In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has conducted a performance audit of certain activities of the Veterans Home at Holyoke (VHH) for the period July 1, 2020 through June 30, 2023.
We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.
Below is a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings.
| Objective | Conclusion |
|---|---|
| 1. Did VHH provide safe, effective veteran care and document rounding in accordance with its NSG-113 Intentional Rounding Policy? | No; see Finding 1 |
| 2. Did VHH follow its ADMIN-041 Incident/Occurrence Report Policy to handle incidents involving veterans and determine whether the nurses involved in the incidents had professional licenses to provide care to veterans? | Yes |
| 3. Did VHH’s system for tracking patient records operate effectively in accordance with Section 150.013(c) of Title 105 of the Code of Massachusetts Regulations (CMR)? | No; see Finding 3 |
| 4. Did VHH have an emergency operation plan (EOP) in place duringthe audit periodand has it been updated to address the risks involved in providing adequate patient care during an emergency in accordance with 105 CMR 150.015(E)? | No; see Findings 2a, 2b, and 2c |
| 5. Did VHH expend COVID-19 funds in accordance with requirements established by the American Rescue Plan Act? | Yes |
To accomplish our audit objectives, we gained an understanding of the VHH internal control environment relevant to our objectives by reviewing VHH’s policies and procedures, as well as by conducting inquiries with its staff members and management. We also tested the operating effectiveness of the Finance Department’s approval control related to expenditures of COVID-19 funds.
Veteran Safety
To determine whether VHH provided safe, effective veteran care and documented rounding in accordance with NSG-113 Intentional Rounding Policy, we obtained a list of veterans who were at VHH during the audit period. We selected a nonstatistical,5 random sample of 35 veterans out of a population of 218.
Next, we obtained the medical record for each veteran in our sample and reviewed the Intentional Rounding Logs to determine whether the licensed professional nursing staff members performed rounds every hour between 6:00 am and 10:00 pm and every two hours between 10:00 pm and 6:00 am.
Based on the results of our testing, we determined that VHH did not provide safe, effective veteran care in accordance with its NSG-113 Intentional Rounding Policy. See Finding 1 for more information.
Incident Reporting
To determine whether VHH followed its ADMIN-041 Incident/Occurrence Report Policy to handle incidents involving veterans, we obtained a log of all incidents that occurred during the audit period. We filtered the incident log to only include incidents that directly affected the care of a veteran. These incident types included falls, medical incidents (medication errors or reactions to medication), and veteran care (neglect or abuse). Below is a chart that breaks down the number of each type of incident in our population.
| Incident Type | Count |
|---|---|
| Falls | 466 (49%) |
| Medical | 357 (37%) |
| Veteran Care | 131 (14%) |
| Total | 954 |
We selected a nonstatistical, random sample of 60 incidents out of a population of 954. We reviewed the hardcopy incident reports and any accompanying documents, such as staff member statements, witness statements, veteran care plans, veteran treatment records, and veterans’ Medication Administration Records. We determined whether the details of the incident were recorded on the Incident Report form, whether a veteran care coordinator or supervisor reviewed the form, and whether a veteran care coordinator or supervisor completed the assessment and follow-up sections and signed the form. We also reviewed each veteran’s medical record to determine whether there was a reference to the incident in the record describing what occurred and the results of the evaluation and treatment provided.
In addition, we examined the licensing documentation of licensed nursing professionals involved in each incident in the sample to ensure that all nursing professionals were properly licensed.
Based on the results of our testing, we determined that VHH had no significant issues in documenting the incidents according to its policy and that all nursing professionals were properly licensed. Examples of actions VHH has taken for veterans who have fallen include increased rounding, bed rails, bed alarms, and non-slip socks. For medical errors, VHH has provided re-education to clinical staff members and contacted veterans’ physicians for new prescription orders. For veteran care incidents, VHH has provided medical care, interviews, and re-education to clinical staff members who were involved.
