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May 30, 2007: 

The Honorable Carl Levin: 
Chairman: 
The Honorable John McCain: 
Ranking Member: 
Committee on Armed Services: 
United States Senate: 

The Honorable Ike Skelton: 
Chairman: 
The Honorable Duncan Hunter: 
Ranking Member: 
Committee on Armed Services: 
House of Representatives: 

Subject: Armed Forces Retirement Home: Health Care Oversight Should Be 
Strengthened: 

The Armed Forces Retirement Home (AFRH), an independent executive 
branch entity, operates two continuing care retirement communities 
(CCRC).[Footnote 1] It provides care in three settings--independent 
living, assisted living, and a nursing home--and also operates a health 
and dental clinic for residents. The responsibilities of a CCRC 
generally include (1) appropriately transitioning residents from 
independent living to other settings as their care needs increase, (2) 
ensuring the availability of appropriate health services as residents 
progress to higher-level settings, and (3) ensuring residents' access 
to community-based or on-site health care. The law establishing AFRH 
sets forth the framework for its oversight and management. The National 
Defense Authorization Act (NDAA) for Fiscal Year 2006 required GAO to 
assess the oversight of health care provided by AFRH.[Footnote 2] 

As of 2006, AFRH served about 1,200 individuals at its Washington, 
D.C., campus who have served primarily as enlisted personnel in the 
armed forces. Eighty-three percent of AFRH residents are divorced, 
widowed, or single; the majority are male and the average age is 
79.[Footnote 3] About 77 percent of residents reside in independent 
living and the remainder are in either assisted living or the nursing 
home. While AFRH is required by statute to seek accreditation by a 
nationally recognized civilian accrediting organization, such as "the 
Continuing Care Accreditation Commission and the Joint Commission…", 
the statute does not address the accreditation of specific levels of 
care.[Footnote 4] The Joint Commission accredits the nursing home and 
the AFRH clinic, which provides physician and routine dental services. 

AFRH is financed through a dedicated trust fund. The AFRH Trust Fund 
has several revenue sources, including a 50-cent monthly payroll 
deduction primarily from enlisted personnel. Concerns about the 
solvency of the Trust Fund led to the creation in 2001 of a joint 
military services study group within the Department of Defense (DOD) 
and, in response to the group's findings, Congress restructured 
oversight and management of AFRH in the NDAA for Fiscal Year 
2002.[Footnote 5] 

The restructuring increased DOD's oversight role by giving it 
supervisory responsibility over the management of AFRH. The act 
established a Chief Operating Officer (COO) for AFRH appointed by and 
reporting to the Secretary of Defense. The COO is required to have 
experience and expertise in the operation and management of retirement 
homes and in the provision of long-term medical care for older persons. 
The COO replaced the National Board; the Board's chairman was the chief 
executive officer of AFRH and was responsible to the National Board 
rather than to the Secretary of Defense. Moreover, Local Boards were 
made advisory to the COO.[Footnote 6] The Local Boards are required to 
have at least 11 members, with expertise in areas such as law, finance, 
nursing home or retirement home administration, and gerontology; 
several positions are designated for senior representatives of specific 
military offices, such as a senior representative of a personnel chief 
of one of the armed forces. 

The Secretary of Defense delegated appointment and oversight 
responsibility to the Under Secretary of Defense for Personnel and 
Readiness and the Under Secretary's Principal Deputy (PDUS). Under this 
delegation, the PDUS exercises primary oversight responsibility; within 
the PDUS's office, the Deputy Under Secretary for Military Community 
and Family Policy's staff for Morale, Welfare, and Recreation Policy 
interacts more frequently with AFRH. Two other DOD components have 
oversight responsibilities: (1) the Inspectors General (IG) for the 
Departments of the Air Force, Army, and Navy alternate inspections of 
AFRH every 3 years and (2) the DOD IG has authority to conduct 
investigations of AFRH, including complaints.[Footnote 7] 

The first COO of AFRH, who was appointed in 2002, has changed how AFRH 
operates. Key COO changes involving health care included (1) remodeling 
of the health and dental clinics and changing clinic staffing and (2) 
upgrading transportation for medical appointments through outsourcing 
to a licensed contractor.[Footnote 8] In addition, AFRH's 2006 annual 
report indicated that from fiscal years 2003 through 2006, the Trust 
Fund increased from $94 million to $146 million. Residents filed a 
lawsuit in 2005 alleging problems with access to and quality of health 
care at AFRH. The U.S. District Court for the District of Columbia 
dismissed the lawsuit.[Footnote 9] As of May 2007, the residents' 
appeal was pending in the U.S. Court of Appeals for the District of 
Columbia Circuit. 

The NDAA for Fiscal Year 2006 required GAO to assess the regulatory 
oversight and monitoring of health care and nursing home care services 
provided by AFRH. As discussed with the committees of jurisdiction, we 
focused our review on (1) the standards that could be used to monitor 
health care provided by AFRH and (2) the adequacy of DOD oversight of 
AFRH health care. To address these issues, we: 

* identified existing standards applicable to health services in the 
three settings at AFRH and similar facilities; 

* discussed accreditation process and follow-up between accreditation 
surveys with officials from standard-setting organizations; 

* reviewed the statutory oversight structure for AFRH; 

* reviewed relevant DOD and AFRH reports related to oversight issues, 
including complaints; 

* interviewed DOD, DOD IG, and service IG officials involved in 
oversight, including the PDUS;[Footnote 10] 

* interviewed two civilian experts in health care for the elderly and 
retirement home administration serving on the AFRH-Washington Local 
Advisory Board; and: 

* compared health care-related problems identified during Joint 
Commission accreditation reviews with those identified during service 
IG inspections. 

Because Hurricane Katrina resulted in the closure of AFRH-Gulfport, we 
focused our review on AFRH-Washington. We did not evaluate the quality 
of health care provided by AFRH or its compliance with provisions of 
the NDAA for Fiscal Year 2006 regarding available services because of 
the pending lawsuit. We conducted our review from November 2006 through 
May 2007 in accordance with generally accepted government auditing 
standards. 

In April 2007, we briefed your staffs on the results of our work. The 
briefing slides which have been updated with agency comments are 
included as enclosure I. This report documents the information we 
provided in the briefing and transmits our recommendations to the 
Secretary of Defense. 

Results in Brief: 

Several organizations have standards applicable to the health care 
provided by AFRH, but no single standard-setting organization has 
standards that cover all such care. The Joint Commission accredits 
providers of clinic and nursing home services but does not accredit the 
independent or assisted living settings (see table 1). Oversight of the 
independent and assisted living settings is important because AFRH--as 
a CCRC--must ensure that residents are in the appropriate setting as 
their care needs increase. The Joint Commission conducts on-site 
surveys of clinic and nursing home services at AFRH every 3 years and 
investigates complaints. During the most recent AFRH triennial survey 
in 2005, the Joint Commission cited 10 requirements for improvement in 
clinic care and 8 in nursing home care, placing it in the bottom 
quartiles of such facilities surveyed by the Joint Commission that 
year. Requirements for improvement are among the most serious Joint 
Commission findings. 

Table 1: AFRH Care Settings and Current Oversight Standards Applied: 

Care setting: Independent living; 
Standards applied: None. 

Care setting: Assisted living; 
Standards applied: None. 

Care setting: Nursing home; 
Standards applied: Joint Commission standards. 

Care setting: Clinics; 
Standards applied: Joint Commission standards. 

Source: GAO. 

