JUNE 24, 2020.....The independent investigation by a former U.S. prosecutor into the Holyoke Soldiers' Home concluded that two key dynamics led to at least 76 veteran residents dying from COVID-19: repeated errors made by the facility's leaders and poor oversight of that leadership team by the Baker administration.
The bombshell report from attorney Mark Pearlstein released Wednesday prompted an immediate shuffle in the management hierarchy, both at the home and within Gov. Charlie Baker's cabinet.
Veterans' Services Secretary Francisco Urena resigned on Tuesday, one day ahead of the report's publication. Baker announced at a Wednesday news conference that Cheryl Poppe, superintendent at the Chelsea Soldiers' Home, will step into the secretary position on an acting basis.
Baker, who described the results of the investigation as "gut-wrenching," also said the administration will move to fire Bennett Walsh, the superintendent of the Holyoke facility who has been on paid administrative leave since the crisis became clear in late March.
"Errors were made at the Holyoke soldiers home before COVID-19, more errors were made in preparation for COVID-19, and still more errors were made during the home's initial clinical response to the pandemic in March," Baker said at a news conference. "Veterans who deserve the best from state government got exactly the opposite, and there's no excuse or plausible explanation for that."
Asked how much responsibility he takes for the crisis as governor, Baker replied, "The report makes clear that the Department of Veterans' Services, which oversees the soldiers' homes, didn't properly oversee Holyoke or Bennett Walsh, and that one's on us."
Pearlstein's report, based on interviews with 100 witnesses and more than 17,000 documents, raises questions not only about Walsh's leadership during the pandemic but also about his performance in the job in the nearly four years before the outbreak.
Baker appointed Walsh, a Springfield native with a 24-year military career that included seven combat deployments but little experience in residential care, as superintendent of the Holyoke Soldiers' Home in May 2016. Urena and the home's trustees had recommended Walsh for the position, according to the report.
They tapped another veteran with more relevant experience who had been a candidate for the top job, John Crotty, as deputy superintendent.
Walsh left the military in 2016 as a lieutenant colonel and began a career search, which the report said involved applying for a security operations post at the MGM Springfield Casino. He "pivoted," Pearlstein wrote, when Sen. John Velis, who was then a member of the House, reached out and suggested that Walsh apply to become superintendent of the home.
The job posting described searching for someone who had a track record in operating a residential outpatient facility. Walsh told Velis, a Westfield Democrat, he was concerned that he did not have a clinical background.
According to Pearlstein's report, Velis replied that "this was not a requirement for the job."
Velis was not interviewed for the independent investigation. He told the News Service on Wednesday that he did not have a personal relationship with Walsh, but at a constituent's request agreed to meet him at a Westfield Friendly's to discuss the transition from military to civilian life.
Velis said Walsh expressed interest in the Holyoke Soldiers' Home job and asked about the necessity of medical experience.
"At that cup of coffee, the soldiers' home came up and whether or not you need a medical or clinical type of background," Velis said. "My understanding is that it's not a prerequisite. However, I offered an admonition that if the superintendent doesn't have that medical or clinical background, in my opinion, it is absolutely critical, paramount, that the deputy have that background. That's precisely what happened."
Holyoke staff and Baker administration officials told Pearlstein there were significant issues during Walsh's tenure. Urena and his staff described Walsh's communication skills as "poor" and said he was "in over his head," according to the report. The state hired an executive coach to work with the superintendent on anger management.
At one point, Urena told Pearlstein, Walsh asked Health and Human Services Secretary Marylou Sudders -- Urena's direct superior in the Cabinet -- to bar the veterans affairs secretary from making unannounced visits to the Holyoke home.
The home experienced significant staff turnover, and key support positions were left vacant. After Crotty's resignation in June 2019, the deputy position was not filled until March. Pearlstein found that administration officials knew the home had "a void of leadership" following Crotty's departure but did not intervene.
"While the Home's leadership team bears principal responsibility for the events described in this report, Mr. Walsh was not qualified to manage a long-term care facility, and his shortcomings were well known to the Department of Veterans' Services -- yet the agency failed to effectively oversee the Home during his tenure despite a statutory responsibility to do so," Pearlstein wrote.
In April, Walsh issued a statement through an attorney claiming that he notified state officials about conditions at the home in a timely fashion and that he unsuccessfully asked for National Guard medical personnel to supplement the home's staff.
Walsh's attorney could not be reached Wednesday for comment on the Pearlstein report, or the governor's move to fire him.
Urena, a Marine veteran who served as a tank commander during Operation Iraqi Freedom and who has previously held veterans' services posts in Lawrence and Boston, has been the state's veterans secretary since the start of the Baker administration in 2015.
During his Wednesday news conference, Baker said Urena was "asked to step down, and he gracefully did" based on the results of the report. Asked if Urena ever alerted higher-ups in the administration about his concerns with Walsh, Baker said the "one thing" the secretary mentioned was communication issues that led to the hiring of a "coach."
The governor voiced "full confidence and faith" in Sudders and in Dan Tsai, the MassHealth secretary who was named acting Health and Human Services secretary while Sudders leads the state's COVID response.
"When the full extent of what was going on there became available to both of them, within 11 hours, they had a new management team on the ground there, brought in Holyoke Medical Center as a partner, brought in resources from across Western Mass. and across the commonwealth, brought the National Guard in and created a framework and an operating model that actually made it possible to get to the point today where there are no positive cases at the Holyoke Soldiers' Home," Baker said.
Long-term care facilities have been devastated by the pandemic due to the highly infectious nature of the virus and its increased deadliness for older adults with other comorbidities. Through Tuesday afternoon, the state Department of Public Health reported that 4,970 deaths in long-term care were likely or confirmed to be linked to COVID-19.
According to previous news reports, at least 30 residents also died amid an outbreak at the Chelsea Soldiers' Home, where Poppe had been in charge until she was named acting secretary.
Baker praised Poppe's record, noting that she spent four months as the interim superintendent in Holyoke before Walsh was hired and left him a "comprehensive document" outlining issues that should have been addressed.
"Cheryl Poppe is probably one of the most respected clinical managers in the senior care world in Massachusetts," he said. "She is by all accounts a terrific leader and a terrific administrator and for years has done a spectacular job in Chelsea."
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06/24/2020