Soldiers’ Home in Holyoke
December 14, 2017 · Read the full official report (PDF) ↗
Published December 14, 2017 Audit covers July 1, 2014 – June 30, 2016 Under Suzanne M. Bump · 2011–2023
source
“SHH could not substantiate that it properly authorized overtime incurred by its nursing department personnel.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of the Soldiers’ Home in Holyoke covering July 1, 2014 through June 30, 2016.
“I am pleased to provide this performance audit of the Soldiers’ Home in Holyoke.”
The auditors reviewed staffing schedules, nursing overtime, safety equipment inspections, maintenance, and how the facility responded to inspection issues.
“In this performance audit, we examined the scheduling of nursing personnel, overtime incurred by nursing personnel, facility and equipment inspections and preventive maintenance, and facility corrective maintenance work orders performed in response to issues identified during facility inspections.”
The report matters because missing approvals and inspection records can mean wasted money and greater safety risk in a facility serving veterans.
“Without required inspections and testing of this type of equipment being performed and documented, there is a higher-than-acceptable risk of equipment malfunction or failure, which could create safety issues.”
For an ordinary citizen, this report shows whether public money and veteran care facilities were being managed with enough oversight and documentation.
“As a result of these issues, SHH may have incurred unnecessary payroll costs for overtime hours that were not essential to meeting the care needs of the veterans it serves, and it may therefore have lost the opportunity to use these funds for other purposes.”
The facility needed better controls and records for overtime, safety equipment checks, dormitory inspections, and daily housekeeping inspections.
“SHH had inadequate documentation to substantiate that all required facility inspections were performed.”
The audit recommended that SHH keep using overtime approval procedures, improve controls on unscheduled hours, document safety checks in CAMIS, and keep inspection records.
“SHH should ensure that all required daily housekeeping inspections are performed and that the documentation related to them is retained in accordance with its policy.”
The findings are significant because they involve veteran care, public payroll spending, and safety procedures at a state-run healthcare facility.
“The Soldiers’ Home in Holyoke (SHH) was established in 1952 to provide various healthcare services to eligible veterans of the Commonwealth of Massachusetts.”
“Premium overtime” means higher-than-normal pay for hours above 8 in a day or 40 in a week; “standard overtime” means regular-rate pay for extra scheduled hours that do not cross those limits.
“Premium overtime is paid at more than the standard hourly rate for work that exceeds 8 hours per day or 40 hours per week.”
2 figure(s) pending source verification - not shown
What the Auditor checked
- Complied Did SHH schedule the nursing department staff in accordance with its policy and Part 51.130 of Title 38 of the Code of Federal Regulations (CFR) in order to provide the needed level of care to veterans?
- Did not comply Did SHH ensure that the need for nursing department staff overtime was documented and approved according to SHH policy?
- Did not comply Were facility and equipment inspections and preventive maintenance conducted in a manner consistent with the SHH Utilities Management Plan; the Joint Commission’s Environment of Care standards for nursing care centers; Section 6 of Title 146 of the General Laws, which regulates annual boiler inspections; and Section 8.01 of Title 524 of the Code of Massachusetts Regulations, which regulates elevator testing and inspections?
- Did not comply Did SHH provide a sufficient housekeeping and maintenance staff to keep the interior of its facilities safe, clean, orderly, attractive, sanitary, and in good repair?
What the Auditor found
Why it matters: SHH may have incurred unnecessary payroll costs for overtime hours that were not essential to veterans’ care needs.
Standard: Best-practice guidance recommends overtime preapproval, and SHH policy limits work beyond scheduled hours. ( Section 12 of Chapter 11 of the Massachusetts General Laws )
3 recommendations
- SHH should continue its newly implemented process for overtime approval.agency: already implemented
- SHH should investigate ways to prevent employees from clocking in or out for unscheduled hours.
- SHH should require nursing management to document the necessity of overtime hours and have overtime approved by either the director of nursing or an appropriate SHH operations manager at or before the time it is incurred.
Agency response & Auditor reply
Agency: "The Soldiers’ Home in Holyoke continues to use the process for [incremental] overtime approval that was implemented prior to the commencement of the audit."
Why it matters: The lack of documented inspections and testing creates a higher-than-acceptable risk of equipment malfunction or failure, which could create safety issues.
Standard: The Joint Commission’s Environment of Care standards require monthly emergency-light testing and weekly fire-pump testing; the SHH Utilities Management Plan requires inspections, testing, and preventive maintenance to be documented in CAMIS. ( The Joint Commission’s Environment of Care standards for nursing care centers; SHH Utilities Management Plan )
1 recommendation
- SHH should ensure that all required monthly inspections and testing of facility equipment are conducted and documented in CAMIS.
Agency response & Auditor reply
Agency: "The Soldiers’ Home in Holyoke is in the process of working with representatives from the Division of Capital Asset Management and Maintenance (DCAMM) to enter all required inspections and testing of facility equipment, whether performed directly by Soldiers’ Home staff or through an outside contractor, into the CAMIS system to be properly tracked and monitored."
Why it matters: Missing inspection documentation increases the risk that problems requiring corrective maintenance may not be identified in a timely manner, which could create safety issues.
Standard: SHH’s dormitory handbook states that dormitory room inspections are conducted monthly. ( SHH handbook on policies and procedures for the dormitory )
1 recommendation
- SHH should develop a system to ensure that documentation of all monthly dormitory room inspections is retained.
Agency response & Auditor reply
Agency: "The monthly dormitory inspection forms will be maintained electronically in a folder on the Soldiers’ Home server accessible to Administration and staff assigned to the dormitory."
Why it matters: Without documentation of daily housekeeping inspections, SHH may not ensure that veteran care areas meet health and safety quality standards.
Standard: SHH’s Housekeeping Department Inspection Monitoring Policy requires daily facility inspections and retention of inspection documentation. ( SHH’s Housekeeping Department Inspection Monitoring Policy )
1 recommendation
- SHH should ensure that all required daily housekeeping inspections are performed and that the documentation related to them is retained in accordance with its policy.
Agency response & Auditor reply
Agency: "Pursuant to the Policy, all housekeeping inspection forms will be maintained electronically on the Soldiers’ Home server accessible to Administration and the Housekeeping Supervisors."