Surf’s up starting at the Soldiers’ Home? (WMP&I)

On the heels of a devastating Boston Globe report about Governor Charlie Baker and Health & Human Services Secretary Marylou Sudders and the Holyoke Soldiers’ Home, a legislative panel is weighing in. Like previous investigators, the Special Joint Oversight Committee on the Soldiers’ Home in Holyoke COVID-19 Outbreak lays into former Superintendent Bennett Walsh. Beyond him, the target of blame is oblique on an individual level. Still, the report bashes the administration for miserly allocations of attention and support to the facility.

Both The Globe and the committee report point to a toxic environment under Walsh at the Home. Both cite his lack of qualifications as factors in the tragedy. While The Globe turned to Baker’s role and Sudders’s ham-handed attempts to manage Walsh, the committee aims at administrative failures. Its recommendations include a reshuffling of the chains of command and installing ombudsmen so staff, patients and family can seek redress when issues arise.

“Most critical to this investigation was the testimony presented by staff and family members during our initial hearings in Holyoke,” the chairs Rep Linda Dean Campbell and Senator Michael Rush said in a statement accompanying the report.

Rep Campbell (via Twitter/@StateRepLDC)

“Their courage in coming forth to speak before us cannot be explained or commended enough, as the tragedy was so fresh and raw. This report honors their courage and demands that our work here is followed by legislation to improve Veteran care at our Soldiers’ Homes and throughout the Commonwealth,” they continued.

Significantly, the panel called for sweeping changes to the appointments at both Holyoke and at the Chelsea Soldiers’ Home. Among them would be streamlining statutes and establishing a clear chain of command to the governor. The report also recommends bringing the Holyoke home up to federal standards and establishing one board to oversee both facilities.

Where the committee splits with The Globe most dramatically is the approach to Attorney Mark Pearlstein. Baker selected him to ascertain what happened at the Soldiers’ Home. Pearlstein worked pro bono. While The Globe found glaring errors on Pearlstein’s part, the committee both suggests his report left gaps  and thanks him profusely.

The report itself does not seem particularly critical of Pearlstein, even saying he should be commended for his contribution. Campbell and Rush’s statement may be less generous.

Sen. Mike Rush (via Facebook/official)

“We are grateful for Attorney Pearlstein’s report and his testimony before our committee, however, we found Attorney Pearlstein’s report generated more questions than answers,” the co-chairs said. “He indicated during his testimony that there were questions still unanswered in his report.”

A similar line appears in passing in the report.

The Globe answered some of those questions. For example, the paper corrected Pearlstein’s claim that Westfield Senator John Velis steered Walsh to the Soldiers’ Home job.

The newspaper also had the benefit of direct cooperation from former Veteran Services Commissioner Francisco Urena. He only submitted written testimony to the committee. Still, the panel credited Urena’s insistence that he had passed along a request for National Guard assistance. It also appeared to agree with his claim that Sudders had involved herself deeply in correcting Walsh’s management issues.

Thus, the committee heaps blame on Sudders and the Baker administration if not as bluntly as the newspaper.

Despite not addressing the culture the administration promotes—or how a superintendent it says lacked key qualifications received his Excellency’s support—the criticism comes through. The committee highlights former Superintendent Paul Barbani’s concern Boston was not properly supporting the Home as far back as 2015. His resignation letter said insufficient resources would have left him unable to lead the facility.

Specifically, the report cites instability of staffing. While again it blames Walsh’s inadequacy as superintendent, it cites studies that warned about staffing problems at the home.

“Severe coverage issues were an inevitable consequence of staff shortages and high staff turnover, mandatory overtime, and an overreliance on external hires to provide services (per diem),” the report reads. It also notes the mad dash of retirements Baker’s Early Retirement Incentive Program (ERIP) created.

Walsh, Sudders, Urena & Baker long before the coronavirus belly-flopped into the pool. (via Twitter/@masshhs)

The result was rampant overtime, which a 2017 report from State Auditor Suzanne Bump criticized. A 2019 report from the Moakley Center at Suffolk University highlighted the same issue. Sudders told the committee that overtime procedures needed changes. Yet, as the committee’s report observes, this did not happen until after the novel coronavirus crashed upon the Home.

Inconsistency of staffing and constant mandatory overtime made the Home a less desirable workplace. “A healthy, productive, and just organizational culture was sacrificed as staffing practices changed,” the report reads.

The report also needles Sudders for focusing on “if there was enough staff,” while neglecting other staffing shifts. Even in just the three years of data the Executive Office of Health & Human Services gave the committee, there was a pronounced decrease in full-time staff at the Soldiers’ Home. Part-time and per diem staff increasingly filled the gap.

As for recommendations, the report calls for consolidating the Holyoke Chelsea homes’ boards of trustees. Veterans Services should become a cabinet-level post rather than a subdivision of EOHHS. Meanwhile, the Holyoke Soldiers’ Home’s superintendent would become a gubernatorial appointee, but with layers of review.

The Holyoke home would also receive upgrades to qualify for Medicare and Medicaid support. These recommendation are in addition to the ombudsmen at both state veterans facilities.

Despite the Special Joint Committee’s more careful language, legislators have begun agitating for more answers since last week.

Rep Campbell did not respond to a request for comment about the facts revealed in The Globe. However, she told the paper it was possible her committee could vote to seek more testimony, namely from Baker. The full committees still must vote to approve the report.

The ripple effect continues. (WMP&I)

The paper spoke to several senators who want more answers about Pearlstein’s errors and Baker’s role in Walsh’s hiring.

On Monday, Ben Downing, a former state senator seeking the 2022 Democratic nomination for governor, said the Baker administration had “abandoned” the vets in Holyoke. Given the personnel and policy failures The Globe identified, Downing called for Baker’s testimony about what he knew.

“At the bare minimum, Governor Baker’s interview for the Pearlstein Report should be made public and available to the legislature in full,” Downing said in a statement. “But most critically, the Governor should testify before the legislature to address gaps between the Pearlstein Report and recent media accounts.”

Baker, a Republican, has not indicated whether he will seek a third term.

As for the legislature, it must consider its next steps eventually. Legislative leaders either declined to answer queries about The Globe report or did not respond to inquiries.

Asked about The Globe’s story prior to the committee report’s release, Senate President Karen Spilka said her thoughts were with the 76 veterans who died from COVID-19 during the outbreak at the Holyoke Soldiers’ Home.

“I look forward to reviewing and working to implement the recommendations of the Special Joint Oversight Committee on the Soldiers’ Home in Holyoke to ensure that proper oversight, accountability and quality control measures are in place, so this tragedy does not happen again,” she said in a statement to WMP&I. “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.”

The office of the governor and Secretary Sudders did not immediately respond to request for comment on the committee’s report.