The IG found mismanaged oversight of the Holyoke Soldiers’ Home. (WMP&I)

The Massachusetts Office of the Inspector General released its long-awaited report on Bennett Walsh’s Superintendency of the Holyoke Soldiers’ Home. Unlike prior government reports, this review did not focus on the events during the Home’s coronavirus outbreak early in the pandemic. Rather, it analyzed Walsh’s tenure and the events that led up to his appointment.

In this sense, it mirrors The Boston Globe’s damning portrait of his tenure, period published last year. Inspector General Glenn Cunha squarely accuses Governor Charlie Baker and Executive Office Health & Human Services Secretary Marylou Sudders for interfering in the appointment process. Thereafter, his report claims Sudders and EOHHS undermanaged Walsh during his rocky four years at the Valley’s hallowed long-term care home for vets.

“The Office found extensive mismanagement and oversight failures at the Home,” the report says, listing three main factors. One was the Home’s odd place within EOHHS hierarchies.

“Second, senior leaders at EHS and DVS ineffectively supervised the superintendent and the Home, oftentimes in a sporadic and disjointed manner in reaction to complaints or events,” the report continues. “Third, Superintendent Walsh did not have the managerial skills or temperament to properly oversee the Home’s operations.”

The OIG’s probe predates the pandemic, beginning with a 2019 complaint. The office devoted “substantial” resources to interviewed witnesses and review available records from multiple agencies.

Senator John Velis, who represents Holyoke and co-chairs the legislature’s Veterans Committee, praised the OIG’s work. His office had been in communication with Cunha’s office and wrote some of its suggestions into legislation Beacon Hill is considering.

“The Inspector General’s report highlights a lot of the problems at the Holyoke Soldiers’ Home that recently came to light and makes critical recommendations for instituting best practices,” he said in statement to WMP&I.

The governor’s office did not respond to a request for comment. However, in public remarks, Baker has emphasized legislation, too.

Happier and less scrutinized times for Walsh, Sudders, Urena & Baker in 2016. (via Twitter/@masshhs)

Walsh did not cooperate with the OIG’s investigation, citing his Fifth Amendment right against self-incrimination. In media reports, Walsh and his lawyer have declined to comment on the findings.

EOHHS is also focused on bills before the legislature. The agency includes the Department of Veterans Services which, in turn, oversees the commonwealth’s Soldiers’ Homes.

“The Administration filed legislation almost two years ago to strengthen oversight of the soldiers’ homes and looks forward to addressing these issues with the Legislature,” a spokesperson emailed.

Unlike The Globe, the avoided implications of political interference on Walsh’s behalf. Given Walsh’s pedigree in Springfield politics, chatter about Walsh’s connections has abounded in the media and the Valley commentariat.

Beacon Hill is considering legislation to revise the leadership structure of the Home and its analog in Chelsea. Current law empowers a Board of Trustees to appoint the superintendent in Holyoke. Various laws and operating norms divide oversight between the Board and EOHHS, often via DVS. Day-to-day, Walsh reported to then-Veteran Services Commissioner Francisco Urena.

Prior reports have alleged errors attributed to Walsh and slow action from state officials contributed to the outbreak of the virus in March 2020. Baker hired Attorney Mark Pearlstein to review what happened during the outbreak. He found Urena had failed to properly oversee Walsh before and when the shroud of the coronavirus fell upon the earth. Baker and Sudders did not receive much if any criticism from Pearlstein.

A legislative report last year echoed many of Pearlstein’s findings, though it was less hard on Urena and less delicate with Sudders.

Urena resigned. Baker tried to fire Walsh, but the courts voided that action, observing only the Home’s Board could terminate him. Walsh did resign after Attorney General Maura Healey filed criminal elder abuse charges against him and the facility’s medical director. Hampden Superior Court Judge Edward McDonough dismissed the charges last year. Healey appealed and her office’s brief is due next month.

Secretary Sudders’s office and its sub-agencies lies in OIG’s crosshairs. (via mass.gov)

Pearlstein’s report had issues, too. He had written Walsh was the overwhelming choice of the Board. Questions about this claim emerged that summer amid Walsh’s legal battle over his termination. Sudders signed a legal document claiming the Board had not specifically recommended Walsh. Sudders later removed that claim in an amended filing.

