Inspection of the
 

VA Regional Office
 

Fort Harrison, Montana
 

OFFICE OF AUDITS AND EVALUATIONS

November 3, 2011 

11-03211-12 
ACRONYMS AND ABBREVIATIONS
 

C&C Confirmed and Continued 

OIG Office of Inspector General 

RVSR Rating Veterans Service Representative 

SAO Systematic Analysis of Operations 

STAR Systematic Technical Accuracy Review 

TBI Traumatic Brain Injury 

VARO Veterans Affairs Regional Office 

VBA Veterans Benefits Administration 

VSC Veterans Service Center 

To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Report Highlights: Inspection of the VA
 

Regional Office, Fort Harrison, Montana
 

Why We Did This Review outreach to homeless shelters and service 

providers was not always effective. 

The Veterans Benefits Administration has a 

nationwide network of 57 VA Regional 

Offices (VAROs) that process claims and 

provide services to veterans. We conducted 

this inspection to evaluate how well the Fort 

Harrison VARO accomplishes this mission. 

What We Found 

Fort Harrison VARO staff accurately 

processed herbicide exposure-related claims, 

corrected errors identified by the Veterans 

Benefits Administration’s Systematic 

Technical Accuracy Review program, and 

timely processed homeless veterans’ claims. 

VARO performance was generally effective 

in processing traumatic brain injury claims 

and handling claims-related mail. 

However, the VARO lacked effective 

controls and accuracy in processing some 

disability claims. Inaccuracies in processing 

temporary 100 percent disability evaluations 

resulted from human error when staff did 

not schedule required future medical 

reexaminations. Overall, VARO staff did 

not accurately process 13 (16 percent) of 

83 disability claims reviewed. 

Management did not complete all elements 

of Systematic Analyses of Operations as 

required. Management misinterpreted 

policy and erroneously thought it had the 

discretion to omit certain elements of VARO 

operations from its analyses. VARO staff 

did not always consider whether Gulf War 

veterans were eligible to receive health care 

treatment for mental disorders. Further, 

What We Recommend 

We recommend the Fort Harrison VARO 

Director implement a plan to monitor the 

effectiveness of training for Rating Veterans 

Service Representatives to ensure they 

accurately address Gulf War veterans’ 

entitlement to mental health treatment. 

We recommend the Director ensure staff 

receive training to properly address all 

required elements of Systematic Analyses of 

Operations. We also recommend the 

Director implement and monitor a plan to 

oversee and coordinate programs for 

homeless veterans that ensures regular 

contact with homeless shelters and service 

providers. 

Agency Comments 

The VARO Director concurred with our 

recommendations. Management’s planned 

actions are responsive and we will follow up 

as required on all actions. 

BELINDA J. FINN
 

Assistant Inspector General
 

for Audits and Evaluations
 

i 
TABLE OF CONTENTS
 

Introduction..................................................................................................................................... 1
 

Results and Recommendations ....................................................................................................... 2
 

1. Disability Claims Processing ................................................................................................. 2
 

2. Management Controls ............................................................................................................ 5
 

3. Workload Management.......................................................................................................... 6
 

4. Eligibility Determinations...................................................................................................... 7
 

5. Public Contact ........................................................................................................................ 8
 

Appendix A VARO Profile and Scope of Inspection............................................................11
 

Appendix B VARO Director’s Comments............................................................................13
 

Appendix C Inspection Summary..........................................................................................16
 

Appendix D Office of Inspector General Contact and Staff Acknowledgments...................17
 

Appendix E Report Distribution ...........................................................................................18
 

ii 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Objective
 

Scope of
 

Inspection
 

INTRODUCTION 

The Benefits Inspection Program is part of the Office of Inspector General’s 

(OIG) efforts to ensure our Nation’s veterans receive timely and accurate 

benefits and services. The Benefits Inspection Division contributes to 

improved management of benefits processing activities and veterans’ 

services by conducting onsite inspections at VA Regional Offices (VAROs). 

These independent inspections provide recurring oversight focused on 

disability compensation claims processing and performance of Veterans 

Service Center (VSC) operations. The objectives of the inspections are to: 

	 Evaluate how well VAROs are accomplishing their mission of providing 

veterans with access to high quality benefits and services. 

	 Determine whether management controls ensure compliance with VA 

regulations and policies; assist management in achieving program goals; 

and minimize the risk of fraud, waste, and other abuses. 

	 Identify and report systemic trends in VARO operations. 

In addition to this standard coverage, inspections may examine issues or 

allegations referred by VA employees, members of Congress, or other 

stakeholders. 

In July 2011, the OIG conducted an inspection of the Fort Harrison VARO. 

