Over the past several weeks, as coronavirus deaths in the United States neared 100,000, the Holyoke Soldiers’ Home has been decimated by COVID-19. With scores of its residents killed by the virus, it is now being investigated by the governor, state attorney general, state inspector general, and U.S. Attorney.
Former Massachusetts Inspector General Gregory Sullivan is Research Director at the Pioneer Institute — which released a new study this week concluding that chronic understaffing due to federal and state standards made the nursing home “particularly vulnerable” during the pandemic.
Give us a sense of what the study found and why you wanted to look into the Holyoke Soldiers’ Home.
Our study basically is pointing out that at the time that the coronavirus pandemic hit the Holyoke Soldiers’ Home, and lead to the to the day of scores of veterans there, were more than 74 as of today, they were already fighting with one hand tied behind their back because of chronic understaffing. So our paper’s looking at recommendations that had been made by the Federal CMS, Centers for Medicaid and Medicare Services, calling for much higher staffing at facilities like the Holyoke nursing home. And we compared the staffing that was in place at the Holyoke Soldiers’ Home before the pandemic hit and showed that it was it was deeply understaffed, particularly with RNs. Probably a lot of people were not aware of the fact that the administration that the state government had done a study that was conducted by the Moakley Center at Suffolk University that pointed out that there was severe understaffing. This judged by the Federal recommendations of CMS at the Holyoke Soldiers’ Home before the pandemic hit. And we kind of laid out their analysis in our report. The local SEIU, Local 888 out there at the Holyoke Soldiers’ Home, had been screaming bloody murder about understaffing for several years. They’d signed statements widely signed by employees there saying that understaffing was putting the patients in danger. The Springfield Republican Newspaper did an investigative series by reporter Mike Plaisance that laid out the number of falls and injuries which was like a plague at that facility. This is before the pandemic hit. So this paper, the paper that we put out, is pointing out that not just at the Holyoke Soldiers’ Home, but in long-term care facilities across the country. There's chronic understaffing, according to experts, and according to the recommendations of the federal office in charge of it, so we there's a problem. In this country, unfortunately, I think this is just a tolerance of a relatively low level of safety care at nursing homes and long-term care facilities. The number of patients who fall and injure themselves is astronomically high. It was high at the Holyoke Soldiers’ Home before the pandemic hit. The Springfield Republican investigative series pointing out there has been a tsunami of falls there at the3 Holyoke Soldiers’ Home with veterans falling and being injured. We laid out the details in this report. It's not acceptable and it has to be fixed.
Specifically, what is the staffing level there? What has it been? And when you say chronically understaffed, where should it be in your mind?
Basically, our paper’s pointing out that there was a minimum staffing that's established by the federal and state government facilities like this. The number of employees, of nursing staff, per patient per day. And that minimum standard was met. There were two audits conducted, one by the federal government, one by the state government of the Holyoke Soldiers’ Home in the lead-in one year before the coronavirus pandemic hit the Holyoke Soldiers’ Home that showed that they were meeting minimum staffing. This is countered by the staff at the Holyoke Soldiers’ Home which were screaming that they were chronically understaffed and that patients were not safe. That the only way they've been able to jury rig their staffing is by having massive amounts of mandatory overtime and moving, scrambling and moving staff around to adjust. So, in fact, the SEIU Local 888 Union out of Holyoke Soldiers’ Home actually called for, you know, called for the state to step in and have an emergency increase staffing. So their cries were mostly ignored. And when the pandemic hit, they were ill prepared. They were behind the eight ball. They had to go into a fight with one hand tied behind their back to begin with. They were not prepared for the crisis.
Do you think that the way a place like this operates with a sort of mix of federal and state responsibility for the facility played into any of these issues?
Yeah, I think I think that the blame for the understaffing and staffing assignment problems at Holyoke Soldiers’ Home, is it falls on the federal government and the state government. Both. The state government directly runs the facility, but it's under federal standards and the federal reimbursement. So the federal government and the state government really both bear the blame for chronic understaffing at the Holyoke Soldiers’ Home that contributed to the problems with deaths when the Coronavirus hit.
We spoke with the Massachusetts State Auditor Suzanne Bump, whose office looked at this facility several years ago. You know, a lot of audits get done in government, as you well know. They don't always or maybe not often lead to immediate action. So what should the Holyoke Soldiers' Home have done to better prepare for a virus like this? I mean, this is something that our healthcare system has never seen before. I guess what I'm asking is, if staffing had been improved, that doesn't necessarily mean that the coronavirus would have been easier to corral in this particular place, right?
No, it's already, some of the facts have already come out about what would happen happening inside the Holyoke Soldiers’ Home when the COVID-19 virus hit. And they made mistakes. Part of it was made worse by the fact that they were that they were understaffed. But if a patient were in a room with four patients in a room, one contracted COVID-19. They, they moved the other patients out of that room into the general population on other wards. This looking back was a terrible mistake because those the patients had been exposed to the first patient. In other words, the intermingling of patients with symptoms of COVID-19, they were kind of oblivious to this. Staff was also assigned, staff who was working in the COVID-19 patients were then working on the same shifts with non COVID-19 patients. It was a management catastrophe from a public health point of view at Holyoke Soldiers’ Home. On the other hand, it's hard to imagine the challenge that they were up against there with this completely overwhelming and unexpected attack of COVID-19. But containment of viruses within a continuing care facility or nursing home is one of the principal jobs. This is something that they should have been prepared for.
I mentioned in the introduction that you spent, you know, two terms as the state Inspector General. There's obviously a lot of investigations going on right now, at least four that we’re aware of, of what happened here. In general, what kind of things are looked at in an investigation after a tragedy like this?
Well, we have a whole series of investigations underway from the US Attorney's Office, civil rights, the state attorney general, and the state inspector general. And they're looking at different aspects of what happened. I think that the inspector general's office will be going back and doing a retrospective and trying to analyze and pull apart what happened. And I think a lot of the intent in a review like this is to find out exactly what went wrong to prevent that from happening again, in other facilities. I think they will look at the actions that were taken by the administrators, actions that were taken by the funding agencies. The regulations, whether they were followed, etc. You know, it's a retrospective critique of what happened. It's not really looking for fraud or criminality. It's looking for mismanagement and mistakes so that they can be corrected in the future.
Your latest paper, the Pioneer Institute's paper, is getting a good bit of attention now since the Holyoke Soldiers’ Home is a national news story. The headline on it is that these standards were the federal standard, so that your point is a lot of the problems we saw there were inevitable in a way. How do you change a federal standard like that?
Well, as our paper’s pointing out, the US Center of Medicaid Medicare Services recommended 4.1 hours of nursing staff on hand per patient per day. That's a standard that they think was necessary for safety. But the federal agency that oversees the nursing homes and like the Soldiers’ Home, didn't take their recommendation. They said they only need 2.5 hours. That's a lot less. So I hope that the rash of tragedy at veterans homes across the country, with Holyoke being the worst in the country, will draw our attention to the need to increase safety staffing levels, at long-term care facilities in the United States.
Greg, is there anything I didn't ask you that you'd like to add?
I would say for the families of the soldiers who died at the Holyoke Soldiers’ Home, it's a horrible irony and a tragedy that these great soldiers would suffer death at the hands of an event like this. It's terrible, in our opinion, part of it was due to the negligence of the federal and state government not providing sufficient staffing.