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of 7 selected states, 6 of 19 child welfare and adoption organizations, and 5 of the 15 adoption agencies we interviewed said services can be expensive, particularly intensive services such as mental health counseling and residential treatment. We have previously reported that the cost to support a youth in a residential setting can amount to thousands of dollars per month. In addition to cost, adoptive families may have challenges finding mental health providers that are “adoption competent”—that is, knowl
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edgeable about adoption-related issues, according to officials from five selected states, seven child welfare and adoption organizations, and eight adoption agencies. These stakeholders said mental health providers who do not understand issues unique to adoptive families will likely be less effective in helping these families work through issues. For example, one official told us adoptive families need therapists who can distinguish between normal adolescent behavior and a child acting out due to grief and
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loss resulting from his or her adoption. Several stakeholders also noted that families in rural areas may have even more difficulty accessing effective mental health providers. We reported in 2013 that a Florida behavioral health service provider had been advertising a child psychiatrist position for 5 years without success. In a 2011 report, we found that child psychiatrists and psychologists were among the most difficult specialist referrals to obtain for children in low-income families covered by Medicai
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d and the Children’s Health Insurance Program, both of which can cover children adopted from foster care and internationally. Lastly, families may not know about available services from their child welfare or adoption agency, and therefore do not seek help when needed, according to officials from four selected states and five adoption agencies. For example, Virginia officials said families that did not adopt from foster care may not know about support services they can access through their local child welfa
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re agency. Wisconsin officials also said they struggle to find sufficient resources to provide outreach to all adoptive parents about state resources. Officials from two selected states also raised concerns that families may not remember whether their adoption agency provides post-adoption services. They explained that some families may not need services for years after an adoption is final because issues may not arise until the child reaches adolescence. By that point, families may no longer have contact w
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ith their adoption agency. Families in need of help may be reluctant to ask child welfare agencies for assistance, according to officials from three child welfare and adoption organizations and four adoption agencies. For example, these officials noted that there is a stigma associated with contacting child welfare agencies since those agencies are also generally responsible for investigating cases of child abuse. A few of these officials further noted that families, including those who adopted from foster
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care and internationally, may fear that contacting an agency will prompt an investigation into how they care for all of their children. They also said families may be afraid that they will not be able to adopt again if they are involved with a child welfare agency. Officials in five of our seven selected states acknowledged the dilemma that families face if they contact child welfare agencies for services. In addition, officials in one selected state said parents cannot voluntarily relinquish custody of a c
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hild in their state (e.g., for care or services) without being charged with child abandonment. Officials in all seven selected states said families who decide to relinquish custody to the state may be required to pay ongoing child support. Similarly, families who adopted internationally may also be hesitant to reach out to their adoption agency. Representatives from 9 of the 15 adoption agencies we interviewed told us that families may be ashamed or embarrassed to contact the agency to discuss problems. Rep
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resentatives from one adoption agency explained that families have gone through a rigorous home study process to prove that they will provide a good home to an adopted child. Thus, they said these families may be reluctant to contact their agency and admit that that they are facing challenges in their adoptions. Because unregulated child custody transfers are an underground practice that happens outside the purview of the courts and the child welfare system, they are difficult to track, and no federal agenc
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y keeps statistics on their occurrence. These transfers may involve an exchange of a power of attorney that may not be filed with or approved by a court of law, although it may be signed by both parties and notarized. State laws vary, but generally a parent may use a power of attorney to temporarily grant another person certain powers regarding their child’s care and physical custody, such as the authority to make medical and educational decisions. For example, a military service member may sign a power of
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attorney to allow a family member or friend to take care of and make medical decisions for his or her child while he or she is deployed. However, because a power of attorney does not terminate the legal parent-child relationship, the adoptive parent still retains certain rights and responsibilities. For example, according to HHS, delegating responsibility for a child through a power of attorney does not insulate adoptive parents from state laws regarding imminent risk of serious harm. State laws determine a
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ny time limits (e.g., 1 year) for grants of power of attorney, and also establish the procedures required to make such an arrangement effective. For example, officials in three of our seven selected states told us their state laws do not require power of attorney documents to be approved by a court, and officials in one selected state said their laws require court approval in certain circumstances. However, officials in three of these selected states said they were not aware of any mechanisms in their state
