The investigations to the Tomah VA Medical Center was one of the major stories from this past year.
Whistleblower's allegations that Tomah VA doctors relied too heavily on powerful prescription opiates to treat pain among veterans led to a series of investigations at the Tomah VA.
"I remember our son calling Tomah VA candy land when he was alive, I remember that," Lorraine Ward recalled. Her son, Jacob was treated at the Tomah VA.
"He was in la-la land, he didn't even know who we were. it was very sad," Ward said describing her son's demeanor while receiving treatment at the VA.
Families of patients claimed the drugs sometimes led to fatal overdoses.
Jacob Ward was 27-years-old when he died of an accidental heroin and cocaine overdose on Sept. 4, 2013, although the Wards say the VA is not entirely at fault.
A series of investigations into the VA found unsafe clinical practices and that Tomah VA patients were 2.5 times more likely than the national average to be prescribed high doses of opiates.
"If there is anything that we need to have deep core competency in as an institution, as a health care institution, it's pain management. And it can't be a bag of pills all the time," Sloan Gibson, VA Deputy Secretary said.
Some employees at the VA claimed they faced retaliation when they brought their concerns to administrators.
"Uniformly the staff there warned me that if I questioned Dr.Houlihan's prescriptions, that I would be fired," Noelle Johnson, former pharmacist at the VA said.
David Houlihan, one the the doctors under investigation for over prescribing pain meds, was put on administrative leave, eventually being fired last month.
Just before that, former VA Director Mario De Sanctis was terminated in September. Now Victoria Brahm sits as the Acting Director.
"It's not one particular action but there is a basic foundational movement for trust. It is to build trust between the employees and the leadership, to build trust between the employees, to build trust between veterans and us. So this is a rebuilding effort. It's a foundational effort to build that kind of trust so we can move forward in the future in a unified positive direction," Brahm said.
Lawmakers also got involved, passing legislation included in the year-end budget meant to better the VA.
"More protection for whislteblowers, including our health care providers. That was one of the problems we had at Tomah. People were afraid of coming forward with necessary information," Rep. Ron Kind, (D) Wisconsin, said.
The new legislation will expand transparency by requiring the Inspector General's office to fully disclose all investigations and findings.
New leadership and legislation, both changes Kind said have to happen to ensure the Tomah VA is providing the best care for Wisconsin veterans.