VHC did not always update its veterans’ assessments as required. Specifically, 5 (14%) of the 35 veterans in our sample did not have assessments completed within 14 days of their admission. In addition, for 19 (54%) of the 35 veterans in our sample, VHC did not properly review the veterans’ assessments every three months during the audit period.
If VHC does not complete and review each veteran’s assessment, then VHC cannot ensure that it meets the nursing needs of each veteran in its care.
Authoritative Guidance
According to 38 CFR 51.110(b),
Comprehensive assessments. . . .
- Frequency. Assessments must be conducted–
- No later than 14 days after the date of admission;
- Promptly after a significant change in the resident’s physical, mental, or social condition; and
- In no case less often than once every 12 months.
- Review of assessments. The nursing facility management must examine each resident no less than once every 3 months, and as appropriate, revise the resident’s assessment to assure the continued accuracy of the assessment.
Reasons for Issue
According to VHC officials, the missing assessments could have been left in the old Quigley building during the move into the new Community Living Center (CLC), or, when the medical records were scanned into the new electronic medical record (EMR) system, some items were missing or skipped during the process.
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.
Auditee’s Response
An electronic medical record (EMR) system was implemented at MVH Chelsea in November 2024. In November 2025, an internal audit of the nursing assessments within the Minimum Data Set (MDS) section of the EMR confirmed that the required 14-day admission assessments were completed on time. Resident assessments are conducted at least every three months, or more frequently if a significant change requires reassessment.
These new digital processes ensure timely and complete clinical documentation, improving both continuity of care and regulatory compliance.
Auditor’s Reply
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.
| Date published: | January 14, 2026 |
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