State Auditor Diana DiZoglio Wednesday released the findings of an audit of soldiers’ homes in Chelsea and Holyoke that identified issues with safety and emergency planning at the long-term care facilities where more than 100 veterans died during the COVID-19 pandemic.
DiZoglio’s office also said it is considering taking legal action to acquire documents it was denied from a law firm hired by former Governor Charlie Baker that conducted an independent study of the state-run facilities amid the pandemic crisis.
The Holyoke audit covered the period between July 1, 2020 to June 30, 2023, and the Chelsea audit from July 1, 2021 to June 30, 2023.
A spokesperson for the state Office of Veterans Services could not immediately be reached to comment on the audit’s findings.
The audit is the latest examination of operations at the state facilities, which have come under intense scrutiny since the pandemic.
In 2020, the law firm of McDermott Will & Emery, LLP, was commissioned by the Baker administration to conduct a study focusing on the deaths at the Holyoke home during the epidemic. The report highlighted errors and failures of leadership that likely contributed to the elevated death toll during the outbreak.
The state auditor’s office requested interview notes and records that were used to compile the report and that would have been useful to the audit. But the documents “were unlawfully withheld,” DiZoglio’s statement said.
“Either this was an independent investigation, as was claimed, in which case, attorney-client privilege does not apply, or this was legal representation on behalf of the Governor, where Pearlstein was providing legal advice in anticipation of lawsuits,” DiZoglio said. “Both can’t be true simultaneously.”
“Lives were lost and families were devastated,” DiZoglio said. “It’s unacceptable to hide these records from auditors who have the legal authority to review them.”
DiZoglio demanded that the state auditor’s office be allowed to pick a lawyer of its choosing to oversee the matter.
“It’s critical that this matter be adjudicated and litigated by an attorney who is not beholden to this Administration — or the one prior,“ she said. ”Anything less is a denial of justice to all impacted by this tragedy.”
Speaking to reporters at the State House on Wednesday, Governor Maura Healey did not directly address the auditor’s allegations that the administration improperly withheld the records. She instead offered a general defense of her handling of the soldiers homes with an eye cast toward the homes’ futures.
Healey said she hasn’t yet looked at the auditor’s report but she is aware of the ground it covers.
“As Attorney General, we took action then, and I did as governor,” she said.
Healey said that as the state’s top law enforcement official she brought prosecutions in the Holyoke case against “individuals in that home who, in my view, had failed to provide” proper care.
“This was a tragic situation,” Healey said. “I have been a strong supporter of efforts to make sure that we’ve transformed our veterans homes here in Massachusetts, and I believe that we have.”
“Today, both in Holyoke and in Chelsea, we have world-class facilities staffed up where veterans are appropriately cared for and supported,” she continued. “And we’re going to continue to do everything that we can to support our veterans in Massachusetts.”
Since 1949, the Holyoke Soldiers’ Home provided care for veterans. During the epidemic, 76 veterans died there in what has been recorded as one of the deadliest COVID-19 outbreaks at a long-term care facility in the country.
At the Chelsea facility, 31 veterans died during the pandemic.
The veteran deaths prompted a myriad of investigations, terminations and resignations, regulatory reforms, and lawsuits.
Several of the investigations, including one by the Globe Spotlight team, found that gross mismanagement and underlying failures of communication between leadership at the facility and in state government led to what could have been preventable. The facility was run by Bennett Walsh, a politically connected hire with no prior health care experience, who was chosen by then-Governor Charlie Baker.
Decisions made by Walsh and others, described as “utterly baffling,” led to the deaths, many of the investigations concluded.
As attorney general, Healey brought criminal charges against Walsh and the facility’s medical director. Under the terms of plea deals, they were each sentenced to three months of probation.
In 2022, the state also agreed to pay $56 million to settle a class action lawsuit brought by the families of the veterans who died.
According to the state audit, both homes failed to post emergency operation plans, as required, throughout the facilities. They also failed to conduct simulated emergency drills during all shifts.
The audit also found that the nursing staff at the Holyoke home did not make regular rounds of the patients, and the home lacked an electronic record-keeping system.
Specific to the Chelsea home, the audit concluded that employees did not properly train for emergency situations, they failed to update patient assessments, and there were errors with documenting the need and approval for overtime shifts.
“I am confident that the Holyoke and Chelsea Veterans’ Homes are committed to working to ensure that all of our veterans are treated with the dignity, honor, and respect they deserve,” DiZoglio said in her statement.
“Both the Holyoke and Chelsea Veterans’ Homes have a noble and worthy mission of providing high-quality personal health care services to Massachusetts veterans,” she said. “We hope that our audit recommendations are adopted to help ensure that mission is the reality for every veteran relying on these necessary services.”
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