Inspection of the
 

VA Regional Office
 

Boston, MA
 

OFFICE OF AUDITS & EVALUATIONS

February 10, 2011 

10-03564-86 
ACRONYMS AND ABBREVIATIONS
 

COVERS Control of Veterans Records System 

NOD Notice of Disagreement 

OIG Office of Inspector General 

PTSD Post-Traumatic Stress Disorder 

RVSR Rating Veterans Service Representative 

SAO Systematic Analysis of Operations 

STAR Systematic Technical Accuracy Review 

STR Service Treatment Records 

TBI Traumatic Brain Injury 

VACOLS Veterans Appeals Control and Locator System 

VARO VA Regional Office 

VBA Veterans Benefits Administration 

VSC Veterans Service Center 

To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
 

Report Highlights: Inspection of the VA 

Regional Office, Boston, MA 

Why We Did This Review 

The Benefits Inspection Division conducts 

onsite inspections at VA Regional Offices 

(VAROs) to review disability compensation 

claims processing and Veterans Service 

Center (VSC) operations. 

What We Found 

The Boston VARO correctly processed 

post-traumatic stress disorder (PTSD) 

disability claims. Management ensured staff 

followed the Veterans Benefits 

Administration (VBA) policy to establish 

correct dates of claims in the electronic 

record. Further, staff corrected all errors 

that VBA’s Systematic Technical Accuracy 

Review (STAR) program identified. 

VARO management needs to improve the 

control and accuracy of processing 

temporary 100 percent evaluations, 

traumatic brain injury (TBI) claims, and 

herbicide exposure-related claims. Overall, 

VARO staff did not accurately process 

42 (35 percent) of the 120 disability claims 

reviewed. 

Management also needs to strengthen 

controls over recording Notices of 

Disagreement (NODs) for appealed claims, 

timely completing Systematic Analyses of 

Operations (SAOs), and processing mail and 

final competency determinations. 

What We Recommended 

We recommended that Boston VARO 

management review all temporary 

100 percent evaluations to determine if 

reevaluations are required and take 

appropriate action. Management needs to 

implement controls to ensure VSC staff 

establish diaries to request medical 

examinations for temporary 100 percent 

disability reevaluations. Further, we 

recommended management provide 

refresher training on the proper procedures 

for processing TBI and herbicide 

exposure-related disability claims, and 

implement a plan to have an additional level 

of review prior to finalizing claims 

decisions. 

We also recommended that Boston VARO 

management strengthen controls to ensure 

timely establishment of NODs in the 

Veterans Appeals Control and Locator 

System (VACOLS). Additionally, we 

recommended that Boston VARO 

management implement plans to ensure 

timely and complete preparation of SAOs, 

and accurate and timely processing of 

incoming mail. 

Agency Comments 

The Director of the Boston VARO 

concurred with all recommendations. 

Management’s planned actions are 

responsive and we will follow up as required 

on all actions. 

(original signed by:) 

BELINDA J. FINN
 

Assistant Inspector General
 

for Audits and Evaluations
 

i 
TABLE OF CONTENTS
 

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

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

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

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

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

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

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

Appendix A VARO Profile and Scope of Inspection ............................................................17 

Appendix B VARO Director’s Comments............................................................................19 

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

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

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

ii 
Inspection of the VA Regional Office, Boston, MA 

Objective
 

Scope of
 

Inspection
 

INTRODUCTION 

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

Inspector General (OIG) to ensure our Nation’s veterans receive timely and 

accurate benefits and services. The Benefits Inspection Division contributes 

to improved management of benefits processing activities and veterans’ 

services by conducting onsite inspections at VAROs. These independent 

inspections provide recurring oversight focused on disability compensation 

claims processing and performance of VSC operations. The objectives of the 

inspections are to: 

	 Evaluate how well VAROs are accomplishing their mission of providing 

veterans with convenient access to high quality benefits and services. 

	 Determine if management controls ensure compliance with VA 

regulations and policies, assist management in achieving program goals, 

and minimize the risk of fraud, waste, and other abuses. 

	 Identify and report systemic trends in VARO operations. 

In addition to this standard coverage, inspections may examine issues or 

allegations referred by VA employees, members of Congress, or other 

stakeholders. 

In August 2010, the OIG conducted an inspection of the Boston VARO. The 

inspection focused on 5 protocol areas examining 10 operational activities. 

The five protocol areas were disability claims processing, data integrity, 

management controls, workload management, and eligibility determinations. 

We reviewed 90 (22 percent) of 414 disability claims related to PTSD, TBI, 

and herbicide exposure that the VARO completed during April to June 2010. 

In addition, we reviewed 30 (21 percent) of 146 rating decisions where 

VARO staff granted temporary 100 percent evaluations for at least 

18 months, generally the longest period a temporary 100 percent evaluation 

may be assigned under VA policy without review. 

Appendix A provides details on the VARO and the scope of our inspection. 

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

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

activity and a summary of our inspection results. 

VA Office of Inspector General 1 
Inspection of the VA Regional Office, Boston, MA 

RESULTS AND RECOMMENDATIONS 

1. Disability Claims Processing 

The OIG inspection team focused on disability claims processing related to 

temporary 100 percent evaluations, PTSD, TBI, and herbicide exposure. We 

evaluated claims processing accuracy and its impact on veterans’ benefits. 

Finding	 VARO Staff Need To Improve Disability Claims 

Processing Accuracy 

The Boston VARO needs to improve the accuracy of disability claims 

processing. VARO staff incorrectly processed 42 (35 percent) of the total 

120 disability claims reviewed. VARO management concurred with our 

findings and initiated action to correct the inaccuracies identified. 

The following table reflects the errors affecting, and those with the potential 

to affect, veterans’ benefits processed at the Boston VARO. 

Table Disability Claims Processing Results 

Type Reviewed 

Claims Incorrectly Processed 

Total Affecting Potential To 

Veterans’ Affect Veterans’ 

Benefits Benefits 

Temporary 100 

Percent Evaluations 30 25 4 21 

PTSD 30 0 0 0 

TBI 30 11 5 6 

Disabilities Related to 

Herbicide Exposure 30 6 4 2 

Total 120 42 13 29 

Temporary 

100 Percent 

Evaluations 

VARO staff incorrectly processed 25 (83 percent) of 30 temporary 

100 percent disability evaluations we reviewed. VBA policy requires a 

temporary 100 percent evaluation for service-connected disabilities needing 

surgery or specific treatment. At the end of a mandated period of 

convalescence or cessation of treatment, VARO staff must request a 

follow-up medical examination to help determine whether to continue the 

veteran’s 100 percent disability benefits. 