The inspection focused on five protocol areas examining eight operational 

activities. The five protocol areas were disability claims processing, 

management controls, workload management, eligibility determinations, and 

public contact. We did not examine eligibility determinations related to 

fiduciary incompetency determinations because VBA has centralized all 

Western Area fiduciary activities at the Salt Lake City VARO. 

We reviewed 53 (36 percent) of 148 disability claims related to traumatic 

brain injury (TBI) and herbicide exposure completed from January through 

March 2011. In addition, we reviewed 30 (36 percent) of 84 rating 

decisions where VARO staff granted temporary 100 percent disability 

evaluations for at least 18 months, generally the longest period a temporary 

100 percent disability evaluation may be assigned under VA policy without 

review. 

Appendix A provides details on the VARO and the scope of our inspection. 

Appendix B provides the VARO Director’s comments on a draft of this 

report. Appendix C provides criteria we used to evaluate each operational 

activity and a summary of our inspection results. 

VA Office of Inspector General 1 
Inspection of the VA Regional Office, Fort Harrison, Montana 

RESULTS AND RECOMMENDATIONS 

1. Disability Claims Processing 

The OIG inspection team focused on disability claims processing related to 

temporary 100 percent disability evaluations, TBI, and herbicide exposure. 

We evaluated claims processing accuracy and its impact on veterans’ 

benefits. 

Finding 1	 Disability Claims Processing Accuracy Could Be 

Improved 

The Fort Harrison VARO lacked controls and accuracy in processing claims 

for temporary 100 percent and TBI-related disabilities. VARO staff 

incorrectly processed 13 (16 percent) of the total 83 disability claims we 

reviewed. VARO management agreed with our assessments and initiated 

action to correct the inaccuracies identified. 

The table below reflects the errors affecting, and those with the potential to 

affect, veterans’ benefits processed at the Fort Harrison VARO. 

Table Disability Claims Processing Results 

Type Reviewed 

Claims Incorrectly Processed 

Total Affecting 

Veterans’ 

Benefits 

Potential To 

Affect Veterans’ 

Benefits 

Temporary 

100 Percent Disability 

Evaluations 

30 10 1 9 

Traumatic Brain 

Injury Claims 23 3 1 2 

Herbicide ExposureRelated Disability 

Claims 

30 0 0 0 

Total 83 13 2 11 

Temporary 100 

Percent Disability 

Evaluations 

Source: VA OIG 

VARO staff incorrectly processed 10 (33 percent) of 30 temporary 

100 percent disability evaluations we reviewed. Veterans Benefits 

Administration (VBA) policy requires a temporary 100 percent disability 

evaluation for a service-connected disability following surgery or when 

specific treatment is needed. At the end of a mandated period of 

convalescence or upon cessation of treatment, VARO staff must request a 

VA Office of Inspector General 2 
Inspection of the VA Regional Office, Fort Harrison, Montana 

follow-up medical examination to help determine whether to continue the 

veteran’s temporary 100 percent disability evaluation. 

For temporary 100 percent disability evaluations, including confirmed and 

continued (C&C) evaluations where rating decisions do not change veterans’ 

payment amounts, VSC staff must input suspense diaries in VBA’s 

electronic system. A suspense diary is a processing command that 

establishes a date when VSC staff must schedule a reexamination. As the 

diary matures, the electronic system generates a reminder notification 

alerting VSC staff to schedule the reexamination. 

Our analysis of available medical evidence showed that 1 (10 percent) of 

10 processing inaccuracies involved an overpayment to a veteran. The 

overpayment occurred when a Rating Veterans Service Representative 

(RVSR) established an incorrect effective date for service-connected prostate 

cancer. As a result, VA overpaid the veteran $2,823 over 1 month. 

The remaining nine inaccuracies had the potential to affect veterans’ 

benefits. We could not determine if the evaluations would have continued 

for these nine cases because the veterans’ claims folders did not contain 

medical examination reports needed to reevaluate each case. 

These processing inaccuracies were the result of human error. The most 

frequent processing inaccuracy noted in 5 (50 percent) of the total 10 cases 

occurred when VSC staff did not establish suspense diaries in the electronic 

record. Without suspense diaries, VSC staff did not receive reminder 

notifications to schedule required VA medical reexaminations. 

For those cases requiring reexaminations, delays ranged from approximately 

4 months to 10 years and 7 months. An average of 4 years and 3 months 

elapsed from the time staff should have scheduled the reexaminations until 

the date of our inspection—the date staff ultimately took corrective actions to 

obtain the necessary medical evidence. 

