Inspection of the
 

VA Regional Office
 

Reno, Nevada
 

OFFICE OF AUDITS AND EVALUATIONS

June 24, 2011 

11-00517-204 
ACRONYMS AND ABBREVIATIONS
 

COVERS Control of Veterans Records System

NOD Notices of Disagreement

OIG Office of Inspector General

PTSD Post-Traumatic Stress Disorder

RVSR Rating Veterans Service Representative

SAO Systematic Analysis of Operations

STAR Systematic Technical Accuracy Review

TBI Traumatic Brain Injury

VACOLS Veterans Appeals Control and Locator System

VAMC Veterans Affairs Medical Center

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)
 
i 

Report Highlights: Inspection of the VA 

Regional Office, Reno, Nevada

Why We Did This Review 

The Benefits Inspection Division conducts 

onsite inspections at VA Regional Offices 

(VAROs) to review disability compensation 

claims processing and Veterans Service 

Center operations. 

What We Found

The Reno VARO staff correctly processed 

post-traumatic stress disorder disability 

claims and errors identified by the Veterans 

Benefits Administration’s Systematic 

Technical Accuracy Review program. 

VARO performance was generally effective 

in processing herbicide exposure-related 

disability claims, establishing correct dates 

of claim in the electronic record, and timely 

establishing Notices of Disagreement for 

appealed decisions. 

However, VARO management lacked 

effective control and accuracy in processing 

temporary 100 percent disability evaluations

as well as traumatic brain injury claims. 

Overall, VARO staff did not accurately 

process 23 (24 percent) of the 95 disability

claims reviewed. Further, controls over 

completion of Systematic Analyses of 

Operations and mail handling were not 

adequate. 

What We Recommended

VARO management needs to provide 

refresher training and develop a plan to 

ensure staff follow the proper procedures for 

identifying and returning inadequate 

traumatic brain injury examination reports. 

VARO management needs to establish an 

additional level of review for traumatic brain 

injury rating decisions. 

We recommended VARO management 

develop and implement a plan to ensure staff 

timely complete and address all required 

elements of Systematic Analyses of 

Operations. Finally, we recommended that 

management strengthen mail handling by 

developing a plan to ensure compliance with 

the Control of Veterans Record System and 

amending the mail plan to ensure proper 

mail handling procedures. 

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
TABLE OF CONTENTS
 

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

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

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

2. Data Integrity ..........................................................................................................................6
 

3. Management Controls.............................................................................................................7
 

4. Workload Management...........................................................................................................8
 

Appendix A VARO Profile and Scope of Inspection............................................................12

Appendix B VARO Director’s Comments............................................................................14

Appendix C Inspection Summary..........................................................................................18

Appendix D OIG Contact and Staff Acknowledgments........................................................19

Appendix E Report Distribution ...........................................................................................20

ii
Inspection of the VA Regional Office, Reno, Nevada 

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 if 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 March 2011, the OIG conducted an inspection of the Reno VARO. The

inspection focused on four protocol areas examining nine operational

activities. The four protocol areas were disability claims processing, data

integrity, management controls, and workload management. We did not

examine eligibility determinations because VBA has centralized all Western

Area fiduciary activities at the Salt Lake City VARO.

We reviewed 65 (31 percent) of 207 disability claims related to posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and herbicide

exposure completed by the VARO from October through December 2010.

In addition, we reviewed 30 (22 percent) of 139 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 Reno 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, Reno, Nevada 

RESULTS AND RECOMMENDATIONS 

1. Disability Claims Processing 

The OIG inspection team focused on disability claims processing related to

temporary 100 percent disability evaluations, PTSD, TBI, and herbicide

exposure. We evaluated claims processing accuracy and its impact on

veterans’ benefits.

Finding 1	 VARO Staff Need to Improve Disability Claims 

Processing Accuracy 

The Reno VARO needs to improve the control and accuracy of processing

temporary 100 percent disability evaluations and TBI residual disability

claims. VARO staff incorrectly processed 23 (24 percent) of the total

95 disability claims reviewed. We advised VARO management regarding

the inaccuracies noted during our inspection and management initiated

corrective measures to address them.

