Gov. Charlie Baker announced a series of reforms and legislative proposals Thursday after a scathing report detailed "utterly baffling decisions" that exacerbated the COVID-19 outbreak at the Holyoke Soldiers' Home.
Many of the reforms are in response to recommendations in the report, including Department of Veterans Services oversight for the state's Soldiers' Homes, adding two people with healthcare experience to the board of trustees, implementing a permanent staffing schedule, implementing an electronic health record system, hiring a designated occupational health nurse, better education and training, improving labor relations, raising the qualifications for the superintendent to include a preference for a licensed nursing home administrator and increasing the frequency of inspections.
"This report lays out, in heartbreaking detail, the terrible failures that unfolded at the facility and the tragic outcomes that followed," Baker said Wednesday. "We now have an accurate picture of what went wrong and will take immediate action to deliver the level of care that our veterans deserve."
Baker's administration is also recommending several other reforms not included in the report.
One calls for the filing of legislation making the appointing authority for the superintendents of both the Holyoke and Chelsea soldiers' homes the secretary of health and human services, with final approval coming from the governor.
Another calls for making much needed capital improvements at the Holyoke Soldiers' Home.
The state will also be adding on-site employee assistance for staff starting in July.
Additional reforms are expected in the weeks to come, the administration said.
An independent investigation into the deadly coronavirus outbreak at the facility released Wednesday said its leadership team made "substantial errors" in responding to the outbreak that resulted in the deaths of at least 76 veterans and the infection of an additional 84 veterans and over 80 staff members.
Families of patients were livid after reading the report.
“These veterans were victims and there’s not enough negative words to describe what’s illustrated in this report," said Eileen Driscoll, whose father, 91-year-old Alfred Healy, died in April from COVID-19.
Baker said Thursday he plans to apologize to the families.
“These reforms will ensure that the Holyoke Soldiers' Home is restored to its rightful place," Health and Human Services Secretary Marylou Sudders said.
The independent investigation, conducted by former federal prosecutor Mark Pearlstein, found "substantial errors" that "likely contributed to the scope of the outbreak, and its horrific toll."
The most egregious error by the Soldiers' Home's leadership, Pearlstein said, was a decision on March 27 to move all veterans from one of the two locked dementia units into the other locked dementia unit, where they were crowded in with veterans already living there. At the time, the unit had some veterans who were positive for coronavirus, some who were suspected of having it and others displaying no symptoms.
The investigation found that the Soldiers' Home failed to promptly isolate patients suspected of having COVID-19, delayed testing veterans showing symptoms, delayed closing common spaces to reduce the spread of the virus and failed to stop rotating staff members from unit to unit.
Pearlstein wrote that the decisions were "utterly baffling."
The handling of the COVID-19 outbreak resulted in Bennett Walsh, superintendent of the facility, being placed on paid administrative leave on March 30. Baker said Wednesday that the state is moving to end Walsh's employment.
Secretary of Veterans’ Services Francisco Urena resigned Tuesday as well in anticipation of the release of the report.
More on the Holyoke Soldiers' Home Report
The full list of Baker's proposed reforms is included below:
Department of Veteran Services Oversight of the Soldiers’ Homes
• The Department of Veterans’ Services 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 the Department of Veterans' Services and 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. 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 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.
• 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.
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.
• 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. There will be two distinct phases:
o 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.
o 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.
• 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.