(CNN) Veterans have continued to die while waiting for care at the Phoenix VA medical center, the focal point of 2014 scandal that shook the Department of Veterans Affairs and ignited reforms intended to fix the troubled healthcare system, according to a report released Monday.
The VA inspector general found that 215 patients died with appointments still pending in the medical center's database in 2015, and in one case, the report concluded the delayed care directly contributed to a patient's death.
As of July, the Phoenix VA had about 38,000 pending requests for consults, or appointments, a number which grew by 5,000 just since March, according to the report.
In 2014, a CNN investigation found that dozens of veterans died while waiting for treatment at the Phoenix VA and that officials manipulated appointment data with "secret" waitlists and other schemes in order to hide the backlog of requests for care.
Over the past two years, the inspector general has issued six reports calling on VA officials in Phoenix to address mishandling of appointment scheduling and other forms of mismanagement, but Monday's report concluded, "These issues remain."
The report found that patients continue to encounter delays in care at the Phoenix VA due to administrators not appropriately reviewing appointment requests, not rescheduling canceled appointments, and in some cases, even misplacing lab results.
The VA's inspector general attributed some of the issues at the medical center to staffers' confusion over policies and procedures.
Investigators found that staffers inappropriately canceled about 24% appointments for specialty care they reviewed, but they concluded this occurred because some administrators were "generally unclear" on the appropriate way to manage requests.
In the case highlighted by the report in which delayed-care contributed to a patient's death, a new patient in his 50's complained of chest pain during an examination at the medical center in May 2015. A VA physician referred him for testing, but the patient died in June 2015 due to heart disease and the test had never been scheduled.
"Timely testing ... could have forestalled his death," the report found.
In another case, a patient waited more than 300 days for a vascular appointment but ultimately did receive care in October 2015.
The chairman of the House Committee on Veterans Affairs, GOP Rep. Jeff Miller, not only critiqued the Phoenix VA for a lack of improvement in the last two years, but he also exhorted the inspector general's report for not holding VA officials accountable.
"It's clear veterans are still dying while waiting for care," Miller said in a statement Monday. "VA's performance in Phoenix and across the nation will never improve until there are consequences up and down the chain of command for these and other persistent failures."
A separate report issued by the inspector general in October 2015 found that 45% of urology appointments at the Phoenix VA were delayed, and 10 patients experienced "significant delays," some of whom died.
In June, the VA announced the firing of three additional senior officials at the Phoenix VA for negligence and lack of oversight of healthcare scheduling.
The former director of the Phoenix VA, Sharon Helman, was terminated in the wake of the 2014 wait-time scandal and later plead guilty to not reporting $50,000 in gifts from a lobbyist, but since Helman's removal, the Phoenix VA has had six directors.
The VA received criticism over its most recent appointment of Phoenix VA director from some Arizona members of Congress in September who described the official as having a "questionable record."
The Phoenix VA's new director, RimaAnn Nelson, previously presided over the St. Louis VA when the hospital closed twice due to unsanitary conditions. The VA's inspector general found staff in St. Louis had not been trained to sterilize equipment, and according to a whistleblower, the poor sanitation contributed to infections.
Responding to the report issued Monday, VA officials said the Phoenix medical center has implemented a new appointment management policy and has increased staff training and compliance tools, but VA Deputy Secretary Sloan Gibson said the department as a whole is still in the midst of a massive transformation
"Though we have made irrefutable progress, there is still much work to be done," Gibson said.