Audit of the Veterans Home at Chelsea (January 14, 2026)
January 14, 2026 · Veterans Home at Chelsea · Read the full official report on mass.gov ↗
Published January 14, 2026 Audit covers July 1, 2021 – June 30, 2023 Under Diana DiZoglio · 2023–present
source
“VHC did not always meet the total nursing care needs for its veterans as determined by veterans’ assessments.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of the Veterans Home at Chelsea covering July 1, 2021 through June 30, 2023.
“In accordance with Section 12 of Chapter 11 of the Massachusetts General Laws, the Office of the State Auditor has performed an audit of the Veterans Home at Chelsea (VHC) for the period July 1, 2021 through June 30, 2023.”
The audit checked whether the home fixed issues from a prior audit, including staffing, overtime documentation, and emergency planning.
“In this performance audit, we examined whether VHC implemented recommendations from our prior audit report (Audit No. 2020-0065-3S), issued on March 30, 2021.”
The report says gaps in care and planning can affect veterans’ health and safety, and can also strain staff.
“Failure to meet the needs of veterans, as determined by VHC’s own assessment of those needs, can lead to a variety of negative consequences for veterans, including an increased risk of mortality, physical decline, and infections, as well as emotional distress.”
If you are a veteran, family member, taxpayer, or community member, this report explains whether the home is meeting care, safety, and spending-control responsibilities.
“Without maintaining proper records, VHC cannot ensure that it is properly staffed and providing necessary care to veterans.”
The Auditor concluded that VHC did not meet the audited requirements in staffing, overtime controls, and emergency preparedness.
“Below is a list of our audit objectives, indicating each question we intended our audit to answer; the conclusion we reached regarding each objective; and, if applicable, where each objective is discussed in the audit findings.”
VHC says it is making changes, and the Auditor says the office will check back in about six months.
“Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months as part of our post-audit review process.”
The most serious concern is that emergency-planning gaps could put veterans and staff at risk during a disaster or emergency.
“Without training employees on tasks they must complete during an emergency, VHC cannot ensure that all employees are properly prepared to respond to disasters and emergencies, which may jeopardize the safety of veterans and employees at VHC in the event of an emergency.”
An individualized plan of care means a written plan for a resident’s health needs, goals, services, and treatments.
“An individualized plan of care is a document that outlines an individual’s specific health conditions, goals, necessary services, and the treatments needed to meet their goals.”
3 figure(s) pending source verification - not shown
What the Auditor checked
- Did not comply Did VHC have policies and procedures in place to ensure that it had sufficient staffing to meet its veterans’ needs in accordance with Sections 51.110(b) and 51.130 of Title 38 of the Code of Federal Regulations (CFR)?
- Did not comply Did VHC ensure that the need for nursing overtime was documented and approved in accordance with VHC’s Overtime Policy 180-11-2022-A?
- Did not comply Did VHC have an emergency operations plan (EOP) in place, and was it updated to address the risk involved in providing adequate patient care during an emergency in accordance with Section 150.015(E) of Title 105 of the Code of Massachusetts Regulations (CMR)?
What the Auditor found
Why it matters: Veterans faced increased risk of mortality, physical decline, infections, emotional distress, and nursing staff could face excessive burdens.
Standard: Section 51.130 of Title 38 of the Code of Federal Regulations ( Section 51.130 of Title 38 of the Code of Federal Regulations )
1 recommendation
- VHC should develop formal policies and procedures to ensure that all veterans’ nursing care needs are met based on their individualized plans of care and assessments.
Agency response & Auditor reply
Agency: "Since the establishment of [the Executive Office of Veterans Services (EOVS)] in March 2023, [Massachusetts Veteran Home (MVH)] Chelsea has undergone significant leadership, structural, and quality improvements."
Auditor: "Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months as part of our post-audit review process."
Why it matters: VHC could not ensure that it met each veteran’s nursing needs.
Standard: 38 CFR 51.110(b)(2)–(3) ( 38 CFR 51.110(b) )
1 recommendation
- VHC should ensure that all assessments are completed within 14 days of admission and should review each veteran’s assessment at least once every three months.agency: already implemented
Agency response & Auditor reply
Agency: "An electronic medical record (EMR) system was implemented at MVH Chelsea in November 2024."
Auditor: "Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months, as part of our post-audit review process."
