Denofri ee From: Denoftio, James ry, Ie and Sent: Tuesday, August 27, 2013 9106 AM / Onrainal Eom “year re Service Chief of Staff, Altoona ( a ; © et ce Struthers, Frederick DO; Kurlan, Santha, MD Fallow wp nefoa Ue Subject: FW Polytrauma Case managment F ove 50 PM&RS action complete and submitted for your review, Jay DeNofiio ‘AShlieatve Oftexe Ppa Meine € eb Sevie ses, Ven Zed VANE Atos, PA \ ce ack .rtcewing (619) 948-164 Ext 85 \C beth mee Taek -rtccunis SS failos -up ce at Alten, t From: Struthers, Frederick DO oy ‘Sent: Tuesday, August 27, 2013 6:47 AM VA medical carter Tot Denofrio, Jaines Subject: RE: For Concurrence: Polytiauma Case managment J approved Frederick Struthers DO Chief of PMRS James E Van Zandt Medical Center 2907 Pleasant Valley Blvd Altoona, Pa 16602 email: FrederickStruthers@va.gove 1-814-943-8164, ext, 7342 From: Denofrio, James Sent: Monday, August 26, 2013 3:46 PM To: Struthers, Frederick DO Ceci Krause, Theadora; Kaplan, Robert; Kananen, Timothy; Mayhue, Karen Subject: For Concurrence: Polytrauma Case managment ‘Importance: High Dr, Struthers, For concurrence (__Polytrauma Review s completed of the 647 patients identified with a Positive 1" level TB Screen or identified on the SSC Polytrauma List for Altoona VAMC: * SE Veterans are currently active [nthe Polytrauma program and have future appointment currently scheduled Jn the Polytrauma Clinic,‘+ 97'Veterans have pending case management and/or scheduling follow-up due to recent no-show or cancellation, * 414 Veterans were removed and / discharged from the Polytrauma Program following review. The reason for (discharge Is documented in medical record and signed by members the of the Polytrauma Team In CPRS Poltrauma Share Point has been created to assist in folowing up with current Polytrauma Veterans, (IInk below) httos://vaww.visn4.nortal.va.gov/altoona/altoonahome/polvtrauma/Shared%20Documents/Polytraumars20Review%20 ePolnt.xlsx Additionally, MCM 11-07, Polytrauma Support Clinle Team anid MCM 11P-08, Polytrauma Case Management are completed and have been sent to the Director for final signature, Jey DeNofio ‘Adminsuatve Offcee Plynical Main de Rehab Service James B. Van Zande VANG, Altos, PA (B14) 943 - 8164 Fit, B45 yA LF From: Denofrio, James ‘Sent: Friday, June 07, 2013 9:07 AM To: Kurlan, Santha, MD Cet Ferrell, Jeannie ‘Subject: FW: For Concurrence: Polytrauuma Case managment Importance: High PMS follow-up action response Is below. Jay DaNofio ‘Adilalstatie Offcee hype Medicine & Rehab Service James ©. Van Zandt VAMC, loons, PA (14) 943 8164 Et. 8845 From: Struthers, Frederick DO 5 Sent: Friday, June'07, 2013 8:52 AM ‘To: Denoftio, James ‘Subject: FW: For Concurrence: Polytrauma Case managment Importance: High concur From: Denofrlo, James ‘Sent: Thursday, June 06, 2013 5:07 PM. To: Struthers, Frederick DO ‘Subject: For Concurrence: Polytrauma Case managment Importance: High For Concurrence: Per discussion with Polytrauma Case Manager, data self-reported to VISN Is Incorrect, PM&RS submitted the following MMs (Attached) for facility review In order to comply with VHA Handbook 1172.02, Polytrauma System of Care March 20, 2013 for the case management of Polytrauma Veterns : 2 V 4" MCM 42P-07, Polytrauma Support Clinie Team IMCM 12-08, Polytrauma Case Management In order to ensure correct data Is reported to VISN, PMA&RS Is conducting a full 1* level review of all Veterans seen in a Polytraumia Clinic and /or identified with a positive 1" level TBI screen followed by a 2" level screen by the Polytrauma Case managers and Interdisciplinary Polytrauma Team if needed In order to sure that appropriate follow-up Is completed. PMA&.RS has identified a total of 627 Veteran charts for review and has completed 54 chart reviews to date with anticipated completion date of August 45, 2013, Jy Davin ‘Rrsoustre oti Piped Rea Sec Jur Vn Za VN on, PA (Gis 949 a164 Bue 843 From: Kurlan, Santha, MD Sent: Tuesday, June 04, 2013 4:00 PM errell, Jeannie Ge: Denofilo, James; Struthers, Frederick DO; Krause, Theadora ‘Subject: FW; Polytrauma Case managment Importance: High ACTION TO 41P. Please review and respond Santha Kurlan, M.D. Chief of Stat ‘Alloona VAMC From: Macpherson, Davi § (SES EQV) —> hoe he A 7 SentrTuesny,sureotaoiszsen ISN 4 Chu Medien OFFrce x “To: Kurlan, Santha, MD Subjects FW: Polyrauma Case managment Santha, \have bean looking atthe data régarding polytrauma Veterans who are case managed, It's attached. VISN 4 sites self report the data to Chris Brush and she compiles. Altoona reports an very large number of case managed polytrauma Veterans and | don't think the report Is likely accurate. | suspect many on your Ist are not now belng case managed. While ths s only an internal VSN report, ask that you work with your polytrauma lead to cull the list Indeed active case management Is not occurring. The national policies regarding this are attached, This s not urgent but would lke to have your staff have this cleaned up by September 1. We can have a call Ifyou wish to discuss further, Thanks Dave From: Cress, Willam ‘Sent: Tuesday, June 04, 2013 2:47 PM To: Macpherson, David $ (SES EQV) Subject: Polytrauma Case managment Dr, Macpherson, ‘The first attachment Is the entire Polytrauma section from the VHA handbook, 3The second attachment Is the section of the handbook that specifically outlines Polytrauma case management and discharge criteria. Thanks. Bi2nd Finds aol Cee yeor lar 90 pe did nak thave Follow ep T paturts 94, the Wis! Denofrio, James Saturday, Novernber 15, 2014 9:33 AM ) VAQIG Hotline Denofrio, James Whistleblower Complaint -90 Polytrauma Veterans at the James , Van Zandt VAMC (Altoona PA) Not Receiving Follow-up Care and Case Management Attachments: Email to Chief of Staff and Director regarding Polytrauma