Inspection of the
 

VA Regional Office
 

Salt Lake City, Utah
 

OFFICE OF AUDITS AND EVALUATIONS

April 13, 2011
 

10-03880-142
 
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, Salt Lake City, Utah

Why We Did This Review What We Recommended
 

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

Salt Lake City VARO management ensured 

staff generally followed Veterans Benefits 

Administration policy for processing 

post-traumatic stress disorder and herbicide 

exposure-related disability claims. VARO 

staff ensured timely completion of 

Systematic Analyses of Operations and 

corrected errors identified by the Veterans 

Benefits Administration’s Systematic 

Technical Accuracy Review program. 

VARO management lacked effective 

controls and accuracy in processing 

temporary 100 percent disability evaluations 

and traumatic brain injury claims. Overall, 

VARO staff did not accurately process 

32 (27 percent) of the 120 disability claims 

we reviewed. Additionally, VARO 

management lacked control of outstanding 

action items related to disability claims 

processing. 

Although VARO staff were not timely in 

recording Notices of Disagreement for 

appealed claims, they were better than the 

national average for processing the appeals. 

Further, establishing correct dates of claim 

in the electronic record and managing mail 

in the Triage Team also were not fully 

effective. 

We recommended Salt Lake City VARO 

management review all remaining temporary 

100 percent disability evaluations identified 

during our inspection to determine if 

reevaluations are required and take 

appropriate action. We recommended 

management implement controls to ensure 

Veterans Service Center staff establish 

suspense diaries to request medical 

examinations for temporary 100 percent 

disability reevaluations and follow policy 

for processing related action items. We 

recommended VARO management provide 

comprehensive training for processing 

traumatic brain injury claims. Further, we 

recommended management strengthen 

controls to ensure accurate dates of claim in 

the electronic record and timely processing 

of incoming mail. 

Agency Comments

The Director of the Salt Lake City 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 ...........................................................................................................10
 

4. Workload Management.........................................................................................................11
 

Appendix A VARO Profile and Scope of Inspection ............................................................13 

Appendix B VARO Director’s Comments............................................................................15 

Appendix C Inspection Summary..........................................................................................21 

Appendix D OIG Contact and Staff Acknowledgments........................................................22 

Appendix E Report Distribution ...........................................................................................23 

ii 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Objective
 

Scope of
 

Inspection
 

INTRODUCTION

The Benefits Inspection Program is part of the efforts of the Office of 

Inspector General (OIG) 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 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 November 2010, the OIG conducted an inspection of the Salt Lake City 

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 competency determinations because VBA has 

centralized all Western Area fiduciary activities at the Salt Lake City VARO. 

We reviewed 90 (18 percent) of 502 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 (35 percent) of 85 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 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, Salt Lake City, Utah 

RESULTS AND RECOMMENDATIONS

1. Disability Claims Processing

The OIG inspection team focused on disability claims processing related to 

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

exposure. We evaluated claims processing accuracy and its impact on 

veterans’ benefits. 

Finding 1	 VARO Staff Need To Improve Disability Claims

Processing Accuracy

The Salt Lake City VARO needs to improve the accuracy of disability claims 

processing. VARO staff incorrectly processed 32 (27 percent) of the total 

120 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 Salt Lake City VARO. 

Table Disability Claims Processing Results 

Type Reviewed 

Cla

Total Affecting 

Veterans’ 

Benefits 

ims Incorrectly 

Potential To 

Affect Veterans’ 

Benefits 

Processed 

Temporary 

100 Percent Disability 

Evaluations 

30 16 4 12 

PTSD 30 2 1 1 

TBI 30 12 2 10 

Herbicide 

Exposure-Related 

Disabilities 

30 2 1 1 

Total 120 32 8 24 

Temporary 

100 Percent 

Disability 

Evaluations 

VARO staff incorrectly processed 16 (53 percent) of 30 temporary 

100 percent disability evaluations we reviewed. Veterans Benefits 

Administration (VBA) policy requires a temporary 100 percent disability 

evaluation for service-connected disabilities needing surgery or specific 

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

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

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

VA Office of Inspector General 2 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Based on analysis of available medical evidence, 4 of the 16 processing 

inaccuracies affected veterans’ benefits—2 involved overpayments totaling 

$113,834 and 2 involved underpayments totaling $11,674. Details on the 

most significant overpayment and underpayment follow. 

	 A Rating Veterans Service Representative (RVSR) incorrectly granted 

one of the highest levels of special monthly compensation based on the 

veteran needing assistance dressing and bathing. VBA policy states a 

veteran is entitled to the higher level of special monthly compensation 

when medical evidence shows the need for daily services provided by a 

licensed healthcare provider or a person under the supervision of a 

licensed healthcare provider. In this case, the VA medical examination 

did not show the veteran met this criterion. As a result, VA overpaid the 

veteran $80,294 over a period of 2 years and 3 months. 

