Massachusetts would transform the oversight of its two state-run soldiers' homes, impose new certification requirements at the facilities and on its top leaders, and elevate the secretary of veterans' services to a Cabinet-level position, under a sweeping reform bill lawmakers plan to file Thursday.
Drawing from the legislative investigation they led into last year's fatal COVID-19 eruption at the Holyoke Soldiers' Home, Rep. Linda Dean Campbell and Sen. Mike Rush will submit an omnibus bill aimed at creating new safeguards in a realm where mismanagement before and during the pandemic sparked disaster.
Their proposal lands 18 months after the highly infectious virus swept through the Holyoke facility, killing at least 76 veterans in one of the deadliest long-term care outbreaks in the country. It also arrives more than a year after Gov. Charlie Baker offered a package of similar reforms, which have failed to advance.
In an interview, Campbell said the committee's work found that broken chains of communication, faulty governance structures and individual failures combined to form "a perfect storm" at the facility.
"There was no single cause of this tragedy. It resulted from multiple deficiencies of governing. So I think to address those, you have to approach this and present multiple changes," the Methuen Democrat said. "This has to be comprehensive change. We can't just fix the chain of command. We have to address all of these issues, because all of them contributed in one way or another."
The legislation would recast the governance structure at the Holyoke Soldiers' Home and the Chelsea Soldiers' Home, eliminating the boards of trustees that currently oversee each facility and creating new local stewardship bodies to provide community representation for the homes.
It would also revoke a section of state law assigning the responsibility for appointing a superintendent to run the Holyoke home to its board and instead require the hiring process for leaders at both facilities to take place fully inside the executive branch.
Under the bill, the secretary of veterans affairs, the secretary of health and human services and the executive director of veterans' homes and housing would recommend appointing or removing a superintendent and deputy superintendent, and the governor would have the final authority to execute the moves.
The homes' superintendents would need to be licensed nursing home administrators — a qualification that former Holyoke superintendent Bennett Walsh lacked — and state-operated veterans' homes would also need to employ a full-time infection control and emergency preparedness specialist.
Several investigations, including one by the legislative committee and another that former U.S. Attorney Mark Pearlstein conducted at Gov. Charlie Baker's request, found that Walsh was not qualified or equipped for the position, yet remained in the post despite several red flags.
Walsh is now facing criminal charges for his alleged role in exacerbating the tragedy. Former Veterans' Services Secretary Francisco Urena, who told lawmakers he felt "powerless" to address his concerns about Walsh, resigned in June 2020 one day before publication of the Pearlstein investigative report.
Campbell said the special legislative committee she and Rush chaired, which published its 186-page findings in May, "demanded a much deeper and wider investigation than the Pearlstein Report provided."
In a statement, Rush thanked the veterans, family members, workers and advocates who spoke to the committee.
"The testimony and conversations we heard were heartbreaking and difficult yet provided us with much needed information to develop this reform legislation," Rush, a West Roxbury Democrat, said. "It is our hope that through legislative action, and our continued commitment to our veterans, we can transform long-term care of our veterans with a system that they deserve."
The legislation Campbell and Rush penned also aims at other issues that may have contributed to the crisis, such as slow hiring for oversight positions and communications issues.
Their bill would require the homes to post any vacant jobs and begin interviews within two months for leadership positions or a single month for positions critical to emergency operations. Each facility would need to employ an ombudsperson to handle complaints and would need to stand up an emergency hotline.
The Department of Public Health would be required to inspect both veterans' homes at least twice per year and publicly release inspection reports. The facilities would also need to maintain certification from the Centers for Medicare and Medicaid Services.
Also, instead of continuing to operate under the umbrella of the Executive Office of Health and Human Services, the Department of Veterans' Services would stand as its own executive office and the secretary would rise to become a member of the governor's Cabinet if the legislation is approved. Additional oversight would also come from a new 12-member Massachusetts Veterans' Homes Advisory Council.
Campbell said that change aims to address a "very muddled chain of command" surrounding the soldiers' homes that the investigation uncovered.
"Establishing accountability and responsibility and a very, very clear chain of command and communication was absolutely essential," she said. "If we are going to hold people responsible for their actions, then we need to make sure that they know who to contact in an emergency and a crisis, and also during the day-to-day operations of the home."
The pair of lawmakers did not say when they expect their bill to emerge for a vote in either chamber, but the bill's support at this stage from committee co-chairs in both branches could enhance its chances of passage.
"It is a complex piece, but leadership has made it clear in both the House and the Senate that it will be a priority," Campbell said.
Legislative leaders opted not to take up soldiers' home legislation Baker filed in June 2020, which included similar reforms such as requiring additional inspections and amending the selection process for the Holyoke superintendent.
Baker in May he said the legislative committee's report that inspired the legislation suggested "critical reforms."
"The good news, to the extent there is some on this issue, is the legislative report and the Pearlstein report and our legislation that we filed earlier in the year are all basically chasing the same reforms, and they're critical reforms," Baker said. "They're important reforms, and I'm anxious to work with the Legislature to get them done, and I fully expect those are things we'll be talking to them about in the weeks ahead."