Urena, Sudders and Baker’s involvement in Walsh’s appointment is not a new detail. Yet, the OIG found they did not follow the Home’s statutory framework. EOHHS staff were heavily involved. One trustee felt Walsh’s appointment had been “predetermined,” according to the report. Other trustees disagreed that assessment.  The Board forwarded three names up the chain, including Walsh. Urena and Sudders only interviewed Walsh.

“In summary, although the law requires that the Board appoint the Home’s superintendent, [EOHHS] staff led much of the hiring process, Secretary Sudders met with only one of the three top candidates, and Governor Baker made the actual appointment,” the report reads.

Beyond this appointment, the OIG spread plenty of blame around. The report identifies several half-assed investigations into Walsh’s behavior. These EOHHS probes downplayed evidence, betrayed the confidence of witnesses and avoided wide-angle views of the situation.

“Nevertheless, [EOHHS]’s leadership seemed to view each complaint in a vacuum, rather than examining all the complaints and performance problems as a whole to determine whether Superintendent Walsh was suited to lead the Home,” the report reads.

Complaints included Walsh’s interaction with staff, namely angry outbursts. One alleged incident claimed he seized a phone out of a Home employee’s hand. The OIG also identified accusations of misusing government time and absences from the Home—albeit (mostly) for official business.

Walsh early in his tenure as the Soldiers’ Home Super. (via Facebook/HCC)

To some extent, such allegations are not new either. However, the OIG said EOHHS seemingly took Walsh’s side whenever possible, even hampering an investigation the commonwealth’s Investigations Center of Expertise. The Center examines workplace incidents such as those the OIG identified.

The OIG also faults Sudders and EOHHS for failing to oversee the use and effectiveness of a leadership coach hired to assist Walsh.

In response to questions about the finding, a spokesperson for EOHHS referred to prior investigations that heaped blame on Walsh and his staff.

“The Baker-Polito Administration commissioned an independent report by Attorney Mark Pearlstein to investigate the circumstances that led to the tragedy at the Soldiers’ Home in Holyoke and multiple investigations, including one by the Legislature and another by the Attorney General, reached many of the same conclusions, that failures by Bennett Walsh and senior medical team members led to the outbreak,” the spokesperson said.

As for the other failures of oversight the OIG found, the spokesperson said the administration was reviewing the report. Some recommendations were already being implemented. The House and Senate have both passed bills. Senator Velis and Chicopee State Rep are among the members of the legislation’s conference committee.

“From ensuring that DPH has oversight of the facility, to elevating the Veterans Secretary to cabinet level, and streamlining the Chain of Command, there’s a lot of good ideas in the legislation that build directly off the Inspector General’s findings. Now it’s all about getting those ideas across the finish line and signed into law,” Velis said in his statement.

The OIG’s report includes correspondence with legislators about recommendations it would make.

Both chambers’ bills create an ombudsman position and establish minimum qualifications for home superintendents in Holyoke and Chelsea. The OIG recommended these reforms.

Beacon Hill edges closer to legislation, which will likely contain many OIG suggestions. (WMP&I)

The Senate adopted other OIG recommendation, though. Among them are elevating the Veterans Secretary to cabinet-level, bring in the Department of Public Health to inspect the Homes, and place superintendents directly under the Veterans Secretary. Local and statewide councils would recommend supers, but the decision and supervision would belong to the secretary.

On the executive side, the Baker administration announced changes in June 2020. These include implementation of scheduling reform, better labor relations and electronic medical records. Issues with staff, scheduling and their unions have featured in virtually every anecdote, investigation and report about the outbreak.

The OIG’s recommendations are somewhat more expansive than those referred to the legislature. In short, OIG urges DVS to establish goals for subordinates like the superintendents and providing better management and oversight. As for EOHHS, it should make more management resources available. However, the office must also do better to protect the integrity of HR investigations.

Since the June 2020 actions Baker announced, EOHHS has said it is improving scheduling and staffing levels. In March of this year, EOHHS, DVS and both Soldiers Homes signed contracts for electronic medical records.

The agency has also claimed to have improved leadership at the Homes and across DVS. Specifically, it has pointed to appointments with experience in delivery of veteran health services including Veterans Services Secretary Cheryl Lussier Poppe, who has led both Homes in the past, and new senior staff at the Holyoke Soldiers’ Home.