Medical Records
To determine whether VHH patient record files contained all required information in accordance with 105 CMR 150.013(C), we obtained a list of veterans who were at the home during the audit period. We selected a nonstatistical, random sample of 35 veterans from a population of 218. To complete our testing, we requested the hardcopy medical records for each veteran in our sample. We determined whether the medical records contained the following documentation: the Summary Sheet, referral intake information, admission data, medical evaluation, progress notes, consultation reports, medication and treatment records, nursing care plans, nursing notes, periodic reviews, lab reports, personal effects, and discharge information.
Our testing did not reveal any exceptions with veteran medical records; however, VHH has not implemented an electronic health record system and still relies on paper medical records. See Finding 3 for more information.
EOP
To determine whether VHH had an 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), we obtained and reviewed a copy of VHH’s fiscal year 2022 and fiscal year 2023 EOPs and their attachments from VHH. Next, we performed the following procedures:
- We conducted a tour of VHH to determine whether there was a written plan in place and whether there were copies posted throughout the facility.
- We reviewed the hardcopy EOP contained in the incident command center to determine whether the plan detailed which people should be notified and when; the location of alarm signals, fire extinguishers, and evacuation routes; procedures for evacuation of veterans; and assignment of responsibilities to the personnel of each shift.
- We reviewed the sign-in sheets from the annual Safety Fair to determine whether personnel were trained to perform assigned tasks.
- We reviewed After Action Reports to determine whether staff members conducted a minimum of two drills per year per shift.
- We reviewed After Action Reports to determine whether a reliable means of communication was always available for sending and receiving information from the Department of Public Health.
In addition, we reviewed the sign-in sheets from the annual Safety Fair to determine whether VHH senior leadership received training on the EOP.
Based on the results of our testing, VHH’s EOP did not meet the requirements of 105 CMR 150.015(E). See Findings2a, 2b, and 2cfor more information.
COVID-19 Funds
To determine whether VHH expended COVID-19 funds in accordance with requirements established by the American Rescue Plan Act, we obtained a list of expenditures from VHH during the audit period. We then filtered the data to include only expenditures using COVID-19 funds. We selected a nonstatistical, random sample of 40 COVID-19 expenditures (totaling $215,984.49) from a population of 512 (totaling $2,527,263.57) that were appropriated from COVID-19 funds during the audit period. For our sample, we reviewed supporting documentation, including receipts, purchase orders, invoices, bills, and time sheets to determine whether the COVID-19 funds had been used for the following:
- to replace lost public sector revenue;
- to support the COVID-19 public health and economic response;
- to provide premium pay for eligible workers performing essential work; or
- to make necessary investments in water, sewer, and broadband infrastructure.
Based on the results of our testing, we did not identify problems related to VHH’s expenditure of COVID-19 funds during the audit period.
We used nonstatistical sampling for all our objectives; therefore, we did not project the results to the populations.
Data Reliability Assessment
In 2022, the Office of the State Auditor performed data reliability assessments of the Massachusetts Management Accounting and Reporting System (MMARS) focused on testing selected system controls (access, security awareness, audit and accountability, configuration management, identification and authentication, as well as personnel security). In addition, as part of our current audit, we tested controls in place over VHH’s personnel security. Further, we selected a random sample of 20 invoices from VHH’s files and determined whether the information on the invoices matched the data in MMARS. We also selected a random sample of 20 transactions from MMARS and traced the information to physical documentation (invoices).
To determine the reliability of data from the incident log of all incidents involving veterans that occurred at VHH during the audit period, July 1, 2020 through June 30, 2023, we traced a sample of 20 incidents from the incident log to the incident reports and selected 20 incident reports to trace back to the incident log.
To determine the reliability of the data from the list of all veterans at VHH during the audit period that we obtained from VHH, we traced a sample of 20 veterans from the list to veteran files and selected 20 veteran files that we traced back to the list. In addition, we conducted tests to identify any duplicates to determine the integrity of the information on the list.
Based on the results of the data reliability assessment procedures described above, we determined that all data we obtained during the course of our audit was sufficiently reliable for the purposes of our audit.
| Date published: | January 14, 2026 |
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