Audit of the Veterans Home at Holyoke (January 14, 2026)
January 14, 2026 · Veterans Home at Holyoke · Read the full official report on mass.gov ↗
Published January 14, 2026 Audit covers July 1, 2020 – June 30, 2023 Under Diana DiZoglio · 2023–present
source
“VHH could not ensure that nurses performed intentional rounding, potentially resulting in an unsafe environment for veterans.”
Read the plain-English breakdown
This is a state performance audit of the Veterans Home at Holyoke, covering July 1, 2020 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 Holyoke (VHH) for the period July 1, 2020 through June 30, 2023.”
The Auditor reviewed whether the home was providing safe care, handling incidents properly, keeping records properly, preparing for emergencies, and using COVID-19 funds correctly.
“However, we were able to examine other issues related to safety, including the following:”
The home serves veterans in long-term care, so missed checks, weak emergency planning, and paper-only records can affect residents’ safety and quality of care.
“If intentional rounding is not being completed, then it could increase the risk of veterans having falls or other issues that could adversely contribute to veteran safety and well-being.”
If you are a veteran, family member, taxpayer, or Massachusetts resident, this report shows whether a state-run veterans facility is protecting residents and using public resources responsibly.
“The Veterans Home at Holyoke (VHH), established in 1952, is a long-term care facility that provides healthcare services to eligible veterans in the Commonwealth.”
The Auditor says the office will check back in about six months on the corrective steps the home says it is taking.
“As part of our post-audit review process, we will follow up on this matter in approximately six months.”
This report matters because the Holyoke home had already been the site of a deadly COVID-19 outbreak, and the Auditor says some requested records about that period were withheld.
“In spring 2020, at least 76 military veterans who lived at VHH died of COVID-19, the deadliest COVID-19 outbreak at a long-term care facility in the country.”
“Intentional rounding” means nurses or aides regularly check on residents, including pain, bathroom needs, position, and whether important items are within reach.
“Intentional rounding is the practice of professional nursing staff checking on veterans regularly throughout the day and providing necessary care.”
What the Auditor checked
- Did not comply Did VHH provide safe, effective veteran care and document rounding in accordance with its NSG-113 Intentional Rounding Policy?
- Complied Did VHH follow its ADMIN-041 Incident/Occurrence Report Policy to handle incidents involving veterans and determine whether the nurses involved in the incidents had professional licenses to provide care to veterans?
- Did not comply Did VHH’s system for tracking patient records operate effectively in accordance with Section 150.013(c) of Title 105 of the Code of Massachusetts Regulations (CMR)?
- Did not comply Did VHH have an emergency operation plan (EOP) in place during the audit period and has it been updated to address the risks involved in providing adequate patient care during an emergency in accordance with 105 CMR 150.015(E)?
- Complied Did VHH expend COVID-19 funds in accordance with requirements established by the American Rescue Plan Act?
What the Auditor found
Why it matters: Incomplete rounding documentation increases the risk of falls, injuries, reduced care quality, and other veteran safety issues.
Standard: VHH’s NSG-113 Intentional Rounding Policy, Section VI ( Section VI of VHH’s NSG-113 Intentional Rounding Policy )
2 recommendations
- VHH should ensure that timely intentional rounding is performed and documented on Intentional Rounding Logs.agency: already implemented
- VHH should establish monitoring controls to ensure that Intentional Rounding Logs are completed and maintained.agency: already implemented
Agency response & Auditor reply
Agency: "At present, the Massachusetts Veteran Home at Holyoke (HLY) has a robust intentional rounding program."
Auditor: "Based on its response, VHH is taking measures to address our concerns regarding this matter."
Why it matters: Without drills for all shifts, VHH cannot ensure an effective emergency response, which jeopardizes veterans and staff members.
Standard: Section 150.015(E)(4) of Title 105 of the Code of Massachusetts Regulations ( Section 150.015(E)(4) of Title 105 of the Code of Massachusetts Regulations )
1 recommendation
- VHH should ensure that it conducts simulated emergency drills for all shifts at least twice a year.
Agency response & Auditor reply
Agency: "During the audit period July 1, 2020, through June 30, 2023, the Veterans Home at Holyoke did not fall under 105 CMR 150 but was subject to life safety requirements in [Section 51.200 of Title 38 of the Code of Federal Regulations]."
Auditor: "We disagree that VHH was not subject to 105 CMR 150 because 105 CMR 150.001 defines a long-term care facility as the following:"
Why it matters: Without conspicuous posting of the EOP, VHH may be unable to ensure an effective disaster or emergency response.
Standard: Section 150.015(E)(1) of Title 105 of the Code of Massachusetts Regulations ( 105 CMR 150.015(E)(1) )
2 recommendations
- VHH should ensure that its EOP is available at all nurses’ and attendants’ stations and is posted in conspicuous locations throughout the facility.
- VHH should also make its EOP accessible in digital form from all computer terminals.
Agency response & Auditor reply
Agency: "The Home currently has added its emergency operations plan onto every computer desktop throughout the facility."
Auditor: "While VHH does not agree that it was subject to DPH regulations during the audit period, based on its response, VHH is taking measures to address our concerns regarding this matter."
Why it matters: Missing emergency location information could delay or impede safe evacuation of veterans, staff members, and visitors.
Standard: Section 150.015(E)(2) of Title 105 of the Code of Massachusetts Regulations ( 105 CMR 150.015(E)(2) )
1 recommendation
- VHH should add the locations of alarm signals, fire extinguishers, and evacuation routes to its EOP.
Agency response & Auditor reply
Agency: "Copies of the Evacuation Route signs have been added to the Emergency Operations Plan."
Auditor: "While VHH does not agree that it was subject to DPH regulations during the audit period, based on its response, VHH is taking measures to address our concerns regarding this matter."
Why it matters: Reliance on hardcopy records can reduce real-time access to medical information and increase risks of medical errors, treatment delays, inaccurate records, unclear records, and weaker medical record security.
Standard: Electronic health records are a best practice, and 105 CMR 130.375 requires Massachusetts hospitals and community health centers to implement EHR systems. ( American Recovery and Reinvestment Act of 2009; 105 CMR 130.375 )
1 recommendation
- We recommend that VHH implement an EHR system as soon as possible.agency: already implemented
Agency response & Auditor reply
Agency: "[This system] became operational at [VHH] on September 9, 2024."
Auditor: "Based on its response, VHH is taking measures to address our concerns regarding this matter."
Why it matters: Withholding records limited transparency and prevented the Auditor from independently examining potentially valuable information about safety and management issues at VHH.
Standard: Section 12 of Chapter 11 of the Massachusetts General Laws ( Section 12 of Chapter 11 of the Massachusetts General Laws )
2 recommendations
- Agencies, such as VHH and the Office of the Governor, should only exercise attorney-client privilege when appropriate.
- The work of vendors, including fact-finding investigators and consultants, should be turned over to the contracting agency and made available to the Office of the State Auditor when conducting an audit, and more widely to the public in accordance with the public records law.
Agency response & Auditor reply
Agency: "The Baker Administration determined that McDermott’s interview notes and work papers were subject to the attorney client privilege and the work product doctrine and, on that basis, denied numerous requests for the materials."
Auditor: "We disagree with VHH’s assessment that the interviews, interview notes, and other documentary evidence used to write the Pearlstein Report are subject to attorney-client privilege, as any attorney-client privilege related to the Pearlstein Report was waived when the report was released to the public under Massachusetts public records law."