Systemic Issues Reported
 

During Inspections at
 

VA Regional Offices
 

OFFICE OF AUDITS AND EVALUATIONS

May 18, 2011 

11-00510-167 
ACRONYMS AND ABBREVIATIONS
 

C&C Confirmed and Continued 

C&P Compensation and Pension 

COVERS Control of Veterans Records System 

IRIS Inquiry Routing and Information System 

NOD Notice of Disagreement 

OIG Office of Inspector General 

PII Personally Identifiable Information 

PTSD Post-Traumatic Stress Disorder 

RVSR Rating Veterans Service Representative 

SAO Systematic Analysis of Operations 

STAR Systematic Technical Accuracy Review 

TBI Traumatic Brain Injury 

VACOLS Veterans Appeals Control and Locator System 

VARO Veterans Affairs Regional Office 

VBA Veterans Benefits Administration 

VSC Veterans Service Center 

To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Report Highlights: Systemic Issues 

Reported During Inspections at VA 

Regional Offices 

Why We Did These Reviews What We Recommend
 

The Office of Inspector General established 

its Benefits Inspection Program in March 

2009 as a major initiative to help ensure 

timely and accurate delivery of veterans’ 

benefits and services. This report is a 

summary of systemic issues identified 

at 16 VAROs inspected from April 2009 to 

September 2010. We did not inspect all 

operational activities at each VARO. 

What We Found 

VARO management teams face multiple 

challenges in providing benefits and services 

to veterans. Challenges include providing 

additional oversight and training for 

personnel responsible for processing 

disability compensation claims related to 

temporary 100 percent disability 

evaluations, post-traumatic stress disorder, 

traumatic brain injury, herbicide-related 

disabilities, and Haas cases. We projected 

that VARO staff did not correctly process 

23 percent of approximately 45,000 claims. 

We also found weaknesses associated with 

processing Notices of Disagreements for 

appealed claims, correcting errors identified 

by VBA’s Systematic Technical Accuracy 

Review Program, ensuring timely and 

complete Systematic Analyses of 

Operations, and processing claims-related 

mail. Additionally, VARO staff did not 

always safeguard veterans’ personally 

identifiable information or make timely final 

competency decisions for beneficiaries 

unable to manage their affairs. 

As a result of the 16 inspections, we made 

86 recommendations to improve VARO 

operations regarding the systemic issues 

addressed. VARO Directors concurred with 

all of the recommendations. 

We further recommend the Acting Under 

Secretary for Benefits revise the policy on 

evaluating residuals of Traumatic Brain 

Injuries and provide training to medical 

examiners conducting traumatic brain injury 

medical examinations to ensure compliance 

with current examination requirements. We 

also recommend the Acting Under Secretary 

develop a clear and measurable standard for 

timely completion of competency 

determinations. 

Agency Comments 

The Acting Under Secretary for Benefits 

concurred with our recommendations. 

Management’s planned actions are 

responsive and we will follow up as required 

on all actions. 

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 ........................................................................................................................12
 

3. Management Controls ...........................................................................................................13
 

4. Workload Management and Information Security................................................................16
 

5. Eligibility Determinations.....................................................................................................19
 

Appendix A Scope of the Inspections....................................................................................22 

Appendix B Acting Under Secretary for Benefits Comments ..............................................24 

Appendix C Statistical Sampling Methodology ....................................................................28 

Appendix D VARO Inspection Results.................................................................................32 

Appendix E OIG Contact and Staff Acknowledgments........................................................33 

Appendix F Report Distribution ...........................................................................................34 

ii 
Benefits Inspection Annual Summary Report 

Objective
 

Scope of
 

Inspection
 

INTRODUCTION 

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

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

benefits and services. The Benefits Inspection Division conducts onsite 

inspections at VA Regional Offices (VAROs). These inspections contribute 

to the improvement and management of benefits processing activities and 

veterans’ services. The purpose of these independent inspections is to 

provide recurring oversight of VAROs by focusing on disability 

compensation claims processing and performance of Veterans Service Center 

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

	 Evaluate to what extent VAROs are accomplishing their mission of 

providing veterans with access to high quality benefits 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. 

From April 2009 through September 2010, we conducted inspections of the 

following 16 VAROs (listed in order of inspection): 

	 Nashville, TN  Waco, TX 

	 Wilmington, DE  Albuquerque, NM 

	 Baltimore, MD  Muskogee, OK 

	 San Juan, PR  Denver, CO 

	 Anchorage, AK  Cheyenne, WY 

	 Roanoke, VA  Detroit, MI 

	 Togus, ME  Jackson, MS 

	 Philadelphia, PA  Newark, NJ 

Appendix A provides additional details on the scope of the inspections. 

Appendix B contains the Acting Under Secretary for Benefits’ comments. 

Appendix C provides a summary of the inspection results for the 16 VAROs 

inspected and includes the criteria used to evaluate each operational activity. 

We did not always review the same operational activities at each VARO 

inspected. 

VA Office of Inspector General 1 
Benefits Inspection Annual Summary Report 

RESULTS AND RECOMMENDATIONS 

1. Disability Claims Processing 

The OIG inspection team focused on disability claims processing related to 

temporary 100 percent disability evaluations, post-traumatic stress disorder 

(PTSD), traumatic brain injury (TBI), herbicide exposure, and Haas cases. 

Haas1 claims involve veterans who served in waters off Vietnam, never 

having set foot in Vietnam, and whether those veterans are entitled to the 

presumption of exposure to herbicide agents, including Agent Orange. 

Finding 1	 Veterans Benefits Administration Needs to Improve 

Disability Determination Accuracy 

The Veterans Benefits Administration (VBA) needs to improve the accuracy 

of disability claims processing. Based on 16 VARO inspections, we 

projected that VARO staff incorrectly processed about 23 percent of an 

estimated 45,000 claims. Of these, about 8 percent affected veterans’ 

benefits and approximately 15 percent had inaccuracies with the potential to 

affect veterans’ benefits. Table 1 summarizes our projection of the errors 

affecting veterans’ benefits, and those with the potential to affect benefits. 

Table 1	 Disability Claims Processing Results 

Type Reviewed 

Claims Incorrectly Processed (Projected)* 

Error Rate Affecting 

Veterans’ Benefits 

Potential To Affect 

Veterans’ Benefits 

Temporary 

100 Percent 

Disability 

Evaluations 

277 82% 20% 62% 

PTSD 470 8% 4% 4% 

TBI 325 19% 11% 8% 

Herbicide 

ExposureRelated 

Claims 

453 8% 6% 1% 

Haas 89 13% 2% 11% 

Total 1614 23% 8% 15% 

*Numbers for projected error rates do not equal due to rounding. 

1

Haas claims are affected by a U.S. Court of Appeals for Veterans Claims decision in Haas 

v. Nicholson. VA put a stay of adjudication on these claims; however, it lifted the stay in 

January 2009. 

VA Office of Inspector General 2 
Benefits Inspection Annual Summary Report 

Temporary 

100 Percent 

Disability 

Evaluations 

In October 2009, we began inspecting temporary 100 percent disability 

evaluations. None of the 10 VAROs inspected followed VBA policy in 

processing these claims. VBA policy allows a temporary 100 percent 

evaluation for service-connected disabilities requiring surgery or specific 

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

treatment, VARO staff must review the veteran’s medical condition to 

determine if staff should continue the temporary evaluation. 

We projected that VARO staff did not adequately process temporary 

100 percent evaluations for about 6,800 (82 percent) of approximately 

8,300 veterans. This generally occurred because VARO management did not 

establish controls to ensure staff input reminder notifications (also known as 

diaries) for reexaminations into VBA’s electronic record as required. As a 

result, veterans did not always receive accurate benefit payments. 

Our Audit of VBA’s 100 Percent Disability Evaluations, (Report No. 09­

03359-71, January 2011), projected approximately $1.1 billion dollars in 

overpayments over the next 5 years if VBA does not implement controls to 

improve processes associated with 100 percent disability evaluations. 

Further, this report disclosed that VAROs are not correctly evaluating and 

monitoring 100 percent evaluations. As the Acting Under Secretary for 

Benefits provided comments to that report, we make no additional 

recommendations. 

Figure 1 depicts projected error rates in temporary 100 percent disability 

claims processing. 

