The Department of Veterans Affairs has never fully recovered from the firestorm of criticism it received after a whistleblower revealed a nationwide scheme to cover up long delays in healthcare in 2014.
The discovery that 110 VA facilities had used secret patient waiting lists to cover up veterans' long wait times led to the ouster of VA Secretary Eric Shinseki, but only three employees involved in the manipulation were fired.
More than a half million veterans still must wait at least a month to see a VA doctor, and even when they do manage to get an appointment, the care they receive is not always up to the standards patients expect to see in the private sector.
Current VA Secretary Bob McDonald struck a nerve when he compared VA wait times to wait times at Disney parks in late May. The backlash over his comments drew attention, if only for a moment, back to the shortcomings that have plagued the VA for years.
The following nine recent VA failures offer a glimpse at an agency that sometimes struggles to provide the most basic services to veterans.
1. Cockroaches in the kitchen
Whistleblowers at the Edward Hines Jr. VA hospital outside Chicago came forward in April with reports of a cockroach infestation in the clinic's kitchen. The cockroaches reportedly ended up in patients' food, causing some veterans to refuse their meals. Equipment in the kitchen was coated in grime, VA employees said, because no one at the hospital bothered to clean.
Apparently, the infestation had persisted for years as complaints about the filthy conditions were swept under the rug.
But the VA has reportedly covered up the unsanitary conditions in the Hines VA kitchen for years. Whistleblowers recalled fellow food-service workers who stopped coming to work for fear that the bugs would find their way to their homes.
The pestilence prompted Sen. Mark Kirk, R-Ill., to introduce legislation that would force VA hospital kitchens to maintain the same health standards as kitchens at private hospitals.
Whistleblowers at the Edward Hines Jr. VA hospital outside Chicago came forward in April with reports of a cockroach infestation in the clinic's kitchen. (iStock Photo)
2. Death notices for the living
Thousands of veterans saw their VA benefits abruptly cut off when government officials accidentally registered them as dead when they were very much alive.
Between 2011-15, the VA was forced to restore benefits to 4,201 veterans who had received mistaken death notices that resulted in the severance of their VA payments.
The VA declined to say what caused the mishaps, but has suggested that "employee error" or computer glitches could be to blame. In some instances, veterans were marked as deceased when an individual or family member with a similar name died.
One affected veteran told the Washington Examiner last year that such a sudden loss of income could be "devastating" to a veteran who relied on his or her VA benefits to survive.
What's more, the VA relied on the veterans who were declared dead to prove to the government that they were, in fact, still living.
Last year alone, 1,025 veterans had to notify the VA that they were alive after discovering their VA payments had been cut off.
3. Suicide hotline goes to voicemail
A VA hotline established in 2007 to assist veterans contemplating suicide was found to be a near-complete failure by the agency's inspector general.
The agency watchdog discovered veterans' calls had gone to voicemail or were placed on hold and passed from operator to operator without ever receiving help. VA employees tasked with running the hotline did not even know the voicemail system existed, so they never returned the calls of suicidal veterans who left a message.
In other instances, VA workers told veterans who called the hotline to contact a different organization or simply ended the call without providing any help.
Roughly one out of every six calls to the suicide line was reportedly routed to a backup center because VA employees were unavailable to address the veteran.
Following the backlash over the inspector general's report, the suicide hotline was transferred to the control of the VA's Health Resource Center.
But that division of the agency has dropped as many as 1.4 million calls since September 2014, one whistleblower said. The center abandoned hundreds of thousands of calls to a help line that veterans were instructed to dial if they had questions about matters such as eligibility or benefits.
Roughly one out of every six calls to the suicide line was reportedly routed to a backup center because VA employees were unavailable to address the veteran. (AP Photo)
4. Drugs passed out like candy
The VA hospital in Tomah, Wis., earned the nickname "Candyland" from local veterans due to the frequency with which physicians there wrote prescriptions for painkillers. At least one veteran reportedly died from the cocktail of medications he was prescribed at the Tomah facility.
Under the leadership of Dr. Dan Houlihan, a VA physician who came to be known as the "Candyman," the number of opiate prescriptions at the Tomah clinic nearly quadrupled in less than a decade.
The VA promoted Houlihan to lead the Wisconsin VA hospital in 2004, shortly after he had been hired by the agency in spite of previous charges from the Iowa State Board of Medical Examiners that he had had inappropriate interactions with a patient.
A Center for Investigative Reporting review uncovered whistleblower allegations that veterans were "doped up" and "zombified" by the narcotics they were told to take and would sometimes drool on themselves or fall asleep during their appointments.
But even though VA employees tried to sound the alarm about the drug abuse at Tomah for years, the VA inspector general was slow to investigate the claims and pushed to keep its findings under wraps when it finally did look into the allegations.
The VA hospital in Tomah, Wis., earned the nickname "Candyland" from local veterans due to the frequency with which physicians there wrote prescriptions for painkillers. (iStock Photo)
5. Elderly vets neglected
In October 2015, the Office of Special Counsel released the findings of an investigation into charges that the VA hospital in Puerto Rico was potentially abusing elderly veterans.
