Inspection of the
 

VA Regional Office
 

Houston, Texas
 

OFFICE OF AUDITS AND EVALUATIONS

March 21, 2011
 

10-03770-125
 
i

ACRONYMS AND ABBREVIATIONS
 

COVERS Control of Veterans Records System

NOD Notice of Disagreement

OIG Office of Inspector General

PTI Permanent Transfer In

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, Houston, Texas 

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 (VSC) operations. 

What We Found 

Houston VARO management ensured staff 

generally followed Veterans Benefits 

Administration (VBA) policy to correctly 

establish dates of claims in the electronic 

record and process incoming mail. VARO 

management lacked effective controls and 

accuracy in processing temporary 

100 percent disability evaluations, and 

post-traumatic stress disorder, traumatic 

brain injury, and herbicide exposure-related 

claims. Overall, VARO staff did not 

accurately process 68 (57 percent) of the 

120 disability claims reviewed. 

The VARO also was not timely in recording 

Notices of Disagreement for appealed 

claims, correcting errors identified by 

VBA’s Systematic Technical Accuracy 

Review program, and completing 

Systematic Analyses of Operations. 

Processing competency determinations, 

managing mail in the Triage Team, and 

safeguarding personally identifiable 

information also were not fully effective. 

What We Recommended 

We recommended that Houston VARO 

management review all remaining temporary 

100 percent disability evaluations identified 

during our inspection to determine if 

reevaluations are required and take 

appropriate actions. Management needs to 

implement controls to ensure VSC staff 

establish suspense diaries for temporary 

100 percent disability reevaluations. We 

recommended management implement 

controls to improve accuracy and quality 

review of post-traumatic stress disorder 

claims. Further, management needs to 

provide refresher training and improve 

quality review of traumatic brain injury and 

herbicide exposure-related disability claims. 

We recommended VARO management 

strengthen controls to ensure timely 

establishment of Notices of Disagreement in 

the Veterans Appeals Control and Locator 

System and timely completion of Systematic 

Analyses of Operations. Management also 

needs to implement plans to ensure 

oversight of mail handling, accurate 

processing of final competency 

determinations, and safeguarding of 

personally identifiable information. 

Agency Comments 

The Director of the Houston 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 

ii 
TABLE OF CONTENTS
 

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

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

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

2. Data Integrity ..........................................................................................................................8

3. Management Controls...........................................................................................................10

4. Workload Management.........................................................................................................12

5. Eligibility Determinations.....................................................................................................15

6. Safeguarding of Personally Identifiable Information............................................................16

Appendix A VARO Profile and Scope of Inspection............................................................18

Appendix B VARO Director’s Comments............................................................................21

Appendix C Inspection Summary..........................................................................................25

Appendix D OIG Contact and Staff Acknowledgments........................................................26

Appendix E Report Distribution ...........................................................................................27

iii
 
Inspection of the VA Regional Office, Houston, Texas 

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 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 October 2010, the OIG conducted an inspection of the Houston 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 90 (9 percent) of 971 disability claims related to post-traumatic

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

that the VARO completed from April through June 2010. In addition, we

reviewed 30 (4 percent) of 765 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 the inspection.

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

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

activity and a summary of our inspection results.

VA Office of Inspector General 1 
0 0 0

0

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Inspection of the VA Regional Office, Houston, Texas 

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 Houston VARO needs to improve the accuracy of disability claims

processing. VARO staff incorrectly processed 68 (57 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 Houston 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 27 10 17

PTSD 30 7 2 5

TBI 30 22 3 19

Herbicide 

Exposure-Related 

Disabilities 

30 12 3 9

Total 120 68 18 50 

Temporary 

100 Percent 

Disability 

Evaluations 

VARO staff incorrectly processed 27 (90 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

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

determine whether to continue the veteran’s 100 percent disability

evaluation.

VA Office of Inspector General 2 
Inspection of the VA Regional Office, Houston, Texas 

Based on analysis of available medical evidence, 10 of the 27 processing

inaccuracies affected veterans’ benefits—all 10 involved overpayments

totaling $730,768. Two examples of the most significant overpayments

follow.

	 VARO staff did not request a future medical examination to evaluate a

veteran’s acute lymphocytic leukemia. Medical evidence in the claims

folder warranted a reduction in benefits as of September 1, 1998. As a

result, VA overpaid the veteran $355,476 over a period of 11 years and

8 months.

	 VARO staff did not request a future medical examination to evaluate a

veteran’s prostate cancer. Medical evidence in the claims folder

warranted a reduction in benefits as of November 1, 2005. As a result,

the veteran was overpaid $133,128 over a period of 4 years and

6 months.

The remaining 17 inaccuracies had the potential to affect veterans’ benefits.

Following are summaries of these inaccuracies.

	 In 12 cases, VSC staff did not schedule the follow-up medical

examinations needed to determine whether the temporary 100 percent

disability evaluations should continue.

	 In two cases, the Rating Veterans Service Representatives (RVSRs)

continued the 100 percent disability evaluation without requiring future

examinations. In making these decisions, the RVSRs did not consider

entitlement to the additional benefit of Dependents’ Educational

Assistance as required by VBA policy.

	 In two cases, an RVSR continued the temporary 100 percent disability

evaluations and annotated the need for follow-up medical examinations.

However, VSC staff did not establish controls for scheduling the future

medical examinations.

