The Veteran Affairs Office of Inspector General (VAOIG) is currently investigating the Altoona Pennsylvania VA Medical Center (VAMC) for manipulating data in treating patients with traumatic brain injuries (TBI).
“We have opened a case based on a review of the information you sent to our office,” according to a May 10 email sent to James DeNofrio, an Altoona VAMC employee and whistleblower who originally filed the complaint.
Because veterans who suffer TBIs can develop all sorts of physical and psychological issues ranging from Post-Traumatic Stress Disorder (PTSD) to chronic traumatic encephalopathy (CTE) they require specialized care which is provided in polytrauma at the Altoona VAMC.
The problems started in 2013 when Dr. David MacPherson, then the Chief Medical Officer for Veteran Integrated Services Network (VISN) 4, a region which includes the Altoona VAMC, expressed concerns that the number of TBI patients purported to be treated at the Altoona VAMC appeared to be unusually high.
“Altoona reports a very large number of case managed polytrauma Veterans and I don’t think the report is accurate,” Dr. MacPherson said in a 2013 email to Dr. Santha Kurian, the chief of staff of the Altoona VAMC.
A call to VISN 4 was left unreturned and Andrea Young, public affairs officer for the Altoona VAMC said Dr. MacPherson has since retired.
DeNofrio was then tasked with reviewing the TBI files.
According to subsequent emails sent to superiors, DeNofrio found that not only did Altoona VAMC take credit for providing polytraumatic care to patients who were not receiving it — many who the hospital claimed were receiving care had moved to other parts of the country and DeNofrio discovered one was in jail. He also found dozens of veterans with TBI who were receiving no care at all.
In his initial 2013 review, DeNofrio found that out of 647 patients identified as having a TBI who the hospital said were receiving care 414 were not receiving any care. Out of those left, DeNofrio found that 97 were still in need of follow-up appointments.
In his initial 2013 review, DeNofrio found that out of 647 patients who had a TBI who the hospital said were receiving care in the polytraumatic unit 414 were not receiving any care in that unit; from those left, DeNofrio found that 97 were still in need of follow-up appointments after those patients missed a scheduled appointment.
Despite sharing his findings with Dr. Kurian, and William Mills, then the director of Altoona VAMC, a follow up review in 2014 found that little had been fixed; DeNofrio found that 90 patients were still not receiving follow-up appointments in 2014.
DeNofrio found that of those who did not receive follow up care seven veteran deaths.
Mills has since left the Altoona VAMC and is now the interim director at the Memphis VAMC; Mills left the Altoona VAMC days after the Office of Special Counsel published its findings of complaints by DeNofrio and another whistleblower, Dr. Tim Skarada.
Willie Logan, public affairs officer for the Memphis VAMC, did not respond to an email for comment.
In 2015, DeNofrio took his complaints to Congressman Bill Shuster, a Republican from Pennsylvania’s 9th District, which includes the Altoona VAMC.
When Shuster’s office investigated DeNofrio’s complaints, Mills downplayed the issues, specifically that any deaths could be attributed to poor patient care.
“My most serious concern was Mr. DeNofrio’s newest claim to you that there had been danger to public health or safety, and even patient deaths related to the VAMC.” Mills said to Shuster’s office in a letter from April 29, 2015. “Upon receipt of the names of patients from Mr. DeNofrio, a full review was conducted by our Patient Safety Manager and reviewed by our Chief, Quality Management. Both concurred that the patients identified were reviewed, and had been followed up by the Polytrauma team and had been followed up by other disciplines.”
Mills also claimed that DeNofrio asked several investigative bodies, including VAOIG, to investigate the matter “and each of these has been investigated through appropriate channels.”
In his reply to Congressman Shuster, DeNofrio pushed back saying that while he did file complaints with numerous agencies “it is not true that each of these has been investigated through appropriate channels.”
DeNofrio also took issue with the suggestion that Mills was only recently made aware of patient deaths telling Shuster, “Please note that this information was reported by me in email directly to Mr. Mills and the Patient Safety Manager as well as other members of Altoona VAMC leadership in November 2014, following a similar finding in 2013.”
Casey Contres, press secretary for Congressman Shuster, declined formal comment saying only: “Our office has been in contact with Mr. DeNofrio and continues to be in contact with him, but we do not comment on ongoing constituent inquiries.”
Andrea Young, public affairs officer at the Altoona VAMC, issued this statement:
“At the Altoona VA Medical Center, the health and well-being of our Veterans is our top priority. We are also fully committed to collaborative efforts with the Office of the Inspector General (OIG) to ensure safe and high quality practices are continuously implemented within the medical center for our Veterans.
“While we appreciate the Office of Inspector General’s independent review, due to the ongoing investigation, we cannot provide further details at this time.”