Clinic 11-13-2...pdf; VISN 4 Polytrauma Case Management Action Item 8-27-2013,paf Correspondence with Polytrauma Case Manager Regarding Polytrauma Follow-up Appointments 11-15-2014 pdf Copy of Polytrauma Review SharePoint 11-13-2014.pdf Importance: High Tracking: Reciplent Dativery Read VAOIG Hotine Delivered: 1/18/2014 933 AM Deno, James Delivered 31/15/2014 933 AM “Read: 31/15/2014 9.39 AM Please review the following direct and immediate threat to patient care and safety at the Altoona VAMC. Specifically ‘OEF/OIF Polytrauma Veterans with a positive 2" level Traumatic Braln Injury screen are not recelving appropriate case ‘management and follow-up by the Altoona VAMC Poytrauma Team at the James E. Van Zandt VA Medical Center in Altoona, PA. | have forwarded my findings to the Medical Center Chief of Staff and Director, but have not recelved a response: | request your review of the attached reports regarding 90 PM&RS patients at the Altoona VAMC that did not receive follow-up appointments in the PM&RS Polytrauma clinic dating back to 2013, (Email to Chief of Staff and Director regarding Polytrauma Clinic 11-13-2014 and copy of Polytrauma Review SharePoint). Per VHA HANDBOOK 1172.01 - POLYTRAUMA SYSTEM OF CARE , Polytrauma is defined as two or more injuries, one of which may be life threatening, sustained in the same incident that affect multiple body parts or organ systems and result in physical, cognitive, psychological, or psychosocial impairments and functional disabilities. Traumatic Brain Injury (TB) frequently occurs in polytrauma in combination with other disabling conditions, such as: traumatic amputations, open wounds, ‘musculoskeletal injuries, burns, pain, auditory and visual impairments, post traumatic stress disorder (PTSD), and other ‘mental health problems, When present, injury to the brain often dictates the course of rehabilitation due to the ‘complexity of the related cognitive, emotional, and behavioral deficits These patients are often at very high risk for suicide, drug abuse, homelessness, and other significant issue that require case management by a VA social worker. There are multiple case mangers (soctal workers) that work In our building ‘who have the responsibility of ensuring that the Polytrauma patients follow thelr recommended plan of care including follow-up appointments in the Polytrauma clinic. However, upon my review this week | found that 90 patients enrolled in the Polytrauma program had no follow-up appointments inthe cline some dating back to 2013. 14 additional patients on the case management list were no longer patients atthe Altoona VAMC and/or had moved to another state. ‘This had previously been a problem identified in 2013 by the VISN Chief Medical Officer (Or. David Macpherson, who is now Acting Director of the Pittsburgh VA Health Care System) to our Chief of Staff, Dr. Kurian. | was assigned to complete a full review of the program in 2013 and also come up with an action plan to correct the problems in 2013. (please see attached email VISN 4 Polytrauma Case Management Action Item) |n 2013 | reviewed 647 patients identified with a positive 1* level TBI screen or identified on the VSSC Polytrauma List for the Altoona VAMC. The majority of the patients that | reviewed at that time were not receiving follow-up care and case management dating back to 2007. Following my review 414 Veterans were removed and / discharged from the 1 3 review spp voPolytrauma Program by the Altoona VAMC Polytrauma Team. Of significant concern in my 2013 review was that some of the Veterans | reviewed in 2013 had died and one Veteran on the Altoona VAMC case management Ist was serving a life sentence in prison for multiplevictim homicide. These patients were on the Altoona VAMC case management ist at the time of my review in 2013, 1 presented my full review and findings to my supervisor and faclty leadership in 2013. | also created a SharePoint site for the Polytrauma case managers could individually monitor and follow-up with each patient in the program. | also wrote two local policies (CM 11P-07, Polytrauma Support Cline Team and MCM 11P-08, Polytrauma Case Management) to ensure a uniformed standard of practice of care and management for Polytrauma patients was in place. | was subsequently removed from duties and responsibilities with the Polytrauma Program. | uncovered the current problems with Altoona VAMC Polytrauuma Program as an incidental finding when completing a separate action item for PM&RS related to missed opportunities. Before my findings this week | believed that the previous issues identified in 2023 regarding lack of case management for the Polytrauma Veterans had been resolved. Prior to sending the email, discussed my preliminary findings with the Chief of PM&RS, Dr. Struthers (my supervisor) and he told me that | should not do anything because he “would just talk to everyone so that no one got mad”. He later told me that | should first worry about the most recent patients on the list because the other patients had not been addressed in so long. (basically that they had already waiting this long, soit was OK If they continued to walt.) | spoke with the nurse practitioner, Thea Krause, who Is the practitioner providing direct medical care in the Polytrauma clinic and she told that | should not be sending emalls to "everyone and their mother” about the problem and Just let the Polytrauma Case Manager, Tim Kananen “take care of It l explained to her that all employees have a responsibility to report issues that negatively impact patient care and! safety. Or. Struthers and Thea Krause met with me together on’ 11/12/2014 and tried to blame the new PM&RS secretary Sandy Showalter for the problem. | explained that Sandy Showalter has only been working at the Altoona VAMC