Department of Veterans Affairs 

Office of Inspector General 

Audit of the 

Veterans Benefits Administration 

Compensation and Pension 

 Site Visit Program 

Report No. 08-02436-126 May 13, 2009

VA Office of Inspector General 

Washington, DC 20420 
To Report Suspected Wrongdoing in VA Programs and Operations 

Telephone: 1-800 488-8244 between 8:30AM and 4:00PM Eastern Time, 

Monday through Friday, excluding Federal holidays 

E-Mail:vaoighotline@va.gov
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Contents 

Page 

Executive Summary ....................................................................................................i-iv 

Introduction

Purpose............................................................................................................................. 1

Background...................................................................................................................... 1

Scope and Methodology .................................................................................................. 2

Results and Conclusions

C&P Site Visit Program Lacks Management Plan and Program Infrastructure to 

Support Mission and Goals ............................................................................................. 3 

Conclusions and Recommendations ............................................................................. 11 

Management Comments and OIG Response ................................................................ 12 

Appendixes

A. Methodology............................................................................................................ 13 

B. Under Secretary for Benefits Comments ................................................................. 15 

C. OIG Contact and Staff Acknowledgments............................................................... 18 

D. Report Distribution .................................................................................................. 19 

VA Office of Inspector General 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Executive Summary 

Results in Brief 

The VA Office of Inspector General (OIG) conducted this audit to determine whether the 

Veterans Benefits Administration’s (VBA) Compensation and Pension (C&P) Site Visit 

program effectively monitors and evaluates Veteran Service Center (VSC) operations. 

We assessed the effectiveness of Site Visit planning, identifying and reporting 

operational issues and best practices, and the disposition of action requiring attention. 

The C&P Site Visit program lacks the adequate infrastructure and management strategy 

to meet its mission and goals. Improvements are needed in staffing and staff 

independence, program performance measurement, ensuring that all VAROs are visited 

within the agency’s stated goal of 3 years, and reporting and follow-up. Unless 

enhancements and comprehensive changes are made to the C&P Site Visit program’s 

design and execution, C&P Service is likely to miss opportunities to improve 

performance across its regional office field structure. 

Background 

The mission of the C&P Site Visit program is to ensure centralized oversight and provide 

technical assistance to VSC operations within VBA’s 57 VA Regional Offices (VAROs). 

Site Visit teams monitor compliance with C&P policies and procedures and identify best 

practices to assist VSCs in achieving high performance. The Site Visit program is 

organizationally aligned under the Director of C&P Service, who reports to the Associate 

Deputy Under Secretary for Policy and Program Management. 

In accordance with the Millennium Act requirements, VBA administers a multi-faceted 

quality assurance program in an effort to ensure C&P benefits are provided in a timely, 

accurate, and consistent manner. This comprehensive program includes four tiers: 

(1) Systematic Technical Accuracy Review (STAR), (2) VSC compliance oversight visits 

(Site Visits) conducted by central office site survey teams, (3) special ad-hoc reviews, 

and (4) rating consistency reviews. Site visits are conducted separately and 

independently for each of the business lines within VBA—C&P, Education, Vocational 

Rehabilitation and Employment, Loan Guaranty, and Insurance. However, this audit 

assessed VBA’s C&P Site Visit program. 

Site visits provide C&P Service with an important mechanism to monitor VSC operations 

within each VARO by evaluating compliance with C&P policies and procedures and 

identifying best practices. Site visits also provide the opportunity for C&P Service to 

conduct on-site inspections of VSC operations, discuss issues with regional office 

employees, and provide on-site training. From FY 2001 through FY 2008, the C&P Site 

Visit program conducted 132 evaluations, 69 of which occurred from FY 2005 through 

VA Office of Inspector General i 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

FY 2008. Since FY 2005, the C&P Site Visit program has reported 687 actions requiring 

attention in an effort to improve VSC operations. 

Findings 

The C&P Service Site Visit program lacks a comprehensive management plan and 

program infrastructure that provides for workforce and succession planning, and program 

performance measures. In addition, the program needs to ensure the agency’s 3-year 

review cycle is met, and review protocols are updated as needed. C&P Service also 

needs to ensure the Site Visit program identifies and disseminates best practices to 

provide opportunities for continuous improvements for its VSC operations. 

• Workforce and Succession Planning. The Veterans Millennium Health Care and 

Benefits Act requires quality assurance programs to be staffed with sufficient fulltime employees (FTE) to perform quality assurance functions. In addition, VBA’s 

Workforce and Succession Plan for FY 2005–FY 2008 requires the administration to 

sustain talent in mission-critical positions, to assure continuity of operations, and 

avoid losses of productivity caused by turnover. Although the Site Visit team 

experienced significant turnover during FY 2006 and FY 2008 and has never been 

fully staffed to the allotted eight FTE, C&P Service has not developed a staffing plan 

for the Site Visit program. Program officials stated that they have been unable to 

maintain adequate staffing of the Site Visit program because of difficulties in 

recruiting qualified candidates from field offices who are willing to relocate to the 

Washington, D.C. area. As a result, the high turnover rate of experienced team 

leaders may lead to a loss of institutional knowledge of Site Visit program operations 

and a lack of continuity in the planning and performance of site visits. In addition, 

we found that C&P Service cannot ensure that on-site evaluations are performed in 

compliance with generally applicable governmental standards for independence or 

that sufficient independence exists between the Site Visit program’s employees and 

VSCs reviewed. 

