Citation Nr: 21012765 Decision Date: 03/05/21 Archive Date: 03/05/21 DOCKET NO. 12-32 158 DATE: March 5, 2021 REMANDED Entitlement to special monthly compensation (SMC) based on the need for regular aid and attendance or housebound status is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1986 to September 1990. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the matter in February 2019 for further development. Entitlement to SMC based on the need for regular aid and attendance or housebound status is remanded. The Board previously remanded the issue of entitlement to SMC to obtain updated treatment records and a current examination. In this regard, there are no medical records in the file dated after 2010. A VA examination was last conducted in March 2010. This gap of over ten years in the evidence remains. Following the Board’s remand, the agency of original jurisdiction (AOJ) sent the Veteran letters in September 2019 and July 2020 asking him to fill out and return authorized release forms for any private treatment records. The forms were enclosed with the letter. In response, he submitted a general authorization form (VA Form 21-4142), but did not submit the form identifying the medical facilities where he was treated (VA Form 21-4142a). He has not otherwise informed VA where he has received treatment since 2010. Consequently, VA has been unable to obtain updated private treatment records. In addition, a new examination could not be conducted due to safety concerns stemming from the COVID-19 pandemic. The July 2020 VA medical opinion is based solely on review of the March 2010 VA examination report and treatment records dated in 2010 or earlier. Moreover, the examiner’s conclusion that the Veteran is able to perform self care does not account for his report that his wife had to assist him with getting out of bed, dressing and undressing, and bathing, and that she prepared all his meals, according to the March 2010 VA examination report. A January 2010 examination report filled out by a private provider states that the Veteran was unable to prepare his own meals. Finally, the July 2020 medical opinion does not reflect consideration of certain items of evidence, as instructed in the Board’s February 2019 remand. Therefore, there has not been substantial compliance with that directive. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). On remand, the Veteran should be provided another opportunity to identify where he has received treatment since 2010, and to authorize the release of those records so that VA can attempt to obtain those records on his behalf. He should also be invited to submit the records himself. Any outstanding VA treatment records must also be obtained and added to the file. Another attempt should be made to arrange for a VA examination of the Veteran to assess whether he has a need of regular aid and attendance due to service-connected disabilities. If an in-person examination cannot be conducted in a timely manner due to pandemic safety protocols, a telehealth examination should be considered, if feasible. The matters are REMANDED for the following action: 1. Any outstanding VA treatment records pertaining to the Veteran (if such exist) dated since January 2010 must be obtained and added to the file. 2. Request the Veteran to authorize the release of any private treatment records dated after January 2010. Inform him that he must identify the provider or facility name, address, and dates of treatment by filling out and returning VA Form 21-4142a. He should also be invited to submit the records himself. 3. When considered safe, arrange for a VA examination of the Veteran to assess whether he has a need of regular aid and attendance due to service-connected disabilities. If an in-person examination cannot be conducted in a timely manner due to pandemic safety protocols, a telehealth examination should be considered, if feasible. In addition to all other pertaining findings, the examiner must address the January 2010 private aid and attendance examination report authored by Dr. C.N. J. Rutkin Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Frazier, Associate Attorney The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.