Massachusetts General Court | May 2021 Report of the Special Joint Oversight Committee on the Soldiers’ Home in Holyoke COVID-19 Outbreak Findings & Recommendations To care for those “who shall have borne the battle” and for their families and survivors – Abraham Lincoln Table of Contents Foreword ........................................................................................................................................ 1 Introduction and Purpose of Report ........................................................................................... 2 Establishment of the Special Committee .................................................................................... 4 Scope of the Committee .............................................................................................................. 5 Committee Membership .............................................................................................................. 6 Executive Summary ...................................................................................................................... 8 Findings and Recommendations ................................................................................................ 11 Methodology ................................................................................................................................ 35 Hearing Schedule ...................................................................................................................... 36 Participating Witnesses ............................................................................................................. 36 Hearings ....................................................................................................................................... 38 Overview of Hearings ............................................................................................................... 38 Hearing Summaries ................................................................................................................... 39 Previous Legislative Actions Pertaining to the Holyoke Soldiers’ Home .............................. 54 Appendices ................................................................................................................................... 60 Appendix A: Press Release Regarding the State Auditor’s Report on HSH ............................ 60 Appendix B: Testimony of State Auditor Bump ....................................................................... 62 Appendix C: Testimony of Paul Barabani ................................................................................ 65 Appendix D: Testimony of John Paradis .................................................................................. 68 Appendix E: Testimony of the Massachusetts Nurses Association .......................................... 77 Appendix F: Opening Remarks of Trustee Kevin Jourdain ...................................................... 87 Appendix G: Opening Remarks of Trustee Isaac Mass ............................................................ 92 Appendix H: Invitation to Testify to DVS Chief of Staff ......................................................... 93 Appendix I: Withdrawal from Hearing of DVS Chief of Staff ................................................. 95 Appendix J: Public Statement from Labor Unions ................................................................... 96 Appendix K: Opening Remarks from NECHV ......................................................................... 99 Appendix L: Opening Remarks from Secretary Poppe, January 2021 ................................... 101 Appendix M: Opening Remarks from Secretary Sudders, January 2021 ............................... 104 Appendix N: Opening Remarks from Secretaries Sudders and Poppe, February 2021 .......... 107 Appendix O: Testimony of Secretary Ureña ........................................................................... 110 Appendix P: Testimony of Nathalie Grogan of CNAS ........................................................... 115 Appendix Q: Testimony of Terence Dougherty of UMMS .................................................... 118 Appendix R: EOHHS Privilege Log for Emails in Pearlstein Investigation, Part 1 ............... 120 Appendix S: EOHHS Privilege Log for Emails in Pearlstein Investigation, Part 2 ................ 126 Appendix T: EOHHS Privilege Log for Text Messages in Pearlstein Investigation .............. 131 Appendix U: Cover Letter from Secretary Sudders Regarding Staffing Data ........................ 132 Appendix V: HSH Transitional Plan ....................................................................................... 136 Appendix W: Board of Trustees Vacancy Review, EOHHS .................................................. 154 Appendix X: Holyoke Staff Turnover Analysis, EOHHS ...................................................... 157 Appendix Y: HSH ERIP and Backfill Information, EOHHS ................................................. 174 Appendix Z: HSH Staffing Data Comparison, EOHHS ......................................................... 175 Appendix AA: Soldiers’ Homes Census Overview 2021 ....................................................... 176 Citations ..................................................................................................................................... 179 Abbreviations Center for a New American Security CNAS Centers for Medicare and Medicaid Services CMS Certified Nursing Assistant CNA Chelsea Soldiers’ Home CSH Department of Veterans’ Services DVS Early Retirement Incentive Program ERIP Executive Office of Health and Human Services EOHHS Holyoke Soldiers’ Home HSH Licensed Practical Nurse LPN Massachusetts Nurses Association MNA Nursing Facilities NF Personal Protective Equipment PPE Registered Nurse RN Skilled Nursing Facilities SNF U.S. Department of Veterans Affairs VA Foreword In the course of the proceedings of the Special Joint Oversight Committee on the Soldiers’ Home in Holyoke COVID-19 Outbreak, what has become clear is that the tragic COVID-19 outbreak at the Holyoke Soldiers’ Home occurred due to a multitude of factors and points of failure, both systemic and acute. Members of the Special Committee are resolute in their determination that the recommendations contained in this report be acted upon legislatively and that all relevant recommendations be enacted into statute. We look forward to following through on this mission. We are thankful to all who contributed to this report and for the strong participation of our colleagues. We would also like to express our gratitude to Holyoke Community College and the General Court’s Legislative Information Services, both of whom were instrumental in facilitating operations for the Special Committee’s hearings, both in-person and virtual. Most importantly, we cannot express how profoundly grateful we are for the testimony of family members of residents and staff from the Holyoke Soldiers’ Home who were impacted in a way that we will never be able to fully understand. For many, this is a life-altering event that will impact their well-being for many years. We must honor their courage by taking legislative action to turn these recommendations into policies that will honor our profound gratitude to our Veterans. Sincerely, Linda Dean Campbell Michael F. Rush th State Representative, 15 Essex District State Senator, Norfolk and Suffolk District Chair, Special Joint Oversight Committee on Chair, Special Joint Oversight Committee on the Soldiers’ Home in Holyoke COVID-19 the Soldiers’ Home in Holyoke COVID-19 Outbreak Outbreak 1 Introduction and Purpose of Report On March 21, 2020, the Holyoke Soldiers’ Home (“HSH”) received the first positive test result for COVID-19 for a Veteran residing at the Home.1 In the days and weeks that followed, a horrific outbreak unfolded that resulted in the tragic COVID-19-related deaths of 77 Veterans at the Home. It is one of the deadliest outbreaks of COVID-19 in the Commonwealth.2 A crisis of leadership on many counts contributed substantially to this tragedy. As we outline in this report, the causes were both immediate, including inexplicable decisions made by the Home’s leadership in the days and weeks preceding the outbreak, and long-standing, including systemic issues that left the Home mismanaged, understaffed, lacking sufficient oversight, and ill- equipped to protect its residents from a deadly infectious disease. On March 30, 2020, the Baker Administration placed HSH Superintendent Bennett Walsh on administrative leave and sent a response team to take control of the Home, including support from the National Guard. The response team worked quickly to implement sound infection control policies. Since that time, former Superintendent Walsh and former HSH Medical Director David Clinton have been indicted on criminal neglect charges for their roles in the deadly COVID-19 outbreak,3 and former Secretary of Veterans’ Services Francisco Ureña and Vanessa Lauziere, the former Chief Nursing Officer at the Home, submitted their resignations.4,5 In the wake of the tragedy, numerous state and federal agencies initiated investigations into the crisis, including an independent investigation commissioned by Governor Charlie Baker, conducted by Attorney Mark W. Pearlstein, and investigations by Massachusetts Attorney General Maura Healey, Massachusetts Inspector General Glenn Cunha, and the former U.S. Attorney for 1 Pearlstein, Mark. The COVID-19 Outbreak at the