[End of table] 

Two federal agencies--the Centers for Medicare & Medicaid Services 
(CMS) and the Department of Veterans Affairs (VA)--also have standards 
applicable to nursing home care. AFRH is not subject to CMS standards 
because such standards only apply to facilities paid by Medicare or 
Medicaid. VA nursing homes are accredited by the Joint Commission, and 
VA inspects state veterans' homes using standards similar to CMS's. 
Overall, the standards applied to nursing homes serving veterans 
include CMS, VA, and Joint Commission standards. While CARF-CCAC has 
standards applicable to all three care settings at AFRH, it has no 
standards for clinic services. AFRH has not sought CARF-CCAC 
accreditation, which would result in inspections once every 5 years. In 
general, independent and assisted living facilities are less regulated 
than nursing homes. 

DOD oversight of AFRH health care is inadequate because it is too 
limited and lacks sufficient independent input. The PDUS--the DOD 
official who exercises primary oversight over AFRH---told us that he 
sees the COO as an expert in managing retirement homes and that the COO 
has health care experts on his staff. The PDUS noted, however, that he 
recently called on Health Affairs, an office within Personnel and 
Readiness, for health care expertise. Because he can reach out for 
health care expertise independent of the COO on an as-needed basis and 
because he views AFRH as primarily a retirement community for which he 
must ensure a high quality of life, rather than a health care facility, 
the PDUS told us that the delegation of AFRH oversight responsibility 
to his office is the best option within DOD. The PDUS told us, however 
that the other sources of information independent of the COO that he 
has to assist him in his oversight of AFRH health care have 
limitations. 

First, he told us that Joint Commission accreditation every 3 years may 
be insufficient. He recognized that there was no oversight of 
independent or assisted living and told us he is exploring 
alternatives. Additionally, service IG inspections occur during the 
same year as Joint Commission accreditation, resulting in a 3-year gap 
in scheduled oversight. Second, we found that as a result of direction 
by the office of the PDUS the service IGs no longer focus their reviews 
on health care provided by AFRH in all three settings. This 2005 change 
may result in health care problems remaining unidentified. Our 
comparison of service IG and Joint Commission inspection reports since 
1999 found that the service IGs had concerns about access to outpatient 
specialty care and about residents residing in settings not staffed to 
meet their needs--areas not addressed by Joint Commission 
findings.[Footnote 11] Moreover, the PDUS and the COO declined to 
provide the 2005 service IG inspection team with the Joint Commission 
accreditation report for AFRH-Washington, preventing the team from 
effective follow-up to ensure AFRH was taking appropriate corrective 
actions. 

Third, the Local Boards, which could be another source of independent 
information for the PDUS, have met infrequently and have not been 
allowed to fulfill their advisory roles. While members of the Local 
Boards include an expert in CCRC administration and a gerontologist, 
the COO told us that the Local Boards are "not helpful" and lack 
appropriate expertise. The two Local Board members we interviewed said 
that meetings consist of presentations by the COO to members rather 
than requests by the COO for members' advice. Despite the fact that the 
service IG raised concerns about the functioning of the Local Boards in 
2005, PDUS actions to make the Local Boards effective in their advisory 
role have been limited since then. In March 2007, PDUS directed the COO 
to recommend new members to serve on the Local Boards before the 
current board members' terms expire in 2007. At the same time, the PDUS 
directed the COO to propose how best to make the boards effective in 
their advisory role. 

Conclusions: 

Oversight of health care at AFRH is inadequate. Currently, there are no 
inspections of AFRH's independent and assisted living settings. Such 
oversight is important to ensure that residents are receiving 
appropriate care and are transitioned to other care settings as their 
care needs increase. Although the primary oversight responsibility for 
AFRH has been delegated to PDUS, this office's health care oversight 
has been limited and the sources of independent information to inform 
PDUS oversight have shortcomings. For example, the Joint Commission and 
service IG inspections occur triennially in the same year and, 
according to the PDUS, a Joint Commission inspection once every 3 years 
may be insufficient. In addition, PDUS shifted the focus of service IG 
inspections away from health care in 2005, but directed the service IGs 
to review Joint Commission accreditation reports to ensure AFRH follow- 
up. Our review of service IG and Joint Commission inspection reports 
demonstrated that this decision may result in health care problems 
remaining unidentified. Moreover, according to the service IG team that 
conducted the 2005 AFRH inspection, it was not provided the data that 
it needed on Joint Commission findings, such as the full accreditation 
report, to enable it to provide adequate oversight. Although Local 
Boards have the potential to assist in the PDUS's oversight, they have 
not been allowed to fulfill their advisory roles to the COO, which 
could provide useful information to the PDUS. The PDUS response to the 
2005 service IG inspection findings that the Local Boards were not 
fulfilling their advisory role has been limited. In March 2007, 
however, the PDUS directed the COO to find ways to effectively use the 
Local Boards. 

Recommendations for Executive Action: 

To improve health care oversight at AFRH, we recommend that the 
Secretary of Defense take the following four actions: 

* refocus service IG inspections on health care, particularly in the 
independent and assisted living settings, which are not covered by 
external accreditation; 

* ensure that service IG inspections do not occur in the same year as 
Joint Commission accreditation; 

* ensure that service IGs have access to all relevant data on Joint 
Commission inspections; and: 

* ensure that the Local Boards are allowed to fulfill their advisory 
roles. 

Agency Comments and Our Evaluation: 

We obtained written comments from DOD on our draft report. Agreeing 
that our recommendations would strengthen health care oversight of 
AFRH, DOD partially concurred with the first recommendation and 
concurred with the other three recommendations. Although DOD's response 
indicated only partial concurrence with our recommendation to refocus 
service IG inspections on health care, its proposed actions fully meet 
the intent of our recommendation. Thus, beginning in 2008, DOD will 
ensure that the service IG triennial inspections include a 
comprehensive review of health care services and ensure appropriate 
follow-up with the independent accreditation of the independent and 
assisted living and long-term care settings. To address the current 
lack of oversight of the independent and assisted living settings, DOD 
said that AFRH is arranging for CARF-CCAC accreditation. According to a 
DOD official, the partial concurrence reflected a decision to have the 
service IG inspections continue to examine areas other than health 
care, which we believe is not inconsistent with our recommendation. DOD 
comments are included in enclosure II. 

In addition, DOD commented on the steps it had taken regarding a letter 
from the Comptroller General concerning serious allegations by health 
care professionals about the quality of care provided by the home. We 
were referred to these health care professionals during the course of 
our interviews on AFRH oversight. As noted in this report, we did not 
evaluate the quality of health care provided by AFRH because of a 
pending lawsuit, and instead brought these allegations to DOD's 
attention. DOD's comments indicated that it took some immediate steps 
to investigate these allegations and that follow-up by the DOD IG was 
still under way. 

We are sending copies of this report to the Secretary of Defense and 
appropriate congressional committees. We will also provide copies to 
others upon request. In addition, the report will be available at no 
charge on GAO's Web site at http://www.gao.gov. 

If you and your staffs have any questions or need additional 
information, please contact Kathleen King at (202) 512-7119 or 
kingk@gao.gov. Contact points for our Offices of Congressional 
Relations and Public Affairs may be found on the last page of this 
report. Major contributors to this report were Walter Ochinko, 
Assistant Director; Carrie Davidson; Joanne Jee; Grace Materon; and 
Jennifer Whitworth. 