	 An RVSR did not grant a veteran entitlement to special monthly 

compensation based on evaluations of multiple disabilities, as required 

by VBA policy. As a result, VA underpaid the veteran $7,662 over a 

period of 2 years. 

The remaining 12 inaccuracies had the potential to affect veterans’ benefits. 

Following are summaries of these inaccuracies: 

	 In one case, VSC staff proposed reducing a veteran’s temporary 

100 percent disability evaluation, but failed to take final action on the 

proposal. However, medical evidence showed residual complications 

that might negate a reduction in the service-connected condition. 

Without a current medical reexamination and review of the evidence, it is 

not possible to determine whether the temporary 100 percent disability 

evaluation should continue. 

	 In 11 cases, VSC staff failed to schedule the follow-up medical 

examinations needed to determine whether the temporary 100 percent 

disability evaluations should continue. 

For these 11 cases, we could not determine whether the temporary 

100 percent disability evaluations 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 examinations until the date of our 

inspection—the date staff ultimately ordered the examinations to obtain the 

necessary medical evidence. The delays ranged from 3 months to 11 years 

and 5 months. 

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 

VA Office of Inspector General 3 
Inspection of the VA Regional Office, Salt Lake City, Utah 

PTSD Claims 

electronic system. A diary is a processing command that establishes a date 

when VSC staff must schedule a reexamination. As a diary matures, the 

electronic system generates a reminder notification, known as an 810 work 

item, to alert VSC staff to schedule the reexamination. 

Eight of the 16 temporary 100 percent disability evaluation errors resulted 

from staff not establishing suspense diaries to schedule reexaminations for 

confirmed and continued evaluations. VSC management and staff believed 

suspense diaries were automatically generated from the rating decision and 

were not aware these diaries required manual input. VARO management 

had no procedure or oversight measures in place to ensure staff properly 

input suspense diaries to VBA’s electronic system to generate reminder 

notifications to schedule the reexaminations. 

We found approximately 390 pending reminder notifications (i.e., 810 work 

items); the oldest had been pending since May 2010. VSC’s Workload 

Management Plan requires bi-weekly review of work items. However, VSC 

staff indicated that based on misunderstanding of requirements for 

scheduling reexaminations, supervisors instructed them to stop reviewing 

810 work items. As a result, medical reexaminations were not timely 

scheduled. 

VARO staff incorrectly processed 2 (7 percent) of 30 PTSD claims. We did 

not consider the frequency of errors as significant; however, one error 

affected a veteran’s benefit, and one error had the potential to affect a 

veteran’s benefit. Following are summaries of the inaccuracies identified 

regarding PTSD claims: 

	 In one case, an RVSR incorrectly granted service connection for PTSD 

based on an inadequate VA medical examination conducted by a 

non-mental health practitioner. As a result, the veteran was overpaid 

$10,764 over a period of 1 year and 6 months. 

	 In one case, an RVSR determined a veteran was unemployable due to 

service-connected disabilities. However, the RVSR did not address 

either the need for a future examination or entitlement to the additional 

benefit of Dependents’ Educational Assistance as required by VBA 

policy. 

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

determined the VARO generally followed VBA policy related to PTSD 

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

area. 

The Department of Defense and VBA commonly define a TBI as 

traumatically induced structural injury or physiological disruption of brain 

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

TBI Claims 

VA Office of Inspector General 4 
Inspection of the VA Regional Office, Salt Lake City, Utah 

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. Two of 

the processing inaccuracies affected veterans’ benefits with overpayments 

totaling $3,186. Details on the two overpayments follow. 

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

disabilities as 40 percent disabling based on symptoms related to the 

veteran’s PTSD. The VA medical examination showed TBI-related 

subjective symptoms warranting no more than a 10 percent disability 

evaluation. The VA medical examiner attributed all other symptoms to 

the veteran’s service-connected PTSD. As a result, the veteran was 

overpaid $2,301 over a period of 1 year and 1 month. 

	 An RVSR incorrectly assigned a 10 percent disability evaluation for 

residual TBI-related disabilities based on cognitive impairment. The 

medical examiner determined the cognitive impairment was related to the 

veteran’s currently service-connected PTSD and not related to a TBI. As 

a result, VBA was compensating the veteran’s cognitive symptoms under 

both PTSD and TBI-related disabilities. Therefore, the veteran was 

overpaid $885 over a period of 5 months. 

Following are details on the remaining 10 TBI inaccuracies that had the 

potential to affect veterans’ benefits: 

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

disabilities using inadequate medical examinations. In these cases, the 

medical examinations did not specifically state, as required, whether the 

veterans’ complaints and symptoms were due to either TBI or a mental 

disorder. 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 adequate or complete medical evidence. 