	 In one case, an RVSR proposed reducing the veteran’s temporary

100 percent disability evaluation. However, the medical examination

results showed a diagnosis of active prostate cancer and that the

evaluation should not be reduced. No action had been taken at the time

of our inspection. The RVSR should have continued the 100 percent

disability evaluation and requested a follow-up medical examination.

We could not determine if 12 of the 17 temporary 100 percent disability

evaluations would have continued because the veterans’ claims folders did

not contain medical evidence needed to reevaluate each case. An average of

approximately 3 years and 6 months elapsed from the time staff should have

scheduled these medical examinations until the date of our inspection—the

date staff ultimately ordered the examinations to obtain the necessary

VA Office of Inspector General 3 
PTSD Claims 

Inspection of the VA Regional Office, Houston, Texas 

medical evidence. The delays ranged from approximately 2 months to

12 years and 7 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

electronic system. A suspense 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 to alert

VSC staff to schedule the reexamination.

Twenty-four of the 27 errors resulted from staff not establishing suspense

diaries when processing rating decisions requiring temporary 100 percent

disability reevaluations. Twelve of these errors involved confirmed and

continued rating decisions. VSC management stated, and we verified, that

the office had no procedure in place requiring senior staff members to review

implementation of confirmed and continued rating decisions. As such,

oversight did not occur to ensure staff properly established suspense diaries

for reevaluating these decisions.

VARO staff incorrectly processed 7 (23 percent) of 30 PTSD claims we

reviewed. Two of these errors affected veterans’ benefits resulting in an

overpayment totaling $22,087 and an underpayment of $640.

	 An RVSR incorrectly increased a veteran’s 30 percent service-connected

PTSD evaluation to 100 percent based only on a VA medical

examination. However, treatment reports from the Houston VA Medical

Center showed entitlement for no more than a 50 percent disability

evaluation. The RVSR is required to review all available medical

evidence before rendering a decision. As a result, VA overpaid the

veteran over a period of 1 year and 1 month.

	 An RVSR granted service connection for PTSD with an evaluation of

70 percent disability. However, the RVSR did not address entitlement to

an additional special monthly compensation as required by VBA policy.

As a result, VA underpaid the veteran over a period of 2 months.

Following are details on the remaining five PTSD inaccuracies that had the

potential to affect veterans’ benefits.

	 In three cases, RVSRs did not grant service connection for associated

disorders diagnosed through VA examinations. Granting service

connection for additional disorders would not change the overall assigned

evaluations, but may affect future evaluations for additional benefits.

	 In one case, an RVSR continued the evaluation of a veteran’s

service-connected PTSD. However, the VA medical examiner also

VA Office of Inspector General 4 
TBI Claims 

Inspection of the VA Regional Office, Houston, Texas 

diagnosed major depressive disorder without discussing the relationship

between the newly diagnosed condition and the PTSD, and the extent of

impairment as required by VBA policy. Neither VARO staff nor we can

ascertain the relationship or the extent of impairment without adequate or

complete medical evidence.

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

based on medical evidence that did not satisfy requirements outlined by

VBA policy. Neither VARO staff nor we can establish service

connection for PTSD without adequate or complete medical evidence.

Generally, errors associated with PTSD claims processing resulted from

ineffective quality assurance. Interviews with VARO staff revealed the

office provided training on PTSD regulations and policies. Staff told us they

understood the regulations and policies. However, our inspection revealed

that RVSRs made decisions on seven PTSD claims without following the

regulations and policies. RVSRs incorrectly established or evaluated PTSD,

or incorrectly established or denied service connection for conditions

associated with PTSD. A local quality review conducted by the VSC on one

of the seven inaccuracies had not identified any errors, despite what we

found during our inspection. As a result, veterans did not always receive

correct healthcare entitlements or benefit payments.

The Department of Defense and VBA commonly define a TBI as

traumatically induced structural injury or physiological disruption of brain

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

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

policy requires staff to evaluate these residual disabilities.

VARO staff incorrectly processed 22 (73 percent) of 30 TBI claims. Three

of the 22 processing inaccuracies affected veterans’ benefits—one involved

an overpayment of $10,344 and two involved underpayments totaling

$11,649. Details on the overpayment and most significant underpayment

follow.

	 An RVSR incorrectly evaluated a residual TBI-related disability as

30 percent disabling. A VA medical examination showed this residual

TBI-related disability warranted no more than a 10 percent evaluation.

As a result, the veteran was overpaid $10,344 over a period of 2 years.

	 An RVSR incorrectly continued an evaluation for residuals of TBI at

10 percent disabling based on a VA medical examination. However, the

examination results showed entitlement to a 40 percent disability

evaluation. As a result, the veteran was underpaid $9,723 over a period

of 1 year and 9 months.

VA Office of Inspector General 5 
Inspection of the VA Regional Office, Houston, Texas 

Herbicide 

Exposure-Related 

Claims 

Following are details on the remaining 19 TBI inaccuracies that had the

potential to affect veterans’ benefits. These ratings did not affect the

veterans’ current disability evaluations, but may affect future evaluations for

additional benefits if these inaccuracies remain unaddressed.

	 In six cases, RVSRs incorrectly assigned separate evaluations for

headaches as residuals of TBI based on the medical evidence. However,

medical evidence showed no diagnoses of migraine headaches or

Meniere’s disease to support entitlement to the separate evaluations for

headaches.

	 In five cases, RVSRs incorrectly evaluated residual TBI-related

disabilities shown on VA medical examination reports.

