VA Office of Inspector General 

OFFICE OF AUDITS & EVALUATIONS 

Inspection of the 

VA Regional Office 

Portland, OR

February 22, 2011 

11-00070-93
ACRONYMS AND ABBREVIATIONS 

COVERS Control of Veterans Records System 

NOD Notices of Disagreement 

OIG Office of Inspector General 

PTSD Post-Traumatic Stress Disorder 

RVSR Rating Veterans Service Representative 

SAO Systematic Analyses of Operations 

STAR Systematic Technical Accuracy Review 

TBI Traumatic Brain Injury 

VACOLS Veterans Appeals Control and Locator System 

VARO VA Regional Office 

VBA Veterans Benefits Administration 

VSC Veterans Service Center 

 

To Report Suspected Wrongdoing in VA Programs and Operations: 

Telephone: 1-800-488-8244 

E-Mail: vaoighotline@va.gov

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

Regional Office, Portland, OR 

Why We Did This Review 

The Benefits Inspection Division conducts 

onsite inspections at VA Regional Offices 

(VAROs) to review disability compensation 

claims processing and Veterans Service 

Center operations. 

What We Found 

The Portland VARO correctly processed 

disability claims for post-traumatic stress 

disorder. Additionally, VARO staff corrected 

errors identified by the Veterans Benefits 

Administration’s (VBA) Systematic 

Technical Accuracy Review program and 

established correct dates of claim in the 

electronic record. Generally, VARO staff 

correctly processed herbicide exposurerelated disability claims and ensured timely 

controlling of Notices of Disagreements for 

appealed decisions. 

VARO staff should emphasize the need to 

improve the control of processing temporary 

100 percent disability evaluations and 

ensure the accuracy of processing traumatic 

brain injury claims. Further, we found the 

staff made rating decisions based on 

inadequate medical examinations. Overall, 

VARO staff did not accurately process 24 

(20 percent) of the 120 disability claims 

reviewed. Further, the controls over mail 

handling and completion of Systematic 

Analyses of Operations need strengthening. 

What We Recommended

We recommended that Portland VARO 

management review all temporary 

100 percent evaluations to determine if 

reevaluations are required and take 

appropriate actions. Management needs to 

implement controls to ensure reminder 

notifications for temporary 100 percent 

disability reevaluations are established. 

Further, we recommended management 

provide refresher training on the proper 

procedures for processing traumatic brain 

injury claims and develop a plan to ensure 

the staff returns inadequate medical 

examinations to the appropriate hospitals for 

correction. We also recommended VARO 

management strengthen controls to ensure 

timely and complete preparation of 

Systematic Analyses of Operations and 

implement a plan to ensure accurate control 

and processing of incoming mail. 

Agency Comments

The Director of the Portland 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 ..........................................................................................................................6

3. Management Controls .............................................................................................................6

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

Appendix A VARO Profile and Scope of Inspection ............................................................10

Appendix B VARO Director’s Comments ............................................................................11

Appendix C Inspection Summary..........................................................................................15

Appendix D OIG Contact and Staff Acknowledgments ........................................................15

Appendix E Report Distribution ...........................................................................................17

ii 
Inspection of the VA Regional Office, Portland, OR 

INTRODUCTION 

The Benefits Inspection Program is part of the Office of Inspector General’s 

(OIG) efforts to ensure our Nation’s veterans receive timely and accurate 

benefits and services. The Benefits Inspection Division contributes to 

improved management of benefits processing activities and veterans’ 

services by conducting onsite inspections at VA Regional Offices (VAROs). 

These independent inspections provide recurring oversight focused on 

disability compensation claims processing and performance of Veterans 

Service Center (VSC) operations. The objectives of the inspections are to: 

Objective 

• Evaluate how well VAROs are accomplishing their mission of providing 

veterans with convenient 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 Portland VARO. 

The inspection focused on four protocol areas examining nine operational 

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

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

examine eligibility determinations because VBA has centralized all Western 

Area fiduciary activities at the Salt Lake City VARO. 

Scope of 

Inspection 

We reviewed 90 (10 percent) of 899 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 (14 percent) of 213 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 Portland VARO Director’s comments on a draft of 

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

operational activity and a summary of our inspection results. 