Figure 1 Projected Errors Rates in Temporary 100 Percent Disability Claims 

C&C Processing 

23% 

Data Processing 

Rating Decision 

11% 

Decisions Not 

Finalized 

7% 

42% 

Medical Exam 

Notifications Not 

Processed 

17% 

VA Office of Inspector General 3 
Benefits Inspection Annual Summary Report 

We estimated 42 percent of the errors involved confirmed and continued 

(C&C) rating processing errors. A C&C rating is one where the evidence 

does not necessitate changing the veteran’s existing disability evaluation. 

For example, a veteran receives a temporary 100 percent evaluation for 

prostate cancer. Medical evidence from reexamination to determine if the 

evaluation should continue shows the veteran still receives treatment for this 

condition. Therefore, the RVSR confirms the veteran remains entitled to the 

temporary 100 percent evaluation and decides to continue the evaluation until 

the next required reexamination period, as established by diaries. 

The inaccuracies occurred when VARO staff did not input suspense diaries 

for reexaminations in an electronic system as mandated by VBA policy. A 

diary is a processing command that establishes a date when VSC staff must 

schedule reexaminations. As diaries mature, the electronic system generates 

reminder notifications to alert VSC staff to schedule the mandatory 

reexaminations. When staff omit diaries, the temporary 100 percent 

disability evaluation will continue throughout a veteran’s lifetime because 

nothing calls such cases into question again for reexamination. 

Following are descriptions of the remaining error types for which we made

projections. 

	 Data processing errors: Incorrectly using computer applications, such as 

canceling reexamination reminder notifications designed to manage 

workloads associated with temporary evaluations. 

	 Medical exam notifications not processed: Taking no action upon

receiving a notification from the Benefits Delivery Network to schedule a

medical examination. (VBA no longer uses the Benefits Delivery 

Network to generate these notifications.) 

	 Rating decision inaccuracies: Omitting diary dates in rating decisions for

mandatory future medical examinations. When the date is omitted, VSC 

staff do not recognize the need to input a diary to prompt a future

examination. 

	 Decisions not finalized: Proposing in rating decisions to reduce 

temporary 100 percent disability evaluations, but not taking final action

to follow through with the reductions. 

In November 2009, VBA’s Compensation & Pension (C&P) Service 

published guidance reminding VAROs about proper system input for C&C 

evaluation ratings. Based on our analysis, it does not appear VAROs are 

following this guidance. To assist VBA in monitoring VARO compliance 

with guidance for processing temporary 100 percent disability evaluations, 

including C&C evaluations, we provided VBA our procedures for extracting 

data from VA systems on cases in existence for 18 months or more. VBA 

would benefit from using such data to monitor VARO compliance on an 

ongoing basis. 

VA Office of Inspector General 4 
PTSD Claims 

Benefits Inspection Annual Summary Report 

In his comments on a draft of this report, the Acting Under Secretary for 

Benefits stated the computer system did not properly maintain the future 

examination dates and VBA identified multiple computer system errors. We 

did not examine the sufficiency of this computer system and make no 

comment on the system errors VBA identified. However, the problems we 

found were due to employee errors in not entering suspense diaries in the 

system for confirmed and continued decisions. During our inspections, for 

numerous cases and at various locations, we showed VARO staff in the 

computer system that no histories existed of suspense diaries ever having 

been input. 

The results of our inspection work reinforce the findings identified in the 

January 2011 Audit of VBA’s 100 Percent Disability Evaluations. As such, 

we will continue to review temporary 100 percent disability evaluations 

during our annual inspection work to ensure that VBA implements a process 

to improve accuracy in this area. 

Of the 16 VAROs inspected, 8 (50 percent) did not follow VBA policy when 

processing PTSD claims. Service connection for PTSD requires credible 

evidence that a claimed in-service stressful event occurred, medical evidence 

diagnosing the condition, and a nexus (established by medical evidence) 

linking current symptoms and the in-service stressful event. 

We projected VARO staff did not correctly process about 1,350 (8 percent) 

of approximately 16,000 PTSD claims completed from April 2009 through 

July 2010. This generally occurred because VARO staff lacked sufficient 

experience and training to process these claims accurately. Additionally, 

some VAROs were not conducting monthly quality assurance reviews. For 

these reasons, veterans did not always receive accurate benefits. The figure 

below provides projected error rates by the types of PTSD errors identified. 

Figure 2 Projected Error Rates in PTSD Claims Processing 

Incorrect 

Evaluations 

19% 

Improper
 

Stressor
 

Verification
 

38%
 

Lack of Nexus 

11% 

Additional 

Benefits Not 

Considered 

8% 

Incorrect 

Effective Dates 

24% 

VA Office of Inspector General 5 
TBI Claims 

Benefits Inspection Annual Summary Report 

For example, we projected that of the PTSD claims incorrectly processed, 

about 38 percent involved improper verification of a related in-service 

stressful event. Stressor verification errors occurred when staff did not 

obtain sufficient evidence that the alleged stressful events actually occurred. 

Further, inaccuracies related to incorrect effective dates occurred because 

RVSRs used the wrong dates to establish benefits, often resulting in 

inaccurate payments to veterans. 

Following are descriptions of the remaining three types of PTSD errors. 

	 Incorrect evaluations: Assigning incorrect evaluations for veterans’ 

mental status inconsistent with evidence in medical examination reports. 

	 Lack of nexus: Improperly granting service connection for PTSD 

without a medical opinion linking a current diagnosis of PTSD to a 

claimed, in-service stressful event. 

	 Additional benefits not considered: Not considering entitlements, such 

as Dependents’ Educational Assistance. 

Effective July 13, 2010, VA amended its rule for processing PTSD disability 

compensation claims. The new rule allows VARO staff to rely on a 

veteran’s lay testimony alone to establish a stressor related to fear of hostile 

military or terrorist activity, provided the claimed stressor is consistent with 

the circumstances of service. Prior to the rule change, we identified a 

13 percent error rate associated with PTSD claims processing. From the date 

of the rule change until September 2010, however, we identified a 5 percent 

error rate. Because of this noticeable improvement in PTSD claims 

processing, we made no recommendations for corrective actions in this area. 

We may modify our review of PTSD claims in future inspections until 

VAROs have sufficient time to implement fully the amended rule. 

Of the 16 VAROs inspected, 12 (75 percent) did not follow VBA policy 

when processing claims for residuals of TBI. The Department of Defense 

and VBA commonly define a TBI as a traumatically induced structural injury 

or physiological disruption of brain function because of an external force. 

The major residual disabilities of a TBI fall into three main 

categories-physical, cognitive, and behavioral. VBA policies require staff to 

evaluate residual disabilities. 

We projected that VARO staff did not adequately process about 

800 (19 percent) of approximately 4,100 TBI claims completed from 

April 2009 through July 2010. This generally occurred because VARO staff 

lacked sufficient experience and training to process TBI claims accurately. 

Further, some VAROs did not perform adequate quality reviews of 

completed TBI claims. For these reasons, veterans did not always receive 

accurate benefits. 

VA Office of Inspector General 6 
Benefits Inspection Annual Summary Report 

Figure 3 reflects projected error rates by the types of TBI errors identified. 

Figure 3	 Projected Error Rates in TBI Claims Processing 

Incorrect Incorrect 

Effective Dates Grant/Denial of 

7% Service
 

Conneciton
 

9%
 

Inadequate Incorrect 

Medical Evaluations 

Examinations 42% 

42% 

We estimated 42 percent of TBI errors occurred because VARO staff used 

medical examinations that did not contain sufficient information to make 

accurate benefit decisions. VA medical examiners did not always use the 

most current examination formats when conducting medical examinations. 

As such, some examiners provided VARO staff with medical examination 

reports that did not contain the necessary information to properly render 

disability determinations. Some RVSRs did not always return inadequate 

medical examinations to the appropriate medical facilities for correction as 

required by VBA policy. 

Additionally, 42 percent of TBI errors occurred because RVSRs incorrectly 

evaluated TBI-related residual disabilities. VBA policy requires a separate 

evaluation for any disability with a distinct diagnosis related to a TBI, such 

as migraine headaches or tinnitus. However, in these instances, RVSRs did 

not grant separate evaluations for distinct disabilities related to TBI. In other 

cases, RVSRs provided separate evaluations for symptoms without medical 

examiners providing distinct diagnoses. 

Neither VARO staff nor we can correctly ascertain all of the residual 

disabilities of TBIs without adequate medical examinations. As a result, 

veterans might not always receive accurate benefit payments. Following are 

descriptions of the remaining types of TBI claims processing errors. 

	 Incorrect Grant/Denial of service connection: Incorrectly granting or 

denying entitlement to benefits. 

	 Incorrect effective dates: Using wrong dates to establish benefits, often 

resulting in inaccurate payments to veterans. 