Signed by: 

Kathleen King: 
Director, Health Care: 

Enclosures - 2: 

[End of section] 

Enclosure I: 

Armed Forces Retirement Home: Health Care Oversight Should Be 
Strengthened: 

GAO Briefing on Study Required by National Defense Authorization Act 
for Fiscal Year 2006: 

Key Questions: 

As discussed with the committees of jurisdiction, we focused on two 
questions: 

What standards could be used to monitor health care provided by the 
Armed Forces Retirement Home (AFRH)? 

Is the Department of Defense (DOD) providing adequate oversight of AFRH 
health care? 

Table Of Contents: 

* Background: 

* Finding I: Several Organizations Have Standards Applicable to the 
Health Care Provided by AFRH, but No Single Standard-Setting 
Organization Has Standards That Cover All Such Care: 

* Finding II: DOD Oversight of AFRH Health Care Is Inadequate: 

* Conclusions: 

* Recommendations: 

Background: 

AFRH Is a Continuing Care Retirement Community (CCRC): 

AFRH is an independent entity in the executive branch providing care in 
3 settings: 

* Independent living: 

* Assisted living: 

* Nursing home: 

Responsibilities of a CCRC generally include: 

* Appropriately transitioning residents from independent living to 
other settings as their care needs increase: 

* Ensuring availability of appropriate health services as residents 
progress to higher-level settings: 

* Ensuring residents' access to community-based or on-site health care: 

...accreditation is required by law to seek .accreditation by a 
nationally recognized civilian accrediting organization such as the 
Continuing Care Accreditation Commission and the Joint 
Commission..."[Footnote12] 

Law does not address the accreditation of specific levels of care: 

Joint Commission accredits AFRH clinic and nursing home services: 

AFRH serves about 1,200 individuals[Footnote 13] who have served: 

primarily as enlisted personnel in the armed forces: 

* Gulfport campus destroyed by Hurricane Katrina, and many residents 
moved to D.C. campus: 

* 83 percent of residents are divorced, widowed, or single: 

* Majority are male and average age is 79: 

* About 77 percent of residents reside in independent living: 

AFRH Financed through Dedicated Trust Fund: 

AFRH Trust Fund has several revenue sources, including a 50-cent 
monthly payroll deduction primarily from enlisted personnel: 

Concerns about solvency of Trust Fund led to creation of a 2001 joint 
military services study group within DOD: 

In response to study group findings, Congress restructured management 
and oversight of AFRH in the National Defense Authorization Act (NDAA) 
for FY 2002[Footnote 14] 

NDAA 2002 Increased Secretary of Defense Oversight Role: 

NDAA 2002: 

Established Chief Operating Officer (COO), appointed by and reporting 
to Secretary of Defense: 

* COO must have experience and expertise in the operation and 
management of retirement homes and in the provision of long-term 
medical care for older persons: 

* COO replaced National Board, whose chairman was CEO of AFRH but was 
not responsible to the Secretary of Defense: 

Local Boards, appointed by the Secretary, were made advisory to the 
COO[Footnote 15]: 

* Law specifies at least 11 members, including senior representatives 
of a specific military office, e.g., official from one of the chief 
personnel offices of the armed forces: 

Secretary of Defense Delegated Oversight Responsibility: 

* Supervisory responsibility over management of AFRH delegated to the 
Under Secretary of Defense for Personnel & Readiness (P&R) and the 
Principal Deputy Under Secretary (PDUS): 

[See PDF for Image] 

Sources: GAO analysis of DOD organizational chart and DOD officials. 

[End of figure] 

[See PDF for image] 

[End of figure] 

Two Other DOD Components Have Oversight Responsibilities: 

Inspectors General (IG) for the Departments of the Air Force, Army, and 
Navy, which alternate inspections of AFRH every 3 years[Footnote 16] 

DOD IG has authority to conduct investigations of AFRH and has 
investigated complaints[Footnote 16] 

COO Has Changed How AFRH Operates: 

Administrative: 

Made administration of the two campuses consistent: 
Reduced staff by contracting for some administrative and maintenance 
services: 

Health: 

Remodeled health and dental clinic: 

Changed clinic staffing so that physician is on duty during business 
hours and health care professionals are either on duty or on call after 
hours: 

Upgraded transportation for medical appointments through outsourcing to 
licensed contractor[Footnote 17] 

Finances: 

AFRH reported that the Trust Fund increased from $94 million in FY 2003 
to $146 million in FY 2006: 

Residents Filed Lawsuit Concerning Health Care Quality: 

2005 lawsuit: 

AFRH is required by law "to provide for the overall health care needs 
of residents in a high quality and cost-effective manner"[Footnote 18] 

Residents alleged problems with access to, and quality of, health care 
and filed a lawsuit: 

U.S. District Court for D.C. dismissed lawsuit, citing NDAA 2006 
requiring the availability of a physician and dentist during daily 
business hours, daily scheduled transportation, and establishment by 
COO of uniform standards for access to health care services: 

As of May 2007, residents' appeal pending in U.S. Court of Appeals for 
D.C. Circuit: 

AFRH Has Few Comparable Models: 

CCRCs: 

* Approximately 4,000 nationwide)[Footnote 19]: 

* 15 identified by a Feb. 2006 AFRH study as serving military retirees: 

Other facilities serving veterans focus on nursing home services and 
are not CCRCs: 

* State veterans' homes: 

- 139 nationwide: 

* Federal Department of Veterans Affairs (VA) facilities: 

- 133 nationwide: 

GAO Methodology: 

Identified existing standards applicable to health services at AFRH and 
similar facilities: 

Discussed accreditation process and follow-up between accreditation 
surveys with officials from standard-setting organizations: 

Reviewed statutory oversight structure for AFRH: 

Reviewed relevant DOD and AFRH reports related to oversight issues, 
including complaints: 

Interviewed DOD, DOD IG, and service IG officials involved in 
oversight, including the PDUS[Footnote 20] 

Interviewed two civilian experts in health care for the elderly and 
retirement home administration serving on AFRH-Washington Local Board: 

Compared health care-related problems identified during Joint 
Commission accreditation reviews with those identified during service 
IG inspections: 

Focused review on AFRH-Washington because Hurricane Katrina forced 
closure of AFRH-Gulfport: 

Did not evaluate quality of health care provided by AFRH or its 
compliance with provisions of 2006 law because of pending lawsuit: 

Conducted our review from Nov. 2006 through May 2007 in accordance with 
generally accepted government auditing standards: 

Finding I: 

Several Organizations Have Standards Applicable to the Health Care 
Provided by AFRH, but No Single Standard-Setting Organization Has 
Standards That Cover All Such Care: 

No Single Standard-Setting Organization Has Standards Covering All 
Health Care at AFRH: 

Standard-setting organizations: 

Joint Commission: 

Centers for Medicare & Medicaid Services (CMS): 

VA: 

Commission on Accreditation of Rehabilitation Facilities-Continuing 
Care Accreditation Commission (CARF-CCAC)[Footnote 21] 

Joint Commission Standards Apply to Some Health Care Provided by AFRH: 

AFRH is accredited by Joint Commission: 

Joint Commission standards are applied to AFRH's: 

* Clinic services: 

* Nursing home services: 

Compliance with Joint Commission standards results in accreditation: 

* On-site surveys occur at least once every 3 years: 

* AFRH last accredited in 2005 and next survey will take place in 2008: 

* At any time, Joint Commission may conduct a complaint survey: 

Joint Commission does not accredit independent living or assisted 
living: 

* Joint Commission ceased accreditation program for assisted living in 
Jan. 2006: 

* Joint Commission offered to reaccredit assisted living until 2008, 
but AFRH declined: 

