID-19 patients were placed side by side only a few feet from each other.

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Pearlstein voluntarily testified before our committee, and his testimony and report corroborated the courageous testimony of family and staff at our hearings conducted in Holyoke. Their testimony described horrific scenes where the COVID outbreak was ineffectually managed and some veterans died without proper medication to ease their passing — while others died completely alone. Many family members and staff will never recover from the trauma of what they witnessed and experienced.

Yet Pearlstein’s report was only a launching point for our investigation, and indeed, committee members concluded that his report raised more questions than answers. He corroborated the “how” of those fateful few days, whereas we asked, “Why?”

The legislative report lays bare in excruciating detail the many points of failure that existed within the Baker administration’s oversight of the Soldiers’ Home well before the coronavirus pandemic struck.

Beyond describing these points of failure, the special committee’s report makes recommendations to address them. Legislation to carry out these recommendations is currently being drafted. A few examples of some of the findings and recommendations included in this report are:

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1. Bennett Walsh was not qualified to serve as superintendent of the Holyoke Soldiers’ Home and, furthermore, continued to serve after his leadership failures and unsuitability for the position were clearly identified, well before tragedy struck.

Information provided to the committee (including testimony received by former secretary of veterans’ services Francisco Ureña) clearly spells out that the process for the selection of Walsh was haphazard at best. Report recommendations include, among others:

▪ Requiring that future superintendents be licensed nursing home administrators, as is required for all other facilities in Massachusetts.

▪ Requiring that both the Holyoke and Chelsea Soldiers’ Homes be enrolled in the Centers for Medicare and Medicaid Services as participating facilities subject to all requirements and inspection protocols.

▪ That the secretary of veterans’ services be elevated to the role of secretary of veterans affairs (not a commissioner) with a seat in the Governor’s Cabinet.

▪ Putting in place a professional nomination process where candidates for superintendent are reviewed by the proposed secretary of veterans’ affairs and the secretary of health and human services;

▪ Creating a system of accountability where the governor appoints (and removes if necessary) a superintendent and deputy superintendent from a pool of qualified and recommended candidates.

▪ Establishing a similar clear and professional process for selecting other positions within the Soldiers’ Homes and annually evaluating personnel performance.

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2. A muddled and ineffectual chain of command hindered the response to the crisis and the management of the Holyoke Soldiers’ Home well before COVID-19 emerged.

Clear and effective communication between the Soldiers’ Home and the governor’s office was nonexistent during the crisis. The report documents this in meticulous detail, including testimony provided by staff and former veterans’ services secretary Ureña. The report explores the lack of accountability that was spread between boards, secretariats, and staff. There were no direct and clear lines of authority, accountability, and communication. The report recommends in part:

▪ That documented chains of command be established within the Soldiers’ Homes and that annual routine training be provided along with written plans developed and practiced for normal and emergency operations. This training would be reviewed by the executive director of the Office of Veterans’ Homes and Housing and the proposed secretary of veterans’ affairs.

▪ That the chain of command at both Soldiers’ Homes be from the superintendent to the executive director of veterans’ homes and housing to the proposed secretary of veterans’ affairs to the governor.

3. Longstanding staffing deficiencies at the Holyoke Soldiers’ Home and the vacancy of key leadership positions contributed substantially to the tragedy.

It is difficult to overestimate the extent to which insufficient staffing, the decision not to fill key leadership positions as required by law, labor relation friction, floating staff, mandatory overtime, and other staffing-related problems contributed to this tragedy.

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A sign in front of the Holyoke Soldiers' Home, in May 2021, flashes the words, "To care for him who shall have borne the battle."
A sign in front of the Holyoke Soldiers' Home, in May 2021, flashes the words, "To care for him who shall have borne the battle." Jessica Rinaldi/Globe Staff

The Committee concluded after reviewing a report by the state auditor’s office, and extensive oral testimony provided by the nurses union and others that, by 2016, the reputation of the facility had clearly changed. Mandatory overtime, the use of external hiring services, and staff turnover were all indicators that there was trouble at the Soldiers’ Home. The failure of Baker administration officials, from 2016 to 2020, to dig deeper into the union’s concerns of working conditions, the erratic staffing patterns, and Walsh’s anger management issues allowed the facility’s tailspin to continue unabated. An intervention was warranted, but none came.

Some recommendations that the Committee puts forth include:

▪ Staffing the Soldiers’ Homes to achieve, at a minimum, the gold standard certified by the Centers for Medicare and Medicaid Services.

▪ Creating a full-time ombudsman position with direct access to the executive director of veterans’ homes and housing.

▪ Filling critical leadership within the administration within required timeframes.

▪ Requiring an infection control specialist on staff.

4. A lack of structures for coordination between the two Soldiers’ Homes contributed to the tragedy.

The committee found substantial differences in policies and procedures at the Soldiers’ Homes in Chelsea and Holyoke that led to different outcomes in managing the COVID-19 pandemic.

The committee makes broad recommendations to standardize many policies pertaining to both Soldiers’ Homes, to include creating a centralized state board of directors that will provide oversight and make policy recommendations to the proposed secretary of veterans’ affairs on all matters pertaining to the homes and ensure that all veterans in the Commonwealth have access to the care provided at the homes. The composition of the board will reflect the composition of veterans throughout the Commonwealth.

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Legislation to enact these recommendations will be forthcoming. Our veterans and their families deserve nothing less.

State Representative Linda Dean Campbell and State Senator Michael Rush are veterans currently serving as chairs of the Special Joint Oversight Committee on the Soldiers’ Home in Holyoke COVID-19 Outbreak.