Based on analysis of available medical evidence, 4 of the 25 processing 

inaccuracies affected veterans’ benefits—all 4 involved overpayments 

VA Office of Inspector General 2 
Inspection of the VA Regional Office, Boston, MA 

totaling $106,133. Two examples of the most significant overpayments 

follow: 

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

veteran’s lung cancer. Medical evidence in the claims folder warranted a 

reduction in benefits as of May 1, 2009. As a result, VA overpaid the 

veteran a total of $40,800 over a period of 1 year and 4 months. 

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

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

warranted a reduction in benefits as of June 1, 2009. As a result, VA 

overpaid the veteran a total of $40,376 over a period of 1 year and 

2 months. 

The remaining 21 inaccuracies had the potential to affect veterans’ benefits. 

Following are summaries of these inaccuracies: 

	 In 14 cases, VSC staff did not schedule the follow-up medical 

examinations needed to determine whether the temporary 100 percent 

evaluations should continue. 

	 In three cases, VSC staff were not timely requesting reexaminations. The 

delay in requesting the reexaminations ranged from 7 months to 1 year 

and 3 months. 

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

continued the 100 percent evaluations without requiring future 

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

entitlement to the additional benefit of Dependents’ Educational 

Assistance as required by VBA policy. 

	 In one case, the RVSR continued the 100 percent evaluation; however, 

the rating did not indicate whether a future examination was required. 

	 In one case, the RVSR proposed reducing the evaluation of a veteran’s 

condition based on an examination conducted 30 days after the cessation 

of treatment. According to VBA’s policy, VSC staff are to request 

reexaminations 6 months following cessation of treatment. 

We could not determine if the 14 temporary 100 percent disability 

determinations would have continued because the veterans’ claims folders 

did not contain evidence of the medical examinations needed to reevaluate 

each case. An average of 3 years and 4 months elapsed from the time staff 

should have scheduled these medical examinations until the date of our 

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

necessary medical evidence. The delays ranged from 3 months to 14 years 

and 11 months. 

VA Office of Inspector General 3 
Inspection of the VA Regional Office, Boston, MA 

PTSD Claims 

TBI Claims 

For temporary 100 percent evaluations, including those where rating 

decisions do not change a veteran’s payment amount (confirmed and 

continued evaluations), VSC staff must input suspense diaries in VBA’s 

electronic system. A 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 reexaminations. 

Eight of the 25 temporary 100 percent errors resulted from staff not 

establishing diaries for confirmed and continued evaluations. VSC staff 

stated that until just prior to our inspection, they were unaware of the 

requirement to input the suspense diaries. The Post Decision Team 

supervisor stated, and we verified, the office had no procedure in place that 

required senior staff members to review implementation of confirmed and 

continued rating decisions. As such, oversight did not occur to ensure staff 

properly established diaries for these decisions. 

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

we made no recommendations for improvement in this area. 

The Department of Defense and VBA commonly define a TBI as 

traumatically induced structural injury or physiological disruption of brain 

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

fall into three main categories: (1) physical, (2) cognitive, and (3) behavioral. 

VBA policy requires staff to evaluate these residual disabilities. 

VARO staff incorrectly processed 11 (37 percent) of 30 TBI claims. Five of 

the 11 processing inaccuracies affected veterans’ benefits—2 involved 

underpayments totaling $41,283 and 3 involved overpayments totaling 

$30,946. Examples of the most significant underpayment and overpayment 

follow: 

	 An RVSR incorrectly evaluated the residual TBI-related disabilities as 

70 percent disabling. The medical examination results showed these 

residual TBI-related disabilities were 100 percent disabling. As a result, 

the veteran was underpaid $31,797 over a period of 2 years and 1 month. 

	 An RVSR continued granting service connection for residual TBI-related 

disabilities without evidence showing the veteran actually experienced a 

TBI. Additionally, the rating decision increased the evaluation of 

TBI-related disabilities from 0 to 100 percent. As a result, the veteran 

was overpaid $16,995 over a period of 1 year and 3 months. 

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

potential to affect veterans’ benefits. 

VA Office of Inspector General 4 
Inspection of the VA Regional Office, Boston, MA 

Herbicide 

Exposure-Related 

Claims 

	 In two cases, RVSRs denied claims for TBI-related disabilities without 

requesting evidence from the veteran as outlined in VA regulations. 

Although there was no evidence to support granting service connection 

for residuals of a TBI, the veterans may have submitted it if provided the 

opportunity. 

	 In one case, an RVSR incorrectly denied a combat veteran service 

connection for residuals of a TBI without a medical opinion to say no 

link existed between the medical diagnosis and the in-service injury. The 

examiner’s opinion might have provided the link necessary to approve 

the benefits claimed. 

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

inadequate VA medical examination. Additionally, the RVSR failed to 

assign a separate evaluation for migraine headaches diagnosed at the VA 

medical examination. These errors do not immediately affect this 

veteran’s benefits; however, failure to assign separate evaluations may 

affect future evaluations for additional benefits. 

	 In one case, an RVSR granted service connection for residuals of a TBI 

without a medical opinion linking the TBI-related residuals to an 

in-service event or injury. Neither VSC staff nor we can determine if the 

veteran’s TBI-related residuals are service-connected without further 

clarification from the medical examiner. 

	 In one case, an RVSR granted service connection for residuals of a TBI 

without evidence indicating the veteran suffered an injury during service. 

This rating did not affect the veteran’s monthly benefits, but it may affect 

future evaluations for additional benefits. 

Generally, errors associated with TBI claims processing occurred because of 

a lack of training. Interviews with VSC management and staff revealed that 

the last training regarding TBI occurred on January 29, 2009. The Assistant 

VSC Manager stated she was aware that RVSRs felt TBI claims were 

confusing and difficult. According to VSC supervisory staff, RVSRs had not 

communicated any problems related to TBI claims processing. Additionally, 

VSC supervisory staff acknowledged a limited understanding of rating 

procedures due to a lack of prior RVSR experience. As a result of this lack 

of training and experience, veterans did not always receive correct healthcare 

entitlements or benefits payments. 

VARO staff incorrectly processed 6 (20 percent) of 30 herbicide 

exposure-related claims reviewed. Four of the six processing inaccuracies 

affected veterans’ benefits—two involved underpayments totaling 

$16,528 and two involved overpayments totaling $9,665. Examples of the 

most significant underpayment and overpayment follow: 

VA Office of Inspector General 5 
Recommendations 

Inspection of the VA Regional Office, Boston, MA 

	 An RVSR failed to grant service connection for all secondary diabetic 

complications diagnosed at the VA exam. As a result, the veteran was 

underpaid $15,760 over a period of 1 year and 4 months. 

	 An RVSR incorrectly confirmed and continued a 40 percent diabetes 

evaluation. As a result, the veteran was overpaid $8,468 over a period of 

3 years and 7 months. 

Following are details on the two remaining herbicide exposure-related 

inaccuracies that had the potential to affect veterans’ benefits. 