• On-site Reviews. C&P Service plans site visits at VAROs to provide oversight on a 

3-year cycle. However, our analysis of completed site visits from FY 2001 to 

FY 2008 indicates that C&P Service failed to review all 57 VSCs in any 3-year 

period, and 7 (12 percent) of 57 VSCs were only visited once during that entire 8-year 

period. Because the 3-year cycle of review coverage has not been met, potentially 

low-performing VSCs who could most benefit from a Site Visit program evaluation 

may not be visited frequently enough. In addition, C&P Service does not have formal 

policies and procedures to ensure site survey protocols are modified to reflect 

emerging C&P issues and systemic deficiencies identified during site visits. As a 

result, C&P Service may not have assurance that on-site work at VSCs is focused on 

reviewing current, high-risk areas of VSC operations. 

VA Office of Inspector General ii 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

• Reporting and Follow-up. C&P Service established goals and objectives that 

include identifying best practices and trends, unique challenges, and out-of-line 

situations to support their mission. However, we determined C&P Service has not 

established procedures and guidelines to identify and disseminate best practices. 

Also, C&P Service has not developed reports that adequately develop the causes of 

errors identified, and a follow-up process to ensure that action items are resolved. In 

addition, C&P does not adequately identify and report system-wide trends to its 

stakeholders, thus missing out on opportunities to proactively address issues and 

concerns found during individual site visits nationwide. 

While the C&P Site Visit program provides centralized oversight and technical assistance 

to VSC operations, efforts are still needed to implement an adequate infrastructure and 

management strategy. These improvements will help to ensure this program meet its 

mission and goals and provide opportunities to continually improve VSC operations. 

Recommendations 

1. We recommend the Under Secretary for Benefits require C&P Service to develop a 

staffing plan that complies with VA Directive 5002, Workforce and Succession 

Planning, to ensure that sufficient resources are made available to the Site Visit 

program to complete VSC reviews on a three-year cycle. 

2. We recommend the Under Secretary for Benefits require C&P Service to comply with 

generally applicable government standards for independence when performing site 

visits. 

3. We recommend the Under Secretary for Benefits require C&P Service to develop a 

procedure to continuously monitor and update protocols to address systemic issues 

identified during site visit reviews, management concerns and priorities, and changes 

in program operations. 

4. We recommend the Under Secretary for Benefits require C&P Service to develop a 

process for the identification of best practices and resolution of inconsistencies in the 

application of policies and procedures. 

5. We recommend the Under Secretary for Benefits require C&P Service to develop and 

implement policies, procedures, and performance measures to strengthen follow-up 

on corrective action plans developed by Regional Offices on issues identified during 

on-site evaluations.

6. We recommend the Under Secretary for Benefits require C&P Service to ensure Site 

Visit reports issued for VSC operations to more fully identify the root cause of issues 

affecting VSC performance. 

VA Office of Inspector General iii 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

VA Office of Inspector General iv 

Management Comments and OIG Response 

The Under Secretary for Benefits concurred with our findings and recommendations. 

VBA agreed to formulate a workforce and succession plan for the Program Oversight 

Staff, develop standard operating procedures for updating site visit protocols, formalized 

procedures to record noted best practices, and revamp the program operations intranet 

site to share those practices. In addition, VBA also agreed to develop procedures to 

require evidence of improvement in identified challenge areas before action items will be 

closed, and ensure that the final reports include as much information as possible on 

potential root causes of issues affecting VSC performance. 

The Under Secretary for Benefits concurred with our findings and recommendations. 

The planned corrective actions for the recommendations are responsive to our concerns. 

We will close the recommendations when all proposed actions have been completed by 

VBA. The Director of VBA’s C&P Service also agreed that the they will incorporate the 

requirements for independence and impairment statements into C&P Service’s standard 

operating procedures for future site visits. These statements will be completed by each 

participant of the site visit reviews. Appendix B contains the full text of the Under 

Secretary’s comments. 

 (original signed by:)

BELINDA J. FINN 

Assistant Inspector General 

for Auditing 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

VA Office of Inspector General 1 

Introduction 

Purpose 

The VA Office of Inspector General (OIG) conducted this audit to determine whether the 

Veterans Benefits Administration’s (VBA) Compensation and Pension (C&P) Site Visit 

Program effectively monitors and evaluates Veteran Service Center (VSC) operations. 

During the audit, we assessed the effectiveness of Site Visit program planning, 

identifying and reporting operational issues and best practices, and the disposition of 

action items requiring attention. 

Background 

For many years, VSCs in each of the VAROs have experienced challenges processing 

veterans’ disability compensation and pension claims, including large backlogs of 

pending claims, lengthy processing times, and questions about the consistency of its 

Regional Office decisions.1

 VBA’s disability compensation and pension claims 

processing is handled within the 57 VAROs. Each state, except Wyoming, has at least 

one VARO; California has three; and New York, Pennsylvania, and Texas have two each. 