VA Office of Inspector General 7 
Benefits Inspection Annual Summary Report 

Herbicide 

Exposure-Related 

Disability Claims 

During interviews, several VARO managers specifically attributed these 

errors to the complex policies regarding the TBI evaluation process, which 

RVSRs found difficult to follow. VBA training materials acknowledge that 

symptoms of co-existing mental disorders and TBI residuals commonly 

overlap; it can be hard or impossible for a VA medical examiner to attribute 

the overlapping symptoms to one specific disability. For example, if a 

veteran reports for a medical examination with symptoms of memory loss, 

examiners find it difficult to determine if those symptoms are a result of a 

TBI or a mental condition such as PTSD. 

Based on the percentage of inadequate TBI medical examinations provided 

to VAROs, it appears physicians also had difficulty with this issue. 

Following are examples of inadequate medical examinations found during 

our inspections: 

	 Physicians did not identify if symptoms were related to mental disorders 

or residuals of TBI. 

	 Physicians did not fully evaluate all residual disabilities related to TBI. 

	 Physicians did not always provide distinct diagnoses. 

Because of the complex policies related to processing TBI claims and the 

high percentage of inadequate medical examinations, VBA would benefit 

from having more experienced staff perform an additional level of review of 

these claims prior to finalizing benefit determinations. As a means to ensure 

adequate medical evidence when veterans claim TBI related-residual 

disabilities with co-existing mental conditions, VBA would benefit from 

requiring staff to request a current mental medical examination concurrently 

with medical examinations for TBI residuals. 

Of the 16 VAROs inspected, 7 (44 percent) did not follow VBA policy when 

processing herbicide exposure-related claims. VBA policy states for 

veterans claiming exposure to herbicide agents during active military service, 

certain disabilities should be service-connected, provided VBA has 

verification of the herbicide exposure and the disease manifested to a degree 

of 10 percent or more disabling at any time after discharge from service. 

We projected that VARO staff did not adequately process about 

800 (8 percent) of approximately 10,500 herbicide exposure-related 

disability claims completed from April 2009 through July 2010. These 

processing inaccuracies occurred because VARO staff lacked sufficient 

experience and training to process these types of claims accurately. 

Additionally, some VAROs did not perform adequate quality reviews of 

completed herbicide exposure-related claims. For these reasons, veterans did 

not always receive accurate benefits. 

VA Office of Inspector General 8 
Benefits Inspection Annual Summary Report 

Figure 4 depicts projected error rates by type for herbicide exposure-related 

claims. 

Figure 4	 Projected Error Rates in Herbicide Exposure Claims Processing 

Haas Claims 

Secondary Incorrect 

Disabilities Not Effective Dates 

Properly 22% 
 

Addressed
 Medical Exams 11% 

Not Requested 

4% 

Additional 

Incorrect Benefits Not 

Evaluations Considered 

62% 1% 

The majority of inaccuracies occurred when VARO staff assigned incorrect 

evaluations for veterans’ disabilities. For example, an RVSR incorrectly 

determined a veteran’s service-connected diabetes was 40 percent disabling 

although medical evidence in the veteran’s claims folder revealed the 

disability was 20 percent disabling. These incorrect evaluations involved 

both over/under payments to veterans. 

Following are descriptions of the remaining types of herbicide exposurerelated claims processing errors. 

	 Incorrect effective dates: Using wrong dates to establish benefits, often 

resulting in inaccurate payments to veterans. 

	 Improperly addressed secondary disabilities: Improperly granting or 

denying benefits for secondary conditions related to disabilities such as 

diabetes and prostate cancer. This might include making incorrect 

decisions regarding renal dysfunction caused by diabetes. 

	 Medical examinations not requested: Failing to request follow-up 

medical examinations to determine a veteran’s current level of disability. 

	 Additional benefits not considered: Not considering additional benefits, 

such as allowances for adaptive automobile equipment. 

Of the six VAROs inspected for compliance with this issue, five (83 percent) 

did not follow VBA policy when processing these claims. Haas claims 

involve veterans who served in waters off Vietnam, never having set foot in 

Vietnam, and whether those veterans are entitled to the presumption of 

exposure to herbicide agents, including Agent Orange. 

VA Office of Inspector General 9 
Benefits Inspection Annual Summary Report 

VA’s interpretation of the 38 Code of Federal Regulations was that a service 

member had to have actually set foot on Vietnamese soil or served on craft in 

its rivers in order to be entitled to the presumption of exposure to herbicides. 

The Court of Appeals for Veterans Claims in Haas vs. Nicholson determined 

that Vietnam veterans who served in the waters off Vietnam and did not set 

foot in Vietnam were entitled to a presumption of exposure to herbicide 

agents, including Agent Orange. 

VA appealed this decision to the U.S. Court of Appeals for the Federal 

Circuit and put a stay of adjudication on Haas claims. VA lifted the stay in 

January 2009 after the Federal Circuit reversed the decision by the Court of 

Appeals for Veterans Claims and the Supreme Court denied petition to 

review the case. 

We projected that VARO staff did not adequately process about 

850 (13 percent) of approximately 6,400 Haas claims completed from 

April 2009 through September 2009. These processing inaccuracies 

occurred because VARO staff lacked sufficient experience and training to 

process these claims accurately. 

Additionally, some VAROs were not conducting monthly quality assurance 

reviews that could have provided the oversight needed to identify and correct 

Haas claims processing errors. For these reasons, veterans did not always 

receive accurate benefits. Figure 5 depicts projected error rates by type of 

error in processing Haas claims. 

Figure 5 Projected Error Rates in Haas Claims Processing 

Incorrect 

Improperly 

Identified as a 

Haas Claim 

Evaluations 

35% 

Necessary 

Evidence Not 

Obtained 

45% 

20% 

The majority of the inaccuracies occurred because Veterans Service 

Representatives (VSRs) did not develop necessary evidence to support rating 

decisions. The remaining errors consisted of incorrect evaluations and 

improper delays of claims by placing them under the Haas stay. In one 

VA Office of Inspector General 10 
Benefits Inspection Annual Summary Report 

Previous 

Recommendations 

Recommendation 

instance, the VARO received evidence one month after a veteran submitted 

his claim, enabling staff to decide the case immediately. However, VARO 

staff did not complete the claim for 6 months. 

We discontinued our review of Haas claims because VA lifted the stay and 

VBA resumed processing these claims. Ultimately, completed Haas claims 

are included in our universe of herbicide claims for future inspections. 

To improve the accuracy of disability claims processing, we made 

37 recommendations to VARO Directors, including the following: 

	 Review all temporary 100 percent disability evaluations under their 

jurisdictions to determine if reevaluations are required and take 

appropriate actions. 

	 Implement controls to ensure staff establish suspense diaries for 

temporary 100 percent disability reevaluations. 

	 Provide training to ensure RVSRs properly evaluate PTSD, TBI, and

herbicide exposure-related disabilities, and Haas claims. 

	 Provide training to ensure RVSRs recognize inadequate TBI 

examinations. 

	 Improve oversight of the quality assurance process to ensure staff follow

correct procedures for processing PTSD, TBI, and herbicide exposurerelated disabilities, and Haas claims. 

VARO Directors reported they have implemented corrective measures in 

response to all 37 recommendations related to claims processing. The 

following recommendation will address systemic issues related to processing 

disability claims for TBI-related residuals. 

1.	 We recommend the Acting Under Secretary for Benefits work 

collaboratively with the Under Secretary for Health to ensure that all 

clinicians performing traumatic brain injury compensation and pension 

examinations complete the new training for traumatic brain injury 

available in the VA Learning Management System under VA Item 

Number 7833, Compensation and Pension Evaluation Program 

Traumatic Brain Injury Examination. 

2.	 We recommend the Acting Under Secretary for Benefits develop and 

implement a strategy for ensuring the accuracy of decisions on traumatic 

brain injury claims, prior to finalizing benefit payments. 

3.	 We recommend the Acting Under Secretary for Benefits collaborate with 

the Veterans Health Administration to develop and implement a 

mechanism to ensure that when a veteran has a mental disability coexisting with a traumatic brain injury examination, medical examiners 

clearly state in their examination reports which emotional/behavioral 

signs and symptoms are related to which disability. 

