GOV. CHARLIE BAKER promised to follow through on all of the recommendations contained in a report documenting a series of management and medical mistakes at the Holyoke Soldiers’ Home, but he backed away from one of the key initiatives in filing a number of reforms on Thursday.
The 174-page report, compiled by attorney Mark Pearlstein, documented a series of tragic mistakes made by medical personnel at the facility and management lapses by the former superintendent, Bennett Walsh, that contributed to the COVID-19 deaths of 76 veterans. One of the key findings was that Walsh, a military veteran with no health care background, was not equipped to manage the facility, particularly after his top deputy, who did have a health care background, resigned in 2019 and was not replaced.
In his list of recommendations at the end of the report, Pearlstein said future superintendents at the Soldiers’ Home “should be licensed nursing home administrators with substantial healthcare experience.” The report said the licensing requirement was a way of guaranteeing a baseline level of competence.
Baker on Thursday unveiled a long list of reform measures, but took a different tack on the superintendent position. The governor’s package said the new posting for the superintendent’s job “will include a preference for hiring a licensed nursing home administrator,” and made no mention of a licensing requirement.
The same preference was contained in the job description for the post when Walsh was hired.
Attorney General Maura Healey said she supports what Pearlstein recommended. “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?” she asked.
Baker did promise to hire an experienced health care professional at the Department of Veterans’ Services to provide management support for the Holyoke and Chelsea Soldiers’ Homes. Francisco Urena, the Veterans’ Services secretary, resigned on Tuesday ahead of the Pearlstein report’s release, which found him negligent for failing to take “sufficient action in addressing Walsh’s deficits.”
Baker promised to file legislation giving the secretary of health and human services, rather than the board of the Soldiers’ Home, the power to appoint the superintendent. The legislation would also require an annual inspection of the home by the Department of Public Health and expand the number of board members at the home from seven to nine. The two new members would need to have health care backgrounds and the secretaries of veterans’ services and health and human services would be added to the board as ex officio members.
Another staffing change will include the hiring of a designated occupational health nurse, a role that was filled for the first time when the Clinical Command team took over administration of the home on March 30 through a contract with UMass Medical School/ Commonwealth Medicine.
Bi-weekly labor management meetings with the Massachusetts Nurses Association and SEUI 888, which represent employees at the Soldiers’ homes, have been established to discuss concerns including staffing and scheduling. Both unions sent written requests for information to the Soldiers’ Home on four different dates before a March 24 conference call with administrators. These requests all went unanswered.
Brenda Rodrigues, president of local 888, said that members were concerned that they were not hearing “anything” from management about preparedness protocols.
Baker said the Holyoke Soldiers’ Home has brought on an executive nurse consultant to focus specifically on education, both general best practices as well as enhanced infection control protocols.
Baker noted his Fiscal Year 2021 Capital Investment Plan included $2 million for a joint electronic management record system for the two soldiers’ homes. That process is ongoing, and The Holyoke Soldiers’ Home has identified an individual to oversee the implementation of the project.
Additionally, $6 million has been allocated to refresh the units and certain furnishings of the building. Upgrades underway are to meet hospital grade physical plant requirements. The state has also initiated an expedited Capital Project process managed by the Division of Capital Asset Management and Maintenance.
Other investigations into the Soldiers’ Home are ongoing by the Justice Department and Massachusetts Attorney General Maura Healey. Baker said additional reforms related to the Soldiers’ home will be announced in the coming weeks related to family support.
House Speaker Robert DeLeo said last night he is hitting the brakes on Baker’s move for reform because the Pearlstein report only answered some of many questions about what went wrong at the facility.
“The independent investigation conducted for the governor answers some of the basic questions as to how this tragedy occurred,” DeLeo said. “Before we begin to consider any legislative solutions the governor may propose, however, we need the answers to many more questions, starting with why this tragedy was able to occur.”
DeLeo said he intends to recommend a special legislative oversight committee to the full House next week to be headed by Veterans Affairs Committee co-chair Rep. Linda Dean Campbell.