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s to track expired power of attorney documents to determine if families are attempting to use them to permanently transfer custody. Unregulated transfers are also difficult to track because many adoptions are not monitored after the adoption is finalized. For those international adoptions subject to reporting requirements set by individual countries, reporting may occur for a limited time. For example, according to the State Department website, one country requires adoptive parents to provide information ab
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out the adoption at certain time intervals for the first 2 years. Officials from the State Department and several adoption agencies we interviewed told us that while parents may sign a contract when they adopt a child saying they will report the required information to the adoption agency, parents may not comply with post-adoption reporting requirements, and agencies have little leverage to enforce compliance. In addition, officials in our seven selected states said their state does not specifically monitor
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whether adopted children remain with their families after the adoption is finalized. Our observations of forums on social media websites indicate that some parents have been using these venues to seek new homes for their children. We observed posts in five social media forums and found a total of 23 posts in which a person wrote that they were seeking a new family for their child. Among the 9 posts that included information on a child’s age, those ages ranged from 7 to 16. Generally, parents in these forum
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s who said they wanted to transfer a child indicated that they were in distress or crisis, and most often said they were seeking a new home because of the child’s behavioral issues or severe mental illness. These children included those who were adopted from foster care and internationally. For example, one post asked for a new home for a 7-year- old boy who had been diagnosed with numerous mental illnesses, including Reactive Attachment Disorder, Oppositional Defiance Disorder, and autism, and who was phys
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ically abusive to his siblings and family pets. Several posters responded with information about their family and location or said that they had sent the poster a private message. Another poster wrote that her son, who she adopted internationally, had been diagnosed with multiple mental illnesses and was currently hospitalized for psychiatric reasons, and she was seeking a new home for him. In addition, we found 40 cases in which a person posted that they wanted to adopt a child. In some cases, posters wrot
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e that they had successfully completed a home study. In other cases it was not clear whether they had undergone a home study. For example, only a third of the posts we observed in one online forum referenced a home study—either that the person seeking to adopt had completed one or the person seeking a new home for the child required one. Some posters said they had adopted children already in the home, and some wrote they had adopted a previously adopted child, although it was unclear whether they had legall
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y adopted the child or whether the child was transferred without court oversight. It is possible that conversations on the specifics of transferring a child were held either through private messages within the social media platform or by another means, such as email or phone. Because we did not investigate these posts further and because discussions between online participants can be continued privately, we were unable to determine whether a child was actually transferred to another family. Similarly, we we
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re unable to determine, if such a transfer occurred, whether it was done through official means or an unregulated transfer. We identified 15 states in which laws were enacted, proposed legislation was introduced, or recent changes had been made to child welfare programs that were intended to safeguard children who may be subject to unregulated transfers. These included the seven states we selected for interviews as well as eight states recommended by representatives from child welfare and adoption organizat
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ions because of legislative activity initiated in these states during the course of our review. Of these 15 states, 7 enacted legislation and 3 made changes to child welfare programs. In addition, legislators in 10 of the 15 states introduced proposed legislation that had not been enacted as of July 2015 (see table 3). These selected laws, proposed legislation, and other actions within the 15 states reflect a variety of approaches to addressing unregulated transfers. The most common approaches were to crimi
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nalize unregulated transfers or actions that may lead to these transfers, and to restrict the advertising of children or potential homes for placement. Other approaches may deter unregulated transfers by requiring that parents or certain other individuals report cases in which custody of a child may have been transferred. Some approaches may help prevent transfers from occurring. These included revising requirements for preparing prospective parents for adoption and increasing outreach about services availa
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ble to families after adopting (see table 4). The five states that enacted laws to criminalize unregulated transfers or actions that could lead to these transfers made the following changes: Arkansas and Louisiana enacted laws that define the practice of “re- homing” and impose criminal penalties for those engaging in it. The laws provide that those who commit the offense of re-homing, which each state defines differently but generally includes transferring physical custody of a child to a non-relative with
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out court approval with the intent of avoiding permanent parental responsibility (or assisting in such a transfer), will be subject to a fine of up to $5,000 and imprisonment for up to 5 years. Similarly, Florida enacted a law establishing the crime of “unlawful desertion of a child,” which provides that a caregiver who deserts a child (leaves the child with a non-relative with the intent to not return and provide for the child’s care) under circumstances in which the caregiver knew or should have known tha
