VHC could not provide multiple types of documentation related to staffing and veteran safety. Specifically, VHC could not provide any daily staffing schedules for the audit period, and it could only provide six months of incident logs for the audit period.
Without maintaining proper records, VHC cannot ensure that it is properly staffed and providing necessary care to veterans. Further, failure to maintain proper records can create liability for the Commonwealth, should VHC need to demonstrate the sufficiency or quality of the care it provided to a veteran.
Authoritative Guidance
Section D04-03 of the Massachusetts Statewide Records Retention Schedule, issued by the Secretary of the Commonwealth, describes the time and attendance records as follows:
Documents actual hours worked by unit employees and types and amounts of leave taken. Includes time sheets, time cards, attendance forms, absence reports, leave reports, and related correspondence.
D04-03(a): Fiscal/ Payroll Office records. Retain 6 years.
According to Section 150.013 of Title 105 of the Code of Massachusetts Regulations (CMR),
(B) All records shall be complete, accurate, current, available on the premises of the facility. In addition to the clinical record for each resident, the following records shall be maintained: . . .
(3) Incident, fire, epidemic, emergency and other report forms . . .
(9) Identification and summary sheets on all residents . . .
(D) All clinical records of residents including those receiving outpatient rehabilitation services shall be completed within two weeks of discharge and filed and retained for at least five years. Provisions shall be made for safe keeping for at least five years of all clinical records.
Reasons for Issue
According to VHC officials, the missing documentation could have been left in the old Quigley building during the move into the new CLC, or, when the medical records were scanned into the new EMR system, some items were missing or skipped during the process.
Recommendation
VHC should ensure that it properly stores, and has available for review, all documentation related to staffing and incidents.
Auditee’s Response
A new Executive Director joined MVH Chelsea on January 28, 2024. In February 2024, the Home implemented ScheduleAnywhere, a cloud-based scheduling and documentation platform that replaced all paper systems. This tool provides real-time visibility into staffing levels, assignments, and coverage, ensuring compliance with state and federal staffing standards.
Incident Reports are now maintained by the [Quality Assurance and Performance Improvement] Manager with oversight by the Director of Nursing and Executive Director and are routinely reviewed by EOVS leadership as part of statewide performance monitoring. All records are maintained in accordance with Massachusetts record-retention requirements.
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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