Inspection of the
 

VA Regional Office
 

St. Louis, Missouri
 

OFFICE OF AUDITS AND EVALUATIONS

May 20, 2011
	

11-00519-172
	
ACRONYMS AND ABBREVIATIONS
	

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

TBI Traumatic Brain Injury

VACOLS Veterans Appeals Control and Locator System

VARO Veterans Affairs Regional Office

VBA Veterans Benefits Administration

VSC Veterans Service Center

To Report Suspected Wrongdoing in VA Programs and Operations:
	

Telephone: 1-800-488-8244
	

E-Mail: vaoighotline@va.gov
 

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

VA Regional Office, St. Louis, Missouri 

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 St. Louis VARO staff correctly

processed post-traumatic stress disorder

disability claims, properly established the

correct dates of claim in the electronic

record, and ensured staff corrected errors

identified by the Veterans Benefits

Administration’s Systematic Technical

Accuracy Review Program. The VARO

was generally effective in recording Notices

of Disagreement for appealed claims and

timely in completing Systematic Analyses of

Operations.

VARO management lacked effective

controls and accuracy in processing

temporary 100 percent disability

evaluations, traumatic brain injury claims,

and herbicide exposure-related claims.

Overall, VARO staff did not accurately

process 38 (32 percent) of the 117 disability

claims reviewed. Management also lacked

effective controls over handling mail and

processing final competency determinations.

What We Recommended 

We recommended St. Louis VARO

management implement controls to ensure

Veterans Service Center staff establish

suspense diaries to request the medical

reexaminations for temporary 100 percent

disability reevaluations as needed.

In addition, we recommended VARO

management implement oversight plans to

ensure staff return inadequate medical

examination reports to healthcare facilities

to obtain the evidence needed to support

traumatic brain injury claims rating

decisions, improve accuracy and quality

review of herbicide exposure-related claims

processing, and ensure staff obtain

supporting medical evidence in cases

involving court declarations of

incompetency. Finally, we recommended

VARO management strengthen controls to

ensure proper mail handling.

Agency Comments 

The Director of the St. Louis VARO

concurred with all recommendations.

Management’s planned actions are

responsive and we will follow up as required

on all actions.

(original signed by:)

 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
 

5. Eligibility Determinations.....................................................................................................12
 

Appendix A VARO Profile and Scope of Inspection............................................................15

Appendix B VARO Director’s Comments............................................................................17

Appendix C Inspection Summary..........................................................................................20

Appendix D OIG Contact and Staff Acknowledgments........................................................21

Appendix E Report Distribution ...........................................................................................22

ii
Inspection of the VA Regional Office, St. Louis, Missouri 

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 January 2011, the OIG conducted an inspection of the St. Louis VARO.

The inspection focused on 5 protocol areas examining 10 operational

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

integrity, management controls, workload management, and eligibility

determinations.

We reviewed 87 (10 percent) of 855 disability claims related to

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

herbicide exposure that the VARO completed from July through September

2010. In addition, we reviewed 30 (7 percent) of 411 rating decisions where

the 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 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, St. Louis, Missouri 

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 Needs To Improve Disability Claims 

Processing Accuracy 

The St. Louis VARO needs to improve the accuracy of disability claims

processing. VARO staff incorrectly processed 38 (32 percent) of the total

117 disability claims reviewed. VARO management agreed with our

findings and initiated action to correct the inaccuracies identified.

The following table reflects the errors affecting, and those with the potential

to affect, veterans’ benefits processed at the St. Louis 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 20 4 16

PTSD 30 0 0 0

TBI 27 14 2 12

Herbicide

Exposure-Related

Disabilities

30 4 2 2

Total 117 38 8 30

Temporary 

100 Percent 

Disability 

Evaluations 

Source: VA OIG

VARO staff incorrectly processed 20 (67 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, St. Louis, Missouri 

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

determine whether to continue the veteran’s 100 percent disability benefits.

For temporary 100 percent disability evaluations, including those where

rating decisions do not change a veteran’s payment amount (confirmed and

continued evaluations), 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 medical reexamination. When a suspense

diary matures, the electronic system generates a reminder notification to alert

VSC staff to schedule the reexaminations.

Based on analysis of available medical evidence, 4 of the 20 processing

inaccuracies affected veterans’ benefits—3 involved overpayments totaling

$117,856 and 1 involved an underpayment totaling $1,536. Details of the

most significant overpayment and the underpayment follow.