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t the child would be exposed to unreasonable risk of harm commits a third degree felony. Maine also enacted a similar law, modifying its definition of “abandonment of a child.” This law provides that a person is guilty of child abandonment if they transfer physical custody of a child to a non-relative without court approval with the intent to avoid or divest themselves of permanent parental responsibility. The law specifies that violation of this provision constitutes different classes of crimes, depending
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on the age of the child. Wisconsin enacted a law that placed parameters on parental delegations made through a power of attorney, and established criminal penalties for unauthorized transfers of children across state lines. This law provides that delegations to a non-relative of a child’s care and custody under a power of attorney may be effective for no longer than 1 year unless approved by a juvenile court, and those who violate this provision are subject to a fine of up to $10,000 and/or imprisonment for
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up to 9 months. In addition, the law states that any person who sends a child out of the state, brings a child into the state, or causes such actions to occur for the purpose of permanently transferring physical custody of the child to a non-relative is guilty of a misdemeanor. Six states enacted laws to restrict the advertising of children or potential homes for adoption or other permanent placement. Specifically, Arkansas, Colorado, Florida, Louisiana, Maine, and Wisconsin created or expanded prohibition
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s on who can place such advertisements, limited the purposes for which these advertisements can be placed, restricted the public media that can be used (e.g., the internet), and/or provided penalties for violations. Officials from selected states, child welfare and adoption organizations, and adoption agencies we interviewed discussed some trade-offs and considerations in implementing these approaches to deterring unregulated transfers. For example, several stakeholders said a power of attorney can be used
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for legitimate purposes, such as a military parent transferring custody of their child to a trusted friend while on deployment. They noted that placing additional conditions on power of attorney transfers can create a burden for these families. In addition, officials from three selected states and three child welfare and adoption organizations questioned how states could enforce the use of a power of attorney. Officials from one national organization specializing in adoption law said courts that may be invo
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lved in approving power of attorney agreements have other priorities and may not have time to monitor these agreements. Several stakeholders also said families often go online to access adoption resources and peer support forums. They said states need to consider the information that these online forums provide to adoptive families when considering laws related to the internet. In addition to approaches that would deter unregulated transfers, 4 of the 15 states we reviewed enacted laws or made changes to ch
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ild welfare programs to improve post-adoption services for families. Specifically: Arkansas enacted a law that directed the state child welfare agency to adopt rules to ensure that post-adoptive services are provided to all parents who seek assistance to prevent their adoptions from being disrupted. Virginia enacted a law and made changes to its state child welfare programs to improve post-adoption services based on recommendations from a study it conducted on unregulated transfers. The law requires the sta
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te registrar to issue, along with new adoptive birth certificates, a list of available post-adoption services, and requires the state child welfare agency to provide a list of such services to the registrar and publish it on its website. In addition, Virginia officials said the state child welfare agency plans to modify the solicitation for its post-adoption services contracts to allow services to be provided by multiple regional providers rather than one statewide provider. Virginia officials said the inte
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nt of this change is to increase access to services for families statewide. Illinois and New York also made changes to their child welfare programs to increase outreach specifically to new parents who adopted from foster care, although these states did not make statutory changes. Illinois developed a pilot project for agencies facilitating foster care adoptions to host celebrations and social events to build relationships with these families and connect them with other families. New York developed a brochur
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e for adoption agencies to provide to new adoptive parents that includes information on unregulated transfers and possible sources of help with post-adoption needs. While many stakeholders we spoke with highlighted families’ challenges with accessing pre- and post-adoption services as key reasons for unregulated transfers, they also commented on possible challenges in implementing certain policy options to improve access to and availability of such services. For example, officials from nearly half of the ch
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ild welfare and adoption organizations we spoke with said building a strong infrastructure for adoption services can be a lengthy and costly task. They said states have been trying to bolster services, but have had limited success. Given limited funding, officials from most selected states, child welfare and adoption organizations, and adoption agencies we interviewed expressed concern about the level of support for post- adoption services. Many of these stakeholders said families experiencing difficulties
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in their adoptions need services, and unregulated transfers are a last resort for desperate families who feel they have no other option. They also stated that improving access to effective services may ultimately help all families meet the needs of their adopted children. Federal agencies have made some collaborative and individual efforts to address unregulated transfers, mainly by raising awareness of the need for improved pre- and post-adoption services and by sharing information with states (see table 5