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

affect, veterans’ benefits processed at the Reno 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 18 5 13

PTSD 30 0 0 0

TBI 5 4 1 3

Herbicide ExposureRelated Disabilities 30 1 1 0

Total 95 23 7 16 

Temporary 

100 Percent 

Disability 

Evaluations 

Source: VA OIG analysis.

VARO staff incorrectly processed 18 (60 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 needing surgery or specific

treatment. At the end of a mandated period of convalescence or cessation of

VA Office of Inspector General 2 
Inspection of the VA Regional Office, Reno, Nevada 

treatment, VARO staff must request a follow-up medical examination to help

determine whether to continue the veteran’s temporary 100 percent disability

evaluations.

Based on analysis of available medical evidence, 5 of the 18 processing

inaccuracies identified affected veterans’ benefits—4 involved overpayments

totaling $399,638 and one involved an underpayment totaling $9,930.

Examples of the most significant overpayment and underpayment follow:

	 A Rating Veterans Service Representative (RVSR) correctly proposed

reducing a veteran’s prostate cancer evaluation from 100 percent to

40 percent disabling. However, at the time of our inspection, VSC staff

had not taken the final action to reduce the veteran’s benefits. As a

result, VA overpaid the veteran $242,153 over a period of 11 years and

8 months.

	 An RVSR did not grant service-connection for bone cancer caused by a

veteran’s prostate cancer. Further, the RVSR did not grant entitlement to

special monthly compensation as required based on an evaluation of

multiple disabilities. As a result, VA underpaid the veteran $9,930 over a

period of 3 years and 2 months.

The remaining 13 inaccuracies had the potential to affect veterans’ benefits.

In 11 of these cases, VSC staff did not establish or improperly canceled

reminder notifications in the electronic record to schedule future

reexaminations. We could not determine if these 11 temporary 100 percent

disability evaluations would have continued because the veterans’ claims

folders did not contain the medical examination reports needed to reevaluate

each case. In the two remaining cases, VSC staff erroneously scheduled

reexaminations although the veterans had medical conditions known to be

incurable.

Delays in scheduling reexaminations ranged from approximately 6 months to

7 years and 8 months. An average of 3 years and 1 month elapsed from the

time staff should have scheduled these medical reexaminations until the date

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

the necessary medical evidence.

For temporary 100 percent disability evaluations, including confirmed and

continued evaluations where rating decisions do not change veterans’

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

electronic system. A 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.

VA Office of Inspector General 3 
Inspection of the VA Regional Office, Reno, Nevada 

PTSD Claims 

TBI Claims 

The most frequent temporary 100 percent disability claims processing errors

occurred when VARO staff did not properly establish suspense diaries for

future medical reexaminations. VSC management stated, and we verified,

the VARO did not have a procedure in place requiring VSC staff to review

confirmed and continued rating decisions mandating future reexaminations.

As a result, veterans did not always receive correct benefit payments.

The Acting Under Secretary for Benefits has already concurred with a

recommendation regarding temporary 100 percent disability evaluations in

our national report, “Veterans Benefits Administration: Audit of 100 Percent

Disability Evaluations,” (Report Number 09-03359-71, January 24, 2011).

The Acting Under Secretary for Benefits agreed, as part of VBA’s national

review plan, to review all temporary 100 percent disability evaluations and

ensure each evaluation has a future exam date entered in the electronic

record. We will monitor implementation progress and gauge effectiveness of

VBA’s national review plan as we move forward in conducting our

individual VARO inspections.

In accordance with VBA policy, VARO staff correctly processed all 30 of

the PTSD claims we reviewed. We made no recommendations for

improvement in this area.

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 staff to evaluate these residual disabilities.

VARO staff incorrectly processed four (80 percent) of five TBI claims we

reviewed. One of these processing inaccuracies affected a veteran’s benefits,

while the remaining three had the potential to affect veterans’ benefits. The

inaccuracy that affected a veteran’s benefits occurred when an RVSR

incorrectly evaluated residuals of a TBI as 40 percent disabling although VA

medical examination results showed the disability warranted a 10 percent

evaluation. As a result, VA overpaid the veteran $3,375 over a period of

1 year and 3 months.