VA Office of Inspector General 1
Inspection of the VA Regional Office, Portland, OR 

RESULTS AND RECOMMENDATIONS 

1. Disability Claims Processing 

The OIG inspection team focused on disability claims processing related to 

temporary 100 percent 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 Portland VARO needs to improve the accuracy of disability claims 

processing for temporary 100 percent disability evaluations and TBI. VARO 

staff incorrectly processed 24 (20 percent) of the total 120 disability claims 

reviewed. We advised VARO management of the inaccuracies noted during 

our inspection and they initiated corrective measures to address them. The 

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

affect, veterans’ benefits processed at the Portland VARO. 

Table Disability Claims Processing Results

Type Reviewed 

Claims Incorrectly Processed 

Total 

Affecting 

Veterans’ 

Benefits 

Potential To 

Affect 

Veterans’ 

Benefits 

Temporary 100 

Percent Disability 

Evaluations 

30 16 3 13 

PTSD 30 0 0 0 

TBI 30 7 2 5 

Herbicide ExposureRelated Claims 30 1 1 0 

Total 120 24 6 18 

Temporary 

100 Percent 

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 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 benefits. 

Based on analysis of available medical evidence, 3 of the 16 processing 

inaccuracies identified involved overpayments totaling $137,262, which 

VA Office of Inspector General 2
Inspection of the VA Regional Office, Portland, OR 

affected veterans’ benefits. The most significant overpayment occurred 

when a Rating Veterans Service Representative (RVSR) correctly proposed 

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

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

not taken the final action to reduce the veteran’s benefits. As a result, VA 

overpaid the veteran $76,413 over a period of 2 years and 6 months. 

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

In 12 cases, VSC staff did not establish the reminder notifications needed to 

alert VARO staff that VA reexaminations needed to be scheduled. For the 

remaining case, a rating decision required a reexamination in November 

2011. At the time of our inspection, no reminder notification was in place to 

ensure the reexamination would actually occur. 

We could not determine if these 13 temporary 100 percent disability 

evaluations would have continued because the veterans’ claims folders did 

not contain evidence of the medical examinations needed to reevaluate each 

case. An average of 1 year and 9 months elapsed from the time staff should 

have scheduled these medical examinations until the date of our inspection 

(the date staff ultimately took corrective actions to obtain the necessary 

medical evidence). The delays ranged from 61 days to 5 years and 7 months. 

For temporary 100 percent disability evaluations, including confirmed and 

continued evaluations where rating decisions do not change a veteran’s 

payment amount, VSC staff must input a suspense diary (or reminder 

notification) in VBA’s electronic system. A diary is a processing command 

that establishes a date when VSC staff must schedule a reexamination. As 

the diary matures, the electronic system generates a reminder notification 

alerting VSC staff to schedule the reexamination. 

The most frequent processing inaccuracies noted in 6 (38 percent) of the 

16 cases reviewed occurred when VARO staff did not properly establish 

suspense diaries for future VA examinations. VSC management stated, and 

we verified, the VARO did not have a procedure in place requiring VSC staff 

to review implementation of confirmed and continued rating decisions 

calling for routine future examinations. 

VARO staff correctly processed all 30 PTSD claims reviewed. Therefore, 

we made no recommendations for improvement in this area. 

PTSD Claims 

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: (1) physical, (2) cognitive, and (3) behavioral. 

VBA policy requires staff to evaluate these residual disabilities. 

TBI Claims 

VA Office of Inspector General 3
Inspection of the VA Regional Office, Portland, OR 

VA Office of Inspector General 4

VARO staff incorrectly processed 7 (23 percent) of 30 TBI claims. 

Following is a summary of the two inaccuracies affecting veterans’ benefits. 

• An RVSR granted service-connection for headaches related to TBI; 

however, no medical evidence provided a distinct diagnosis of 

headaches. Additionally, the RVSR failed to grant special monthly 

compensation for loss of use of a creative organ. As a net result, VA 

overpaid the veteran $2,753 over a period of 8 months. 

• An RVSR failed to assign a separate 30 percent evaluation for migraine 

headaches related to a TBI despite medical evidence showing a link 

between the two. As a result, VA underpaid the veteran $1,864 over a 

period of 8 months. 