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). In some instances they have also collaborated with non-governmental organizations that have relationships with state child welfare and law enforcement agencies, such as the Association of Administrators of the Interstate Compact on the Placement of Children and the National Association of Attorneys General. As shown in table 5, the State Department established an interagency working group in October 2013 to develop a coordinated federal response to unregulated transfers. Other federal agency participants
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are USCIS, HHS, and Justice. With input from the group, the State Department began work to revise regulations regarding international pre-adoption training requirements. State Department officials said the revisions may potentially include an increased number of minimum required hours and additional required content, drawing from training curriculum used by child welfare agencies for prospective parents in foster care adoptions. In addition, the revisions may include required in-person components for train
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ing. State Department officials said they plan to provide proposed revisions to the Office of Management and Budget by the end of 2015 for review, and the proposed regulations will be subject to a public comment period before being finalized. In addition, in February 2015, USCIS issued revised immigration applications and petitions which are used by certain families applying to adopt from certain countries. The revisions included a requirement that families disclose whether they have previously filed intern
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ational adoption applications or petitions and the result of the filings (i.e., approval, denial, withdrawal). Additionally, the revisions require families to disclose if they have experienced a disruption or dissolution of an international adoption in the past. HHS has also taken a number of actions to help improve access to adoption services. For example, it issued a memorandum in May 2014 to states that encouraged them to promote services to all adoptive families and outlined various sources of available
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federal funds. The memo also shared information on how unregulated transfers may violate state laws and encouraged states to review their laws and policies. In addition, HHS awarded two cooperative agreements with 5-year project periods in October 2014 to national organizations to improve post-adoption services. The National Adoption Competency Mental Health Training Initiative aims to build a web-based training curriculum for child welfare professionals and mental health practitioners to meet the mental h
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ealth needs of adopted children, develop a national certification process for those completing it, and evaluate its outcomes and effectiveness. The National Quality Improvement Center for Adoption/Guardianship Support and Preservation aims to develop evidence-based pre- and post-adoption interventions and services for prospective and current adoptive families. Interventions and services will be evaluated at six to eight selected sites (e.g., state, county, or tribal child welfare agencies). Both projects ar
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e expected to be completed in September 2019. HHS officials also noted that information on pre-adoption requirements and post-adoption services, by state, is available on HHS’s Child Welfare Information Gateway, a website that provides information, resources, and tools on child welfare, child abuse and neglect, out-of-home care, adoption, and other topics. In addition, they said HHS has been involved in discussions with states regarding post-adoption services over the years. For example, HHS hosted a confer
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ence on the needs of adopted children—including post-adoption services—in August 2012, and was involved in a forum on unregulated transfers and services for adoptive families in February 2014 through the National Association of State Adoption Programs, Inc. Because states are responsible for much of the work to improve adoption services, the interagency working group has collaborated with national organizations to share information with states. Specifically, Justice worked with the National Association of A
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ttorneys General to gather information on existing state laws and pending legislative proposals to address unregulated transfers. Research fellows at the National Association compiled this information for all states. The organization also requested information from all state attorneys general offices, and received responses from six states and the District of Columbia. The organization completed this work in June 2015, and Justice officials said they are reviewing the study and will work with the interagenc
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y working group to determine next steps, if any, to be taken. In addition, the Association of Administrators of the Interstate Compact on the Placement of Children is working to develop a national outreach campaign to raise awareness about unregulated transfers and provide information on alternatives to this practice. Officials from the Association said they are in the process of soliciting funds from private and non-profit organizations to support such a campaign. Despite these efforts, federal officials a
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cknowledged that gaps in services for adoptive families remain, and determining how to provide them is a difficult task for public and private agencies working with these families. For example, HHS officials noted limitations to the federal government’s ability to support post-adoption services. They said that while all adopted children will need some level of support after an adoption is final, the main source of federal support—the Title IV-E Adoption Assistance program—is limited, and is generally availa
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ble only to families who adopted eligible children from foster care. Consistent with our findings in previous reports, HHS officials said funds from other federal programs that states can use to support services for private adoptions, including international adoptions, are limited. Officials said families who cannot afford services on their own must often rely on services supported by state and local funding or those provided by private adoption agencies, and funds from these sources are also limited. HHS o