In all four cases, RVSRs incorrectly evaluated TBI-related disabilities

because they used inadequate medical examination reports when making

disability determinations. In these cases, the veterans had residual

disabilities associated with TBI and coexisting mental conditions. VA policy

requires medical examiners to attribute cognitive and behavioral symptoms

to either TBI or coexisting mental conditions, which best supports claims

rating decisions.

VA Office of Inspector General 4 
Inspection of the VA Regional Office, Reno, Nevada 

Herbicide 

Exposure-Related 

Claims 

Recommendations 

Management 

Comments 

In these instances, the medical examiners did not attribute the symptoms to

either of the specific disabilities as required. Instead of returning the medical

examination reports to the appropriate medical centers for correction, RVSRs

made their own decisions in attributing the symptoms to either of the specific

disabilities. Neither VARO staff nor we can ascertain whether residual

disabilities are the results of TBI without adequate or complete medical

examination reports.

VARO management stated these errors occurred because of insufficient

VBA training provided, ongoing problems with inadequate medical

examination reports from local VA Medical Centers (VAMCs), and pressure

on RVSRs to process claims quickly to meet production standards. RVSRs

generally supported the assertions made by management. Because of the

processing errors, veterans did not always receive correct healthcare

entitlements or benefits payments.

VARO staff incorrectly processed 1 (3 percent) of 30 herbicide

exposure-related claims we reviewed. An RVSR incorrectly granted

entitlement to special monthly compensation benefits a month before the

veteran was entitled. As a result, VA overpaid the veteran $96. Given the

infrequency of errors, we concluded the VARO generally followed VBA

policy when processing these claims and made no recommendations for

improvement in this area.

1.	 We recommend the Reno VA Regional Office Director ensure Rating

Veterans Service Representatives receive refresher training on how to

identify inadequate traumatic brain injury medical examinations.

2.	 We recommend the Reno VA Regional Office Director develop and

implement a plan to ensure traumatic brain injury medical examinations

determined to be inadequate for rating purposes are returned to the

appropriate VA medical facilities for correction.

3.	 We recommend the Reno VA Regional Office Director establish an

additional level of review for all traumatic brain injury claims prior to

finalizing ratings decisions as a means of ensuring accurate benefit

payments.

The VARO Director concurred with our recommendations related to

improving disability claims processing. The Director informed us that in

March 2011, Rating Veterans Service Representatives received refresher

training on identifying inadequate VA medical examinations. The Director

stated Supervisory Veterans Service Representatives will review all TBI

medical examinations and return inadequate examinations to the appropriate

VA medical facility for correction. Further, the Reno VARO will follow

VBA’s national guidance, which requires a second level of review for all

TBI claims.

VA Office of Inspector General 5 
Inspection of the VA Regional Office, Reno, Nevada 

OIG Response 

Dates of Claim 

Notices of 

Disagreement 

A draft of this inspection report included an additional recommendation that

the VA Regional Office Director implement controls to ensure staff establish

suspense diaries for scheduling temporary 100 percent disability evaluations.

We have removed the recommendation because the Acting Under Secretary

for Benefits has already concurred with a corresponding recommendation in

our national report, Veterans Benefits Administration: Audit of 100 Percent 

Disability Evaluations (Report Number 09-03359-71, January 24, 2011).

The Acting Under Secretary for Benefits has agreed to review all temporary

100 percent disability evaluations and ensure each evaluation has a future

exam date entered in the electronic record. The Acting Under Secretary

explained that VBA’s national review plan entails use of three medical

diagnostic codes to comprise a sample for testing whether future examination

dates are established in the electronic record. Those diagnostic codes relate

to Non-Hodgkin’s Lymphoma, Malignant Neoplasms of the Genitourinary

System, and Post-traumatic Stress Disorder. Further, the Acting Under

Secretary stated, “the remainder of the cases will be identified through a

batch process, and VBA will establish the appropriate future diary controls

electronically.”