Joint Commission survey process: 

* On-site triennial survey of facility by trained health care 
professionals: 

- Unannounced visit includes validating implementation of action plans: 

submitted since last review, visits to care areas guided by sample of 
resident records, and interactive sessions with staff exploring care 
processes; AFRH surveys have averaged 2 to 3 days: 

-Noncompliance with standards results in findings: 

-- Requirement for improvement (RFI) is one of the most serious types 
of findings: 

-- RFIs require corrective action, including submission of evidence of 
compliance within 45 days[Footnote 22]  

Periodic Joint Commission review of facility's self-assessment of 
compliance with standards: 

Summary of 2005 Joint Commission AFRH surveys: 

* Nursing home: 

- Complaint survey (June) resulted in 2 RFIs: 

- Triennial survey (October) resulted in 8 RFIs, placing AFRH in the 
bottom quartile of nursing homes it surveyed that year: 

* Clinics: 

- Triennial survey (October) resulted in 10 RFIs, placing AFRH in the 
bottom quartile of clinics it surveyed that year: 

AFRH provided evidence of corrective actions and retained its 
accreditation: 

AFRH submitted its periodic self-assessments of compliance with 
standards in Oct. 2006: 

Examples of issues identified in 2005 Joint Commission RFIs: 

* Care plans not appropriate, given residents' needs: 

* Preventive interventions not performed according to plans of care, 
resulting in residents with pressure ulcers and fecal impaction: 

* Physician ordered referrals for follow-up care not carried out: 

* Errors in medication documentation: 

* Invasive dental procedures performed without documenting informed 
consent, confirmation of patient's identity, and pain assessment: 

* Insufficient progress since last survey to correct fire safety 
violations: 

Federal Nursing Home Standards Not Applicable to AFRH: 

CMS: 

* Annual inspections[Footnote 23] 

* Complaint investigations as required: 

* AFRH not subject to CMS standards because such standards only apply 
to facilities paid by Medicare or Medicaid: 

VA: 

* State veterans' homes: 

- VA inspects using standards similar to CMS standards: 

-- Annual inspections: 

-- Complaint investigations as required: 

* VA nursing homes are accredited by the Joint Commission: 

* VA standards do not apply to AFRH: 

CARF-CCAC Has the Only Standards Applicable to All CCRC Care Settings 
but Does Not Cover All AFRH-Provided Health Care: 

AFRH has not sought CARF-CCAC accreditation[Footnote 24] 

CARF-CCAC has standards that apply to all three CCRC settings: 

* Independent living: 

* Assisted living: 

* Nursing home: 

CARF-CCAC does not have standards applicable to clinic services: 

Inspections occur every 5 years: 

* Annual compliance review between inspections: 

* Complaint investigations: 

Independent Living and Assisted Living Less Regulated Than Nursing 
Homes: 

Some states license assisted living facilities: 

Generally, few federal regulations or standards apply to these two 
settings: 

Various Standards Applied to Facilities Serving Veterans: 

State veterans' homes: 

* Some homes bill Medicare and Medicaid for nursing home services and 
are inspected by CMS: 

* VA inspects state veterans' homes using standards modeled after CMS 
standards: 

VA nursing homes: 

* Joint Commission accreditation: 

Other: 

* VA places some veterans in community nursing homes, which are 
inspected by CMS: 

Finding II: DOD Oversight of AFRH Health Care Is Inadequate: 

Oversight by Principal Deputy Under Secretary (PDUS) for P&R Has Been 
Limited and Lacks Sufficient Independent Input: 

[See PDF for Image] 

Source: Office of the Principal Deputy Under Secretary for P&R. 

[End of figure] 

PDUS sees the COO as an expert in managing retirement homes who has 
health care professionals on his staff: 

PDUS can turn to other experts within DOD: 

* Office of Assistant Secretary for Health Affairs: 

- Immediate staff of PDUS do not have health care expertise but in 2007 
called on Health Affairs, an office within P&R: 

* DOD IG: 

- PDUS recently began reviewing all DOD IG hotline complaints 
concerning AFRH: 

PDUS has other sources of information independent of the COO to inform 
AFRH oversight, but these have limitations: 

* Joint Commission accreditation: 

- PDUS suggested accreditation every 3 years may not be sufficient: 

- PDUS acknowledged gap in oversight of independent and assisted living 
and is exploring alternatives: 

* Service IG inspections: 

- Occur in same year as Joint Commission inspections: 

- No longer focus on health care: 

Appropriateness of Delegation of Responsibility for Oversight of AFRH: 

* Secretary of Defense delegation letter to Under Secretary of Defense 
for P&R and the PDUS acknowledged that there may be better arrangements 
for ensuring appropriate management of AFRH: 

* According to PDUS, delegation to P&R is best option because AFRH is 
primarily a retirement community, and oversight has largely to do with 
quality of life provided to residents: 

- No other organization in DOD would be a better fit than P&R: 

Overall, PDUS Weakened Health Care Oversight by Service IGs: 

In preparation for 2005 service IG inspection, PDUS made some 
structural changes: 

* Addressed continuity issues stemming from rotation of inspections 
among the service IGs: 

- Began standardization of inspection criteria: 

- Included a representative from the service IG responsible for the 
next inspection on current inspection team: 

* Assumed responsibility for follow-up on AFRH responses to service IG 
findings: 

- Previously, neither PDUS nor service IGs followed up to ensure 
corrective actions were taken: 

Beginning in 2005, PDUS also shifted focus of the service IG 
inspections and, as a result, the primary responsibility for health 
care inspections now rests with the Joint Commission: 

* Shifted focus to reduce perceived duplication between service IG and 
Joint Commission inspections: 

- Service IG inspections used to focus on health care but now focus on 
administration and management: 

- Service IGs health care oversight responsibility limited to reviewing 
Joint Commission accreditation reports to ensure AFRH follow-up: 

For 2005 service IG inspection, PDUS did not provide Joint Commission 
accreditation report for AFRH-Washington: 

* PDUS and COO declined to provide a copy of the accreditation report 
with findings, including AFRH corrective actions, requested by the 
service IG team: 

* Joint Commission confirmed that information provided to the service 
IG by PDUS and COO was insufficient for effective follow-up: 

PDUS decisions to shift focus may result in health care problems 
remaining unidentified: 

* GAO compared service IG inspection and Joint Commission inspection 
reports since 1999: 

- Service IGs examined health care in clinics and all three care 
settings, while the Joint Commission's inspections were more limited: 

There were service IG findings in some care areas that were not 
addressed in Joint Commission findings: 

* Concerns about access to outpatient specialty care: 

* Inadequate number of dental hygienists to meet needs - Residents in 
settings not staffed to meet their needs: 

* Outdated Memorandum of Agreement with local medical facility: 

There were a few care areas, however, where service IG and Joint 
Commission findings were similar: 

* Poorly maintained medical record documentation: 

* Medication delivery system prone to errors: 

* Inadequate pharmacy staff involvement: 

Service IG and Joint Commission inspections occur in the same year 
every 3 years. 