	 In one case, an RVSR failed to obtain the current VA medical 

examination results before evaluating the veteran’s service-connected 

diabetes. This oversight did not affect the veteran’s monthly benefits, but 

it may affect future evaluations for additional benefits. 

	 In one case, an RVSR failed to grant service connection for a 

diabetes-related complication diagnosed at the VA medical examination. 

This rating did not affect the veteran’s monthly benefits, but it may affect 

future evaluations for additional benefits. 

Generally, errors occurred because management did not provide adequate 

oversight of herbicide exposure-related claims. The VSC supervisory staff 

stated that RVSRs have expressed concerns over the complexity of diabetes 

claims and their ability to meet individual performance standards. However, 

the VSC supervisory staff responsible for quality reviews acknowledged 

being unaware that RVSRs were missing secondary conditions. VSC 

supervisory staff also had not indentified any error trends in processing 

herbicide exposure-related claims. Because of this lack of management 

oversight, veterans did not always receive correct healthcare entitlements or 

benefits payments. 

1.	 We recommend the Boston VA Regional Office Director conduct a review 

of all temporary 100 percent determinations under the regional office’s 

jurisdiction to determine if reevaluations are required and, if they are, 

take appropriate action. 

2.	 We recommend the Boston VA Regional Office Director implement 

controls to ensure staff establish suspense diaries for temporary 

100 percent disability evaluations. 

3.	 We recommend the Boston VA Regional Office Director conduct 

refresher training to ensure Rating Veterans Service Representatives 

properly evaluate disabilities related to traumatic brain injuries and 

herbicide exposure-related claims. 

4.	 We recommend the Boston VA Regional Office Director implement a 

plan to provide an additional level of review prior to finalizing decisions 

VA Office of Inspector General 6 
Inspection of the VA Regional Office, Boston, MA 

Management 

Comments 

OIG Response 

on traumatic brain injury and herbicide exposure-related claims to 

ensure accurate benefit payments. 

The VARO Director concurred with our recommendations and discussed 

actions taken to improve claims processing accuracy. VSC staff reviewed all 

remaining claims that we did not include in our sample and determined 56 of 

107 of them did not have controls in place to ensure staff scheduled future 

examinations. VSC staff received training on the proper procedures for 

establishing future suspense diaries and on reviewing and authorizing awards 

where rating decisions indicate future examinations are required. The 

Director indicated authorizers would maintain a log of all awards requiring 

future examinations and management would conduct periodic audits to 

ensure compliance. Further, the Director amended VSC’s statistical quality 

control reviews to ensure compliance with future examination procedures. 

The Director stated that in November 2010, VSC staff received training on 

procedures for processing herbicide exposure-related claims and TBI claims. 

He reported the VSC had scheduled for January 2011 training on 

complications due to diabetes. He said VSC staff would receive additional 

training on processing TBI claims in August 2011. Also, VARO 

management implemented a Rating Quality Team to improve the overall 

quality of disability claims processing. The Director amended the VSC’s 

quality control procedures to require a second review for accuracy of all 

herbicide exposure-related claims and TBI claims. 

The Director did not concur with our characterization of the VARO’s claims 

processing accuracy in a bar graph and related discussions in a draft of this 

report. He said that the VSC’s staff review of the remaining temporary 

100 percent disability evaluations showed a 52 percent error rate—a much 

lower error rate than the 83 percent we found in our sample. As such, the 

Director requested we add an appendix to the report outlining our sample 

selection methodology. Further, he asked that we include in our report a 

copy of a letter he sent to the OIG Project Manager requesting specific data 

filters we used to identify the sub-population of cases at risk of having errors. 

Management comments and actions are responsive to the recommendations. 

We acknowledge that the Director obtained a lower error than we did in our 

sample of temporary 100 percent disability claims. In using a different 

sample population and possibly different criteria, it was inevitable that the 

resulting error rates would be different. However, regardless of the different 

outcomes, both our reviews disclosed an unacceptable rate of error in 

temporary 100 percent disability claims processing and the need for 

corrective action. The training, guidance, and quality control initiatives that 

the Director outlined are positive steps toward effecting improvement. 

VA Office of Inspector General 7 
Effective Dates 

Inspection of the VA Regional Office, Boston, MA 

We do not believe it would be appropriate to include in our report a copy of 

the Director’s letter requesting details on our review methodology. We will 

nonetheless forward to the Director, under separate cover, information on our 

sample selection approach. We will likewise provide other VARO officials 

our sample selection methodology prior to conducting future Benefits 

Inspections. 

2. Data Integrity 

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

policy to establish effective dates and dates of claims in electronic records 

and to timely record NODs in VACOLS. 

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

arose. VARO staff incorrectly established an effective date for 4 (3 percent) 

of 120 disability claims we reviewed. All four errors affected veterans’ 

benefits—two involved overpayments totaling $7,968 and one involved an 

underpayment totaling $21,637. The amount of the underpayment related to 

the fourth error could not be determined due to lack of medical evidence. 

Details on the most significant underpayment and overpayment related to 

incorrect effective dates follow: 

	 An RVSR granted an incorrect effective date for PTSD. The VARO 

received the veteran’s original claim on January 20, 2005 and denied 

service connection for PTSD. The veteran’s appeal was pending at the 

time of our review. The RVSR granted service connection for PTSD 

effective May 14, 2009, the date the VARO received a request from the 

veteran to reopen his claim. VA regulations state the effective date is the 

original date of claim. As a result, the veteran was underpaid 

$21,637 over a period of 4 years and 4 months. 

	 An RVSR incorrectly granted service connection for a veteran’s prostate 

cancer effective August 15, 2008, approximately 2 months prior to the 

actual receipt of the claim. This occurred because the veteran had a 

claim pending for approximately 2 months for other disabilities at the 

time the VARO received the veteran’s claim for prostate cancer on 

October 7, 2008. VA regulations state the effective date of benefits is the 

claim receipt date or the date evidence revealed the disability existed, 

whichever is later. As a result, the veteran was overpaid $5,520 over a 

period of 2 months. 

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

determined the VARO is generally following VBA policy regarding data 

integrity. As such, we made no recommendation for improvement in this 

area. 

VA Office of Inspector General 8 
Inspection of the VA Regional Office, Boston, MA 

Dates of Claim 

Notices of 

Disagreement 

Finding 

In addition to establishing the timeframe for benefits entitlement, VBA 

generally uses a date of claim to indicate when a document arrives at a VA 

facility. VBA relies on accurate dates of claim to establish and track key 

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

VARO staff established the correct dates of claim in the electronic records 

for all 30 claims reviewed. These claims were pending processing from 

31 to 60 days at the time of our inspection. As a result, we determined the 

VARO is following VBA policy regarding dates of claims and we made no 

recommendations for improvement in this area. 

