HOLYOKE — Nursing staff who were not checking patients on a regular basis, a lack of simulated emergency drills for all shifts and not posting emergency operation plans throughout the facility are among issues identified at the Veterans Home at Holyoke in a just-released audit covering a period from July 1, 2020 to June 30, 2023.
Also as part of the 33-page report disseminated Wednesday, State Auditor Diana DiZoglio said she intends to pursue litigation against Gov. Maura Healey to compel the production of various documents and records connected to the deaths of at least 76 veterans living at the Holyoke Soldiers’ Home during a COVID-19 outbreak earlier in 2020.
While the audit examined both the Holyoke location and the Veterans Home at Chelsea, the Executive Office of Veterans Services released a statement that it covers a time that largely predates Healey’s inauguration in January 2023 as successor to Gov. Charlie Baker.
The executive office notes that Healey immediately identified a problem that veterans were not receiving the care they deserved at either site, which prompted her to create the executive office and to appoint the first-ever secretary for veterans services. This has led to both progress and a commitment to continuous improvement, the executive office states.
“We have transformed the veterans homes in Holyoke and Chelsea into world-class facilities that meet the standards our heroes deserve,” reads the statement, issued by Jacqueline Manning, director of communications. “Today, Chelsea operates in a brand-new facility, and the current Veterans Home at Holyoke has earned a perfect rating from the U.S. Department of Veterans Affairs, placing it among the top-performing veterans’ facilities in America.”
DiZoglio said the audit should be seen as containing recommendations to ensure necessary services are being provided to veterans.
“I am confident that the Holyoke and Chelsea veterans homes are committed to working to ensure that all of our veterans are treated with the dignity, honor and respect they deserve,” DiZoglio said. “Both the Holyoke and Chelsea veterans homes have a noble and worthy mission of providing high-quality personal health care services to Massachusetts veterans.”
Specific to Holyoke, one recommendation is for nurses to do “intentional rounding” to reduce the risk of veterans having falls or other health issues that adversely contribute to veteran safety and well-being.
Another is to use an electronic health record system for veterans as required of other, similarly situated health care facilities. Such an electronic health record system can reduce medical errors and delays in treatment and improve the accuracy and clarity of medical records.
At both sites, the recommendations are to comply with state regulations by conducting simulated emergency drills for all shifts, posting their emergency operation plans throughout their facilities as required, to ensure an effective response to disasters and emergencies and to make sure the emergency operations plans contain the locations of alarm signals, fire extinguishers and evacuation routes.
The Executive Office of Veterans Services outlines all that has been done in recent years, including obtaining Department of Public Health licensure in July 2024 and Centers for Medicare & Medicaid Services certification in April 2025; implementing a robust “intentional rounding” program for nurses; implementing an electronic medical record system in September 2024; and updating, digitizing, posting and incorporating into staff training the emergency operation plans.
Following the release of the audit, Healey told reporters Wednesday that she brought prosecution against those who had failed veterans when she was Massachusetts attorney general and is well aware of what needed to be done.
“I have been a strong supporter of efforts to make sure that we have transformed our veterans homes in Massachusetts, and I believe that we have,” Healey said.
Demands for more records
Meanwhile, DiZoglio contends her office is entitled to more information that was developed following the COVID-19 outbreak, including materials from an Office of the Inspector General investigation for a period from May 2016 through February 2020. That investigation was based on a complaint that office received about the leadership of the superintendent for Holyoke, who was in charge leading up to and during the initial phases of the COVID-19 outbreak.
“The governor unlawfully blocked our office’s access to records connected to the tragedy that resulted in over 70 veteran fatalities,” DiZoglio said. “This raises serious concerns and warrants strong legal action. Lives were lost and families were devastated. It’s unacceptable to hide these records from auditors who have the legal authority to review them.”
The governor’s office commissioned the law firm of McDermott Will & Emery LLP to conduct an independent study, now known as the Pearlstein Report, which focused on the COVID-19 outbreak. That report highlighted errors and failures of leadership that likely contributed to the elevated death toll during the outbreak.
In addition to the findings made by the auditor’s office, requests were made to access interview notes and other records that went into the development of the Pearlstein Report. DiZoglio contends these were unlawfully withheld, preventing her office from conducting its audit as intended.
Healey’s office responded in the audit report: “The Baker Administration determined that McDermott’s interview notes and work papers were subject to the attorney-client privilege and the work product doctrine and, on that basis, denied numerous requests for the materials. The (auditor’s) suggestion to the contrary appears to be based on a misunderstanding of the scope of privilege and work product in the investigatory context.”
DiZoglio, though, is arguing that if this was an independent investigation, attorney-client privilege does not apply. She is asking Attorney General Andrea Campbell to get involved.
“I’m calling on the AG to authorize our office’s appointment of an attorney of our choosing. It’s critical that this matter be adjudicated and litigated by an attorney who is not beholden to this administration, or the one prior,” DiZoglio said. “Anything less is a denial of justice to all impacted by this tragedy.”