Inspection of the
 

VA Regional Office
 

Seattle, Washington
 

OFFICE OF AUDITS AND EVALUATIONS

September 8, 2011 

11-00515-266 
ACRONYMS AND ABBREVIATIONS
 

C&C Confirmed and Continued 

COVERS Control of Veterans Records System 

NOD Notice 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 

STR Service Treatment Record 

TBI Traumatic Brain Injury 

VACOLS Veterans Appeals Control and Locator System 

VARO VA 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, Seattle, Washington 

Why We Did This Review 

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 

Seattle VARO accomplishes this mission. 

What We Found 

Seattle VARO staff were generally effective 

in processing post-traumatic stress disorder 

and herbicide-related claims, correcting 

errors identified by the Veterans Benefits 

Administration’s Systematic Technical 

Accuracy Review program, and ensuring 

Systematic Analyses of Operations were 

timely and complete. 

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. Errors in processing 

traumatic brain injury claims were due to 

inadequate training. Overall, staff did not 

accurately process 34 (28 percent) of the 

120 disability claims we reviewed. 

VARO management did not have 

mechanisms in place for Veterans Service 

Center staff to accurately establish dates of 

claim or timely process Notices of 

Disagreement for appealed claims within the 

Veterans Benefits Administration’s 7-day 

standard. In addition, management 

directives lacked procedures for ensuring 

proper mail handling. 

What We Recommended 

We recommended the Seattle VARO 

Director develop and implement a plan to 

assess the effectiveness and adequacy of 

Rating Veterans Service Representative 

training related to processing traumatic brain 

injury claims. Management needs to 

strengthen controls over establishing dates 

of claim, processing Notices of 

Disagreement, and handling claims-related 

mail. Moreover, management needs to 

ensure staff receive training on how to use 

the Control of Veterans Records System to 

manage mail. 

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. Data Integrity ..........................................................................................................................7
 

3. Management Controls .............................................................................................................9
 

4. Workload Management.........................................................................................................10
 

Appendix A VARO Profile and Scope of Inspection ............................................................14 

Appendix B VARO Director’s Comments............................................................................16 

Appendix C Inspection Summary..........................................................................................19 

Appendix D Office of Inspector General Contact and Staff Acknowledgments...................20 

Appendix E Report Distribution ...........................................................................................21 

ii 
Inspection of the VA Regional Office, Seattle, Washington 

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 May 2011, the OIG conducted an inspection of the Seattle 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 the Veterans Benefits 

Administration (VBA) has centralized all Western Area fiduciary activities at 

the Salt Lake City VARO. 

We reviewed 90 (14 percent) of 622 disability claims related to traumatic 

brain injury (TBI), post-traumatic stress disorder (PTSD), and herbicide 

exposure that the VARO completed from January through March 2011. In 

addition, we reviewed 30 (6 percent) of 494 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, Seattle, Washington 

RESULTS AND RECOMMENDATIONS 

1. Disability Claims Processing 

The OIG inspection team focused on disability claims processing related to 

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

exposure. We evaluated claims processing accuracy and its impact on 

veterans’ benefits. 

Finding 1	 Disability Claims Processing Accuracy Could Be 

Improved 

The Seattle VARO lacked controls and accuracy in processing claims for 

temporary 100 percent disabilities and TBI. VARO staff incorrectly 

processed 34 (28 percent) of the total 120 disability claims 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 Seattle 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 17 3 14 

Traumatic Brain 

Injury Claims 30 12 4 8 

Post-Traumatic Stress 

Disorder Claims 30 2 2 0 

Herbicide ExposureRelated Claims 30 3 3 0 

Total 120 34 12 22 

Source: VA OIG Analysis 

Temporary VARO staff incorrectly processed 17 (57 percent) of 30 temporary 

100 Percent 100 percent disability evaluations we reviewed. VBA policy requires a Disability temporary 100 percent disability evaluation for a service-connected disability Evaluations 

following surgery or when specific treatment is needed. At the end of a 

VA Office of Inspector General 2 
Inspection of the VA Regional Office, Seattle, Washington 

mandated period of convalescence or treatment, VARO staff must request a 

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 a 

suspense diary matures, the electronic system generates a reminder 

notification alerting VSC staff to schedule the reexamination. 