	 In three cases, RVSRs incorrectly evaluated TBI-related residuals in 

veterans who were also service-connected for PTSD. In each case, the 

RVSR attributed symptoms to the veteran’s TBI-related residual 

disabilities; however, the medical examiners stated the symptoms were 

due to the veteran’s service-connected PTSD. These ratings did not 

affect the veterans’ overall disability evaluations but may affect future 

evaluations for additional benefits. 

	 In one case, an RVSR evaluated residual TBI-related disabilities using an 

inadequate medical examination. Pertinent medical evidence was 

available in Virtual VA—the Department’s system for electronically 

VA Office of Inspector General 5 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Herbicide 

Exposure-Related 

Claims 

Recommendations 

maintaining veterans’ claims folders. However, the medical examiner 

did not review this evidence because Virtual VA is not available to 

medical examiners. VSC staff should have provided a copy of this 

medical evidence to the medical examiner. Neither VARO staff nor we 

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

adequate or complete medical examination. 

Generally, errors associated with TBI claims processing occurred because 

management did not provide adequate training. Although VSC management 

conducted TBI training in May 2010, a Systematic Analysis of Operations 

(SAO) completed in July 2010 continued to identify a high error rate in 

TBI-related rating decisions and local quality reviews disclosed errors 

similar to those found during our inspection. The most recent TBI training 

occurred in August 2010; however, the training lasted approximately 

10 minutes and did not address what to do in case of inadequate medical 

examinations. Because of this lack of adequate training, veterans did not 

always receive correct benefits. 

VARO staff incorrectly processed 2 (7 percent) of 30 herbicide 

exposure-related claims we reviewed. We did not consider the frequency of 

errors significant; however, one error affected a veteran’s benefit and one 

error had the potential to affect a veteran’s benefit. Following are summaries 

of the inaccuracies identified regarding herbicide exposure-related disability 

claims. 

	 In one case, an RVSR granted a 0 percent disability evaluation for 

prostate cancer due to Agent Orange exposure although the latest medical 

evidence showed active cancer warranting a 100 percent disability 

evaluation. As a result, the veteran was underpaid $16,992 over a period 

of 7 months. 

	 In one case, an RVSR failed to increase a diabetes evaluation from 

10 to 20 percent disabling. Medical evidence showed treatment with 

medication warranting a 20 percent disability evaluation. Because of the 

veteran’s multiple service-connected disabilities, this error does not 

immediately affect this veteran’s benefits; however, failure to assign a 

higher evaluation may affect future evaluations for additional benefits. 

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

determined the VARO generally followed VBA policy related to herbicide 

exposure-related claims. Therefore, we made no recommendations for 

improvement in this area. 

1.	 We recommend the Salt Lake City VA Regional Office Director conduct 

a review of the 55 temporary 100 percent disability claims remaining 

VA Office of Inspector General 6 
Management 

Comments 

Inspection of the VA Regional Office, Salt Lake City, Utah 

from our universe of 85 to determine if reevaluations are required and 

take appropriate action. 

2.	 We recommend the Salt Lake City VA Regional Office Director 

implement controls to ensure staff establish suspense diaries for 

scheduling temporary 100 percent disability reevaluations. 

3.	 We recommend the Salt Lake City VA Regional Office Director develop 

and implement comprehensive training to ensure Rating Veterans Service 

Representatives properly evaluate disabilities related to traumatic brain 

injury claims. 

4.	 We recommend the Salt Lake City VA Regional Office Director conduct 

a review of all pending 810 work items to determine if medical 

reexaminations are required and take appropriate actions. 

5.	 We recommend the Salt Lake City VA Regional Office Director 

implement oversight to ensure staff follow Veterans Benefits 

Administration guidance and the local Workload Management Plan for 

reviewing 810 work items. 

The VARO Director concurred with our recommendations for improving 

disability claims processing accuracy. To address Recommendations 1 and 

2, VSC staff reviewed an additional 55 temporary 100 percent disability 

cases identified by the OIG and determined 30 required reexaminations. The 

Director stated that until May 2010, VSC management incorrectly assumed 

the electronic system automatically established suspense diaries for 

confirmed and continued rating decisions. Given this misunderstanding, 

VARO management proceeded to review all of its temporary 100 percent 

disability evaluation decisions since February 2007 and scheduled immediate 

reexaminations or established suspense diaries as needed. As a result of the 

inaccuracies identified, VSC management provided additional guidance and 

procedures to its claims processing staff for properly establishing suspense 

diaries. 

Similarly, to address Recommendation 3, VARO management requested for 

review all of its recent TBI decisions. To ensure improved processing in the 

future, the VARO provided training in September 2010 and December 2010 

to all RVSRs on the proper procedures for rating TBI claims. Additionally, 

the Director stated Quality Decision Review Officers would conduct a local 

inter-rater reliability study in the current month, review a random sample of 

36 (10 percent) of the 364 TBI cases identified, and conduct a second interrater reliability study in May 2011 to assess effectiveness of the training 

provided. 

