Trustees of the Soldiers’ Home in Holyoke have endorsed multiple recommendations from an investigation that determined “utterly catastrophic” and “baffling” decisions led to dozens of coronavirus infections and deaths at the facility.
The board of trustees met by teleconference on Tuesday for the first time since the report was released on June 24. Chairman Kevin Jourdain called the report “very difficult to read, very painful to read,” but members mostly limited their discussions to recommendations made in the report.
Members passed 13 resolutions to make widespread improvements to the operations and management of the home. They also passed a second package of reform plans calling on state officials to update the building to meet infection control standards, fill the now-vacant state director of Veterans Services position quickly with an experienced health care leader, and provide funding for a new electronic record-keeping system.
The resolutions passed in 6-0 votes.
Member Richard Girard, who had only been on the board a few months, resigned recently, leaving the seventh seat vacant.
The investigation, which was conducted by attorney Mark Pearlstein at the request of Gov. Charlie Baker, placed much of the blame for the outbreak on Superintendent Bennett Walsh, who was fired from his $122,299-a-year job shortly after the report came out. Pearlstein called Walsh an inept administrator who bullied his staff and lacked any experience to direct a health care facility.
Francisco Urena, the state director of Veterans Services, who was the direct supervisor of the Soldiers’ Home, submitted his resignation upon the request of the governor the day before the report was released.
Walsh’s attorney and uncle, former Hampden District Attorney William M. Bennett, has said the report was filled with “baseless accusations” that misrepresented facts and offered Walsh no opportunity for rebuttal. He is fighting Walsh’s termination and has threatened to sue the Baker administration.
The report contained nine primary recommendations for the board of trustees.
“My personal view is I agree with all of his recommendations and I suspect my colleagues on the board do as well,” Jourdain said Tuesday.
The recommendations include ending the Soldiers’ Home’s exemption from licensing and inspections conducted by the Department of Public Health; hiring an occupational health nurse to ensure proper staffing levels for all shifts; creating policies to increase staff training and education; creating an electronic record-keeping system; closing the indoor smoking room and requiring smoking to be limited to designated outdoor areas.
In a nod to the constant complaint that the superintendent’s position has long been filled by political appointees, trustees voted to require the superintendent or deputy superintendent to hold a Massachusetts Nursing Home Administrator license, as all managers of private nursing homes must have. The resolution also called for the superintendent to have “substantial healthcare experience in the field of gerontology.”
“Veteran status shall never be a substitute for satisfying the minimum experience or qualifications for employment at the Holyoke Soldiers’ Home at any level including, but not limited to, the position of superintendent,” an additional resolution reads.
Trustees said they were especially concerned about information in the report that said staff were instructed to call families pushing them to change orders to “do not hospitalize,” “do not resuscitate” and “do not intubate” when the outbreak hit.
Trustee Isaac Mass said he found that one of the most egregious things in a report that was full of information about horrifying decisions and actions taken by managers.
“It is medically unethical and resulted in deaths,” he said.
“It is beyond their scope of practice, it is against the law to ask that,” trustee Carmen Ostrander said.
The trustees’ first resolution called for employees to be banned from taking any position on the contents of medical orders for life-sustaining treatment or questioning the family’s or veteran’s decisions. Employees can provide factual information for families.
Trustees also discussed creating a fast-tracked study to decide how to renovate and possibly expand the Soldiers’ Home so it can meet modern infection control and general living standards so small rooms are not shared by two or three veterans.
State officials said they are working to complete a study and plans for renovations or rebuilding the home to meet an April 2021 deadline to apply for funding from the federal Department of Veterans Affairs.
“I hope we look at exemplars around the country of the best facilities,” Mass said. “That is what the veterans of Western Massachusetts deserve.”
Trustees also discussed efforts to start replacing multiple vacant management positions created by resignations — some of which came before the coronavirus outbreak and some of which were forced after the deaths of 76 veterans.
“We have retained a professional services search firm given the number of management and clinical staff positions that need to be filled,” said Daniel Tsai, deputy secretary of the state Executive Office of Health and Human Services, which also oversees the Soldiers’ Home.
Some of the positions that are currently vacant are the superintendent and deputy superintendent, the chief medical officer, director of operations, director of nursing, assistant director of nursing and infection control nurse. Val Liptak, chief executive officer of Western Massachusetts Hospital, has been serving as interim director since Walsh was placed on leave on March 30.
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