A report from the Veterans' Administration Office of Inspector General identified at least 1,700 veterans at the agency's beleaguered Phoenix clinic who were not properly registered on waiting lists, putting them "at risk of being forgotten or lost."
The independent report, released Wednesday, confirmed recent allegations that VA locations have been relying on sketchy scheduling practices amid treatment delays, some of which have resulted in the deaths of vets.
Investigators, in a sample of 226 patients, found that the average wait time for the first primary care appointment at the Phoenix medical center was 115 days, but that the average waiting time reported to the VA was just 24 days.
The report said that the VA Office of Inspector General (OIG) identified 1,700 veterans at the Phoenix VA who were waiting for a primary care appointment, but were not on the electronic waiting list. It also found that Phoenix leadership "significantly understated the time new patients waited for their primary care appointment ... which is one of the factors considered for awards and salary increases."
The report follows accusations that as many as 40 people died waiting for treatment at the Phoenix facility, and that a secret patient wait list was used to hide delays in care.
"Leadership significantly understated the time new patients waited for their primary care appointment in their FY 2013 performance appraisal accomplishments, which is one of the factors considered for awards and salary increases," the report said of the Phoenix facility.
The OIG also said it received "numerous allegations daily of mismanagement, inappropriate hiring decisions, sexual harassment, and bullying behavior by mid- and senior-level managers" in Phoenix, and said it was assessing the validity of the complaints.
VA Secretary Eric Shinseki, who many lawmakers have called upon to resign, called the findings of the OIG report "reprehensible."
"I am directing that the Phoenix VA Health Care System (VAHCS) immediately triage each of the 1,700 Veterans identified by the OIG to bring them timely care," Shinseki said in a statement, adding he had already placed leaders in Phoenix on administrative leave.
Sources at the Phoenix VA told NBC News that interim Director Steve Young has increased the number of staffers working on electronic scheduling for new appointments from two to six. He has added five “floating” physicians to see patients when other doctors are not available. He has also added six primary care teams, which can include physicians, registered nurses or practitioners.
The report primarily focused on Phoenix, but there were findings that had national implications, too, including the fact that inappropriate scheduling practices are "systemic throughout the VA."
Most of the waiting time discrepancies appeared to have happened because of delays between the veteran's requested appointment date and the date the appointment was created, according to the report.
The Iraq and Afghanistan Veterans of America, the largest organization for new vets, called the report "damning and outrageous."
"It also reveals the need for a criminal investigation. Each day we learn how awful things are in Phoenix and across the country," the organization said in a statement. "The VA’s problems are broad and deep - and President Obama and his team haven’t demonstrated they can fix it."
—Elizabeth Chuck and Kelly O'Donnell