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fficials told us that the administration included in its fiscal year 2016 budget request a legislative proposal that would provide an increase of $587 million over 10 years for pre- and post-adoption services. They said this funding would target services to families with children who may be subject to unregulated transfers as well as those at risk of entering foster care due to an adoption in crisis. Federal officials said they will continue to examine ways to address unregulated transfers. For example, the
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State Department has developed a charter to outline its goals and plans for future work. State Department officials said they will use this charter to facilitate future efforts with the interagency working group. We provided a draft of this report to the Secretaries of Health and Human Services, Homeland Security, and State and the Attorney General of the United States for review and comment. The Departments of Health and Human Services, Homeland Security, and State provided technical comments that were in
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corporated, as appropriate. The Department of Justice had no comments. We are sending copies of this report to relevant congressional committees, the Secretaries of Health and Human Services, Homeland Security, and State, the Attorney General of the United States, and other interested parties. In addition, this report will be available at no charge on GAO’s website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7215 or [email protected]. Conta
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ct points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff that made key contributions to this report are listed in appendix II. GAO examined (1) the reasons adoptive families consider unregulated child custody transfers, and services that exist to support these families before they take such an action; (2) what is known about the prevalence of these transfers; and (3) actions selected states and federal agencies have taken to help address
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such transfers. To address these objectives, we used a variety of methods. Specifically, we conducted interviews with 45 agencies and organizations, including officials from federal and selected state agencies, child welfare and adoption organizations, and adoption agencies, to acquire a range of perspectives on this topic; reviewed relevant federal laws and regulations, selected state laws, and federal and selected state policies; reviewed and analyzed documentation provided by officials we interviewed; c
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onducted a search of related literature and reviewed relevant articles; and searched online forums on selected social media sites to find illustrative examples of families who may be considering unregulated transfers. Because children adopted domestically as infants and those in biological families may be less likely to have mental health issues due to trauma and institutionalization, and reports of unregulated transfers have primarily pertained to children adopted internationally or from foster care, our r
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eport focuses on international and foster care adoptions. To understand why families consider unregulated child custody transfers, what training and services are available to adoptive families, and actions selected states and federal agencies have taken to help address such transfers, we conducted interviews with 45 agencies, states, and organizations, including federal officials, representatives from national child welfare and adoption organizations, officials from selected states, and representatives from
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adoption agencies. Federal officials we interviewed included those from the Department of State (State Department), the Department of Homeland Security’s U.S. Citizenship and Immigration Services (USCIS), the Department of Health and Human Services (HHS), and the Department of Justice (Justice). We interviewed representatives from 19 organizations that work on child welfare and adoption issues. The 19 organizations we interviewed were selected to represent a variety of views on adoption and child welfare-
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related policy, training, and research. For example, these organizations specialized in certain aspects of adoption, including adoption law, home studies, pre-adoption training, and post-adoption services. We interviewed the following child welfare and adoption organizations and experts: American Academy of Adoption Attorneys; American Bar Association’s Center on Children and the Law; Association of Administrators of the Interstate Compact on the Placement of Children; Center for Adoption Policy; Center for
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Adoption Support and Education; Child Welfare League of America; Coalition for Children, Youth, and Families; Congressional Coalition on Adoption Institute; Council on Accreditation; the Donaldson Adoption Institute; Joint Council on International Children’s Services; Madeline Freundlich; Maureen Flatley; National Center for Missing and Exploited Children; National Center on Adoption and Permanency; National Conference of State Legislatures; North American Council on Adoptable Children; Spaulding for Child
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ren; and Voice for Adoption. In addition, we interviewed officials from state child welfare agencies and other relevant offices in seven selected states: Colorado, Florida, Illinois, Louisiana, Ohio, Virginia, and Wisconsin. These states were chosen based on factors such as legislative activity related to unregulated transfers in the state, as identified by representatives from child welfare and adoption organizations during our initial interviews, and the state’s post-adoption programs. These states also p
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rovided variety in numbers of adoptions in relation to the state’s population. Interviews with officials were conducted through site visits to Florida and Wisconsin, and phone calls to the remaining states. In the states selected, the team conducted interviews with officials from state child welfare agencies and other relevant offices, such as those from state attorney general offices, departments of justice, and adoption agency licensing offices. Finally, we interviewed representatives from 15 internationa
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l and domestic adoption agencies. The adoption agencies we interviewed were selected from those either recommended by national organization representatives or those licensed or accredited in the states we visited in- person to achieve variation in agency size, including budget and staff and types of adoptions facilitated. For example, 11 of the 15 adoption agencies facilitate international adoptions. The remaining 4 agencies facilitate domestic adoptions only, such as through the child welfare system (throu
