Did Altoona VA cover-up and retaliate against whistleblowers?

Two Altoona VA whistleblowers paint a troubling picture of the new head of the Memphis VA Medical Center.


ALTOONA, Pa., March 2, 2016 — The leadership team at the James E. Van Zandt VA Medical Center (VAMC) in Altoona, Pennsylvania, is accused of ignoring numerous reports of a doctor’s loss of cognitive functions and retaliating against whistleblowers determined to bring these issues to light.

Whistleblowers James DeNofrio and Dr. Timothy Skarada issued a letter published by the Office of Special Counsel (OSC) and released the last week of February.

The letter alleges that, starting in March 2013, several people brought forward complaints that Dr. Frederick Struthers, then the head of the Physical Medicine and Rehabilitation Services (PM&RS) Department, was exhibiting characteristics of cognitive deficiencies.

Among the complaints are chronic tardiness, difficulty remembering conversations, and agitation. The doctor allegedly performed a testicular exam without gloves, treated patients in the hallway, and on three occasions didn’t provide recommendations to a treating physician.

But the whistleblowers stated that leadership refused to do anything for about five months.

“The VA concluded that Altoona VA leadership did not initially send Dr. Struthers for evaluation of the reported concerns of the impairment until September 2013 (five months after the whistleblowers’ initial reporting of concerns of impairment)” according to DeNofrio and Skarada’s letter.

Retaliation against VA whistle-blower in Memphis continues

Struthers passed a cognitive test administered by the Altoona VA, but the complaints continued. At that point, Altoona VA leadership instructed the whistleblowers to stop bringing forward complaints.

According to the letter, on Oct. 29, 2013, “Mr. Skarada met with VAMC Altoona Director at the Director’s request. Mr. Skarada was directed to no longer report concerns related to impairment and Dr. Struthers.”

On Nov. 29, 2013, DeNofrio was given the same directive by the Altoona VA director, according to the letter.

The Altoona VAMC director at the time was James Mills; Mills, it was recently announced, was taking over as the head of the Memphis VAMC, where the former director, C. Diane Knight, was removed due to underperformance.

“Mr. Mills brings experience as the director of the Altoona, Pennsylvania, VA Medical Center, which is consistently rated as one of VA’s top facilities.”

Willie Logan, public affairs officer at the Memphis VA, declined comment on the letter.

More problems at Memphis VA

The head Veteran Integrated Services Network (VISN) 9, a network of VA hospitals that includes Memphis VAMC, John Patrick, made this statement in welcoming Mills: “As a former Tennessean, Bill brings a wealth of operational and administrative experience. He has the right skillset to improve our operations in Memphis and ensure veterans receive the quality and timely care they deserve.”

Sandra Glover, public affairs officer for VISN 9, did not respond to an email for comment on the letter.

The letter was released just two days before it was announced that Mills would be taking over at the Memphis VA.

Besides ignoring complaints from whistleblowers about Struthers’ behavior, the letter alleges that Altoona VAMC leadership engaged in a series of retaliatory acts against the whistleblowers: DeNofrio, a veteran, says his medical records were illegally accessed; Struthers was told who reported him; and the whistleblowers were repeatedly investigated and removed from committees.

Finally, after DeNofrio in January 2016 went to OSC to file a complaint for witness tampering, Mills brought him up on what’s called an Administrative Investigative Board, a bureaucratic process that could remove DeNofrio from his job.

The VAMC in Altoona never found any cognitive issues in Struthers, and an internal investigation found it followed protocols. However, he was inexplicably removed from seeing in patients in March 2015, placed on administrative leave in June 2015 and allowed to retire shortly after he reached five years of service in November 2015.

A report issued by the VA Office of Medical Investigations cleared the Altoona VA leadership of any wrongdoing. “VA did not substantiate that Medical Center officials have failed to respond to continuing concerns regarding Dr. Struthers’ impairment and incompetency.”

The VA made this conclusion even though it also concluded the initial testing given to Struthers was faulty, “The Medical Center’s first evaluation of Dr. Struthers for impairment did not comply with the procedures outlined in the VA Handbook.”

