We identified several issues regarding VHH’s access to and understanding of its emergency operation plan (EOP), leading to multiple findings detailed below.
A. The Veterans Home at Holyoke violated state regulation by not conducting simulated emergency drills for all shifts.
VHH did not perform simulated drills of its EOP for all shifts at least twice a year; however, VHH did perform two drills each year for day shift employees during the audit period.
Without 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.
Authoritative Guidance
According to Section 150.015(E)(4) of Title 105 of the Code of Massachusetts Regulations (CMR), “Simulated drills testing the effectiveness of the plan shall be conducted for all shifts at least twice a year.”
Reasons for the Issue
VHH officials stated that, during the audit period, VHH was not licensed as a long-term care facility or nursing home under the Department of Public Health (DPH), so it operated in accordance with the US Department of Veterans Affairs and the Joint Commission’s guidelines instead of DPH’s guidelines. However, our office disagrees and believes VHH is subject to 105 CMR 150.
Auditee’s Response
During the audit period July 1, 2020, through June 30, 2023, the Veterans Home at Holyoke did not fall under 105 CMR 150 but was subject to life safety requirements in [Section 51.200 of Title 38 of the Code of Federal Regulations]. Pursuant to An Act Relative to the Governance Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes, [Chapter 144 of the Acts of 2022], the Veterans Home at Holyoke became a Department of Public Health licensed nursing facility on July 25, 2024. Prior to July 25, 2025, the Veterans Home at Holyoke was compliant with [National Fire Protection Association (NFPA)] 101. NFPA 101 involves many standards related to Life Safety & Fire Safety Standards including Emergency Drills that were conducted for all shifts each quarter. These drills have been under scrutiny of an annual [Veterans Affairs] regulatory survey from which the home did not receive any citation during that period. The Home currently has added its emergency operations plan onto every computer desktop throughout the facility. Additionally, staff are trained in the emergency operations plan by the Director of Facilities during new hire orientation and during their annual Safety Fair each March.
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 VHH does not agree that it was subject to DPH regulations during the audit period, based on its response, VHH 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 Holyoke violated state regulation (Section 150.015(E)(1) of Title 105 of the Code of Massachusetts Regulations) by not posting its emergency operation plan throughout the facility.
VHH’s EOP was not posted at nurses’ and attendants’ stations and in conspicuous locations throughout the facility. The staff we spoke to at the nurses’ stations we visited did not know where the plan was or how to access the plan online.
Without 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.
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 the Issue
VHH officials stated that, during the audit period, VHH was not licensed as a long-term care facility or nursing home under DPH, so it operated in accordance with the US Department of Veterans Affairs and the Joint Commission’s guidelines disregarded DPH’s guidelines. However, our office believes VHH is subject to 105 CMR 150.
Auditee’s Response
During the audit period July 1, 2020, through June 30, 2023, the Veterans Home at Holyoke did not fall under 105 CMR 150 but was subject to life safety requirements in [Section 51.200 of Title 38 of the Code of Federal Regulations]. Pursuant to An Act Relative to the Governance Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes, [Chapter 144 of the Acts of 2022], the Veterans Home at Holyoke became a Department of Public Health licensed nursing facility on July 25, 2024. The Home currently has added its emergency operations plan onto every computer desktop throughout the facility. Additionally, staff have been trained in its emergency operations plan by the Director of Facilities. The Emergency Operations Plan is located on the HLY Shared Drive and in the Incident Command Center.
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 VHH does not agree that it was subject to DPH regulations during the audit period, based on its response, VHH 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.
C. The Veterans Home at Holyoke violated state regulation (Section 150.015(E)(2) of Title 105 of the Code of Massachusetts Regulations) by its emergency operation plan not containing the locations of alarm signals, fire extinguishers, and evacuation routes.
VHH’s EOP does not contain the location of alarm signals, fire extinguishers, and evacuation routes at VHH.
If 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.
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 the Issue
VHH officials stated that, during the audit period, VHH was not licensed as a long-term care facility or nursing home under DPH, so it operated in accordance with the US Department of Veterans Affairs and the Joint Commission’s guidelines instead of DPH’s guidelines. However, our office disagrees and believes VHH is subject to 105 CMR 150.
Recommendations
- VHH should ensure that it conducts simulated emergency drills for all shifts at least twice a year.
- 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.
- VHH should add the locations of alarm signals, fire extinguishers, and evacuation routes to its EOP.
Auditee’s Response
During the audit period July 1, 2020, through June 30, 2023, the Veterans Home at Holyoke did not fall under 105 CMR 150 but was subject to life safety requirements in [Section 51.200 of Title 38 of the Code of Federal Regulations]. Pursuant to An Act Relative to the Governance Structure and Care of Veterans at the Commonwealth’s Veterans’ Homes, [Chapter 144 of the Acts of 2022], the Veterans Home at Holyoke became a Department of Public Health licensed nursing facility on July 25, 2024. In preparation for licensure, the Holyoke Veterans Home engaged Code Red Consultants to guide the facility through Fire Safety Evaluation System life safety requirements. Code Red made several recommendations to the facility on April 10, 2024, which were promptly implemented. The Home currently has Evacuation Route signs throughout the building including all Veteran occupied units. These Evacuation Route signs also contain the location of the fire alarm pull stations and fire extinguishers for that area. Copies of the Evacuation Route signs have been added to the Emergency Operations Plan.
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 VHH does not agree that it was subject to DPH regulations during the audit period, based on its response, VHH 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.
| Date published: | January 14, 2026 |
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