VARO management did not provide adequate oversight to ensure VSC staff 

entered suspense diaries for C&C rating decisions. In November 2009, VBA 

provided guidance reminding VAROs about the need to input suspense 

diaries in the electronic record for C&C rating decisions. However, VARO 

management did not have a local policy in place requiring VSC staff to 

review the electronic record for C&C rating decisions needing medical 

reexaminations. As such, veterans may not always receive correct benefits 

payments. Because effective controls were not in place, temporary 

100 percent disability evaluations could have continued uninterrupted over 

the course of the veterans’ lifetimes. 

VA Office of Inspector General 3 
TBI Claims 

Inspection of the VA Regional Office, Fort Harrison, Montana 

In response to a recommendation in our report, Audit of 100 Percent 

Disability Evaluations (Report No. 09-03359-71, January 24, 2011), the 

Acting Under Secretary for Benefits agreed to review all temporary 

100 percent disability evaluations and ensure each evaluation had a future 

examination date entered in the electronic record. As such, we are making 

no additional recommendation for improvement in this area. To assist in 

implementing the agreed upon review, we provided the VARO with 

54 claims remaining from our universe of 84 temporary 100 percent 

disability evaluations. During our inspection of the Fort Harrison VARO, 

we observed a demonstration where system modifications allowed automatic 

population of a suspense diary in the electronic record to provide a reminder 

notification to schedule a reexamination related to a C&C rating decision. 

We will continue to monitor VBA’s progress in addressing this issue 

nationwide. 

Additionally, we observed eight temporary 100 percent disability medical 

reexamination dates that extended 3 years beyond the dates selected by 

RVSRs. A review of the claims processing award documents revealed VSC 

staff had accurately entered the reexamination dates in the electronic record. 

VSC staff stated they took no action to extend the future examination dates 

beyond the dates selected by the RVSRs. Neither VARO staff nor we could 

explain this anomaly. If not for our inspection, the temporary 100 percent 

evaluations for these eight veterans would have continued 3 years beyond the 

reexamination dates that RVSRs requested. We will continue monitoring 

reexamination date entries to determine the frequency of such occurrences. 

The Department of Defense and VBA commonly define a TBI as 

traumatically induced structural injury or physiological disruption of brain 

function caused by an external force. The major residual disabilities of TBI 

fall into three main categories—physical, cognitive, and behavioral. VBA 

policy requires that staff evaluate these residual disabilities. 

VARO staff incorrectly processed 3 (13 percent) of 23 TBI claims—1 of 

these processing inaccuracies affected a veteran’s benefits. In this instance, 

an RVSR incorrectly assigned a 70 percent evaluation for a TBI-related 

disability; however, medical treatment reports in the claim folder revealed 

the disability warranted a 40 percent evaluation. As a result, VA overpaid 

the veteran $9,138 over a period of 6 months. 

The remaining two cases had the potential to affect veterans’ benefits. 

Following are descriptions of these inaccuracies. 

	 An RVSR did not provide the medical examiner the veteran’s claim file 

for review as required by VBA policy, thereby rendering the medical 

examination insufficient. The RVSR used the insufficient examination 

report to evaluate a TBI-related disability. According to VBA policy, 

VA Office of Inspector General 4 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Herbicide 

Exposure-Related 

Claims 

Systematic 

Technical 

Accuracy 

Review 

Systematic 

Analysis of 

Operations 

when a medical examination report does not address all required 

elements, such as a review of the claim file, VSC staff should return the 

examination to the issuing clinic or health care facility as insufficient. 

Neither VARO staff nor we can substantiate all of the TBI-related 

disabilities without sufficient or complete medical evidence. 

	 Based on medical treatment records, an RVSR correctly determined a 

veteran’s disability was over-evaluated; however, VSC staff did not take 

the appropriate action to reduce benefits. Even though the veteran’s 

overall disability evaluation remained unchanged, the reduction was 

necessary as it may affect future disability evaluations. 

The three TBI claims processing errors were unique and did not constitute a 

common trend, pattern, or systemic issue. As such, we made no 

recommendation for improvement in this area. 

VARO staff correctly processed all 30 herbicide exposure-related claims we 

reviewed. Therefore, we made no recommendation for improvement in this 

area. 

2. Management Controls 

We assessed management controls to determine whether VARO 

management adhered to VBA policy regarding correction of errors identified 

by VBA’s Systematic Technical Accuracy Review (STAR) staff. The STAR 

program is VBA’s multifaceted quality assurance program to ensure that 

veterans and other beneficiaries receive accurate and consistent 

compensation and pension benefits. VBA policy requires that VARO staff 

take corrective action on errors that STAR staff identify. STAR program 

staff identified errors in six claims files from January through March 2011. 

