Deepening last year’s tragedy at the Holyoke Soldiers’ Home, where 77 veterans died after contracting COVID-19, was the facility’s muddled oversight. Failures of management were obvious and have now been studied and documented to a fare thee well. Less clear was how and why someone outside the home didn’t step in sooner to intervene.

It’s time to act tp prevent future tragedies involving this important group of people, whose service to our country earns them the best possible care and a close attention to detail when it comes to oversight. Clearer lines of authority must be drawn for the state’s two retirement facilities for veterans.

Rep. Linda Dean Campbell, D-Methuen, is co-sponsoring a bill that would make the state’s secretary of veterans’ services a cabinet-level job reporting to the governor, rather than the secretary of health and human services. The veterans’ services secretary would oversee the director of veterans’ homes, whose job includes managing the superintendents of both facilities.

The bill is an important step in parting the fog of finger-pointing, blame and shifting accountability that rolled in as one of the deadliest COVID-19 outbreaks in the country fell over the Holyoke home. The legislation draws from a 181-page report issued by a special legislative committee that Campbell co-chaired with state Sen. Mike Rush, D-Boston.

The bill, which Rush is also co-sponsoring, closely follows the panel’s 14 recommendations. Other suggestions include creating an ombudsman and hotline to allow residents, their families and staff to air problems at the homes; an advisory council to ensure the level of care given at the homes; and groups that would act as advocates for the homes in their communities.

The bill requires superintendents of each home be licensed nursing home administrators. Selecting the people for those roles would have be done as part of a “consistent, transparent process” under the legislation. Each home would be required to employ an inspection control specialist, and seek a five-star rating from the federal Centers for Medicare and Medicaid Services that’s only given to facilities with adequate staffing.

Campbell says in a press release the bill aims to fix “systems and critical governing deficiencies” that existed before the COVID-19 outbreak at the Holyoke home but created a “perfect storm for this preventable tragedy.”

Clearly there’s much to address. The most significant step is putting both homes under closer oversight of the Department of Veterans Services and the governor.

The Holyoke home’s superintendent, Bennett Walsh, was certainly responsible for myriad failures including a decision in the initial wave of the pandemic to board veterans who’d not yet tested positive for COVID-19 in a ward with those who had. Less obvious was whose responsibility was it to oversee Walsh.

Oddly enough, it wasn’t Francisco Urena, even though he was the state’s secretary of veterans services at the time. Urena had influence but no direct authority over Walsh, though he was blamed for not surfacing concerns about Holyoke home quickly enough.

The committee wrote: “The lack of situational awareness and effective communication on the part of senior leadership about the situation unfolding at the Holyoke Soldiers’ Home proved to be a significant, immediate cause of the tragedy.”

Urena lost his job as a result, and deservedly so. Still, Secretary for Health and Human Services Marylou Sudders bore just as much responsibility.

One could make many good arguments for elevating the secretary of veterans services to a cabinet-level post. Start with the importance of taking care of those who’ve made such significant contributions to our country. The job is as critical as cultivating a strong labor force or ensuring the best education for our children.

Ensuring the best possible care for veterans who’ve reached retirement and need regular nursing support is another reason. We’ve witnessed the tragedy that can unfold when that responsibility is shirked. The Legislature should quickly act on Campbell and Walsh’s bill to help prevent it from happening again.

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