Further, in response to Recommendations 4 and 5, the VARO Director 

indicated that VSC management had incorrectly interpreted VBA guidance 

to mean that review and processing of 810 work items were no longer 

VA Office of Inspector General 7 
Inspection of the VA Regional Office, Salt Lake City, Utah 

OIG Response 

Effective Dates 

Notices of 

Disagreement 

necessary. VSC staff reviewed all 810 work items pending at the VARO 

during our inspection and requested reexaminations, as appropriate. To meet 

requirements of the workload management plan, VSC supervisors now 

provide staff with a list of pending 810 work items every Monday and 

Thursday for review and processing. Additionally, VSC management will 

review all pending 810 work items the first day of each month. 

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

follow up as required on all actions. 

2. Data Integrity

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

policy to establish correct effective dates in the electronic record. Generally, 

an effective date indicates when entitlement to a specific benefit arose. 

VARO staff incorrectly established an effective date for 1 (less than 

1 percent) of 120 disability claims we reviewed. 

In the one inaccuracy, the VARO denied the veteran’s claim for service 

connection on August 23, 2001, because the veteran did not have a diagnosis 

of prostate cancer. The veteran reopened the claim on May 22, 2002, and 

provided medical evidence showing a diagnosis of prostate cancer on 

April 15, 2002. The RVSR granted service connection for prostate cancer 

with an incorrect effective of May 22, 2002. Because the veteran submitted 

the medical evidence within 1 year of the denial, VA regulations state the 

effective date is the date of diagnosis. As a result, the veteran was underpaid 

$1,682 over a period of 1 month. 

Because we found only one inaccuracy, we determined the VARO is 

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

made no recommendations for improvement in this area. 

An NOD is a written communication from a claimant expressing 

dissatisfaction or disagreement with a benefit decision and a desire to contest 

the decision. An NOD represents 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. 

VARO staff did not meet this standard for 13 (43 percent) of 30 NODs we 

reviewed. Staff took an average of 24 days to record these 13 disagreements 

in VACOLS. However, as of October 2010, the VARO was achieving 

VBA’s goal by averaging 6 days to control NODs, which was 1 day below 

the 7-day standard. In addition, the VARO’s NODs have been pending 

completion an average of 126 days, 95 days better than the national average 

VA Office of Inspector General 8 
Inspection of the VA Regional Office, Salt Lake City, Utah 

of 221 days. Therefore, we made no recommendations for improvement in 

this area. 

Dates of Claim	 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 using the date of claim to establish the timeframe for benefits entitlement, 

VBA generally uses it 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	 Controls over Recording Dates of Claim Need

Strengthening

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

for 4 (13 percent) of 30 documents reviewed. Details on the four 

inaccuracies follow. 

	 The date of claim could not be verified because VSC staff used a 

hand-held date stamp. VBA policy required VARO management to 

replace all hand-held date stamps located in a VARO, with lockable 

electronic date stamps no later than May 15, 2009. 

	 VSC staff did not select the earliest date to establish a veteran’s claim as 

required, even though the document contained two official date stamp 

entries. 

	 VSC staff established an incorrect date of claim of August 27, 2010, 

based on the use of a hand-held date stamp on the claim. The claim 

document, located in Virtual VA—the Department’s system for 

electronically maintaining veterans’ claims folders, showed the veteran 

requested to file a claim on September 3, 2010. Neither VARO staff nor 

we can ascertain why the hand-held date stamp was earlier than the 

actual receipt of the claim. 

	 The date of claim for a paperless claim could not be verified. The 

original claim document could not be located in either the claims folder 

or Virtual VA. 

Generally, errors occurred because management did not provide adequate 

quality review oversight to ensure staff accurately documented dates of 

claim. Although the VSC Workload Management Plan dated 

January 15, 2010, and updated June 11, 2010, indicates management will 

conduct local quality reviews, a VSC supervisor stated the reviews started 

only 1 month prior to our November 2010 inspection. The supervisor also 

reported staff had been using an unofficial date stamp for any undated mail 

received by the Triage Team. VSC management stated staff had submitted a 

request to obtain an official electronic date stamp for the Triage Team; 

VA Office of Inspector General 9 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Recommendations 

Management 

Comments 

OIG Response 

Systematic 

Technical 

Accuracy 

Review 

however, the date stamp had not been received by the time we completed our 

inspection. 

Incorrect dates recorded in the electronic record affect data integrity and 

misrepresent VARO performance. Data integrity issues make it difficult for 

senior leadership to accurately determine office performance. Further, not 

ensuring the correct date of claim increases the risk of inaccurate benefits 

payments. 

6.	 We recommend the Salt Lake City VA Regional Office Director develop 

and implement a plan for providing adequate quality review oversight to 

ensure staff correctly establish dates of claim. 