VARO staff followed VBA policy by correcting all the errors identified 

during that period. As such, we made no recommendation for improvement 

in this area. 

We assessed whether VARO management had controls in place to ensure 

complete and timely submission of each Systematic Analysis of Operations 

(SAO). We also considered whether VSC staff had adequate data to support 

the analyses and recommendations in each SAO. An SAO is a formal 

analysis of a VSC organizational element or operational function. An SAO 

provides an organized means of reviewing VSC operations to identify 

existing or potential problems and propose corrective actions. VARO 

management must publish an annual SAO schedule designating the staff 

required to complete the SAOs by specific dates. The VSC Manager is 

responsible for ongoing analysis of VSC operations, including completing 

11 SAOs annually. 

VA Office of Inspector General 5 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Finding 2
 

Recommendation 

Management 

Comments 

OIG Response 

Mailroom 

Operations 

Triage Mail 

Processing 

Procedures 

Systematic Analyses of Operations Missing Required 

Elements 

Two (18 percent) of 11 SAOs were incomplete, missing several required 

elements and their analysis. This occurred because VARO management 

misinterpreted VBA policy and did not realize it was necessary to address all 

required elements of each SAO. As a result, management may not have 

adequately identified existing and potential problems for corrective action to 

improve VSC operations. 

VSC management knew the 11 SAOs were mandatory, but did not include 

all required elements and related analyses for each of those SAOs. For 

example, the SAO on Claims Processing Timeliness did not include 

assessments of the VSC’s pending inventory or non-rating related claims 

pending over 6 months. VBA policy outlines the minimum elements staff 

must cover in each SAO and states management may expand on these; 

however, it does not allow discretion to omit elements and their analyses. 

1.	 We recommend the Fort Harrison VARO Director ensure all staff 

responsible for completing Systematic Analyses of Operations receive 

training on addressing all required elements of those analyses. 

The VARO Director concurred with our recommendation. In July 2011, the 

VSCM trained staff on addressing all required elements of SAOs. Further, 

the Director informed us that in August 2011, the staff rewrote the two 

incomplete SAOs we identified during our inspection. 

The Director’s comments and actions are responsive to the recommendation. 

3. Workload Management 

We assessed controls over VARO mailroom operations to ensure staff timely 

and accurately processed incoming mail. VBA policy states staff will open, 

date-stamp, and route all mail to the appropriate locations within 4 to 6 hours 

of receipt at the VARO. The Fort Harrison VARO assigns responsibility for 

mailroom activities, including processing of incoming mail, to the VSC. The 

VARO mailroom staff processed mail according to VBA policy; therefore, 

we made no recommendation for improvement in this area. 

We assessed the VSC Triage Team’s mail-processing procedures to ensure 

staff reviewed, controlled, and processed all claims-related mail in 

accordance with VBA policy. VBA policy indicates that oversight to ensure 

staff use available plans and systems is the most important part of workload 

management. It also states that effective mail management is crucial to the 

control of workflow within the VSC. 

VA Office of Inspector General 6 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Search and Drop 

Mail 

Entitlement to 

Medical Treatment 

for Mental 

Disorders 

Finding 3 

VBA policy requires that VARO staff use the Control of Veterans Records 

System, an electronic tracking system, to track claims folders and control 

search mail. VBA defines search mail as active claims-related mail waiting 

to be associated with veterans’ claims folders. Conversely, drop mail 

requires no immediate action after staff place the mail in the claims folders. 

The Triage Team staff did not properly manage 1 (2 percent) of 60 pieces of 

mail we reviewed. As a result, we determined the Fort Harrison VARO was 

generally complying with national and local mail-handling policies. 

Therefore, we make no recommendation for improvement in this area. 

4. Eligibility Determinations 

Veterans with Gulf War military service are eligible for medical treatment 

for any mental disorder they develop within 2 years of the date of separation 

from service. According to VBA, whenever an RVSR denies a Gulf War 

veteran service connection for any mental disorder, the RVSR must consider 

whether the veteran is entitled to receive mental health treatment. 

Gulf War Veterans Not Receiving Accurate Entitlement 

Decisions for Mental Health Treatment 

VARO staff did not properly address whether four (57 percent) of seven Gulf 

War veterans were entitled to receive treatment for mental disorders. RVSRs 

stated that despite training and their understanding of the policy, they 

generally found it difficult to remember additional benefits they needed to 

consider even when not claimed by veterans. As a result, veterans may be 

unaware of potential entitlement to treatment for mental disorders. 

