HOLYOKE – The new report from the Office of the Inspector General about the Holyoke Soldiers’ Home paints a picture of incompetency and poor decisions not just from former Superintendent Bennett Walsh, but also Gov. Charlie Baker and other state officials.

Criminal charges against Walsh were dropped last November. There is also a separate civil suit that has not yet been resolved.

Michael Jennings, the attorney representing Walsh, told Reminder Publishing, “We’re currently solely focused on our response to the Attorney General’s appeal of the Superior Court’s well-reasoned opinion dismissing all criminal charges against Mr. Walsh. We have no comment at this time relating to the newly released inspector general’s investigation report, which has no relevance to our work responding to that appeal.”

In response to a request for a reaction to the report from the governor, a spokesperson for the Executive Office of Health and Human Services released the following statement to Reminder Publishing, “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 administration is reviewing the report from the inspector general, which identified several recommendations that have already been addressed by the Department of Veterans’ Services and the Soldiers’ Home. 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.”

State Sen. John Velis said, “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.”

Velis continued, “I appreciate that the inspector general worked alongside my office throughout this process and offered vital recommendations for the Soldiers’ Home Governance legislation. That is why the pending legislation includes many of the recommendations laid out in the report.

“From ensuring that DPH [Department of Public Health] 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,” he said.

The report noted, “The Office [of the Inspector General] found extensive mismanagement and oversight failures at the Home. First, the current location of the Home within EHS [Executive Office of Health and Human Services] and DVS [Department of Veterans Services] does not create a clear structure for oversight. 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. Third, Superintendent Walsh did not have the managerial skills or temperament to properly oversee the Home’s operations.”

The report continued, “Specifically, the Office found:The governor, EHS and the board failed to follow the required statutory framework for hiring a new superintendent for the Home. The EHS secretary met only with Superintendent Walsh and the governor appointed him. After deferring to the governor on Superintendent Walsh’s hiring, the board regularly deferred to the superintendent throughout his tenure.

Superintendent Walsh did not have and did not develop the leadership capacity or temperament for the role of superintendent, during his nearly four years on the job. He created a negative work environment, engaged in retaliatory behavior, demonstrated a lack of engagement in the Home’s operations, circumvented the chain of command and bristled against supervision.

EHS and DVS failed to adequately address complaints from the Home’s senior managers and other employees about Superintendent Walsh’s leadership and the management of the Home. EHS and DVS staff did not recognize that multiple similar complaints about Superintendent Walsh pointed to serious leadership and management issues at the Home. EHS did not have an organized, systematic method for addressing, documenting or investigating employee complaints. When EHS conducted investigations into the complaints, the investigations were limited, flawed and biased. In addition, EHS’s human resources managers hampered an investigation by the commonwealth’s Investigations Center of Expertise into the superintendent.
EHS leadership spent time and public resources attempting to improve Superintendent Walsh’s management skills. However, EHS failed to regularly document, coordinate or review the efficacy of these efforts. Although Superintendent Walsh was not improving, EHS and DVS leadership did not coordinate with each other or with the board to evaluate whether he should remain in his role.”

“Based on its findings, the report recommended a set of steps for ‘meaningful and long-lasting improvements.’ Those include ‘fixing longstanding structural problems, addressing fundamental flaws related to oversight, streamlining management and promoting accountability at the Home and its counterpart in Chelsea (together, the Soldiers’ Homes).’”

The report also recommended the Legislature to take action on the recommendations:

“Vest the DVS secretary with the responsibility and authority necessary to ensure the superintendents properly manage the Soldiers’ Homes. This would include elevating the DVS secretary to the governor’s cabinet and providing the DVS secretary with the authority to appoint, supervise and remove the superintendent of each of the Soldiers’ Homes. Create specific requirements for the superintendents, including that all future superintendents be licensed nursing home administrators and have extensive management experience. Remove management responsibilities from the Boards of Trustees for the Soldiers’ Homes (boards); if the Legislature keeps the boards, reconstitute them as advisory bodies whose members have experience with veterans’ issues, healthcare, nursing, fiscal management and labor relations
Establish and fully fund an ombudsperson and hotline to allow confidential reporting by residents, relatives, staff and concerned citizens. Vest the Department of Public Health (DPH) with the authority to provide independent and ongoing clinical oversight and support for the Soldiers’ Homes.”

Although the Holyoke Soldiers’ Home Coalition has not specifically commented about the inspector general report, spokesperson John Paradis did say, “As our coalition has stated during numerous public testimonies, we are very concerned over the current chain of command structure at the two homes and have been resolute in stating that a new chain of command be simple, straightforward and efficient. The Senate version of proposed governance reforms would be a major improvement with a very clear chain of command. There needs to be no doubt who is in charge and who is held accountable for the care of the veterans.”

The report continued, “We have also called for a process whereby the veteran community is involved with the selection of a new superintendent. We would love to see a community meet and greet with the final candidates. Ultimately, the person should inspire collaborative efforts and should be someone who looks for a common vision in leading the Soldiers’ Home and with effecting systemic change to rebuild trust with employees and with the veteran community at large. The selection should be made with the greatest transparency and the individual selected should be a leader who is approachable and creates positive relationships with the veteran community.”