The Veterans Home at Chelsea (VHC) was established in 1882 and is a nursing facility that provides healthcare services for eligible veterans in the Commonwealth.
VHC’s name changed in March 2023 from “Soldiers’ Home” to “Veterans Home” to be more inclusive of all branches of the military. Authorized by Chapter 115A of the Massachusetts General Laws, VHC historically operated within the Department of Veterans Services, which was organized under the Executive Office of Health and Human Services (EOHHS). As of March 2023, VHC is now under the Executive Office of Veterans Services. According to its website, VHC’s mission is “to provide the highest quality personal health care services to Massachusetts veterans with dignity, honor, and respect.”
VHC operates a facility that consists of the new Community Living Center (CLC) and nine domiciliary buildings that are proposed for rehabilitation. The Quigley building was in use during most of the audit period and had previously been set to be demolished after the completion of the new CLC. The Quigley building is now under the control of EOHHS as an emergency shelter. The estimated total cost of the project at VHC is $201.2 million, and the estimated completion date is fall 2027. The new CLC building has 154 long-term care beds, and veterans began moving in on October 18, 2023.
VHC’s day-to-day operations are overseen by an executive director (previously referred to as the superintendent) who is appointed by and reports to the Secretary of Veterans Services. VHC’s executive director is responsible for managing the facilities and maintaining a high quality of care at VHC. VHC is licensed as a skilled nursing facility by the Department of Public Health and is fully accredited by the Joint Commission, which has a mission to continuously improve healthcare for the public.
VHC received the following budget appropriations for fiscal years 2022 and 2023, respectively, $36,100,637 and $49,295,995.
Previous Superintendent
The previous superintendent (executive director) of VHC, who served during the audit period, started in December 2020. After allegations of sexual harassment and bullying, he was placed on paid leave in June 2022 but later returned to the job in October 2022. According to a letter from the Massachusetts Inspector General, dated January 3, 2023, many serious problems existed at VHC, including that the superintendent “[lacked] the capacity and integrity to manage the Home.” The previous superintendent was fired in January 2023 by the Governor, and an acting superintendent was placed in charge of the home.
Issues with Previous Acting Director of Nursing
There were multiple investigations into the excessive amounts of overtime being paid to VHC’s acting director of nursing (ADON). These investigations revealed that the ADON was paid approximately $87,000 in overtime, making them one of the most highly compensated managers on the state payroll, according to The Boston Globe.1 Investigations have found that there were no overtime forms used for the ADON, and overtime approval was given verbally by the previous superintendent, who was also investigated for a number of issues related to not following VHC policies. An investigation by EOHHS found that the ADON often billed for hours that had not been worked at the home, had abused the telework policy, and had worked from locations that violated policies (for example, conducting meetings from the airport, other states, and places other than home). In addition, the EOHHS investigation revealed that the ADON received almost $15,000 in COVID-19 pandemic weekend bonuses that were inappropriately paid as telework when they were intended to be paid for direct care in VHC. However, according to its investigation, EOHHS could not substantiate that the ADON knowingly received these bonuses inappropriately.
Scheduling Nursing Staff Members
VHC does not have formal written policies and procedures for scheduling nursing staff members. However, through interviews with VHC staff members, we learned that schedules are created based on how many veterans reside in each unit and their individual needs. VHC schedules each unit with two certified nursing assistants2 and one registered nurse3 for each shift, which when calculated based on the number of veterans per unit put the hours per patient day at 5.3, exceeding the federal minimum of 2.5. VHC adds nursing staff members to a unit if a veteran requires 1:1 care, which is prescribed by the medical director through an assessment. This prescription for 1:1 care can be found in the veteran’s medical file. In addition, VHC has assignment sheets for each month broken down by shift and unit. The charge nurse is responsible for assigning duties to each scheduled nurse. These assignments are created based on the daily nurse care plan. The assignment sheets include specific responsibilities for each nurse, for example, which veterans need 1:1 care, medications needed, if a veteran needs side rails, the type of assistance they need, and who is a fall risk.
Schedules are developed on paper two weeks in advance by a scheduler and are managed by supervisors and the director of nursing. In an effort to minimize cross-contamination of illnesses such as COVID-19, staff members do not work between floors or units. Nurses’ hours per patient day are verified against the schedule to ensure that there is sufficient staffing for each unit. The supervisors for day, evening, and night shifts are responsible for ensuring that scheduled staff members report to their shifts or the supervisors need to find replacements. Furthermore, supervisors manage situations in which staff members call out of a shift or do not call and do not arrive for a shift. When managing these situations, a supervisor calls the next shift employees to see if they can come in early, calls unscheduled staff members to see if they can come in, or asks employees from the previous shift if they can stay. Staff members cannot leave until a replacement has been confirmed. Supervisors note any changes to the original schedule on the Daily Staffing Sheet.4 The only people who have access to change the schedule are the supervisors, and the schedule is kept in the director of nursing’s office.
Nursing Staff Member Overtime
In our previous audit of VHC (Audit No. 2020-0065-3S), issued before the overtime scandal described above, our office made the following recommendations:
- [VHC] should enhance its policies and procedures by establishing monitoring controls to ensure that it properly documents the need and prior approval for overtime worked and that its supervisors properly complete the Daily Staffing Schedules and Weekly Overtime Summary Forms.