VBA also has VAROs in Washington, D.C.; San Juan, Puerto Rico; and Manila in the 

Philippines. In FY 2008, VBA paid about $42 billion in eligibility benefits to veterans 

and their beneficiaries under its disability compensation and pension programs. VBA 

employs more than 11,400 full-time employees to administer these programs. 

The mission of the C&P Site Visit program is to ensure centralized oversight and provide 

technical assistance to VSC operations within VBA’s 57 VA Regional Offices (VAROs). 

Site Visit teams monitor compliance with C&P policies and procedures and identify best 

practices to assist VSCs in achieving high performance. VSCs are scheduled for site 

visits on a 3-year cycle. From FY 2001 through FY 2008, the Site Visit program 

conducted 132 evaluations, 69 of which occurred from FY 2005 through FY 2008. The 

Site Visit program is organizationally aligned under the Director of C&P Service, who 

reports to the Associate Deputy Under Secretary for Policy and Program Management. 

In accordance with the Millennium Act requirements, VBA administers a multi-faceted 

quality assurance program in an effort to ensure C&P benefits are provided in a timely, 

accurate, and consistent manner. This comprehensive program includes four tiers: 

(1) Systematic Technical Accuracy Review (STAR), (2) VSC compliance oversight visits 

(site visits) conducted by central office site survey teams, (3) special ad-hoc reviews, and 

(4) rating consistency reviews. Site visits are conducted separately and independently for 

each of the business lines within VBA—C&P, Education, Vocational Rehabilitation and 

 

1

 In December 2005, the Government Accountability Office (GAO) issued a report that addresses veterans 

benefits—Further Changes in VBA’s Field Office Structure Could Help Improve Disability Claims Processing, 

GAO-06-149. 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Employment, Loan Guaranty, and Insurance. However, the audit assessed VBA’s C&P 

Site Visit program. 

Prior to performing a site visit, the VBA team leader conducts pre-site analyses of each 

VSC operation. The pre-site visit analysis includes a review of workload management 

plans, claim folder reviews, and prior C&P Site Visit reports. During the on-site review, 

the Site Visit team conducts a review of VSC operations using the following standard 

protocols—Service Center Operations; Workload Management; Training; STAR 

Reviews; Data Integrity; Internal Controls; and Service Organizations. In addition, while 

performing work at VAROs, the Site Visit team provides daily briefings to VSC 

management. At the conclusion of a site survey the team briefs VSC management on all 

potential actions requiring attention (also known as action items) and commendable 

practices noted during the visit. 

Upon completion of the site visit, the Program Operations staff issue a series of reports 

beginning with a post-site visit summary (also known as the “48-Hour Report”). The 48- 

Hour Report is a summary of the exit briefing provided to the respective VARO Director 

and is disseminated to senior VBA leadership including the Under Secretary for Benefits, 

the Associate Under Secretary for Field Operations, the Associate Under Secretary for 

Policy and Program Management, and the Director of C&P Service. The Program 

Operations staff then issues the final report to the VARO Director and senior VBA 

leadership. VAROs have 60 days from the final site visit report to provide an action plan 

to C&P Service to address action items. Upon receipt of the action plan, C&P Service 

provides a report confirming if the VARO’s response or implementation plan is sufficient 

to close each action item. 

Scope and Methodology 

We conducted our work from July to November 2008. We reviewed 26 reports from the 

69 site visits conducted from FY 2005 to FY 2008, and issued between May 2006 and 

July 2008. We visited four VSCs—New York, NY; Los Angeles, CA; Indianapolis, IN; 

and Phoenix, AZ. Each of these offices was visited by a C&P Site Visit team during 

FY 2008. Also, we interviewed 16 VARO Directors and 15 Veteran Service Center 

Managers (VSCMs) located at VAROs we did not visit but that had a completed site visit 

during FY 2008. (See Appendix A for a detailed description of the methodology.) 

VA Office of Inspector General 2 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Results and Conclusions 

The C&P Site Visit program is an integral part of VBA’s Quality Assurance program, 

providing C&P Service with an important mechanism to monitor VSC operations by 

evaluating compliance with C&P policies and procedures and identifying best practices. 

Site visits also provide the opportunity for C&P Service to conduct onsite inspections of 

VSC operations, discuss issues with regional office employees, and provide on-site 

training. Since FY 2005, the C&P Site Visit program completed 66 evaluations and 

recommended 687 corrective actions to improve VSC operations. Nevertheless, the C&P 

Site Visit program lacks an adequate infrastructure and management strategy to meet its 

mission and goals. Unless improvements in planning, executing, reporting, and followup are made to the C&P Site Visit program’s design and execution, C&P Service is likely 

to miss opportunities to improve performance across VBA’s regional office structure. 

Findings 

The C&P Site Visit program lacks a comprehensive management plan and program 

infrastructure that provides for workforce and succession planning, program performance 

measures, frequency and coverage of on-site reviews, and reporting and follow-up.