	 In five cases, RVSRs incorrectly evaluated residual TBI-related

disabilities based on the results of inadequate VA medical examinations.

	 In one case, medical evidence showed a diagnosis of traumatic brain

injury. An RVSR correctly granted service connection for post-traumatic

migraine headaches. The RVSR also did not establish service connection

for residuals of TBI as required.

	 In one case, an RVSR prematurely granted service connection for

residuals of TBI based on an inadequate VA medical examination. The

veteran was previously service-connected for PTSD, and the VA

examination did not separate symptoms associated with PTSD from

those for TBI.

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

residual TBI-related disability without adequate evidence of an in-service

event. The service treatment records did not show complaints of,

medical diagnosis of, or treatment for a TBI.

Generally, errors associated with TBI claims processing occurred because

VSC staff incorrectly interpreted VBA policy. This resulted in the VSC staff

inadequately training RVSRs in rating TBI cases. Given such training, the

RVSRs did not properly evaluate residuals of TBI based on the results of VA

examinations and incorrectly addressed TBI-related residuals in making

rating decisions. As a result, veterans did not always receive correct benefits

payments.

VARO staff incorrectly processed 12 (40 percent) of 30 herbicide

exposure-related claims reviewed. Three of the 12 processing inaccuracies

affected veterans’ benefits—two involved overpayments totaling $4,008 and

one involved an underpayment of $1,632. Details on the most significant

overpayment and the underpayment follow.

VA Office of Inspector General 6 
Inspection of the VA Regional Office, Houston, Texas 

	 An RVSR incorrectly evaluated residuals of non-Hodgkin’s lymphoma

following cessation of treatment as 30 percent disabling. Medical

evidence reported non-Hodgkin’s lymphoma in full remission with no

residuals. This condition warrants a 0 percent evaluation, entitling the

veteran to healthcare for the condition, but not monetary compensation.

As a result, VA overpaid the veteran $2,230 over a period of 5 months.

	 An RVSR did not grant service connection and entitlement to an

additional special monthly compensation for a diabetes-related disability.

As a result, VA underpaid the veteran $1,632 over a period of 1 year and

5 months.

Following are details on the nine herbicide exposure-related inaccuracies that

had the potential to affect veterans’ benefits.

	 In five cases, RVSRs incorrectly granted service connection for

conditions as complications of the veterans diabetes, although medical

evidence showed conditions diagnosed prior to and subsequently

worsened by diabetes. To properly rate conditions worsened by diabetes,

the RVSRs needed to request additional medical evidence to justify

granting benefits.

	 In two cases, RVSRs did not address in the rating decision service

connection for conditions worsened by the service-connected diabetes as

required.

	 In one case, an RVSR incorrectly denied service connection for a

condition worsened by the service-connected diabetes.

	 In one case, an RVSR did not grant service connection for a

diabetes-related complication diagnosed in a VA medical examination as

required. This rating did not affect the veteran’s monthly benefits, but

may affect future evaluations for additional benefits.

In eight of the nine inaccuracies summarized above, VSC staff did not

properly request additional medical evidence from the veterans. VBA policy

requires medical evidence showing the level of severity before the condition

worsened and the current level of severity. VSC staff needs this medical

evidence to determine a baseline level of severity prior to granting or

denying a disability.

Generally, errors associated with herbicide exposure-related claims

processing resulted from ineffective quality assurance and improper training.

A VSC quality review conducted on 1 of the 12 inaccuracies did not identify

any error. VSC staff provided training to RVSRs in July 2010. However,

the training did not discuss VBA policy requirements that VSC personnel

must take prior to addressing medical conditions worsened by a

VA Office of Inspector General 7 
Inspection of the VA Regional Office, Houston, Texas 

Recommendations 

Management 

Comments 

OIG Response 

Effective Dates 

service-connected disability. As a result, RVSRs made inaccurate decisions

on herbicide exposure-related claims and veterans did not always receive

correct benefits payments.

1.	 We recommend the Houston VA Regional Office Director review the 

remaining universe of 735 temporary 100 percent disability evaluations 

to determine if reevaluations are required and take appropriate action. 

2.	 We recommend the Houston VA Regional Office Director conduct 

refresher training and implement controls to ensure staff establish 

suspense diaries for temporary 100 percent disability reevaluations. 

3.	 We recommend the Houston VA Regional Office Director develop and 

implement a plan to improve processing accuracy and quality review of 

post-traumatic stress disorder claims. 

4.	 We recommend the Houston VA Regional Office Director conduct 

refresher training and develop and implement a plan to improve the 

quality review process for traumatic brain injury and herbicide 

exposure-related claims. 

The VARO Director concurred with our recommendations. VSC staff

reviewed 356 of the additional 735 temporary 100 disability evaluations

identified by OIG. The Director estimated VSC staff will complete the

reviews by September 30, 2011. The Director reported VSC staff received

training on the proper procedures for establishing suspense diaries for

medical reexaminations shortly after our visit in October 2010 and again in

November 2010 and early March 2011.

Further, the VARO Director stated RVSRs and Decision Review Officers

received training on TBI-related claims in November 2010. The VSC has

scheduled training on PTSD and herbicide exposure-related claims for April

2011. Additionally, the VSC is developing a plan to improve the quality

review process for PTSD, TBI, and herbicide exposure-related claims; the

VSC expects to implement the plan by May 2011.