Our analysis of available medical evidence showed that 3 of the 

17 processing inaccuracies involved overpayments to veterans totaling 

$97,981. The most significant overpayment occurred when VARO staff did 

not schedule a medical reexamination for a veteran’s prostate cancer as 

required. VA treatment records revealed the condition improved and the 

veteran was no longer entitled to receive a temporary 100 percent disability 

evaluation. As a result, VA overpaid the veteran $59,283 over a period of 

1 year and 9 months. 

The remaining 14 inaccuracies had the potential to affect veterans’ benefits. 

Following are descriptions of the inaccuracies we identified. 

	 In 12 cases, VSC staff did not establish or improperly canceled reminder 

notifications in the electronic record. We could not determine if these 

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. 

	 The two remaining inaccuracies occurred because staff did not promptly 

schedule reexaminations once they received the reminder notifications. 

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

frequent inaccuracy occurred in 8 (47 percent) of 17 cases when VARO staff 

did not properly establish suspense diaries in the electronic record. Without 

suspense diaries, VSC staff do not receive reminder notifications to schedule 

required VA medical reexaminations. 

For those cases requiring future reexaminations, delays ranged from 

5 months to 12 years and 4 months. An average of 2 years and 11 months 

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. 

VA Office of Inspector General 3 
TBI Claims 

Inspection of the VA Regional Office, Seattle, Washington 

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 add 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 to determine the need 

for future reexaminations. Because effective controls were not in place, a 

temporary 100 percent disability evaluation could continue uninterrupted 

over the course of a veteran’s lifetime. 

We provided the VARO with a list of 464 claims remaining from our 

universe of 494 temporary 100 percent disability evaluations selected for 

review. 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 

exam date entered in the electronic record. We will follow-up on VBA’s 

efforts in this area during future inspections. Therefore, we made no 

additional recommendation for improvement in this area. 

The Department of Defense and VBA commonly define a TBI as a 

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 12 (40 percent) of 30 TBI claims we 

reviewed. Our analysis of available medical evidence showed 4 of the 

12 processing inaccuracies affected veterans’ benefits—two resulted in 

underpayments totaling $10,512, and two resulted in overpayments totaling 

$7,134. Following are details on the most significant underpayment and 

overpayment. 

	 A Rating Veterans Service Representative (RVSR) incorrectly assigned a 

10 percent evaluation for a TBI-related disability. The VA medical 

examination report provided evidence that the severity of the disability 

warranted a 40 percent evaluation. As a result, VA underpaid the veteran 

$8,784 over a period of 1 year and 6 months. 

	 An RVSR incorrectly assigned a 10 percent evaluation for a TBI-related 

disability. During the VA medical examination, the veteran provided the 

physician with subjective complaints of a TBI-related disability and the 

RVSR assigned an evaluation based on those complaints. The RVSR 

overlooked the VA examiner’s objective findings in the examination 

report that related the symptoms to a coexisting mental condition and not 

VA Office of Inspector General 4 
PTSD Claims 

Inspection of the VA Regional Office, Seattle, Washington 

a TBI. As a result, VA overpaid the veteran $4,305 over a period of 

1 year and 3 months. 

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

Following are descriptions of these inaccuracies. 

	 In four cases, RVSRs prematurely evaluated TBI-related disabilities 

using insufficient medical examination reports. According to VBA 

policy, when a medical examination report does not address all required 

elements, VSC staff should return it to the issuing clinic or health care 

facility as insufficient for rating purposes. Neither VARO staff nor we 

can ascertain all residual disabilities related to TBI claims without 

adequate or complete medical evidence. 

	 In the remaining four cases, RVSRs incorrectly applied rating criteria 

when evaluating TBI-related disabilities. For example, in two cases, 

RVSRs did not assign separate evaluations for disabilities diagnosed by 

VA examiners. In the remaining two cases, the improper evaluations 

occurred when RVSRs over-evaluated symptoms. RVSRs based 

evaluations on the veterans’ reported history rather than the results of VA 

examination findings. The inaccuracies did not affect the veterans’ 

existing disability evaluations but may affect future evaluations for 

additional benefits. 