An NOD is a written communication from a claimant expressing 

dissatisfaction or disagreement with a benefits decision and a desire to 

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

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

track a veteran’s appeal and manage the pending appeals workload. VBA 

policy states staff must create a VACOLS record within 7 days of receiving 

an NOD. 

Accurate and timely recording of NODs is required to ensure appeals move 

through the appellate process expeditiously. VARO staff need to strengthen 

controls over recording NODs in VACOLS. 

Controls over Recording Notices of Disagreement Need 

Strengthening 

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

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

for 8 (27 percent) of the 30 NODs we reviewed. It took staff an average of 

18 days to record these eight disagreements in VACOLS. The most 

untimely action occurred when staff did not create a record for 34 days. This 

delay occurred because VSC supervisory personnel and staff were unaware 

of the 7-day standard. VSC staff’s untimely recording of NODs in VACOLS 

affects data integrity and misrepresents VARO performance. 

VSC supervisory personnel and staff stated they were unaware of the VBA 

7-day standard for entering NODs into VACOLS. In addition, a VSC 

supervisor did not receive any formal appeals training. According to the 

Assistant VSC Manager, she was aware of the 7-day standard, but was 

unaware of the supervisors lack of knowledge of the standard. 

As of August 2010, the VARO averaged 23 days to control NODs, 

exceeding VBA’s goal by 16 days. In addition to improving appeals control 

time, overall timeliness of NODs pending completion needs improvement. 

For August 2010, pending NODs averaged 246 days—38 days over the 

national average of 208 days. 

VA Office of Inspector General 9 
Inspection of the VA Regional Office, Boston, MA 

Recommendation 

Management 

Comments 

OIG Response 

Systematic 

Technical 

Accuracy 

Review 

Systematic 

Analysis of 

Operations 

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

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

National Call Centers rely upon VACOLS information to provide accurate 

customer service to veterans. Unnecessary delays in controlling NODs affect 

national performance measures for NOD inventory and timeliness. 

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

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

Veterans Appeals Control and Locator System within 7 days as required 

by VBA policy. 

The VARO Director concurred with our recommendation. Management 

provided training to the Appeals Team Supervisor and appropriate Appeals 

Team staff on the timeliness standard and proper procedures for controlling 

NODs. Further, the Director modified local procedures to strengthen 

compliance and oversight. 

Management comments and actions are responsive to the recommendation. 

3. Management Controls 

We assessed management controls to determine if VARO management 

adhered to VBA policy regarding correction of errors identified by VBA’s 

STAR staff. Further, we assessed controls to determine if VARO 

management accurately and timely completed SAOs. We determined 

management needs to improve oversight to ensure SAOs are timely and 

complete. 

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

ensure that veterans and other beneficiaries receive accurate and consistent 

compensation and pension benefits. VBA policy requires that the VARO 

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

VBA policies by taking corrective action on all 29 errors identified by 

VBA’s STAR program. Therefore, we made no recommendations for 

improvement in this area. 

An SAO is a formal analysis of a VSC organizational element or operational 

function. SAOs provide an organized means of reviewing VSC operations to 

identify existing or potential problems and propose corrective actions. 

VARO management must publish an annual SAO schedule designating the 

staff required to complete the SAOs by specific dates. 

VA Office of Inspector General 10 
Inspection of the VA Regional Office, Boston, MA 

Finding
 

Recommendation 

Management 

Comments 

Improved Oversight Is Needed To Ensure Timely 

Completion of SAOs 

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

including completing 12 annual SAOs. The VARO completed 7 (58 percent) 

of the 12 SAOs later than scheduled. For example, management did not 

complete the Appeals SAO or follow VBA policy governing VACOLS. 

Furthermore, the VARO’s workload management plan did not incorporate 

provisions to ensure timely entry of NODs in VACOLS. If management had 

completed the required SAO on time, it might have prevented unnecessary 

delays in the Appeals process. 

The VSC Manager stated his primary focus was ensuring supervisors were 

writing quality SAOs. The Assistant VSC Manager shared this opinion. The 

VSC Manager accepted responsibility for the missing and deficient SAOs 

stating that he did not always have the time to review them due to shifting 

priorities. The delay in completing SAOs is attributable to the station’s lack 

of VSC management oversight of the SAO process. 

Further, 2 (17 percent) of the 12 SAOs were incomplete at of the time of our 

inspection. VARO management did not provide adequate oversight to 

ensure VSC staff addressed all required elements in accordance with VBA 

policy. As a result of these oversight issues, management may not have 

identified existing or potential problems for corrective actions to improve 

VSC operations. 

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

implement a plan to ensure staff complete Systematic Analyses of 

Operations timely and address all required elements. 

The VARO Director concurred with our recommendation. However, the 

Director felt the finding was misleading because the seven late SAOs were 

pending division-level management review and concurrence. He stated that 

although timeliness of SAOs is a concern, management is more concerned 

with the depth and quality of the analysis. The Director indicated VSC 

division-level management coordination with supervisors assigned to 

complete SAOs is considerable, given their lack of supervisory experience. 

The Director has emphasized to VSC division management the importance 

of timely completing SAOs. 

The VARO Director also did not agree with the wording of our 

recommendation regarding SAO accuracy in a draft of this report. He 

indicated we did not address the quality of research or analysis in the SAOs 

and therefore lacked the basis for discussing SAO accuracy. 

VA Office of Inspector General 11 
Inspection of the VA Regional Office, Boston, MA 

OIG Response 

Mail Room
 

Operations
 

Finding 

Management’s action reinforcing the importance of SAO timeliness is 

responsive to the recommendation. We recognize that depth and quality of 

analysis are important; however, completing SAOs timely is also vital. At 

the time of our review, seven SAOs were late by an average of over 

4 months from the day they were due for completion. Two were scheduled 

for completion in January 2010 and one had a due date of March 2010. The 

analysis conducted as part of an SAO is intended to address problems or 

potential problem areas and recommend corrective actions. When VSC 

management do not ensure SAOs are timely completed, areas of concern are 

not properly addressed, recommendations for corrective action are delayed, 

and problems continue. 

Further, we agree with the Director that a review of accuracy in addition to 

timeliness and completion of SAOs would be beneficial. However, we lack 

the staff resources to review the detailed documentation supporting SAOs. 

Therefore, we changed the language of our report finding and 

recommendation to reflect the scope of our inspection work related to the 

accuracy of SAOs more accurately. 

4. Workload Management 

We assessed controls over VARO mailroom operations to ensure staff timely 

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

Triage Team mail processing procedures to ensure staff reviewed, controlled, 

and processed all claims-related mail in accordance with VBA policy. 

Controls over VARO mailroom operations and Triage Team mail processing 

procedures need strengthening. 

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

appropriate locations within 4–6 hours of receipt at the VARO. The Boston 

VARO assigns responsibility for mailroom activities, including processing of 

incoming mail, to the Support Services Division. 