	 A Rating Veterans Service Representative (RVSR) correctly continued a

temporary 100 percent disability evaluation for a veteran’s prostate

cancer and established a reminder for a future medical reexamination.

However, VARO staff failed to take action on the reminder notification

by scheduling the medical reexamination or establishing a new date for

the reexamination as required. Medical evidence we reviewed showed

the cancer was no longer active, warranting no more than a 20 percent

disability evaluation. As a result, VA overpaid the veteran $57,648 over

a period of 2 years.

	 An RVSR did not grant a veteran special monthly compensation based on

the loss of use of a creative organ as required. As a result, VA underpaid

the veteran $1,536 over a period of 1 year and 4 months.

The remaining 16 inaccuracies had the potential to affect veterans’ benefits.

Following are summaries of those inaccuracies.

	 In 11 cases, VSC staff did not schedule the follow-up medical

reexaminations needed to determine whether the temporary 100 percent

disability evaluations should continue.

	 In two cases, RVSRs requested medical reexaminations beyond the date

of our inspection. However, VSC staff did not establish suspense diaries

to alert them of the needed VA medical reexaminations.

	 In one case, an RVSR failed to identify a future medical reexamination

date in the rating decision; therefore, VSC staff did not establish the

suspense diary.

	 In one case, an RVSR correctly continued the 100 percent disability

evaluation, which did not require a future medical reexamination.

However, in making this decision, the RVSR did not consider entitlement

VA Office of Inspector General 3 
Inspection of the VA Regional Office, St. Louis, Missouri 

PTSD Claims 

TBI Claims 

to the additional benefit of Dependents’ Educational Assistance as

required by VBA policy.

	 In one case, an RVSR incorrectly denied entitlement to the additional

benefit of Dependents’ Educational Assistance for a veteran with an

incurable disease.

We could not determine if 12 of the 16 temporary 100 percent disability

evaluations above would have continued because the veterans’ claims folders

did not contain the medical evidence needed to reevaluate each case. An

average of 2 years and 9 months elapsed from the time staff should have

scheduled medical reexaminations until the date of our inspection—the date

staff ultimately ordered the medical reexaminations to obtain the necessary

medical evidence. The delays ranged from 10 months to 7 years and

1 month.

The most frequent error noted in 11 (55 percent) of the 20 temporary

100 percent disability evaluations occurred when VARO staff did not

properly establish suspense diaries for future VA medical reexaminations.

Ten of these errors involved confirmed and continued evaluations. VSC

supervisors stated staff might be rushed due to the large volume of work and

overlook entering the suspense diary for medical reexamination. VARO

management had no procedures or oversight measures in place to ensure staff

input the diaries in VBA’s electronic record system to generate reminder

notifications to schedule the reexaminations. As such, VARO staff did not

always timely schedule medical reexaminations as required.

VARO staff correctly processed all 30 PTSD claims we reviewed.

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

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

traumatically induced structural injury or a 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 14 (52 percent) of 27 TBI claims. Two of

the processing inaccuracies affected veterans’ benefits. Following are

summaries of these inaccuracies.

	 An RVSR incorrectly granted separate disability evaluations for a

veteran’s service-connected PTSD and TBI-related residuals, resulting in

a total disability evaluation of 40 percent. Because the examiner was not

able to state whether the symptoms were related to PTSD or residuals of

TBI, the RVSR should have granted a single disability evaluation, which

would have resulted in a total disability evaluation of 50 percent. As a

VA Office of Inspector General 4 
Inspection of the VA Regional Office, St. Louis, Missouri 

result, the veteran was underpaid $3,172 over a period of 1 year and

1 month.

	 An RVSR incorrectly evaluated a veteran’s residual TBI-related

disability as 10 percent disabling. The medical examination results

showed subjective symptoms warranting no more than a 0 percent

disability evaluation, entitling the veteran to healthcare for the condition

but no monetary compensation. As a result, the veteran was overpaid

$2,848 over a period of 1 year and 4 months.

Following are details on the remaining 12 TBI inaccuracies that had the

potential to affect veterans’ benefits.

	 In 10 cases, RVSRs prematurely evaluated TBI-related residual

disabilities using inadequate medical examinations. According to VBA

policy, when a medical examination does not address all required

elements, VSC staff should return it to the clinic or healthcare facility as

insufficient for rating purposes. Neither VARO staff nor we can

ascertain all of the residual disabilities related to TBI without an adequate

or complete medical examination.