Why it matters: VHC could not ensure proper staffing and care, and the Commonwealth could face liability if VHC needed to demonstrate sufficiency or quality of care.
Standard: Massachusetts Statewide Records Retention Schedule Section D04-03 and 105 CMR 150.013 ( Section D04-03 of the Massachusetts Statewide Records Retention Schedule; Section 150.013 of Title 105 of the Code of Massachusetts Regulations )
1 recommendation
- VHC should ensure that it properly stores, and has available for review, all documentation related to staffing and incidents.agency: already implemented
Agency response & Auditor reply
Agency: "In February 2024, the Home implemented ScheduleAnywhere, a cloud-based scheduling and documentation platform that replaced all paper systems."
Auditor: "Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months, as part of our post-audit review process."
Why it matters: VHC had a higher-than-acceptable risk of incurring unnecessary overtime expenses.
Standard: VHC’s Overtime Policy 180-11-2022A ( Section 5 of VHC’s Overtime Policy 180-11-2022A )
1 recommendation
- VHC should enhance its policies and procedures by establishing effective monitoring controls that are properly designed and implemented to ensure that it properly documents the need and prior approval for overtime, including incremental overtime worked.agency: already implemented
Agency response & Auditor reply
Agency: "EOVS and MVH Chelsea leadership have implemented comprehensive oversight of time management and overtime authorization."
Auditor: "Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months, as part of our post-audit review process."
Why it matters: VHC could not ensure an effective emergency response, jeopardizing the safety of veterans and hospital staff members.
Standard: 105 CMR 150.015(E)(4) ( 105 CMR 150.015(E)(4) )
1 recommendation
- VHC should ensure that it conducts simulated emergency drills for all shifts at least twice a year.agency: already implemented
Agency response & Auditor reply
Agency: "Under [the Executive Office of Veterans Services’] oversight, fire safety training is now conducted annually and during employee orientation, and fire-emergency drills are conducted at least twice per year on each shift."
Auditor: "While VHC does not agree that it was subject to Department of Public Health regulations during the audit period, based on its response, VHC is taking measures to address our concerns regarding this matter."
Why it matters: VHC could not ensure an effective emergency response, which could impede the safety of veterans and hospital staff members.
Standard: 105 CMR 150.015(E)(1) ( 105 CMR 150.015(E)(1) )
1 recommendation
- VHC should ensure that its EOP is available at all nurses’ and attendants’ stations and is posted in conspicuous locations throughout the facility.agency: already implemented
Agency response & Auditor reply
Agency: "One-page “Quick Reference Guides” summarizing emergency procedures are posted at every nurse’s station and throughout the facility."
Auditor: "While VHC does not agree that it was subject to Department of Public Health regulations during the audit period, the audit team was able to confirm that policies and procedures were located at the nursing stations; however, several nursing staff members told us that they were not aware of the EOP and where it was located."
Why it matters: Veterans, staff members, and visitors could be delayed or unsafe during evacuation in a disaster.
Standard: 105 CMR 150.015(E)(2) ( 105 CMR 150.015(E)(2) )
1 recommendation
- VHC should add the locations of alarm signals, fire extinguishers, and evacuation routes to its EOP.agency: already implemented
Agency response & Auditor reply
Agency: "Section D of the [new] EOP includes Evacuation Floor Plans, and Appendix E includes Evacuation Route Maps."
Auditor: "Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months as part of our post-audit review process."
Why it matters: Employees may not be prepared to respond to emergencies, jeopardizing the safety of veterans and employees.
Standard: 105 CMR 150.015(E)(3) ( 105 CMR 150.015(E)(3) )
1 recommendation
- VHC should include emergency disaster training as part of its annual training requirement to ensure that all VHC employees are properly trained to perform their duties during an emergency.agency: already implemented
Agency response & Auditor reply
Agency: "All new staff receive emergency preparedness training during orientation, and annual refresher courses address the most likely scenarios, including:"
Auditor: "Based on its response, VHC is taking measures to address our concerns regarding this matter, and our office will follow up in approximately six months, as part of our post-audit review process."
Prior findings revisited
"The Veterans Home at Chelsea did not implement the monitoring controls recommended from our previous audit to ensure that it documents the need or approval for Nursing Department overtime, including incremental overtime, as required by its Overtime Policy 180-11-2022A."