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Investigator: Governor's Office Imposed No Limits On Probe Of Holyoke Soldiers' Home Outbreak

Soldiers from the Massachusetts National Guard talk with residents of the Holyoke Soldiers' Home.
Army Spc. Samuel D. Keenan
Massachusetts National Guard
Soldiers from the Massachusetts National Guard talk with residents of the Holyoke Soldiers' Home.

Attorney Mark Pearlstein's probe into the COVID-19 outbreak that killed at least 76 veterans who lived at the Holyoke Soldiers' Home did not face any constraints imposed by Gov. Charlie Baker's administration, Pearlstein said Friday. But he acknowledged the inquiry's timeframe left investigators unable to dig more deeply into "a long and rich history" of issues at the facility, 

Nine months after the release of his bombshell report prompted the departure of Veterans' Services Secretary Francisco Urena and the termination of former Holyoke Soldiers' Home Superintendent Bennett Walsh, Pearlstein sat for nearly two hours to field questions from the legislative panel conducting its own review of the tragedy.

Pearlstein said Friday that his team conducted its investigation pro bono after Baker tapped them last year, and he said the governor did not place any limits or roadblocks on their work.

Sen. Anne Gobi, a Spencer Democrat, asked Pearlstein why his 174-page report focused as closely as it did on Walsh's managerial decisions and Urena's gaps in oversight and why there was not "more of a look at the real systemic problems" that she said the home has faced for years.

Pearlstein responded that he was tasked with answering the governor's questions about what happened at the home and how it happened. His analysis focused on some broader issues such as staffing shortages that had been apparent before the pandemic hit, Pearlstein said, noting that investigators "did not have the luxury of time to do a comprehensive history of the soldiers' home."

"There's no doubt that there is a long and rich history at the soldiers' home of problems and dysfunction," Pearlstein said, offering labor management as an example that "at least indirectly" contributed to the deadly outbreak. "But to dissect the history of labor management dysfunction at the home would have been a very lengthy exercise, to be sure, and really would have been beyond the scope of what we were asked to do."

Despite that, Pearlstein stressed that a deeper analysis of structural issues would not have changed his conclusions about the sequence of decisions and oversight failures that exacerbated the public health crisis.

He added that other investigative bodies that have a "broader scope," such as the special legislative committee holding Friday's hearing, might have the bandwidth to "take a more panoramic view."

Plenty of attention related to the outbreak has focused on decisions made in Holyoke, such as combining two dementia wards as COVID-19 was spreading. But Rep. Mindy Domb, a Democrat from Amherst, wanted to hear more about decisions made in Boston, including not filling a position the legislature created: executive director of veterans' homes.

"There's no question in my mind,” Pearlstein replied, “that that would have enhanced oversight of the home at a time when it desperately needed it."

The Baker Administration did bring on a new assistant secretary for veterans' homes last December, who oversees the Holyoke facility.

The Soldiers' Home now has a superintendent who's a licensed nursing home administrator – a recommendation contained in Pearlstein's report.

This report includes information and writing from Chris Lisinski of State House News Service and NEPM's Alden Bourne.

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