The VARO Director concurred with our recommendation. The Director 

stated VSC management provided refresher training to its staff and now 

conducts monthly quality reviews on proper dates of claim. Additionally, 

the VARO Director indicated that date of claim accuracy, as reported by 

STAR, was 100 percent in December 2010, 95.8 percent in January 2011, 

and 100 percent in February 2011. 

The Director provided additional comments regarding our mention of the use 

of a hand-held date stamp. The Director stated the VARO neither uses nor 

possesses a hand-held date stamp and our reference to the existence of one at 

the regional office was inaccurate. 

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

follow up as required on all actions. We are encouraged by the Director’s 

information regarding STAR findings on the accuracy of dates of claim. 

With respect to the Director’s additional comments, our review found two 

pieces of documentation that obviously had been stamped with a hand-held 

date stamp. VBA policy states that “All VBA date stamps, both electronic 

and manual, must contain the regional office name, station number and date 

received (mm/dd/yyyy).” In both of the examples we identified, the date 

stamp did not contain the VARO name and station number, and the date of 

receipt was not in the required format. Although we cannot determine 

whether the VARO or an intake site used the hand-held date stamp, we 

maintain VARO personnel should have stamped the documentation with an 

official date stamp as required when they received the documentation. 

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 10 
Inspection of the VA Regional Office, Salt Lake City, Utah 

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 did not correct 1 (6 percent) of 16 errors identified by VBA’s 

STAR program staff from April through June 2010. Because Salt Lake City 

VARO management generally followed VBA policy regarding correction of 

STAR errors, we made no recommendations for improvement in this area. 

We assessed controls to determine whether VARO management had controls 

in place to ensure complete and timely submission of Systematic Analysis 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. 

All SAOs were complete at the time of our inspection. However the VSC 

completed three of the required SAOs more than 30 days after the assigned 

due dates. The delays had no impact on VSC operations. Because Salt Lake 

City VARO management generally followed VBA policy regarding SAOs, 

we made no recommendations 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 Salt Lake City 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 was following VBA policy. Therefore, we made no 

recommendations 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 

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

with a veteran’s claims folder. VBA policy also allows the use of a storage 

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

able to identify an associated claims folder in the system. We found controls 

VA Office of Inspector General 11 
Inspection of the VA Regional Office, Salt Lake City, Utah 

over Triage Team mail processing search mail and use of the military file 

needs strengthening. 

Finding 4	 Triage Team Mail Management Procedures Need

Strengthening

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

policy. For 8 (27 percent) of 30 pieces of search mail reviewed, staff did not 

properly use COVERS to ensure timely processing and adequate control of 

search mail. This occurred because the workload management plan did not 

include supervisory oversight procedures to ensure periodic review of mail 

remaining in the search bin. As a result, beneficiaries may not receive 

accurate and timely benefit payments. 

VSC Triage Team staff did not manage the Military File according to VBA 

policy. The staff stored mail according to the date it was received at the 

regional office, instead of alphabetically as required by VBA policy. Filing 

by date received made it difficult for staff to quickly retrieve the mail and 

place it with the associated claims folder once the folder was located. 

Further, VSC staff placed Service Treatment records in the Military File, 

instead of sending them to the Records Management Center as required by 

VBA policy. This occurred because the workload management plan did not 

address oversight of the Military File. Additionally, supervisory staff were 

unaware of VBA’s policy requiring documents be filed alphabetically. As a 

result, mail may not be associated with claims and beneficiaries may not 

receive accurate and timely benefit payments. 

Recommendations 7.	 We recommend the Salt Lake City VA Regional Office Director develop 

and implement procedures to ensure management oversight and control 

of Triage Team search mail activity and the Military File. 

Management The VARO Director concurred with our recommendation. The Director 

Comments stated that on November 17, 2010, VSC management conducted training on 

proper procedures for maintaining the Military File. Management oversaw 

reorganization of the Military File to meet VBA policy requirements. The 

Directors stated that VSC management would update the workload 

management plan to require monthly review of the Military File. Further, 

VSC management assigned a staff member to review pending search mail 

weekly, instead of sporadically as prior to our inspection. Additionally, VSC 

supervisors drafted standard operating procedures for managing search mail. 

OIG Response	 Management’s actions are responsive to our recommendation. We will 

follow up as required on all actions. 

VA Office of Inspector General 12 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Appendix A

Organization 

Resources 

Workload 

Scope 

VARO Profile and Scope of Inspection

The Salt Lake City VARO is responsible for delivering non-medical VA 

benefits and services to veterans and their families in Utah. The VARO 

fulfills these responsibilities by administering compensation and pension 

benefits, vocational rehabilitation and employment assistance, and outreach 

activities. 

As of September 2010, the Salt Lake City VARO had a staffing level of 

492 full-time employees. Of these, the VSC had 249.6 employees 

(51 percent) assigned. 