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gh a contract with the state child welfare agency) or privately. In the report we refer to different types of organizations when reporting information from our interviews with the 7 selected states, 19 child welfare and adoption organizations, and 15 adoption agencies. References to “stakeholders” include responses from officials in all three of these groups. In our interviews with stakeholders, we used a semi-structured interview protocol that included open-ended questions about reasons that families may c
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onsider unregulated transfers, types of services adoptive families may need to prevent them from resorting to these transfers, and types of services that are available to adoptive families. Information was volunteered by officials in each interview in response to these open- ended questions. Thus, the counts of organizations citing such responses vary. “All” stakeholders represents 41 “Most” stakeholders represents 21-40 “Many stakeholders” represents 10-20 “Several” stakeholders represents 4-9 “A few” stak
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eholders represents 2-3 We reviewed relevant documents to corroborate information obtained in our interviews. To examine federal efforts related to unregulated transfers, we reviewed relevant documents obtained in our interviews with federal officials. We also reviewed relevant federal laws, regulations, and policies on agency roles and responsibilities as well as GAO criteria on internal controls. To examine selected state efforts related to unregulated transfers, we reviewed information on recently enacte
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d laws, proposed legislation, and other documents provided by child welfare and other agency officials in our seven selected states. Through our interviews with representatives from child welfare and adoption organizations and others, we identified at least eight additional states that had initiated legislative activity related to unregulated transfer since we began our review: Arkansas, Maine, Maryland, Massachusetts, Nebraska, New York, North Carolina, and South Carolina. For these eight identified states
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, we also reviewed relevant laws, proposed legislation, and other documents provided by child welfare and other agency officials in these states. For proposed legislation, we reviewed only the version confirmed by the state officials. We did not do further research on the status of these proposals; therefore, additional changes may have been made that are not reflected in this report, and some proposed legislation included in the report may no longer be pending. We asked officials in the 15 selected and ide
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ntified states to confirm whether their state had enacted a law, introduced proposed legislation, or took other relevant activity as of July 2015. We did not report on such activity after this date. Since we did not attempt to identify all activity related to unregulated transfers in all states, there may be other states with relevant legislative or other activity not included in our review. We conducted a search of literature related to unregulated child custody transfers in order to gather information abo
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ut why families may consider these transfers, what policies exist to safeguard children who might be subject to such transfers, what training is required to adopt, and what services are available to adoptive families. While our search resulted in some literature on adoption dissolutions and disruptions as well as services for adoptive families, we were unable to locate academic literature regarding unregulated transfers. We searched online forums on selected social media sites to find illustrative examples
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of families who may be considering unregulated child custody transfers. Using keywords such as “rehoming” and “adoption disruption,” we searched selected social media sites to locate online forums—such as groups and message boards—that parents might use to seek new homes for their children. For example, these forums were characterized on the sites as support groups for parents who wish to dissolve an adoption or whose children have behavioral issues. The results of our searches were not exhaustive as we wer
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e unable to ascertain whether we identified most or all social media sites and forums with online activity that may relate to unregulated child custody transfers. We observed posts by participants in eight forums on two websites over a 15-month time period (January 1, 2014, through April 1, 2015). We analyzed posts on two of the eight forums that involved individuals who posted that they were seeking a new family for their child or who posted that they wanted to adopt a child. We did not find posts involvin
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g individuals seeking a new family for their child in the remaining six forums. The online posts we identified did not provide sufficient information to determine whether the posters intended to pursue an unregulated transfer, or to pursue an adoption or other legal placement. Since we did not investigate individual cases, our approach did not allow us to determine whether the information posted by online participants was accurate. Moreover, because discussions between online participants can be continued p
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rivately, we were unable to determine whether a child was actually transferred to another family and, if so, whether this was done through a court-approved process or through an unregulated transfer. One of the eight forums we observed was shut down in March 2015 by the social media site that hosted it. We conducted this performance audit from October 2014 to September 2015 in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obta
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in sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. In addition to the contact name above, the following staff members made key contributions to this report: Elizabeth Morrison, Assistant Director; Elizabeth Hartjes; Nhi Nguyen; and Amy Sweet. Also contributing to this report were: Susan Aschoff; Laurel
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Beedon; Maurice Belding; Sarah Cornetto; Sara Edmondson; Kirsten Lauber; Ashley McCall; Mimi Nguyen; Brynn Rovito; and Almeta Spencer.