	 In one case, an RVSR incorrectly continued a 70 percent evaluation for

TBI-related residual disabilities. The medical examiner attributed the

symptoms to the veteran’s service-connected PTSD, not the TBI-related

residual disabilities. Because of the veteran’s multiple service-connected

disabilities, this error did not affect the veteran’s monthly benefits, but it

may affect future evaluations for additional benefits.

	 In one case, an RVSR correctly deferred a decision for TBI-related

residual disabilities due to an inadequate medical examination. VBA

policy requires VSC staff set-up a control mechanism, known as an end

product, which must remain in place until all decisions on the claim are

completed. In this case, VSC staff did not continue the end product and

no mechanism was in place to ensure control of the deferred TBI-related

residual disabilities decision. If not for our inspection, VARO staff

might not have completed all evaluations of the TBI-related disabilities.

Generally, errors associated with TBI claims processing occurred because

RVSRs used VA medical examinations that were inadequate for

decision-making purposes. RVSRs stated they did so because they felt

pressured to rate cases quickly. VSC management similarly attributed the

errors to increased demands to meet VARO production goals. Further, VSC

training employees were aware RVRSs found TBI claims complex and

confirmed the RVSRs’ practice of making decisions on inadequate

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

payments.

VA Office of Inspector General 5 
Inspection of the VA Regional Office, St. Louis, Missouri 

Herbicide 

Exposure-Related 

Claims 

Recommendations 

VARO staff incorrectly processed 4 (13 percent) of 30 herbicide

exposure-related claims reviewed. Two of the four processing inaccuracies

affected veterans’ benefits with underpayments totaling $16,184. Following

are summaries of the two underpayments.

	 An RVSR granted a 60 percent disability evaluation for residuals of lung

cancer due to herbicide exposure; however, medical evidence showed

active cancer warranting a 100 percent disability evaluation. The

increased evaluation for the active cancer also entitled the veteran to

additional special monthly compensation benefits based on multiple

disabilities. As a result, the veteran was underpaid $14,072 over a period

of 8 months.

	 An RVSR failed to grant entitlement to an additional special monthly

benefit as required based on the loss of use of a creative organ. As a

result, the veteran was underpaid $2,112 over a period of 1 year and

10 months.

Following are details on the remaining two herbicide exposure-related

inaccuracies that had the potential to affect veterans’ benefits.

	 An RVSR did not address several of the veteran’s claimed disabilities, to

include service connection for herbicide exposure-related disabilities.

The RVSR’s failure to address all disabilities claimed did not affect

monthly benefits but may affect future evaluations.

	 An RVSR failed to consider service connection for a diabetes-related

complication diagnosed in VA treatment records. The RVSR should

have requested a medical examination to rate this case. Neither VARO

staff nor we can ascertain all of the residual disabilities related to

diabetes without an adequate or complete medical examination.

Generally, errors in processing herbicide exposure-related claims resulted

from inadequate quality review. VSC training supervisors responsible for

local quality review reported their staff did not identify any errors in

herbicide exposure-related claims processing similar to those found during

our inspection. Additionally, VARO management indicated errors occurred

due to an increased emphasis on production goals. As a result, veterans did

not always receive correct benefits payments.

1.	 We recommend the St. Louis VA Regional Office Director implement

controls to ensure staff establish suspense diaries for temporary

100 percent disability reevaluations.

2.	 We recommend the St. Louis VA Regional Office Director develop and

implement a plan to ensure Rating Veterans Service Representatives

return inadequate medical examination reports to healthcare facilities to

VA Office of Inspector General 6 
Inspection of the VA Regional Office, St. Louis, Missouri 

Management 

Comments 

OIG Response 

obtain the evidence needed to support traumatic brain injury claims

rating decisions.

3.	 We recommend the St. Louis VA Regional Office Director develop and

implement a plan to improve accuracy and oversight of herbicide

exposure-related claims processing.

The VARO Director concurred with our recommendations. In response to

recommendation 1, the Director agreed the electronic system should

automatically populate future exam dates. Additionally, the Director stated

the VARO would follow the national review plan developed by VBA in

response to our national report, Veterans Benefits Administration: Audit of 

100 Percent Disability Evaluations, (Report Number 09-03359-71, January

24, 2011).

In response to recommendations 2 and 3, the Director stated VSC’s Policy,

Analysis, Star Review, and Training Team provided training to RVSRs on

processing TBI-related claims in February 2011 and diabetes in March 2011.