Generally, these errors occurred because TBI training did not ensure RVSRs 

had the skills needed to make accurate disability determinations. For 

example, training staff developed an internal test to assess how well RVSRs 

comprehended TBI claims processing policies. Results of the test revealed 

RVSRs had difficulty identifying insufficient TBI medical examination 

reports that they needed to return to physicians for correction to support their 

rating decisions. VARO management did not implement controls, such as 

additional quality reviews to ensure claims processing accuracy, or more 

frequent TBI training to ensure RVSRs were proficient in identifying 

insufficient medical examination reports. Because of the TBI claims 

processing errors, veterans did not always receive accurate benefits 

payments. 

VARO staff incorrectly processed 2 (7 percent) of 30 PTSD claims we 

reviewed. Both of the errors affected veterans’ benefits, resulting in 

overpayments totaling $7,728. Following are descriptions of these 

inaccuracies. 

	 An RVSR erroneously granted service connection for PTSD effective 

January 2010. An earlier rating decision in September 2004 had already 

granted service connection for PTSD. As a result, by the time of our 

VA Office of Inspector General 5 
Inspection of the VA Regional Office, Seattle, Washington 

Herbicide 

Exposure-Related 

Claims 

Recommendation 

Management 

Comments 

inspection VA had overpaid the veteran $4,304 over a period of 1 year 

and 4 months. 

	 An RVSR incorrectly granted service connection for PTSD without 

medical evidence diagnosing the veteran with this condition. As a result, 

VA overpaid the veteran $3,424 over a period of 1 year and 4 months. 

Because we did not consider the frequency of errors significant, we 

determined the VARO generally followed VBA policy when processing 

PTSD claims. Therefore, we made no recommendation for improvement in 

this area. 

VARO staff incorrectly processed 3 (10 percent) of 30 herbicide 

exposure-related claims we reviewed. All three of the processing 

inaccuracies affected veterans’ benefits—two resulted in underpayments 

totaling $3,224, and one resulted in an overpayment of $1,600. Following 

are descriptions of these inaccuracies. 

	 An RVSR incorrectly assigned a veteran a non-compensable evaluation 

for residuals of prostate cancer. Medical evidence showed the severity of 

two residual disabilities warranted a combined 30 percent evaluation. As 

a result, VA underpaid the veteran $1,880 over a period of 5 months. 

	 An RVSR did not grant a veteran special monthly compensation for a 

residual disability related to diabetes mellitus. As a result, VA underpaid 

the veteran $1,344 over a period of 1 year and 2 months. 

	 An RVSR incorrectly granted entitlement to special monthly 

compensation based on multiple disabilities, one of which was unrelated 

to a herbicide disability. According to VBA policy, the veteran was not 

entitled to special monthly compensation. As a result, VA overpaid the 

veteran $1,600 over a period of 5 months. 

The three inaccuracies identified were a result of human error. Because we 

did not identify a systemic trend associated with processing these claims, we 

made no recommendation for improvement. 

1.	 We recommend the Seattle VA Regional Office Director develop and 

implement a plan to assess the effectiveness of Rating Veterans Service 

Representative training related to processing traumatic brain injury 

claims. 

The VARO Director concurred with our recommendation and provided TBI 

training to RVSRs and Decision Review Officers on June 7-8, 2011. To 

gauge the effectiveness and adequacy of training, VARO staff reviewed 

218 TBI claims completed since June 2, 2011. The internal review revealed 

17 claims processed in error and demonstrated approximately 93 percent 

VA Office of Inspector General 6 
Inspection of the VA Regional Office, Seattle, Washington 

effectiveness in rating those TBI cases. The Director informed us VARO 

staff would perform another Independent Rating Review (IRR) for TBI 

claims in October 2011, to continue the assessment of the effectiveness and 

adequacy of TBI training. 

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

2. Data Integrity 

Dates of Claim	 We analyzed claims folders to determine if the VARO was following VBA 

policy on establishing 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 days to complete a claim. 