Management 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 was following VBA

policy to establish correct effective dates in electronic records. Generally, an

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

determined VARO staff incorrectly established an effective date for

4 (3 percent) of 120 disability claims we reviewed. All four errors affected

veterans’ benefits—three involved underpayments totaling $19,211 and one

VA Office of Inspector General 8 
Inspection of the VA Regional Office, Houston, Texas 

Dates of Claim 

Notices of 

Disagreement 

involved an overpayment of $6,588. Details on the most significant

underpayment and the overpayment follow.

	 An RVSR incorrectly granted service connection for an herbicide

exposure-related condition effective December 2, 2009. The actual date

of claim for the herbicide exposure-related condition was June 27, 2009,

and medical evidence showed the condition existed on that date. VA

regulations state the effective date of benefits is the claim receipt date or

the date evidence revealed the disability existed, whichever is later. As a

result, the veteran was underpaid $14,412 over a period of 6 months.

	 An RVSR incorrectly established an effective date of January 23, 2008,

for an herbicide exposure-related condition. The VARO did not receive

the veteran’s claim until a year later on January 23, 2009. According to

VA regulations, when a claimant submits a claim more than 1 year after a

legislative change, VA may authorize benefits for a period of 1 year prior

to the date of receipt of claim, if eligible. In this case, eligibility did not

exist to pay the veteran one year prior to submission of his claim because

medical evidence did not show the veteran had the medical condition

when the law changed. As a result, VA overpaid the veteran

approximately $6,588 over a period of 1 year.

Because we found only 4 inaccuracies out of a total of 120 claims, we

determined the VARO is generally following VBA policy regarding effective

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

area.

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

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

establishing the time frame 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.

We reviewed 30 claims folders to determine if the VARO is following VBA

policy regarding correct establishment of dates of claim in the electronic

record. We found only one inaccuracy; therefore, we determined the VARO

is generally following VBA policy regarding dates of claim and we made no

recommendations for improvement in this area.

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

policy to timely record Notices of Disagreement (NODs) in the Veterans

Appeals Control and Locator System (VACOLS). An NOD is a written

communication from a claimant expressing dissatisfaction or disagreement

with a benefits decision and a desire to contest the decision. An NOD is the

first step in the appeals process. VACOLS is a computer application that

VA Office of Inspector General 9 
Inspection of the VA Regional Office, Houston, Texas 

Finding 2

Recommendation 

Management 

Comments 

OIG Response 

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 need to strengthen controls over recording NODs

in VACOLS.

Controls over Recording Notices of Disagreement Need

Strengthening

The VARO’s Appeals Team did not consistently record NODs in VACOLS

within VBA’s 7-day standard. VARO staff exceeded the standard for

21 (70 percent) of the 30 NODs we reviewed. It took staff an average of

14 days to record these 21 NODs in VACOLS. The most untimely action

occurred when staff did not create a record for 36 days. Although the

Appeals Team was aware of the 7-day standard, delays occurred because the

Houston VARO workload management plan and local procedures did not

incorporate provisions to ensure prompt control of NODs in VACOLS.

VARO staff’s untimely recording of NODs in VACOLS affects data

integrity and misrepresents VARO performance.

As of October 2010, the VARO averaged 13 days to establish NODs,

exceeding the VBA goal by 6 days. The VARO’s NODs have been pending

completion an average of 324 days, 103 days over the national average of

221 days.

Data integrity issues make it difficult for VARO and senior VBA leadership

to accurately measure and monitor VARO performance. Further, VBA’s

National Call Centers rely upon VACOLS information to provide accurate

customer service to veterans. Unnecessary delays in controlling NODs affect

national performance measures for NOD inventory and timeliness.

5.	 We recommend the Houston VA Regional Office Director develop and 

implement a plan to ensure staff record Notices of Disagreement in the 

Veterans Appeals Control and Locator System within 7 days as required 

by Veterans Benefits Administration policy. 

The VARO Director concurred with our recommendation. The Director

reported the Appeals Team revised its procedures for controlling NODs,

including those received from the VARO’s offsite office.

Management actions are responsive to the recommendation. We will follow

up as required on all actions.

VA Office of Inspector General 10 
Inspection of the VA Regional Office, Houston, Texas 

Systematic 

Technical 

Accuracy 

Review 

Systematic 

Analysis of 

Operations 

Finding 3

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 multifaceted quality assurance program to ensure that veterans and

other beneficiaries receive accurate and consistent compensation and pension

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

errors that STAR identifies.

VARO staff did not correct 4 (11 percent) of 36 errors identified by VBA’s

STAR program from April through June 2010. VARO management reported

to STAR staff that corrective actions on two STAR errors were completed.

However, review of the claims folders showed no evidence of the

corrections. In addition, the VARO staff did not take action to correct the

other two STAR errors. These errors had no impact on claimants’ benefits.

VARO management did not provide adequate oversight for correction of

STAR errors. By not fully completing and reporting their STAR error

corrections, VARO management cannot provide assurance that they are

fulfilling VBA’s National Quality Assurance Program. While we were on

on-site and based on the preliminary results of our inspection, VSC

management amended its STAR Quarterly Error Report response procedures

and now requires VSC supervisors to review claims folders and ensure

correction of STAR errors. Because such actions provide oversight needed

to address STAR errors, we make no recommendation in this area.