Workforce and Succession Planning. The Veterans Millennium Health Care and 

Benefits Act requires quality assurance programs to be staffed with sufficient FTE to 

perform quality assurance functions. In addition, VBA’s Workforce and Succession Plan 

for FY 2005 – FY 2008 requires the administration to sustain talent in mission-critical 

and leadership positions, to assure continuity of operations, and avoid losses of 

productivity caused by turnover. Since FY 2006, however, the C&P Site Visit program 

has experienced significant turnover and has never been fully staffed up to the allotted 

eight FTE. C&P Service has not developed a staffing plan to ensure that sufficient, 

experienced and independent staff is available to lead on-site visits to accomplish the Site 

Visit program’s mission. As a result, the C&P Site Visit program may continue to 

experience high turnover that affects program efficiency until staffing issues are resolved. 

In both FYs 2006 and 2008, the Site Visit program experienced significant turnover, and 

staffing levels for FYs 2007 and 2008 averaged five employees. (Table 1 that follows 

shows Site Visit staffing since FY 2006): 

Table 1: Site Visit Staffing 

Fiscal Year Authorized Assigned Turnover 

2006 8 6 6 

2007 8 5* 1 

2008 8 6* 3 

 *One FTE assigned but permanently detailed to another group 

In addition to staff shortages, Site Visit program staff stated they are also assigned 

collateral duties that consume an estimated 30 percent of their time. For example, two 

VA Office of Inspector General 3 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

employees were assigned to Veterans Network (VETSNET) report testing and two 

employees were assigned to the Rating Veteran Service Representative performance 

standards work group. Team Leads stated that collateral duties take away from the full 

attention needed to perform site visit field work. All three Team Leads interviewed 

expressed a desire to reduce or eliminate their collateral duties to enhance the quality and 

depth of their work. 

VBA’s Associate Under Secretary for Benefits and Director of C&P Service stated that 

they have been unable to maintain adequate staffing of the Site Visit program because of 

difficulties in recruiting qualified candidates from field offices who are willing to relocate 

to the Washington, D.C. area. To ease their recruitment challenges, VBA has reportedly 

considered relocating the Site Visit program and team to Nashville, TN, where the cost of 

living may be more attractive to potential employees. However, VBA has not made a 

final decision on relocating the team, and the Director of C&P Service has not developed 

a workload and succession plan to ensure that the Site Visit team has sufficient staff to 

accomplish their mission while meeting the demands of collateral duties. As a result, Site 

Visit team staffing shortages are continuing into FY 2009. 

Lack of Compliance with Government Standards for Staff Independence. Title 38, 

Part V, Chapter 77 requires the Secretary to carry out a quality assurance program 

operated to meet generally applicable governmental standards for independence for the 

performance of quality reviews. However, we found that C&P Service cannot ensure that 

site surveys are performed in compliance with these standards, or that sufficient 

independence exists between the Site Visit employees and the VSCs reviewed. The Site 

Visit program lacks adequate policies and procedures to identify, report, and resolve 

personal impairments to independence as well as to document the steps taken to identify 

potential personal independence impairments. As a result, C&P Service has not 

demonstrated compliance with generally applicable governmental standards for 

independence for its staff who conduct site visits. 

The current process involves only verbally verifying if each Site Visit team member has 

previously worked at an office they are assigned to review and no documentation of this 

verbal assessment is created. Because the concepts of objectivity and independence are 

very closely related, problems with independence may impair objectivity and potentially 

call into question the results of the review. For example, the appearance of a conflict of 

interest occurred when one Site Visit team member, who was a field representative from 

Fiduciary Service, was placed in a position to review Fiduciary work at the VSC where 

she had been temporarily assigned to provide technical guidance and training in the same 

area. 

Program Performance Measures. C&P has not established performance standards to 

measure accomplishment of the Site Visit program’s mission and stated goals. 

VA’s MP-1, Performance Measures and Standards, requires performance measures to be 

developed for all measurable activities within the agency. Furthermore, Executive Order 

VA Office of Inspector General 4 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

13450 requires the Secretary to implement clear annual and long-term goals defined by 

objectively measurable outcomes and specific plans for achieving the goals for each VA 

Program. The Executive Order requires specific agency personnel to be authorized and 

assigned the duties to achieve the goals and provided with the resources necessary to 

accomplish those duties. The Order also requires the Secretary to use the measurement 

of objective performance and accurate estimates of the full costs information to make 

budget and appropriations recommendations regarding VA Programs. The Secretary is 

required to develop a way to measure VA's progress toward achieving the goals, the 

efficient use of resources in making that progress, and continuous accountability of the 

specified agency personnel for achieving the goals and efficient use of resources. 

C&P Service has not established performance standards to measure accomplishment of 

the Site Visit program’s stated mission and goals. According to the Assistant Director of 

Quality Assurance, she wants to build the program prior to developing criteria to measure 

its success. However, the Director of C&P Service agreed developing formal 

performance standards would be beneficial to the program. As a result of not having 

performance measures, C&P Service does not have a method to ensure accountability of 

the Site Visit program. 

