The scandal at the Department of Veterans Affairs deepened late yesterday — and this time picked up a paper trail. CBS News obtained an e-mail from an official at a fifth VA office, this time in Wyoming, explaining how to game the wait-list system in order to stay off of “the bad boys list.” And it’s not the first time the VA has had an issue with the Cheyenne office, either:

The email, written by Telehealth Coordinator David Newman, a registered nurse, describes how patients at the Cheyenne VA Medical Center are always listed getting appointments within a 14-day window, no matter when the appointment was first requested, and no matter how long the patient actually waited. The memo admitted, “Yes, this is gaming the system a bit…” because “when we exceed the 14 day measure, the front office gets very upset, which doesn’t help us.” The employee further instructs staff on how to “get off the bad boys list” by “cancelling the visit (by clinic) and then rescheduling it with a desired date within that 14 day window.”

VA Secretary Eric Shinseki, already under fire for the scandal in Phoenix and three other locations, issued a statement demanding an immediate audit of the Cheyenne office and a suspension of the employee who wrote the memo. However, CBS also learned that the VA knew of “improper scheduling practices” in December of last year, when the Office of Special Counsel was informed of the situation. That was also based on a whistleblower, just as the scandal in Phoenix was exposed, although the specific allegations in the earlier Cheyenne inquiry were different than this particular kind of scheduling fraud.

That leaves a few questions, though. What kind of follow-up did the VA do in Cheyenne? Did the follow-up include coaching on how to manipulate data rather than improve service? What kind of follow-up did the VA do on its 14-day wait-list metric in other offices? Any metric imposed on an organization will produce attempts to mitigate the work necessary to achieve it, and clearly that’s what happened in five different locations, if not across the entire VA chain. Either the leadership at the VA didn’t care to follow up to make sure that offices weren’t manipulating data, or they actively encouraged them to do so. With the problem now demonstrated at five different offices in various regions of the country, there really is no third option.

At best, this is a massive leadership failure that allowed veterans to die without proper medical care, at least in Phoenix and probably elsewhere, too. The VA needs some housecleaning, and it should start at the top.