BOSTON — Gov. Charlie Baker on Thursday issued a series of reforms aimed at improving conditions at the Holyoke Soldier's Home in the wake of Wednesday's scathing report on how mismanagement, neglect and miscommunication led to the deaths by COVID-19 of 76 veterans and the illnesses of another 84 patients and 80 staff members.

Meanwhile, leaders in the state Legislature, including state Rep. Linda Dean Campbell, D-Methuen, who chairs the joint committee on Veterans and Federal Affairs, are launching their own investigation into the tragic breakdown at the facility.

Campbell and House Speaker Robert DeLeo announced late Wednesday the creation of a joint committee that will not only investigate what happened at the home during the months of March and April, but  also comb through the other investigations currently underway.

Attorney Mark Pearlstein’s report, commissioned by the governor in April and released publicly Wednesday, is just one of numerous investigations occurring into the tragedy at the Soldiers’ Home. The state attorney general and the U.S. attorney are conducting their own investigations, as are the state inspector general and auditor.

The impact of Pearlstein's report was immediate, leading to the resignation of Francisco Urena from his position as secretary of Veterans' Services. Urena, a former Lawrence resident, was at one time the director of the veterans' division in his hometown, where he remains much beloved and considered a true success story, having gone from being a Dominican immigrant to the top echelons of state government.

But the report found that Urena, a decorated war hero, neglected his job of overseeing the home and its superintendent, leading to the catastrophic deaths of veterans. 

On Thursday, Baker issued a detailed outline of changes and recommendations for the oversight and staffing of the Holyoke facility, including such things as filling the position of executive director/assistant secretary of Veterans' Services, a post that had remained vacant under Urena's administration because he said he didn't have the funding for it. The job was posted June 24.

The governor has also proposed changes to the Soldiers’ Homes’ Board of Trustees, which was also found to have fallen short in its oversight role of the superintendent of the Holyoke home.

Baker's plan looks at beefing up staffing to create a "permanent staffing schedule" at the home. Pearlstein's report found that inadequate staffing may have led to the transmission of COVID-19 among patients and employees.

He also wants to implement an electronic health record system, something that Pearlstein's report showed was nonexistent at the facility.

The new posting for the position of superintendent of the Holyoke Soldiers’ Home will include a preference for hiring a licensed nursing home administrator, Baker suggested. Former administrator Bennett Walsh had no such experience, Pearlstein found.

Campbell said Thursday that she welcomed the governor's proposed changes, as well as Pearlstein's report, noting that “as a veteran, the most difficult part of this report to accept was that most of these deaths were preventable and that many of these veterans died in a horrific manner.”

Campbell served in the United States Army for eight years, first in Germany for six years followed by two years as a paratrooper and an Intelligence Officer with the 525th Military Intelligence Brigade (Airborne), VIIIth Airborne Corps at Fort Bragg, North Carolina. 

DeLeo said he was "shocked and disturbed" by the findings of the independent investigation.

"This report lays bare that mismanagement and ineptitude, both administratively and clinically, on multiple levels is to blame for the deaths of at least 76 of our heroes and the illness of 84 more heroes, as well as 80 staff members," he said.

He added that now that the report has been completed, "I am going to recommend to the full House that next week we adopt Chairwoman Campbell’s proposal to form a Special Legislative Oversight Committee to conduct its own investigation of the COVID19 Outbreak at the Soldiers’ Home in Holyoke."

While it was her idea to establish the legislative oversight committee, it's unclear at this point whether she will actually lead the special committee, Campbell said Thursday. She said more will be known next week about the makeup of the committee, but that in any case, her committee will have an integral role in the investigation into what happened at the Soldier's Home.

"What's most important to me, is that it's very important we get the assets we need to conduct our investigation and make meaningful recommendations to the Legislature," she said. "This cannot be a quick couple of hearings and done. Veterans are expecting change and expecting to be heard and for that change to be substantial."


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