Site Visit Frequency. C&P Service plans to conduct 

site visits at VSCs on a 3-year cycle. However, our 

analysis of completed site visits from FY 2001 to 

FY 2008 indicates that C&P Service failed to review all 

57 VSCs in any 3-year period, and 7 (12 percent) of 

57 VSCs were only visited once during that entire 8-year 

period. 

Table 2. Number of Site 

Visits, FY 2001-FY 2008 

Fiscal Year Site Visits 

2008 20 

2007 16 

2006 15 

2005 18 

2004 19 

2003 17 

2002 14 

2001 13 

Total 132 

Because the 3-year cycle of review coverage has not 

been met, potentially low-performing VSCs that could 

most benefit from a site visit may not be visited 

frequently enough. For example, six VSCs were not the 

subject of site visits between FY 2005 and FY 2008. Of 

these six, five (83 percent) generally did not meet VBA’s 

National Performance Standards in areas such as C&P 

Rating Inventory, Average Days Pending, and Accuracy. 

Site Visit Review Protocols. C&P Service does not have formal policies and procedures 

to ensure Site Visit protocols are modified to reflect emerging C&P issues and systemic 

deficiencies identified during site visits. The 2005 Quality Assurance Team Study

recommended emphasis placed on specific topics during a site visit and need to be 

tailored based on pre-site visit analysis and on-going monitoring of the station’s workload 

and performance. In response, the Director of C&P Service concurred with the 

recommendation and stated they would regularly monitor station performance and tailor 

the visits to particular areas requiring improvement, and “place more emphasis on the 

VA Office of Inspector General 5 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

performance indicators and less on compliance issues.” Target completion for this 

recommendation was June 2006. In addition, in July 2008, the Associate Deputy Under 

Secretary for Policy and Program Management stated Site Visit protocols may need to be 

updated or revised to be kept more manageable and attuned to current concerns and 

trends, although this has yet to occur. 

Site Visit protocols have only been changed three times since FY 2005. For example, in 

July of 2008 a protocol was added to the review process as a result of a Site Visit team 

identifying a condition at the New York VSC where employees applied incorrect dates of 

claim into an electronic database. These modifications to the protocols show that the Site 

Visit teams strive to keep their protocols current and relevant. However, they fall short 

of tailoring site visits to the needs of stations based on regularly monitoring station 

workload and performance and placing more emphasis on performance indicators. 

Regularly reviewing and potentially streamlining the protocols would allow the Site Visit 

teams to perform more in-depth reviews on important, high-risk areas of inquiry. For 

example, C&P Site Visit teams review seven categories that include 19 reportable areas. 

Our review of these 26 Site Visit reports (conducted from FY 2005 to FY 2008 and 

issued between May 2006 and July 2008) disclosed 67 percent of all action items 

occurred in the areas of: Quality, Data Integrity, Control and Management, and 

Workflow. At the same time, no findings were reported in the areas of: Staffing, Claims 

Processing Initiative, and Veteran Service Organizations. 

The Site Visit teams reported to us that they were rushed to complete work while on-site. 

Consequently, they may be unnecessarily dedicating resources to areas of lower risk, and 

their work may have resulted in lesser impact on the improvement of VSCs. As a result, 

C&P Service does not have assurance that Site Visit teams are reviewing the most highrisk areas for VSC operations. 

Reporting and Follow-up. C&P Service established goals and objectives for the Site 

Visit program that included identifying best practices and trends, unique challenges, and 

out-of-line situations to support their mission. However, C&P Service is not achieving 

these goals. The Site Visit program has not actively identified best practices since 

FY 2006 and does not adequately identify and report system-wide trends to its 

stakeholders. Additionally, Site Visit reports do not fully develop the root causes of 

errors identified, and C&P Service has not effectively ensured that action items identified 

during site visits are fully resolved by the VAROs. 

Identification and Dissemination of Best Practices 

The Site Visit program mission states “survey teams will monitor operations and identify 

best practices to assist the stations in achieving high performance.” In addition, the 

2005 Quality Assurance Team Study stated that more emphasis on commendable findings 

or best practices noted during site visits was needed. It recommended that C&P Service 

VA Office of Inspector General 6 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

develop a method to test best practices noted during site visits and a means to formalize 

and share them with other regional offices on a timely basis. In response, C&P Service 

stated they concurred with the recommendation and would take the following steps in 

FY 2006: 

• Work with the Office of Field Operations (OFO) on methods to test best practices 

discovered during site visits. 

• Publish a Best Practice Training letter at least annually. 

• “Revitalize” the C&P best practices web page, keeping it updated (as additional best 

practices are identified) and redesigned so that best practices were reported in a 

format that was easy to use and follow. 

Although the former Director of C&P Service agreed to implement these 

recommendations, C&P Service had not implemented them or made the identification 

and dissemination of best practices a priority of the Site Visit program. C&P Service has 

yet to establish guidelines for identifying and disseminating best practices and could not 

provide evidence that C&P Service and OFO have developed and implemented methods 

to test best practices discovered during site visits. C&P Service has not reported any best 

practices since April 2006 when they posted one on the C&P Service Site Visit intranet. 