since 2014, and the same problem went back to 2007, Tim Kananen, met with me on 11/13/2014 and told me that he was aware of the problem, but stating that follow-up the patients was a big job that took a lot of time and he and his staff did not have the time, He referenced my review and follow-up action in 2013. | told him that since 2013 there were 90 polytrauma patients who did not receive follow- up and Tim told me that “sounds about right.” I tried to explain the situation in detall with Dr. Struthers but he did not seem to fully understand the situation and was very concerned about getting in trouble by the Chief of Staff, Dr. Kurlan, On the afternoon of 11/14/2014 my supervisor, Dr. Frederick Struthers, met with me, Tim Skarada (PM&RS Supervisor of Physical Therapy, Occupational Therapy, Speech Pathology, and Audiollogy Departments), and Sandy Showalter (PM&RS Secretary) in my office. He told us that he had discussed the problem with Tim Kananen (Polytrauma Case Manager) and acknowledge there was a problem, but Dr. Struthers again blamed PM&RS scheduling staff for not properly scheduling, and following up to ensuring that Polytrauma Veterans received necessary care. | explained to Dr. Struthers that it was not the responsibilty of the PM&AS schedulers to case manage this very high risk populatlon of patients explaining that responsiblity is clearly assigned to the Polytrauma Team and Polytrauma Case Managers by both local and national policy related to Polytrauma System of Care. | emphatically tried to explain to Dr. Struthers that by not appropriately follow-up with these patients appropriately | believed that the Polytrauma Team was significant risking the Veterans health and safety and violating policy. | also summarized the issues identified In the above 2013 review. | asked if we could meet with Tim Kananen and the Polytrauma Team members and Dr. Struthers to come up with plan of action to immediately get these patients follow-up care, but Or. Struthers refused stated that he would discuss the situation with Robert Kaplan, MD (a Physiatrist in the PM&.RS department) and the Polytrauma Team members. Tim Skarada and Sandy Showalter witness my entire conversation with Or. Struthers. | request investigation into this matter. | am agreeable to have my name released in connection with the Investigation and am not requesting confidentiality, Thank you James DeNefio ‘Adninitne Ofeee Phil Medicine Rea Sesie James 2. Van Zandt VAMC, Altoona, PA (Gis) 943-8164 Bt 8345,Denofrio, James From: Denofrio, James Sent: Wednesday, April 22,2025 1:21 PM To: Bowens, Marca + Adin's, hee ce: Denotrio, James Subject: RE: Please Review - Important Attachments: Copy of 2-27-2015 Report to VA OIG pa Reports to VAMC Leadership regarding Polytrauma findings 11-13-2014 and 11-26-2014.paf; Reports to VAMC Leadership regarding Polytrauma findings 11-14-2014 paf; Email to HR related to Polytrauma report to VA OIG,pat; Memo re investigation - 3-17-15.pdf; Copy of 11-15-2014 Report to VA OIG pdf Ms, Bowens, | will be sending the requested Information to Quality Management and the Director shortly For clarification, information referencing the Polytruama program and the patient deaths was included In the evidence that I presented to you and the Medical Inspector at our meeting on February 9, 2015 here in Altoona. (Please reference the red shx-part folder section Reports to Inspector General ~ Copy of report Copy 11-15-2015 Report to VA OIG Is attached). My report to VA OIG and complete list of patients in the Polytrauma Program and their status should be included in that folder. Per MCM 11P-07, As Physician Chief of PM&RS, Or. Struthers has overall responsibilty for Polytrauma Support Clinic Teams (PSCT) and ensures development and implementation ofa comprehensive Polytrauma System of Care program at the James E, Van Zandt VA Medical Center. The Chief, PM&RS also ensures that effective Inter-disciplinary collaboration exists to assess, evaluate, coordinate, manage, and follow-up wit Veterans and Service Members identified with Traumatic Brain Injury (78) and Polytrauma. This is why I recently reported to your office regarding Or. Struthers continued participation and involvement in the Polytrauma Suppor linc Team meeting. ‘As an update, | also provided the VA OIG follow-up information regarding the matter per their request and emails to Altoona VAMC Leadership, Quality Management, and HR are attached, | recelved no follow-up, direction, or guidance related to ‘these disclosures from the Altoona VAMC which led to my reporting to VA OIG. Following my report to VA OIG I was subjected to an investigation and false reports of contacts were filed against me. I later received a memo from HR noting that the investigation was closed as no corrective action directed toward me would be appropriate, Respectfully, Jey DeNofio ative Ofer Phyl ede € Reb Seve Juner Van Zan VAN ona, PA {bis} 948- 161 Ext 8345 From: Bowens, Marcia L, Sent: Wednesday, April 22, 2015 11:21 AM To: Denofrio, James Cet Bowens, Marcla L. Subje Please Review - Important Mr, DeNofrio, We do not provide guidance about what you should disclose to your medical center leadership, as you still report to and are supervised by Medical Center leadership. If you have specific identifying information about pt deaths that you have concerns about, | would encourage you to provide this to leadership as requested, as is expected of any employee. Unless | 1overlooked something, | have not received information about pt deaths from you. Are these deaths related to care provided by Dr. Struthers? Classfcatlon: Iniemal and Exomnal UseiNol VA Sanstve ‘This messoge has been categorizedby Bones, Maria Lon Wednesday, Apt 22, 2015 at 11:21:12 AM in acondence with VA Handbook 8500 From: