| Organization: | Office of the State Auditor |
|---|---|
| Date published: | January 14, 2026 |
Executive Summary
In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has performed an audit of the Veterans Home at Chelsea (VHC) for the period July 1, 2021 through June 30, 2023.
In this performance audit, we examined whether VHC implemented recommendations from our prior audit report (Audit No. 2020-0065-3S), issued on March 30, 2021. Specifically, we determined the following:
- whether VHC has policies and procedures in place to ensure that the home had sufficient staffing to meet its veterans’ needs in accordance with Section 51.130 of Title 38 of the Code of Federal Regulations (CFR);
- whether VHC ensured that the need for nursing overtime was documented and approved in accordance with VHC’s Overtime Policy 180-11-2022-A; and
- whether VHC had an emergency operations plan (EOP) in place and whether that plan had been updated to address the risk involved in providing adequate patient care during an emergency in accordance with Section 150.015(E) of Title 105 of the Code of Massachusetts Regulations (CMR).
Below is a summary of our findings, the effects of those findings, and our recommendations, with links to each page listed.
| Finding 1 | VHC did not always meet the total nursing care needs for its veterans as determined by veterans’ assessments. |
| Effect | Failure to meet the needs of veterans, as determined by VHC’s own assessment of those needs, can lead to a variety of negative consequences for veterans, including an increased risk of mortality, physical decline, and infections, as well as emotional distress. It can also place excessive burdens on nursing staff members who are required to perform duties in excess of what was planned for during various shifts. |
| Recommendation | VHC should develop formal policies and procedures to ensure that all veterans’ nursing care needs are met based on their individualized plans of care and assessments. |
| Finding 2 | VHC did not always update its veterans’ assessments in accordance with 38 CFR 51.110(b)(2)–(3). |
| Effect | If VHC does not complete and review each veteran’s assessment, then VHC cannot ensure that it meets the nursing needs of each veteran in its care. |
| Recommendation | VHC should ensure that all assessments are completed within 14 days of admission and should review each veteran’s assessment at least once every three months. |
| Finding 3 | VHC did not properly maintain Nursing Department staffing records and incident logs, which may have impacted the quality of care it provided to veterans. |
| Effect | Without maintaining proper records, VHC cannot ensure that it is properly staffed and providing necessary care to veterans. Further, failure to maintain proper records can create liability for the Commonwealth, should VHC need to demonstrate the sufficiency or quality of the care it provided to a veteran. |
| Recommendation | VHC should ensure that it properly stores, and has available for review, all documentation related to staffing and incidents. |
| Finding 4 | VHC did not implement the monitoring controls recommended from our previous audit to ensure that it documents the need or approval for Nursing Department overtime, including incremental overtime, as required by its Overtime Policy 180-11-2022A. |
| Effect | If VHC does not monitor and properly document overtime occurrences, then there is a higher-than-acceptable risk of VHC incurring unnecessary overtime expenses. Based on our testing, we do not believe the overtime was unwarranted but, rather, that a large number of overtime occurrences indicate staffing shortages at VHC. |
| Recommendation | VHC should enhance its policies and procedures by establishing effective monitoring controls that are properly designed and implemented to ensure that it properly documents the need and prior approval for overtime, including incremental overtime worked. |
| Finding 5a | VHC violated state regulation (105 CMR 150.015(E)(4)) by not conducting simulated emergency drills for all shifts. |
| Effect | Without performing simulated emergency drills to test the effectiveness of its EOP, VHC cannot ensure that it has an effective response to disasters and emergencies, thereby jeopardizing the safety of veterans and hospital staff members. |
| Recommendation | VHC should ensure that it conducts simulated emergency drills for all shifts at least twicea year. |
| Finding 5b | VHC violated state regulation (105 CMR 150.015(E)(1)) by not posting its EOP throughout the facility. |
| Effect | Without its EOP posted in conspicuous locations, VHC is unable to ensure an effective response to disasters and emergencies that affect the environment of care and could impede the safety of veterans and hospital staff members. |
| Recommendation | VHC should ensure that its EOP is available at all nurses’ and attendants’ stations and is posted in conspicuous locations throughout the facility. VHC should also make its EOP accessible in digital form from all computer terminals. |
| Finding 5c | VHC violated state regulation (105 CMR 150.015(E)(2)) by its EOP not containing the locations of alarm signals, fire extinguishers, and evacuation routes. |
| Effect | If VHC’s EOP does not contain the location of alarm signals, fire extinguishers, and evacuation routes, then this could affect the timely and safe evacuation of veterans, staff members, and visitors in the event of a disaster. |
| Recommendation | VHC should add the locations of alarm signals, fire extinguishers, and evacuation routes to its EOP. |
| Finding 5d | VHC did not train employees to perform assigned duties, specifically concerning emergency preparedness. |
| Effect | Without training employees on tasks they must complete during an emergency, VHC cannot ensure that all employees are properly prepared to respond to disasters and emergencies, which may jeopardize the safety of veterans and employees at VHC in the event of an emergency. |
| Recommendation | VHC should include emergency disaster training as part of its annual training requirement to ensure that all VHC employees are properly trained to perform their duties during an emergency. |
Table of Contents
- List of Abbreviations in the Audit of the Veterans Home at Chelsea
- Overview of Audited Entity
- Objectives, Scope, and Methodology
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- Finding 1 - The Veterans Home at Chelsea did not always meet the total nursing care needs for its veterans as determined by veterans’ assessments.
- Finding 2 - The Veterans Home at Chelsea did not always update its veterans’ assessments in accordance with Section 51.110(b)(2)–(3) of Title 38 of the Code of Federal Regulations.
- Finding 3 - The Veterans Home at Chelsea did not properly maintain Nursing Department staffing records and incident logs, which may have impacted the quality of care it provided to veterans.
- Finding 4 - The Veterans Home at Chelsea did not implement the monitoring controls recommended from our previous audit to ensure that it documents the need or approval for Nursing Department overtime, including incremental overtime.
- Finding 5 - The Veterans Home at Chelsea’s emergency operations plan did not include all the required components, which could jeopardize the safety of veteran residents.
Downloads
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Open PDF file, 439.31 KB, Audit Report - Veterans Home at Chelsea (English, PDF 439.31 KB)