BOSTON – A series of poor decisions by inexperienced and unqualified leaders led to the spread of the COVID-19 outbreak earlier this year that resulted in 76 deaths of veterans at the Holyoke Soldiers Home, according to the report by Attorney Mark W. Pearlstein, the investigator chosen by Gov. Charlie Baker to determine what happened and who was at fault.

Baker discussed the report at his daily briefing on June 24. It is the product of 111 interviews with 100 witnesses and the review of more than 17,000 documents.

The report put the blame on Soldiers Home Superintendent Bennett Walsh and his leadership staff and read in part, “Indeed, some of the critical decisions made by Mr. Walsh and his leadership team during the final two weeks of March 2020 were utterly baffling from an infection-control perspective, and were inconsistent with the Home’s mission to treat its veterans with honor and dignity.”

The report noted state law requires the people in charge of a long-term care facility be licensed nursing home administrators, however the Department of Public Health has allowed the Home to be exempt because it is a state facility. Walsh lacked any such license or experience.

 Walsh is on leave from the job.

At a press conference on June 24, Baker said, “The report makes clear that the Department of Veterans’ Services, which oversees the soldiers homes, didn’t properly oversee Holyoke or Bennett Walsh, and that one’s on us.”

Baker approved the appointment of Walsh in May 2016.

William Bennett, former Hampden County district attorney who is representing his nephew, released the following statement: “We thank Attorney Pearlstein for his courtesy.

“However, we dispute many of the statements and conclusions in the report, to which we were never given the opportunity to rebut prior to publication. We are also disappointed that the report contains many baseless accusations that are immaterial to the issues under consideration. We are reviewing the report and will have more to say in the days ahead. We are also reviewing legal options, as it appears that the action by [Human Services] Secretary Sudders and Gov. Baker violates the order of the Superior Court and denies Mr. Walsh the opportunity for a fair and public hearing.

 “The report does establish that the original accusations that Mr. Walsh reported nothing to state officials and tried to keep everyone in the dark are false. It is clear that Mr. Walsh reached out for help when the crisis erupted. He indeed did request National Guard medical assistance. The failure of the Commonwealth to affirmatively respond to that request contributed to many of the problems outlined in the report.

“The one thing we do agree with is that Mr. Walsh did and still does care deeply about the veterans at the Holyoke Soldiers’ Home.”

The report also laid blame on the Massachusetts Department of Veterans Services. It noted, “While the Home’s leadership team bears principal responsibility for the events described in this report, Mr. Walsh was not qualified to manage a long-term care facility, and his shortcomings were well known to the Department of Veterans’ Services – yet the agency failed to effectively oversee the Home during his tenure despite a statutory responsibility to do so.”

 Francisco Urena, the secretary of Department of Veterans’ Services, was asked to resign on June 23. Cheryl Poppe, superintendent at the Chelsea Soldiers' Home, has been assigned by Baker to be the acting secretary.

 The staff’s decision to place residents who were not infected with those who were infected was described by the report as “the most substantial error” on March 27.

 At the time, each unit had some veterans who were COVID-19 positive, some who were suspected of having the disease, and others who were displaying no COVID-19 symptoms. Rather than isolating those with the disease from those who were asymptomatic – a basic tenet of infection control – the consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25. This overcrowding was the opposite of infection control; instead, it put those who were asymptomatic at even greater risk of contracting COVID-19.”

The report concludes that when it was apparent the virus was traveling from one resident to another, rather than isolate infected veterans in order to try to stop the spread, the Home’s staff assigned social workers to be ready to tell relatives of the residents about “end of life preferences.”

A social worker is quoted in the report describing the scene in one unit, “I was sitting with a veteran holding his hand, rubbing his chest a little bit. Across from him is a veteran moaning and actively dying. Next to me is another veteran who is alert and oriented, even though he is on a locked dementia unit. There is not a curtain to shield him from the man across from him actively dying and moaning, or a curtain to divide me and the veteran I am with at the time, from this alert, oriented veteran from making small talk with the confused little fellow. He is alert and oriented, pleasantly confused, and talking about the Swedish meatballs at lunch and comparing them with the ones his wife used to make. I am trying to not have him concentrate on the veteran across from him who is actively dying, or the one next to him who I am holding his hand while he is dying. It was surreal . . . I don’t know how the staff over in that unit, how many of us will ever recover from those images. You want to talk about never wanting this to happen again.”

The report asserted that Home leadership were reluctant to test the first veterans believed to have COVID-19 and then delayed in testing others residents. The leadership was “inexcusably slow” in closing communal areas.

The report charges that Walsh lied to Urena about keeping the same staff members with the same group of residents to prevent the spread of the disease.

There are two other investigations that have not yet concluded. One is from the Attorney General’s office, while legislators are conducting the other.

On June 15, The Baker Administration released many proposed reforms for the Home.                                Among those were the following:

• The new posting for the position of Superintendent of the Holyoke Soldiers’ Home will include a preference for hiring a licensed nursing home administrator. 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.
• 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.
• 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 DVS & the Secretary of the Executive Office of Health and Human Services as ex officio members.

Local support

On June 23, about 40 people holding signs and American Flags gathered in Holyoke on Route 5 to call attention to a petition effort calling for improvements to the Soldiers Home.

Former Soldiers Home Superintendent Paul Barabani is one of the people leading an effort to try to convince the Baker Administration and the Legislature to add a new 53,000 square-foot building to the current home that would house 120 private rooms with private bathrooms. The addition would increase the home’s total long-term care capacity.

The group, called Fund Holyoke Soldiers Home Now, has a petition on Change.org. So far more than 1,500 people have signed the petition. The petition noted “the project at Holyoke, approved for 65 percent federal funding in 2013, has not received the commitment from the Baker administration for State Matching Funds.”

Barabani, who left the Home in 2016, fought for the funding for increased “I think the nation was surprised how devastatingly quick moving the virus was,” he said.

He blamed the room size, lack of staff and training as factors leading to the spread of the disease.

 “Its impact on residents was a disaster waiting to happen,” he added.