As they weigh structural reforms to operations at the Holyoke Soldiers' Home in the wake of last year's massive and deadly COVID-19 outbreak, Massachusetts lawmakers must contend with a complicating factor: those already tasked with oversight of the facility have a range of opinions on how their jobs should work.
All five board members who testified before a legislative panel investigating the Holyoke tragedy agreed that lawmakers should update the statute governing the home to make it clearer, but they offered varying views on how hiring and firing the superintendent should work, what qualifications top facility leaders should have, and how long trustees should serve.
Lawmakers have their work cut out to synthesize the disparate opinions and craft a report outlining recommendations by their March 31, 2020 deadline. In the meantime, the Baker administration will step back from legislative reforms it proposed last year and wait to see what the panel decides.
Health and Human Services Secretary Marylou Sudders told the committee that Gov. Charlie Baker will wait to refile his Holyoke Soldiers' Home reform legislation in the new 2021-2022 out of "respect" to the work that lawmakers are doing.
"We'll see where this committee comes out in its recommendations, and then based on that, we'll see what happens," Sudders said during a Tuesday virtual hearing.
Baker filed a bill altering the oversight and governance structure at the state-run facility in June, one day after releasing an investigative report he sought into the March 2020 outbreak that led to the deaths of at least 76 veteran residents at the facility.
Lawmakers did not take up Baker's proposal, which would have given the executive branch clearer authority to appoint the home's superintendent and required at least two members of the board to have clinical or health care administration experience.
The Legislature instead convened its own special committee, helmed by Veterans and Federal Affairs Committee Co-chairs Rep. Linda Dean Campbell and Sen. Walter Timilty, to examine the tragedy and draft recommendations.
Tuesday's hearing focused on the role of the facility's board of trustees and what reforms lawmakers should pursue to better empower it going forward.
Sudders told the committee that she believes the board's primary responsibility should be "oversight," describing citizen-run volunteer boards as "connective tissue" linking state facilities to communities and families.
In September, a judge ruled that the Baker administration did not have the authority to fire former Superintendent Bennett Walsh for his alleged role in exacerbating the COVID-19 outbreak because state law makes clear that those powers rest with the board.
Both Walsh and former medical director David Clinton face criminal charges stemming from the deadly outbreak and have pleaded not guilty.
The crisis and ensuing scandal raised questions about Walsh's ability to lead the home and the hiring process that brought him on board.
Baker administration officials have argued that while it might be beneficial to select a soldiers' home superintendent who is a licensed nursing home administrator, the distinction would not have significantly impacted the March 2020 outbreak.
"Across the country, there have been homes with more deaths than there were at Holyoke, and those homes were led by licensed nursing home administrators," Secretary of Veterans' Services Cheryl Poppe said Tuesday. "Not just licensed nursing home administrators who started two weeks before, they had been there for a long period of time."
The administration hired a licensed nursing home administrator to run the other state-run soldiers' home in Chelsea and into a support role at the Holyoke facility while officials search for a full-time superintendent.
Several trustees told lawmakers they do not think the Holyoke facility's superintendent needs to have that specific license. Trustee Isaac Mass, however, said it would be "unconscionable" not to impose that requirement since it is already in place for other long-term care facilities in Massachusetts.
Mass pointed to former U.S. Attorney Mark Pearlstein's report about the tragedy, recounting an instance in which a nurse could not reach the facility's chief medical officer to get clearance to move patients and instead got that permission from the superintendent.
"That's because the superintendent didn't at that time have any medical experience at all," Mass said. "He didn't know the right questions to ask. Someone who has basic licensure would be required to have that."
Cindy Lacoste, another Holyoke Soldiers' Home trustee who has served in that position since 2017, told the panel that she "didn't see any major red flags" during Walsh's tenure before the COVID-19 pandemic hit. During the first three years they worked together, she said, "I watched him grow."
"I thought that he had a great handle on the Soldiers' Home," Lacoste said. "He knew every resident by name. He was on the floor with them all the time. He knew all the staff members. I thought all the trustees had a good relationship with our superintendent."
The current chair of the home's board of trustees, Massachusetts National Guard Major General Gary Keefe, argued Tuesday that the executive branch should have authority in the future to appoint a superintendent because the home is a state-run entity.
The statute governing the Holyoke home is outdated, Keefe told lawmakers, and does not reflect its operations as a state agency.
"Prior to when this happened, I think you had a board that was, quite frankly, very hands-off and probably didn't expect to be held accountable or empowered to exercise some of the things that have been done," Keefe said. "The problem is the statute needs to be updated to reflect how we operate presently."
Kevin Jourdain, a trustee and Keefe's predecessor as chair, pointed to the September ruling from Hampden Superior Court Judge John Ferrera that concluded the board has clear power over staffing the superintendent role.
Jourdain flagged concerns over how the Baker administration handled the board before the tragedy, saying the executive branch kept it in a "very de minimis role" and treated it as "just an advisory board to the governor."
Sen. John Velis interjected, asking Jourdain how to reconcile that arm's length role for the board with the governing statute convening the board to "manage and control" the home.
Jourdain replied, "Unbelievable. I agree."