* For the years between inspections, there is no routine, on-site 
oversight of health care at AFRH: 

PDUS Has Not Ensured That Local Boards Perform Advisory Role: 

PDUS concurred with COO's actions to limit Local Boards' statutory role 
of advising COO: 

COO told us Local Boards not helpful and lacked appropriate expertise. 
However, members with expertise include: 

* Representatives from VA regional office and Walter Reed Army Medical 
Center: 

* Legal, finance, and human resources professionals: 

* Experts in retirement home administration and gerontology: 

Two Local Board members who are ex experts in CCRC administration and 
gerontology told us that the Local Board for AFRH-Washington was not 
functioning effectively. For example: 

* Their advice was not sought: 

- Meetings consisted of presentations: 

- No operational committees existed: 

- Gerontologist not invited to February 2007 meeting: 

* Designated military representatives often sent proxies, who look 
notes but did not participate: 

PDUS response to 2005 service IG inspection findings on the Local 
Boards has been limited: 

* In July 2005, service IG found: 

- AFRH-Washington Local Board not being used-meetings not held 
regularly: 

- No Local Board existed for AFRH-Gulfport: 

* After 2005 service IG inspection: 

- P&R allowed COO to continue suspension of meetings for 2005: 

- Local Board for AFRH-Gulfport reestablished: 

* In June 2006, Local Boards met, but few members attended; most 
members attended the Feb. 2007 meeting: 

Recently, PDUS took steps to improve the effectiveness of the Local 
Boards, whose current members' terms expire in 2007: 

* In March 2007, PDUS directed the COO to complete the following 
actions by mid-May 2007: 

- Recommend new Local Board members: 

- Propose how best to make these boards effective in their advisory 
role: 

* PDUS told us that he expects new appointees to be at a level such 
that they can attend the meetings themselves: 

DOD IG Oversight Role Is Limited: 

DOD IG hotline received 37 complaints against AFRH over the past 15 
years but received fewer more recently. IG officials said that 7 of the 
37 complaints were health care-related but that only 1 was serious: 

* The 1 serious health care complaint was referred by a congressional 
committee: 

- DOD IG hired an expert to conduct investigation: 

- Complaint was unsubstantiated: 

* Other health care-related complaints characterized as minor, e.g., 
wrong eyeglass frames or generic rather than brand-name drugs: 

AFRH IG Serves Internal Audit Function: 

AFRH IG position: 

* Established administratively in 2005 by COO rather than by statute: 

* Performs internal audit function: 

- IG lacks indicia of independence described in government auditing 
standards for reporting to external third parties: 

Service IG concerns and recommendation: 

* Expressed concerns about: 

- Apparent lack of independence and objectivity of the AFRH IG: 

- Additional requirements the position placed on already limited 
administrative staff: 

* Recommended AFRH use DOD IG services: 

- Secretary authorized to make DOD IG services available to AFRH: 

- AFRH response was to shift responsibility from Chief Financial 
Officer to Chief of Support Services: 

AFRH has not prepared annual reports on audit activity as required by 
the IG Act, as amended: 

Conclusions: 

Currently no one inspects independent and assisted living settings at 
AFRH: 

PDUS oversight has been limited, and sources of information independent 
of the COO to inform PDUS oversight have limitations: 

* Joint Commission and service IG inspections occur triennially in the 
same year: 

- Service IG was not provided the data it needed on the 2005 Joint 
Commission findings, such as the full accreditation report, precluding 
effective follow-up on the findings: 

* Local Boards have not been allowed to fulfill their advisory roles, 
limiting their potential to inform PDUS oversight: 

* PDUS decisions regarding the focus of service IG inspections may 
result in gaps in the identification of health care problems: 

Recommendations: 

Secretary of Defense should improve oversight by taking the following 
four actions: 

* refocus service IG inspections on health care, particularly in the 
independent and assisted living settings, which are not covered by 
external accreditation; 

* ensure that service I G inspections do not occur in n the same year 
as Joint Commission accreditation; 

* ensure that service IGs have access to all relevant data on Joint 
Commission inspections; and: 

* ensure that the Local Boards are allowed to fulfill their advisory 
roles. 

Agency Comments and Our Evaluation: 

DOD agreed that GAO's recommendations would strengthen health care 
oversight of AFRH. 

* DOD partially concurred with the first recommendation to refocus 
service IG inspections on health care. However, its proposed actions 
fully meet the intent of our recommendation. 

- Beginning in 2008, DOD will ensure that the service IG triennial 
inspections include a comprehensive review of health care services and 
ensure appropriate follow-up with accrediting organizations, including 
CARP-CCAC, which AFRH is arranging to have accredit the independent and 
assisted living settings. 

- According to a DOD official, the partial concurrence reflected a 
decision for have the service IG inspections continue to examine areas 
other than health care, which we believe is not inconsistent with our 
recommendation. 

* DOD concurred with our other three recommendations. 

* DOD comments are included in enclosure II. 

[End of section] 

Enclosure II: Comments from the Department of Defense: 

Personnel And Readiness: 
Office Of The Under Secretary Of Defense: 
4000 Defense Pentagon Washington, D.C. 20301-4000: 

May 24 2007: 

Ms. Katherine M. King: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G. Street, N.W. 
Washington DC 20548: 

Dear Ms. King: 

This is the Department of Defense (DoD) response to the GAO draft 
report, GAO-07-790R, Armed Forces Retirement Home: Health Care 
Oversight Should be Strengthened," dated May 10, 2007 (GAO Code 
290588)." 

DoD agrees that the GAO recommendations will strengthen health care 
oversight of the Armed Forces Retirement Home (AFRH). It should be 
noted the leadership of the Defense Department are in regular 
communication with the Chief Operating Officer at AFRH and the 
Department has found no evidence of systematic shortcomings in either 
the conditions or services at AFRH. Reports from every independent 
review of AFRH have indicated the living conditions and services are 
within standards. These include both routine and spot inspections by 
the Joint Commission Accreditation of Health Organizations (JCAHO), the 
triennial inspections by the Service Inspectors General, the annual 
independent audit of AFRH financial statements, routine inspections by 
the Office of Personnel Management, sanitation and Food and Drug 
inspections by the U.S. Army and a range of internal systems to monitor 
services, facilities, and the residents' well-being. 

Most recently, in response to the Comptroller General's letter of March 
19" regarding serious allegations by unnamed healthcare professionals, 
the Assistant Secretary of Defense for Health Affairs assembled an 
experienced medical team to conduct an unannounced inspection, within 
24 hours, to identify and fix any medical care practices deemed to be 
substandard, deficient, or that would jeopardize resident health care. 
During their brief inspection, the team could find no evidence to 
corroborate inferior care; the facility appeared clean and well-run 
with well cared-for residents but recommended a more thorough and 
detailed inspection take place as soon as possible. The Pentagon then 
notified JCAHO and welcomed a no-notice review by them. JCAHO arrived 
unannounced the next day to conduct an independent review. There were 
four unrelated findings but the JCAHO surveyor did not substantiate any 
of the serious allegations listed in the GAO letter that had not 
previously been addressed and documented. 

Senior DoD leadership personally toured the facility, within 4 days of 
receipt of the allegations, with professional staff members from the 
House and Senate Armed Services Committees and House Veterans Affairs 
Committee and saw no evidence of the substandard conditions alleged in 
GAO's letter and found the facilities and grounds to be clean and well 
maintained. Finally, we asked the Department of Defense Inspector 
General (DoDIG) to conduct follow-up interviews, which are still 
underway. In an old historic facility such as AFRH there are many 
structural problems we need to work on and plans are in place to move 
forward on these. 

As the GAO notes in its report, the Armed Forces Retirement Home is a 
Continuing Care Retirement Community (CCRC) for eligible retired 
enlisted military personnel and qualifying veterans. These organized 
communities provide housing and services to individuals in different 
settings. The individual can move from independent living to assisted 
living to nursing home care as needed. A CCRC provides some health care 
but it is not a health care facility. The AFRH CCRC is unique in the 
federal government. There are many CCRC's in the private sector, which 
are regulated by state governments and are not considered health care 
facilities. AFRH, as a CCRC, does not fit a health care model 
appropriate for a hospital. 