VA Office of Inspector General 11 
Benefits Inspection Annual Summary Report 

Management 

Comments 

OIG Response 

Notices of 

Disagreement 

Finding 2 

The Acting Under Secretary for Benefits concurred with our 

recommendations for improving areas related to the processing of traumatic 

brain injury claims. He informed us that VBA is working collaboratively 

with the Under Secretary for Health to ensure that clinicians performing TBI 

C&P medical examinations complete new training modules on proper 

procedures for completing these types of exams. The Under Secretary for 

Benefits stated that VAROs will now require a second signature review on 

traumatic brain injury cases for each RVSR until the RVSR can demonstrate 

a 90 percent quality score on these types of decisions. Further, VBA will 

collaborate with the Veterans Health Administration’s Disability 

Examination Management Office to ensure medical examiners clearly 

delineate between emotional/behavioral signs and symptoms relating to a 

traumatic brain injury and those relating to a co-existing mental condition. 

Management’s comments and actions are responsive to the 

recommendations. We will follow up on the implementation of these 

recommendations during future inspections. 

2. Data Integrity 

VAROs did not always establish Notices of Disagreement (NODs) within 

VBA’s 7-day standard. An NOD is a written communication from a 

claimant expressing dissatisfaction or disagreement with a decision and 

desiring to contest the decision. It is the first step in the appeals process. 

The Veterans Appeals Control and Locator System (VACOLS) is an 

application that allows VARO staff to control and track veterans’ appeals 

and manage the office’s appeals workload. The effectiveness of VACOLS is 

dependent upon the quality of information entered. 

Controls Over Notices of Disagreement Need 

Strengthening 

We inspected controls over NOD processing at eight VAROs. Of those, 

6 VAROs (75 percent) did not timely control NODs in VACOLS. VARO 

staff exceeded VBA’s 7-day standard for 108 (37 percent) of 294 NODs 

reviewed. Staff took an average of 21 days to record the 108 disagreements 

into VACOLS. The VAROs nonetheless generally met VBA’s pending 

timeliness goal of 145 days for NOD processing. The untimely recording of 

NODs in VACOLS occurred because of a lack of staff training and 

inadequate oversight of the appeals workload. Further, one VARO did not 

consider this work a priority and one VARO did not utilize available 

electronic databases to assist in timely NOD recording. Delays in recording 

NODs affect the integrity of VACOLS data and misrepresent performance. 

VA Office of Inspector General 12 
Benefits Inspection Annual Summary Report 

Previous 

Recommendations 

Systematic 

Technical 

Accuracy 

Review 

Finding 3 

Data integrity issues we identified make it difficult for VAROs and senior 

VBA leadership to accurately measure and monitor the performance of 

regional offices. Delays in recording NODs in VACOLS misrepresent 

VBA’s NOD inventory and timeliness--both critical elements for 

consideration in workload decisions. Further, VBA’s National Call Centers 

rely upon VACOLS information to provide accurate customer service to 

veterans regarding their appeals. 

To ensure timely establishment of NODs, we made six recommendations to 

VARO Directors, including the following: 

	 Develop and implement a plan to train Triage Team members on proper 

NODs identification. 

	 Develop and implement a plan to establish NODs in VACOLS within 

VBA’s 7-day standard. 

Regional Office Directors reported they have implemented improvements in 

response to these recommendations. We will follow up on these 

recommendations during future inspections. 

3. Management Controls 

We assessed management controls to determine if the VAROs adhered to 

VBA policy regarding correction of errors identified by VBA’s Systematic 

Technical Accuracy Review (STAR) staff. The STAR Program is VBA’s 

multi-faceted quality assurance program to ensure veterans and other 

beneficiaries receive accurate and consistent C&P benefits. VBA policy 

requires that VAROs take corrective actions on errors the STAR Program 

identifies. Management needs to strengthen oversight to ensure that VARO 

staff correct or appropriately address errors identified by VBA’s STAR 

Program staff. 

Errors Identified by STAR Program Not Always 

Corrected 

Of the 16 VAROs inspected, seven (44 percent) did not follow VBA policy 

when correcting errors identified by VBA’s STAR staff. VARO staff did not 

properly correct 33 (11 percent) of the 294 errors reviewed although VSC 

management erroneously reported to STAR staff that all corrective actions 

were completed. In all instances, VSC management did not provide 

oversight to ensure correction of the errors identified. Because VARO staff 

did not correct these errors, they lacked assurance that veterans and other 

beneficiaries received accurate and consistent benefits. For example, VBA 

underpaid two veterans a total of $21,476 due to uncorrected STAR errors. 

VA Office of Inspector General 13 
Benefits Inspection Annual Summary Report 

Systematic 

Analysis of 

Operations 

Finding 4 

Management 

Vacancies 

In March 2010, the OIG provided testimony to Congress regarding VBA’s 

quality assurance processes. We stated that most regional offices did not 

have formal procedures in place to ensure employees took corrective actions 

on errors identified by STAR staff. 

We assessed whether VARO management timely completed Systematic 

Analyses of Operations (SAOs). SAOs provide an organized means of 

reviewing VSC operations to identify existing or potential problems and 

propose corrective actions. VBA policy requires VSCs perform SAOs 

annually, covering all aspects of claims processing, including quality, 

timeliness, and related factors. 

Improved Oversight is Needed to Ensure Timely and 

Complete SAOs 

Six (38 percent) of the 16 regional offices did not follow VBA policy to 

ensure SAOs were timely and complete. We determined a total of 

53 (30 percent) of 175 SAOs were untimely and/or incomplete. This 

occurred because VARO management did not provide oversight to ensure

SAOs addressed all necessary elements and operations of the VSC. By not 

completing SAOs as required by VBA policy, management may fail to

identify existing or potential problems that could hamper effective delivery

of benefits and services to veterans. 

Of those six VAROs that had untimely and/or incomplete SAOs, five had the

lowest performance in other operational activities inspected, such as claims

processing, mail handling, and data integrity. At five VAROs, vacancies in 

senior management positions contributed to delays in completing SAOs and

implementing corrective actions. Additionally, one of those five offices 

considered SAOs to be of little or no value toward improving VARO 

performance. 

Conversely, five other VAROs that ensured SAOs were timely and complete

were the most compliant in other operational activities we inspected. Based

on this analysis, we see a correlation between VAROs producing complete

and timely SAOs and VSC compliance with other VBA policies. VBA 

would benefit from conducting a further analysis of VARO performance in

comparison to timely completion of SAOs. 

We recognize a number of factors can affect VARO performance. However, 

based on our reviews, vacancies in senior management positions seemed to 

have a negative impact on VARO operations. Of the top five compliant 

VAROs, senior management remained relatively unchanged. Conversely, 

four of the five least compliant VAROs had prolonged vacancies in key 

VARO leadership positions, including the VARO Director and the Veterans 

Service Center Manager positions. We believe prolonged vacancies in these 

positions were a contributing factor to the high level of noncompliant 

activities. 

VA Office of Inspector General 14 
Benefits Inspection Annual Summary Report 

Of the activities inspected, the following VAROs were the lowest 

performing, San Juan, Waco, Albuquerque, Anchorage, and Baltimore. With 

the exception of the Waco, these VAROs had Director or VSCM positions 

vacant or filled with temporary staff for periods of 5 months, or greater. 

Table 2 shows the most compliant and least compliant VAROs and the 

corresponding vacancies. 

Table 2 Comparison of Management Vacancies to Inspection Compliance 

Five most compliant VAROs 

VARO 

Inspection 

Complianc 

e Rate* 

SAO 

Complianc 

e 

Vacant or 

Temporaril 

y-Filled 

Position 

Longest 

Period of 

Vacancy 

Jackson 70% Y None None 

Denver 67% Y None None 

Cheyenne 63% Y None None 

Muskogee 60% Y None None 

Roanoke 57% Y None None 

Five least compliant VAROs 

San Juan 33% N Director 5 months 

Waco 25% N None None 

Albuquerque 22% N Director 

VSCM 8 months 

Anchorage 7% N VSCM 8 months 

Baltimore 7% N VSCM 6 months 

Previous 

Recommendations 

*As reported in Appendix D 

The Director of the Salt Lake City VARO is responsible for overseeing 

operations at the Anchorage VARO. During the 8-month absence of the 

Anchorage Veterans Service Center Manager, that office did not have any 

senior leadership physically in place to manage and oversee operations. 

Further, the St. Petersburg VARO Director provided oversight of the San 

Juan VARO during the period that its Director position was vacant. 

We believe, based on our reviews, VBA would benefit from conducting 

further analysis on improving the timely selection and replacement of key 

VARO leadership positions. 

