Seventy-seven veterans died early in the pandemic due to management failures at the state-operated soldiers’ home in Holyoke. We hope we have identified governance changes that will make future tragedies in that setting much less likely.
The state’s soldiers’ homes – one in Holyoke, one in Chelsea – are nursing homes (also offering other health services) for elderly and disabled veterans. Early in the pandemic, COVID found its way into the Holyoke home and devastated the staff. Managers’ calls for staff assistance from the national guard went unanswered. In desperation, the managers consolidated a group of infected veterans in the same space with uninfected veterans, spreading the disease and leading to many needless deaths.
Two members of the senate who are veterans and reservists themselves – Senators Rush and Velis — participated in the investigation of the tragedy and brought to the Senate floor a bill that reflects the central lesson learned from their investigation: The failure to provide staffing relief when requested stemmed from a confusing chain of command – the request went to multiple senior managers, and no one took responsibility to respond.
The legislation offered by the two veterans, which we passed unanimously, establishes a clear chain of command for the soldiers’ homes, running up to the Governor. The bill establishes the secretary of veterans’ services as a cabinet level position and empowers the secretary to appoint the executive director of the Office of Veterans’ Homes and Housing who, in turn, appoints the superintendent of each soldiers’ home. A unanimously adopted floor amendment requires the secretary of veterans’ services to be a veteran.
Beyond clarifying the chain of command, the bill requires the superintendent of each home to be a licensed nursing home administrator hired through a transparent process. The bill establishes regional advisory councils for each soldiers’ home and requires that they be notified of a vacancy in the superintendency.
The bill adds oversight from the state department of public health, subjecting the homes to DPH inspection. A floor amendment requires each soldiers’ home to achieve DPH licensure. The bill also requires that each home employ both a full-time infection control specialist and an emergency preparedness specialist.
One of the saddest aspects of the Holyoke breakdown was that, at the height of the crisis, management stopped communicating with the families of the soldiers. One veteran’s daughter, unable to get answers as to whether her father was still alive, drove to the facility with that grim question written on her windshield. The legislation creates an ombudsman to assure that complaints will get addressed in a timely way.
The House has previously adopted a bill to address the tragedy and the House and Senate will now need to negotiate the differences between their two bills.
Last year we passed legislation to take advantage of federal funds made available by Congress to support the reconstruction and physical modernization of the Holyoke home. An important part of the discussion around both the recent governance legislation and the previous capital investment was the need for more veterans’ services in other regions: The two soldiers’ homes – in Chelsea and Holyoke — provide needed services for veterans within their regions, but there are veterans in need across the state.
The continuing conversation about meeting the needs of veterans statewide will tie into the larger conversation about how best to care for the elderly and disabled. A major legislative effort over the past couple of decades has been to move away from the large facility model – most people want to age in place and avoid the nursing home experience. As a result of available home health assistance, many nursing homes in the state are running below capacity and have insufficient revenue to cover their fixed costs.
The consistent goal of the legislature is to assure that Massachusetts is the best state in the country for a veteran to return to. In every session, we pass legislation to further advance this goal. All legislators feel a sacred obligation to care for those who have put their lives at risk for the country. The legislature still has more work to do to assure that elderly or disabled veterans in every region have access to the care they need, whether in a “home” or at home.
Thanks, Will, for your work on this and update on its status. Ensuring that all veterans across the state can age in place or in a facility near their loved ones in indignity and safety is such an important priority, and I’m reassured that this has gotten the attention it requires and hopefully will continue to.
Thank you for doing this. Apparently, A LOT of reform was needed, and I’m glad it is happening. I am worried about other parts of our healthcare system here in Mass – especially the mental health system in general – and hope that those can be reformed, too.
Thank you Will for this summary and perspective. Adequate elder care is always a challenge but it is good to see that our legislature identified and mitigated the particular issues of oversight and chain of command protocol at these facilities.
What an impressive move forward. Thank you so much. Polly
Thank you Will for your detailed report on this matter.