Finding 2	 Insufficient Controls Over Recording Correct Dates of 

Claim 

VSC staff did not always record correct dates of claim in the electronic 

record. This occurred because VARO management did not provide 

standardized training to staff responsible for establishing dates of claim. 

Consequently, veterans were at risk of receiving inaccurate benefits 

payments. 

VSC staff did not accurately record 5 (17 percent) of the 30 dates of claim 

we reviewed. These incorrect dates ranged from 6 to 146 days. For 

example, in two cases VSC staff used mail submitted by veterans to establish 

claims in the electronic record. In both cases, the claims had previously been 

submitted and reviewed, but misclassified as mail requiring no action. If not 

for our review, VSC staff may have processed these claims using incorrect 

dates, which could have resulted in these veterans receiving inaccurate 

benefits. 

Management acknowledged it did not provide standardized training for 

claims assistants and file clerks—staff typically responsible for establishing 

claims in the electronic record. Instead, supervisors individually trained their 

team members independent of other teams. This approach led to inconsistent 

practices in establishing dates of claim in the electronic record. 

Incorrect dates in the electronic record affect data integrity and misrepresent 

VARO performance. Data integrity issues make it difficult for senior VBA 

leadership to assess VARO performance accurately. Further, by not ensuring 

staff record correct dates of claim, the risk of veterans receiving inaccurate 

benefits payments increases. 

VA Office of Inspector General 7 
Inspection of the VA Regional Office, Seattle, Washington 

Recommendation 

Management 

Comments 

OIG Comments 

Notices of 

Disagreement 

Finding 3 

2.	 We recommend the Seattle VA Regional Office Director develop a plan 

to provide standardized training to claims assistants and file clerks on the 

proper procedures for establishing dates of claim in the electronic record. 

The VARO Director concurred with our recommendation. Claims Assistants 

and File Clerks received training on the proper procedures for establishing 

dates of claim and routing of mail in June 2011. Further, the Director 

created a plan to provide recurring standardized training to Claims Assistants 

and File Clerks. 

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

We analyzed claims folders to determine whether the VARO was following 

VBA policy to timely record 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 the decision. 

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 an NOD. Accurate and 

timely recording of NODs is required to ensure appeals move through the 

appellate process expeditiously. 

Insufficient Controls Over Recording Notices of 

Disagreement 

The Appeals Team did not always control NODs in VACOLS within VBA’s 

7-day standard. VARO staff exceeded VBA’s standard for 12 (40 percent) 

of the 30 NODs we reviewed. These delays ranged from 9 to 39 days. Staff 

took an average of nearly 18 days to record the 12 NODs in VACOLS. 

This occurred because VARO management was unaware of VBA’s national 

timeliness standard. The VSC workload management plan did not provide 

staff with guidance regarding any timeliness standard for recording NODs in 

the electronic record. Further, the plan lacked an oversight mechanism for 

supervisors to review this type of work. 

As of April 2011, VBA performance reports showed the average time for the 

VARO to complete an NOD was 329.4 days. The VARO exceeded the 

national average of 182 days by approximately 147 days. 

Untimely recording of NODs makes it difficult for VARO and senior VBA 

leadership to accurately measure and monitor VARO performance. Further, 

VBA’s National Call Centers rely upon VACOLS information to provide 

accurate customer service to claimants. Unnecessary delays in controlling 

VA Office of Inspector General 8 
Inspection of the VA Regional Office, Seattle, Washington 

Recommendation 

Management 

Comments 

OIG Response 

Systematic 

Technical 

Accuracy 

Review 

Systematic 

Analyses of 

Operations 

NODs affect national performance measures for NOD inventory and appeals 

management timeliness. 

3.	 We recommend the Seattle VA Regional Office Director amend the 

Workload Management Plan to incorporate clear instructions and 

oversight mechanisms for recording Notices of Disagreement within the 

Veterans Benefits Administration’s 7-day standard. 

The VARO Director concurred with our recommendation and amended the 

Appeals Team SOP on May 16, 2011. The Director assigned responsibility 

for establishing the VACOLS record within 7 days to Claims Assistants. 

Further, management amended the Workload Management Plan to reflect the 

7-day standard. 

