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.