How many failures of management must we have until we begin to approach a critical problem of government: management performance, practices, planning, reporting, and transparency?
One off investigations and corrections are necessary but not sufficient. One could make a long list of management failures of the last decade, failures lasting longer than decades. For example, consider: DCR—aggravated by reduced funding and political appointees; State Police—overtime; State Police—performance for the rising diversity of our Commonwealth; MBTA—a long list. These are just the few obvious. I am sure others can add to the list far beyond what I can add.
Without a government wide focus on management, we will not be prepared for the future.
Still, I am enduringly optimistic.
All the best—
Thank you Will for your detailed report on this matter.
How many failures of management must we have until we begin to approach a critical problem of government: management performance, practices, planning, reporting, and transparency?
One off investigations and corrections are necessary but not sufficient. One could make a long list of management failures of the last decade, failures lasting longer than decades. For example, consider: DCR—aggravated by reduced funding and political appointees; State Police—overtime; State Police—performance for the rising diversity of our Commonwealth; MBTA—a long list. These are just the few obvious. I am sure others can add to the list far beyond what I can add.
Without a government wide focus on management, we will not be prepared for the future.
Still, I am enduringly optimistic.
All the best—
This is not a duplicate, because it indicates the size of the problem.
State government is a very big thing. It is like the San Francisco Bay Bridge — we will never finish painting it. We just have to keep struggling to get ahead of the problems and do a solid job fixing the ones that get ahead of us.
Thank you for your reply. Yet, if painting is the metaphor, we paint like children not the adults we are.
Babson College and Harvard Business School are just a few of the significant internationally known management schools in metropolitan Boston teaching the practice of management. One of the tools they teach is management through planning: who is in charge; what are the detailed tasks of a project; what is the time required to accomplish each task; how does the time to perform each task fit together to finish the project on time (sometimes called critical path); what is the cost of each and therefore the project budget; what is the regular project reporting and oversight to assure performance (on time completion and within budget).
I am sure there are those more experienced than I who can support this management practice and better performance.
By the way, those signs installed 3 weeks ago at Huron Avenue intersection Fresh Pond Parkway still direct a turn toward Harvard Square with the sign and arrow: Somerville(sic). Now two weeks after the reports to at least two governments and at least one representative, the 3×3 foot green sign still stands.
Thank you so much, Will. This is so tragic. Just the first sentence alone ‘Seventy-seven veterans died early in the pandemic due to management failures…’ seems impossible – unthinkable. The unanimously passed legislation is a huge step forward towards fixing the dangerous breakdown of management communication and oversight. The move to require a full-time infection control and emergency preparedness specialist is also an important move towards protecting our aging veterans. I applaud this action for our veterans and would love to see this legislation apply to all elders and disabled individuals in Nursing Care facilities.
The devastating stories of what happened at the Holyoke home is an absolute nightmare. Learning from this tragedy and applying these lessons to the care of all elders and disabled veterans and neighbors in need is a step towards healing. There is so much to do.
Thank you again for your help everyday towards this healing in so many ways.
I was appalled by what happened at the Holyoke home during the pandemic and eager to see the legislature enact reforms, but the reforms you’ve described here seem… excessive, perhaps? I feel the pendulum may have swung too far in the other direction.
Will there really be enough work on an ongoing basis for a full-time “Secretary of Veterans’ Services”? Is the work done by the person in this role really sufficiently important and broadly impactful that it is justified for it to be a cabinet-level position? To me, that seems unlikely.
Is there really enough steady work for each home to employ a full-time infection control specialist and a full-time emergency preparedness specialist? Again, that seems like overkill.
These are fair questions. I think there will definitely be enough to do for the Secretary. Less sure on the two full-time positions in each home. We will see how that comes out in the final legislation.
Will, Thank you…happy to see these extensive reforms in terms of Veterans Homes and that they will also be licensed under DPH. BUT we will need to increase funding to that department as we have seen through this pandemic a huge strain on an already underfunded DPH.