Following are descriptions of the four inaccuracies: 

	 In three cases, RVSRs did not address entitlement to mental health 

treatment when they denied veterans’ service connection for a mental 

disorder. For two cases, the medical evidence in the claims files 

indicated the veterans developed mental disorders within the applicable 

time frame and were entitled to health care. In the remaining case, the 

veteran claimed service connection for a mental disorder. However, 

evidence did not show the veteran had a mental disorder diagnosed 

within the 2-year period following separation, which would have entitled 

the veteran to treatment. 

	 In one case, the RVSR indicated the veteran was entitled to treatment for 

a mental condition; however, the medical records did not show the 

veteran had a diagnosed mental condition. 

VSC management was aware staff were not addressing this entitlement as 

STAR staff identified related errors on two (25 percent) of eight claims 

VA Office of Inspector General 7 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Recommendation 

Management 

Comments 

OIG Response 

Expedited 

Claims 

Processing for 

Homeless 

Veterans 

completed from October through December 2010. RVSRs interviewed were 

able to explain the correct process for addressing this entitlement issue, but 

stated it was generally difficult to remember all of the issues to consider 

when processing claims. Most RVSRs and Decision Review Officers 

received refresher training on this topic in March 2011. We were unable to 

assess whether this training was effective because staff finalized the cases we 

reviewed prior to completing the training. 

In February 2011, VBA updated its Rating Board Automation 2000, a 

computer application designed to assist RVSRs in preparing disability 

ratings. The application provides a pop-up notification, known as a tip 

master, to remind staff to consider entitlement to health care treatment when 

they deny service connection for a mental disorder. However, RVSRs stated 

it was easy to click past the tip master and not address the issue. Our review 

contained two cases completed after the update, both of which did not 

contain errors. At this time, we cannot ascertain whether this update will 

minimize future processing inaccuracies. 

2.	 We recommend the Fort Harrison VA Regional Office Director develop 

and implement a plan to monitor the effectiveness of Rating Veterans 

Service Representative training on correctly addressing Gulf War 

veterans’ entitlement to mental health treatment. 

The VARO Director concurred with our recommendation. In August 2011, 

the Director issued policy requiring decision makers to consider entitlement 

under 38 United States Code 1702 as a separate and distinct issue in rating 

decisions for every Gulf War veteran denied service connection for a mental 

disorder. Further, in August 2011, RVSRs and Decision Review Officers 

received refresher training on the proper procedures for rating claims related 

to the denial of mental conditions for Gulf War veterans. 

The Director’s comments and actions are responsive to the recommendation. 

5. Public Contact 

In November 2009, VA developed a 5-year plan to end homelessness among 

veterans by assisting every eligible homeless veteran willing to accept 

service. VBA generally defines homeless as lacking a fixed, regular, and 

adequate nighttime residence. VBA provided guidance to all VAROs that 

homeless veterans’ claims should receive priority processing. 

We found no excessive delays in processing homeless veterans’ claims. 

VBA’s national target for processing homeless veterans’ claims is an average 

of 75 days. At the time of our inspection, the VARO had two homeless 

veterans’ claims pending for an average of 40.5 days—34.5 days better than 

VBA’s national target. VBA calculates the average days a homeless 

VA Office of Inspector General 8 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Outreach to 

Homeless 

Shelters and 

Service 

Providers 

Finding 4 

veteran’s claim is pending from the date a VARO receives a claim, divided 

by the total number of claims pending. 

Although VBA does not have a target for the number of days it takes 

VAROs to complete homeless veterans’ claims, the Fort Harrison VARO 

established a local goal of 100 days. The VARO completed 10 claims for 

homeless veterans from January through March 2011 in an average of 

78 days—22 days better than the local goal. As we did not find any 

excessive delays, we make no recommendation for improvement in this area. 

Congress mandated at least one full-time employee oversee and coordinate 

programs for homeless veterans at each of the 20 VAROs that VA 

determined to have the largest veteran populations. VBA guidance, last 

updated in September 2002, directed that the coordinators at the remaining 

37 VAROs be familiar with the requirements for improving the effectiveness 

of VARO outreach to homeless veterans. These requirements for each 

VARO include developing and updating a directory of local homeless 

shelters and service providers. Additionally, the coordinators should attend 

regular meetings with local homeless service providers, community 

governments, and advocate groups to provide information on VA benefits 

and services. 

No Clear Measures to Assess Effectiveness of 

Homeless Veterans Outreach Program 

The Fort Harrison VARO’s outreach to homeless shelters and service 

providers was not always effective. This occurred because VARO 

management did not have a local process or procedure in place to assess the 

effectiveness of outreach efforts. As a result, VARO management had no 

assurance that homeless shelters and service providers were aware of 

available VA benefits and services. 