To improve oversight related to the correction of errors identified by STAR 

staff and the completion of SAOs, we made 13 recommendations to VARO 

Directors, including the following: 

VA Office of Inspector General 15 
Benefits Inspection Annual Summary Report 

VARO Mail
 

Processing
 

Procedures
 

Finding 5 

	 Develop a plan to ensure VSC management takes corrective action to 

address errors identified by STAR Program staff. 

	 Develop and implement a mechanism to ensure the VSC management 

team performs complete analyses of VSC operations within the 

prescribed time and takes appropriate corrective actions to address 

identified problems. 

Regional Office Directors reported they have implemented improvements in 

response to these recommendations. We will make no recommendations 

regarding SAOs and management vacancies at this time and we will continue 

to monitor these during future inspections. 

4. Workload Management and Information Security 

We assessed controls over VARO mailroom operations to ensure staff timely 

and accurately processed incoming mail. Further, we assessed the VSC’s 

Triage Team procedures to ensure staff reviewed, controlled, and processed 

all claims-related mail in accordance with VBA policy. We determined that 

controls over VARO mailroom operations and Triage Team mail processing 

procedures need strengthening. 

Controls over VARO Mail Processing Need 

Strengthening 

Of the 16 VAROs inspected, 12 (75 percent) did not always control and 

process mail according to VBA policy. This occurred because VARO 

management and staff were generally unaware of policy requirements, 

including date stamping, governing mail processing at VA facilities. 

Further, VARO workload management plans contained unclear procedures

or first-line supervisors did not always follow guidance delineated in these

plans. Consequently, beneficiaries may not have received accurate or timely

benefit payments. 

At three (19 percent) of the VAROs inspected, mailroom staff did not always

process all incoming mail daily, including not date stamping all mail the

same day it arrived in the VA facility as required by VBA policy. Typically,

the mail delivery date determines the date VBA will pay benefits to veterans

or beneficiaries. 

Generally, a benefit payment date is the first of the month following the date

stamped on the incoming claim. For example, if mailroom staff properly

date stamp claims-related mail received on January 31, the benefits would be

payable on February 1. However, if mailroom staff improperly date stamp

this same mail on February 1, the payment date would be March 1, and

VARO staff would unintentionally underpay the beneficiary by 1 month.

Neither VARO employees nor we could identify specific veterans’ claims 

affected by this incorrect process. 

VA Office of Inspector General 16 
Benefits Inspection Annual Summary Report 

Triage Mail 

Processing 

Procedures 

Destruction and 

Safeguarding of 

Documents 

At 10 (63 percent) of the 16 VAROs, staff untimely controlled and 

improperly managed claims-related mail. Triage Teams are responsible for 

reviewing, controlling, and processing or routing all incoming mail received 

from the VARO mailroom. Triage Teams did not always control incoming 

mail within 7 days of receipt or use the Control of Veterans Records System 

(COVERS) to electronically track search mail as VBA policy requires. 

Search mail is active claims-related mail waiting to be associated with a 

veteran’s claims folder. Following is a summation of our review of 

individual pieces of mail and the associated mail handling weaknesses we 

identified. 

	 Staff did not control 25 (21 percent) of 120 pieces of incoming mail in 

the electronic system within 7 days of receipt, as required. 

	 Staff did not properly use COVERS to ensure timely processing and 

control of 57 (24 percent) of 240 pieces of search mail. 

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

delays in processing disability claims. Because VARO staff did not properly 

use COVERS to control search mail, RVSRs did not always consider all 

available evidence when making disability determinations. 

We issued a Management Advisory to the Veterans Health Administration’s 

Under Secretary for Health requesting action to develop procedures for 

ensuring prompt return of veterans’ claims folders. We issued this advisory 

because at one VARO, we found 1,462 pieces of search mail, 

476 (33 percent) of which were waiting to be associated with claims folders 

temporarily located at a VA Medical Center. Untimely return of claims 

folders following completion of examinations has resulted in claims 

processing delays because VARO staff could not associate claims-related 

mail with the appropriate folders. 

The Director of the Eastern Colorado Health Care System implemented 

Standard Operating Procedures that provided guidance for employees to 

return claims folders to the VARO upon completion of medical 

examinations. Further, the Director instructed staff to use COVERS to track 

the location of claims folder and return them to the VARO once physicians 

complete medical examinations. 

In September 2009, we issued Audit of VA Regional Office Claim-Related 

Mail Processing, (Report No. 08-01759-234), which disclosed that VARO 

mailrooms needed improvements in the handling, processing, and protection 

of claims-related documents. In addition, staff had inappropriately placed 

some claims-related documents in shred bins. In response to this report, 

VBA issued policy stating that under no circumstances will claims or 

guardianship files, loose mail, or material of any kind that has 

VA Office of Inspector General 17 
Benefits Inspection Annual Summary Report 

Finding 6 

Previous 

Recommendations 

claimant/veteran Personally Identifiable Identification (PII) be stored in desk 

drawers, credenzas, personal two-drawer lockable cabinets, or other personal 

storage containers. 

Veterans’ Personally Identifiable Information Not 

Always Safeguarded 

We inspected controls over the safeguarding of PII at nine VAROs and 

found those nine did not always safeguard veterans’ PII. During those 

inspections, we found 78 instances (42 percent) of improper safeguarding of 

veterans’ sensitive information. VBA policy requires supervisors to perform 

routine inspections of workstations; however, some VAROs were not 

performing these inspections as directed. As a result, VAROs did not always 

properly safeguard veterans’ PII. 

Although we found no evidence of improper document destruction, we did 

find evidence of improper storage of documents and other materials 

containing PII. Examples of unsecured items were training materials, 

original claims documentation including service treatment records, and 

administrative-type reports, all with veterans’ identifiable information. In 

addition, we discovered claims documentation improperly marked for 

shredding and an unauthorized paper-shredding machine. 

In September 2009, we submitted a Management Advisory to the Under 

Secretary for Benefits recommending VBA issue to all VAROs immediate 

guidance on safeguarding the handling and storage of Deoxyribonucleic Acid 

(DNA) specimens labeled with PII. We issued this advisory because at one 

VARO we found within a common area in the VSC an unmarked shipping 

box containing 14 DNA specimen packages, one laboratory glass vial, and 

23 dental x-rays, all containing veterans’ names and Social Security numbers 

(Initially, this material was associated with the veterans’ service treatment 

records and improperly removed by VARO staff). VBA issued guidance to 

VAROs indicating that staff should shred or incinerate this type of material. 

We discontinued our review of this topic because the majority of the material 

found was relatively low-risk such as unredacted training materials. 

To improve controls over processing mail and safeguarding veterans’ PII, we 

made 24 recommendations to VARO Directors, including the following: 

	 Develop and implement a plan to ensure all mail is properly controlled 

and processed within the Triage Team. 

	 Develop and implement a plan to ensure VSC staff are timely and 

correctly recording incoming mail in the electronic record and promptly 

retrieving search mail to enable accurate benefits decisions. 

VA Office of Inspector General 18 
Benefits Inspection Annual Summary Report 

	 Develop and implement a plan to ensure staff process and date stamp all 

incoming mail the same day it arrives in the VARO mailroom. 

	 Develop and implement a plan to ensure supervisors and records 

management officers consistently perform thorough reviews of 

workstations and common areas to ensure safeguarding of veterans’ PII. 

Regional Office Directors reported they have implemented improvements in 

response to these recommendations. We will follow up on these 

recommendations during future inspections. 

5. Eligibility Determinations 

Competency Controls over the processing of competency determinations need 

Determinations strengthening. VA must consider the competency of beneficiaries in every 

case involving a mental health condition that is totally disabling or when 

evidence raises a question as to a beneficiary’s mental capacity to manage 

his or her financial affairs, including VA benefits. We reviewed competency 

determinations at 7 of the 16 VAROs and identified several areas for 

improvement. We did not examine eligibility determinations at all VAROs 

because VBA has centralized fiduciary activities in their Western Area at the 

Salt Lake City VARO. 

Finding 7	 Controls over Competency Determinations Need 

Strengthening 

We determined staff at seven VAROs unnecessarily delayed making final 

competency decisions in 54 (34 percent) of 159 cases completed from April 

2009 to March 2010. These delays ranged from approximately 17 to 

530 days. The delays occurred because VARO workload management plans 

did not make competency determinations a priority or include measures for 

oversight of this work. As a result, incompetent beneficiaries received their 

benefits directly without fiduciaries in place to manage their financial 

resources. While the beneficiaries were entitled to these payments, fiduciary 

stewardship may have been needed to ensure effective funds management 

and the welfare of the beneficiaries. 