Also, C&P Service has yet to issue a best practices training letter to all field stations. 

In March 2006, C&P Service briefed VSCs on five potential best practices discovered 

during site visits in FY 2004 and FY 2005. C&P Service believed these best practices 

would have a major impact on improving operations and would study them with OFO. 

For example, one involved VSCs implementing the use of separate post office boxes for 

replies from veterans received in response to VA development letters. Despite this 

information, C&P Service could produce no evidence it evaluated these potential best 

practices to determine whether any of the best practices identified would be beneficial to 

operations nationwide. 

Despite the fact that identifying best practices is part of the stated mission of the program 

and VSC managers stated that sharing best practices would be beneficial to their 

operations, Site Visit team members and program officials agreed that little emphasis has 

been placed on defining and identifying best practices. The lead management analyst for 

OFO stated “OFO does not work with Site Visit consultants on methods to identify or test 

best practices as they fall under C&P’s jurisdiction.” The Assistant Director of Quality 

Assurance stated that they were still rebuilding the staff and had deemphasized best 

practices in the interests of accomplishing site surveys with limited staff. As a result, 

C&P Service may be missing opportunities to assist VSCs in achieving high performance 

nationwide. 

VA Office of Inspector General 7 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Reporting System-Wide Trends

C&P Service does not adequately identify and report system-wide trends to its 

stakeholders, thus missing out on opportunities to proactively address issues and concerns 

found during individual site visits nationwide. One of C&P Service’s stated goals for the 

Site Visit program is to identify trends, unique challenges, and out-of-line situations. In 

addition, VBA’s 2005 Quality Assurance Team Study section on the Site Visit program 

states that one objective of the C&P Site Visit program is to identify “trends that trigger a 

review of policies and procedures established by Central Office to determine if they 

should be rewritten for clarification or changed.” 

Nevertheless, C&P Service’s trend analysis of issues and concerns identified during site 

visits is limited to an annual roll-up of all issues on their web-site. However, this roll-up 

is primarily a numerical presentation of issue areas in broad categories instead of 

identifying specific trends and system-wide deficiencies. The Director of C&P Service 

believes that stations review the annual roll-up in preparation for site visits. However, 

VBA’s Associate Deputy Under Secretary for Policy and Program Management, VARO 

Directors, and station managers—senior managers who would most likely benefit from a 

report providing trends in Site Visit program issues and concerns—were generally 

unaware of the annual report, and thus, would not be able to take proactive actions to 

address issues and concerns found commonly in VSCs. As a result, and according to 

senior officials, information from Site Visit reports has resulted in some changes to C&P 

policies and procedures throughout its regional office structure; however, C&P Service 

may not be maximizing the use of information collected. 

C&P Service has not developed procedures to analyze Site Visit program results and to 

develop and report system-wide trends to stakeholders because the Director of C&P 

Service stated the annual roll-up was sufficient. As a result, the lack of identifying 

system-wide trends may have contributed to similar deficiencies occurring in the regional 

offices: 

• Our analysis of the 26 C&P Site Visit reports issued between May 2006 and July 

2008 disclosed that 25 (96 percent) had reported 236 deficiencies requiring corrective 

action. 

• Of the 236 deficiencies, 157 (67 percent) occurred in the following categories: 

 Twenty-two (85 percent) of 26 had 37 action items in Quality that primarily 

focused on quality of information furnished to beneficiaries and violation of 

Privacy Act and Freedom of Information Act (PA/FOIA) requirements. 

 Fourteen (54 percent) of 26 had 22 action items in Data Integrity that primarily 

focused on accuracy and regional offices taking double work credit and incorrectly 

reporting work in electronic databases. 

 Seventeen (65 percent) of 26 had 39 action items in Control and Management that 

primarily focused on updating Workload Management Plan (WMP), developing 

VA Office of Inspector General 8 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

fiduciary procedures, controlling Fiduciary-Beneficiary Super-user access, and 

identifying and investigating alleged misuse. 

 Twenty (77 percent) of 26 had 59 action items in Alignment and Workflow that 

primarily focused on ensuring the WMP is followed as it relates to strengthening 

the control, review and processing of mail, and all rating and non-rating End 

Products. 

Follow-up on VSC Corrective Actions

VA Directive 0070, Management Accountability and Control Program, requires 

managers to promptly evaluate findings and recommendations by reviewers, determine 

proper actions, and complete all actions to correct or resolve the reported weakness. 

However, C&P Service does not have effective processes or methods to ensure that VSCs 

adequately implement corrective action plans. As a consequence, issues and concerns 

may remain at VSCs after these action items have been deemed to be closed by C&P 

Service or may repeat at the same VSC during a subsequent site visit. Closer 

coordination with Area Offices and OFO and regular monitoring of VSC performance 

data is needed to resolve these issues. 