As of the end of FY 2010, the VARO reported 4,092 pending compensation 

claims. The average time to complete claims during FY 2010 was 

156.6 days—6.6 days longer than the national target of 150 days. As 

reported by STAR staff, the accuracy of compensation rating-related issues 

was 81.3 percent—8.7 percent below the 90 percent VBA target. The 

accuracy of compensation authorization-related issues was 

95 percent—1 percent below the 96 percent VBA target. 

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 90 (18 percent) of 502 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 (35 percent) of 85 existing claims from VBA’s Corporate 

Database. The 85 claims represented all instances in which VARO staff 

granted temporary 100 percent disability determinations for at least 

18 months. We provided the VARO with the 55 claims remaining from our 

universe of 85 to assist in implementing our first report recommendation. 

We reviewed 16 errors identified by VBA’s STAR program from April 

through June 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 13 
Inspection of the VA Regional Office, Salt Lake City, Utah 

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

processing involving temporary 100 percent disability determinations. 

For our review, we selected dates of claims and NODs 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. 

VA Office of Inspector General 14 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Appendix B VARO Director’s Comments

Department of Memorandum Veterans Affairs

Date: March 17, 2011 

From: Director, Salt Lake City VA Regional Office (341/00) 

Subj: Inspection of the Salt Lake City VA Regional Office 

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

1.	 Enclosed are the Salt Lake City (SLC) VA Regional Office’s (RO) comments 

and responses to the OIG Draft Report, Inspection of the VA Regional Office, 

Salt Lake City, Utah, received March 9, 2011. Except as otherwise noted below, 

the RO concurs with the findings and recommendations regarding RO activities 

requiring improvement, which include the accuracy of disability claims 

processing, data integrity, and workload management. Attached are our 

comments and responses to the specific recommendations and action items that 

arose as a result of the review. 

2. We appreciate the professionalism and courtesy exhibited by the audit team 

members during their review of our operations, as well as the analysis they 

provided. This analysis and the corresponding recommendations for 

improvement are invaluable in our continued efforts to provide the best possible 

service to our veterans. 

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

regarding our reply. 

MARK M. BILOSZ 

Director 

Attachment 

VA Office of Inspector General 15 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Responses to the Office of Inspector General, Benefits Inspection Division, Draft Report 

– Inspection of the Salt Lake City VA Regional Office 

Recommendation 1: We recommend the Salt Lake City VA Regional Office (RO) Director 

conduct a review of the 55 temporary, 100-percent, disability claims [awards] remaining 

from our universe of 85 to determine if reevaluations are required and take appropriate 

action. 

RO Comments: Concur 

The Salt Lake City RO completed a review of the 55 temporary, 100-percent, disability 

awards remaining from the OIG’s original universe of 85 award actions on January 5, 2011. 

Thirty of the 55 cases required reexamination/reevaluation. The Pre-Determination Team 

has since scheduled all of the review examinations. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 2: We recommend the Salt Lake City VA Regional Office Director 

implement controls to ensure its staff establishes suspense diaries for scheduling temporary 

100-percent disability reevaluations. 

RO Comments: Concur 

Up until May 2010, the Post-Determination management team was operating under the 

mistaken assumption that VETSNET pulls future examination dates from RBA 2000 and 

automatically establishes a diary to control for scheduling of the review examination, 

regardless of whether or not the VSR promulgating the rating decision takes award action in 

VETSNET. The result was that no future diaries for review examinations were being 

established on rating decisions that only confirmed and continued the current disability 

evaluation(s) (i.e., when no award action in VETSNET was necessary). 

Once RO management discovered the oversight described above, it submitted a data request 

to the Office of Performance Analysis & Integrity (OPA&I) in an attempt to identify the 

claim numbers for all rating decisions promulgated since February 2007, which contained a 

future examination date, but for which there was no corresponding future diary in the 

corporate record. On January 31, 2011, OPA&I provided the results of the data request to 

the Salt Lake City Regional Office. The Post-Determination Team reviewed each of the 

rating decisions in question and established future diaries, as necessary, or forwarded the 

claim folder to the Pre-Determination Team for scheduling an at-once review examination. 

The RO completed action on these claim folders by the end of February 2011. 

In order to ensure that diaries are consistently established in the corporate record for future 

examination dates identified in rating decisions, the Post-Determination management team 

has taken the following action: The Post-Determination management team met with Veterans 

Service Representatives (VSRs) and Senior VSRs (authorizers) in November 2010 to 

reemphasize the importance of checking the corporate record after promulgating a rating 

VA Office of Inspector General 16 
Inspection of the VA Regional Office, Salt Lake City, Utah 

decision, and confirm establishment of a future diary, whenever the need for a review 

examination is indicated in the rating decision. 