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

potential to affect veterans’ benefits. 

• In two cases, RVSRs incorrectly evaluated residual TBI-related 

disabilities using inadequate medical examinations. Neither VARO staff 

nor we can ascertain all of the residual disabilities related to TBI without 

an adequate or complete medical examination. 

• In one case, an RVSR failed to assign a separate evaluation for migraine 

headaches diagnosed in a VA examination. This change did not affect 

the veteran’s current 80 percent evaluation, but may affect future 

evaluations for additional benefits. 

• In one case, an RVSR granted service connection for headaches related 

to TBI. However, there was no medical evidence providing a distinct 

diagnosis of headaches. This change did not affect the veteran’s current 

90 percent disability evaluation, but may affect future evaluations for 

additional benefits. 

• In one case, an RVSR improperly proposed reducing a veteran’s 

evaluation of TBI residuals from 40 percent to 20 percent disabling 

despite a VA examination clearly showing symptoms to support the 

disability evaluation of 40 percent. If not for our review, VSC staff 

would have incorrectly reduced the veteran’s benefits. 

Generally, errors associated with TBI claims processing occurred because 

VARO staff interpreted VBA policy incorrectly and used VA medical 

examinations that were inadequate for decision-making purposes. VARO 

management stated these errors were due to inexperienced RVSRs, a lack of 

understanding of TBI evaluation procedures, and pressure to process claims 

more quickly. VARO staff indicated the process of returning inadequate 

medical examinations was time consuming; therefore, RVSRs made 

decisions based on the information initially provided instead of returning 
Inspection of the VA Regional Office, Portland, OR 

inadequate medical examination reports for clarification. As a result, 

veterans did not always receive correct benefits payments. 

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

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

significant; however, this error affected a veteran’s benefits. An RVSR 

failed to grant entitlement to special monthly compensation benefits, which 

resulted in an underpayment of $960 over a period of 10 months. 

Herbicide 

ExposureRelated 

Claims 

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

remaining universe of 183 temporary 100 percent determinations under 

the regional office’s jurisdiction to determine if reevaluations are 

required and take appropriate action. 

Recommendations 

2. We recommend the Portland VA Regional Office Director implement 

controls to ensure staff establish suspense diaries for temporary 

100 percent disability reevaluations. 

3. We recommend the Portland VA Regional Office Director ensure Rating 

Veterans Service Representatives receive training on how to properly 

evaluate disabilities related to traumatic brain injuries and identify 

inadequate medical examinations. 

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

implement a plan to ensure medical examinations determined to be 

inadequate for rating purposes are returned to the appropriate VA 

medical facility for correction. 

The VARO Director concurred with our recommendations for improving 

disability claims processing accuracy. The Director indicated VSC staff will 

complete and review 183 additional temporary 100 percent evaluations by 

February 28, 2011, and will request medical examinations when appropriate. 

On November 8, 2010, the Director implemented a Standard Operating 

Procedure that requires VARO staff to review all confirmed and continued 

temporary 100 percent evaluations to ensure staff properly record future 

medical examination dates in the electronic record. 

Management 

Comments 

Further, VARO staff received training during January 2011 on all facets of 

rating traumatic brain injury claims, to include the procedures to return an 

inadequate medical examination to the VA Medical Center for correction. In 

addition, management will cite unreturned inadequate examinations as a 

substantial error and included as part of the review of the individual’s endof-year performance appraisal. 

OIG Response Management’s actions are responsive to the recommendations. 

VA Office of Inspector General 5
Inspection of the VA Regional Office, Portland, OR 

2. Data Integrity 

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

policy to establish effective dates and dates of claim in the electronic record 

and timely record Notices of Disagreement (NOD) in the Veterans Appeals 

Control and Locator System (VACOLS). Because the VARO correctly 

followed VBA policy when establishing effective dates and dates of claim 

and generally followed VBA policy for NODs, we made no 

recommendations for improvement. 

Generally, an effective date indicates when entitlement to a specific benefit 

arose. VARO staff followed VBA policy and correctly established effective 

dates for all 120-disability claims we reviewed. 