We assessed controls to determine if VARO management completed timely

Systematic Analyses of Operations (SAOs) that addressed necessary

elements and operational functions of the VSC. An SAO is a formal analysis

of a VSC organizational element or operational function. SAOs provide an

organized means of reviewing VSC operations to identify existing or

potential problems and propose corrective actions. VARO management

must publish an annual SAO schedule designating the staff required to

complete the SAOs by specific dates.

Improved Oversight is Needed to Ensure Timely

Completion of SAOs

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

including completion of 12 annual SAOs. Two (17 percent) of the 12 SAOs

were incomplete at the time of our inspection. This occurred because VARO

management did not provide adequate oversight to ensure VSC staff

completed SAOs in accordance with VBA policy.

VA Office of Inspector General 11 
Inspection of the VA Regional Office, Houston, Texas 

Recommendation 

Management 

Comments 

OIG Response 

Mailroom 

Operations 

The two SAOs identified problems within the VSC. However, one SAO did

not provide processing improvement solutions because Central Area Office

staff were monitoring the problem and, in VSC management’s opinion, the

system in place was sufficient. The second SAO did not contain sufficient

depth of analysis to explain the problems clearly. The prior VSC Manager

had reviewed the SAO and current VSC leadership could not explain why

the depth of analysis was insufficient.

The VARO did not follow VBA policy for completion of SAOs. For

example, in the Quality of Compensation, Pension, and Ancillary Actions

SAO, VSC management indicated current controls were adequate. However,

the SAO reported monthly internal quality review findings were trending

upward, noting improvement, while STAR findings were trending

downward. VSC management did not take adequate steps to address the

discrepancies identified in the quality review trends, including developing

and implementing a plan to improve quality. Additionally, the Quality and

Training Team did not identify three claims processing errors we

subsequently found during our inspection.

6.	 We recommend the Houston VA Regional Office Director develop and 

implement a plan to ensure staff complete Systematic Analyses of 

Operations timely and address all required elements. 

The VARO Director concurred with our recommendation. The Director

stated that the VARO has implemented a plan to ensure VSC staff submit

SAOs in accordance with established schedules. Additionally, the Director

stated SAOs completed in January 2011 and March 2011 addressed concerns

we raised during our inspection.

Management actions are responsive to the recommendation. We will follow

up as required on all actions.

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 Houston VARO assigns responsibility for

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

Services Division. Mailroom staff timely and accurately processed, date

stamped, and delivered 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 recommendations for improvement in

this area.

VA Office of Inspector General 12 
Inspection of the VA Regional Office, Houston, Texas 

Triage Mail 

Processing 

Procedures 

Finding 4
 

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. If claims folders are located in the file storage

area, staff should not place related mail on search.

VBA policy defines drop mail as mail received where no processing action is

necessary and the VARO does not need the associated claims folder. VARO

staff can initiate processing of priority drop mail without the related claims

folder, but must ultimately associate the mail with the related folder for

further processing. The folder for this type of mail is located in the local file

storage area.

VBA policy defines permanent transfer in (PTI) mail as that received in

Triage for which the related claims folder is located in other regional offices

or Federal records storage centers. The Triage Team requests the claims

folder and stores this type of mail in a holding area until the folder arrives.

Once Triage Team staff receive the claims folder, they should remove the

mail from the PTI holding area and associate it with the claims folder.

Controls over Triage Team mail processing need strengthening.

Triage Team Mail Management Procedures Need

Strengthening

Triage Team members did not consistently manage search mail according to

VBA policy. For 15 (50 percent) of 30 pieces of search mail, VSC staff

placed mail on search although the related files were located in the file

storage area, did not control the mail through a corresponding search in

COVERS, or did not retrieve the mail and clear each search in COVERS

once the mail was located. The most significant error occurred when an

employee acknowledged receipt of a claims folder in COVERS on

October 1, 2010. COVERS includes a feature to alert employees when

search mail associated with a claim is available for pick-up. However, in this

case the VSC employee did not retrieve mail associated with this folder that

had been on search since June 22, 2010.

Triage Team members did not consistently manage drop mail, including

priority drop mail, according to VBA policy. Four (13 percent) of 30 pieces

of drop mail reviewed were incorrectly placed into drop mail or priority drop

mail holding areas. The most egregious error occurred when an employee

placed a piece of mail requiring processing action into the drop mail holding

area instead of associating it with the claims folder. Neither VSC staff nor

VA Office of Inspector General 13 
Recommendation 

Inspection of the VA Regional Office, Houston, Texas 

we can determine when an employee placed this piece of mail in the drop

mail holding area.

Further, Triage Team members did not consistently manage PTI mail

according to VBA policy. Nine (30 percent) of 30 pieces of PTI mail had

related claims folders located at the Houston VARO. However, VSC staff

did not associate this mail with the claims folders. The two most substantial

errors identified during our October 2010 inspection involved mail found in

the PTI holding area although VARO staff had received the related files on

August 9, 2010.

The above errors occurred because of a lack of management oversight to

ensure the timely and accurate movement of mail throughout the Service

Center. For example, VSC management have no oversight procedures to

ensure employees actually retrieve search mail. The Service Center sends

out a weekly reminder to all employees to pick up search mail. All

employees have access to the search “delete” function in COVERS and

therefore an employee can delete a search without collecting the search mail.

Further, the quality review process for the Triage Team does not always

address search mail and drop mail. Management also does not conduct

quality reviews on a consistent basis. Triage Team supervisors told us they

review between 5 and 10 pieces of mail from each employee monthly, if

possible. The SAO on Quality of Files Activities recommended that for each

employee a supervisor review handling of 20 pieces of mail per month.

