We identified several issues regarding VHC’s access to and understanding of its emergency operations plan (EOP), leading to multiple findings detailed below.
A. The Veterans Home at Chelsea violated state regulation (Section 150.015(E)(4) of Title 105 of the Code of Massachusetts Regulations) by not conducting simulated emergency drills for all shifts.
VHC did not perform simulated drills of its EOP for all shifts at least twice a year; however, VHC did perform one drill in 2022 for day shift employees and two drills in 2023 for day shift employees.
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.
Authoritative Guidance
According to 105 CMR 150.015(E)(4), “Simulated drills testing the effectiveness of the plan shall be conducted for all shifts at least twice a year.”
Reasons for Issue
VHC officials stated that they were not aware that they needed to conduct simulated drills on all shifts.
Recommendation
VHC should ensure that it conducts simulated emergency drills for all shifts at least twice a year.
Auditee’s Response
During the audit period (July 1, 2021 – June 30, 2023), [Massachusetts Veterans Home (MVH)] Chelsea was not yet a [Department of Public Health (DPH)]-licensed facility and therefore was subject to 38 C.F.R. 51.200 life-safety requirements rather than 105 CMR 150. Following enactment of An Act Relative to the Governance Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes ([Chapter 144 of the Acts of 2022]), MVH Chelsea obtained DPH licensure on September 28, 2023.
Prior to licensure, the Home complied with [National Fire Protection Association] 101 Life Safety Code standards, including quarterly emergency drills for all shifts. Under [the Executive Office of Veterans Services’] oversight, fire safety training is now conducted annually and during employee orientation, and fire-emergency drills are conducted at least twice per year on each shift.
MVH Chelsea also participates in semi-annual Emergency Management Exercises, including an annual statewide drill coordinated through the Massachusetts Long Term Care Mutual Aid Plan (MassMAP). The Home routinely updates its emergency procedures and has recently revised its “Code Yellow” (Missing Veteran) plan, conducting drills on all three shifts.
Auditor’s Reply
We disagree that VHH was not subject to 105 CMR 150 because 105 CMR 150.001 defines a long-term care facility as the following:
Any institution whether conducted for charity or profit that is advertised, announced or maintained for the express or implied purpose of providing four or more individuals admitted thereto with long-term resident, nursing, convalescent or rehabilitative care; supervision and care incident to old age for ambulatory persons; or retirement home care for elderly persons. Long-term care facility shall include convalescent or nursing homes, rest homes, infirmaries maintained in towns and charitable homes for the aged. Facility as used in 105 CMR 150.000, shall mean a long-term care facility or unit thereof and units within acute hospitals converted under provisions of [Section 32 of Chapter 23 of the Acts of 1988].
While VHC does not agree that it was subject to Department of Public Health regulations during the audit period, based on its response, VHC is taking measures to address our concerns regarding this matter. As part of our post-audit review process, we will follow up on this matter in approximately six months.
B. The Veterans Home at Chelsea violated state regulation (Section 150.015(E)(1) of Title 105 of the Code of Massachusetts Regulations) by not posting its emergency operations plan throughout the facility.
VHC’s EOP was not posted at nurses’ and attendants’ stations and in conspicuous locations throughout the facility.
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.
Authoritative Guidance
According to 105 CMR 150.015(E)(1),
Every facility shall have a written plan and procedures to be followed in case of fire, or other emergency, developed with the assistance of local and state fire and safety experts, and posted at all nurses’ and attendants’ stations and in conspicuous locations throughout the facility.
Reasons for Issue
The staff members we spoke to at VHC stated that they do not have access to the EOP, and VHC management explained that staff members did not have access to the EOP due to the sensitive information contained in it.
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.
Auditee’s Response
During the audit period, [the Massachusetts Veterans Home (MVH)] Chelsea was governed by federal rather than [Department of Public Health (DPH)] regulations. In preparation for DPH licensure of the new Community Living Center (CLC), MVH Chelsea engaged Jensen Hughes: Safety, Security & Risk Consulting Services to update and finalize its EOP. The new, 500-page plan was completed in September 2023.