DoD is committed to providing high quality services to AFRH residents. 
At AFRH-Washington, 77 percent of residents who live in their own rooms 
in independent living enjoy freedom of choice in selecting health care. 
Some prefer to use the military health care services at the Walter Reed 
Army Medical Center while others go to the physicians of their choice 
using their TRICARE or Medicare insurance benefits. The AFRH provides 
daily regularly scheduled service for medical appointments. AFRH has 
made many changes in its health care services in the last four years, 
which are described in Enclosure 1. Similar services will be available 
at AFRH-Gulfport when it re-opens in 2010: 

We appreciate the opportunity to comment on the draft report; our 
specific comments to the recommendations are attached and supplemented 
by the enclosures. 

Sincerely, 

Signed by: 

Leslye A. Arsht: 
Deputy Under Secretary of Defense: 
(Military Community and Family Policy): 

Enclosures: 

1. Health Care Services at AFRH-Washington DC: 

2. Armed Forces Retirement Home (AFRH) Health Services Inspection Guide 
2005 (Draft as of 3 August 2005): 

GAO Draft Report - Dated May 10, 2007 GAO Code 290588/GAO-07-790R: 

"Armed Forces Retirement Home: Health Care Oversight Should Be 
Strengthened" 

Department Of Defense Comments To The Recommendations: 

Recommendation 1: The GAO recommends that the Secretary of Defense 
refocus service IG inspections on health care, particularly in the 
independent and assisted living settings, which are not covered by 
external accreditation. 

DOD Response: Partially concur. Because nothing is more important that 
the health and well-being of our military veterans, DoD is taking steps 
to improve oversight of the assisted and independent living services. 
Since JCAHO stopped accrediting assisted living facilities, AFRH is 
arranging for the Commission on Accreditation of Retirement Facilities/ 
Continuing Care Accreditation Commission (CARF-CCAC) to conduct 
independent reviews of assisted living and independent living. This 
recently combined organization provides accreditation services for all 
aspects of a retirement community associated with long term care, 
assisted living dementia care, ambulatory care, independent living, 
medical rehabilitation, etc. To become accredited by CARF-CCAC a 
minimum of six months is required, prior to the site survey, for each 
service being accredited. CARF-CCAC certification is every 3 years. 

As evidence by Tab K - the Medical section of the 2005 Triennial 
Inspection Report, the Air Force Inspection Agency (AFIA) did review 
medical services but had no findings since JCAHO accreditation had 
already been awarded. However, beginning in 2008, DoD will ensure the 
Military Inspectors General (IG) Triennial Inspection conduct a 
comprehensive review of health care services and ensure appropriate 
follow-up with the independent accreditation of independent, assisted 
living and long-term care. AFIA prepared draft procedures for these 
medical reviews (see Enclosure 2), which will be provided to the Army 
Inspector General for their review/update/use next year. Additionally, 
consistent with DoD Instruction 4161.03, "Triennial Inspection of the 
Armed Forces Retirement Home," dated June 26, 2006, the IG team will 
review admissions/eligibility, civil engineering, human resources 
management, information technology, records management, resident 
services, safety, security, and senior management. This will maintain a 
standardized approach to the triennial IG inspections. 

Recommendation 2: The GAO recommends that the Secretary of Defense 
ensure that the service IG inspections do not occur in the same year as 
Joint Commission accreditation. 

DOD Response: Concur. DoD will ensure the Service IG inspections occur 
the year following the independent accreditation reviews, as soon as 
schedules can be synchronized and remain consistent with statute (e.g., 
statute requires the IG review be completed every three years; the next 
one is scheduled for 2008). 

Recommendation 3: The GAO recommends that the Secretary of Defense 
ensure that service IGs have access to all relevant data on Joint 
Commission inspections. 

DOD Response: Concur. DoD will ensure the Service IG teams have access 
to all relevant data on all independent accreditation inspections. 

Recommendation 4: The GAO recommends that the Secretary of Defense 
ensure that the Local Boards are allowed to fulfill their advisory 
roles. 

DOD Response: Concur. Consistent with statute, DoD will appoint new 
members to the local boards to be effective at the next meeting 
scheduled for September, 2007, outline their expected roles and 
responsibilities, and ensure appropriate follow-up. 

Enclosure 1. Health Care Services at AFRH-Washington DC: 

Wellness Center and Community Health Clinic: AFRH revised its approach 
to health care services to embrace the concept of wellness, an approach 
followed by the best assisted living facilities in the private sector. 
The goal is to keep all of our residents active and healthy with an 
emphasis on preventive health care. Residents are encouraged to eat 
well and exercise and Home staff helps them obtain medications needed 
to manage chronic medical conditions. The Wellness Center is located in 
the Scott Building, the geographic center for our resident population 
in independent living, and consolidates Dentistry, Optometry, Community 
Health, Ambulatory Care and Medical Records all in the same area. These 
services had been spread among three buildings which were a significant 
distance from each other. The residents say they welcome the 
convenience and availability of centralized care. 

Treatment Room: A physician is assigned to the Community Health Clinic, 
Monday through Friday, from 7:30 am until 12 noon to see all walk-in 
residents. The medical doctor sees patients for scheduled appointments 
from 1:00 pm to 4:00 pin every weekday. After hours, a geriatric nurse 
practitioner is on duty at the Wellness Center, from 4:00 pro until 
7:30 am, to assess and assist residents in the independent setting. The 
nurse practitioner assesses the resident's medical status, treats the 
resident or calls 911 in the event of a medical emergency. In case of 
an emergency; i.e., shortness of breath or chest pain, we encourage 
residents to call 911 and not wait for the nurse. A physician is on- 
call between the hours of 4:00 pin until 7:30 am seven days a week for 
consultation with the Nurse Practitioner. Assisted living and long term 
care residents have round the clock nursing coverage independent from 
the coverage listed above. 

Doctors on Staff: AFRH has 4 physicians and 2 Nurse Practitioners. All 
residents are assigned to one of these providers when entering the home 
to maintain quality care for each resident. Appointments are set up 
with their providers through a centralized in-house appointment system. 
The Medical Director on staff works with both internal and external 
providers when needed. Residents have access to physicians at the 
Walter Reed Medical Center, the Veterans Administration and local 
hospitals. Residents also have freedom of choice in choosing physicians 
in the private sector. In the past, the Home employed five Physician 
Assistants who were neither certified nor in compliance with required 
health care standards. This lack of certification was specifically 
challenged by the Inspector General. Now all residents see a fully 
qualified medical doctor. 

Pharmaceuticals: The independent living building has a medication room 
for medications pick-up obtained through prescription from Walter Reed. 
Independent residents can receive their medication within 24 hours. 
Refills take three days, which is consistent with the service delivery 
model used throughout the military. Residents are responsible for 
ensuring that they have a seven day reserve of medications at all 
times. In the private sector, an on-site pharmacy is not available for 
residents in independent living. Long Term Care residents receive their 
medication through a contract pharmacy called Neighborcare. Medications 
come in unit-dose packaging which provides a safe and accurate 
administration system. Residents' supplemental insurance is billed for 
the medications monthly. Medication costs for those residents who do 
not have supplemental insurance are paid by the home. 