The following procedures were specified for paper rating decisions: 1) If the rating decision 

requires award action in VETSNET, VSRs will confirm establishment of a future diary in the 

corporate record. Regardless of whether establishment is confirmed or manual establishment 

of the diary is required, VSRs will annotate the corresponding award print to document their 

actions; 2) If no award action is required (i.e., the rating decision confirms and continues the 

current disability evaluation(s), VSRs will manually establish a future diary for a review 

examination and annotate the award/notification letter to document they took this action; 

3) Senior VSRs will, similarly, confirm establishment of a future diary in the corporate 

record before authorizing/approving the actions VSRs take and annotate either the award 

print or award/notification letter to document their review. For paperless rating decisions, 

the process for confirming the establishment of future diaries for review examinations is the 

same as described above for both VSRs and Senior VSRs. However, because no hard-copy 

award print or award/notification letter exists, VSRs and Senior VSRs must document their 

actions by inserting a “public annotation” into the veteran’s electronic folder. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 3: We recommend the Salt Lake City VA Regional Office Director 

develop and implement comprehensive training to ensure Rating Veterans Service 

Representatives properly evaluate disabilities related to traumatic brain injury (TBI) claims. 

RO Comments: Concur 

The RO submitted a data request to OPA&I to identify recently rated claims involving TBI. 

The purpose for identifying these cases was to review the corresponding rating decisions to 

ensure they were in compliance with national guidance on the handling of these claims. The 

RO received the report from OPA&I, which contained a total of 364 claim numbers, on 

March 15, 2011. 

The RO provided training to all its RVSRs on the proper method for rating claims involving 

TBI in September 2010 and again (following the OIG visit) in December 2010. The RO also 

took the opportunity to provide one-on-one training with those RVSRs who prepared the 

rating decisions OIG identified as erroneous during the course of its inspection. 

The RO will take the following actions to ensure its RVSRs are implementing the rating 

principles they learned through training: 1) Quality Decision Review Officers (QDROs) will 

conduct a local inter-rater reliability (IRR) study, using a rating scenario involving TBI, 

before the end of the current month; 2) The QDROs will review a random sample of 

36 rating decisions (approximately 10%) from the list of 364 claim numbers OPA&I 

provided in its report. Based on the results of this review and the IRR study referenced 

above, the Veterans Service Center (VSC) will provide additional training to all RVSRs in 

April 2011; 3) The QDROs will conduct a second IRR study, using a rating scenario 

involving TBI, in May 2011. The RO will randomly select 30 RVSRs (approximately 

30 percent of all RVSRs) to participate in the study, the purpose of which is to validate the 

effectiveness of the training provided to that point in time. If the results of the second IRR 

VA Office of Inspector General 17 
Inspection of the VA Regional Office, Salt Lake City, Utah 

study show the average quality of rating decisions involving TBI is at or above the current 

national average for rating quality, the RO will discontinue further training on this topic 

(other than routine refresher training). If the results of the second IRR study show the 

average quality of rating decisions involving TBI remain substandard, the RO will draft a 

supplemental training plan by May 31, 2011, and continue training on the topic until the 

average quality of rating decisions involving TBI reaches an acceptable level. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 4: We recommend the Salt Lake City VA Regional Office Director 

conduct a review of all pending 810 work items to determine if medical reexaminations are 

required and take appropriate actions. 

RO Comments: Concur 

Pre-Determination Team management misinterpreted Fast Letter 10-14, Procedural Change 

Regarding Routine Future Examinations, by inferring that the review/processing of end 

product (EP 810) work items was no longer necessary. 

The RO completed its review of the EP 810 work items, which were pending at the time of 

the OIG visit, in December 2010, and ordered review examinations, as appropriate. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 5: We recommend the Salt Lake City VA Regional Office Director 

implement oversight to ensure staff follow Veterans Benefits Administration guidance and 

the local Workload Management Plan for reviewing 810 work items. 

RO Comments: Concur 

The oldest 810 work items currently pending are only three days old. The Pre-Determination 

management team currently runs a VOR report of pending work items twice each week 

(Mondays and Thursdays, as per the workload management plan) and assigns them to VSRs 

for review and processing. 

The RO believes the Pre-Determination team now has the 810 work items under control. 

However, to ensure the team continues to effectively manage this element of its operations, 

the Assistant Veterans Service Center Manager (AVSCM) overseeing the Pre-Determination 

team will run a VOR report of pending 810 work items on the first workday of each month. 

Once the AVSCM has run the report for three consecutive months without finding any work 

items that are out of control, the AVSCM will continue to monitor the volume of pending 

work items but on a less-frequent basis. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 6: We recommend the Salt Lake City VA Regional Office Director 

develop and implement a plan to ensure adequate quality review oversight to ensure staff 

correctly establish dates of claim. 

VA Office of Inspector General 18 
Inspection of the VA Regional Office, Salt Lake City, Utah 

RO Comments: Concur 

The Salt Lake City RO concurs with the OIG recommendation. The RO would like to point 

out that on pages eight and nine of the OIG draft report, reference is made to a hand-held 

stamp that the VSC staff uses. The RO does not possess a hand-held stamp, nor does it use 

one. The RO destroyed all hand-held stamps in May 2009, per the instructions in VBA 

Letter 20-09-10, VBA Policy to Maintain Accountability of Official Date Stamps. 