Controls over Mail Processing Need Strengthening 

VARO mailroom staff did not always date stamp mail the same day it arrived 

in the mailroom as required. This delay occurred because the Support 

Service Division management and mailroom staff were unaware of VBA’s 

policy. As a result, beneficiaries may not have received accurate benefit 

payments. 

According to the mailroom staff, approximately 1 to 2 days each month the 

VARO will receive a large volume of mail. When this occurs, the mailroom 

is unable to process all of the mail on the same day. As a result, some mail is 

processed and date stamped the following morning. The mailroom staff 

VA Office of Inspector General 12 
Inspection of the VA Regional Office, Boston, MA 

Triage Mail 

Processing 

Procedures 

Finding 

expressed a lack of awareness of how delayed date stamping can adversely 

affect dates of claim. 

Because the VARO did not always properly date stamp incoming mail, 

beneficiaries may not have been paid benefits on the correct dates. 

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 the 

VSC staff would inadvertently underpay the beneficiary by 1 month. 

Neither VARO employees nor we could identify any veterans’ claims 

affected by improper date stamping of mail. However, because mailroom 

staff does not always correctly date stamp all mail on the day it arrives, VA 

could potentially underpay veterans by 1 month. 

VARO staff are required to use VBA’s tracking system, Control of Veterans 

Records System (COVERS), to electronically track veterans’ claims folders 

and control search mail. VBA defines search mail as active claims-related 

mail waiting to be associated with a veteran’s claims folder. VBA defines 

essential mail as mail that has evidentiary value, which should be filed in the 

claims folder. Non-essential returned mail is mail that has no evidentiary 

value, such as letters provided to veterans informing them of cost of living 

increases. If a returned envelope contains a forwarding address, VSC staff 

must update VA systems to show the new address and resend the 

correspondence. Staff may destroy returned mail that does not contain a 

forwarding address. 

Triage Team Mail Management Procedures Need 

Strengthening 

Triage Team members did not manage essential and non-essential mail 

according to VBA policy. We found approximately 4,000 pieces of 

unprocessed mail in containers under tables located in the VARO mailroom 

with some pieces date stamped in 2008. The majority of the 4,000 pieces of 

mail was non-essential returned mail; however, we also identified some 

essential mail such as marital questionnaires and dependency questionnaires. 

VSC supervisory personnel expressed a lack of awareness of this mail. 

Additionally, the Support Service Division Chief and mailroom employee 

stated they were unsure of how to process this mail. This occurred because 

supervisory personnel did not provide appropriate oversight of all essential 

and non-essential mail processing. The potential effect of not processing 

essential mail is a delay in claims processing and ultimately, incorrect 

benefits decisions. 

VA Office of Inspector General 13 
Recommendations 

Inspection of the VA Regional Office, Boston, MA 

Additionally, Triage Team staff did not always handle original Service 

Treatment Records (STRs) according to VBA policy. STRs were found 

improperly stored in cabinets labeled “Military Files.” This occurred 

because the Boston VARO workload management plan incorrectly directed 

storage of STRs in such cabinets. VBA policy requires STRs to be 

associated with claims folders or stored at the VA’s Records Management 

Center. Of the 30 STRs reviewed, staff stored 28 (93 percent) in the military 

file cabinets for more than 90 days, with the oldest being received by the 

VARO on October 17, 2007. Furthermore, 8 (27 percent) of the 30 STRs 

had claims for benefits either pending or decided without the RVSR 

reviewing the original STRs. VBA policy requires review of original STRs 

as part of claims processing. In one example, an RVSR denied service 

connection for all of the veteran’s claimed conditions without considering 

the original STRs which were improperly stored. We provided this file to 

VSC management to reevaluate the veteran’s claim. 

Finally, Triage Team staff did not always manage search mail according to 

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

did not properly use COVERS to ensure timely processing and adequate 

control of it. These lapses occurred because the mail plan did not 

incorporate procedures for the Triage Team supervisor to oversee the search 

mail process. As a result, beneficiaries may not receive accurate payments. 

In one example, Triage staff received medical evidence on June 3, 2010, 

while the claims folder was located at the VA hospital pending a medical 

examination. The station received the file on June 14, 2010, but at the time 

of our inspection, the evidence was not properly marked for search in 

COVERS. 

VSC management acknowledged weaknesses associated with mail 

processing. Specifically, the plan governing mail processing does not 

incorporate oversight procedures for controlling essential mail, reviewing 

military files, or managing search mail. Consequently, RVSRs may not have 

all available evidence when making disability determinations. Untimely 

association of STRs, search mail, or other essential mail with veterans’ 

claims folders can cause delays in processing disability claims. As a result, 

beneficiaries may not receive accurate and timely benefit payments. 

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

implement controls to ensure Support Services Division staff process and 

date stamp all incoming mail the same day it arrives in the mailroom. 

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

implement a plan to ensure proper oversight and control of all returned 

mail. 

VA Office of Inspector General 14 
Inspection of the VA Regional Office, Boston, MA 

Management 

Comments 

OIG Response 

Competency 

Determinations 

Finding 

9.	 We recommend the Boston VA Regional Office Director add steps to the 

workload management plan to ensure proper handling of Service 

Treatment Records. 

10. We recommend the Boston VA Regional Office Director amend the mail 

plan to incorporate procedures for management oversight and control of 

search mail. 

The VARO Director concurred with our recommendations. The Director 

provided training to the Support Services Division staff on the proper 

processing of incoming mail and to the Triage Team staff on procedures for 

handling returned mail. In January 2011, all VSC employees will receive 

training on search mail procedures and COVERS compliance. Further, in 

February 2011 all VSRs and Claims Assistants will receive refresher training 

on the proper management of Service Treatment Records. 

Additionally, the Support Services Division Chief coordinated with the VSC 

Triage Team and the VARO Records Management Officer to review existing 

policy and reinforce proper procedures for processing returned mail. The 

Director has arranged to shift employee resources from other divisions in the 

VARO to assist with surges in mailroom workload at the end of each month. 

Division management has also increased oversight, including periodic 

random audits of mailroom activities. The Director ensured review and 

processing of the backlog of mail identified during our inspection. Further, 

the Director indicated the Workload Management Plan is undergoing 

extensive revisions, which will comply with our recommendations. 

Management comments and actions are responsive to the recommendations. 

5. Eligibility Determinations 

VA must consider beneficiary competency in every case involving a mental 

health condition that is totally disabling or when evidence raises questions 

about a beneficiary’s mental capacity to manage his or her affairs. The 

Fiduciary Unit supports implementation of competency determinations by 

appointing a fiduciary—a third party that assists in managing funds for an 

incompetent beneficiary. We reviewed competency determinations 

completed by the VSC Decision Team to ensure staff completed them 

accurately and timely. Delays in making these determinations ultimately 

affect the Fiduciary Unit’s ability to be timely in appointing fiduciaries. 