Denofrio, James Wednesday, April 22, 2015 10:54 AM jowens, Marcia L. enoftio, James ‘Subject: Please Review - Important |.was asked to meeting this morning at 9:45am by the Gina Homan (Altoona VAMC Chief of Quality Management Service). Ms. Homan stated that she was directed by Mr. Mils (Altoona VAMC Director) to meet with me, The meeting was held in Gina's office and Deborah Waters (Altoona VAMC Patient Safety Manger] was in Ms. Homan’s office (apparently as witness for Ms. Homan} when I entered the office, | asked if! needed representation for the meeting and was told by Ms, Homan that | did not. Iwas then told by Ms. Homan that Mr. Mls told her to meet with me. She stated that the she was ‘aware that |had reported multiple patient deaths to VA Medical Inspector or the VA Office ofthe inspector General, However, I did not provide your offices or the VA OIG with specific patient identifying information so that you could Investigate the disclosure, Ms. Homan stated that | was to provide the patient identifying information to her per Mr Mills’ direction as he has been tasked with following up on the complaint by VA leadership, stated that l would not go into specific details of my protected disclosures, but | had already provided the patient specific Information to support all of my disclosures to the aforementioned offices. Iwas then told that the request was actually from Congress or “some Congressman’ and that they need the information by close of business today. | stated that | would request guidance and send them then Information requested, After sending the below, email Gina Homan and Deb Waters came to my office this morning. Ms. Homan stated that she had read my emall below and wanted to follow-up with me. She stated that | was not going to respond to my emall in ‘writing and that we had a verbal understanding from earlier previous meeting, | asked for clarification, who specifically was requesting the information and she confirmed that it was an member of Congress, but they did not know who It was, 1 explained that the Information that they were requesting was submitted to oversight authorities who to my understanding were actively investigating the disclosure. Both Ms. Homan and Ms, Waters then stated that if there are patient deaths then they need to be made aware so that it did not happen again and they could conduct a Root Cause Analysis (RCA). 1 confirmed that | would send them the information via electronic email, Respectfully, Jay DeNofio ‘dminieatve Officer ‘hytial Medicine & Rehab Service James B. Van Zandt VANC, Altoona, PA (614) 943 - 8164 Ext 8345 From: Denofrio, James Sent: Wednesday, April 22, 2015 10:09 AM foman, Gina; Waters, Deborah ils, William H. ‘Subject: Follow-up to your request for InformationPer follow-up of your discussion with me this morniig following the System Redesign Meeting, my understanding is that you ‘are requesting the specific patient names and information related to my reports to the VA OIG and VA Office of Medical Inspector for a Altoona VAMC related to individual patient deaths for a station response with a short turn-around suspense date due to the US Congress and/or unspecified Congressman, My understanding is that per Mr, Mil, lam being directing me to provide this information to you by the close of business today. !f my understanding is incorrect please let me know. Jay DeNofrio ‘Adinisuatve Officer Physical Nedicise& Rehab Service James B, Van Zande VANG, Altona, PA (B14) 943 - 8164 Bs. 8345Denofrio, James From: Denoftio, James Sent: Wecinestay, April 22, 2015 1:32 PM. To: Bowens, Marca L ce Denotfo, James Subject: FW: Requested Information - 4 { | Ms. Bowens, formation has been sent per below. Requeste Thank you, Me Mille ses mend Jy DiNofro ‘Rintote Offer ' ye Ned hb Service Janes Van Zant VANG aloes PA {ats 943 e160 bat as is VAC aber He ctlease oF Me From: Denoftio, James ‘i Sent: Wednesday, April 22, 2015 1:30 PM To: Homan, Gina; Waters, Deborah Ce: Mills, Wiliam H.; Denofrio, James ‘Subject: Requested Information Gina, Documentation supporting my disclosures related to the Polytrauma program and reported patient deaths are attached per my understanding of your request. Please note that this information was provided to my supervisor, the Chief of Staff, and the Director without a response to my request for direction and guidance prior to my submission to VA OIG, Individual patient names are included on the attached Copy of 2-27-2015 Report to VA OIG. Thank you Jey DeNofio ‘Administative cee DPhysieal Meine & Reba Service James B, Van Zand VAMC, Aloo, PA (14) 943 - 8164 Exe. 8345 From: Denofrio, James. ‘Sent: Wednesday, April 22, 2015 10:09 AM To: Homan, Gina; Waters, Deborah Ce: Mills, William H. Subject: Follow-up to your request for information Per follow-up of your discussion with me this morning following the System Redesign Meeting, my understanding is that you are requesting the specific patient names and information related to my reports to the VA OIG and VA Office of Medical Inspector fora Altoona VAMC related to Individual patient deaths for a station response with a short turn-around suspense date due to the US Congress and/or unspecified Congressman. My understanding is that per Mr. Mills am being directing me to provide this information to you by the close of business today, If my understanding is incorrect please let me know.Jay Dida ‘Reine Offer Piya edie et Seve Jas. Van Zed VANE ons, PA (619 949 bter ext aisM mishads Conwessuns Wilken Mills. ses UG.Departmnent pe en fetus Affais RECEIVED wiroymp = ou fist ond Patt Deaths. see a ee Tells Comosmen O16 Menten esoeer7 sid akan. twee 28 208 Dae sobbed oF he 503/00P_ pescll: ‘THE HONORABLE BILL SHUSTER 910 PENN STREET, SUITE 200 HOLLIDAYSBURG, PA 16648 he Dear Congressman Shuster: ‘Thank you for your follow-up letter from Mr. James DeNofrio regarding his concerns regarding the Department of Veterans Affairs (VA), Over the last several years, Mr. DeNofro has fled humerous concems, and each of these has been investigated through appropriate channels, The following agencies have investigated concerns on behalf of Mr. DeNofrio: Office of Resolution Nanagement, Equal Opportunity Employment Commission, Office of Special Counsel, Office of the Inspector General, VA Medical Center (VAMC) Privacy Office, Veterans Health Administration (VHA) Privacy Office. In each case, outcomes of the investigations have bean communicated to Mr. DeNofrio. My most serfous concern was Mr. DeNofio's newest otalm to you that there had aen danger to public health or safety, and even patient deaths related to the VAMC. I Immediately asked the Chief, ‘Quality Management and Patient ‘Safety Manager to Investigate to assure that there were no incidents of patient safety or deaths telated to care received from our medical center. 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 ‘coneurred that the patients identified were reviewed) and had been followed by the Polytrauma team, as well as other disciplines uthin the medical center, ‘The Initial consults and referrals were addressed timely in all cases. Appointments were ‘scheduled for follow-up. Some patients no-showed for the appointments (not only for pelytrauma but primary care and behavioral health), land ve followed the process for notification of the patient to reschedule with calls being made and letters sent. It was determined by this review that none ofthe patients deaths were related to treatment from the Polytrauma team, as Mr. DeNofrlo implies. Regarding his allegation of a privacy violation claimed In Mr, DeNofrio's letter to you, itwas concluded that his medical record was accessed by VAMC staff for the performance of oficial duties only. This conclusion came after an exhaustive and - Comprehensive investigation atthe VAMC by the facility's Alternate Privacy Officer at my direction, Two additional reviews were made by the VHA Privacy Office, andIncluded interviews with staff identified by Mr, DeNofrio and a review of the additional documents that were submitted by him. The attachments to his letter to you illustrate the bulk of these examinations andthe outcomes, Regarding the allegations of having been denied reasonable accommodation, false reports belng filed, recommendations to leadership that he undergo psychological testing, and multiple investigations for possible disciplinary action, these have all been thoroughly evaluated by Mr. Michael Eggert, (VAMC Employee Relations Specialist), who Indicated that none of these allegations has merit and each has been addressed with Mr, DeNofrlo. He is very well aware of the processes of recourse available to him through the American Federation of Government Employees (AFGE) and the EEO process if he feels these Issues merit further investigation, Ifyou have any further questions or conoems about Mr, DeNoftlo's claims, ! would welcome any follow up that you wish to have either with me or the VA staff. ‘Thank you for your service to our Nation's Heroes. Sinoerely, Ai hhh Meee DirectorBILL SHUSTER Cconnrres on teanspoRrarion. "ah intaastqUCTURE amas Mr, James DeNoftio 3230 West Chestnut Ave Altoona, PA 16601-1546 Dear Mr, DeNoftio: ‘ConmirTes ON ARMED SERVICES Congress of the Uniten States Bouse of Representatives Washington, BE 20515-3809 May 6, 2015 ‘This letter is in reference to your request for assistance with your problem, ‘As you know, we were glad to contact the Department of Veterans Airs in your behalf, ‘and we are enclosing their response which provides detailed information about the matter, falter reading the letter you feel that there is something further we can do, please do not hesitate to call the Blair County office at (814) 696-6318 or (800) 854-3035, With kind regards, Tremain WFS:mmb Enelosure Sincerely, SHUSTER Member of Congress ‘itera ee paca 8 sacfiorensJames DeNoftio 3230 West Chestnut Ave, ‘Altoona, PA 16601 (B14) 931-9477 May 12, 2015 ‘The Honorable Bill Shuster 310 Penn Street, Suite 200 Hollidaysburg, PA 16648 ‘Dear Congressmian Shuster: {wanted to wrte to thank you very much for your assistance withthe problem that I brought to yout attention egarding the Jemes E, Van Zandt VA Medical Center. However, ater reading the leter {fom the Medical Center Ditector, Mr, William Mills Ihave significant concerns that I need to bring to your attention, Following review ofthe leter, Iam conoemned tha the information provided to ‘you inthe leter from Ms, Mills presents false and misleading information. In the letter Me, Mills reported that: Over the last several years, Mr. DeNoftio, has fled mumerous concerns, and each ofthese has been investigated through appropriate charmels. The following . “agencies have investigated concerns on behalf of Mr. DeNoio: Offic af Resolution Manageme, Fuel Opportunity Commission, Office of Special Counsel, Ofc of Inspector General, VA Medica! Cantar (VAMC) Privacy Office, Veterans Heath Administration (VBA) Privacy Office. In each case, ‘outcomes of the Investigation have been communtcated fo Mr. DeNojtio. ‘tis true that filed numerous concems to the Office of Resolution Management, Equal Opportunity Commission, Offce of Special Counsel, Office of Inspector General, VA Medical Centex (VAMC) Privacy Offiee, Vetorns Health Administration (VHA) Privacy Offioe. These concerns related to protected disclosures, discrimination, privacy violations, and whistleblower retaliation. However, iis atte that each ofthese has been investigated through appropriate channels and in each case, sutcomes of the investigation have been communicated to Mr. DeNofrio. Specifically