Effective Dates 

VBA commonly uses the date of claim to indicate when a document arrives 

at a VA facility. VBA relies on accurate dates of claim to establish and track 

key performance measures, including the average days to complete a claim. 

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

all 30 claims reviewed. 

Dates of Claim 

An NOD is a written communication from a claimant expressing 

dissatisfaction or disagreement with a benefits decision and a desire to 

contest the decision. An NOD is the first step in the appeals process. 

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

track veterans’ appeals and assist with managing 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. 

The VARO exceeded VBA’s 7-day standard for 2 (7 percent) of 30 NODs 

we reviewed. 

Notices of 

Disagreement 

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. 

Systematic 

Technical 

Accuracy

Review 

The STAR program is VBA’s multi-faceted quality assurance program to 

ensure that veterans and other beneficiaries receive accurate and consistent 

compensation and pension benefits. VBA policy requires that the VARO 

take corrective action on errors that STAR identifies. VARO staff adhered to 

the policy by taking corrective actions to address all 12 errors VBA’s STAR 

program identified. In addition, VARO management appropriately used 

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

we made no recommendations for improvement in this area. 

VA Office of Inspector General 6
Inspection of the VA Regional Office, Portland, OR 

We assessed operations to determine if VARO management had controls in 

place to ensure complete and timely submission of Systematic Analyses of 

Operations (SAOs). We determined management should improve oversight 

of SAO completion. 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. 

Systematic 

Analyses of 

Operations 

Finding 2 Improved Oversight Is Needed To Ensure SAOs Are 

Timely and Complete 

The Veterans Service Center Manager is responsible for ongoing analysis of 

VSC operations, including completing 11 annual SAOs. Our analysis 

revealed 4 (36 percent) of the 11 SAOs were either incomplete or not 

completed within the designated time frame as listed on the annual SAO 

schedule. This occurred because VARO management did not provide 

adequate oversight to ensure VSC staff completed SAOs in accordance with 

VBA policy. As a result, the VARO may not have adequately identified 

existing or potential problems in need of correction to improve VSC 

operations. 

At the time of our inspection, 3 of the 11 SAOs were not completed and 

1 did not assess all of the required areas. For the three not completed, the 

dates ranged from 73 to 101 days late. For one SAO, Quality of Control 

Actions, staff did not complete a portion related to the analysis of mail 

processing. 

The Veterans Service Center Manager attributed the inadequate oversight of 

the SAO process to his decision to place higher priority on new VSC 

performance measures implemented by VBA in July 2010. Consequently, 

staff did not complete the three remaining FY 2010 SAOs. The Veterans 

Service Center Manager identified other factors contributing to delays in 

completing SAOs. For example, VBA and VARO leadership temporarily 

reassigned several managers normally responsible for SAOs to other duties 

within the VARO and at other offices. Further, VSC supervisors received 

the additional task of overseeing the hiring of 50 additional employees 

during the last quarter of FY 2010. 

In one instance, VARO staff did not complete the SAO for Appeals 

processing. A VBA report revealed that the Portland VSC did not achieve 

the VBA’s FY 2010 Appeals goal of timely processing and reducing the 

inventory of pending NODs. If VARO managers had ensured proper 

VA Office of Inspector General 7
Inspection of the VA Regional Office, Portland, OR 

completion of the required SAO on Appeals, they may have identified 

potential weaknesses affecting performance. 

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

implement a plan to ensure staff complete Systematic Analyses of 

Operations timely and address all required elements.

Recommendation 

The VARO Director concurred with our recommendation and informed us 

the Veterans Service Center Manager implemented a stringent deadline for 

completing SAOs timely. Further, timely and complete SAOs are now part 

of an individual’s performance standards. 

Management 

Comments 

OIG Response Management’s actions are responsive to the recommendations. 

4. Workload Management 

We assessed controls over mailroom operations to ensure VARO staff timely 

and accurately processed incoming mail. VBA uses various plans and 

applications to control workload. VBA policy indicates the most important 

part of workload management is oversight to ensure the staff efficiently uses 

the plans and systems available. It also states that effective mail 

management is crucial to the success and control of workflow within the 

VSC. 