Controls over Competency Determinations Need 

Strengthening 

VARO staff unnecessarily delayed making final decisions in 6 (35 percent) 

of the 17 incompetency determinations completed during April–June 2010. 

VA Office of Inspector General 15 
Inspection of the VA Regional Office, Boston, MA 

Delays ranged from 19 to 299 days, with an average completion time of 

95 days. Delays occurred because VSC staff were unaware of the timeliness 

criteria. The risk of incompetent beneficiaries receiving benefit payments 

without fiduciaries assigned to manage those funds increases when staff do 

not complete competency determinations immediately. 

VBA policy requires staff to obtain clear and convincing medical evidence 

that a beneficiary is incapable of managing his or her affairs prior to making 

a final competency decision. The policy allows the beneficiary a 65-day due 

process period to submit the evidence showing an ability to manage funds 

and other personal affairs. At the end of the due process period, VARO staff 

must take immediate action to determine if the beneficiary is competent. 

In the absence of a definition of “immediate,” we allowed 14 calendar days 

after the due process period to determine if staff were timely in completing a 

competency decision. We considered this a reasonable period to control, 

prioritize, and finalize these types of cases. 

Using our interpretation of immediate, the most significant case we identified 

occurred when VARO staff unnecessarily delayed making a final 

incompetency decision for a veteran for approximately 10 months. During 

this period, the veteran received $15,470 in disability payments. While the 

veteran was entitled to these payments, fiduciary stewardship was not in 

place to ensure effective funds management and the welfare of the veteran. 

VARO management and staff stated they were unaware of VBA’s policy 

requiring immediate action to determine competency after the 65-day due 

process period. Although VSC supervisory staff reportedly reviewed all due 

process cases that had been pending for more than 100 days, these cases 

were already 35 days past the 65-day due process period when identified. As 

a result, incompetent beneficiaries received benefits payments for extended 

periods despite being determined incapable of managing these funds 

effectively. 

We recommended in an August 16, 2010, Management Advisory 

Memorandum that VBA establish a clear standard for the timely completion 

of final competency determinations. We plan to raise this issue to senior 

management in our fiscal year 2010 summary. Therefore, we make no 

recommendation to the Director of the VARO regarding this issue. 

VA Office of Inspector General 16 
Inspection of the VA Regional Office, Boston, MA 

Appendix A 

Organization 

Resources 

Workload 

Scope 

VARO Profile and Scope of Inspection 

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

and services to veterans and their families in Massachusetts. The VARO 

fulfills these responsibilities by administering compensation and pension 

benefits, vocational rehabilitation and employment assistance, and outreach 

activities. 

As of July 2010, the Boston VARO had a staffing level of 123 full-time 

employees. Of these, 96 employees (78 percent) were assigned to the VSC. 

As of August 2010, the VARO reported 5,615 pending compensation claims. 

The average time to complete these claims during FY 2010 was 

190.2 days—39 days longer than the national target of 151.2 days. As 

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

76.3 percent—13.7 percent below the 90 percent VBA target. Accuracy of 

compensation authorization-related issues was 91.9 percent—4.1 percent 

below the 96 percent VBA target. 

We reviewed selected management controls, benefits claims processing, and 

administrative activities to evaluate compliance with VBA policies regarding 

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

beneficiaries. We interviewed managers and employees and reviewed 

veterans’ claims folders. 

Our review included 90 (22 percent) of 414 claims related to PTSD, TBI, and 

herbicide exposure-related disabilities that the VARO completed during 

April–June 2010. For temporary 100 percent disability evaluations, we 

selected 30 (21 percent) of 146 existing claims from VBA’s Corporate 

Database. We provided the VARO with the 116 claims remaining from the 

universe of 146 to assist in implementing the first recommendation in this 

report. 

The 146 claims represented all instances in which VARO staff granted 

temporary 100 percent disability determinations for at least 18 months. 

Because VARO staff processed too few temporary 100 percent evaluations 

during April–June 2010 for us to review and draw conclusions, we selected a 

sample from the universe of 146 existing claims. 

We reviewed 17 available competency determinations and 29 errors 

identified by VBA’s STAR Program during the period of April–June, 2010. 

VBA measures the accuracy of compensation and pension claims processing 

through its STAR Program. STAR’s measurements include a review of 

work associated with claims that require a rating decision. STAR staff 

review original claims, reopened claims, and claims for increased evaluation. 

VA Office of Inspector General 17 
Inspection of the VA Regional Office, Boston, MA 

Further, they review appellate issues that involve a myriad of veterans’ 

disability claims. 

Our process differs from STAR in that we review specific types of claims 

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

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

processing involving temporary 100 percent disability determinations. 

For our review, we selected dates of claims and NODs pending at the VARO 

during the time of our inspection. We completed our review in accordance 

with the President’s Council for Integrity and Efficiency’s Quality Standards 

for Inspections. 

VA Office of Inspector General 18 
Inspection of the VA Regional Office, Boston, MA 

Appendix B VARO Director’s Comments 

Department of MEMORANDUM 

Veterans Affairs 

Date: December 28, 2010 

From: Director, VA Regional Office Boston 

Subj: Inspection of the VARO Boston, MA 

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

1.	 Enclosed for your review is the response to the draft VA Office of Inspector 

General (VAOIG) Audit Inspection Report for the Boston VA Regional 

Office. A copy of this response was provided to the Eastern Area Director, 

the Office of Field Operations and the Compensation and Pension Service. 

2.	 Specific responses to each VAOIG audit team recommendation are provided 

in the attachment to this memorandum. 

3.	 Also included as an attachment to this memorandum is my formal request, 

dated September 1, 2010, to VAOIG audit team leader. To date, I have not 

received a response to my request. I again, respectfully request a copy of this 

letter be included in the VAOIG Audit Inspection Report and that the specific 

data filters used to identify the sub-population of cases at risk of having an 

error be provided to my Office. I believe this information could assist VARO 

Boston in improving service to Veterans in the Commonwealth of 

Massachusetts. 

4.	 We appreciate the courtesy and cooperation your staff showed during the 

inspection. If you have any questions or would like to discuss our response, 

please contact me at 617-303-4250. 

(Original signed) 

BRADLEY G. MAYES
 

Director
 

Attachments 

VA Office of Inspector General 19 
Inspection of the VA Regional Office, Boston, MA 

AUDIT RECOMMENDATIONS AND RESPONSES 

Recommendation 1: We recommend the Boston VA Regional Office Director conduct a review 

of all temporary 100 percent determinations under the regional office’s jurisdiction to determine 

if reevaluations are required and, if they are, take appropriate action. 

Response: Concur. 