The letter from Carolyn Lerner, head of OSC, to the president and Congress piggybacked onto the conclusions of the VA Agency report, “Finally, the investigation did not substantiate that Medical Center officials failed to respond to concerns about the PM&RS chief,” Lerner’s letter stated. “I have determined the report meets all statutory requirements and the findings appear reasonable.”

Nick Schwellenbach, senior communications specialist for OSC, issued this statement when asked to square the whistleblower’s letter with OSC’s conclusions:

“OSC mandated that the VA investigate the whistleblowers’ disclosures. Once OSC receives the agency’s investigative report, the whistleblower is given the opportunity to review and comment on the agency’s report. The Special Counsel then determines whether it contains all the required information and its findings appear ‘reasonable.’ This standard of ‘reasonableness’ is met if the report’s findings and conclusions are credible, consistent, and complete, based upon all the information presented by all parties.”

But a series of emails from DeNofrio to OSC and others in the months before the letter was issued warned that OMI’s investigation was flawed and OSC was accepting it at face value.

“I received a complaint this afternoon from one of the witnesses I had named to the VA Medical Inspector.” DeNofrio wrote in an email on Feb. 23, 2016. “(The witness) brought to my and Mr. Skarada’s attention today that she was not included in the list of witnesses on the Agency report even though she was interviewed and provided testimony (to OMI).”

In other emails, DeNofrio noted several other witnesses were not included in the OMI investigation’s final report.

“It (is) my understanding from our discussion that the reviews detailed in your below email are being completed by staff physicians here at the Altoona VAMC.” DeNofrio wrote to an OSC investigator on Dec. 11, 2015. “I believe this to be a conflict of interest both in appearance and in reality as these reviews are related to wrongdoing alleged against the Altoona VAMC and leadership at Altoona VAMC and likewise Altoona VAMC has a personal, vested interest in the outcome of these reviews.”

In the same email, DeNofrio pointed out that OMI was relying on subordinates of Mills and the hospital’s chief of staff, Dr. Santhan Kurian, in determining if the hospital followed proper protocol in dealing with Struthers even though both Mills and Kurian were accused of leading the cover up and retaliation.

“I believe this to be a mockery of due process and accountability, and I am really struggling to rationalize how this can be considered a fair and objective review by any stretch of the imagination,” DeNofrio stated further.

According to a source at the House Veteran Affairs Committee (HVAC), that committee is currently conducting its own investigation of this matter.

Meagan Lutz, a press person at the VA’s central office, did not respond to an email for comment.

Andrea Young, public affairs officer at the Altoona VAMC, released this statement to CDN, “The Altoona VAMC has established a record of safe, exceptional health care that is consistently recognized by independent reviews and organizations.  We take seriously any issue that occurs at our medical center or community based clinics.  The full report from the Office of Special Counsel offers an overview of the allegations and also a full summary of the findings, which indicated the primary allegations were unfounded.  The recommendations related to training, privacy, hand hygiene, and documentation have all been addressed by the Altoona VAMC.”

Reports from the Office of Special Counsel further show that the very detailed review of the cases found all patients received appropriate care from Struthers, and all patients’ primary clinical concerns were addressed.

Specifically regarding the retirement of Dr. Struthers, it is clear from the OSC report that he retired voluntarily without any pending action, and after having been fully evaluated with no findings of impairment through the investigative process.  Dr. Struthers is a decorated Vietnam combat Veteran, and we commend him for the many years of service he gave to his country and to his fellow Veterans.  We are fortunate to have had such a dedicated and compassionate physician serving the Veterans in Altoona.

We fully cooperate with the Office of Special Counsel, the Inspector General or any other investigative agency to understand what happened, prevent similar incidents in the future, hold those responsible accountable consistent with due process under the law, and share lessons learned across VA’s system.

We must protect whistleblowers and create workplace environments that enable full participation of employees, and the Altoona VAMC has zero tolerance for intimidation or retaliation – not just against whistleblowers, but against any employee who raises a hand to identify a problem, make a suggestion, or report what may be a violation in law, policy, or our core values – is absolutely unacceptable.”

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