While the Acting Under Secretary for Benefits’ national review plan differs

from the approach we previously recommended in a draft of this VARO

inspection report, we believe the intent is the same. We will monitor

implementation progress and gauge effectiveness of VBA’s national review

plan approach as we move forward in conducting our individual VARO

inspections.

2. Data Integrity 

We analyzed claims folders to determine whether the VARO is following

VBA policy to establish dates of claim in the electronic record. VBA

generally uses a date of claim to indicate when a document arrives at a VA

facility. VBA relies on accurate dates of claim to establish and track key

performance measures, including the average number of days to complete a

claim. VARO staff established an incorrect date of claim in the electronic

record for 1 (3 percent) of the 30 claims we reviewed. Generally, VARO

staff followed VBA policy when establishing dates of claim, so we made no

recommendation for improvement in this area.

We reviewed claims folders to determine whether VARO staff timely

recorded Notices of Disagreement (NODs) in the Veterans Appeals Control

and Locator System (VACOLS). An NOD is a written communication from

a claimant expressing dissatisfaction or disagreement with a benefits decision

and a desire to contest it. An NOD is the first step in the appeals process.

VACOLS is a computer application that allows VARO staff to control and

track veterans’ appeals and manage the pending appeals workload. VBA

policy states staff must create a VACOLS record within 7 days of receiving

VA Office of Inspector General 6 
Inspection of the VA Regional Office, Reno, Nevada 

Systematic 

Technical 

Accuracy 

Review 

Systematic 

Analyses of 

Operations 

Finding 2 

an NOD. Accurate and timely recording of NODs is required to ensure

appeals move through the appellate process expeditiously.

The VARO exceeded VBA’s 7-day standard for 3 (10 percent) of 30 NODs

reviewed. However, of the 30 NODs we reviewed, the average time to

create a VACOLS record was 4 days, well below the standard. Therefore,

we made no recommendations for improvement in this area.

3. 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 multi-faceted quality assurance program to ensure that

veterans and other beneficiaries receive accurate and consistent

compensation and pension benefits. VBA policy requires that the VARO

take corrective action on errors that STAR identifies.

VARO staff adhered to the policy by taking corrective actions to address all

eight errors VBA’s STAR program identified during the first quarter of

Fiscal Year 2011. In addition, VARO management appropriately used

information regarding these errors to develop a plan to train staff. As such,

we made no recommendations for improvement in this area.

We assessed whether VARO management had controls in place to ensure

complete and timely submission of Systematic Analyses of Operations

(SAOs). An SAO is a formal analysis of a VSC organizational element or

operational function. SAOs provide 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 that

identifies specific dates and designates staff to complete each analysis.

Improved Oversight Is Needed To Ensure SAOs Are 

Timely and Complete 

VARO staff did not always ensure SAOs were timely and complete. This

occurred because VARO management did not provide adequate oversight to

ensure VSC staff timely completed SAOs according to the annual schedule

and addressed all elements required by VBA policy. As a result, VARO

management may not have identified existing and potential problems, which

after taking correction action, could have improved VSC operations.

The VSC Manager is responsible for ongoing analysis of VSC operations,

including completing the required 11 annual SAOs. Our analysis revealed

6 (55 percent) of the 11 SAOs were either incomplete or not completed

VA Office of Inspector General 7 
Inspection of the VA Regional Office, Reno, Nevada 

Recommendation 

Management 

Comments 

OIG Response 

Mailroom 

Operations 

within the time frames listed on the annual SAO schedule. Specifically,

staff did not complete three by the date on the annual SAO schedule, two

were never completed, and one did not address all required elements. For the

SAOs not timely completed, the delays ranged from 32 to 91 days.

Management had not completed two SAOs, Division Management and

Internal Controls, since 2006 and 2007, respectively. Additionally, staff did

not address the required element of “Implementation of Workload

Management Plan and Effectiveness” for the Claims Processing Timeliness

SAO.

Management informed us they placed a higher priority on meeting

end-of-year performance goals than on oversight of the SAO process. Based

on this finding, the VSC manager recommended changing the annual

schedule to allow SAO completion earlier in the year when the VARO has

fewer conflicting priorities.