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In fiscal year 2007, the Department of Veterans Affairs (VA) paid about $37.5 billion in disability compensation and pension benefits to more than 3.6 million veterans and their families. Through its disability compensation program, the VBA pays monthly benefits to veterans with service- connected disabilities (injuries or diseases incurred or aggravated while on active military duty). Monthly benefit amounts vary according to the severity of the disability. Through its pension benefit program, VBA pays mon
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thly benefits to wartime veterans with low incomes who are either elderly or permanently and totally disabled for reasons not service- connected. In addition, VBA pays dependency and indemnity compensation to some deceased veterans’ spouses, children, and parents and to survivors of servicemembers who died while on active duty. When a veteran submits a benefits claim to any of VBA’s 57 regional offices, a Veterans Service Representative (VSR) is responsible for obtaining the relevant evidence to evaluate th
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e claim. For disability compensation benefits, such evidence includes veterans’ military service records, medical examinations, and treatment records from VA medical facilities and private providers. Once a claim is developed (i.e., has all the necessary evidence), a Rating Veterans Service Representative (RVSR) evaluates the claim, determines whether the claimant is eligible for benefits, and assigns a disability rating based on degree of impairment. The rating determines the amount of benefits the veteran
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will receive. For the pension program, claims processing staff review the veteran’s military, financial, and other records to determine eligibility. Eligible veterans receive monthly pension benefit payments based on the difference between their countable income, as determined by VA, and the maximum pension amounts as updated annually by statute. In fiscal year 2007, VBA employed over 4,100 VSRs and about 1,800 RVSRs to administer the disability compensation and pension programs’ caseload of almost 3.8 mil
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lion claims. In 2001 the VA Claims Processing Task Force noted that VSRs were responsible for understanding almost 11,000 separate benefit delivery tasks, such as tasks in claims establishment, claims development, public contacts, and appeals. To improve VBA’s workload controls, accuracy rates, and timeliness, the Task Force recommended that VA divide these tasks among a number of claims processing teams with defined functions. To that end, in fiscal year 2002, VBA developed the Claims Processing Improvemen
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t model that created six claims processing teams, based on phases of the claims process. (See table 1.) According to one VA official, new claims processing staff generally begin as VSRs and typically have a probationary period of about one year. After their probationary period ends, staff can either continue to qualify to become senior VSRs or apply for RVSR positions. VSRs are also given the option to rotate to other VSR claim teams to gain a broader understanding of the claims process. VBA has established
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a standardized curriculum for training new VSRs and RVSRs on how to process claims, and it has an 80-hour annual training requirement for both new and experienced staff; however, it does not hold individual staff accountable for meeting this requirement. VBA has designed a uniform curriculum for training new VSRs and RVSRs that is implemented in three phases—initial orientation training, a 3-week training session referred to as centralized training, and comprehensive on- the-job and classroom training afte
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r centralizing training. It also requires all staff to meet an annual 80-hour training requirement. To ensure that staff meet this requirement, each regional office must develop an annual training plan, which can contain a mix of training topics identified by VBA central office and by the regional office. However, individual staff members are not held accountable for meeting their training requirement. VBA has a highly structured, three-phased program for all new claims processors designed to deliver standa
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rdized training, regardless of training location or individual instructors. (See fig. 1.) For example, each topic included in this training program contains a detailed lesson plan with review exercises, student handouts, and copies of slides used during the instructor’s presentation. Each phase in this program is designed to both introduce new material and reinforce material from the previous phase, according to a VBA official. According to VBA policy, the first phase of training for new VSRs and RVSRs is p
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rerequisite training. New VSRs and RVSRs begin prerequisite training at their home regional office as soon as they begin working. Prerequisite training lays the foundation for future training by introducing new VSRs to topics such as the software applications used to process and track claims, medical terminology, the system for maintaining and filing a case folder, and the process for requesting medical records. Although VBA specifies the topics that must be covered during prerequisite training, regional of
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fices can choose the format for the training and the time frame. New VSRs and RVSRs typically spend 2 to 3 weeks completing prerequisite training in their home office before they begin the second program phase, centralized training. During what is referred to as centralized training, new VSRs and RVSRs spend 3 weeks in intensive classroom training. Participants from multiple regional offices are typically brought together in centralized training sessions, which may occur at their home regional office, anoth
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er regional office, or the Veterans Benefits Academy in Baltimore, Maryland. According to VBA officials in three of the four offices we visited, bringing together VSRs and RVSRS from different regional offices helps to promote networking opportunities, while VBA officials from two of these offices also stated that it provides a nationwide perspective on VBA. Centralized training provides an overview of the technical aspects of the VSR and RVSR positions. Training instructors should follow the prescribed sch
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edule and curriculum dictating when and how material is taught. For example, for a particular topic, the instructor’s guide explains the length of the lesson, the instructional method, and the materials required; lays out the information that must be covered; and provides exercises to review the material. (See fig. 2 for a sample of an instructor’s guide from the centralized training curriculum.) Centralized training classes have at least three instructors, but the actual number can vary depending on the si