VSC management did not have a mechanism in place to determine whether 

homeless shelters and service providers received information from the 

VARO regarding benefits and services available to homeless veterans. 

Further, management did not update a resource directory of shelters, 

homeless day-care facilities, and homeless service providers, as required by 

VBA policy. The Fort Harrison VARO does not have a full-time coordinator 

dedicated to address homeless veterans’ needs. VARO management 

assigned one employee to perform this function as a collateral duty. 

We attempted to contact Program Directors at 10 (48 percent) of 

21 homeless shelters and service providers listed on a directory provided by 

VSC staff. While three Program Directors confirmed the VARO had made 

contact with their organizations, five indicated they had not heard from the 

VARO or received information regarding VA benefits and services. The 

VA Office of Inspector General 9 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Recommendation 

Management 

Comments 

OIG Response 

remaining two Program Directors did not have updated contact information; 

therefore, we could not reach out to these organizations. 

VSC staff agreed they did not routinely follow up with shelters or homeless 

service providers to ensure these facilities received outreach information 

mailed from the VARO. However, staff reported they attempted to contact 

the facilities when outreach information mailings were returned as 

undeliverable. VARO management stated VBA policy regarding outreach 

procedures was unclear on matters such as the frequency of contact the 

coordinator should have with homeless shelters and service providers. 

VARO managers stated they measured the success of their homeless 

program by whether or not they met VBA’s 75-day goal for expedited claims 

processing. VBA has not established a performance measure or goal to 

determine whether VARO outreach efforts are effective. Although we 

determined the Fort Harrison VARO did not maintain contact with the 

shelters on a regular basis or fully update the resource directory, we found it 

took initiative in other areas. For example, the VARO attempted to stay in 

touch with all homeless veterans on a quarterly basis regardless of whether a 

claim was pending. The purpose of the contact was to inquire about their 

homeless status and answer questions regarding VA benefits and/or services. 

3.	 We recommend the Fort Harrison VA Regional Office Director develop 

a mechanism to oversee and coordinate programs for homeless veterans 

that will ensure VA Regional Office staff regularly contact homeless 

shelters and service providers. 

4.	 We recommend the Fort Harrison VA Regional Office Director develop 

and implement a plan to monitor and assess effectiveness in providing 

outreach information to homeless shelters and service providers. 

The VARO Director concurred with our recommendations. The Director 

created a draft plan that will require VARO staff to contact homeless shelters 

and service providers semi-annually. Further, in October 2011 the Director 

issued policy requiring that two weeks after mailing outreach materials on 

available VA benefits and services, VARO staff contact the homeless 

shelters by telephone to ensure they received the information. 

The Director’s comments and actions are responsive to the recommendation. 

VA Office of Inspector General 10 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Appendix A VARO Profile and Scope of Inspection 

Organization The Fort Harrison VARO administers a variety of services and benefits, 

including Compensation, Vocational Rehabilitation and Employment, 

specially adapted housing grants, benefits counseling, and outreach to 

homeless, elderly, minority, and women veterans. 

Resources As of July 2011, the Fort Harrison VARO had a staffing level of 57.9 fulltime equivalent employees. Of these employees, 49.9 (86 percent) were 

assigned to the VSC. 

Workload As of May 2011, the VARO reported 1,178 pending compensation claims. 

The average time to complete these claims was 104 days—approximately 

71 days better than the national target of 175 days. As reported by STAR, 

the accuracy of compensation rating-related issues was 91.5 percent, which 

was better than the 90 percent target set by VBA. 

Scope We reviewed selected management, claims processing, and administrative 

activities to evaluate compliance with VBA policies regarding delivery of 

benefits and nonmedical services to veterans and other beneficiaries. We 

interviewed managers and employees and reviewed veterans’ claims folders. 

Our review included 53 (36 percent) of 148 disability claims related to TBI 

and herbicide exposure completed from January through March 2011. For 

temporary 100 percent disability evaluations, we selected 30 (36 percent) of 

84 existing claims from VBA’s Corporate Database. We provided VARO 

officials with 54 claims remaining from our universe of 84 for their review. 

These 84 claims represented all instances where VARO staff had granted 

temporary 100 percent disability evaluations for at least 18 months or longer 

as of June 9, 2011. 

We reviewed all six files containing errors identified by VBA’s STAR 

program from January through March 2011. VBA measures the accuracy of 

compensation and pension claims processing through its STAR program. 

STAR assessments include a review of work associated with claims 

requiring rating decisions. STAR staff review original claims, reopened 

claims, and claims for increased evaluations. Further, they review appellate 

issues that involve a myriad of veterans’ disabilities claims. 