- [VHC] should create policies and procedures to require overtime documentation to be retained for at least six years in accordance with the Massachusetts Statewide Records Retention Schedule.
- [VHC] should enhance its overtime policies, procedures, and processes to apply the same rules to incremental overtime that apply to other overtime.
To address our recommendations, VHC updated its overtime policy as of December 2022 to include an Overtime Committee. According to VHC’s policy, the Overtime Committee meets biweekly to review overtime reports and discuss the use of overtime for each department, incremental overtime, excessive overtime, approval forms, and staffing vacancies. The committee includes department managers, the budget director, the chief financial officer, and the deputy executive director.
The budget director acts as the chair of the Overtime Committee and is required to meet with the executive director and the director of nursing at least quarterly to review all approved and denied overtime.
In addition to running the Overtime Committee, according to Section 5(G) of VHC’s Overtime Policy 180-11-2022-A,
The Budget Director shall:
a. Submit overtime reports tracking total spending and bi-weekly utilization by employee to the Superintendent; and
b. Review the overtime utilization report with the Department Heads and Supervisors.
In addition, VHC added to its policy that the budget director should retain the overtime request forms for a minimum of six years. Finally, incremental overtime was specifically added to VHC’s Overtime Policy and required an overtime request form.
Requesting Overtime
Each department head or supervisor is responsible for making sure that each floor is sufficiently staffed. Overtime is dispersed based on a rotation of seniority that has been agreed upon by the nurse’s union. The nursing staff members have a set daily schedule, and it is updated as changes occur. If a department head or supervisor determines that overtime is needed, VHC has an overtime request form that staff members need to fill out and get approved by the department head or supervisor before they work the overtime. In addition, department heads and supervisors are responsible for addressing overtime worked by staff members without being approved by supervisors. If there are repeated occurrences, a supervisor can issue an informal warning or provide coaching to the staff member.
Below are the different types of overtime that we looked at during our audit.
Premium and Straight Overtime
Premium overtime is work that exceeds eight hours per day or 40 hours per week; it is paid at more than the standard hourly rate. In contrast, straight overtime is work that exceeds a worker’s scheduled hours but does not exceed eight hours per day or 40 hours per week; it is paid at the standard hourly rate.
Callback Premium and Callback Straight Overtime
Callback overtime is time earned by an employee who has been called after a shift to answer questions remotely or who has been requested to come back into work physically. At VHC, remote questions result in a minimum of two hours of overtime,5 while coming in physically results in a minimum of four hours of overtime. The overtime earned would either be straight or premium time, depending on the hours worked by the employee. If the employee is designated as part time (under 40 hours) then the overtime is straight (i.e., paid at their normal hourly rate). If the employee is designated as full-time (40 hours), then the overtime is premium (i.e., paid at a higher rate than their normal hourly rate).
Incremental Overtime
VHC nursing staff members can accumulate incremental overtime by clocking in early before shifts, clocking out late after scheduled shifts, and/or not clocking out for unpaid meal periods. In our previous audit of VHC, we recommended that VHC “enhance its overtime policies, procedures, and processes to apply the same rules to incremental overtime that apply to other overtime.” VHC has updated its policy on overtime to treat incremental overtime the same as other overtime, requiring the home to document the need and approval.
Below is a summary of overtime paid to nursing staff members during the audit period.
| Position | Sum of Overtime Paid | Sum of Overtime Hours Worked | Number of Employees |
|---|---|---|---|
| Licensed Practical Nurse II | $696,580 | 14,552 | 34 |
| Nursing Assistant I | 536,869 | 16,834 | 114 |
| Registered Nurse III | 263,966 | 3,202 | 12 |
| Registered Nurse II | 260,281 | 3,341 | 20 |
| Registered Nurse IV | 183,178 | 2,315 | 4 |
| Nurse Practitioner | 145,999 | 1,708 | 2 |
| Licensed Practical Nurse I | 140,456 | 2,950 | 10 |
| Registered Nurse V | 117,543 | 1,290 | 4 |
| Nursing Assistant II | 20,727 | 618 | 1 |
| Registered Nurse I | 3,979 | 60 | 3 |
| Grand Total | $2,369,578 | 46,870 | 204 |
Emergency Operations Plan
VHC has an emergency operations plan (EOP) that outlines actions to take in case of a manmade or natural disaster or other emergencies that present imminent danger of death or serious physical harm of a veteran. This plan also helps address the medical and physical needs of its staff members and veterans during an emergency. VHC’s EOP establishes the procedures, responses, and infrastructure required to maintain safety for all of VHC’s staff members and veterans. The EOP addresses four phases of its management processes, specifically, mitigation, preparedness, response, and recovery. The EOP was developed by the VHC leadership team and the safety committee, which includes medical staff members and local public safety and emergency management teams (e.g., the local fire department). Each staff member is trained on their specific role and responsibilities during an emergency, which helps VHC staff members provide a safe and dignified response to emergencies.
| Date published: | January 14, 2026 |
|---|