The team will also conduct additional training sessions on TBI in July 2011

and August 2011. Further, VSC management will add TBI examination

issues to its agenda for their quarterly meetings with Compensation and

Pension Service at the local VA Medical Centers. In April 2011, the Policy,

Analysis, Star Review, and Training Team will have training on Agent

Orange and follow-up training on diabetes. The Director stated Decision

Review Officers are completing a second review of herbicide exposurerelated decisions and RVSRs who made inaccurate decisions will receive

feedback and mentoring.

Management’s actions are responsive to the recommendations. We will

follow up as required on all actions.

A draft of this inspection report included an additional recommendation that

the VA Regional Office Director review the remaining temporary

100 percent disability evaluations identified but not included in our

inspection sample to determine if reevaluations are required and take

appropriate action. We have removed the recommendation from this

individual VARO inspection report since 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

VA Office of Inspector General 7 
Effective Dates 

Inspection of the VA Regional Office, St. Louis, Missouri 

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. Removing the

recommendation from our draft inspection report will allow VBA time to

implement its national plan for reviewing all temporary 100 percent

disability evaluations to correct processing errors. The target completion

date is September 30, 2011, as the Acting Under Secretary for Benefits

previously indicated.

We have requested from VBA’s Office of Field Operations a copy of both

VBA’s national review plan for sample testing using the diagnostic codes

specified above, as well as a documented explanation of its batch process for

identifying the remaining cases and establishing appropriate future diary

controls electronically. We will use such information to monitor

implementation progress and gauge effectiveness of VBA’s national review

plan approach as we move forward in conducting our individual VARO

inspections. Based on the magnitude of errors and associated financial risks

we have identified in temporary 100 percent disability evaluation processing

to date, we have an ongoing responsibility to exercise continued oversight in

this area.

2. Data Integrity 

We analyzed claims folders to determine if the VARO is following VBA

policy to establish correct effective dates. Generally, an effective date

indicates when entitlement to a specific benefit arose. VA regulations state

the effective date of benefits is the claim receipt date or the date evidence

revealed the disability existed, whichever is later.

VARO staff incorrectly established effective dates for 2 (2 percent) of

117 disability claims we reviewed. Both errors affected veteran’s benefits

and involved overpayments totaling $11,748. Details on the effective date

errors follow.

	 An RVSR incorrectly granted service connection for a veteran’s prostate

cancer effective July 29, 2008, the date the VARO received the claim.

Medical evidence showed a diagnosis of the condition on

November 3, 2008. As a result, the veteran was overpaid $6,384 over a

period of 4 months.

VA Office of Inspector General 8 
Inspection of the VA Regional Office, St. Louis, Missouri 

Dates of Claim 

Notices of 

Disagreement 

Systematic 

Technical 

Accuracy 

Review 

	 An RVSR incorrectly granted service connection for prostate cancer

effective September 6, 2006, approximately 2 months prior to actual

receipt of the claim. This occurred because the veteran had a claim

pending for other disabilities at the time the VARO received the

veteran’s claim and supporting evidence of prostate cancer on

November 8, 2006. As a result, the veteran was overpaid $5,364 over a

period of 2 months.

Because we found only two inaccuracies, we determined the VARO is

generally following VBA policy regarding effective dates. As such, we

made no recommendations for improvement in this area.

We analyzed claims folders to determine if the VARO is following VBA

policy to establish correct dates of claim in the electronic record. In addition

to establishing the timeframe for benefits entitlement, 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.

VARO staff established the correct dates of claim in the electronic record for

all 30 claims reviewed. As a result, we determined the VARO is following

VBA policy and we made no recommendation for improvement in this area.

We analyzed claims folders to determine if the VARO is 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 a veteran’s appeal 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.

VARO staff exceeded VBA’s 7-day standard for 1 (3 percent) of 30 NODs

we reviewed. As a result, we determined the VARO is generally following

VBA policy regarding NODs and we made no recommendation for

improvement in this area.

3. Management Controls 

We assessed management controls to determine if 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 veterans and

VA Office of Inspector General 9 
Inspection of the VA Regional Office, St. Louis, Missouri 

Systematic 

Analysis of 

Operations 

Mail Room 

Operations 

Triage Mail 

Processing 

Procedures 

other beneficiaries receive accurate and consistent compensation and pension

benefits. VBA policy requires the VARO take corrective action on errors

identified by STAR.

VARO staff adhered to VBA policy by taking corrective action on all

18 errors identified by STAR from July through September 2010. Therefore,

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 an organizational element or

operational function of the VSC. 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 designating the staff required to complete the SAOs by

specific dates.