VBA policy requires staff to prepare a rating decision proposing a finding of 

incompetency after receiving clear and convincing medical evidence the 

beneficiary is incapable of managing his or her affairs. Prior to making a 

final decision, policy allows a 65-day due process period for the beneficiary 

to submit evidence showing he or she is capable of independently handling 

funds and managing his or her affairs. At the end of the due process period, 

VARO staff must immediately take final action to determine if the 

beneficiary is incompetent. 

VA Office of Inspector General 19 
Benefits Inspection Annual Summary Report 

In the absence of VBA providing a clear definition of “immediate,” we 

allowed 14 calendar days after the due process period to determine if staff 

were timely completing competency decisions. We considered 14 calendar 

days a reasonable period to take final action on competency determinations if 

staff used available computer applications to track these claims. 

Our inspections revealed VARO managers have different interpretations of 

“immediate.” Following are varying perspectives and definitions of 

“immediate” provided by managers at six of the seven VAROs inspected. 

 One Director stated the term was unrealistic. 

 One Director stated the definition changes with the station’s workload. 

 Four VSC Managers stated the term meant 3 to 30 days. 

Such responses indicate the term “immediate” is not clear or consistent, 

leaving the interpretation of this standard to the discretion of VARO 

leadership. However, regardless of the differing definitions, three of the 

VAROs did not process competency determinations within their own 

definition or our 14-day standard. In addition, managers at one VARO were 

unaware of the requirement to complete these decisions “immediately” until 

we informed them of the policy. 

The risk of incompetent beneficiaries receiving benefit payments without 

fiduciaries assigned to manage those funds increases if staff do not complete 

competency determinations promptly. As a result, in August 2010, we 

issued a Management Advisory to VBA’s Director of C&P Service 

recommending VBA establish a clear standard for timely completion of final 

competency determinations. In October 2010, the Director of C&P Service 

responded to our Management Advisory, disagreeing with our 

recommendation and informing us “immediate” is sufficient as a clear 

standard. 

The Director also informed us that the C&P Site Visit team (a VBA internal 

quality control program) would modify their protocols to include a review of 

competency determinations to ensure VARO staff take immediate action to 

process them. However, the Director did not indicate how the C&P Site 

Visit team would measure “immediate” completion of these determinations. 

We still believe VBA needs to create a measurable standard to reduce the 

risk of incompetent beneficiaries receiving monthly benefits without 

fiduciaries in place to manage those funds. 

In addition to the inaccuracies related to processing delays, we identified 

10 instances where VARO staff did not follow VBA policy when 

determining if beneficiaries were competent to handle VA funds. In five 

cases, VARO staff incorrectly determined beneficiaries were incompetent 

VA Office of Inspector General 20 
Benefits Inspection Annual Summary Report 

Previous 

Recommendations 

Recommendation 

Management 

Comments 

OIG Response 

without adequate medical evidence demonstrating they could not manage 

their affairs. In four cases, VAROs determined the beneficiaries were 

incompetent without providing the mandatory 65-day due process period for 

the beneficiaries to provide evidence to the contrary. Such practices resulted 

in $97,763 provided to fiduciaries that VSC staff prematurely or erroneously 

appointed. The remaining case involved an RVSR who did not properly 

assess a veteran’s competency despite medical evidence indicating the 

veteran had difficulty managing his affairs. 

To improve the accuracy and timeliness of eligibility determinations, we 

made six recommendations to VARO Directors, including the following: 

	 Provide training to ensure RVSRs follow VBA policy when making 

competency determinations. 

	 Develop and implement a plan to increase oversight to ensure immediate 

completion of final competency determinations. 

Regional Office Directors reported they have implemented improvements in 

response to these recommendations. We will follow up on these 

recommendations during future inspections. 

4.	 We recommend the Acting Under Secretary for Benefits develop a clear 

and measurable standard for timely completion of competency 

determinations. 

The Acting Under Secretary for Benefits concurred with our 

recommendation and stated a 21-day standard will be sufficient time to 

complete competency determinations. Further, VBA will issue written 

guidance on this and notify field offices during weekly Office of Field 

Operations conference calls and monthly Veterans Service Center Managers’ 

bulletins. 

The Acting Under Secretary for Benefits’ comments and actions are 

responsive to the recommendation. We will follow up on the 

implementation of this recommendation during future inspections. 

VA Office of Inspector General 21 
Benefits Inspection Annual Summary Report 

Appendix A Scope of the Inspections 

Scope This report is a summary of systemic issues identified during 16 VARO 

inspections performed between April 2009 and July 2010. This summary 

report focused on 11 operational activities in 5 protocol areas, as outlined 

below. 

Table 3 Protocols and Operational Activities Inspected 

Protocol Operational Activity 

Claims Processing Issues 

 Temporary 100 Percent Disability 

Evaluations 

 Post-Traumatic Stress Disorder 

 Traumatic Brain Injury 

 Herbicide Exposure-related disabilities 

 Haas 

Data Integrity  Notices of Disagreement 

Management Controls 

 Systematic Technical Accuracy Review 

 Systematic Analysis of Operations 

Workload Management and Information 

Security 

 Mail Handling Procedures 

 Destruction and Safeguarding of 

Documents 

Eligibility Determinations  Competency Determinations 

Methodology We designed the five protocols based on a risk analysis of previous OIG 

national audits and Combined Assessment Reviews, VBA’s C&P Site Visit 

reports, Government Accountability Office reports, and information provided 

by the Senate and House Veterans Affairs Committees. We review the 

protocols annually to identify new high-risk areas and make adjustments as 

necessary. Generally, we determined a VARO was non-compliant in an 

inspection area if the error rate was 10 percent or greater. 

The Claims Processing protocol encompassed a review of 1,614 (16 percent) 

of 10,304 claims requiring rating decisions, completed from October 

2008 through March 2010. Of those, 1,337 (83 percent) were related to 

PTSD, TBI, herbicide exposure, and Haas cases that VAROs completed. 

The remaining 277 (17 percent) involved rating decisions where VARO staff 

granted temporary 100 percent disability evaluations for at least 18 months, 

generally the longest period under VBA policy such evaluations can be 

assigned without review. We reviewed these temporary 100 percent 

disability evaluations at 10 VAROs from October 2009 through July 2010. 

VA Office of Inspector General 22 
Benefits Inspection Annual Summary Report 

Reliability of 

ComputerProcessed Data 

Compliance with 

Quality Standards 

for Inspection 

The Data Integrity protocol involved reviewing 294 NODs to ensure timely 

reporting in VACOLS. The Management Controls protocol entailed 

determining whether VARO staff followed policy regarding correction of 

294 errors identified by VBA STAR staff. Additionally, we determined if 

VARO management ensured 175 SAOs were timely and complete. 

The Workload Management and Information Security protocol encompassed 

a review of 120 individual pieces of newly received mail to determine if 

VARO staff timely placed it under electronic control. In addition, we 

reviewed 240 individual pieces of mail to determine if VARO staff properly 

used COVERS to track and control the mail. We observed VARO mailroom 

operations with regard to receipt and initial date stamping of incoming mail. 

We conducted inspections of 186 employee workstations and unassigned 

areas to ensure VAROs properly safeguarded veterans’ PII. 

The Eligibility Determinations protocol entailed reviewing 159 competency 

determinations to ensure VARO staff avoided unnecessary delays in 

completing final decisions. Additionally, this review addressed the potential 

risk of mishandling VA benefits. 

We assessed the reliability of VBA electronic data by comparing selected 

data elements to documentation in the claims folders (such as veterans’ 

names, dates of birth, and Social Security Numbers). We concluded that the 

data used to accomplish the objectives was sufficiently reliable. 

Our assessment of internal controls focused on those controls relating to our 

inspection objectives. We conducted our review in accordance with the 

Council of the Inspectors General on Integrity and Efficiency’s Quality 

Standards for Inspections. These standards require that we plan and perform 

the inspections to obtain sufficient, appropriate evidence to provide a 

reasonable basis for our findings and conclusions. We believe that the 

evidence obtained provides a reasonable basis for our findings and 

conclusions. 

VA Office of Inspector General 23 
Benefits Inspection Annual Summary Report 

Appendix B Acting Under Secretary for Benefits Comments 

Department of Memorandum Veterans Affairs 

Date: April 26, 2011 

From: Acting Under Secretary for Benefits (20) 

Subj: Systemic Issues Reported During Inspections at VA Regional Offices 

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

1.	 Attached is VBA’s response to the OIG’s Draft Report: Systemic Issues 

Reported During Inspections at VA Regional Offices. 