We identified several areas where, by not providing adequate oversight to

ensure timely and complete SAOs, management did not identify VSC

operational problems for corrective action. For example, had management

thoroughly completed the Claims Processing Timeliness SAO, it might have

determined the current workload management plan was not effective to

ensure staff followed search mail and claims folder follow-up procedures, as

required.

4.	 We recommend the Reno VA Regional Office Director develop and

implement a plan to ensure staff complete Systematic Analyses of

Operations timely and address all required elements.

The Director concurred with our recommendation and assigned oversight

responsibility for Systematic Analyses of Operations to a VARO

management analyst. Further, the Director indicated management created a

VARO circular that will provide additional guidance for the management

analyst to follow.

Management’s comments and actions are responsive to the recommendation.

4. Workload Management 

We assessed controls over mailroom operations to ensure VARO staff timely

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

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

of receipt at the VARO. The Reno VARO assigns responsibility for

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

VARO mailroom staff processed, date stamped, and delivered all VSC mail

to the Triage mail point on a daily basis as required; therefore, we made no

recommendations for improvement in this area.

VA Office of Inspector General 8 
Inspection of the VA Regional Office, Reno, Nevada 

Military File Mail	 VBA policy allows the use of a storage area, known as the Military File, for

VSC staff to store mail temporarily. Typically, the mail stored in this area

involves matters over which VA has jurisdiction or the mail does not refer to

a claim for benefits and/or does not have a return address. The VARO

correctly processed all 10 pieces of mail maintained in the Military File;

therefore, we made no recommendations for improvement in this area.

Drop Mail	 We found 4 (13 percent) of 30 pieces of drop mail had been erroneously

processed or misrouted. Generally, this means staff did not correctly

categorize and follow local procedures for processing this mail. VSC

management provided on-the-spot training to a Triage Team employee

responsible for three of the errors. Our findings do not indicate a systemic

issue; therefore, we concluded the Triage Team generally followed policy

when processing drop mail. As such, we made no recommendations for

improvement in this area.

Triage Mail	 

Processing 

Procedures 

We assessed the VSC mail processing procedures to ensure Triage Team

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

accordance with VBA and local policies. 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 success and control of workflow within the

VSC.

VBA policy requires staff use the Control of Veterans Records System

(COVERS), an electronic tracking system, to track claims folders and search

mail. Additionally, VBA policy states VSC staff will route and process mail

requiring action according to established procedures. VBA defines search

mail as active claims-related mail waiting to be associated with a veteran’s

claims folder and drop mail as mail received where no processing action is

necessary.

Finding 3	 Controls Over Mail Processing Need Strengthening 

The Triage Team did not always process mail according to VBA and local

policies. This occurred because current local policies did not incorporate

oversight of all search mail procedures, lacked specific procedures for drop

and search mail functions, and conflicted with current procedures.

Consequently, RVSRs may not always have all available mail in the claims

folders to support making disability determinations and claimants may not

always receive prompt and accurate benefits.

Overall, VARO staff did not correctly process or control 21 (28 percent) of

75 pieces of mail reviewed from search, drop, and military mail.

Specifically, we identified weaknesses associated with the processing of

VA Office of Inspector General 9 
Search Mail 

Inspection of the VA Regional Office, Reno, Nevada 

search mail, which included mail related to claims folders temporarily

transferred to medical centers.

For 17 (49 percent) of 35 pieces of search mail reviewed, VSC staff did not

properly use COVERS functions to ensure accurate and timely processing.

Staff did not retrieve and associate 13 individual pieces of search mail with

the claims folders as required even though COVERS contained electronic

notices of pending search mail requests. For the remaining four inaccuracies,

staff did not conduct follow-up requests to ensure staff returned claims

folders with pending searches to the VARO. Following are examples of

inaccuracies associated with search mail.

	 VSC staff temporarily transferred a veteran’s claims folder to a VAMC

for a medical examination while search mail was pending. VSC staff did

not ensure that medical facility personnel returned the claims folder upon

completion of the medical examination, as required. As a result, VSC

staff delayed processing the veteran’s claim for 177 days after the

medical examination was completed.

