News  Report on the Holyoke Soldiers’ Home, May 2016 to February 2020

The Holyoke Soldiers’ Home (Home) is a facility for veterans that provides long-term, hospice, dental and outpatient care. Delivering these important healthcare and residential services requires effective leadership, oversight, procedures, staffing and operations. 

The Legislature created the Office of the Inspector General (Office), the first statewide inspector general’s office in the nation, with the mandate to promote good government by preventing and detecting the misuse of public funds and public property.  

In keeping with this mission, the Office investigated the oversight, governance and management of the Home between May 2016 and February 2020. The Office began its investigation in 2019 after receiving an anonymous complaint raising several concerns about then-Superintendent Bennett Walsh. The Office’s investigation identified critical shortcomings in the management of the Home as well as concerns regarding the supervision of Superintendent Walsh.

The Office’s report on its investigation, Holyoke Soldiers’ Home, May 2016 to February 2020, details the Office’s findings and outlines a comprehensive blueprint for lasting improvements. As more fully described in its report, the Office found:

• The governor, secretary of the Executive Office of Health and Human Services (EHS) and the Home’s Board of Trustees (Board) did not follow the statute that gives the Board the power to appoint the superintendent. Rather, the Board recommended three candidates, the EHS secretary met only with Mr. Walsh and the governor appointed him as the Home’s superintendent.
• Superintendent Walsh did not have and did not develop the leadership capacity or temperament for the role of superintendent. He created an unprofessional and negative work environment, retaliated against employees he deemed disloyal, demonstrated a lack of engagement in the Home’s operations and circumvented his chain of command.
• EHS and Department of Veterans’ Services (DVS) officials failed to adequately address serious complaints by senior managers and others at the Home. Administration officials, primarily at EHS, failed to recognize that the recurring complaints indicated that Superintendent Walsh did not have the leadership skills or temperament to lead the Home.
• EHS undertook two investigations of Superintendent Walsh’s actions during his four-year tenure but those investigations were flawed, unnecessarily restricted in scope and biased in Superintendent Walsh’s favor.

In the report, the Office makes recommendations to fix longstanding structural problems, address fundamental flaws related to oversight, and strengthen management and accountability. The legislative recommendations include:

• DVS, which is currently within EHS, should be elevated to a cabinet-level secretariat. One person must be responsible for the oversight and management of the superintendent; one person must have the authority and responsibility to appoint, supervise, discipline and remove the superintendent. The DVS Secretary should have this authority and responsibility for the superintendents at the Soldiers’ Homes in Holyoke and Chelsea (together the Soldiers’ Homes).
• Superintendents of the Soldiers’ Homes must meet certain requirements, including being licensed nursing home administrators with extensive management experience.
• The Department of Public Health (DPH) should have the authority and funding to provide independent clinical oversight and support for the Soldiers’ Homes.
• DVS should establish an ombudsperson and a hotline to allow confidential reporting by residents, relatives, staff and concerned citizens.

The Office’s investigation focused on leadership, management and oversight at the Home during the period May 2016 to February 2020. As the devastating impacts of the pandemic on the Home in March 2020 became clear, the Massachusetts Office of the Attorney General and the United States Attorney’s Office for the District of Massachusetts announced investigations into the events related to COVID-19. The Office did not conduct its own investigation into these events; such an investigation would have fallen outside of the Office’s mandate and expertise.

This report is only one piece of a larger effort by the Office to address issues related to both Soldiers’ Homes. The Office has made outreach to the Legislature a priority and has made extensive recommendations to the Legislature. The recommendations include critical changes to the oversight and management of the Soldiers’ Homes; they also provide for accountability and appropriate supervision of the superintendents. The Legislature has adopted many of the Office’s recommendations.

For a copy of the full report, see: Holyoke Soldiers’ Home, May 2016 to February 2020