The Veterans Service Center Manager is responsible for ongoing analysis of

VSC operations, including completion of 12 annual SAOs. The VSC

completed all 12 SAOs timely; however, 1 (8 percent) of the 12 SAO’s did

not address all required elements. Because we determined VSC management

generally followed VBA policy, 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 4–6 hours

of receipt at the VARO. The St. Louis VARO assigns responsibility for

mailroom activities (including the processing of incoming mail) to the

Support Services Division. Mailroom staff were timely and accurate in

processing, date stamping, and delivering VSC mail to the Triage Team

control point daily. As a result, we determined the VARO Support Services

mailroom is following VBA policy. Therefore, we made no

recommendation for improvement in this area.

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

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

accordance with VBA policy. VARO staff are required to use VBA’s

tracking system, Control of Veterans Records System (COVERS), to

electronically track veterans’ claims folders and control search mail. VBA

policy defines search mail as active claims-related mail waiting to be

associated with a veteran’s claims folder. Conversely, drop mail requires no

processing action upon receipt. VBA policy allows the use of a storage area,

VA Office of Inspector General 10 
Inspection of the VA Regional Office, St. Louis, Missouri 

known as the Military File, to hold mail temporarily when staff are not able

to identify an associated claims folder in the system.

Finding 2		 Triage Team Mail Management Procedures Need 

Strengthening 

Triage Team staff did not consistently manage search mail according to VBA

policy. For 5 (17 percent) of 30 pieces of search mail, VSC staff did not

properly use COVERS to ensure timely processing and adequate control of

search mail. The most significant error identified during our inspection

occurred when the VARO received a veteran’s claim for disability benefits

on August 11, 2010, and did not place this mail on search so it could be

associated with the claims folder. As a result, a processing delay of

approximately 5 months occurred.

Triage Team staff did not always follow VBA’s drop mail policy. Thirteen

(43 percent) of 30 pieces of mail were incorrectly placed in drop mail

holding areas without review or processing. The most egregious error

occurred when the VARO received a claim for additional compensation

payments on September 29, 2010 based on the veteran having dependents,

and incorrectly sent it to the file storage area. By the time of our inspection

in January 2011, no one had taken any action on this claim.

Triage Team staff did not always manage mail in the cabinets labeled

“Military File-No Record Bin” according to VBA policy. Sixteen

(53 percent) of 30 items reviewed were incorrectly stored in these cabinets.

The most substantial error occurred when the VARO received a claim for

death benefits on July 27, 2010, and incorrectly placed it in the Military

File-No Record cabinet. By the time of our inspection in January 2011, the

VARO had not taken any action on this claim.

The above errors occurred because of lack of supervisory oversight to ensure

timely and accurate movement of mail throughout the VSC. Triage Team

employees complete reviews of search mail; however, supervisors did not

provide oversight to ensure search mail was properly marked in COVERS.

In addition, the station’s workload management plan did not clearly define

drop mail or the use of the Military File. Triage Team supervisors and

employees stated they were unsure of the requirements for control of the

Military File. Further, VSC training staff reported they did not perform

consistent quality reviews of Triage Team management of search, drop, or

Military File mail.

Untimely association of mail with veterans’ claims folders can cause delays

in processing disability claims. As a result, beneficiaries may not receive

accurate and timely benefit payments.

VA Office of Inspector General 11 
Inspection of the VA Regional Office, St. Louis, Missouri 

Recommendations 

Management 

Comments 

OIG Response 

Competency 

Determinations 

Finding 3 

4.	 We recommend the St. Louis VA Regional Office Director implement a

plan to ensure management oversight of search mail and amend the

workload management plan to incorporate procedures for oversight and

control of drop and Military File mail.

The VARO Director concurred with our recommendation. The Director

stated management updated the Triage team’s search mail procedures,

developed Standard Operating Procedures, and revised the Workload

Management Plan.

Management’s actions are responsive to the recommendation. We will

follow up as required on all actions.

5. Eligibility Determinations 

VA must consider beneficiary competency in every case involving a mental

health condition that is totally disabling or when evidence raises questions as

to a beneficiary’s mental capacity to manage his or her affairs. The

Fiduciary Unit supports implementation of competency determinations by

appointing a fiduciary, which is a third party that assists in managing funds

for an incompetent beneficiary. We reviewed competency determinations

made at the VARO to ensure staff completed them accurately and timely.