	 VSC staff received a veteran’s claim for benefits and properly placed it

on search in COVERS. The staff then temporarily transferred the claims

folder to a VAMC for the veteran’s medical examination without first

associating the mail with the file and completing the initial development

of additional evidence to support the claim. As a result, VSC staff

delayed initial processing on this claim for 114 days despite three

separate inquiries by the veteran to the National Call Center and one

inquiry on behalf of the veteran by a veteran’s service organization.

	 VSC staff received a form from a veteran allowing VA to obtain private

medical records to support a pending claim for benefits. Despite

receiving electronic notifications in COVERS, staff did not associate this

mail with the claims folder. Consequently, VSC staff delayed requesting

the medical records for 62 days until the time of our inspection.

VARO leadership acknowledged weaknesses associated with search mail

procedures. VSC management prepared an initial mail plan in January 2011;

however, the plan did not contain the minimum requirements required by

VBA policy. Specifically, the plan did not incorporate workload

management procedures to ensure compliance with COVERS search mail

requirements to timely associate mail with veterans’ claims folders.

Additionally, the plan did not incorporate specific information on how drop

and search mail should be managed within the VSC. For example, we

identified VSC staff placing drop mail on search in COVERS even though

the related claims folders were located within the VSC. VBA policy states

that staff will not place mail on search if the claims folder is located at the

VARO.

VA Office of Inspector General 10 
Inspection of the VA Regional Office, Reno, Nevada 

Recommendations 

Management 

Comments 

OIG Response 

Further, current VSC procedures conflicted with the VSC’s written policy

regarding how staff would follow-up with VAMCs to ensure the return of

claims folders to the VARO. The COVERS written user plan requires Triage

Team staff to follow up every 2 weeks on claims folders transferred to

VAMCs. However, VSC management verbally informed Veterans Service

Representatives assigned to the Pre-Determination Team that they were

responsible for conducting such follow-up. Because of this conflicting

guidance, neither the staff on the Triage Team nor Predetermination Teams

ensured the timely return of claims folders from the VAMCs after

completion of medical examinations. One team expected the other team

would carry out the responsibility and at times, amid the confusion, the

responsibility lapsed. Ultimately, delays in returning claims folders to the

VARO caused delays in overall time to process veterans’ claims.

5.	 We recommend the Reno VA Regional Office Director develop a plan to

ensure compliance with Control of Veterans Records System procedures

for staff to associate search mail with related claims folders.

6.	 We recommend the Reno VA Regional Office Director amend the mail

plan to include specific information regarding how drop and search mail

should be managed within the Veterans Service Center.

7.	 We recommend the Reno VA Regional Office Director ensure Veterans

Service Center management provides clear, consistent guidance for

ensuring timely return of claims folders from VA Medical Centers.

The VARO Director concurred with our recommendations to strengthen

controls over mail processing. The Director informed us that in March 2011,

supervisors received training on their COVERS oversight responsibilities as

delineated in the VARO’s COVERS user plan. He stated the VARO mail

plan will be amended to include detailed guidance on how search and drop

mail will be managed in the VSC.

Further, VSC management provided refresher training to supervisors

regarding procedures for following-up on all claims folders temporarily

transferred to other locations, as outlined in the Workload Management Plan.

The COVERS user plan will be updated to define user responsibilities for

performing follow-up actions for pending claims.

Management’s comments and actions are responsive to the

recommendations.

VA Office of Inspector General 11 
Inspection of the VA Regional Office, Reno, Nevada 

Organization 

Resources 

Workload 

Scope 

Appendix A VARO Profile and Scope of Inspection 

The Reno VARO is responsible for delivering nonmedical VA benefits and

services to veterans and their families in Nevada and the California counties

of Alpine, Lassen, Modoc, and Mono. The VARO fulfills these

responsibilities by administering compensation and pension benefits,

vocational rehabilitation and employment assistance, and outreach activities.

As of February 2011, the Reno VARO had a staffing level of 96 full-time

employees. Of these, the VSC had 83 employees (86 percent) assigned.

