The Veterans Home at Holyoke, formerly known as the Holyoke Soldiers Home, is undergoing a $480 million renovation. In spring 2020, at least 76 military veterans who lived at the Veterans’ Home at Holyoke died of COVID-19.
Republican file photo
HOLYOKE — An audit report released by State Auditor Diana DiZoglio’s office on Jan. 14 found violations and oversight gaps at the Holyoke Veterans’ Home that resulted in the deaths of nearly 80 veterans during the coronavirus pandemic.
The home is a long-term care facility that provides healthcare services to eligible veterans in the state. DiZolgio’s office found these violations after her office conducted a review period between June 1, 2020 and June 30, 2023.
The audit found multiple deficiencies at the Holyoke veterans’ facility that jeopardized veteran safety and quality of care, including inconsistent nursing practices and gaps in emergency preparedness. The audit reported the facility could not ensure that nurses consistently perform check-ins, increasing the risk of falls, injuries and other health complications.
The audit also determined the facility violated state regulations by failing to conduct emergency drills across all shifts and by not posting required emergency operation plans throughout its buildings. As a result, the facility could not adequately test or ensure the effectiveness of its emergency response during disasters.
Additionally, emergency operation plans were incomplete, missing critical information such as alarm locations, fire extinguishers and evacuation routes. The audit further found Holyoke does not use an electronic health record system, limiting real-time access to medical information and increasing the risk of errors, delays and compromised patient care.
In spring 2020, at least 76 military veterans who lived at the Veterans’ Home at Holyoke died of COVID-19. These deaths prompted multiple investigations, terminations and resignations, regulatory reforms and lawsuits.
The commonwealth’s office of the inspector general investigated during the period between May 2016 and February 2020. This investigation was prompted due to a complaint that the Office of the Inspector General received about the leadership of Holyoke superintendent, who was in charge leading up to and during the initial phases of the COVID-19 outbreak in Holyoke.
The OIG determined that there were issues concerning the oversight and management of the Holyoke facility. The governor’s office also commissioned McDermott Will & Emery, LLP to conduct an independent study, now known as the Pearlstein Report, which focused on the COVID-19 outbreak that led to the deaths of veterans. The report highlighted errors and failures of leadership that likely contributed to the elevated death toll during the outbreak.
The state auditor’s office requested access to interview notes and other records that contributed to the development of the Pearlstein Report. Those documents and records were unlawfully withheld, according to a press release sent to reminder Publishing.
While the state auditor’s office examined other issues related to safety, the withholding of requested documentation prevented the office from conducting its audit as intended concerning these matters.
The state auditor’s office is pursuing litigation to force the withheld documents and records connected to the Holyoke Soldiers’ Home tragedy to be made public. “Either this was an independent investigation, as was claimed, in which case attorney-client privilege does not apply, or this was legal representation on behalf of the governor, where Pearlstein was providing legal advice in anticipation of lawsuits,” DiZoglio’s press release stated. “Both can’t be true simultaneously.”
Although the state auditor’s office said they respect the sanctity of attorney-client privilege, they said that these records are not protected under attorney-client privilege. In a June 26, 2021 article, the Boston Globe reported that Pearlstein himself stated he did not provide private legal advice to the governor’s office. Therefore, these records are subject to audit, according to the press release.
“The governor unlawfully blocked our office’s access to records connected to the tragedy that resulted in over 70 veteran fatalities,” DiZoglio said in a statement. “Lives were lost and families were devastated. It’s unacceptable to hide these records from auditors who have the legal authority to review them.”
DiZoglio said she is calling on the attorney general to authorize her office’s appointment of an attorney of their 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. Anything less is a denial of justice to all impacted by this tragedy,” DiZoglio said.
“We hope that our audit recommendations are adopted to help ensure that mission is the reality for every veteran relying on these necessary services,” she concluded.