VBA policy states staff will open, date stamp, and route all mail to the 

appropriate locations within four to six hours of receipt at the VARO. The 

Portland VARO has assigned responsibility for mailroom activities, 

including processing of incoming mail, to the VSC. We made no 

recommendations in this area because VSC mailroom staff timely and 

accurately processed, date stamped, and delivered VSC mail to the Triage 

Team daily as required. 

Mail Room 

Operations 

Further, 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. We determined that the VARO’s search mail 

procedures need strengthening. 

Triage Mail 

Processing 

Procedures 

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

associated with a veteran’s claims folder. The VARO staff is required to use 

the Control of Veterans Records System (COVERS) to electronically track 

veterans’ claims folders and control search mail. COVERS provides 

notification of search mail awaiting pick-up when staff access an electronic 

record for a specific claims folder. 

VA Office of Inspector General 8
Inspection of the VA Regional Office, Portland, OR 

Finding 3 Triage Team Search Mail Procedures Need 

Strengthening

The Triage Team did not always control and process search mail according 

to VBA policy. For 4 (13 percent) of 30 pieces of search mail reviewed, 

staff did not properly use COVERS to ensure accurate processing and control 

of search mail. This occurred because the VSC’s local guidance was unclear 

and conflicted with current VBA policy. As a result, claimants may not have 

received prompt and accurate decisions on benefits. 

Staff delayed processing by not properly controlling two of the four pieces of 

search mail in COVERS. The most significant delay occurred when VARO 

staff did not immediately associate search mail with a claims folder. Further, 

on September 10, 2010, the VARO received mail regarding a pending claim. 

Staff did not put the evidence on search in COVERS and were not aware of 

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

unnecessarily delayed processing this claim by 54 days. For the remaining 

two errors, staff did not retrieve search mail even though COVERS 

generated electronic reminders of pending search mail available for pickup. 

The VSC had two local written policies that provided conflicting guidance to 

staff. For example, a local VSC Circular governing the use of COVERS 

directed employees to make every effort to associate search mail with the 

claim folder upon initial electronic notification in COVERS. In contrast, the 

local Standard Operating Procedures allowed staff to delay association of 

search mail until processing or transferring the file, regardless of when 

COVERS generated an electronic notification. 

6. We recommend the Portland VA Regional Office Director amend the 

Workload Management Plan and local mail policies to ensure consistent 

procedures for processing search mail. 

Recommendations 

The VARO Director concurred with our recommendation and amended the 

local circular on the use of COVERs to ensure consistency with the VSC’s 

Standard Operating Procedures regarding search mail. 

Management 

Comments 

OIG Response Management’s actions are responsive to the recommendations.

VA Office of Inspector General 9
Inspection of the VA Regional Office, Portland, OR 

Appendix A VARO Profile and Scope of Inspection 

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

and services to veterans and their families in Oregon. The VARO fulfills 

these responsibilities by administering compensation and pension benefits, 

vocational rehabilitation and employment assistance, and outreach activities. 

Organization 

As of October 2010, the Portland VARO had a staffing level of 231 full-time 

employees. Of these, the VSC had 184 employees (80 percent) assigned. 

Resources 

As of October 2010, the VARO reported 7,540 pending compensation 

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

159.5 days—9.5 days longer than the national target of 150 days. As 

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

86.2 percent, or 3.8 percent below the 90 percent target set by VBA. 

Workload 

We reviewed selected management controls, claims processing, and 

administrative activities to evaluate compliance with VBA policies regarding 

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

beneficiaries. We interviewed managers and employees and reviewed 

veterans’ claims folders. 

Scope 

Our review included 90 (10 percent) of 899 disability claims related to 

PTSD, TBI, and herbicide exposure that the VARO completed during July to 

September 2010. For temporary 100 percent disability evaluations, we 

selected 30 (14 percent) of 213 existing claims from VBA’s Corporate 

Database. We provided the VARO with the 183 claims remaining from the 

universe of 213 to assist in implementing our first report recommendation. 

These claims represented instances in which staff granted temporary 

100 percent disability determinations for at least 18 months. 

