VA OIG report finds more problems at Altoona VA Medical Center

A new VA Office of Inspector General (VAOIG) report finds nine ongoing, and serious, deficiencies at Altoona VA Medical Center.

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US Department of Veterans Affairs - Image courtesy VA.Gov

WASHINGTON, August 21, 2017 – The Altoona VA Medical Center is facing more scrutiny in the form of a new VA Office of Inspector General (VA OIG) report.

The VA OIG found deficiencies in these nine areas:

  • The facility takes actions for weaknesses identified in peer review and Focused Professional Practice Evaluations.
  • Facility leadership is able to perform appropriate oversight of all members of the medical staff.
  • The access log for the Huntingdon County VA Clinic information technology network room contains required elements.
  • Patients’ personally identifiable information is secured at the Huntingdon County VA Clinic.
  • The facility involves a physician in the anticoagulation management program.
  • The facility uses data to improve inter-facility transfers.
  • Clinicians document facility required actions in response to glucose point-of-care testing results.
  • The facility effectively oversees the community nursing home program and monitors and assures the safe care of patients in the program.
  • Facility employees are trained to reduce and prevent disruptive behaviors.

“We conducted the review during the week of March 20, 2017, and identified certain system weaknesses in taking actions for issues identified by quality, safety, and value reviews; medical staff membership; general safety and security of personally identifiable information at the Huntingdon County VA Clinic; the anticoagulation management program; inter-facility transfer data collection and reporting; point-of-care testing follow-up; community nursing home oversight and clinical visits; and Prevention and Management of Disruptive Behavior training.” The VA OIG report stated.

The Altoona VA Medical Center has faced intense scrutiny since an Office of Special Counsel report was released based on employees and whistleblowers James DeNofrio and Tim Skarada in which they alleged that the hospital was engaging in behavior which threatened patient care.


Though the OSC largely concluded the hospital was not at fault, then medical director William Mills was quietly moved to the Memphis VA Medical Center days before the report came out. The hospital went through a series of medical directors, the top position at the hospital, after Mills departure.

Since then the hospital has seen its rating- called Strategic Analytics for Improvement and Learning (SAIL), fall from the top 10% to the bottom 30%.

A nurse, Nicole Bukoski, alleged in January 2017, that hospital management abused their authority in launching an administrative investigative board (AIB) against her.

Both Skarada and DeNofrio also faced AIBs where they could have been terminated but after a nearly year-long process, the investigation concluded with no punishment.

DeNofrio, an army veteran, has since alleged that management illegally accessed his medical records as part of the investigation. DeNofrio had his Merit Systems Protection Board hearing in July 2017, where his allegations of whistleblower retaliation were covered locally and nationally.

Andrea Young, the public affairs officer for the Altoona VA Medical Center, says the hospital made its statements in the VAOIG report.

In the report, the Altoona VA Medical Center committed to fixing all deficiencies or noted that deficiencies had already been fixed.

For instance, on the issue of information technology deficiencies at their Huntingdon facility, the hospital stated:

“On March 22, 2017, the process for lab specimens was changed per the OIG recommendation. The patient will no longer place the specimen in the pass-through window. The pass-through window has been sealed shut by the building maintenance staff and a sign was hung instructing the patient to hand the specimen directly to the Lab Technician. The Facility Manager has verified sustained compliance as the pass-through window remains sealed and the process of the patient handling of specimens directly to the Lab Technician remains intact since March 22, 2017. Future sustainment will be evaluated through the ongoing Medical Center’s Environment of Care rounds.”

DeNofrio issued this statement:

“All VA employees have a duty to report wrongdoing and threats to Veterans care and safety.  I am encouraged by the findings of the OIG that at least in this instance my whistleblower reports did not fall on deaf ears.”

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