The Quality of Files Activities SAO found other deficiencies in the search

mail and drop mail sections and made recommendations for improvement.

VSC management acknowledged weaknesses associated with mail

processing but did not implement these recommendations or follow up on the

deficiencies. VSC leadership stated they do not follow up on SAO

recommendations and could not provide a reason why.

Until VSC management addresses these weaknesses, RVSRs may not have

all available evidence when making disability determinations. Untimely

association of search, drop, and PTI mail with veterans’ claims folders can

cause delays in processing disability claims. As a result, beneficiaries may

not receive accurate and timely benefit payments.

7.	 We recommend the Houston VA Regional Office Director develop and 

implement a plan to address all deficiencies and recommendations 

identified in the Systematic Analysis of Operations regarding mail 

handling. 

8.	 We recommend the Houston VA Regional Office Director develop and 

implement a plan to ensure management oversight of mail handling. 

VA Office of Inspector General 14 
Inspection of the VA Regional Office, Houston, Texas 

Management 

Comments 

OIG Response 

Competency 

Determinations 

Finding 5

The VARO Director concurred with our recommendations. The Director

stated starting in February 2011 the Central Area Immersion Team began

working with VSC management and the Triage Team to develop and

implement a plan to ensure management oversight of mail handling. The

Director said efforts were also underway to develop efficient procedures for

mail processing.

Management actions are responsive to the recommendations. 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 final decisions in 15 (50 percent) of the

30 competency determinations completed from April through June 2010.

The delays ranged from 17 to 461 days, with an average completion time of

103 days. Delays occurred because the VSC workload management plan did

not contain procedures emphasizing immediate completion of competency

determinations, managers were not aware of timeliness standards regarding

these cases, and the VSC does not prioritize completion of these types of

cases. The risk of incompetent beneficiaries receiving benefits without

fiduciaries assigned to manage those funds increases when 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 the 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.

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

VA Office of Inspector General 15 
Inspection of the VA Regional Office, Houston, Texas 

Recommendation 

Management 

Comments 

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 1 year and 3 months. During this

period, the veteran received $24,191 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 this policy and they did not

prioritize these cases. They acknowledged that 14 days was a sufficient

definition of “immediate.” We also spoke with VSC leadership who defined

“immediate” as the same day the due process period expires. However, the

workload management plan lacked procedures to meet this goal and ensure

oversight of the competency determination process. As a result, incompetent

beneficiaries received benefits payments for extended periods despite being

incapable of managing these funds effectively.

We plan to raise this issue to senior VBA management in our fiscal year

2010 summary. Therefore, we make no recommendation to the Director of

the VARO regarding this issue.

Further, in 4 (13 percent) of 30 competency determinations reviewed, staff

did not follow VBA policy to withhold retroactive payments until

appointment of a fiduciary when beneficiary incompetency is proposed. In

the most egregious case, the veteran received payment of all benefits with no

withholding of $15,697 at the time incompetency was proposed. To fulfill

VBA’s policy, VARO staff should have paid the full monthly benefit of

$1,427, and withheld the retroactive benefits of $14,270 from

November 1, 2009, until the appointment of a fiduciary in June 2010.

These errors were a result of lack of understanding of VBA policy. When

the policy changed in October 2009, VSC management sent an e-mail to all

employees. Training schedules for fiscal year 2010 showed the VARO gave

no additional training on this issue.

9.	 We recommend that the Houston VA Regional Office Director conduct 

refresher training and implement controls to ensure staff follow current 

Veterans Benefits Administration policy regarding the processing of 

competency determinations. 

The VARO Director concurred with our recommendation. The Director

reported providing training in December 2010 and February 2011 on

VA Office of Inspector General 16 
Inspection of the VA Regional Office, Houston, Texas 

OIG Response 

Recommendation 

processing competency determinations. Further, refresher training was

scheduled for March 2011.

Management actions are responsive to the recommendation. We will follow

up as required on all actions.

6. Safeguarding of Personally Identifiable Information

In addition to the 10 operational activities reviewed during the inspection, we

identified another area requiring VARO management’s attention. This area

involves the failure to safeguard veterans’ personally identifiable information

by placing documents ready for destruction in unlocked containers.

According to VBA’s policy, access to shred bins must be strictly controlled

and limited to senior management, Records Management Officers, and

Division Records Management Officers. Further, VARO’s are required to

keep shred bins secured with locks or in locked rooms.

We observed documents in six unlocked shred bins on the loading dock

leaving veterans’ personally identifiable information potentially at risk.

Additionally, some shred bins were overflowing and documents accessible

through a slot in the top of the bins. After we notified management, they

moved the shred bins into the mailroom. The Support Services Division

management stated the mailroom and loading dock are lockable areas.

Further, management informed us when the VARO receives a delivery, an

employee is there at all times. Our subsequent observation revealed

management did not lock one shred bin. Additionally, the shred bins were

accessible to personnel other than those approved by VBA’s policy.

VBA’s policy requires two signatures on any document that could potentially

affect benefit entitlement before the VARO can destroy the document. A

review of 30 documents from the open shred bins found VARO staff

complied with VBA’s policy. However, one document was an incomplete

and unsigned original claim for benefits and another was a request for a copy

of a letter. Review of the claims folder and VA electronic systems

confirmed the VARO took no action on these requests. We provided

management with the two documents for further action. Because the shred

bins were in an unsecured area, neither VARO staff nor we can ascertain

who placed these documents in the shred bins.