We reviewed 12 errors identified by VBA’s STAR program during the 

period of April to 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 requiring 

rating decisions. The STAR staff reviews original claims, reopened claims, 

and claims for increased evaluations. Further, they review appellate issues 

that involve a myriad of veterans’ disabilities claims. 

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

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

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

involving temporary 100 percent disability claims. 

We selected for review dates of claim 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 10
Inspection of the VA Regional Office, Portland, OR 

Appendix B VARO Director’s Comments 

Department of 

Veterans Affairs Memorandum

Date: February 2, 2011 

From: Director, Portland VA Regional Office (348/00) 

Subj: Inspection of the VA Regional Office Portland, OR 

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

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

Inspection of VA Regional Office, Portland, OR. 

2. Please feel free to contact me at (503) 412-4530 with any questions or 

concerns regarding our reply. 

(original signed by:) 

Chris Marshall 

Director 

Attachment 

VA Office of Inspector General 11
Inspection of the VA Regional Office, Portland, OR 

OIG Recommendations: 

Recommendation 1: We recommend the Portland VA Regional Office Director review the 

remaining universe of 183 temporary 100 percent determinations under the regional office’s 

jurisdiction to determine if reevaluations are required and take appropriate action. 

Regional Office Response: We concur with the recommendation. We began the review in 

mid-January and expect to have all available cases reviewed by February 28, 2011. If cases 

require re-examinations, we will submit those requests by February 28, 2011. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 2: We recommend the Portland VA Regional Office Director implement 

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

reevaluations. 

Regional Office Response: We concur with the recommendation. On November 8, 2010, the 

Regional Office implemented Standard Operating Procedures (SOP) to ensure Veterans Service 

Representatives assigned to the Post-Determination Team review all confirmed and continued 

rating decisions for a future examination date. A copy of the SOP was provided to the OIG team 

during their inspection. 

The Regional Office previously discovered, and communicated to the OIG team during their 

inspection, that if the Regional Office were to confirm and continue a temporary 100% 

evaluation using the PCLR command, all routine future examination dates in the system prior to 

the command would disappear, resulting in no mechanism to conduct a follow-up review. The 

new SOP requires a review of the system following the PCLR command, and if the future 

examination date has indeed disappeared, the SOP identifies instructions for correcting the 

system and appropriate future follow-up. 

On January 8, 2011, all Veterans Service Representatives responsible for completing PostDetermination functions were instructed to establish future examination dates in accordance with 

M21-MR III.iv.3.C.17. Authorizers were instructed that mandatory reviews at the time awards 

are authorized are required to ensure future examination dates are correctly coded. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 3: We recommend the Portland VA Regional Office Director ensure Rating 

Veterans Service Representatives receive training on how to properly evaluate disabilities 

related to traumatic brain injuries and identify inadequate medical examinations. 

Regional Office Response: We concur with the recommendation. On January 6 and January 

11, 2011, the Regional Office conducted training for its Rating Veterans Service Representatives 

and Decision Review Officers. All facets of rating claims for traumatic brain injuries and its 

residuals were covered during this training. 

VA Office of Inspector General 12
Inspection of the VA Regional Office, Portland, OR 

On January 13 and 18, 2011, training was conducted to the same audience on the proper review 

of examinations, including those for traumatic brain injuries and its residuals. One of the 

emphasized topics of this training was when to return an examination to the VA Medical Center 

as inadequate. 

On January 20, 2011, training was conducted to the same audience on writing examination 

requests for traumatic brain injury claims. This reinforced the training provided earlier and 

should serve to elevate the quality of completed examinations returned to the Regional Office by 

the VA Medical Center. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 4: We recommend the Portland VA Regional Office Director develop and 

implement a plan to ensure medical examinations determined to be inadequate for rating 

purposes are returned to the appropriate VA medical facility for correction. 

Regional Office Response: We concur with the recommendation. The above training provided 

to the Regional Office’s Rating Veterans Service Representatives and Decision Review Officers 

is intended to improve their ability to identify and return inadequate VA examinations. On 

January 1, 2011, the Regional Office tasked its Service Center’s Quality Team to conduct 

thorough reviews of examination reports as part of the quality review process. If an individual 

fails to return an inadequate examination to the VA Medical Center, it will be cited as a 

substantial error and included as part of the review of the individual’s end-of-year performance 

appraisal. 