the following investigations are presently open and ongoing without fine! decision or iWere open and ongoing without final decision onthe date of Mr. Mil letter of April 29, 2015: 1. OSC Disslosure Case DI-13-4570; Mr, Mills neglested to inform you in his ete thet this ‘ase was forwarded by the United Stated States Special Counsel tothe Secretary of Veterans ‘Atfuts for investigation, The investigations involves the reporting ofan impaired physician » vo was not removed from patient cave for neatly two years, failure of Altoona VAMC Tendership to property address the issue, and thatthe Altoona VAMC actively attempted to cover-up the allogations resulting n a direct threat to patient care and safety. ‘The tion was conducted personally by the VA Medical Inspector, Dr. David Cox, and his team who were onsite at the Altoona VAMC ovet a period of two weeks in February 2015 ‘conducting witness interviews, The investigation due date for the Agency investigative eport was due tothe Special Counsel on May 11, 2015 which is 12 days after the date of Me,DeNofrio~ May 22, 2015 Mills letter, Ihave an attached an email from the Office of Special Counsel to support this claim, (Attachment A) When completed the Agency iavestigative report will be forwarded fo me and another walstloblower for reviow and comment and inclusion in a summary by the Special Counsel, The Special Counsel findings will then be provided to the President of the United States, the Chairpersons of the United States House and Senate Committee on Veterans Affairs, and released ina public file by the OSC. OSC Whistleblower Retaliation Case MA roceived a predetermination letter fom the Office of Special Counsel (OSC) on May 4, 2015 notifying me of the completion of the Investigation. Please note the letter from OSC is dated 5 days after the date of Mi. Mills ‘Apa 29, 2015 letter to you. ‘This case Involves intial retliation tat I eosived from ‘Atoona VAMC leadership following my protected disolosures. Please note this case Is based onthe protected diselosures made to the OSC in OSC Diselosure Case DI-13-4570. Without troubling you with the lengthy details ofthis investigation and my belie that the OCS Dellas Field Office handle the case poorly, I will note that in accordance with 5 U.S. Code § 1214 T am responding to the OSC requesting reconsideration of their predeterminstion decision, 1 also have pending appeal right to the Merlt System Promotion Board, [have an attached the fetter ftom the Office of Special Counsel to suppor this claim. (Attachment B) SC Whistleblower Retaliation Case MA I received a predetermination letter ‘om the Office of Special Counsel (OSC) on May 4, 2015 notifying me of the completion of the investigation. Please note the letter from OSC is dated 5 days after the dato of Mr, Mills ‘April 29, 2015 letter to you, This case involves continuing retaliation that I received from ‘Altoona VAMC leadership following my protected disclosures. Please note this ease is based onthe proteoted dislosures made tothe OSC and OIG in OSC Disclosure Case DI-13-4570 Gd VA OIG Case 20155208, Without troubling you with the lengthy details of this investigation and my belief thatthe OCS Dallas Field Offce handle the case poorly, will rote that in aceordance with 5 U.S, Code § 1214 Tam responding to the OSC requesting feconsiderttion of thei predetermination decision. [have an attached the letter from the Office of Special Counsel to suppor this claim. (Attachment C) ‘VA O1G Case 2015-5208: The last communication tht I had with the VA OIG wes on, FiTAOLS when T requested status update tothe investigation, This case involves the lack: of follow-up cate and case management of OEF/OIF Polytrauma Veterans and included my report of danger tothe public health and safety and even patient deaths related tothe Altoone VAMC. To my knowledge I did not receive a response oF notification thatthe ase was ‘loand and to my knowledge the investigation is currently open, I have attached a copy of my femal fo the VA OIG to support my claim. (Attachment D) va 016 Core OR: “The Lest communication that Thad with the VA OIG was on. Tarbes when | requested a status update to the investigation. ‘This case isan Investigation tito my reports that Aifoona VAMC staff members not involved in my cate has been ‘apeutelyageessing my VA medical records as previously communicated to you. To my Ieesledge | didnot eceve a reaponse or otifiaton thatthe case was closed and to my rotedee the Investigtin is curently open Ihave attached a copy of my email tothe VA O1G to support my claim, (Attachment E)DeNofrlo~ May 12, 2015 6. YA Office of Resolution Management Case No, 2001-5034 On May 8, 2015 1 zecelved an email response from the VA Office of Resolution Management notifying me the case was referred to the VA Otfice of Employment Disability Complaint Adjudicstion (ORDCA) on January 12, 2015 and is currently pending a final agency decision, (Attachment ¥) 7. YA Office of Resolution Management Case No, 2000s ‘May 8, 2015 1 received an email response from the VA Office of Resolution Management notifying me the case was referred to the VA Office of Employment Disability Complaint Adjudication (OEDCA) on January 12, 2015 and is currently pending a final ageney decision, (Attachment F) Regarding my claim to you that there had been danger to the public health and safety and even. patient death related to the Altoona VAMC. I believe the Ditectot’s response to that concer is also false as this claim is not new to Mr. Mills or the Patient Safety Manager, Please note that this formation was reported by me in emall directly to Mr, Mills andthe Patlent Safety Manager as well 1s other members of Altoona VAMC Leadership in November 2014 following a similar finding in 2013, also reported the