2.	 Questions may be referred to Catherine Milano, Program Analyst, at 202­

461-9216. 

(original signed by:) 

Michael Walcoff 

Attachment 

VA Office of Inspector General 24 
Benefits Inspection Annual Summary Report 

Veterans Benefits Administration (VBA) 

Comments on OIG Draft Report 

Systemic Issues Reported During Inspections at VA Regional Offices 

The Veterans Benefits Administration provides the following comments: 

In the “Report Highlights” and in Finding 1, OIG discusses VBA’s challenges in processing 

disability compensation claims related to temporary 100 percent disability evaluations as found 

through VA Regional Office (VARO) inspections and the January 2011, Audit of VBA’s 100 

Percent Disability Evaluations. The OIG draft attributes the cause of the errors identified to RO 

staff not correctly processing evaluations. However, during the January 2011 audit, the OIG 

noted a significant number of cases identified in which RO staff did correctly establish future 

exam dates in the disability review process, but the computer system did not properly maintain 

the future exam dates. VBA identified multiple computer system errors, rather than employee 

error, that accounted for a high percentage of the tracking or monitoring errors noted by the OIG. 

These systemic errors and VBA’s efforts to complete necessary software corrections were 

acknowledged by OIG in the January 2011 audit report. They should also be included in this 

report. 

VBA makes every effort to ensure that Veterans are paid correctly and disability evaluations are 

assigned appropriately at all levels. We continue to identify system enhancements as the most 

effective protocol for making certain that future examinations are entered in the electronic record 

for all temporary 100 percent evaluations. 

Page 3, third paragraph: 

VBA Comment: VBA is addressing the errors identified in the January 2011 Audit of VBA’s 100 

Percent Disability Evaluations, and we suggest the following verbiage be added after the third 

paragraph: 

“VBA responded to this report and agreed to address the errors identified with temporary 100 

percent evaluations. We noted in the report a significant number of cases in which RO staff did 

correctly establish future exam dates in the disability review process, but the computer system 

did not properly maintain the future exam dates. VBA identified multiple computer system 

errors, rather than employee error, that accounted for the high percentage of the tracking or 

monitoring errors. System enhancements are being identified by VBA as the most appropriate 

method of establishing future examinations for these cases. In the interim, regional office 

employees will be provided with instructions that would ensure future diaries are established and 

maintained from this point forward.” 

Page 6, fourth paragraph: 

VBA Comment: The OIG noted improvement in Post Traumatic Stress Disorder (PTSD) claims 

processing since the rule change effective July 2010, and we suggest replacing this paragraph 

with the following verbiage: 

VA Office of Inspector General 25 
Benefits Inspection Annual Summary Report 

“Prior to the rule change, we identified a 13 percent error rate associated with PTSD claims 

processing. From the date of the rule change until September 2010, however, we identified a 5 

percent error rate. Because of this noticeable improvement in PTSD claims processing, we made 

no recommendations for improvement in this area. We may modify our review of PTSD claims 

in future inspections until VAROs have sufficient time to fully implement the amended rule.” 

The following comments are submitted in response to the recommendations in the OIG 

Draft Report: 

Recommendation 1: We recommend the Acting Under Secretary for Benefits work 

collaboratively with the Under Secretary for Health to ensure that all clinicians performing 

traumatic brain injury compensation and pension examinations complete the new training for 

traumatic brain injury available in the VA Learning Management System under VA Item 

Number 7833, Compensation and Pension Evaluation Program Traumatic Brain Injury 

Examination. 

VBA Response: Concur. VBA is collaborating with the Veterans Health Administration (VHA) 

to address this recommendation. VHA is ensuring that all compensation and pension (C&P) 

examination providers have completed the training on traumatic brain injury (TBI) examinations 

that is published in the Learning Management System. This initiative is approximately 70 

percent complete, and all clinicians performing TBI medical examinations will have completed 

this training no later than June 30, 2011. 

Target Completion Date: June 30, 2011 

Recommendation 2: We recommend the Acting Under Secretary for Benefits develop and 

implement a strategy for ensuring the accuracy of decisions on traumatic brain injury claims, 

prior to finalizing benefit payments. 

VBA Response: Concur. VBA agrees to develop and implement a strategy for ensuring the 

accuracy of traumatic brain injury decisions. Regional offices will require a second signature on 

traumatic brain injury cases for each Rating Veterans Service Representative (RVSR) until the 

RVSR demonstrates a 90 percent quality average on a minimum of 10 TBI cases. Once an 

RVSR has reached a 90 percent quality score average for a rolling 10 TBI cases, he or she will 

be awarded single-signature authority for future TBI cases. Data obtained during this period of 

required second signatures will be used to identify training needs and to create any needed 

training sessions. 

Target Completion Date: September 30, 2011 

Recommendation 3: We recommend the Acting Under Secretary for Benefits collaborate with 

the Veterans Health Administration to develop and implement a mechanism to ensure that when 

a veteran has a mental disability co-existing with a traumatic brain injury examination, medical 

examiners clearly state in their examination reports which emotional/behavioral signs and 

symptoms are related to which disability. 

VA Office of Inspector General 26 
Benefits Inspection Annual Summary Report 

VBA Response: Concur. VBA will collaborate with the VHA’s Disability Examination 

Management Office (DEMO) to ensure that medical examiners clearly state which 

emotional/behavioral signs and symptoms are related to which disability when there are coexisting mental disabilities. DEMO will send an information letter to all C&P facilities to 

instruct providers to follow the current Traumatic Brain Injury (TBI) Examination worksheet, 

and to be certain that attempts are made to differentiate whether neuropsychiatric or behavioral 

signs and symptoms are related to the TBI diagnosis or another diagnosis. If they cannot make 

the differentiation, they must make a statement that they are unable to differentiate the source of 

the neuropsychiatric or behavioral signs or symptoms. 

Target Completion Date: June 30, 2011 

Recommendation 4: We recommend the Acting Under Secretary for Benefits develop a clear 

and measurable standard for timely completion of competency determinations. 

VBA Response: Concur. VBA has reviewed this cadre of work and determined that a 21-day 

standard would be sufficient for timely completion of competency determinations. This will be 

measured from the date of expiration of due process to the date of completion. Guidance will be 

issued in a fast letter. Notice will also be provided to the field offices through the weekly Office 

of Field Operations conference call and the monthly Veterans Service Center Managers’ 

bulletin. 

Target Completion Date: June 30, 2011 

VA Office of Inspector General 27 
Benefits Inspection Annual Summary Report 

Appendix C 

Population 

Sampling Design 

Weights 

Projections and 

Margins of Error 

Statistical Sampling Methodology 

The population consisted of about 45,000 completed disability claims for 

temporary 100 percent disability evaluations, PTSD, TBI, herbicide 

exposure, and Haas across all 57 VAROs during the timeframe for our 

reviews. 

The sample is representative of the population from which it was drawn. We 

used probability-sampling methods that gave all veterans records a chance of 

selection. We inspected 16 VAROs during a fifteen-month timeframe. We 

reviewed the VAROs in random order so that these 16 first inspected form 

stage one of a representative two-stage random sample of all 57 VAROs. 

Within each VARO, we sampled claims in each of the five categories 

included in our review using simple random sampling techniques. 

We weighted each sample benefits claim based on the probability of 

selection at each stage of sampling. The weights affected projections we 

ultimately made based on the sample results. We used the weights to project 

error rates, which would not equal error rates computed based on the raw 

number of records sampled. 

All sample projections shown in the body of this report are also included in 

Tables 4, 5, and 6 below along with their associated margins of error. We 

computed the margins of error and confidence intervals based on a 

90 percent confidence interval. This means that 90 percent of all possible 

samples we could have selected under the same essential conditions would 

have produced a projection within the upper and lower limits of the 

90 percent confidence interval. 

