Soldiers' Home in Massachusetts-Chelsea
October 28, 2016 · Read the full official report (PDF) ↗
Published October 28, 2016 Audit covers July 1, 2013 – June 30, 2015 Under Suzanne M. Bump · 2011–2023
source
“The Soldiers’ Home in Massachusetts—Chelsea is not providing its residents with safe and sanitary living conditions.”
Read the plain-English breakdown
This is a Massachusetts State Auditor performance audit of the Soldiers’ Home in Chelsea, covering July 1, 2013 through June 30, 2015.
“This report details the audit objectives, scope, methodology, findings, and recommendations for the audit period, July 1, 2013 through June 30, 2015.”
The Auditor reviewed whether the facility was being kept safe, clean, sanitary, and properly maintained for residents.
“In this performance audit, we reviewed and assessed SHC’s operations related to its general upkeep of the facility and the physical condition of the spaces accessed and occupied by residents.”
The problems were not just cosmetic; auditors said they could affect residents’ health and safety if ignored.
“These problems, if left unattended, could have a negative effect on the health and safety of residents.”
If you are a veteran, family member, taxpayer, or local resident, this report shows whether a state-run veterans’ home was meeting basic safety and cleanliness expectations.
“SHC’s mission is to provide healthcare, housing, and human services to eligible Massachusetts veterans.”
The audit found two main issues: unsafe or unsanitary living conditions, and equipment or supplies that were not properly maintained, inspected, or stored.
“Equipment at SHC was not properly maintained or inspected, and supplies were not kept in a sanitary manner.”
The Auditor recommended repairs, better inspection logs, clearer reporting rules, more frequent inspections, and stronger checks on boilers, fire extinguishers, ceilings, and storage areas.
“SHC should repair all the unsafe and unsanitary conditions we observed.”
The most serious concern is that unsafe food handling, pest evidence, damaged ceilings, and contaminated supplies could put vulnerable residents at real risk.
“Severe illness or death may occur if food prepared for consumption is contaminated.”
The report uses terms like SHC for the Soldiers’ Home in Massachusetts—Chelsea, Domiciliary Unit for residential housing, and Quigley Memorial Hospital for the long-term-care facility.
“SHC operates a 174-bed long-term-care facility that includes skilled nursing care and a dementia unit.”
What the Auditor checked
- Did not comply Are all equipment and supplies kept clean, sanitary, and in good working condition?
- Complied Is every resident provided with basic equipment and supplies such as an adequate bed, chair, bathroom supplies, and storage space?
- Complied Are bed linens changed when necessary, but at least weekly?
- Did not comply Does the facility provide a sufficient housekeeping and maintenance staff to keep the interior of the facility safe, clean, orderly, attractive, sanitary, and in good repair?
- Did not comply Are the floors, walls, and ceilings cleaned regularly and kept free of cracks and falling plaster?
- Partially Does the facility maintain a pest-control program either internally or with a contracted pest-control company?
What the Auditor found
Why it matters: Unsafe and unsanitary conditions could negatively affect residents’ health and safety and could cause serious health issues, safety concerns, or food contamination.
Standard: SHC resident handbook and Room Inspection Procedure; 105 CMR 410.602(D); 105 CMR 150.016(E); 42 CFR 483.35(i); 42 CFR 483.15(h); 105 CMR 410.550(B). ( Section 410.602(D) of Title 105 of the Code of Massachusetts Regulations; 105 CMR 150.016(E); Section 483.35(i) of Title 42 of the Code of Federal Regulations; 42 CFR 483.15(h); 105 CMR 410.550(B) )
5 recommendations
- SHC should repair all the unsafe and unsanitary conditions we observed.agency: already implemented
- SHC should develop and maintain a centralized room-inspection log to document all monthly and follow-up inspections, establish a process by which staff members will be assigned to conduct these inspections, and implement monitoring controls to ensure that all required inspections are performed and any problems noted are addressed in a timely manner.agency: already implemented
- SHC should create and distribute a written policy and procedure instructing staff members to report any maintenance deficiencies to their department heads and making the department heads responsible for informing the director of Facilities of those deficiencies.
- SHC should consider increasing the frequency of its environmental and safety inspections.
- SHC should ensure that the staff members doing the environmental and safety inspections are performing their duties as accurately as possible.
Agency response & Auditor reply
Agency: "Unsafe and unsanitary conditions observed during the audit have been repaired . . . and areas that are not used or that are under construction have been locked and will not be accessible to residents in order to maintain their safety."
Auditor: "Based on its response, SHC is taking measures to address our concerns in this area."
Why it matters: Lapsed inspections, an inoperable fire extinguisher, exposed insulation, and contaminated storage areas could create safety risks, property damage, injury, illness, or death.
Standard: Section 6 and Section 8 of Chapter 146 of the General Laws; 522 CMR 4.03; 42 CFR 483.70(d)(2); 527 CMR 1.1.4; 42 CFR 483.35(i)(2); 105 CMR 150.015(G)(2). ( Section 6 of Chapter 146 of the Massachusetts General Laws and 522 CMR 4.03; Section 8 of Chapter 146 of the General Laws; 42 CFR 483.70(d)(2); 527 CMR 1.1.4; 105 CMR 150.015(G)(2) )
7 recommendations
- The director of Facilities should establish the necessary controls to ensure that annual inspection requests are promptly submitted to DPS and that all boilers’ inspection certificates are up to date.agency: already implemented
- SHC should amend its Utilities Management Plan to address the requirement of annual boiler inspections.agency: already implemented
- SHC should ensure that all fire extinguishers are operating properly.
- SHC should immediately repair the damaged kitchen ceiling.agency: already implemented
- SHC should cover the loose insulation in the damaged kitchen ceiling and properly clean the surrounding area that could be contaminated.agency: already implemented
- As recommended in Finding 1, SHC should create and distribute a written policy for reporting maintenance deficiencies and periodically remind employees to report them.
- As recommended in Finding 1, SHC should consider increasing the frequency of its environmental and safety inspections.
Agency response & Auditor reply
Agency: "SHC has created a system to track all Facility related testing and inspections, including inspections of boilers."
Auditor: "Based on its response, SHC is taking measures to address our concerns in this area."