Our process differs from that of STAR as we review specific types of 

disability claims such as those related to TBI and herbicide exposure that 

require rating decisions. We review rating decisions and awards processing 

involving temporary 100 percent disability evaluations. Additionally, we 

reviewed the 11 mandatory SAOs completed in FYs 2010 and 2011. 

VA Office of Inspector General 11 
Inspection of the VA Regional Office, Fort Harrison, Montana 

We reviewed selected mail in various processing stages in the VARO 

mailroom and the VSC. We reviewed all seven claims completely processed 

for Gulf War veterans from January through March 2011 to determine 

whether VSC staff addressed entitlement to mental health treatment in the 

rating decision documents. We reviewed all 10 homeless veterans claims 

completed from January through March 2011, as well as two claims that 

were pending at the time of our inspection. Further, we reviewed the 

effectiveness of the VARO’s homeless veterans outreach program. 

We completed our review in accordance with the Council of the Inspectors 

General on Integrity and Efficiency’s Quality Standards for Inspection and 

Evaluation. We planned and performed the review to obtain sufficient, 

appropriate evidence to provide a reasonable basis for our findings and 

conclusions based on our review objectives. We believe that the evidence 

obtained provides a reasonable basis for our findings and conclusions based 

on our review objectives. 

VA Office of Inspector General 12 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Appendix B VARO Director’s Comments 

Department of Memorandum Veterans Affairs 

Date: October 13, 2011 

From: Acting Director, Fort Harrison VA Regional Office (436/00) 

Subj: Inspection of the VA Regional Office, Fort Harrison, Montana 

To: Assistant Inspector General for Audits and Evaluations (52) 

Enclosed are the Fort Harrison VA Regional Office’s (RO) comments and responses to 

the OIG Draft Report, Inspection of the VA Regional Office, Fort Harrison, Montana, 

received September 30, 2011. The RO concurs with the findings and recommendations 

regarding RO activities requiring improvement, which include management controls, 

eligibility determinations, and public contact. Attached are our comments and 

responses to the specific recommendations and action items that arose as a result of the 

review. 

1. 

We appreciate the professionalism and courtesy exhibited by the audit team members 

during their review of our operations, as well as the analysis they provided. This 

analysis and the corresponding recommendations for improvement are invaluable in our 

continued efforts to provide the best possible service to our Veterans. 

2. 

3.	 Please feel free to contact me at (801) 326-2400 with any questions or concerns 

regarding our reply. 

(original signed by:) 

JOYCE CANGE
 

Acting Director
 

Enclosure 

VA Office of Inspector General 13 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Ft. Harrison VA Regional Office
 

Response to the Office of Inspector General, Benefits Inspection
 

Division, Inspection of the VA Regional Office Draft Report
 

Comments and Implementation Plan 

OIG Recommendations 

Recommendation 1. We recommend the Fort Harrison VA Regional Office Director ensure all 

staff responsible for completing Systematic Analyses of Operations (SAOs) receive training on 

addressing all required elements of those analyses. 

Concur with recommendation. 

Planned/Completed Action: 

The SAO schedule for FY 2012 (attached) has been updated to reflect all required elements of 

the required SAOs per M21-4, Chapter 5. In order to address prior omissions, the two 

incomplete SAOs identified during the inspection that did not address all required elements 

(Appeals and Claims Processing Timeliness) were assigned on July 7, 2011 and rewritten on 

August 9 and 23, 2011, respectively. The Staff, as well as those Veterans Service Center 

employees assigned to write the SAOs, received the necessary training from the Veterans Service 

Center Manager to address all required elements of the SAOs on July 7, 2011. In addition, the 

FY 2012 SAO Schedule was distributed to the staff and all those assigned to write SAOs, as well 

as sent to the Director’s Office, on September 30, 2011. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 2. We recommend the Fort Harrison VA Regional Office Director develop 

and implement a plan to monitor the effectiveness of Rating Veterans Service Representative 

training on correctly addressing Gulf War veterans’ entitlement to mental health treatment. 

Concur with recommendation. 

Planned/Completed Action: In March and August 2011 Rating Veteran Service 

Representatives and Decision Review Officers received refresher training on this topic. On 

August 16, 2011, local policy was issued to decision makers to consider entitlement under 38 

USC 1702 as a separate and distinct issue in the rating decision for every Gulf War veteran 

claiming service connection for a mental disorder whose claim is denied. This item will continue 

to be monitored during local and National STAR reviews. Based on results of the quality 

reviews on decisions rated after August 16, 2011, consideration will be given to instituting 

second signature review on claims involving denials for mental disorders. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendations 3 and 4. We recommend the Fort Harrison VA Regional Office Director 

develop a mechanism to oversee and coordinate programs for homeless veterans that will ensure 

VA Office of Inspector General 14 
Inspection of the VA Regional Office, Fort Harrison, Montana 

VARO staff regularly contact homeless shelters and service providers. We recommend the Fort 

Harrison VA Regional Office Director develop and implement a plan to monitor and assess 

effectiveness in providing outreach information to homeless shelters and service providers. 