X-Rays and EKGs: In 2003 AFRH Washington discontinued the use of 
available in-house X-Ray equipment because the outdated equipment was 
very old, could not be repaired, and posed a potential health hazard to 
residents and staff. Since May 1, 2005, a contract vendor who comes to 
the resident's bedside or room provides X-Ray services. The resident's 
insurance is billed for the services and the Home pays for the service 
for those without insurance. EKG services are available upon 
physician's request and are provided by the home. Residents with chest 
pain are immediately sent to the Emergency Room. 

Dental Services: Dental Care is provided on a routine basis for 
assisted living and long term care residents. Emergency walk-in clinic 
is handled every morning on a daily basis. Residents in Independent 
Living receive check-ups when requested by appointment. To accommodate 
the resident needs, the dental clinic was relocated to the primary 
independent living building to provide enhanced and more accessible 
dental services. Residents in Long Term Care receive annual check-ups. 
Extensive dental needs are handled by referrals to experts in the 
private sector. A new mobile Dental Clinic has been established in the 
Lagarde Building to serve residents in assisted living, the dementia 
unit, and long-term care. 

Long Term Care and Assisted Living: Although residents are expected to 
live independently when they first come to the Home, many require 
additional services as they age. The Home provides a continuum of care 
for its residents guaranteeing them appropriate services for the entire 
time they live at AFRH. The Home has a 200 bed long term care and 
assisted living facility accredited by the Joint Commission for Health 
Care Organizations and staffed 24 hours a day by nurses and certified 
nursing assistants. Long term plans call for construction of a new 
state of the art long term care facility in the northern portion of the 
campus. There are also 100 assisted living units on a floor of the main 
independent living building. Those residents get assistance in at least 
two activities of daily life from trained staff. 

Enclosure 2. Armed Forces Retirement Home (AFRH) Health Services 
Inspection Guide 2005 (Draft as of 3 August 2005): 

The Medical Manager portion of the AFRH inspection process will consist 
of the following: 

1. Address the standards for Assisted Living (AL) accreditation 
according to the guidance and direction given by the Joint Commission 
on Accreditation of Healthcare Organizations (JCAHO). DOD Directive 
referencing the AFRH Act of 1991, Public Law 101-510 (see Ch 10, sec 
418 of title 24, US Code, notes the requirement for the AFRH to be 
accredited by the JCAHO or comparable civilian-accrediting agency. 
Details regarding JCAHO's purpose and scope of inspection can be found 
in the current AL Survey and Accreditation Process Guide (pub. Mar 
2003) on pages 7 - 13. The AL accreditation program/process has been in 
place since May 2000. Long term care services also undergo applicable 
inspection based on standards from the manuals listed in the ALSPG on 
page 12 (see list of resources below). The JCAHO has conducted several 
accreditations on the AFRH (Gulfport and Washington DC), but until this 
document, no formal DOD HSI Guide existed for the AFRH. 

2. Note the organization's level of performance in specific areas on 
what it actually does based on maximum achievable expectations for 
activities that affect the quality of resident care. These issues are 
depicted and summarized below: 

3. Summarize the ARFH's actions and activities to note progression, 
discrepancies, or deviations from the previous DOD triennial survey. 
*The intent of this guide is not to repeat a JCAHO inspection, but to 
verify that follow-up is being accomplished in the key areas related to 
healthcare services of the AFRH. Some areas may require more focus than 
what is evaluated in the JCAHO arena to balance the "findings" pointed 
out in the JCAHO report and to provide an extensive outlook (both 
positive and negative) in several areas. 

4. In addition to inspection areas #2 and #3 above, the overall goals 
of the Healthcare Summary should provide the following: 

a. To annotate issues in service opportunity: 

b. To note updates and changes made by the facilities: 

c. To recommend avenues and options for growth: 

d. To cover other non-JCAHO associated aspects involved with potential 
political healthcare sensitivities involved in these special 
facilities. 

5. Designated Service inspector composition (Two Medical Personnel, 
grade 0-5 or higher: Preferably 1 Physician and 1 Nurse/Healthcare 
Administrator; Suggestion is that one team member have experience in 
Public Health, Occupational/Preventive Medicine, or Family Practice. 
Additional members consisting of the liaisons of sister services should 
also be considered. 

6. Areas of Inspection: 
a. Gulfport: 

i. Ambulatory Health Care: 

ii. Long Term Care (inpatient/dependent care): 

iii. Home Care/Hospice: 

iv. Assisted Living Facility (includes dementia patients) 

b. Washington: 

i. Ambulatory Health Care: 

ii. Long Term Care (and Special Dementia Care) 

iii. Assisted Living Facility: 

7. Review previous JCAHO survey issues regarding the following to 
ensure that no interim or sentinel eventloccurrence has taken place: 

a. Provider Competency - Current licensure, certification, or 
registration: 

b. Evaluated quality of care: 

c. Planning Care, Treatment, and Services - to include risk assessment 
of inpatients and demented patients: 

d. Behavior management for long term care patients: 

e. Infection Control: 

f. Patient Satisfaction: 

g. Medication Management: 

h. Community Health and Wellness Programs: 

i. Environment of Care: 

j. Pharmacy Services: 

k. Relevant Lab, Dental, and Consultative/Referral issues: 

l. Sustained Performance: 

m. Adverse outcomes: 

n. National Patient Safety Goals (i.e. suicide prevention): 

Resources for the Medical Manager Inspector: 

1. JCAHO Standards for Long Term Care Manual (Current version; 2005 - 
2006) 

2. AL Survey and Accreditation Process Guide (pub. Mar 2003): 

3. Accreditation Manual for Assisted Living (Current version; 2003 - 
2005) 

4. Current Physician's Desk Reference or Medication handbook: 

5. List of approved abbreviations for medications: 

6. Medical care Reference book (i.e. Harrison's Principles of Internal 
Medicine): 

7. DOD Directives, Regulations, and/or References regarding The AFRH 
Act of 1991, Public Law 101-510. (see Ch 10, sec 418 of title 24, US 
Code [currently in draft Dec 2004]; and Title XIV sec 1401 - 1515): 

8. Gather any formal litigation or complaints regarding health 
services, patient treatment, safety, or risk: 

9. Previous AFRH Survey/Inspection with Healthcare Services Summary 

10. AFRH Healthcare Services Report Template (Attached to this Guide): 

11. Items and request list for the Medical Manager/Inspector: 

1. Preparation of an overview or briefing summarizing general 
Healthcare Services of the facility (briefing should attempt to cover 
the following areas): 

a. Services 

b. Metrics 

c. Health and Wellness/Promotion Activities 

d. Medical Demographics: 

e. Access to care measures: 

f. Case management Program 

g. Emergency Care: 

h. Healthcare Strategic Plan 

i. Decision-making processes 

j. Staffing and Funding 

k. Resident Satisfaction 

2. Key personnel available for tour of the following facilities: 

a. Clinical Services: 

b. Dental: 

c. Nursing Services (resident wards - AL, LTC, and IL)

d. Nutritional Services/Dining facilities

e. Pharmacy

f. Laboratory Services

3. Current or most recent JCAHO Inspection Report with listing of 
Requirement(s) for Improvement (RFI). 

4. Recent (last JCAHO) Individual findings for tracer reports that been 
acted upon with an action plan and process in place to correct 
discrepancies? 

5. Executive Committee Minutes and Progress reports/binders reflecting 
evidence of action, discussion, and/or resolution of standards of 
compliance for the RFIs. Applicable time allotted is determined by the 
JCAHO Report. Sufficient progress in the areas noted must be apparent 
or a formal write-up in the HSI report as well as notification to JCAHO 
will be made. 