10. We recommend that the Houston VA Regional Office Director implement 

additional controls to ensure staff follow current Veterans Benefits 

Administration policy regarding safeguarding personally identifiable 

information. 

VA Office of Inspector General 17 
Inspection of the VA Regional Office, Houston, Texas 

Management 

Comments 

OIG Response 

The VARO Director concurred with our recommendation. The Director

stated Support Service Division personnel sealed the slots on the lids of the

shredding bins when OIG was onsite. Additionally, the Director designated

a secure office location for storing the shred bins.

Management actions are responsive to the recommendation. We will follow

up as required on all actions.

VA Office of Inspector General 18 
Inspection of the VA Regional Office, Houston, Texas 

Appendix A	 VARO Profile and Scope of Inspection

The Houston VARO is responsible for delivering nonmedical VA benefits

and services to veterans and their families in 90 counties of southern Texas,

the Republic of Mexico, Central and South America, and the Caribbean. The

VARO fulfills these responsibilities by administering compensation and

pension benefits, vocational rehabilitation and employment assistance, and

outreach activities.

Resources	 As of September 2010, the Houston VARO had a staffing level of 590 fulltime employees. Of these, 387 employees (66 percent) were assigned to the

VSC.

Workload	 As of October 2010, the VARO reported 25,893 pending compensation

claims. The average time to complete claims during fiscal year 2011 was

212.9 days—37.9 days greater than the national target of 175 days. As

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

78.9 percent—11.1 percent below the 90 percent VBA target, and accuracy

of compensation authorization-related issues was 93.8 percent—2.2 percent

below the 96 percent VBA target.

Scope	 We reviewed selected management controls, benefits claims processing, and

administrative activities to evaluate compliance with VBA policies regarding

benefits and nonmedical services provided to veterans and other

beneficiaries. We interviewed managers and employees and reviewed

veterans’ claims folders.

Our review included 90 (9 percent) of 971 claims related to PTSD, TBI, and

herbicide exposure-related disabilities that the VARO completed from April

through June 2010. For temporary 100 percent disability evaluations, we

selected 30 (4 percent) of 765 existing claims from VBA’s Corporate

Database. We provided the VARO with the 735 claims remaining from the

universe of 765 to assist in implementing our first recommendation. The

765 claims represented all instances in which VARO staff granted temporary

100 percent disability determinations for at least 18 months.

We also reviewed a sample of 30 (65 percent) of 46 competency

determinations completed by the Houston VARO during the 3-month period

from April through June 2010. We reviewed 36 errors identified by VBA’s

STAR Program during the same 3-month period. 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 rating decisions. STAR staff review original claims,

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

appellate issues that involve a myriad of veterans’ disabilities claims.

VA Office of Inspector General 19 
Inspection of the VA Regional Office, Houston, Texas 

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

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

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

processing involving temporary 100 percent disability evaluations.

We selected and reviewed dates of claim and NODs and search 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. 

VA Office of Inspector General 20 
Inspection of the VA Regional Office, Houston, Texas 

Appendix B VARO Director’s Comments

Department of Memorandum Veterans Affairs

Date: March 9, 2011

From: Pritz Navaratnasingam Director, VA Regional Office Houston, Texas

Subj: Inspection of the VARO Houston, Texas

To: Assistant Inspector General for Audits (52)

1.&Attached are the Houston VARO’s comments on the OIG Draft Repot:

Inspection of VARO Houston.

2.&Questions may be referred to Daryl Brady, Assistant Director, VARO

Houston. He may be contacted at 713-383-1720.

 (original signed by:)
 

Pritz Navaratnasingam
 

Director
 

Attachment

VA Office of Inspector General 21 
&

Inspection of the VA Regional Office, Houston, Texas 

Houston VA Regional Office
 

Response to the Office of Inspector General,
 

Benefits Inspection Division,
 

Inspection of the VA Regional Office Draft Report
 

Recommendation 1 - We recommend the Houston VA Regional Office Director review the 

remaining universe of 735 temporary 100 percent disability evaluations to determine if 

reevaluations are required and take appropriate action.

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. The Houston RO

is in the process of reviewing the 735 cases. To date 356 have been reviewed, of which 102

have been completed. The estimated completion date of the project is September 30, 2011.

Recommendation 2 - We recommend the Houston VA Regional Office Director conduct 

refresher training and implement controls to ensure staff establishes suspense diaries for 

temporary 100 percent disability reevaluations. 

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. Houston VA

Regional Office provided initial training to the POST Teams on November 23, 2010 for the 800

series work items. Refresher training is scheduled for March 8, 2011. The RVSRs were given

training on March 2, 2011 for the 810 series work items. Prior to this date, in-team training was

accomplished shortly after the OIG visit.

Recommendation 3 - We recommend the Houston VA Regional Office Director develop and 

implement a plan to improve processing accuracy and quality review of post-traumatic stress 

disorder (PTSD) claims.

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. In late FY10

VSRs, RVSRs, and DROs were identified who had not completed the PTSD TPSS modules

developed by C P Services in 2007. Training was completed in late FY2010. A five-hour

PTSD training class is scheduled for April 4-5, 2011. The Houston VSC is working in

collaboration with the Immersion Team to review the quality process. We expect to develop and

implement changes to the process by May 1, 2011 to address accuracy and quality review of

PTSD claims.