VA Office of Inspector General 28 
Benefits Inspection Annual Summary Report 

Table 4: Projections and Margins of Error for Sample Results 

Claim Type Error Type Projection 

Margin of 

Error for 

90% 

Confidence 

Interval 

90% Confidence 

Interval Sample 

Size for 

Error 

Type 

Sample 

Size for 

Claim 

Type 

Lower 

Limit 

Upper 

Limit 

Temporary 

100 Percent 

Disability 

Evaluations 

Number in Error 6,768 466 6,302 7,235 215 

Error Rate 81.7 4.3 77.4 85.9 215 277 

Impact 19.8 4.9 14.9 24.7 52 

Potential Impact 61.9 6.2 55.7 68.1 163 

PTSD 

Number in Error 1,353 478 876 1,831 46 

470 

Error Rate 8.4 2.9 5.6 11.3 46 

Impact 4.5 1.6 2.9 6.1 26 

Potential Impact 3.9 2.0 1.9 5.9 20 

TBI 

Number in Error 788 169 619 957 79 

325 

Error Rate 19.2 4.1 15.1 23.3 79 

Impact 11.1 3.9 7.1 15.0 26 

Potential Impact 8.1 1.8 6.3 9.9 53 

Herbicide 

ExposureRelated 

Claims 

Number in Error 798 250 548 1,049 44 

453 

Error Rate 7.6 2.3 5.3 9.9 44 

Impact 6.2 2.0 4.2 8.2 34 

Potential Impact 1.4 1.1 0.3 2.6 10 

Haas 

Number in Error 847 383 465 1,230 21 

89 

Error Rate 13.2 5.9 7.3 19.1 21 

Impact 2.1 1.7 0.3 3.8 5 

Potential Impact 11.1 6.1 5.0 17.3 16 

Total 

Number in Error 10,555 1,746 8,809 12,301 405 

1,614 

Error Rate 23.3 3.8 19.4 27.1 405 

Impact 7.9 2.4 4.4 9.2 143 

Potential Impact 15.3 3.3 12.1 18.6 262 

VA Office of Inspector General 29 
Benefits Inspection Annual Summary Report 

Table 5: Projections and Margins of Error for Sample Results 

Claim Type Pie Chart Section Projection 

Margin of 

Error for 

90% 

Confidenc 

e Interval 

90% 

Confidence 

Interval 

Sample 

Size for 

Error 

Type 

Sample 

Size for 

Claim 

Type Lower 

Limit 

Upper 

Limit 

Temporary 

100 Percent 

Disability 

Evaluations 

C&C Processing Errors 42.2 6.8 35.4 49.0 87 

277 

Data Processing Errors 22.8 5.5 17.3 28.3 47 

Rating Decision 10.5 3.8 6.8 14.3 25 

Medical Exam 

Notifications not Processed 17.4 5.2 12.2 22.5 39 

Failure to Follow-up on 

Reductions 7.1 3.8 3.4 10.9 17 

PTSD 

Incorrect Effective Date 23.6 17.2 6.3 40.8 7 

470 

Stressor Verification 38.4 16.7 21.8 55.1 13 

Incorrect Evaluations 19.4 11.2 8.3 30.5 13 

Additional Benefits not 

Considered 7.5 6.8 0.7 14.3 7 

Lack of Nexus 11.1 7.5 3.6 18.5 6 

TBI 

Incorrect effective date 7.4 8.4 0.0* 15.7 2 

325 

Improperly Identifying 

Residual Disability 41.9 13.0 28.9 54.8 29 

Inadequate Medical 

Examinations 41.9 10.3 31.7 52.2 41 

Incorrect Evaluations 8.9 6.8 2.1 15.7 7 

Herbicide 

ExposureRelated 

Claims 

Additional Benefits Not 

Considered 1.3 2.3 0.0* 3.6 1 

453 

Incorrect Effective Date 22.2 13.8 8.4 36.0 10 

Incorrect Evaluation 62.3 13.2 49.1 75.6 25 

Medical Examinations not 

Requested 3.9 4.1 0.0* 8.0 3 

Secondary Disability not 

Properly Considered 10.3 8.5 1.8 18.7 5 

Haas 

Improperly Identified as 

Hass Claim 19.9 15.1 4.8 34.9 6 

Incorrect Evaluations 34.9 30.3 4.7 65.2 6 89 

Necessary Evidence not 

Obtained 45.2 29.8 15.4 75.0 9 

*Lower limit of confidence interval equals sample finding. 

VA Office of Inspector General 30 
Benefits Inspection Annual Summary Report 

Table 6: Projections and Margins of Error for Sample Results 

Claim Type 

Net 

Overpayment 

Estimate 

Margin of 

Error for 90% 

Confidence 

Interval 

90% Confidence Interval Sample Size 

for Error 

Type 

Sample Size 

for Claim 

Lower Type 

Limit Upper Limit 

Temporary 

100 Percent 

Disability 

Evaluations 

$81,497,821 $29,316,988 $52,180,832 $110,814,809 215 277 

VA Office of Inspector General 31 
Benefits Inspection Annual Summary Report 

Appendix D VARO Inspection Results
 

VARO Operational Activities Inspected 

Compliance With 

Number of 

Activities Inspected 

Nashville 

PTSD, TBI, Diabetes, Haas, Date of Claim, COVERS, SAO, STAR, Date 

Stamp Accountability, Claims Processing Improvement, Mail Handling, 

Destruction of Documents, Inquiry Routing and Information System 

(IRIS), Congressional Inquiries, and Fiduciary. 

5 of 15 

(33 percent) 

Wilmington 

PTSD, TBI, Diabetes, Haas, Date of Claim, COVERS, SAO, STAR, Date 

Stamp Accountability, Claims Processing Improvement, Mail Handling, 

Destruction of Documents, IRIS, Congressional Inquiries, and Fiduciary. 

7 of 15 

(47 percent) 

Baltimore 

PTSD, TBI, Diabetes, Haas, Date of Claim, COVERS, SAO, STAR, Date 

Stamp Accountability, Claims Processing Improvement, Mail Handling, 

Destruction of Documents, IRIS, Congressional Inquiries, and Fiduciary. 

1 of 15 

(7 percent) 

San Juan 

PTSD, TBI, Diabetes, Haas, Date of Claim, COVERS, SAO, STAR, Date 

Stamp Accountability, Claims Processing Improvement, Mail Handling, 

Destruction of Documents, IRIS, Congressional Inquiries, and Fiduciary. 

5 of 15 

(33 percent) 

Anchorage 

PTSD, TBI, Diabetes, Haas, Date of Claim, COVERS, SAO, STAR, Date 

Stamp Accountability, Claims Processing Improvement, Mail Handling, 

Destruction of Documents, IRIS, and Congressional Inquiries. 

1 of 14 

(7 percent) 

Roanoke 

PTSD, TBI, Diabetes, Haas, Date of Claim, COVERS, SAO, STAR, Date 

Stamp Accountability, Claims Processing Improvement, Mail Handling, 

Destruction of Documents, IRIS, and Congressional Inquiries. 

8 of 14 

(57 percent) 

Togus 

100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

SAO, STAR, Date Stamp Accountability, Mail Handling, Destruction of 

Documents, and Incompetency Determinations. 

4 of 11 

(36 percent) 

Philadelphia 

100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

SAO, STAR, Date Stamp Accountability, Mail Handling, Destruction of 

Documents, and Incompetency Determinations. 

6 of 11 

(55 percent) 

Waco 

100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, Date Stamp Accountability, Mail Handling, 

Destruction of Documents, and Incompetency Determinations. 

3 of 12 

(25 percent) 

Albuquerque 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, and Mail Handling. 

2 of 9 

(22 percent) 

Muskogee 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, Mail Handling, and Incompetency Determinations. 

6 of 10 

(60 percent) 

Denver 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, and Mail Handling. 

6 of 9 

(67 percent) 

Cheyenne 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, STAR, and Mail Handling. 

5 of 8 

(63 percent) 

Detroit 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, Mail Handling, and Incompetency Determinations. 

5 of 10 

(50 percent) 

Jackson 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, Mail Handling, and Incompetency Determinations. 

7 of 10 

(70 percent) 

Newark 100 Percent Disability Evaluations, PTSD, TBI, Diabetes, Date of Claim, 

NODs, SAO, STAR, Mail Handling, and Incompetency Determinations. 

4 of 10 

(40 percent) 

VA Office of Inspector General 32 
Benefits Inspection Annual Summary Report 

Appendix E OIG Contact and Staff Acknowledgments
 

OIG Contact For more information about this report, please 

contact the Office of Inspector General at 

(202) 461-4720. 

Acknowledgments	 Brent Arronte, Director 

Kristine Abramo 

Daphne Brantley 

Brett Byrd 

Robert Campbell 

Madeline Cantu 

Danny Clay 

Kelly Crawford 

Ramon Figueroa 

Lee Giesbrecht 

Kerri Leggiero-Yglesias 

Nora Stokes 

Lisa Van Haeren 

Mark Ward 

VA Office of Inspector General 33 
Benefits Inspection Annual Summary Report 

Appendix F 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 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 

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 issuance. 

VA Office of Inspector General 34