As of February 2011, the Reno VARO reported 6,934 pending compensation

claims. The average time for VARO staff to complete these claims was

259.7 days—84.7 days longer than the national target of 175 days. As

reported by STAR, accuracy of compensation rating-related processing was

89.4 percent, just below the 90 percent target set by VBA.

We reviewed selected management controls, 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 65 (31 percent) of 207 disability claims related to

PTSD, TBI, and herbicide exposure that the VARO completed from

October through December 2010. For temporary 100 percent disability

evaluations, we selected 30 (22 percent) of 139 existing claims from VBA’s

Corporate Database. We provided the VARO with the 109 claims remaining

from our universe of 139 for their review. The 139 claims represented all

instances in which VARO staff granted temporary 100 percent disability

determinations for at least 18 months.

We reviewed eight errors identified by VBA’s STAR program during the

period from October through December 2010. 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 evaluation. Further, they review appellate

issues that involve a myriad of veterans’ disability claims.

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

claims such as PTSD, TBI, and herbicide exposure that require rating

decisions. In addition, we review rating decisions and awards processing

involving temporary 100 percent disability evaluations.

VA Office of Inspector General 12 
Inspection of the VA Regional Office, Reno, Nevada 

For our review, we selected dates of claim, NODs, and Triage Team mail

pending at the VARO during the time of our inspection. We completed our

review in accordance with the Council of the Inspectors General on Integrity

and Efficiency’s Quality Standards for Inspections. 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 13 
Inspection of the VA Regional Office, Reno, Nevada 

Appendix B VARO Director’s Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 8, 2011

From: Director, Reno VA Regional Office (354/00)

Subj: Inspection of the VA Regional Office, Reno, Nevada

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

1.	 Attached are the Reno VARO’s comments on the OIG Draft Report:

Inspection of the VA Regional Office, Reno, Nevada.

2.	 Please feel free to contact me at (75) 321-4701 with any questions or

concerns regarding our reply.

/s/ 

Edward Russell
 

Director
 

Attachment

VA Office of Inspector General 14 
Inspection of the VA Regional Office, Reno, Nevada 

IG Recommendations: 

Recommendation 1: We recommend the Reno VA Regional Office Director implement controls

to ensure staff establishes suspense diaries for scheduling temporary 100 percent disability

reevaluations.

RO Comments: Non-Concur

In response to OIG report "Audit of 100 Percent Evaluations" dated January 24, 2011, VBA

developed a national plan to review temporary 100 percent evaluation cases, which was accepted

by OIG. Therefore, the Reno Regional Office will follow the national review plan.

The Veterans Benefits Administration recommends closure of this recommendation.

Recommendation 2: We recommend the Reno VA Regional Office Director ensure Rating

Veterans Service Representatives receive refresher training on how to identify inadequate

traumatic brain injury medical examinations.

RO Comments: Concur

Refresher training was provided to Rating Veterans Service Representatives on how to identify

inadequate traumatic brain injury medical examinations on March 23, 2011.

The Veterans Benefits Administration recommends closure of this recommendation.

Recommendation 3: We recommend the Reno VA Regional Office Director develop and

implement a plan to ensure traumatic brain injury medical examinations determined to be

inadequate for rating purposes are returned to the appropriate VA medical facilities for correction.

RO Comments: Concur

All TBI medical examinations are routed to a Supervisory Veterans Service Representative for

initial review. Those found to be inadequate for rating purposes are returned to the appropriate

VA medical facility for correction. This change was implemented March 23, 2011.

The Veterans Benefits Administration recommends closure of this recommendation.

Recommendation 4: We recommend the Reno VA Regional Office Director establish an

additional level of review for all traumatic brain injury claims prior to finalizing ratings decisions

as a means of ensuring accurate benefit payments.

RO Comments: Concur

In response to OIG report “Systemic Issues Reported During Inspections at VA Regional

Offices”, dated May 18, 2011, the Office of Field Operations issued second signature guidance

for traumatic brain injury claims on May 31, 2011. Therefore, the Regional Office will follow

this national guidance.

