Report lays out failures, lack of oversight at Holyoke Soldiers’ Home

Hampden County

BOSTON (WWLP/SHNS) – Gov. Charlie Baker plans to file reform legislation and the possibility of legal action remains on the horizon after the release Wednesday of a scathing report outlining failures, errors, delays and “utterly baffling” decisions preceding the deaths of at least 76 veterans with COVID-19 at the Holyoke Soldiers’ Home.

The attorney for Superintendent Bennett Walsh, William Bennett, is out with a statement saying this independent report clearly shows his client tried to get help from the state, but the state didn’t act.

Attorney for Holyoke Soldiers’ Home superintendent calls findings of independent report “baseless accusations”

Susan Kenney’s father is one of the 76 veterans who died from Covid-19 at the Holyoke Soldiers’ Home. The governor’s office released a 174-page independent report, compiled by a former federal prosecutor, that outlined substantial errors in the way the leadership team at the facility handled the outbreak.

“His birthday his 79th birthday would have been yesterday,” Kenney told 22News. “And I think he would have made it to that birthday if this didn’t happen.”

“Veterans who deserve the best from state government got exactly the opposite, and there’s no excuse or plausible explanation for that,” Baker said at a press conference after his administration released a 174-page report from Mark Pearlstein, the former first assistant U.S. attorney that Baker tapped in April to lead an independent investigation into the circumstances in Holyoke.

Governor Baker addresses investigation report on Soldiers’ Home in Holyoke

Baker said that he accepted the resignation of Francisco Urena, his veterans services secretary, and that he is “moving to end the employment” of Bennett Walsh, the home’s superintendent. He said there was an “abject failure of leadership” at the state-run facility, starting with the superintendent and his team.

According to the report, Superintendent Walsh wasn’t qualified to manage a long-term care facility.
The report said he and his leadership team made decisions that were quote, “utterly baffling from an infection-control perspective.”

Among them was a decision to move veterans from one dementia unit into another, both of which housed veterans who already had the virus. The report said – this decision was a catastrophe. Staff described the move as, “total pandemonium,” “when hell broke loose,” and “a nightmare.”

REPORT: Independent Investigation at Holyoke Soldier’s Home

“I think the thing the report makes absolutely clear to all of us is that the Department of Veterans’ Services, our administration, did not do the job that we should have done in overseeing Bennett Walsh and the soldiers’ home,” the governor said.

Baker said the report was “hard to read” and called its contents “nothing short of gut-wrenching.”

“Where it said the staff felt like they were walking veterans to their deaths, there are no words for that,” Cheryl Turgeon, daughter of a veteran said. “And the fact they were terrified like they were in another war and they were prisoners. No good could come of it.”

By the weekend of March 28, eight veterans would die. Holyoke Mayor Alex Morse is mentioned in the report because he contacted the governor’s executive branch, including Health and Human
Services Secretary Marylou Sudders. Morse pleaded with state officials to do something fast.

“Communication was incredibly difficult through this entire process, where we were hearing reports on our social media, I was getting emails to the office describing the deteriorating conditions at the Holyoke Soldiers’ Home,” Morse shared with 22News.

Pearlstein wrote that the “worst decision” made at the home in response to the outbreak was combining two locked dementia care units that housed some patients who had tested positive for COVID-19 and others who were negative, because of a “looming staff shortage.”

Staff quoted in the report describe the move as “total pandemonium,” and “when hell broke loose.” A recreational therapist is quoted as saying she felt like she was “walking [the veterans] to their death,” and a social worker “felt it was like moving the concentration camp — we [were] moving these unknowing veterans off to die.”

Baker said one social worker’s recollection detailed in the report “is one of the most depressing, and utterly shameful descriptions of what is supposed to be a care setting that I’ve ever heard.” The veterans faced “deplorable conditions” once the units were combined, he said.

At the end of March, the Baker administration brought in Val Liptak, the CEO of Western Massachusetts Hospital, to lead the Holyoke Soldiers’ Home, after Walsh had been put on paid leave.

Baker said Liptak and her team “have done a tremendous job of creating a safer long-term care facility for residents and staff,” and that on Tuesday, no residents at the Holyoke home tested positive for COVID-19.

Walsh has pushed back against suggestions from the governor that he did not inform state officials of problems until it was too late, saying that instead he was denied assistance by the administration.

Pearlstein identified “no material violations” of COVID-19 reporting requirements, but said Walsh reported other information that was “inaccurate and incomplete.”

While the Holyoke Soldiers’ Home was particularly hard hit, the COVID-19 pandemic has exacted a tragic toll on long-term care facilities across Massachusetts. Almost 5,000 deaths — 63 percent of all COVID-19 deaths in Massachusetts — have been recorded in long-term care facilities.