Stations are required to provide an implementation plan for each action item listed in the 

Site Visit report. If the station’s response is adequate, such as, C&P Service is convinced 

the actions taken by the station will resolve the issue, the item is considered closed. If the 

response is determined to be inadequate, or the station indicates they will be taking action 

at a future date, the action item is left open and the station is instructed to notify the 

Program Operations staff when the appropriate action has been taken. A follow-up site 

visit may be scheduled to review compliance with action items or C&P Service may wait 

for the next scheduled site visit based on the 3-year cycle. However, our on-site testing at 

three VSCs revealed 8 (44 percent) of 18 conditions still existed after Site Visit teams 

closed the action items: 

• Los Angeles—conditions still existed for 1 (20 percent) of 5 closed action items. 

 timely control of appeal claims in electronic data base 

• Indianapolis—conditions still existed for 4 (44 percent) of 9 closed action items. 

 ensure the procedures for processing Federal Program matching cases 

 local quality reviews are not conducted consistently between managers 

 consistently following the workload management plan 

 controlling appeals workload 

• Phoenix—conditions still existed for 3 (75 percent) of 4 closed action items. 

 controlling appeals workload 

 controlling or timely processing Federal Program matching cases 

 controls over locked files 

VA Office of Inspector General 9 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Nineteen (73 percent) of 26 VSC Site Visit reports issued between May 2006 and July 

2008 contained action items that included repeat findings from the previous site visit. 

The Assistant Director of Quality Assurance stated that implementation of VSC 

corrective action plans were generally taken at “face value” and closed. C&P Service 

also relies on OFO and Area Offices to follow up on reported action items. However, our 

interview with the Lead Management Analyst for OFO indicated they do not provide 

follow-up on completed site visits unless an egregious deficiency is identified. 

Reports 

Site Visit reports do not adequately identify the root cause of significant issues that affect 

VSC performance. VBA’s Quality Control Instructions state the objective of quality 

control includes identifying causes of errors and to determine the actions required to 

eliminate the causes of quality defects, and schedule these actions for completion and 

long-term quality improvement. Our review of nine Site Visit reports (FY 2005 – FY 

2008) determined that the root causes of 84 deficiencies presented in the reports were not 

identified. Partial cause was identified in only 10 of the action items. Of the 84 action 

items, 11 were repeat deficiencies from the previous site visit. Inconsistent identification 

of root causes could lead to VSC managers designing ineffective corrective action plans 

to address identified issues or concerns. 

Nineteen of 26 C&P Site Visit reports issued between May 2006 and July 2008 identified 

56 action items as repeat findings from the prior site visit. Our analysis concluded none 

of the 19 reports provided a full discussion regarding the underlying cause for the 

continuing deficiencies. Additionally, site visit reports did not always disclose that a 

VSC had repeat action items: 

• Twelve (63 percent) of the 19 reports did not identify 39 (70 percent) of the 56 action 

items as repeat action items in the executive summary of the report. 

• Four (21 percent) of the 19 reports did not identify 23 (41 percent) of the 56 action 

items as repeat action items in the body of the report. 

C&P Service may not have allotted sufficient resources for on-site evaluations to perform 

analyses of sufficient depth and breadth. According to a Site Visit Team Lead, Site Visit 

reports are written for upper level managers at VBA and not for VSC managers. 

Consequently, they may omit details that implementing-level managers may need to 

correct issues. Nine (24 percent) of 37 Directors and VSCMs interviewed indicated 

current Site Visit reports do not provide the level of detail needed to enable them to make 

sound decisions to improve their operations. Team Leads stated they did not always have 

the time they needed to identify root causes to recommend appropriate corrective actions 

to regional offices. 

VA Office of Inspector General 10 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

Conclusion 

The C&P Site Visit program is an integral part of VBA’s Quality Assurance program, 

and provides C&P Service with an important mechanism to monitor VSC operations by 

evaluating compliance with C&P policies and procedures and identifying best practices. 

While the C&P Site Visit program provides centralized oversight and technical assistance 

to VSC operations, efforts are still needed to implement an adequate infrastructure and 

management strategy in order to ensure this program meets its mission and goals and 

provide opportunities continually improve VSC operations. 

Recommendations 

1. We recommend the Under Secretary for Benefits require C&P Service to develop a 

staffing plan that complies with VA Directive 5002, Workforce and Succession 

Planning, to ensure that sufficient resources are made available to the Site Visit 

program to complete VSC reviews on a three-year cycle. 

2. We recommend the Under Secretary for Benefits require C&P Service to comply with 

generally applicable government standards for independence when performing site 

visits. 

3. We recommend the Under Secretary for Benefits require C&P Service to develop a 

procedure to continuously monitor and update protocols to address systemic issues 

identified during site visit reviews, management concerns and priorities, and changes 

in program operations. 

4. We recommend the Under Secretary for Benefits require C&P Service to develop a 

process for the identification of best practices and resolution of inconsistencies in the 

application of policies and procedures. 

5. We recommend the Under Secretary for Benefits require C&P Service to develop and 

implement policies, procedures, and performance measures to strengthen follow-up 

on corrective action plans developed by Regional Offices on issues identified during 

on-site evaluations.

6. We recommend the Under Secretary for Benefits require C&P Service to ensure Site 

Visit reports issued for VSC operations to more fully identify the root cause of issues 

affecting VSC performance. 