VA Office of Inspector General 15 
Inspection of the VA Regional Office, Reno, Nevada 

The Veterans Benefits Administration recommends closure of this recommendation.

Recommendation 5: We recommend the Reno VA Regional Office Director develop and

implement a plan to ensure staff complete Systematic Analyses of Operations timely and address

all required elements.

RO Comments: Concur

The RO Management Analyst has been assigned to provide oversight to ensure SAOs are timely

and complete. The Management Analyst will follow the detailed guidance provided by RO

Circular 00-10-3, dated February 5, 2010.

The Veterans Benefits Administration recommends closure of this recommendation.

Recommendation 6: We recommend the Reno VA Regional Office Director develop a plan to

ensure compliance with Control of Veterans Records System procedures for staff to associate

search mail with related claims folders.

RO Comments: Concur

The COVERS user plan dated November 2009, includes direction to team supervisors designed to

ensure compliance with the plan in the Veterans Service Center. Refresher training on supervisor

responsibilities was provided to the team supervisors on March 21, 2011.

The Veterans Benefits Administration recommends closure of this recommendation.

Recommendation 7: We recommend the Reno VA Regional Office Director amend the mail

plan to include specific information regarding how drop and search mail should be managed

within the Veterans Service Center.

RO Comments: Concur

The RO mail plan will be amended to include specific information regarding how drop and search

mail will be managed within the Veterans Service Center. The revised plan will be completed by

July 1, 2011.

Recommendation 8: We recommend the Reno VA Regional Office Director ensure Veterans

Service Center management provides clear, consistent guidance for ensuring timely return of

claims folders from VA Medical Centers.

RO Comments: Concur

The Veterans Service Center Workload Management Plan dated January 14, 2011, clearly

establishes responsibility for follow-up actions on all pending claims. On March 21, 2011,

refresher training on the Workload Management Plan was provided by the Veterans Service

Center Manager to team supervisors. The COVERS user plan dated November 2009, assigns

responsibility to members of the Triage team to follow up on all claims folders temporarily

VA Office of Inspector General 16 
Inspection of the VA Regional Office, Reno, Nevada 

transferred to other locations. This includes claims folders sent to VA Medical Centers as well as

a number of other locations. This COVERS user plan will be amended to define user

responsibilities for performing follow-up actions when claims are pending. The revised plan will

be completed by July 1, 2011.

VA Office of Inspector General 17 
Inspection of the VA Regional Office, Reno, Nevada 

Appendix C Inspection Summary
 

9 Operational 

Activities Inspected Criteria 

Reasonable 

Assurance of 

Compliance 

Yes No 

Claims Processing 

1. 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. Post-Traumatic 

Stress Disorder 

Determine whether VARO staff properly processed claims for PTSD. (38

CFR 3.304(f)) X

3. Traumatic Brain 

Injury 

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

4. 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

Data Integrity 

5. Dates of Claim Determine whether VARO staff properly recorded correct dates of claim 

in the electronic record. (M21-1MR, Part III, Subpart ii, Chapter 1, Section

C)

X

6. Notices of 

Disagreement 

Determine whether VARO staff properly entered NODs into VACOLS. 

(M21-1MR Part I, Chapter 5) X

Management Controls 

7. 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

8. Systematic Analyses 

of Operations 

Determine whether VARO staff properly performed formal analyses of 

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

Workload Management 

9. 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

CFR=Code of Federal Regulations, M=Manual, MR=Manual Re-write

VA Office of Inspector General 18 
Inspection of the VA Regional Office, Reno, Nevada 

Appendix D OIG 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

Kristine Abramo

Daphne Brantley

Robert Campbell

Madeline Cantu

Danny Clay

Lee Giesbrecht

Kerri Leggiero-Yglesias

Mark Ward

VA Office of Inspector General 19 
Inspection of the VA Regional Office, Reno, Nevada 

Appendix E Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Benefits Administration
 

Assistant Secretaries
 

Office of General Counsel
 

VBA Western Area Director
 

VARO Reno 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: Dean Heller, Harry Reid

U.S. House of Representatives: Shelley Berkley, Joe Heck

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 20