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ze of the group. VBA’s goal is to maintain a minimum ratio of instructors to students. The first week of centralized training for VSRs focuses on key concepts, such as security, privacy and records management; terminology; and job tools, such as the policy manual and software applications. The final 2 weeks of training focus on the different roles and responsibilities of VSRs on the Pre-determination and Post-determination teams in processing claims. To practice processing different types of claims and proc
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essing claims from start to finish, VSRs work on either real claims or hypothetical claims specifically designed for training. Centralized training for new RVSRs—many of whom have been promoted from the VSR position— focuses on topics such as systems of the human body, how to review medical records, and how to interpret a medical exam. According to staff in one site we visited, RVSRs new to VBA also take VSR centralized training or its equivalent to learn the overall procedures for processing claims. To acc
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ommodate the influx of new staff it must train, in fiscal year 2007 VBA substantially increased the frequency of centralized training and is increasing student capacity at the Veterans Benefits Academy. During fiscal year 2007, VBA held 67 centralized training sessions for 1,458 new VSRs and RVSRs. Centralized training sessions were conducted at 26 different regional offices during fiscal year 2007, in addition to the Veterans Benefits Academy. By comparison, during fiscal year 2006, VBA held 27 centralized
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training sessions for 678 new claims processors. To implement centralized training, VBA relies on qualified regional office staff who have received training on how to be an instructor. According to VBA officials, centralized training instructors may be Senior VSRs, RVSRs, supervisors, or other staff identified by regional office managers as having the capability and the right personality to be effective instructors. Potential instructors have certain training requirements. First, they must complete the wee
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k-long Instructor Development Course, which covers the ways different adults learn, the process for developing lesson plans, and the use of different training methods and media. During this course, participants are videotaped and given feedback on their presentation style. In addition, each time instructors teach a centralized training session, they are supposed to take the 2.5 day Challenge Curriculum Course, designed to update instructors on changes to the curriculum and general training issues. Between O
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ctober 2006 and February 2008, about 250 VSRs and RVSRs from regional offices completed the Instructor Development Course, and VBA officials reported that, given the influx of new VSRs and RVSRs, they are increasing the number of times this course is offered in order to train more instructors. Instructors can teach centralized training sessions in their home office, another regional office, or the Veterans Benefits Academy. When new VSRs and RVSRs return to their home office after centralized training, they
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are required to begin their third phase of training, which is supposed to include on-the-job, classroom, and computer-based training, all conducted by and at their regional office. In the regional offices we visited, managers indicated that new VSRs and RVSRs typically take about 6 to 12 months after they return from centralized training to complete all the training requirements for new staff. During this final phase, new claims processing staff cover more advanced topics, building on what they learned in
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centralized training. Under the supervision of experienced claims processors, they work on increasingly complex types of real claims. On-the-job training is supplemented in the offices we visited by regular classroom training that follows a required curriculum of courses developed by VBA’s Compensation and Pension Service, specifically for new VSRs and RVSRs. For example, new VSRs might complete a class in processing burial claims and then spend time actually processing such claims. The amount of time spent
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working on each type of claim varies from a couple of days to a few weeks, depending on the complexity of the claim. On-the-job training is also supposed to be supplemented with modules from the Training and Performance Support System (TPSS), an interactive on-line system that can be used by staff individually or in a group. TPSS modules provide detailed lessons, practice cases, and tests for VSRs and RVSRs. Modules for new VSRs cover topics such as burial benefits and medical terminology; RVSR modules cov
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er topics such as the musculoskeletal system, general medical terminology, and introduction to post-traumatic stress disorder. A policy established by VBA’s Compensation and Pension Service requires both new and experienced VSRs and RVSRs to complete a minimum of 80 hours of technical training annually, double the number VBA requires of its employees in other technical positions. VBA officials said this higher training requirement for VSRs and RVSRs is justified because their jobs are particularly complex a
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nd they must work with constantly changing policies and procedures. The 80-hour training requirement has two parts. At least 60 hours must come from a list of core technical training topics identified by the central office of the Compensation and Pension Service. For example, core topics for VSRs in fiscal year 2007 included establishing veteran status and asbestos claims development; topics for RVSRs included due process provisions and eye-vision issues. VBA specifies more core topics than are necessary to
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meet the 60-hour requirement, so regional offices can choose those topics most relevant to their needs. They can also choose the training method used to address each topic, such as classroom or TPSS training. (See app. II for the list of core technical training topics for fiscal year 2007.) Regional offices determine the training topics that are used to meet the remaining 20 hours, based on local needs and input. Regional offices may select topics from the list of core technical training topics or identify
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other topics on their own. The four regional offices we visited varied in the extent to which they utilized their discretion to choose topics outside the core technical training topics in fiscal year 2007. Two sites selected the required 60 hours of training from the core requirements and identified their own topics for the remaining 20 hours. In the other two sites, almost all the training provided to staff in fiscal year 2007 was based on topics from the list of core requirements. An official in one regi
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