Hard copies are maintained in the Incident Command Center and the Director of Environment of Care’s office, while digital copies reside on a shared network drive. One-page “Quick Reference Guides” summarizing emergency procedures are posted at every nurse’s station and throughout the facility. An EOP icon is also being installed on all staff computer desktops for instant digital access.
Section D of the [new] EOP includes Evacuation Floor Plans, and Appendix E includes Evacuation Route Maps. The Chelsea Life Safety Plans, updated on May 1, 2023 identify all fire-extinguisher locations. Staff receive training on these safety elements during orientation, annually, and during scheduled emergency drills.
Auditor’s Reply
We disagree that VHH was not subject to 105 CMR 150 because 105 CMR 150.001 defines a long-term care facility as the following:
Any institution whether conducted for charity or profit that is advertised, announced or maintained for the express or implied purpose of providing four or more individuals admitted thereto with long-term resident, nursing, convalescent or rehabilitative care; supervision and care incident to old age for ambulatory persons; or retirement home care for elderly persons. Long-term care facility shall include convalescent or nursing homes, rest homes, infirmaries maintained in towns and charitable homes for the aged. Facility as used in 105 CMR 150.000, shall mean a long-term care facility or unit thereof and units within acute hospitals converted under provisions of [Section 32 of Chapter 23 of the Acts of 1988].
While VHC does not agree that it was subject to Department of Public Health regulations during the audit period, the audit team was able to confirm that policies and procedures were located at the nursing stations; however, several nursing staff members told us that they were not aware of the EOP and where it was located. Based on its response, VHC is taking additional measures to address our concerns regarding this matter and as part of our post audit review process, we will follow up on this matter in approximately six months.
C. The Veterans Home at Chelsea violated state regulation (Section 150.015(E)(2) of Title 105 of the Code of Massachusetts Regulations) by its emergency operations plan not containing the locations of alarm signals, fire extinguishers, and evacuation routes.
VHC’s EOP does not contain the location of alarm signals, fire extinguishers, and evacuation routes at VHC.
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.
Authoritative Guidance
According to 105 CMR 150.015(E)(2),
The plan shall specify persons to be notified, locations of alarm signals and fire extinguishers, evacuation routes, procedures for evacuating residents, and assignment of specific tasks and responsibilities to the personnel of each shift.
Reasons for Issue
VHC stated that the alarm signals, fire extinguishers, and evacuation routes are posted throughout the facility, and it was not aware that they needed to be in the EOP.
Recommendation
VHC should add the locations of alarm signals, fire extinguishers, and evacuation routes to its EOP.
Auditee’s Response
Section D of the [new] EOP includes Evacuation Floor Plans, and Appendix E includes Evacuation Route Maps. The Chelsea Life Safety Plans, updated on May 1, 2023 identify all fire-extinguisher locations. Staff receive training on these safety elements during orientation, annually, and during scheduled emergency drills.
Auditor’s Reply
Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months as part of our post-audit review process.
D. The Veterans Home at Chelsea did not train employees to perform assigned duties, specifically concerning emergency preparedness.
VHC does not train its employees on their duties during an emergency. VHC stated that each employee is trained on the definitions of specific codes—for example, code colors and their meanings—but not on their responsibilities during an emergency.
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.
Authoritative Guidance
According to 105 CMR 150.015(E)(3), “All personnel shall be trained to perform assigned tasks.”
Reasons for Issue
VHC stated that it plans to implement an annual training fair for all employees; however, it has not been implemented yet.
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.
Auditee’s Response
In July and August 2023, [a fire protection consulting firm] conducted comprehensive training on the newEOP with staff from every department at [Massachusetts Veterans Home] Chelsea. All new staff receive emergency preparedness training during orientation, and annual refresher courses address the most likely scenarios, including:
- Fire
- Missing Resident (Veteran)
- Dangerous or Threatening Situation
- Medical Emergency Response
- Unresponsive Resident
The Home has also acquired new Med Sleds and Evacuation Chairs to expedite safe evacuation. Training on this equipment, conducted with the Chelsea Fire Department, is underway for all staff.
Auditor’s Reply
Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months, as part of our post-audit review process.
| Date published: | January 14, 2026 |
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