BOSTON (SHNS) – More than year after it was rocked by tragedy, lawmakers have started drafting legislation to reform the Holyoke Soldiers’ Home and implement better oversight of care for veterans, building on a bevy of recommendations a panel offered after investigating the deadly COVID-19 outbreak at the facility.
The special committee convened to examine the crisis and structural factors that contributed to it released a 186-page report on Monday evening, prompting renewed criticism of Gov. Charlie Baker and his administration while also shifting pressure onto the Legislature to pursue improvements.
Like the earlier investigation by former U.S. Attorney Mark Pearlstein and a Spotlight report, lawmakers concluded that former Holyoke Soldiers’ Home Superintendent Bennett Walsh was not qualified to lead the facility and that his poor leadership and decision-making contributed directly to the March 2020 outbreak that killed 76 veterans last spring and one more veteran in the winter.
The panel took a broader approach than Pearlstein, who was given a more narrow investigative scope, and tied the COVID-19 crisis to long-standing issues. In their eyes, the fateful decisions by Walsh are intertwined with an unclear chain of command in the facility, insufficient oversight, and years of staffing shortages that went unaddressed.
“If we’re going to effect change and prevent this or something similar from happening again, we have to look at how government structures created a perfect storm, if you will, and an environment where a plane crash took place,” Rep. Linda Dean Campbell, who co-chaired the special committee over its 10 months of work, said in an interview on Tuesday.
Campbell told the News Service that she and her fellow co-chair, Sen. Michael Rush of West Roxbury, have “begun the process” of drafting legislation built on their report’s 14 major findings and extensive recommendations. She said it is still too soon to know if the legislative push will take the form of a single omnibus bill or multiple packages.
Baker and Health and Human Services Marylou Sudders have faced increasing pressure for their handling of the tragedy since the Globe Spotlight team released its own report last week.
Campbell, who said her panel had completed its work before release of the Globe report, said she believes that both the governor and his top health deputy need to respond to questions raised by her committee’s work. She did not say definitively if her panel plans to call on Baker to testify, but described it as “a question that will be discussed” among members.
“Our report clearly indicates that information was presented to them that was not acted upon,” Campbell said. “The qualifications of Bennett Walsh were clearly questioned, officially, and documented. His qualifications were clearly a question. I think his job performance was clearly identified as being toxic. These points were clearly brought to the attention of the secretary.”
However, House Speaker Ronald Mariano told the Boston Globe on Tuesday that he does not see any need for Baker to testify further about the deadly outbreak.
“We just finished an in-depth hearing,” Mariano told the Globe, apparently referring to the special committee’s report. “I don’t think there’s any need for us to do another hearing, to go over and regurgitate the same facts. I think our report stands for itself.”
Neither Mariano nor Senate President Karen Spilka laid out specific plans for a legislative response when asked Tuesday, but it appears a legislative response is coming.
In a statement, Spilka praised Campbell, Rush and the panel for “producing a thoughtful and thorough report.”
“I look forward to reviewing and working with my colleagues to implement the recommendations of the report to ensure that proper oversight, accountability and quality control measures are in place, so this tragedy does not happen again,” Spilka said. “The Senate has been very clear that critical reform is needed of our veterans’ services and the governance of the Soldiers’ Homes so we can rethink how we deliver care to veterans of every generation in every region across our Commonwealth.”
Mariano’s office pointed to a statement he made last week, when the House approved legislation to fund construction of a new Holyoke Soldiers’ Home and additional veterans’ care, pledging to “advance wider legislation being produced by the Committee on Veterans & Federal Affairs.”
Baker’s office did not say whether he or Sudders are willing to offer testimony before a legislative committee. Sarah Finlaw, a spokesperson for Baker, said the administration “took immediate action when the extent of the former superintendent’s failures became clear.”
“Multiple independent investigations, including this one by the Legislature and another by the Attorney General reached many of the same sad conclusions, specifically that Bennett Walsh and senior medical staff at the Home erred in their judgement resulting in the tragedy,” Finlaw said in a statement. “The Administration filed legislation months ago to reform the Home’s leadership structure and looks forward to working with the Legislature to address these issues.”
Walsh and the home’s former medical director, David Clinton, both pleaded not guilty to criminal charges Attorney General Maura Healey sought against them.
In June 2020, Baker filed a bill that would require additional inspections at the home, require the Holyoke superintendent to be selected by the health and human services secretary and approved by the governor as is the case at the Chelsea Soldiers’ Home, and replace a never-filled executive director of veterans homes and housing position with a new assistant secretary of veterans’ services.
Lawmakers did not take up that proposal last year, instead opting to convene the special panel helmed by Campbell and Rush and task the group with making legislative recommendations.
The panel’s suggestions include requiring the Holyoke Soldiers’ Home superintendent to be a licensed nursing home administrator, a qualification that Walsh did not have; implementing statutory chain of command protocols, disease prevention practices, and training requirements; launching a hotline for staff and family of the facilities to report concerns; creating a paid ombudsman at both state-run soldiers’ homes; and requiring the governor to appoint superintendents rather than a board of trustees.
Lawmakers also called for elevating the Department of Veterans’ Services, which currently falls under the umbrella of the Executive Office of Health and Human Services, and making the secretary of veterans’ services a Cabinet-level position with direct access to the governor.
Former Veterans’ Services Secretary Francisco Urena, who resigned last year alongside the release of the Pearlstein report, told the panel in written testimony that he had significant concerns about Walsh’s job performance but felt “powerless” to address the issue.
Urena’s written testimony, lawmakers wrote, indicated that “he was frustrated and concerned about the lack of information coming from the (soldiers’ home), the quality of information he did receive, and the lack of action being taken on the part of EOHHS to accurately assess the situation.”
The secretary also told the panel he pushed to fill the statutorily mandated position of executive director of veterans’ homes and housing, which would have performed oversight of both the Holyoke and Chelsea facilities, but ran into “persistent administrative obstacles.”
“Shortly after the fiscal year 2018 budget (containing the earmark for the Director of Homes) was passed, the Administration froze all earmarks, rendering the Director of Homes position unfunded,” Urena wrote. “When discussing the Director of Homes position with EOHHS officials after that freeze was lifted, they pointedly told me that I could not fill the Director of Homes position because DVS was already at its full-time employee cap.”
The most significant surprise for many members of the panel, Campbell said, was a lack of accountability. Many problems at the home, such as its difficulties retaining enough staff after a Baker-initiated early retirement incentive program, had been flagged for officials well before COVID-19 hit, she said.
During Walsh’s tenure, too, those close to the situation raised concerns “repeatedly, years before this crisis took place,” according to Campbell. She described the answer as to why Walsh remained in his position amid well-known worries as “a shrug.”
“So again, we look to those governance structures: why Walsh was hired, why he wasn’t fired. Why were all of these staffing issues not addressed years before this crisis emerged? Why were the mandated legislative positions never filled?” Campbell said. “All of these individual points could have had an impact on preventing this tragedy from occurring. It was a preventable tragedy.”
Asked if she has confidence in Sudders continuing to lead the Executive Office of Health and Human Services, Campbell responded that “we definitely need to hear from the governor and Secretary Sudders in a more comprehensive way, and I will certainly await judgment on that particular point.”
“I want to focus on preventing this from occurring again, and this is really important, regardless of who is in a particular position,” Campbell said. “We cannot legislate character. We cannot legislate responsibility in terms of individual responsibility, accountability and character. We can’t legislate those individual traits, but we sure can legislate processes that demand it.”