Would love to see major reforms to the public and private sector Nursing Home industry in general. The pandemic cast a bright light on the systemic failures of so many of the nursing homes and the DPH in our Commonwealth. We can do immensely better regulating this major aspect of our “famous” healthcare in Massachusetts.
I agree — DPH has long needed more resources. They are definitely getting more resources now, but we need to sustain that.
Thank you for the information. The reforms were long overdue.
Will, Thanks for this information. The legislation would certainly make it less possible that the catastrophe at Holyoke will be repeated. Nonetheless, I am still chagrined that the Governor and the Secretary of Health and Human Services were never held accountable for their roles in mismanaging the situation and for claiming that only their underlings were to blame.
I’m glad this is happening, but I’m upset that Baker was never held accountable for what happened.
Thank you Will and to all who worked to bring this change that will keep our veterans safe. I hope in the future, it makes a significant difference.
Keep up the good work Will! An avoidable tragedy that hopefully will NEVER happen again!
Dear Will, THANK YOU, as always, for your very crucial work.
Thanks for your good work!
I’m confused why the Senate thinks another level of bureaucracy would benefit the Soldiers Homes? In many quasi-government structures, the responsibility of hiring a Superintendent falls to the Board of Trustees – most if not all MA public school districts operate in this manner – School Committee is responsible for appointing a Superintendent. The members of the Board of Trustees of both Soldiers Homes are appointed by the Governor. Why wouldn’t the Board of Trustees hold that role in the case of the the two state Soldiers Homes?
“The bill establishes the secretary of veterans’ services as a cabinet level position and empowers the secretary to appoint the executive director of the Office of Veterans’ Homes and Housing who, in turn, appoints the superintendent of each soldiers’ home.”
Actually, the effect is to reduce the number of layers in the chain. These are state agencies. They are only advised by their board.
Thank you Senator Will.
What a sad tragedy to their families was the death of these veterans!
But the resolution proposed and implemented will reassure their families that you and your colleagues dealt very seriously with this human tragedy.
May these veterans be in the peace of the Lord!
“ Yet Walsh, the son of an influential Massachusetts family, was protected from repercussions until it was too late.” -Boston Globe Spotlight Team
Ref: https://apps.bostonglobe.com/metro/investigations/spotlight/2021/05/soldiers-home/
I join the chorus of thanks, and also the concern about possibly funding too many oversight positions. Better pay and benefits for the hands-on workers, the aides and nursing assistants, is essential to improving care in all nursing homes. No amount of supervision can protect residents from infection when financial pressures force direct care staff to work multiple jobs at different facilities. This was a major source of COVID transmission that could have been prevented if staff were confined to caring
for only a few patients at one location.
Thank you Senator Brownsberger,
Because this disaster happened as a function of systemic disfunction and corruption, I think we should include it in the list of disasters that struck our Commonwealth.
https://www.masslive.com/news/erry-2018/11/fa8ce0cc02831/massachusetts-worst-disasters.html
Thank you Senator Brownsberger for taking positive steps to prevent this from happening in the future at the Soldier’s Homes.
Do you have any book recommendations to help understand the political history and climate (patronage, families and the like) that came to bear to create this vulnerability in responding to a crisis and the realities the employees faced that they had, ~~ ‘no choice but to feel like they were wheeling patients to their death.’ – mangled Globe Spotlight quote.
Does this, or any other potential, or existing legislation to anything to identify, and rectify other vulnerabilities- disasters-in-waiting, in any institution in the Commonwealth that may only come to light in a future emergency?
You can look for efficiencies in public health, but you can’t do it on the cheap. If you choose to do public health, you have to do it right. What ever example, or scenario you look at there will always be, “inefficiencies,” things that go unused, or “wasted,” It is the COST OF PREPAREDNESS.
As essential as the chain of command is in protecting everyone, does this putative legislation create, or refer to existing procedures, rights and protections that allow nurses, or other employees to raise those concerns and have them “peer reviewed” by orher state agencies, or peer institutions.