matter tothe VA OIG (VA OIG Complaint 2015-5208) in November 2014. Thave included the attached documentation to Altoona VAMC Leadership, Altoona VAMC Quality Management, VA Office of Inspector General, and VA Office of the Medical Inspector in support this claim, (Attachment G) : Finally, itis my understanding thatthe claim that Mr, Mike Eggert evaluated allegations of me ‘having been denied reasonable accommodation, false reports being filed, recommendation to leadership that I undergo psychological testing, and multiple investigations for possible disciplinary action and indicated that none of these allegations has merit and each has been addressed with me is both false and misleading. ‘These allegations are actually part ofthe above investigations being reviewed by the VA Office of Resolution Management, VA Office of Inspector General, and the Office of Special Counsel. Mr, Mills also neglected to inform you that he is one of the subjects named in several ofthe above mentioned investigations. In a memo dated March 17, 2015 Mr, Mike Eggert actually advised me that as a result of a local investigation, it was determined that no coirective action directed toward me would be appropriate and the investigation filed against me following my reporting to leadership and VA (OIG described in the preceding paragraph had been closed, I was not notified nor is It my understanding that my complaint lacked metit, (Attachment H) Prior to this two additional investigations that Mr. Eggert was involved resulted in a Memo of Understanding and a Memo of Agreement between myself and the Altoona VAMC. These documents were signed by Mr, Mills and /or Me. Eggert . Lagain was not notified nor is it my understanding that my complaints lacked merit (Attachment 1) Respectfully, MIL ~ fames M. DeNoftio10 1. 12 43 44 15 “16 uw 18 19 20 21 22 23 ae X ned) Do you have access to the poly-trauma website, their SharePoint site? Excuse me. WITWESS: I created the poly-trauma SharePoint site. I don't know if T still have access. Ms. QUINN: x corgot that. Yes, you did, Do you still have access to it? WITNESS: I don't know. I haven't checked it in quite some time. us, QUIEN. tov tong? Give ne a kind of... witwuss: Since 1 was told to no Longer get in it by Dr. Struthers. vs. QUEM. on, okey. but: you crested 1¢, so very géod. 0 ue have on record that your reports didn't match that of the poly-trauma staft and if you're getting the information from the sane site, why do you think that vas? wrmwess: Actually t wae Dr, NePherson, the Chief Medical Officer of the VisEh [phonetic], who found the anonaly, that thelr records weren't matching what’ the VisEn's records were matching, which led to my conducting the review in the first 4610 a 12 13 u4 is uy 1s 19 20 21 22 23 24 place. WITNESS: The Chief Medical officer assigned the action due -- to Chief of staff. The Chief of Staff assigned the action to me, which resulted in the creation of the poly-trauma spreadsheet, 0 you'd have to ask the Chief Medical Officer what he.saw, but I believe he's retired now, but the Chief of Staff would have it. vis IY. 021, we do ato nave evidence that it was unfounded and that the numbers here and the practices here were very good in Altoona. WITWESS: What was unfounded? eS ee the poly-trauma staff was handing in were correct. And that we gave good care here in Altoona. WITNESS: I didn't question the care. what I questioned was the accuracy of the reports, I have those, reports. I have the emails fron the ~~ br. Kurian and the Chief Medical officer and the action itens that followed up vs. QBBBIBM. anc the chief Medical officer said your report was correct then and theirs 4710 it 12 13 4 15 16 a7 1a 19 20 2a 22, 23 24 was incorrect? WITNESS: ‘The Chief of Staff actually said my report was correct in response ‘back to the Chief Medical Officer. vs. QEMMMMMIIR: And 20 you have that, too? WrTwess: Yeah, sure, Yeah. bo you want that? “sR WITNESS: Sure. Do you want me to email it to you or. Ms. Well, do you'want to just bring it back-up or how do you want to get it? MR. WELLER: You can bring it back up. Ms. Okay. WITNESS: Sure, And who do you Ms. supervise because you said in your statement -~ I think that's what I heard you say and can 7 call you gay? WITNESS: I prefer Mr. DeNofrio on the ecord, 0S. QQNMMMMMN: okay, thon 1 win1 cata you Mr, DeNofrio and I'll try not to forget and you 48Denofrio, James From: Denotfio, James (VA 1G opens yr Sent: Tuesday, Apri 18, 2016 1236 PM a ee VA OIG Hotline \ eal a 2 Denofrio, James D Ceorplainl 17 me Has Subject RE: 53E/44 VA OIG Hotline Contact 2015-16220 email 1 of 2 aber iathal rt porb Attachments: Information sent VA Metical Inspector related to VA OIG Complaint 2015-16220 pl DeNofrio - AIB Investigation Documenation and Statements regarding VA O1G Complaint 2015-16220.pdf; Congresman Shuster and William Mills (SES) Letters - VA OIG Hotline ‘Complaint 2015-16220.paf; DeNofrio Permission to Disclose Complaint Information - OIG Hotline Complaint 2015-16220,pdf Tracking: ecient Delivery read VAoIG Hatin Deivewsansanisszise — Rextanoaossiza2eM Dero es Deivensaanisiziera — Rewanszn61228M Please find attached my signed Permission to Disclose Complaint Information for VA O1G Complaint 2015-16220. Per discussion with the O16 Hotline this morning at 09:00 VA O1G Complaint 2015-16220 is the complaint that | originally filed with the VA OIG Hotline on November 15, 2014@09:33am by email with subject line Whistleblower Complaint ~ 90 Polytrauma Veterans at James €. Van Zandt VAMC (Altoona PA) Not Receiving Follow-up Care ond Case Management. | follow-up to this complaint with the VA OIG Hotline by email response on February 27, 2015 @ 12:32pm providing supporting evidence and a list of 7 patients who had died and one patient who was