Delays in making these determinations ultimately affect the Fiduciary Unit’s

ability to be timely in appointing fiduciaries.

Controls Over Competency Determinations Need 

Strengthening 

VARO staff unnecessarily delayed making final decisions in 7 (41 percent)

of the 17 competency determinations completed from July through

September 2010. The delays ranged from 36 to 131 days, with an average

completion time of 54 days. Delays occurred because VSC managers were

not aware of timeliness standards and the VSC does not prioritize completion

of these types of cases. The risk of incompetent beneficiaries receiving

benefit payments without fiduciaries assigned to manage those funds

increases when VSC staff do not complete competency determinations

immediately.

VBA policy requires staff to obtain clear and convincing medical evidence

that a beneficiary is incapable of managing his or her affairs prior to making

a final competency decision. The policy allows the beneficiary a 65-day due

process period to submit evidence showing an ability to manage funds and

other personal affairs. At the end of the due process period, VARO staff

must take immediate action to determine if the beneficiary is competent.

VA Office of Inspector General 12 
Inspection of the VA Regional Office, St. Louis, Missouri 

In the absence of a definition of “immediate,” we allowed 14 calendar days

after the due process period to determine if staff were timely in completing a

competency decision. We considered this a reasonable period to control,

prioritize, and finalize these types of cases.

Using our interpretation of immediate, the most significant case we identified

occurred when VARO staff unnecessarily delayed a final incompetency

decision for a veteran for approximately 4 months. During this period, the

veteran received $11,096 in disability payments. While the veteran was

entitled to these payments, fiduciary stewardship was not in place to ensure

effective funds management and the welfare of the veteran.

VARO staff responsible for overseeing and processing final competency

determinations stated they were unaware of VBA’s policy requiring

immediate action and therefore did not prioritize these cases. Supervisory

staff reported they did not manage incompetency decisions separately from

other types of claims and made decisions on all claims in order of the dates

the VSC received them. As a result, incompetent beneficiaries received

benefits payments for extended periods despite being determined incapable

of managing these funds effectively.

Until recently, VBA did not have a clear, measurable definition of

“immediate” and this timeframe varied from office-to-office. In response to

our summary report for FY 2010, Systemic Issues Reported During 

Inspections at VA Regional Offices, (Report Number 11-00510-167,

May 18, 2011), the Acting Under Secretary for Benefits defined “immediate”

as 21 days following the expiration of the due process period. VBA plans to

implement this new policy nationwide in June 2011. Therefore, we made no

recommendation to the Director of the VARO regarding this issue. The

VARO processed 10 of 17 determinations in 21 days.

VBA policy states when a court finds a veteran incompetent, the VARO must

obtain additional medical evidence to support the court’s incompetency

determination. VBA policy requires review of all medical evidence related to

incompetency prior to making a final competency determination. Judicial

findings by a court with respect to the competency of a veteran are not binding

upon VBA decisions. They are compelling evidence, but not a sole source of

evidence.

VARO staff incorrectly processed 6 (35 percent) of 17 competency

determinations. In five of the six cases, they did not complete a formal,

documented, decision before appointing the fiduciaries. The incorrect process

resulted from VSC staff’s unawareness of VBA’s policy on obtaining

medical evidence to support court determinations of incompetency. As a

result, VSC staff prematurely deemed veterans incompetent and may have

incorrectly denied their right to independently handle their financial affairs.

VA Office of Inspector General 13 
Inspection of the VA Regional Office, St. Louis, Missouri 

Recommendations 

Management 

Comments 

OIG Response 

5.	 We recommend the St. Louis VA Regional Office Director implement

controls to ensure staff obtain and review current medical evidence in all

cases involving court declarations of incompetency.

The VARO Director concurred with our recommendation. The Director

stated management provided training on the proper processing of court

declarations of incompetency. Further, the Policy, Analysis, Star Review,

and Training Team will conduct accuracy reviews to ensure staff are

following procedures.

Management’s actions are responsive to the recommendation. We will

follow up as required on all action.

VA Office of Inspector General 14 
Inspection of the VA Regional Office, St. Louis, Missouri 

Appendix A 

Organization 

Resources 

Workload 

Scope 

VARO Profile and Scope of Inspection 

The St. Louis VARO is responsible for delivering non-medical VA benefits

and services to veterans and their families. The VARO fulfills these

responsibilities by administering compensation and pension benefits,

vocational rehabilitation and employment assistance, and outreach activities.

