Healthcare Facility Inspection of the VA Altoona Healthcare System in Pennsylvania

Report Information

Issue Date
Report Number
25-00206-14
VISN
4
State
Pennsylvania
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Healthcare Facility Inspection
Report Topic
Care Coordination
Community Care
Patient Care Services Operations
Patient Safety
Major Management Challenges
Healthcare Services
Recommendations
2
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary

This Office of Inspector General (OIG) Healthcare Facility Inspection program report describes the results of a focused evaluation of the care provided at the VA Altoona Healthcare System in Pennsylvania. 

This evaluation focused on five key content domains:
     •    Culture
     •    Environment of care
     •    Patient safety
     •    Primary care
     •    Veteran-centered safety net

The OIG issued two recommendations for VA to correct identified deficiencies in two domains:
   1.    Patient safety
     •    Service-level workflows for test result communication
   2.    Primary care
     •    Standardized process to obtain documents from community providers

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
Closure Date: 12/3/2025

The Executive Director ensures each service has a service-level workflow for test result communication.

No. 2
Open Recommendation Image, Square
to Veterans Health Administration (VHA)

The Executive Director reviews current practices to obtain documents from community providers and determines if leaders can standardize an approach to improve timeliness.