incarcerated for a multiple homicide, but were stil being reported to VA as being actively case-managed and followed by the Altoona VAMC Polytrauma Team. Email subject line is RE: 53/44 VA OIG Hotline Contact 2015-5208. (attached separately) Please be advised that per the attached, the previous Altoona VAMC Director, Mr. Wiliam Mills, SES reported to Congressman Bill Shuster of the Pennsylvania 9"* District during a Congressional Inquiry that the VA Office of Inspector General had investigated my concerns related to VA O1G Complaint 2015-16220 and the outcome of this investigation had been communicated to me. As it is clear that the investigation into these matters is not resolved, | believe that Mr. Mills has misled and/or presented a false report to a member of Congress which | believe to be a violation of law related to this OIG complaint. (Attached ~ Congressman Shuster and William Mills (SES) Letters) ‘Additionally, | presented information related to VA O1G Complaint 2015-16220 to the VA Office of Medical inspector during the OSC wrongdoing investigation of case DI-13-4570. | am concerned that the VA OMI also relied upon inaccurate and/or false information regarding the status and conclusion of VA O1G Complaint 2015-16220 from the Altoona VAMC related to DI-13-4570 in making there finding and recommendations and in-turn impacted the Special Counse!’s report to the President of the United States and the VA Congressional Oversight Committees, Additionally, Altoona VAMC officials including Mr. Mills used their position to intercept information and evidence that | had disclosed to VA OIG regarding VA OIG Complaint 2015-16220. (Attached - Information sent to VA Medical Inspector) Finally, before being transferred to the Memphis VAMC, Mr. Mills convened an Administrative Investigation Board (AIB) against myself and two other whistleblowers at the Altoona VAMC. The AIB (in part) investigated if myself and other whistleblowers were harassing Altoona VA leadership officials by making protected disclosures to oversight authorities and | ‘was questioned in detail regarding the matters | reported in VA OIG Complaint 2015-16220. | have also filed obstruction of justice and other charges with the Office of Special Counsel related this incident. (Attached — DeNofrio —AIB Investigation Documents and Statements). Please feel free to contact me at the number below or on my personal cell phone at (814) 931-9477. Thank youJames DeNofio, MA Administ Oticer Physical Medicine & Rebub Sec James E. Van Zande VAMC, Akoona, PA (Bie) 943-8164 xe. 8345, From: VA OIG Hotline Sent: Monday, April 18, 2016 3:53 PM To: Denofrio, James Subject: 53E/44 VA OIG Hotline Contact 2015-16220 The U.S. Department of Veterans Affairs Office of Inspector General (OIG) Hotline received your complaint dated March 13, 2015. The VA OIG’s mission is to detect and prevent fraud, waste, and abuse within VA programs. The Hotline accepts tips or complaints that, on a select basis, result in reviews of: ~VA-telated criminal activity. ~Systemic patient safety issues. ~-Gross mismanagement. ~-Misconduct by senior VA officials. In order to examine the issues you have raised, it may be necessary for the OIG to take actions that will effectively release your identity as the complainant, Accordingly, we request that you review, complete, and return the enclosed release of identity form to us before we take further action on your complaint. You may return your completed form by fax (202) 495-5861, by email (vaoighotline@va.qov), or by mailing it to: VA Inspector General Hotline (53E) 810 Vermont Ave., NW WASHINGTON, DC 20420 Program Specialist VA OIG Hotline (53E)From: VA OIG Hotline _ bpins Case Hoar Sent: Tuesday, May 10, 2016 3:08 PM / eee , To: Denofrio, James \ Fhe py report By ths bee Subject: VA OIG Hotline Contact # 2016-21914 ' , ey J Aten VA dliedee CiMills ) is. betend ee his VA and ewig chu Dear Mr. Denofrio: bes exch be apa « enh! Fr OSC less cose ‘We have opened a case based on a review of the information you Sent to our office. The case numba” assigned is 2016-03388-HL-0759. Now that we have opened a case, our office will review the issues you reported, or ask an impartial VA official to conduct the review. If we ask someone impartial to conduct the review, we will ensure the reviewer fully examined all of the issues before closing the case. Please be advised that once a case is opened, we cannot discuss its progress. We will contact you again only if we need more information. Otherwise, we will notify you when the case is closed. Our decision to close a Hotline review is final and there are no appeal rights. Sincerely, A te ch Me explratin as te why Bob P ’ VA OIG Hotline OIG Case 18 burried ker IG ten *As. ” vaHealthcare, : 4 I fle nasi ie i Pub PATS March 28, 2016 ‘The Honorable Robert P. Casey, Jr. United States Senate 310 Grant Street, Suite 2415 he Pittsburgh, PA 16219 Dear Senator Casey: Thank you for providing me an opportunity to respond to your concems from Mr. : DeNoftio in regards to an Administrative Investigation Board (AIB) conducted at the Altoona VA Medical Center in which he was named a subject. ‘The Board Chair is currently compiling the final report, which is due to be complete by April 8, 2016 and provided to the medical center Director/Acting Director. Once the final report is received the facility Director/Acting Director will review any recommendations made within the report and determine any actions to be taken. ‘Should you have any further questions, you may contact Gina Dunio, Chief of Human Resources, at the Altoona VA Medical Center, She can be reached at | (814) 943-8164 X7038. | Wile) © Habit. . Michael D, Adelman, MD Network Direcior ~ VISN 4 & Eo. a 5 % | te a | aS PENNSYLVANIA So DELAWARE a NEW Jersey | ono.