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

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 multifaceted quality assurance program to ensure veterans 

and other beneficiaries receive accurate and consistent compensation and 

pension benefits. VBA policy requires that VAROs take corrective action on 

errors identified by STAR. 

VARO staff did not correct 1 (6 percent) of 17 claims files that contained 

errors identified by STAR program staff from October through December 

2010. In this instance, VARO staff reported to STAR they would complete 

the corrective action when they received the claims folder from a remote 

storage location; however, we saw no indication that staff ever requested the 

claims folder. Because VARO management generally followed VBA policy 

regarding correction of STAR errors, we did not consider the error rate 

significant and made no recommendation for improvement in this area. 

We assessed whether VARO management had adequate controls in place to 

ensure complete and timely submission of Systematic Analyses of 

Operations (SAOs). An SAO is a formal analysis of an 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 annual SAO 

schedules designating the staff required to complete the SAOs by specific 

dates. 

VARO management generally followed VBA policy by ensuring SAOs were 

timely and complete. Because only 1 (9 percent) of 11 required SAOs was 

VA Office of Inspector General 9 
Inspection of the VA Regional Office, Seattle, Washington 

Mail Room 

Operations 

Integrated Team 

Mail Processing 

Procedures 

incomplete, we did not consider the error rate significant. As such, we made 

no recommendation for improvement in this area. 

4. 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 Seattle VARO assigns responsibility for 

mailroom activities, including processing of incoming mail, to the Support 

Services Division. VARO mailroom staff processed, date-stamped, and 

delivered all VSC mail to the mail control points as required. Therefore, we 

made no recommendation for improvement in this area. 

VBA has embarked on a multi-year transformation of veterans’ claims 

processing and benefits delivery. As part of this transformation, VBA is 

pursuing new business concepts with the goal of improving the speed, 

accuracy, and consistency of claims decisions rendered to veterans and their 

families. One of the outcomes of this initiative has been the integrated team 

model. In March 2011, based on VBA guidance, the VSC reorganized from 

the previous Claims Processing Improvement business model to this new 

model, where teams are comprised of members with various skill sets from 

across the VARO. For example, an integrated team consists of supervisory 

staff, claims assistants, RVSRs, and Veterans Service Representatives 

collectively assigned to process portions of selected VSC’s compensation 

claims. 

We assessed the integrated 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 

success and control of workflow within the VSC. 

Further, VBA policy requires that staff use the Control of Veterans Records 

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

and 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 upon receipt. VBA policy allows the use 

of a storage area, known as the Military File, to hold mail temporarily when 

staff are unable to identify associated claims folders in the system. 

Typically, mail stored in this area pertains to matters over which VA has 

jurisdiction, does not refer to a claim for benefits, or does not include a 

return address. 

VA Office of Inspector General 10 
Inspection of the VA Regional Office, Seattle, Washington 

Finding 4
 

Search Mail 

Drop Mail 

Oversight Needed for Proper Processing and Control of 

Veterans Service Center Mail 

VSC staff did not correctly process or control 52 (41 percent) of 128 pieces 

of search, drop, and Military File mail according to policy. Existing local 

directives did not incorporate a requirement for supervisory reviews, lacked 

specific procedures for processing search and drop mail, and needed to be 

updated to reflect mail-processing procedures in the new integrated team 

model. Consequently, RVSRs did not always have all available mail in the 

claims folder when making disability determinations and claimants possibly 

did not always receive prompt and accurate benefits. 

For 30 (58 percent) of 52 pieces of search mail reviewed, VSC staff did not 

properly use COVERS to ensure accurate and timely processing. Staff did 

not retrieve 17 of the 30 pieces of search mail and associate it with claims 

folders even though COVERS contained electronic notices of the pending 

search mail requests. Staff did not place 10 pieces of mail on search in 

COVERS at all. For the remaining three pieces of mail, staff did not follow 

policy and attempt to locate related claims folders that had been misplaced. 

Following are descriptions of discrepancies we found during our review of 

search mail. 