As of September 30, 2010, the St. Louis VARO had a staffing level of

670.5 employees. Of these, the VSC had 263 employees (39 percent)

assigned.

As of December 31, 2010, the VARO reported 11,692 pending compensation

claims. The average time to complete these claims was 153.6 days, which

was 21.4 days better than the national target of 175 days. As reported by

STAR staff, the accuracy of compensation rating-related decisions was

84.6 percent, which was 5.4 percent below the 90 percent VBA target. The

accuracy of compensation authorization-related processing was 96.3 percent,

which was 0.3 percent better than the national target of 96 percent.

We reviewed selected management controls, benefits claims processing, and

administrative activities to evaluate compliance with VBA policies regarding

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

beneficiaries. We interviewed managers and employees and reviewed

veterans’ claims folders.

Our review included 87 (10 percent) of 855 claims related to PTSD, TBI, and

herbicide exposure-related disabilities that the VARO completed from

July through September 2010. For temporary 100 percent disability

evaluations, we selected 30 (7 percent) of 411 existing claims from VBA’s

Corporate Database. We provided the VARO with the 381 claims remaining

from the universe of 411. These claims represented all instances in which

VARO staff granted temporary 100 percent disability determinations for at

least 18 months.

We reviewed all 18 errors identified by VBA’s STAR program from

July through September 2010. VBA measures the accuracy of compensation

and pension claims processing through its STAR program. STAR’s

measurements include a review of work associated with claims that require a

rating decision. 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 in that we review specific types of claims

issues such as PTSD, TBI, and herbicide exposure-related disabilities that

VA Office of Inspector General 15 
Inspection of the VA Regional Office, St. Louis, Missouri 

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

processing involving temporary 100 percent disability evaluations.

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 16 
Inspection of the VA Regional Office, St. Louis, Missouri 

Appendix B VARO Director’s Comments 

Department of Memorandum Veterans Affairs 

Date: April 20, 2011

From: Director, VA Regional Office St. Louis, Missouri

Subj: Inspection of the VARO St. Louis, Missouri

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

Attached are the St. Louis VARO’s comments on the OIG Draft Report: Inspection of

VARO St. Louis.
 1.

Questions may be referred to Aaron Givens, Veterans Service Center Manager, at
 

314/552-9801.

2.

(Original Signed) 

DAVID UNTERWAGNER
 

Director
 

Attachment

VA Office of Inspector General 17 
Inspection of the VA Regional Office, St. Louis, Missouri 

ST LOUIS RO RESPONSE TO
 

OIG DRAFT REPORT OF 4/4/11
 

Recommendation 1: We recommend the St. Louis VA Regional Office Director review the

381 temporary 100 percent disability evaluations remaining from our universe of 411 to

determine if medical reevaluations are required and take appropriate action.

St Louis RO Response: Does Not Concur. In response to OIG Report, "Audit of 100 Percent

Evaluations," dated January 24, 2011, VBA developed a national plan to review 100 percent

evaluation cases, which was accepted by OIG. Therefore, the Regional Office will follow the

national review plan.

Recommendation 2: We recommend the St. Louis VA Regional Office Director implement

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

reevaluations.

St Louis RO Response: Concur. We agree that the electronic system should automatically

populate future exam dates. In response to OIG Report, "Audit of 100 Percent Evaluations,"

dated January 24, 2011, VBA developed a national plan to review 100 percent evaluation cases,

which was accepted by OIG. Therefore, the Regional Office will follow the national review

plan.

Recommendation 3: We recommend the St. Louis VA Regional Office Director develop and

implement a plan to ensure Rating Veterans Service Representatives return inadequate medical

examination reports to healthcare facilities to obtain the evidence needed to support traumatic

brain injury claims rating decisions.

St Louis RO Response: Concur. After the IG site visit, our VSC Policy, Analysis, Star Review

and Training (PAST) Team conducted rating training in February, 2011. During the training, the

PAST Team addressed traumatic brain injury (TBI) issues, and answered questions with the goal

of improving our quality in this critical, high profile area. Two additional TBI training classes

are scheduled during this fiscal year (July 18, 2011, and August 15, 2011). The last one is

specifically designated for ordering TBI exams. These comprehensive training sessions will

improve our TBI rating determinations. VSC leadership meets with the Compensation and

Pension Service at VA Medical Centers within our catchment area quarterly. Addressing TBI

examination issues has been added as a regular agenda item. Our next meetings are scheduled in

the third quarter when we visit the Leavenworth, Columbia, and Poplar Bluff Medical Centers.

