And so many claims folders stuffed into file cabinets and stacked on top that three floors of the Poff Federal Building could potentially collapse.
The office, which handles compensation and pension claims, failed to meet requirements in six of 14 areas, according to the report.
"It's outrageous and unacceptable," said U.S. Rep. Tom Perriello, D-Albemarle County, a member of the House Veterans Affairs Committee who discussed the report Thursday with Secretary of Veterans Affairs Eric Shinseki.
It's also "routine," according to one veterans advocate.
"There are 57 regional offices, and none of them are in better shape than yours is," said Jim Strickland, a veteran who helps other vets negotiate the VA claims office. He also writes a column for the Web site www.vawatchdog.org.
Nevertheless, the report has got the attention of Perriello and Rep. Bob Goodlatte, R-Roanoke County, in whose district the office resides.
Goodlatte said his office hears from vets dealing with the VA on a daily basis. The backlog of claims for benefits -- and resulting delays in vets receiving them -- is no secret. But Goodlatte said the report shed light on other issues with the process, including accuracy and security.
The inspection, which took place in late August and early September, found errors in 25 percent of claims reviewed. In one case, a veteran was denied a claim for coronary artery disease and underpaid by $21,857. In another, a vet seeking benefits for exposure to Agent Orange was overpaid by $15,640 because his file didn't show required service in Vietnam.
Inspectors found about 4,200 pieces of returned mail containing veterans' names, Social Security numbers and addresses unsecured in boxes stacked on bookcases.
Perhaps most alarming was the condition of three floors in the Poff Building where veterans claims folders are stored. Inspectors found nearly 11,000 folders stacked on top of filing cabinets. A structural engineer determined the weight load was twice the recommended limit, according to the report, enough to "induce structural damage and possible failure to the integrity of the building."
Nineteen claims folders couldn't be found at all, the report said.
"Obviously when there's backup like that, there's not the kind of efficient system where someone can go and find a file easily," Goodlatte said.
Both he and Perriello said the office of 430 employees has good, dedicated workers.
"This is not just a couple of bad apples," Perriello said. "There are systemic problems that are preventing our veterans from getting the benefits they earned."
The office's management has already located an off-site storage space to accommodate about half the file cabinets temporarily until a more permanent arrangement can be made, the report said. It also notes that the management requested off-site storage four times between October 2008 and April 2009.
Even with more space, it's a system that cries out for digitalization, Goodlatte said. But the VA has "a long, long way to go toward that." And they aren't the only federal agency way behind the technological curve, still dealing with paper files and no electronic backup.
If a veteran's records get lost or destroyed, there's little chance of recovery.
Strickland, the veterans advocate, said the problem is also the result of a perfect storm of factors overwhelming the VA.
The country went to war in 2001 and has created fast-growing numbers of veterans returning home to seek benefits, he said. Meanwhile, Vietnam War-era vets such as Strickland are finding health problems attributable to their service and are seeking benefits. Add to them other eligible vets turning to the VA for their benefits for the first time because of the current economy.
All these groups are converging on an organization that didn't grow with the military since the war started, but shrank, Strickland said.
He figures 80 percent of the VA works well for an organization so large, but the part that doesn't work, the compensation and pension offices, are a huge problem on their own.
Perriello said Shinseki, the current VA secretary, is proving willing to shake things up. Last year the VA implemented the new GI Bill, and now more than 200,000 vets are in college with those benefits, Perriello said.
"This year has got to be about the backlog in cases," he said.
Strickland doesn't expect much change. He's seen plenty of reports like the on one the Roanoke office before.
"The VA gets their hand slapped, and they promise to do better, scout's honor," he said. "Nobody can touch the VA."