	 In November 2010, the VARO received Service Treatment Records 

(STRs) to support a veteran’s pending original claim. VSC staff did not 

control these records in COVERS until March 2011, nearly 4 months 

after the VARO received them. Additionally, staff did not associate this 

mail with the claims folder despite receiving an electronic notification in 

COVERS that the records were available at the VARO. At the time of 

our inspection, this evidence had not been associated with the veteran’s 

claims folder for approximately 6 months. 

	 In January 2011, a veteran submitted a claim for disability compensation. 

VSC staff did not place this claim on search in COVERS so they could 

associate the mail with the claims folder. Staff were unaware of the 

claim until we identified it during our inspection. As a result, staff 

unnecessarily delayed processing this claim by approximately 3 months. 

We found 6 (18 percent) of 34 pieces of mail that had been improperly 

processed as drop mail. Generally, this means staff did not correctly 

categorize and take action on this mail as required. Following are 

descriptions of discrepancies we found during our review. 

	 In March 2011, VSC staff received additional STRs submitted by a 

veteran’s military reserve unit. VSC staff improperly sent these STRs to 

be associated with the claims folder at an off-site, inactive file storage 

facility. According to VBA policy, VSC staff should have requested the 

VA Office of Inspector General 11 
Inspection of the VA Regional Office, Seattle, Washington 

Military File Mail 

veteran’s claims folder for review to determine if the additional STRs 

would have changed the previous disability decision. 

	 In April 2011, VSC staff received a new claim for benefits. VSC staff 

improperly sent this mail to the Federal Records Center instead of 

placing the claim under control in the electronic record for subsequent 

processing. This new claim for benefits would have remained 

unprocessed had we not identified it during our inspection. As a result, 

staff had unnecessarily delayed processing the claim by 29 days. 

VSC staff incorrectly handled 16 (38 percent) of 42 pieces of Military File 

mail we reviewed. Following are examples of discrepancies we identified 

during our review. 

	 On August 6, 2010, a veteran provided responses to a VSC questionnaire 

regarding risk factors related to a disability benefits claim. VSC staff 

misrouted this mail, which remained unassociated with the claims folder 

for 285 days until discovered during our inspection. 

	 On August 9, 2010, a veteran submitted private medical evidence to 

support a pending benefits claim for service-connected hearing loss. 

VSC staff misrouted this mail, which remained unassociated with the 

claims folder for 282 days until discovered during our inspection. 

In both cases, if the mail had not ultimately been associated with the claims 

folders, RVSRs would not have had all available evidence to support their 

rating decisions and claimants may not have received accurate benefits. 

VSC management confirmed weaknesses associated with mail processing 

controls. For example, the Workload Management and Mail plans did not 

incorporate specific procedures for oversight of search, drop, and Military 

File mail processing. When interviewed, some supervisors acknowledged 

they were not properly using COVERS to manage mail. Further, supervisors 

did not consistently check their team’s search mail points to determine if 

staff deleted COVERS searches without retrieving the mail. 

VARO management stated local directives did not ensure oversight of mail 

processing procedures under the new integrated team model. For example, 

an outdated COVERS user plan assigned responsibility for maintaining, 

controlling, attaching, and deleting all search mail to Triage, a team that no 

longer existed under the integrated team model. Without up-to-date 

procedures, supervisors were unaware of their responsibilities for ensuring 

accurate and timely mail processing in their teams. 

4.	 We recommend the Seattle VA Regional Office Director amend the 

Workload and Mail Management plans to provide increased monitoring 

Recommendations 

VA Office of Inspector General 12 
Inspection of the VA Regional Office, Seattle, Washington 

Management 

Comments 

OIG Response 

of processes associated with handling and controlling Veterans Service 

Center mail under the new Integrated Team model. 

5.	 We recommend the Seattle VA Regional Office Director provide up-todate procedures to Veterans Service Center management and staff on the 

proper use of the Control of Veterans Records System to manage mail. 

The VARO Director concurred with our recommendations to improve mail 

processing. The Director amended the Workload Management Plan that 

provided mail handling procedures and supervisory oversight for claims 

establishment. Further, VSC management and staff received training on the 

proper use of COVERS to assist with managing mail. 

The Director’s comments and actions are responsive to the 

recommendations. 

