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Audit

Audit  Audit of the Veterans Home at Holyoke (January 14, 2026)

Our office conducted an audit of the Veterans Home at Holyoke (VHH) for the period July 1, 2020 through June 30, 2023.

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 Holyoke (VHH) for the period July 1, 2020 through June 30, 2023.

When assessing potential audit objectives related to the tragic losses that occurred at VHH during the COVID-19 pandemic, we examined the Pearlstein report (dated June 2020) and requested the supporting documentation, as we believed it would provide valuable insights for our audit. We attempted to add this as an audit objective, but the refusal of the Office of the Governor to provide us requested information prevented us from examining this matter, dating back to spring 2020.

In this performance audit, we sought to examine the facts and conditions that led to the loss of at least 76 veterans at VHH during the COVID-19 pandemic. This examination included requesting the interviews, interview notes, and other documentary evidence used to complete the Pearlstein Report, in order to better understand the significant management and safety issues at VHH that contributed to these tragic events during the COVID-19 pandemic. These documents were inappropriately withheld from our office. (See Other Matters.) However, we were able to examine other issues related to safety, including the following:

  • whether VHH provided safe, effective veteran care and documented rounding in accordance with its Intentional Rounding Policy;
  • whether VHH followed its policy on handling of veterans’ incidents; and whether the staff members involved in the incidents were properly licensed;
  • whether VHH’s system for tracking patient records was operating effectively in accordance with Section 150.013 of Title 105 of the Code of Massachusetts Regulations (CMR);
  • whether VHH had an emergency operation plan (EOP) in place during the audit period and whether it had been updated to address the risks involved in providing adequate patient care during an emergency in accordance with 105 CMR 150.015(E); and
  • whether VHH had controls in place over the receipt, expense, and reporting of COVID-19 funds in accordance with federal requirements.

Below is a summary of our findings, the effects of our findings, and our recommendations, with links to each page listed.

  
Finding 1VHH could not ensure that nurses performed intentional rounding, potentially resulting in an unsafe environment for veterans.
EffectIf intentional rounding is not being completed, then it could increase the risk of veterans having falls or other issues that could adversely contribute to veteran safety and well-being. As already noted (see the “Intentional Rounding” section), intentional rounding reduces falls by an estimated 36%. It is reasonable to conclude that the absence of intentional rounding, as shown here, increased the risk—and likely the number of injuries—while reducing the quality of care, for veterans at VHH.
Recommendations
  1. VHH should ensure that timely intentional rounding is performed and documented on Intentional Rounding Logs.
  2. VHH should establish monitoring controls to ensure that Intentional Rounding Logs are completed and maintained.
Finding 2aVHH violated state regulation by not conducting simulated emergency drills for all shifts.
EffectWithout performing simulated emergency drills to test the effectiveness of its EOP, VHH cannot ensure that it has an effective response to disasters and emergencies, thereby jeopardizing the safety of veterans and hospital staff members.
Finding 2bVHH violated state regulation (105 CMR 150.015(E)(1)) by not posting its EOP throughout the facility.
EffectWithout its EOP posted in conspicuous locations, VHH 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.
Finding 2cVHH violated state regulation (105 CMR150.015(E)(2)) by its EOP not containing the locations of alarm signals, fire extinguishers, and evacuation routes.
EffectIf VHH’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.
Recommendations
  1. VHH should ensure that it conducts simulated emergency drills for all shifts at least twice a year.
  2. VHH should ensure that its EOP is available at all nurses’ and attendants’ stations and is posted in conspicuous locations throughout the facility. VHH should also make its EOP accessible in digital form from all computer terminals.
  3. VHH should add the locations of alarm signals, fire extinguishers, and evacuation routes to its EOP.
Finding 3VHH does not use an electronic health record(EHR) system for veterans as required of other, similarly situated healthcare facilities.
EffectAccording to Centers for Medicare and Medicaid Services, there are multiple benefits to implementing an EHR system, including improved patient care. For example, an EHR system allows healthcare providers to access medical records in real time to provide accurate and timely care. An EHR system can reduce medical errors and delays in treatment and improve the accuracy and clarity of medical records and improve the security of medical records.
RecommendationWe recommend that VHH implement an EHR system as soon as possible.

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