The OIG’s findings with regard to the existence of a hand-held date stamp are inaccurate. 

Regional Office management felt it was important to point out this inaccuracy to avoid future 

questions regarding the VARO's compliance with VBA Letter 20-09-10. VBA Letter 

20-09-10 allows intake sites to possess and use hand-held date stamps. The SLC VARO is a 

rating activity site, not an intake site. Reference was made to "intake sites" in the VARO's 

response for the sole purpose of attempting to explain how the OIG might have inferred from 

a conversation with Triage Team management that the Triage Team used a hand-held date 

stamp. 

For convenience, and because VBA Letter 20-09-10 prohibits the use of hand-held date 

stamps, the VSC requested placement of a third electronic date stamp in the Triage Team's 

work space, which is noted in the OIG’s report. 

The Triage management team held a meeting with its team members on November 17, 2010, 

to provide refresher training on identifying proper dates of claim. As part of this training, the 

team reviewed each of the date-of-claim discrepancies the OIG identified during its site visit. 

Moreover, the Triage management team continues to conduct monthly quality reviews of the 

actions its employees take, to include claims establishment and the selection of proper dates 

of claim. 

Date-of-claim accuracy, based on national Systematic Technical Accuracy Review (STAR), 

was 100 percent for two of the last three months since the OIG’s visit. (Accuracy was 

100 percent for December 2010 and February 2011, and 95.8 percent for January 2011.) 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 7: We recommend the Salt Lake City VA Regional Office Director 

develop and implement procedures to ensure management oversight and control of Triage 

Team search mail activity and Military File. 

RO Comments: Concur 

Triage management team held a meeting with its team members on November 17, 2010, 

during which it reviewed the proper procedures for maintenance of the Military File as set 

forth in M21-1MR, III.ii.4.H.25. Shortly thereafter, the management team oversaw 

reorganization of the Military File, to include placement of documents in alphabetical order 

and removal of those documents that were erroneously stored in the Military File. On March 

1, 2011, the Triage management team reviewed the Military File to ensure employees are 

maintaining it properly. In addition, the Veterans Service Center will add monthly reviews 

of the Military File to its workload management plan to ensure the file remains in proper 

order. The Triage management team will be responsible for conducting the review. 

VA Office of Inspector General 19 
Inspection of the VA Regional Office, Salt Lake City, Utah 

In regard to search mail, the Files Activity had been reviewing its search mail on a somewhat 

sporadic basis prior to the OIG visit. The Triage management team has since assigned one 

file clerk the specific responsibility of reviewing pending search mail on a weekly – if not 

daily – basis. The Files Activity supervisor additionally drafted standard operating 

procedures (SOP) for handling and managing search mail. Once the SOP is finalized, it will 

be distributed to Files Activity personnel. 

The Veterans Benefits Administration recommends closure of this recommendation. 

VA Office of Inspector General 20 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Appendix C Inspection Summary
 

9 Operational

Activities Inspected Criteria

Reasonable 

Assurance of 

Compliance 

Yes No 

Disability Claims Processing 

1. 100 Percent 

Disability 

Evaluations 

Determine whether VARO staff properly reviewed temporary 100 

percent disability evaluations. (38 Code of Federal Regulation 

(CFR) 3.103(b)) (38 CFR 3.105(e)) (38 CFR 3.327) (Manual (M)21­

1Manual 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 service connection for all residual disabilities 

related to in-service TBI were properly processed. (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 herbicide exposure-related disabilities 

(Agent Orange). (38 CFR 3.309) (FL 02-33) (M21-1MR, Part IV, 

Subpart ii, Chapter 2, Section C.10) 

X 

Data Integrity 

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

claim in the electronic records. (M21-1MR, Part III, Subpart ii, 

Chapter 1, Section C) X 

6. Notice 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 

analysis 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 

VA Office of Inspector General 21 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Appendix D OIG Contact and Staff Acknowledgments
 

OIG Contact	 Dawn Provost 

Acknowledgments	 Dana Sullivan 

Bridget Bertino 

Brett Byrd 

Madeline Cantu 

Lee Giesbrecht 

Brian Jeanseau 

David Pina 

Brandi Traylor 

VA Office of Inspector General 22 
Inspection of the VA Regional Office, Salt Lake City, Utah 

Appendix E Report Distribution
 

VA Distribution

Office of the Secretary 

Veterans Benefits Administration 

Assistant Secretaries 

Office of General Counsel 

VBA Western Area Director 

VARO Salt Lake City 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: Orrin Hatch, Mike Lee 

U.S. House of Representatives: Rob Bishop, Jim Matheson, Jason Chaffetz 

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 after it is issued. 

VA Office of Inspector General 23