VA Office of Inspector General 13 
Inspection of the VA Regional Office, Seattle, Washington 

Appendix A 

Organization 

Resources 

Workload 

Scope 

VARO Profile and Scope of Inspection 

The Seattle VARO is responsible for delivering non-medical VA benefits 

and services to veterans and their families in Washington State, nine counties 

in Idaho (Nez Perce, Clearwater, Latah, Lewis, Shoshone, Benewah, 

Kootenai, Boundary, and Bonner), and British Columbia, Canada. The 

VARO fulfills these responsibilities by administering compensation and 

pension benefits, vocational rehabilitation and employment assistance, and 

outreach activities. 

As of May 2011, the Seattle VARO had a staffing level of 591 full-time 

employees. Of these, the VSC had 232 employees (39 percent) assigned. 

As of July 2011, the VARO reported 19,053 pending compensation claims. 

The average time to complete these claims was 184.9 days, which exceeded 

the national target of 175 days by 9.9 days. As reported by STAR staff, 

accuracy of compensation rating-related issues was 81.8 percent, which was 

below the 90 percent target set by VBA. 

We reviewed selected management control, claims processing, and 

administrative activities to evaluate compliance with VBA policies regarding 

delivery of benefits and non-medical services to veterans and other 

beneficiaries. We interviewed managers and employees and reviewed 

veterans’ claims folders. 

Our review included 90 (14 percent) of 622 disability claims related to TBI, 

PTSD, and herbicide exposure that the VARO completed from January 

through March 2011. For temporary 100 percent disability evaluations, we 

selected 30 (6 percent) of 494 existing claims from VBA’s Corporate 

Database. We provided the VARO with a list of 464 claims remaining from 

the universe of 494 for further review. These claims represented instances in 

which VARO staff granted temporary 100 percent disability determinations 

for at least 18 months. 

We analyzed the 11 mandatory SAOs completed in fiscal years 2010 and 

2011. Additionally, we reviewed 17 claims files containing errors identified 

by VBA’s STAR program during the period of October through December 

2010. VBA measures the accuracy of compensation and pension claims 

processing through its STAR program. STAR measurements include a 

review of work associated with claims that require 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’ disability claims. 

VA Office of Inspector General 14 
Inspection of the VA Regional Office, Seattle, Washington 

Our process differs from STAR as we review specific types of claims for 

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

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

involving temporary 100 percent disability evaluations. 

We reviewed dates of claim for those claims pending at the VARO during 

our onsite inspection. NODs reviewed had been pending processing between 

31 and 60 days at the VARO. Further, we reviewed mail in various 

processing stages within the VARO mailroom and the VSC. 

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 15 
Inspection of the VA Regional Office, Seattle, Washington 

Appendix B VARO Director’s Comments 

Department of Memorandum Veterans Affairs 

Date: August 12, 2011 

From: Director, VA Regional Office Seattle (346/00) 

Subj: Inspection of the VA Regional Office, Seattle, Washington 

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

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

Inspection of the VA Regional Office, Seattle, Washington. 

2.	 Please feel free to contact me at (206) 220-6246 with any questions or 

concerns regarding our reply. 

(original signed by:) 

Patrick C. Prieb
 

Director
 

Attachment 

VA Office of Inspector General 16 
Inspection of the VA Regional Office, Seattle, Washington 

Office of the Inspector General – Site Visit May 2011 

IG Recommendations: 

Recommendation 1: We recommend the Seattle VA Regional Office Director develop and 

implement a plan to assess the effectiveness and adequacy of Rating Veterans Service 

Representative (RVSR) training related to processing traumatic brain injury (TBI). 

RO Comments: Concur. 

In response to OIG draft report “Inspection of the VA Regional Office Seattle, Washington,” 

dated August 5, 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. In addition, training was provided on June 7, 2011 and June 8, 2011 for all 

RVSRs and Decision Review Officers (DROs) on TBI. 

To gauge the effectiveness and adequacy of our recent training, we reviewed 218 TBI claims for 

second signature since June 2, 2011. Our review noted 17 errors demonstrating 92.5% 

effectiveness in rating these cases. TBI training will be an ongoing concentration and we will 

conduct a local Independent Rating Review (IRR) on TBI claims on October 26, 2011, to 

continue our assessment of the effectiveness and adequacy of our TBI training. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 2: We recommend the Seattle VA Regional Office Director develop a plan to 

provide standardized training to claims assistants and file clerks on the proper procedures for 

establishing dates of claim in the electronic record. 