Concur with recommendation. 

Planned/Completed Action: A draft plan exists which will ensure semi-annual contacts with 

homeless shelters and service providers, either in person or by mail. A mechanism will be put in 

place to ensure that facilities receive outreach information mailed from the VARO. VARO staff 

will set a two-week suspense for a telephone contact with the shelter after each mailing to ensure 

that the information regarding available VA benefits and services was received. The policy was 

issued to applicable members of the Veterans Service Center on October 11, 2011. 

The Veterans Benefits Administration recommends closure of these recommendations. 

VA Office of Inspector General 15 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Appendix C Inspection Summary
 

Eight Operational 

Activities Inspected 

Criteria Reasonable 

Assurance of 

Compliance 

Yes No 

Claims Processing 

1. Temporary 

100 Percent 

Disability 

Evaluations 

Determine whether VARO staff properly reviewed temporary 100 percent 

disability evaluations. (38 CFR 3.103(b)) (38 CFR 3.105(e)) (38 CFR 3.327) 

M21-1MR Part IV, Subpart ii, Chapter 2, Section J) (M21-1MR Part III, 

Subpart iv, Chapter 3, Section C.17.e) 

X 

2. Traumatic Brain 

Injury Claims 

Determine whether claims for service connection for all residual disabilities 

related to in-service TBI were properly processed. (Fast Letters 08-34 and 

08-36, Training Letter 09-01) 

X 

3. Herbicide 

Exposure-Related 

Claims 

Determine whether VARO staff properly processed claims for service 

connection for herbicide exposure (Agent Orange). (38 CFR 3.309) (Fast 

Letter 02-33) (M21-1MR Part IV, Subpart ii, Chapter 2, Section C.10) 

X 

Management Controls 

4. Systematic 

Technical 

Accuracy Review 

Determine whether VARO staff properly corrected STAR errors in 

accordance with VBA policy. (M21-4, Chapter 3, Subchapter II, 3.03) X 

5. Systematic 

Analysis of 

Operations 

Determine whether VARO staff properly performed formal analyses of 

their operations through completion of SAOs. (M21-4, Chapter 5) X 

Workload Management 

6. Mail Handling 

Procedures 

Determine whether VARO staff properly followed VBA mail-handling 

procedures. (M23-1) (M21-4, Chapter 4) (M21-1MR Part III, Subpart ii, 

Chapters 1 and 4) 

X 

Eligibility Determinations 

7. Gulf War 

Veterans’ 

Entitlement to 

Mental Health 

Treatment 

Determine whether VARO staff properly processed Gulf War Veterans’ 

claims for Medical Treatment for Mental Illness. (38 United States Code 

1702) (M21-1MR Part IX, Subpart ii, Chapter 2) (M21-1MR Part III, Subpart v, 

Chapter 7) (Fast Letter 08-15) (38 CFR 3.384) 

X 

Public Contact 

8. VBA’s Homeless 

Veterans Program 

Determine whether VARO staff expeditiously processed homeless veterans’ 

claims and provided effective outreach services. (38 CFR 1.710) (M21-1, 

Part VII, Chapter 6.06) 

X 

Source: OIG 

CFR=Code of Federal Regulations, M=Manual, MR=Manual Rewrite 

VA Office of Inspector General 16 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Appendix D Office of Inspector General Contact and Staff 

Acknowledgments 

OIG Contact	 For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

Acknowledgments Brent Arronte, Director 

Brett Byrd 

Madeline Cantu 

Kelly Crawford 

Ramon Figueroa 

Lee Giesbrecht 

Nora Stokes 

Lisa Van Haeren 

VA Office of Inspector General 17 
Inspection of the VA Regional Office, Fort Harrison, Montana 

Appendix E Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Benefits Administration 

Assistant Secretaries 

Office of General Counsel 

Veterans Benefits Administration Western Area Director 

VA Regional Office Fort Harrison Director 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Max Baucus, Jon Tester 

U.S. House of Representatives: Dennis Rehberg 

This report will be available in the near future on the OIG’s Web site at 

http://www.va.gov/oig/publications/reports-list.asp. This report will remain 

on the OIG Web site for at least 2 fiscal years. 

VA Office of Inspector General 18