The VA Office of Inspector General (VAOIG) audit team identified a total of 146 claims in 

which VA Regional Office (VARO) Boston claims processing personnel assigned a temporary 

total evaluation for at least 18 months. VARO Boston management concurs with the VAOIG 

finding that 25 claims from the sample of 30 claims reviewed during the audit were processed in 

error. 

In addition to the 30 claims reviewed by the VAOIG audit team, VARO Boston claims 

processing personnel have reviewed all remaining claims identified by the VAOIG audit team 

that are located on-station. The results of that review indicate 56 out of 107 were improperly 

processed which equates to a 52 percent error rate. While this is unacceptable, it is significantly 

lower than the 83 percent error rate reported in the VAOIG Draft Inspection Report. Therefore, 

we do not concur with the characterization of VARO Boston’s accuracy as depicted in the 

VARO Claims Processing Accuracy Comparison figure on page two or the narrative on page 

three of the VAOIG Draft Inspection Report. Further, in order to better understand and replicate 

the VAOIG conclusion for use in workload and training purposes, it is requested that a 

description of VAOIG’s sample selection methodology be added as an Appendix to the Report. 

Corrective action has been initiated on all cases where an error was identified. 

Analysis revealed that the majority of errors were the result of a failure to establish a future diary 

in the Corporate Database through VETSNET award action. This was traced to a training lapse 

associated with conversion from the legacy BDN system to the new VETSNET award 

processing application. Training has been completed on the proper procedure for establishing 

future review examinations. 

Telephone contact with Dawn Provost, Director of the Benefits Inspection Division, verified that 

the 146 claims identified by the VAOIG audit team represent the universe of claims within 

VARO Boston’s jurisdiction where a temporary total evaluation has been in existence for at least 

18 months. Based on this clarification, we concur with the recommendation to review all claims 

fitting this profile under VARO Boston’s jurisdiction and no additional claims beyond the 146 

will be reviewed. 

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

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

evaluations. 

Response: Concur. 

VA Office of Inspector General 20 
Inspection of the VA Regional Office, Boston, MA 

Training on the proper procedure for reviewing and authorizing awards where a future review 

examination is indicated was completed on December 22, 2010. Additionally, procedures have 

been implemented requiring authorizers to maintain a log of all awards requiring a future 

examination suspense control. Veterans Service Center (VSC) management will conduct 

periodic audits of claims identified on the log to ensure compliance with the future examination 

suspense requirement. Finally, compliance with future examination procedures has been 

emphasized as part of local statistical quality control reviews. 

Recommendation 3: We recommend the Boston VA Regional Office Director conduct refresher 

training to ensure Rating Veterans Service Representatives properly evaluate disabilities related 

to traumatic brain injuries and herbicide exposure-related claims. 

Response: Concur. 

Refresher training on procedures for handling claims related to herbicide exposure was delivered 

to VARO Boston rating personnel on November 4, 2010. Refresher training on procedures for 

handling claims related to Traumatic Brain Injury (TBI) was delivered on November 9, 2010. 

The TBI training emphasized requirements published in Training Letter 09-01. 

Additionally, members of the Compensation and Pension Service site survey team delivered 

training related to these topics on November 17, 2010, at the request of VARO Boston 

management. The fiscal year 2011 VARO Boston VSC training schedule provides for training 

on how to evaluate complications due to Diabetes in January and additional TBI training in 

August 2011. 

Recommendation 4: We recommend the Boston VA Regional Office Director implement a plan 

to provide an additional level of review prior to finalizing decisions on traumatic brain injury 

and herbicide exposure-related claims to ensure accurate benefit payments. 

Response: Concur. 

In order to improve overall rating quality, VARO Boston constituted a Rating Quality Team 

responsible for local statistical quality control reviews. The Team will be monitoring quality 

trends for all types of claims, to include those related to TBI and herbicide exposure-related 

diseases in order to evaluate the effectiveness of VARO Boston training and quality 

improvement initiatives. Additionally, a delegation of authority requiring a mandatory second 

signature review for Traumatic Brain Injury and herbicide exposure-related claims was 

completed on December 28, 2010. 

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

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

Control and Locator System within 7 days as required by VBA policy. 

Response: Concur. 

VA Office of Inspector General 21 
Inspection of the VA Regional Office, Boston, MA 

The Appeals Team Supervisor and appropriate Appeals Team personnel have been trained on 

proper procedures and timeliness standards for the control of Notices of Disagreement. In 

addition to training, local procedures have been modified to strengthen compliance and 

oversight. 

The new procedures require all Notices of Disagreement input into the Veterans Appeals Control 

and Locator System (VACOLS) that are older than seven days at the time of input to be tracked 

using an excel spreadsheet log. The log will record the date the VACOLS control was 

established, the date the Notice of Disagreement was received in VARO Boston, the VSR 

responsible for establishing the VACOLS control, and the reason for the delay in establishing 

the VACOLS control. The Appeals Team Coach is responsible for maintaining this log. Trends 

will be analyzed to identify the root cause of delays in establishing VACOLS controls. 

Adjustments will be made to correct any deficiencies that are identified as a result of this 

analysis. Finally, the Appeals Team Coach will be responsible for a monthly audit of five 

randomly selected VACOLS records to ensure compliance with appellate processing procedures. 

VSC division-level management will verify the results of these audits. 

Recommendation 6: We recommend the Boston VA Regional Office Director develop and 

implement a plan to ensure timely and accurate completion of mandatory Systematic Analyses of 

Operations. 

Response: Concur in part. 

VARO Boston management does not question the finding that seven Systematic Analysis of 

Operations (SAOs) were not timely and two were not complete at the time of the audit, however 

we believe the finding is misleading in that the seven “late” SAOs were pending division-level 

management review and concurrence. While VARO Boston management is concerned with the 

timeliness of the SAOs, we are more concerned with the depth and quality of the analysis. As a 

result, there is considerable involvement of VSC division-level management with the supervisors 

assigned responsibility for completion of the majority of SAOs within the division. This is 

necessitated by the fact that, with the exception of one Coach, all division first-line supervisors 

are Assistant Coaches with less than two years of supervisory experience. Therefore, there have 

been delays in “finalizing” SAOs, however it is our opinion that the quality of the analysis and 

proposed corrective actions are far more important than the deadline established in the SAO 

schedule. 

The Veterans Benefits Administration M21-4 Manpower Control and Utilization in Adjudication 

manual describes the purpose of a Systematic Analysis of Operations as “a formal analysis of an 

organizational element or an operational function of the Veterans Service Center (VSC).” The 

Manual goes on to state: “A researched and well-written SAO is a valuable management tool. It 

provides an organized means for reviewing operations to identify existing or potential problems 

and proposing corrective actions. This self-audit technique, when applied conscientiously, is a 

positive guide for operational improvement.” The VA OIG audit team finding does not address 

the quality of the research and/or analysis in VARO Boston SAOs, which in our opinion would 

be more useful for evaluating the effectiveness of our SAO program. 