The Veterans Benefits Administration recommends closure of this recommendation. 

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

implement a plan to ensure staff complete Systematic Analyses of Operations (SAO) timely and 

address all required elements. 

Regional Office Response: We concur with the recommendation. On December 1, 2010, the 

Veterans Service Center Manager implemented a more stringent deadline schedule for 

completing the FY 2011 SAOs. The schedule requires SAOs to be completed with sufficient 

lead-time for review prior to submission to the Director. A follow-up schedule was additionally 

established to remind individuals about SAOs coming due. Moreover, a mechanism for 

recording late reports against an individual’s performance standards has been established. 

The Veterans Benefits Administration recommends closure of this recommendation. 

Recommendation 6: We recommend the Portland VA Regional Office Director amend the 

Workload Management Plan and local mail policies to ensure consistent procedures for 

processing search mail. 

Regional Office Response: We concur with the recommendation. The Regional Office is 

amending its station-wide circular regarding COVERS. These new changes will make the 

VA Office of Inspector General 13
Inspection of the VA Regional Office, Portland, OR 

VA Office of Inspector General 14

COVERS circular consistent with the Veterans Service Center’s SOP for search mail. The new 

circular will be completed by February 28, 2011. 

The Veterans Benefits Administration recommends closure of this recommendation. 
Inspection of the VA Regional Office, Portland, OR 

Appendix C Inspection Summary 

9 Operational 

Activities 

Inspected 

Criteria 

Reasonable 

Assurance of 

Compliance 

Yes No 

Claims Processing 

1. 100 Percent 

Disability 

Evaluations 

Determine whether VARO staff properly reviewed temporary 

100 percent disability evaluations. (38 CFR 3.103(b)) (38 CFR 

3.105(e)) (38 CFR 3.327) (M21-1MR Part IV, Subpart ii, Chapter 2, 

Section J) (M21-1MR Part III, Subpart iv, Chapter 3, Section C.17.e) 

X 

2. Post-Traumatic 

Stress Disorder 

Determine whether VARO staff properly processed claims for 

PTSD. (38 CFR 3.304(f)) X 

3. Traumatic Brain 

Injury 

Determine whether claims for service connection for all residual 

disabilities related to in-service TBI were properly processed. 

(Fast Letters 08-34 and 08-36, Training Letter 09-01) 

X 

4. Herbicide 

Exposure-Related 

Claims 

Determine whether VARO staff properly processed claims for 

service connection for disabilities related to herbicide exposure 

(Agent Orange). (38 CFR 3.309) (Fast Letter 02-33) (M21-1MR 

Part IV, Subpart ii, Chapter 2, Section C.10) 

X 

Data Integrity

5. Date of Claim Determine if VARO staff properly recorded dates of claim in the 

electronic records. (M21-1MR, Part III, Subpart ii, Chapter 1, 

Section C) 

X 

6. Notice of 

Disagreement 

Determine if VARO staff properly entered NODs into VACOLS. 

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

Management Controls

7. Systematic Analysis 

of Operations 

Determine if VARO staff properly performed formal analyses of 

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

8. Systematic 

Technical Accuracy 

Review 

Determine if 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 if 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 15
Inspection of the VA Regional Office, Portland, OR 

Appendix D OIG Contact and Staff Acknowledgments 

OIG Contact Brent Arronte 

Acknowledgments Danny Clay 

Kristine Abramo 

Daphne Brantley 

Robert Campbell 

Madeline Cantu 

Ramon Figueroa 

Lee Giesbrecht 

Mark Ward 

VA Office of Inspector General 16
Inspection of the VA Regional Office, Portland, OR 

Appendix E Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Benefits Administration 

Assistant Secretaries 

Office of General Counsel 

VBA Western Area Director 

VARO Portland 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: Jeff Merkley, Ron Wyden 

U.S. House of Representatives: Earl Blumenauer, Peter DeFazio, Kurt 

Schrader, Greg Walden, David Wu 

This report will be available on the OIG’s Web site at 

http://www.va.gov/oig/publications/reports-list.asp. This report 

will remain on the OIG Web site for at least 2 fiscal years. 

VA Office of Inspector General 17