Investigators say leadership at the Holyoke Soldier’s Home, where nearly 80 residents sickened with the coronavirus have died, made "substantial errors and failures" amid the coronavirus outbreak, and that helped the disease run rampant there.

The report released Wednesday says officials at the home packed dementia patients into a crowded unit as the virus began spreading and failed to properly isolate veterans already sickened with the disease.

An attorney for the home's superintendent said they dispute many of the investigation's findings and are "disappointed that the report contains many baseless accusations."
In the wake of what the Governor called “tragic event” at the soldier’s home in Holyoke, he announced Thursday, after an independent investigation, reforms that are being administered at the home.

Read the full report from the investigation HERE.


See the full announcement release below:

Baker-Polito Administration Announces Reforms to Strengthen Oversight, Governance of Holyoke Soldiers’ Home

BOSTON – Today, the Baker-Polito Administration announced a series of reforms to improve the operations and oversight of the Holyoke Soldiers’ Home. On April 1, Governor Charlie Baker ordered an independent investigation into the tragic impact of COVID-19 at the Holyoke Soldiers’ Home, and on June 24, Attorney Mark Pearlstein released his findings, including specific recommendations.

The Administration has laid out a number of reforms in response to the Pearlstein Report plus additional reforms including:

Department of Veteran Services Oversight of the Soldiers’ Homes

The Department of Veterans’ Services (DVS) is committed to hiring an experienced healthcare leader to advise the Secretary and provide management support for the two soldiers’ homes in the Commonwealth.

The position of Executive Director/Assistant Secretary has been posted as of June 24.
The Administration is filing legislation clarifying this person’s primary responsibility as supporting the Secretary of Veterans’ Services oversight and management of the soldiers’ homes.

Changes to the Soldiers’ Homes’ Board of Trustees Composition

The Administration is filing legislation to make important changes to the Holyoke and Chelsea Soldiers’ Home Boards so they are consistent entities with consistent powers and duties.

The bill would increase both boards from seven members to nine members – adding two individuals who have a health care background either as a clinician or administrator as well as the Secretary of DVS & the Secretary of the Executive Office of Health and Human Services as ex officio members.

Implement a Permanent Staffing Schedule

In August 2019, a staffing study was released to lay the foundation for a more permanent staffing schedule at the Holyoke Soldiers’ Home.

The interim leadership team at the Holyoke Soldiers’ Home conducted a staffing gap analysis to ensure an optimal staffing ratio that aligns with industry standards on Hours Per Patient Day (HPPD). This new staffing pattern accounts for functional staff call-out rates, vacancies, and the actual acuity of residents.

The leadership team has been working collaboratively with staff and unions (MNA, SEIU 888, and SEIU 509) to adjust schedules and reallocate staff to ensure full coverage during each shift and respond to resident acuity.

In agreement with the Unions, the Home now is posting schedules in three month increments in order to provide greater predictability for staff.

The plan is to transition to a permanent staffing schedule during September.

Implement an Electronic Health Record System

The Governor’s Fiscal Year 2021 Capital Investment Plan included $2 million for a joint electronic management record (EMR) system for the two soldiers’ homes.

On June 23, a procurement for an EMR solution was posted on Commbuys – which begins the process of selecting and contracting with a vendor to implement an EMR.
The EMR solution will be coupled with both business process redesign and training.
The Holyoke Soldiers’ Home has identified an individual to oversee the EMR implementation project.

Hire a Designated Occupational Health Nurse

When the Clinical Command team started on March 30, an Occupational Health nurse temporarily was brought on board through a contract with UMass Medical School/ Commonwealth Medicine.

A permanent position is being recruited through a staff recruitment agency.

Better Education and Training

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.
A nurse educator position is posted and actively being recruited for.
In the interim, there have been significant improvements in education and communication for clinical staff, nurse supervisors, and veteran care coordinators. Areas of focus include personal protective equipment and infection control. A computer lab training classroom with 25 computers and a dedicated staff person will go live summer 2020.

Efforts to Improve Labor Relations

The interim leadership team is committed to a collaborative relationship between management and the unions and strives for transparency and open communications.
Bi-weekly labor management meetings with the MNA and SEUI 888 have been established to discuss concerns including staffing and scheduling.

Superintendent Qualifications

The new posting for the position of Superintendent of the Holyoke Soldiers’ Home will include a preference for hiring a licensed nursing home administrator.

Increase Inspections at the Home

To ensure the Soldiers’ Home is subject to the same state surveys as other long term care facilities in the Commonwealth, the governor is filing legislation that will require annual inspections and more frequent inspections by the Department of Public Health if necessary.

In addition to the recommendations put forward in the Pearlstein report, the Administration is committing to several other reforms including:

Appointment of the Superintendent of the Holyoke Soldiers’ Home

The Administration is filing legislation making the appointment of the Superintendents of both homes consistent and that the appointing authority is the Secretary of Health & Human Services and approved by the governor. This process is the current appointment process for the Superintendent of the Chelsea Soldiers’ Home.

Capital Improvements

The Administration has been taking immediate steps to improve the Holyoke Soldiers’ Home to support infection control and resident safety now.

To address urgent issues at the Home, $6 million has been allocated to refresh the units and certain furnishings of the building to address priority infection control, resident safety needs and care. Upgrades underway are to meet hospital grade physical plant requirements. Renovation work has already begun on the 3rd floor, and will be complete this fall so that the veterans currently residing at the Holyoke Medical Center can safely return to the Home.

To address the longer term physical plant needs, the Commonwealth has initiated an expedited Capital Project process managed by the Division of Capital Asset Management and Maintenance (DCAMM).

There will be two distinct phases:

Rapid planning phase from July through fall 2020. This includes the engagement of key stakeholders, completion of a needs assessment, preparation of an expedited project plan and conducting a designer procurement.

Design Phase starting in late fall 2020. This includes refinement of project scope, budget, schedule and timelines. This will include a submission for the VA State Home Construction Grant program by the April 15, 2021 deadline.

Employee Assistance

Since April, there has been a virtual employee assistance program available to all staff in addition to a National Guard chaplain.

Beginning in July, on site employee assistance will be available for staff.

Additional reforms will be forthcoming in the weeks ahead regarding increased family support.

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