Recommendation 4 - We recommend the Houston VA Regional Office Director conduct 

refresher training and develop and implement a plan to improve the quality review process for 

traumatic brain injury (TBI) and herbicide exposure-related claims. 

Concur with recommendation 

VA Office of Inspector General 22 
Inspection of the VA Regional Office, Houston, Texas 

Response: The Houston VARO Director concurs with this recommendation. Herbicide training

is scheduled for April 20, 2011. Second signature reviews were required for the period of

October 15, 2010 to December 1, 2010. The RVSRs and DROs received 5 hours of TBI training

over the period covering November 17–18, 2010. The Houston VSC is working in collaboration

with the Immersion team to review the quality process. We expect to develop and implement

changes to the process by May 1, 2011 plan to improve the quality review process for traumatic

brain injury (TBI) and herbicide exposure-related claims.

Recommendation 5 - We recommend the Houston VA Regional Office Director develop and 

implement a plan to ensure staff record Notices of Disagreement in the Veterans Appeals 

Control and Locator System within 7 days as required by Veterans Benefits Administration 

policy. 

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. In October 2010,

the Appeals team revised its procedures for controlling and processing Notices of Disagreements

(NODs). The plan also included procedures for handling NODs received at the out-based office.

Recommendation 6 - We recommend the Houston VA Regional Office Director develop and 

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

all required elements. 

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. A schedule was

developed and plan was implemented to ensure SAOs are submitted timely and in accordance

with VBA policy. The Quality of Compensation, Pension, and Ancillary Actions SAO dated

January 28, 2011 and the Quality of Files Activity SAO dated March 2, 2011 addresses the

OIG’s concerns raised on the audit.

Recommendation 7- We recommend the Houston VA Regional Office Director develop and 

implement a plan to address all deficiencies and recommendations identified in the Systematic 

Analysis of Operations regarding mail handling. 

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. The Central Area

Immersion Team began working with the Houston VSC management staff February 14, 2011

and is currently working closely with the Triage Team to develop efficient mail processing

procedures. Training is being provided in all areas.

Recommendation 8 – We recommend the Houston VA Regional Office Director develop and 

implement a plan to ensure management oversight of mail handling. 

Concur with recommendation 

VA Office of Inspector General 23 
Inspection of the VA Regional Office, Houston, Texas 

Response: The Houston VARO Director concurs with this recommendation. The Central Area

Immersion Team is developing and implementing a plan to ensure management oversight of

mail handling. The Triage Coach is responsible for daily implementation strategies. The VSCM

and AVSCMs will be responsible for ensuring compliance with the plan.

Recommendation 9 – We recommend that the Houston VA Regional Office Director conduct 

refresher training and implement controls to ensure staff follow current Veterans Benefits 

Administration policy regarding the processing of competency determinations. 

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. Initial Fiduciary

training for competency determinations was provided on December 21, 2010. Due process

training was provided on February 14, 2011 to the POST Teams. Refresher training is scheduled

for March 22, 2011 focusing specifically on the topic of incompetency ratings and subsequent

processing following expiration of due process.

Recommendation 10 – We recommend that the Houston VA Regional Office Director 

implement additional controls to ensure staff follow current Veterans Benefits Administration 

policy regarding safeguarding personally identifiable information. 

Concur with recommendation 

Response: The Houston VARO Director concurs with this recommendation. During the OIG’s

visit, SSD personnel sealed all drop slots located on the lids of the shredding bins to prevent

someone from being able to have access to documents inside the container when full. All bins

have locks and are locked at all times. We have identified a secure office location for the RMO

that is large enough to store all of the shredding bins, which allows us to remove the bins from

the loading dock/mailroom area as an added security measure.

VA Office of Inspector General 24 
Inspection of the VA Regional Office, Houston, TX 

Appendix C Inspection Summary
 

10 Operational

Activities Inspected Criteria

Reasonable 

Assurance of 

Compliance 

Yes No 

Disability Claims Processing 

1. Temporary100 

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)21-1Manual 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 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 

Disabilities 

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 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 

Technical Accuracy 

Review 

Determine whether VARO staff properly corrected STAR errors in 

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

8. Systematic Analysis 

of Operations 

Determine whether VARO staff properly performed formal analyses of 

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

Workload Management 

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

VA Office of Inspector General 25 
Inspection of the VA Regional Office, Houston, TX 

Appendix D OIG Contact and Staff Acknowledgments
 

OIG Contact& Dawn Provost
 

Acknowledgments& Diane Wilson

Kristine Abramo

Ed Akitomo

Orlan Braman

Madeline Cantu

Danny Clay

Michelle Elliott

Lee Giesbrecht

Rachel Stroup

VA Office of Inspector General 26 
Inspection of the VA Regional Office, Houston, TX 

Appendix E Report Distribution

VA Distribution

Office of the Secretary
 

Veterans Benefits Administration
 

Assistant Secretaries
 

Office of General Counsel
 

VBA Central Area Director
 

VARO Houston 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: John Cornyn, Kay Bailey Hutchison

U.S. House of Representatives: Joe Barton, Kevin Brady, K. Michael

Conaway, John Abney Culberson, Bill Flores, Louie Gohmert, Kay Granger,

Al Green, Ralph M. Hall, Jeb Hensarling, Rubén Hinojosa, Sam Johnson,

Sheila Jackson Lee, Michael T. McCaul, Randy Neugebauer, Ron Paul, Ted

Poe, Silvestre Reyes, Mac Thornberry

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 27