Investigators discovered that staff at the Puerto Rico VA facility had "neglected elderly residents by failing to assist them with essential activities of daily living, such as bathing, toileting, eating and drinking. This neglect created significant and serious health issues for those residents."
The report sparked outrage after the public learned elderly veterans had been left in their own filth and denied food and water at the hospital.
However, the VA employees cited for that neglect were not fired. Instead, several were demoted to lower-ranking positions and the entire staff was simply "re-educated" about proper geriatric care.
In October 2015, the Office of Special Counsel released the findings of an investigation into charges that the VA hospital in Puerto Rico was potentially abusing elderly veterans. (AP Photo)
6. Medical records put on Facebook
A report made public in January indicated the VA is the most prolific violator of patient privacy laws in the country.
VA employees spied on veterans' medical records, sent the wrong records to different veterans and even posted about patients on social media.
In one instance, a VA worker accessed the medical records of her ex-husband, who was a veteran, 260 times without permission.
In another, VA employees spied on the medical records of a coworker who got her care at the VA and used the information they found about her mental health conditions to taunt her.
A review found more than a dozen incidences of VA employees posting pictures of patients online, including one VA patient assistant who uploaded a picture of "an ailing veteran's exposed buttocks" to Facebook.
In all, the VA has racked up more than 10,000 privacy breaches since 2011.
However, the Department of Health and Human Services, the government agency tasked with enforcing medical privacy laws, did nothing to punish the VA for its serial breaches.
7. Veterans dying in line for benefits
Nearly a third of all veterans waiting to be enrolled in the VA's benefits system died before the VA got to their applications.
Of the 847,882 veterans awaiting enrollment in the benefits program, 238,657 veterans with pending applications died before the agency could grant them healthcare benefits, a 2015 review found.
The same review discovered that thousands of veterans who had been listed as dead in the agency's records went on to make appointments, undergo surgery and fill prescriptions.
The massive backlog of applications has forced veterans to wait long stretches of time before they could learn whether they were approved for VA benefits.
Following a backlash in July 2015 over the discovery of the backlog's size, a whistleblower came forward and charged that the VA had helped create the problem by giving veterans false instructions on how to put together their applications.
The whistleblower said VA employees told veterans not to include their discharge papers with their application before sidelining all applications that were missing discharge papers in an effort to avoid blame for the backlog.
Email records later suggested the VA issued the misleading guidance for political reasons.
After the size of the backlog was exposed publicly last year, House Republicans vowed to investigate how the VA had allowed nearly one in three veterans to die before dispensing the benefits they were promised.
The massive backlog of applications has forced veterans to wait long stretches of time before they could learn whether they were approved for VA benefits. (AP Photo)
8. Rationing crucial medicines
After VA officials requested $500 million from Congress to pay for expensive hepatitis C drugs, the agency mulled a plan to ration the medications.
Internal documents indicated the VA developed a plan to withhold the hepatitis C drugs from certain veterans even after receiving congressional permission to raid a controversial agency program for the required funding. VA officials took the money from a "choice" program designed to allow veterans to receive care in the private sector and bypass the VA system.
A top VA official testified in June 2015 that the agency had no plans to ration the hepatitis drug, although demand for the treatment was soaring among veterans.
But emails suggested discussions in January 2015 of how to pay for the medicine were stifled by high-ranking VA officials until the budget problems became dire that summer.
By July, a VA executive noted the agency's plan to withhold medicine meant "deferring patients with less serious disease even if there is available capacity/funds."
Some physicians within the VA pushed back on a draft plan for "systemic rationing" of the drugs for ethical reasons.
According to a draft of the plan, the VA considered denying treatment to any veteran whose disease was so severe that his or her life expectancy was less than a year.
Any veterans with "advanced dementia" or who were in a "persistent vegetative state" also would have been denied the crucial medication under the plan.
9. VA employees who steal allowed to keep jobs
The VA faced fierce criticism last year after agency officials refused to punish two employees who had stolen hundreds of thousands of dollars from the government.
Diana Rubens and Kimberly Graves were accused by the VA's inspector general of gaming an agency relocation program to pocket money and land new jobs at the VA.
The program was created to incentivize VA employees to relocate for agency positions that had proven difficult to fill with local talent.
However, Rubens had created a less demanding position for herself in Philadelphia, billing the agency $274,000 in moving expenses and retaining her six-figure salary despite having fewer duties in the new job.
Graves was accused of pressuring a fellow VA official into leaving his post so she could take it and reap the relocation benefits.
The two VA employees invoked their Fifth Amendment rights and refused to testify when called before Congress last year to explain their actions.
The VA later refused to fire either of the officials, nor did it ask Graves and Rubens to return the money they had taken. In fact, the agency blamed a paperwork error in late 2015 when it announced its decision to undo the demotions each VA employee had initially faced as punishment.