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 and staffing ................................................................................................ 29 7. General strengths and weaknesses of the Soldiers’ Home, and comparison to the Chelsea facility ............................................................................. 30 B. Disputes concerning staffing levels and reporting structures during Superintendent Barabani’s tenure ............................................................................................. 33 C. Superintendent Walsh’s tenure ................................................................................................. 36 1. Background and selection as Superintendent ........................................................... 36 2. Management and leadership style ............................................................................... 37 3. Interactions with the Board of Trustees ................................................................... 39 4. Leadership team ............................................................................................................ 41 i. The Deputy Superintendent’s role ............................................................... 43 5. Quality of care and survey results .............................................................................. 45 6. Staffing levels................................................................................................................. 48 i. The Moakley study ......................................................................................... 49 ii. BRG analysis ................................................................................................... 51 iii. Permanent schedule ....................................................................................... 56 D. The COVID-19 outbreak .......................................................................................................... 57 1. Guidance for healthcare facilities on the emerging COVID-19 pandemic ........................................................................................................................ 57 2. COVID-19 preparations at the Soldiers’ Home ...................................................... 63 2 i. 2020 flu outbreak and response ................................................................... 63 ii. Initial COVID-19 preparations .................................................................... 64 iii. The Board of Trustees’ role during the outbreak ...................................... 65 iv. Additional restrictions on visitation and screening measures for staff ........................................................................................... 67 v. Recreation and dining .................................................................................... 70 vi. Personal protective equipment ..................................................................... 71 vii. Other communications with staff about COVID-19 preparations ..................................................................................................... 72 viii. Communications with veterans’ families .................................................... 73 ix. Communications with the state agencies prior to the first suspected case ................................................................................................. 74 x. Communications with labor unions regarding COVID- 19 preparations ............................................................................................... 74 xi. Creation of isolation areas in preparation for COVID-19 cases .................................................................................................................. 76 3. The response to suspected and confirmed cases of COVID-19 at the Soldiers’ Home ....................................................................................................... 78 i. Veteran 1 shows symptoms and is tested for COVID-19 ....................... 78 ii. Dr. Clinton becomes ill and leaves work .................................................... 80 iii. Response to Veteran 1’s positive test results ............................................. 80 iv. Discussions with families regarding MOLST forms ................................. 82 v. Continued discussions and disputes with labor unions regarding COVID-19 .................................................................................... 83 vi. Updated guidance and continued disputes regarding protective equipment and infection control ............................................... 84 vii. Unit 2-North is closed and consolidated with Unit 1- North ................................................................................................................ 87 viii. The outbreak spreads: more veterans test positive and the death toll grows .............................................................................................. 92 4. Reporting out: requests for assistance and communications regarding reportable events ......................................................................................... 94 i. Reporting requirements related to COVID-19 .......................................... 94 ii. Summary of reports-out and requests for advice and assistance .......................................................................................................... 96 3 iii. State and local leaders’ knowledge of the evolving crisis at the Soldiers’ Home .................................................................................. 108 5. Superintendent Walsh is placed on administrative leave, and an Interim Administrator takes command of the Soldiers’ Home ........................... 109 i. Val Liptak is appointed Interim Administrator, and a response team arrives at the facility ........................................................... 109 ii. The response team’s observations regarding the condition of the Soldiers’ Home ................................................................ 111 iii. Additional discussions with family members regarding MOLST status ............................................................................................... 112 iv. Final death toll .............................................................................................. 113 V. Analysis and Recommendations ..................................................................... 114 A. The Soldiers’ Home leadership team made serious errors in responding to the COVID-19 outbreak.......................................................................................................... 114 1. Combining two locked dementia units containing veterans with a mix of COVID-19 statuses, and failing to ensure an appropriate standard of care on the newly combined unit ........................................................ 114 2. Failure to promptly isolate patients suspected of COVID-19 using the rooms set aside for isolation .................................................................... 116 3. Delays in testing additional veterans for COVID-19 ............................................ 117 4. Delays in closing common spaces ............................................................................ 118 5. Failure to stop rotation of staff among units ......................................................... 119 6. Inconsistent policies and practices with respect to personal protective equipment ................................................................................................. 120 7. Document and recordkeeping failures .................................................................... 121 B. The Department of Veterans’ Services did not take steps to address substantial and long-standing concerns regarding the leadership of the Soldiers’ Home .......................................................................................................................... 122 C. Although Mr. Walsh reported other information