VA Office of Inspector General 11 
Audit of the Veterans Benefits Administration Compensation and Pension Site Visit Program 

VA Office of Inspector General 12 

Management Comments and OIG Response 

The Under Secretary for Benefits concurred with our findings and recommendations. 

VBA agreed to formulate a workforce and succession plan for the Program Oversight 

Staff, develop standard operating procedures for updating site visit protocols, a more 

formalized procedure to record noted best practices and revamp the program operations 

intranet site to share those practices. In addition, VBA also agreed to develop procedures 

to require evidence of improvement in identified challenge areas before action items will 

be closed, and ensure that the final reports include as much information as possible on 

potential root causes of issues affecting VSC performance. 

The Under Secretary for Benefits concurred with our findings and recommendations. 

The planned corrective actions for the recommendations are responsive to our concerns. 

We will close the recommendations when all proposed actions have been completed by 

VBA. The Director of VBA’s C&P Service also agreed that the they will incorporate the 

requirements for independence and impairment statements into C&P Service’s standard 

operating procedures for future site visits. These statements will be completed by each 

participant of the site visit reviews. Appendix B contains the full text of the Under 

Secretary’s comments. 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program

Appendix A 

VA Office of Inspector General 13 

Methodology 

During the audit of VBA’s C&P Site Visit program, we assessed the effectiveness of 

program management, the process for identifying and reporting operational issues and 

best practices, and the disposition of reported action items. We visited four VSCs: New 

York, NY; Los Angeles, CA; Indianapolis, IN, and Phoenix, AZ. Each of these offices 

was visited by VBA’s C&P Site Visit team during FY 2008. Site selections were based 

on the number of action items and repeat action items identified in the Site Visit reports 

completed by the Site Visit team during FY 2008.2

 We selected the New York VSC to 

observe an actual site visit to gain a better understanding of the Site Visit program; 

however, we did not perform audit work at that station. We selected the Phoenix VSC 

because this station had a high number of action items identified in the most recent Site 

Visit report and because it is co-located with VBA’s Western Area Office. 

We interviewed the Western Area Director, VARO Directors, Veteran Service Center 

Managers (VSCMs), Assistant Veteran Service Center Managers (AVSCM), and VSC 

staff during our visits to the four VSCs. While at each VSC, we analyzed the VSC 

corrective action plans related to the respective Site Visit report. We tested compliance 

of closed action items by reviewing electronic databases such as Modern Awards 

Processing (MAP-D) and Veterans Appeals Controls and Locator System (VACOLS), 

VSC training records, and claims file sequencing. Also, we interviewed 16 VARO 

Directors and 15 VSCMs located at VAROs we did not visit but had a completed site 

visit during FY 2008. 

We interviewed senior leadership at VBA Central Office, including the Associate Deputy 

Under Secretary for Policy and Program Management, the Director of C&P Service, the 

Assistant Director of Quality Assurance, and Chief of Program Operations. In addition, 

we interviewed the Site Visit team leads and the Lead Management Analyst in OFO. We 

also reviewed pre-site visit planning documents, and Site Visit protocols. We visited the 

Western Area Office in Phoenix, AZ to interview the Western Area Director to discuss 

his role in performing Area site visits, in coordinating with C&P Service for their site 

visits, and in following up on C&P Site Visit reported action items to ensure VSC’s 

timely implement effective corrective actions. 

We selected 26 reports from the 69 site visits conducted from FY 2005 – FY 2008, 

issued between May 2006 and July 2008, to determine the cycle time between the site 

visits, elapsed days to issue final reports, number of action items and continuation of 

action items from prior reports, and reportable categories exhibiting significant numbers 

of action items. 

 

2

 We originally selected the Houston VARO, but changed our plans due to logistical complications resulting from 

Hurricane Ike. We instead substituted the Indianapolis VARO. 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program

Appendix A 

VA Office of Inspector General 14 

Our assessment of internal controls focused only on those controls related to our audit 

objectives. We conducted this performance audit in accordance with generally accepted 

government auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our 

findings and conclusions based on our audit objectives. We believe that the evidence 

obtained provides a reasonable basis for our findings and conclusions based on our audit 

objectives. 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program 

Appendix B 

Under Secretary for Benefits Comments 

VA Office of Inspector General 15 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program 

VA Office of Inspector General 16 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program 

Appendix B 

VA Office of Inspector General 17 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact Timothy Crowe (727) 395-2422 

Acknowledgments Brent Arronte 

Jessica Blake 

Alan Brecese 

Robert Campbell 

Debra Cato 

Tom McPherson 

Victor Milano 

VA Office of Inspector General 18 
Audit of the Veterans Benefits Administrations Compensation and Pension Site Visit Program

Appendix D 

Report Distribution 

VA Distribution

Office of the Secretary 

Veterans Health Administration 

Veterans Benefits Administration 

National Cemetery Administration 

Assistant Secretaries 

Office of General Counsel 

Non-VA Distribution

House Committee on Veterans’ Affairs 

House Committee on Appropriations, Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Committee on 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 

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 19