The COVID-19 Outbreak at the Soldiers’ Home in Holyoke An Independent Investigation Conducted for the Governor of Massachusetts June 23, 2020 Mark W. Pearlstein MCDERMOTT WILL & EMERY LLP 200 Clarendon Street, 58th Floor Boston, Massachusetts 02116 Telephone: +1 617.535.4000 Email:
[email protected] TABLE OF CONTENTS I. Introduction ........................................................................................................ 6 II. Executive Summary ............................................................................................ 9 III. Scope and Approach to the Investigation ........................................................ 18 IV. Fact-finding ...................................................................................................... 22 A. Background: the Soldiers’ Home .............................................................................................. 22 1. Legal posture ................................................................................................................. 22 2. Licensing, surveys, and inspections ........................................................................... 24 3. Funding .......................................................................................................................... 26 4. Physical plant and layout ............................................................................................. 27 5. Veteran population and services ................................................................................ 28 6. Leadership