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This May 2018 file photo shows the Holyoke Soldiers’ Home in Holyoke, Mass.
This May 2018 file photo shows the Holyoke Soldiers’ Home in Holyoke, Mass. (Patrick Johnson/TNS)

HOLYOKE, Mass. (Tribune News Service) — An inexperienced superintendent who created a "hostile work environment," a convoluted chain of command and long-term staffing issues created a perfect storm at the Soldiers' Home in Holyoke, leaving officials unable to stop a deadly outbreak of COVID-19 in the spring of 2020.

Those are among the conclusions of a legislative oversight committee formed to examine the root causes of the outbreak, which infected about 75% of the original about 210 veterans living at the home and killed 77.

Starting in July, the committee of House and Senate members held at least eight hours-long hearings talking to everyone from top state officials and former home leaders to certified nursing assistants and relatives of residents.

The preliminary report was released Monday evening by state Rep. Linda Dean Campbell and Sen. Michael Rush, both Democrats, who jointly chaired the committee. The remaining members have until noon on Tuesday to review and vote to officially release the report, they said.

The committee examined what happened to cause one of the worst outbreaks of the disease at a long-term facility in the country, but also focused on how to ensure it is not repeated. The report comes with 14 recommendations, including:

• requiring the Holyoke and Chelsea Soldiers' Homes to be inspected twice a year by the state Department of Public Health

• changing the hiring process for the superintendent

• making the Holyoke Soldiers' Home a certified Medicare and Medicaid facility

• setting and keeping a five-star staffing level to address shortages that date back at least five years

• adding an ombudsman position to help families with any needs

The report comes a week after the House and the Senate each took unanimous votes to spend $400 million to replace the 1950s building. Many have agreed its design, with shared rooms and restrooms and crowded conditions, contributed to the outbreak.

The report made little mention of the condition of the building, however, mainly focusing on leadership problems that also led to short- and long-term staffing issues.

The leadership structure of the home allowed what the report called a "preventable tragedy."

"The most immediate cause of the tragedy was the inexplicable decision to combine the patients of the two dementia wards, both of which had some patients who were COVID-19 positive and some patients who were not," the report said.

The report repeated the conclusions of other investigations that put much of the blame in the hands of former superintendent Bennett Walsh, who had an extensive military career but no medical experience.

Walsh and medical director Dr. David Clinton were ousted over the fiasco and later criminally indicted. They have pleaded not guilty to 10 neglect counts each, and argue they were scapegoated by state officials.

"(Walsh's) most glaring deficiencies appear to have been in the areas of sound management, human relations and leadership," the report said. "Superintendent Walsh created a hostile work environment for staff in which most all would be fearful to challenge his authority on anything."

Adding to the lack of leadership was an absence at different times of people for other key positions, including a medical director and deputy superintendent. Also left unfilled was the executive director of Veterans' Homes and Housing within the state Department of Veterans' Services, which had direct oversight of the home.

One of the key findings and recommendations comes from a "muddled and seemingly ineffective" chain of command. One of the breakdowns occurred between Walsh and Veterans' Services Secretary Francisco Urena, who had no confidence or trust in each other.

Urena was also forced to resign over the COVID-19 outbreak.

"Urena was frustrated and felt powerless to address problems related to Superintendent Walsh's performance," the report said. "The lack of situational awareness and effective communication on the part of senior leadership about the situation unfolding at the Holyoke Soldiers' Home proved to be a significant cause of the tragedy."

Walsh has argued that he sent requests for assistance from the National Guard after many staff members fell sick with COVID-19, but said they were ignored by Urena and Marylou Sudders, secretary of the state Executive Office of Health and Human Services. No one has revealed publicly where the breakdown occurred.

"Testimony begged the question: who did the superintendent really work for? He was selected by the Board of Trustees for the Holyoke Soldiers' Home and his appointment was confirmed by the governor," the report said. Technical supervision was provided by Urena and Sudders.

The report recommends major changes to correct the problem of a lack of clear chain of command including taking the board of trustees out of the hiring process, having the secretaries of Veterans' Services and Health and Human Services as the recommending authority, and granting the governor final hiring and firing authority.

It also recommends making the secretary of Veterans' Services a cabinet position with a direct line of communication to the governor instead if the secretary answering to the Executive Office of Health and Human Services.

(c)2021 The Republican, Springfield, Mass.

Visit The Republican, Springfield, Mass. at

Distributed by Tribune Content Agency, LLC.

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