We will address the inadequate TBI medical examination issue and countermeasures to improve

them.

Recommendation 4: We recommend the St. Louis VA Regional Office Director develop and

implement a plan to improve accuracy and oversight of herbicide exposure-related claims

processing.

St Louis RO Response: Concur. The PAST Team administers mandatory special issues

training and records the completion of training. We completed diabetes training for the RVSRs

VA Office of Inspector General 18 
Inspection of the VA Regional Office, St. Louis, Missouri 

in March 2011. We assigned an exercise, and scheduled follow-up diabetes training on

April 13, 2011. We also conducted an Agent Orange training review on April 19, 2011. For

RVSRs needing additional guidance, the DROs provide mentoring. The processing of herbicide

exposure-related claims is currently specialized in teams with DRO’s second-signing the rating

decisions. Employees who receive errors called during the quality review process will receive

feedback and mentoring by a member of the training team. Aggregate data will be reviewed to

determine any group training that should be conducted.

Recommendation 5: We recommend the St. Louis VA Regional Office Director implement a

plan to ensure management oversight of search mail and amend the workload management plan

to incorporate procedures for oversight and control of drop and Military File mail.

St. Louis RO response: Concur. The Triage team’s search mail procedures have been

rewritten since the site visit. Standard Operating Procedures (SOPs) have been developed and

distributed appropriately, to reflect the new changes.

The Triage portion of the Workload Management Plan was revised to reflect the changes to the

new search mail procedures as to incorporate procedures for oversight and control of drop and

Military File mail. This was completed on April 15, 2011.

Recommendation 6: We recommend the St. Louis VA Regional Office Director implement

controls to ensure staff obtain and review current medical evidence in all cases involving court

declarations of incompetency.

St Louis RO Response: Concur. Training was provided to the Post Determination and

Fiduciary teams on how to process court declarations of incompetency. They have been trained

to request the medical evidence at the time the court order is received and the field examiner is

establishing the fiduciary. We have provided training to the RVSRs, regarding VBA's policy on

court orders of incompetency. The PAST team will review these claims for accuracy to

determine the procedures are being followed.

VA Office of Inspector General 19 
Inspection of the VA Regional Office, St. Louis, Missouri 

Appendix C Inspection Summary
	

10 Operational

Activities Inspected Criteria

Reasonable

Assurance of

Compliance

Yes No

Claims Processing

1. Temporary

100 Percent

Disability

Evaluations

Determine whether VARO staff properly reviewed temporary 100 percent

disability evaluations. (38 Code of Federal Regulations (CFR) 3.103(b))

(38 CFR 3.105(e)) (38 CFR 3.327) (Manual (M) 21-1 Manual Rewrite (MR)

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 VARO staff properly processed service connection for

all residual disabilities related to in-service TBI. (Fast Letter (FL) 08-34 and

FL 08-36, Training Letter 09-01)

X

4. Herbicide

Exposure-Related

Claims

Determine whether VARO staff properly processed claims for service

connection for disabilities related to herbicide exposure. (38 CFR 3.309)

(FL 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 the 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 Analysis

of Operations

Determine whether VARO staff properly performed formal analyses of

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

8. 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

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

Eligibility Determinations

10. Competency

Determinations

Determine whether VAROs properly assessed beneficiaries’ mental capacity

to handle VA benefit payments. (M21-1MR Part III, Subpart v, Chapter 9,

Section A) (M21-1MR Part III, Subpart v, Chapter 9, Section B) (FL 09-08) X

Source: VA OIG

VA Office of Inspector General 20 
Inspection of the VA Regional Office, St. Louis, Missouri 

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	 Dawn Provost, Director

Bridget Bertino

Madeline Cantu

Lee Giesbrecht

Brian Jeanseau

David Pina

Dana Sullivan

Brandi Traylor

VA Office of Inspector General 21 
Inspection of the VA Regional Office, St. Louis, Missouri 

Appendix E Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Benefits Administration
 

Assistant Secretaries
 

Office of General Counsel
 

VBA Central Area Director
 

VARO St. Louis 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: Roy Blunt, Claire McCaskill

U.S. House of Representatives: W. Todd Akin, Russ Carnahan, Wm. Lacy

Clay, Emanuel Cleaver, Jo Ann Emerson, Sam Graves, Vicky Hartzler, Billy

Long, Blaine Luetkemeyer

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 22