RO Comments: Concur. 

A total of 10 hours of group training was conducted from June 13 through 17, 2011 for claims 

assistants and file clerks. The topics trained were date of claim establishment, control time and 

proper routing of mail. A plan to provide recurring standardized training to claims assistants and 

file clerks was created on August 10, 2011. This training includes proper procedures for 

establishing dates of claim. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 3: We recommend the Seattle VA Regional Office Director amend the 

Workload Management Plan to incorporate clear instructions and oversight mechanisms for 

recording Notices of Disagreement within the Veterans Benefits Administration’s 7-day 

standard. 

RO Comments: Concur. 

VA Office of Inspector General 17 
Inspection of the VA Regional Office, Seattle, Washington 

An amended Appeals Team SOP was finalized on May 16, 2011, which identifies that the claims 

assistants are responsible for establishing the VACOLS record within seven days. In addition, 

an amended Workload Management Plan was issued on August 10, 2011 addressing this item. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 4: We recommend the Seattle VA Regional Office Director amend the 

Workload and Mail Management plans to provide increased monitoring of processes associated 

with handling and controlling Veterans Service Center mail under the new Integrated Team 

model. 

RO Comments: Concur. 

The Workload Management Plan was amended on May 12, 2011. It describes the current mail 

handling procedures for the Integrated Teams and requires supervisory oversight for claims 

establishment, COVERS compliance and search mail auditing. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 5: We recommend the Seattle VA Regional Office Director provide up-todate procedures to Veterans Service Center management and staff on the proper use of the 

Control of Veterans Records System (COVERS) to manage mail. 

RO Comments: Concur: 

At the time of the OIG visit the VSC had just reorganized into integrated work teams. The 

Triage team under the CPI model had previously controlled all mail activity. As a transition to 

the integrated work teams, each POD received a distribution of the mail along with experienced 

claims assistants to manage that mail. Training was provided to VSC management and staff on 

Covers mail handling and procedures on June 7-8, 2011 and June 13-17, 2011. An updated 

COVERS VSC compliance memorandum was issued on August 12, 2011 to strengthen mailprocessing controls. 

The Veterans Benefits Administration recommends closure of this recommendation. 

VA Office of Inspector General 18 
Inspection of the VA Regional Office, Seattle, Washington 

Appendix C Inspection Summary
 

Nine Operational 

Activities Inspected Criteria 

Reasonable 

Assurance of 

Compliance 

Yes No 

Claims Processing 

1. Temporary 100 

Percent Disability 

Evaluations 

Determine whether VARO staff properly processed 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. Post-Traumatic 

Stress Disorder 

Claims 

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

CFR 3.304(f)) X 

4. Herbicide 

Exposure-Related 

Claims 

Determine whether VARO staff properly processed claims for service 

connection for herbicide exposure-related disabilities. (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 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 

Reviews 

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 

Source: VA OIG Analysis 

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

VA Office of Inspector General 19 
Inspection of the VA Regional Office, Seattle, Washington 

Appendix D Office of Inspector General Contact and Staff 

Acknowledgments 

Office of Inspector General For more information about this report, 

Contact 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 

Kelly Crawford 

Lee Giesbrecht 

Kerri Leggiero-Yglesias 

Nelvy Viguera Butler 

Mark Ward 

VA Office of Inspector General 20 
Inspection of the VA Regional Office, Seattle, Washington 

Appendix E Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Benefits Administration 

Assistant Secretaries 

Office of General Counsel 

Veterans Benefits Administration’s Western Area Director 

VA Regional Office Seattle 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: Maria Cantwell, Patty Murray 

U.S. House of Representatives: Norman D. Dicks, Doc Hastings, Jaime 

Herrera Beutler, Jay Inslee, Rick Larsen, Jim McDermott, Cathy McMorris 

Rodgers, David G. Reichert, Adam Smith 

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 21