VA Office of Inspector General 22 
Inspection of the VA Regional Office, Boston, MA 

Therefore, we concur with the finding that improved oversight is needed to ensure the timely 

completion of our SAOs, however we do not concur with the implication in the VA OIG audit 

team’s recommendation that our SAOs are inaccurate. In response to the recommendation, the 

Director of VARO Boston has reinforced with VSC division management the importance of 

timely completion of SAOs as an important component of the local SAO program. 

Recommendation 7: We recommend the Boston VA Regional Office Director develop and 

implement controls to ensure Support Services Division staff process and date stamp all 

incoming mail the same day it arrives in the mailroom. 

Response: Concur. 

Prior to the conclusion of the VA OIG audit, Support Services Division (SSD) staff was 

provided training with regards to the proper processing of incoming mail. The training focused 

on the potential impact to Veterans and their dependents of delays in processing mail, especially 

at the end of the month. 

In addition to training, arrangements have been made to shift resources from the VSC and 

VR&E divisions to assist with end of month surges in mailroom activity as needed. Finally, 

division management has increased oversight to include periodic random audits of mailroom 

activities. Mail processing is now compliant with VBA policy as it relates to the receipt, date 

stamping, and timely routing of incoming mail. 

Recommendation 8: We recommend the Boston VA Regional Office Director develop and 

implement a plan to ensure proper oversight and control of all returned mail. 

Response: Concur. 

The SSD Chief coordinated with the VSC Triage Team and the VARO Boston Records 

Management Officer to review existing policy and reinforce proper procedures for processing 

mail returned to the station by the United States Postal Service as undeliverable. As noted 

above, SSD management has increased oversight to include periodic random audits of mailroom 

activities including returned mail. In addition, the backlog of “dead” mail, which existed during 

the inspection, has been reviewed and processed. 

Training was also provided to Triage Team staff on proper returned mail procedures, to include 

destruction procedures for non-essential mail with no evidentiary value, on November 9, 2010. 

The training incorporated procedures published in Compensation and Pension Service Fast 

Letter 

09-46. 

Recommendation 9: We recommend the Boston VA Regional Office Director add steps to the 

workload management plan to ensure proper handling of Service Treatment Records. 

Response: Concur. 

VA Office of Inspector General 23 
Inspection of the VA Regional Office, Boston, MA 

The VARO Boston workload management plan is undergoing extensive revision and will 

comply with the VAOIG audit team recommendation. Additionally, refresher training on the 

proper handling of Service Treatment Records is scheduled for all VSR and Claims Assistants in 

February as part of VARO Boston’s approved local training plan. The training will incorporate 

procedures outlined in M21-1MR, Part III iii.2.A.2.c and Compensation and Pension Service 

Fast Letter 10-17. 

Recommendation 10: We recommend the Boston VA Regional Office Director amend the mail 

plan to incorporate procedures for management oversight and control of search mail. 

Response: Concur. 

A previously indicated, the VARO Boston workload management plan is undergoing extensive 

revision and will incorporate additional procedures for management oversight and control of 

search mail per the VAOIG audit team recommendation. 

Additionally, training on mail handling procedures was provided to employees of the Triage 

team during October 2010. Refresher training on Search Mail procedures is scheduled for all 

VSC employees in January as part of VARO Boston’s approved local training plan. The training 

will emphasize compliance with the Control of Veterans Records System (COVERS). 

VA Office of Inspector General 24 
Inspection of the VA Regional Office, Boston, MA 

Appendix C Inspection Summary 

10 Operational 

Activities 

Inspected 

Criteria 

Reasonable 

Assurance of 

Compliance 

Yes No 

Claims Processing 

1. 100 Percent 

Disability 

Evaluations 

Determine if VARO staff properly reviewed temporary 100 

percent disability evaluations. (38 CFR 3.103(b)) (38 CFR 3.105(e)) 

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

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

X 

2. Post-Traumatic 

Stress Disorder 

Determine whether VARO staff properly processed claims for 

PTSD. (38 CFR 3.304(f)) X 

3. Traumatic Brain 

Injury 

Determine whether service connection for all residual disabilities 

related to an in-service TBI were properly processed. (Fast Letters 

08-34 and 08-36, Training Letter 09-01) 

X 

4. Disabilities 

Related to 

Herbicide 

Exposure 

Determine whether VARO staff properly processed claims for 

service connection for disabilities related to herbicide exposure 

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

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

X 

Data Integrity 

5. Date of Claim Determine if VARO staff properly recorded the correct date of 

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

Chapter 1, Section C) 

X 

6. Notices of 

Disagreement 

Determine if VARO staff properly entered NODs into VACOLS. 

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

Management Controls 

7. Systematic 

Analysis of 

Operations 

Determine if VARO staff properly performed a formal analysis of 

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

8. Systematic 

Technical 

Accuracy Review 

Determine if VARO staff properly corrected STAR errors in 

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

3.03) 

X 

Workload Management 

9. Mail Handling 

Procedures 

Determine if VARO staff properly followed VBA mail handling 

procedures. (M23-1) (M21-4, Chapter 4) (M21-1MR, Part III, 

Subpart ii, Chapters 1 and 4) 

X 

Eligibility Determinations 

10. Competency 

Determinations 

Determine if VAROs properly assessed beneficiaries’ mental 

capacity to handle VA benefit payments. (M21-1MR, Part III, 

Subpart v, Chapter 9, Section A) (M21-1MR, Part III, Subpart v, 

Chapter 9, Section B) (Fast Letter 

09-08) 

X 

VA Office of Inspector General 25 
Inspection of the VA Regional Office, Boston, MA 

Appendix D OIG Contact and Staff Acknowledgments 

OIG Contact Dawn Provost 

Acknowledgments Dana Sullivan 

Bridget Bertino 

Brett Byrd 

Madeline Cantu 

Kelly Crawford 

Lee Giesbrecht 

Brian Jeanseau 

Kerri Leggiero-Yglesias 

David Pina 

Brandi Traylor 

VA Office of Inspector General 26 
Inspection of the VA Regional Office, Boston, MA 

Appendix E Report Distribution 

VA Distribution 

Office of the Secretary
 

Veterans Benefits Administration
 

Assistant Secretaries
 

Office of General Counsel
 

VBA Eastern Area Director
 

VARO Boston Director
 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans 

Affairs, and Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Scott P. Brown, John F. Kerry, 

U.S. House of Representatives: Michael E. Capuano, Barney Frank, William 

Keating, Stephen F. Lynch, James McGovern, Ed Markey, Richard E. Neal, 

John Olver, John Tierney, Niki Tsongas 

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

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

on the OIG Web site for at least 2 fiscal years after it is issued. 

VA Office of Inspector General 27