IG issues scathing report into hiring of superintendent of Holyoke Soldiers’ Home before COVID hit

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The troubles at the Holyoke Soldiers’ Home, which provides state-funded care for veterans in western Massachusetts, began well before a COVID-19 outbreak that resulted in the deaths of at least 76 residents and widespread illness among staff.

A new report released Friday, by the State’s Inspector General, raises serious questions about the Baker Administration’s hiring of the former superintendent in charge of that soldiers’ home, and his ability to lead.

25 Investigates has reported extensively on troubles at the soldiers’ home, throughout the pandemic.

25 Investigates: Internal emails reveal lack of preparation for COVID-19 outbreak at Holyoke Soldiers’ Home

Bennett Walsh became the superintendent of the Home in May 2016. The IG began its investigation in 2019 after receiving an anonymous complaint raising several concerns about then-Superintendent Bennett Walsh.

“Superintendent Walsh did not have and did not develop the leadership capacity or temperament for the role of superintendent,” according to the IG’s report. “He created an unprofessional and negative work environment, retaliated against employees he deemed disloyal, demonstrated a lack of engagement in the Home’s operations, and circumvented his chain of command.”

The report also indicates Bennett lacked the credentials needed to be superintendent.

“...his resume lists his positions as field and company grade infantry officer, recruiting officer, operations officer/program manager, executive officer, safety officer, faculty instructor, and the executive officer for Parris Island, South Carolina. His duties included overseeing large groups of military personnel. His resume does not include any direct or supervisory experience in a healthcare setting or skilled nursing facility,” according to the IG.

The Office of the Inspector General is an independent state agency tasked with preventing and detecting fraud, waste, and abuse in the use of public funds and public property.

The report says the secretary of the Executive Office of Health and Human Services, Marylou Sudders, and the Home’s Board of Trustees did not follow the statute that gives the Board the power to appoint the superintendent.

“Rather, the Board recommended three candidates, the EHS secretary met only with Mr. Walsh and the governor appointed him as the Home’s superintendent,” according to the report.

“EHS failed to recognize that the recurring complaints indicated that Superintendent Walsh did not have the leadership skills or temperament to lead the Home,” according to the IG.

“The Office’s investigation focused on leadership, management, and oversight at the Home during the period May 2016 to February 2020,” according to a statement from the IG. “As the devastating impacts of the pandemic on the Home in March 2020 became clear, the Massachusetts Office of the Attorney General and the United States Attorney’s Office for the District of Massachusetts announced investigations into the events related to COVID-19.”

Walsh was placed on paid leave on March 30, 2020, and then fired by Secretary Sudders in June of that year after the publication of a report Governor Baker had commissioned to investigate outbreak.

Report: ‘Hell broke loose’ after series of leadership errors at Holyoke Soldiers’ Home

“A court later found this termination letter to be void because the Board, not the EHS secretary, was the proper body through which the governor could have exercised any authority to remove him. A month after the court’s decision, on October 13, 2020, the Board accepted Superintendent Walsh’s resignation,” according to the IG report.

At one point, Walsh and and the home’s medical director were facing criminal charges for their handling of the facility. Those charges were later dismissed.

Judge dismisses all criminal charges against leaders of Holyoke Soldiers’ Home

The Inspector General’s report also makes several recommendations to fix “longstanding structural problems, address fundamental flaws related to oversight, and strengthen management and accountability.”

Inspector General Recommendations:

  • Veteran Services should be elevated to a cabinet-level secretariat. One person must be responsible for the oversight and management of the superintendent; one person must have the authority and responsibility to appoint, supervise, discipline and remove the superintendent. The Department of Veterans Services Secretary should have this authority and responsibility for the superintendents at the Soldiers’ Homes in Holyoke and Chelsea.

  • Superintendents of the Soldiers’ Homes must meet certain requirements, including being licensed nursing home administrators with extensive management experience.

  • The Department of Public Health should have the authority and funding to provide independent clinical oversight and support for the Soldiers’ Homes.

  • DVS should establish an ombudsperson and a hotline to allow confidential reporting by residents, relatives, staff and concerned citizens.

When reached for comment, a spokesperson for the Executive Office of Health and Human Services responded with the following statement:

“The Baker-Polito Administration commissioned an independent report by Attorney Mark Pearlstein to investigate the circumstances that led to the tragedy at the Soldiers’ Home in Holyoke and multiple investigations, including one by the Legislature and another by the Attorney General, reached many of the same conclusions, that failures by Bennett Walsh and senior medical team members led to the outbreak. The Administration is reviewing the report from the Inspector General, which identified several recommendations that have already been addressed by the Department of Veterans’ Services and the Soldiers’ Home. The Administration filed legislation almost two years ago to strengthen oversight of the soldiers’ homes and looks forward to addressing these issues with the Legislature.”

You can read the full IG report is here.

This is a developing story. Check back for updates as more information becomes available.

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