The report, based on interviews of 100 witnesses including Walsh, Sudders, Urena and Baker, and a review of more than 17,000 documents, marks the culmination of only one of three separate investigations into what happened in Holyoke. Attorney General Maura Healey and U.S. Attorney Andrew Lelling each launched their own probes in April.

Healey said Pearlstein’s report “reveals that serious failures by leadership at the home contributed to the tragic loss of life there” and “lays bare systemic failures of oversight by the Baker Administration in adequately preparing, staffing, and responding to this crisis to protect our veterans.”

She said her investigation “will determine whether these missteps and errors warrant legal action.”

Pearlstein’s report faults the Holyoke home’s staff for a failure “to promptly isolate” patients suspected to have COVID-19, delays in testing symptomatic veterans, inconsistent policies and practices around personal protective equipment, and failures in record-keeping and documentation.

The leadership team was “inexcusably slow” in closing communal areas to reduce spread of the contagious and respiratory disease, and failed to prevent rotation of staff among different units, Pearlstein wrote.

His report also knocks the Department of Veterans Services for not addressing “substantial and long-standing concerns” around the home’s leadership, and recommends a number of changes around staffing and technology.

The Department of Veterans’ Services and the state’s two soldiers’ homes in Holyoke and Chelsea fall under the umbrella of the Executive Office of Health and Human Services. Overseen by Secretary Marylou Sudders, who reports to Baker, the office is the largest secretariat in state government and consists of 12 agencies as well as the MassHealth program.

Sen. Mike Rush, a West Roxbury Democrat and officer in the U.S. Navy Reserves, was filing a bill Wednesday that an aide said would move the veterans’ services secretary out from the Executive Office of Health and Human Services and into the governor’s cabinet so the secretary would report directly to the governor.

Baker said Wednesday that he has “full confidence” in Sudders and her undersecretary, Dan Tsai.

“When the full extent of what was going on there became available to both of them, within 11 hours, they had a new management team on the ground there, brought in Holyoke Medical Center as a partner, brought in resources from across Western Mass. and across the commonwealth, brought the National Guard in, and created a framework and an operating model that actually made it possible to get to the point where today, there are no positive cases,” he said.

Sudders said the home’s new management team has “begun to establish positive relationships with the unions and staff,” put training programs in place and committed to creating a permanent staffing schedule, all moves recommended in the report.

Baker said his administration will implement all of the report’s recommendations and that he plans to introduce legislation on Thursday that will “upgrade the governance” of the home. He said he would also outline measures to “address the trauma the staff have experienced.”

Sudders said the reforms will also include plans for “significant capital improvements.”

“There was not proper oversight of the home,” Sudders said. “Going forward, we will ensure that the implementation of reforms is lasting and instituted without delay to allow for the healing of staff, residents and loved ones and to rebuild community trust.”

Specifically, Baker said, his proposal will call for “reformulating” the home’s board of trustees. Pearlstein recommended that at least two of the trustees have relevant clinical or health care administration experience, and Baker said, “We think there’s some other things we should do with the board, too.”

Saying that veterans who served their country deserve at least the same protections as residents of private nursing homes, the report said the Soldiers’ Home “should not be exempt from the requirements for licensing and inspection that apply to other long-term care facilities in Massachusetts.” It recommends that future superintendents be licensed nursing home administrators with “substantial” health care experience.

Walsh did not have health care administration or clinical experience, according to the report. Sudders, the report said, instructed Urena to ensure Walsh’s deputy superintendent would have a long-term care background, and Urena “allowed the Deputy Superintendent role to remain open for nine months — including the period of the COVID-19 outbreak.”

The deputy superintendent post is again vacant, as is the post of executive director of veterans homes, a role the Legislature created in 2016. That position has never been filled, “for budget reasons,” the report said.

The report recommends the veterans department “act immediately to fill this role” and that lawmakers “act to ensure that funding is in place.”

Baker called the two vacant posts “critical.”

“These positions should have been filled,” Baker said.

Pearlstein’s report said it is not discounting the efforts of front line staff, who labored “without competent leadership to manage the crisis,” concluding, “The administration of the Soldiers’ Home failed them too.”

Gus Bickford, chair of the Massachusetts Democratic Party, said the report showed “plenty of blame to go around within the Baker administration for the tragedy that took place at the Holyoke Soldiers’ Home.”

“This administration installed and left in place as Superintendent an individual that was not qualified and was looked upon with caution by one top Baker official,” Bickford said in a statement. “Over the four years the Superintendent was in place, multiple red flags were raised as to his suitability, yet the Baker administration did nothing. Who knows how many veterans would still be alive if the Baker administration demonstrated basic leadership and management skills.”

22News reached out to Bennett Walsh Wednesday night, he said he’s looking forward to talking with the news media in person soon.

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