6. Healthcare Strategic Plan Binder, Minutes, or Notes; Medical care 
policy letters 

7. A list of the scope of medical services provided; i.e. Internal 
Medicine, Family Practice, Rehab, Optometry, Dentistry, Podiatry, etc: 

8. Provider and staff demographics - Number of Physicians, Nursing 
(positions authorized and filled); Numbers broken down showing RNs, 
LPNs, CNPs, Dentists, Technicians and types (i.e. 3 Dental techs and 1 
Pharmacy tech): 

9. Contract physician services used if any: 

10. Nursing shifts (i.e. 3 RNs and 6 LPNs on LTC floor during the day 
shift; 4 LPS and 8 RNs on Assisted Living floor during evening) 

11. Number of total residents; males/females, % Caucasians; Average age 
of males/females 

12. Prevalence of chronic conditions: 

13. Average number of physicals accomplished and by whom (i.e. CNP 
visits/month, Drs. Visits/month); include agency access to care metrics 
if any: 

14. Patient injury lists for the year and incident reports (alcohol- 
related injuries); Independent residents and Assisted living residents 
if any: 

15. Alcohol/tobacco use rates if any: 

16. Information on who performs public health/sanitation inspections 
and industrial hygiene surveillance: 

17. Two Long Term Care patient records. These will be inspected for 
basic documentation of care, legibility, and medication use. 

18. Two LTC outpatient records: 

19. Organizational layout depicting Medical Director oversight - 
describe the decision-making chain of hierarchy: 

20. The two most recent community or town hall meeting minutes (observe 
for discussion on medical issues covering complaints, injury reports, 
safety, and wellness initiatives) Estimates/average number of residents 
attending Town Hall meetings or forums: 

21. Resident survey reports for food surveys (the Inspecting Agency may 
consider sending a survey of its own): 

22. Staff BLS training data/rates - general spread sheet: 

23. Pharmacy prescriptions filled for current year - List other 
programs or contracting agency education/oversight: 

24. Any formal (or informal) Memorandum(s) of Understanding or Letters 
of Agreement between the AFRH and local VA, Military Treatment 
facilities, or area hospitals. 

25. Any local, formal, or on-going litigation or congressional 
complaints regarding AFRH community issues. 

26. Outside medical facilities names used in local network: 

27. Former DOD AFRH Inspection Report (last accomplished by USN 2002): 

28. Contingency Plan for patient evacuation includes renovation during 
construction efforts; is risk and injury mitigation apparent? 

29. Schedule one meeting with 5 - 10 Independent Living (IL) residents 
to discuss healthcare issues and patient satisfaction/morale: 

30. Current Annual Performance and Accountability Report 

31. Performance Improvement data and discussion information 

32. Listing of new medical or healthcare initiatives and/or services 

33. Future healthcare plans and concerns - Master Plan for any facility 
changes or updates: 

Important contacts and interviewees: 

1. Chief Operating Officer: 

2. Site Director: 

3. Chief Medical Officer:

4. Commanding Officer: 

5. Chief Nurse: 

6. Administrator: 

7. Independent Care Residents: 

8. Public Affairs (optional): 

9. Resident Services (optional): 

10. Lab, Dental, Clinical Nurses (optional):

11. Optometry (optional): 

Questions to ask and have surveyed: 

1. Have all former inspections' recommendations been addressed 
regarding healthcare services? 

2. Have the former healthcare services been addressed and documented 
under the guidance of the Executive Management Committee? Are there 
medical staff leadership minutes? 

3. Is there a specific portion of the strategic plan in place for 
healthcare services? 

4. Is there any indication of plans for the quality of life or 
attention to improve patient care? 

5. Have measures been taken to address or discuss patient concerns in 
open community forum? 

6. Are definitive measures in place to reduce employee workload and 
promote health and wellness activities? 

7. What types of innovative solutions are in place? 

8. Is the climate of safety apparent? 

9. Residents' morale and behavioral health stature: 

10. Are there any repeat write-ups on healthcare - Focus on previous 
inspection results also (current - USN 2002 inspection report): 

11. Are there any procedures being performed in the AFRH? 

a. Are procedures accomplished only on an outpatient basis? 

12. Are any IV antibiotics used? 

13. Are there any smoking cessation efforts - in-room risk assessment 
for smoking in a DOD facility issues? 

14. Are there any proactive infection control (IC) proactive risk 
assessments being done - i.e. epidemic exercises - OSMA (Objective 
Scope and Monitor Assessments)? 

15. Is there a definitive IC coordinator with a position description 
showing delegation of responsibility? 

16. Are there any Pharmaceutical processes - risk assessments for 
adverse events; management plan present? 

17. Does a Natural Disaster Plan and contingency events plan exist? 

18. Have issues from the last DOD triennial assessment been addressed, 
discussed, and followed up by the Executive Management Committee? 

19. How do residents receive healthcare service(s) information? 

General Report Issues: 

Overall - US Code requirements --> Accreditation Medical Requirements 

Resolution of any "Systems" issues in terms of quality of care: 

Medical Leadership: 

Environment of Care: 

Management of Human Resources: 

Patient Satisfaction: 

Independent Resident Living Facilities; Number of Long term Beds; 
Number of Assisted Living beds: 

Total residents; Independent Residents; AL and LTC Resident stats: 

Services/Access to medical treatment facilities or other healthcare 
facilities: 

Continuing staff training - in patient assessment, medication error 
reduction: 

Pharmacy issues: 

Risk assessment, admission and discharge issues: 

Overall health quality and safety issues; activates, inspiration, 
health promotion and wellness issues: 

Contract physician availability: 

Familial support services; Pharmacy Services; Dental Care; Nursing 
Services; Nutritional Services: 

Laboratory Services: 

Medication use: 

Total providers - Nurses; Doctors: 

Military medical staffing vs. civilian staffing: 

List and address each individual JCAHO write-up from the previous 
inspection Residents' and Staffs' morale, mental/behavioral health 
status: 

Healthcare recommendations: 

[End of section] 

(290588): 

FOOTNOTES 

[1] Hurricane Katrina destroyed the AFRH Gulfport, Mississippi, 
facility in 2005 and many residents now live at the AFRH Washington, 
D.C., campus. 

[2] Pub. L. No. 109-163, § 909(b), 119 Stat. 3136, 3405. 

[3] AFRH has few comparable models. According to a 2002 census, there 
are about 4,000 CCRCs nationwide. A February 2006 AFRH study identified 
15 CCRCs as serving military retirees. Other facilities serving 
veterans focus on nursing home services and are not CCRCs. For example, 
there are 139 state veterans' homes and the Department of Veterans 
Affairs operates 133 nursing homes. 

[4] The Continuing Care Accreditation Commission was purchased by the 
Commission on Accreditation of Rehabilitation Facilities in 2003 and is 
now known as CARF-CCAC. It is an independent, nonprofit accreditor of 
human service providers, including medical and vision rehabilitation, 
behavioral health, child and adult day care, and CCRCs. The Joint 
Commission, formerly known as the Joint Commission on Accreditation of 
Healthcare Organizations, is a private, nonprofit accreditor of health 
care organizations and programs, including hospitals and clinical labs 
and organizations that provide home care, ambulatory care, and long- 
term care services. 

[5] Pub. L. No. 107-107, §§ 1401-1410, 115 Stat. 1012, 1257-67 (2001) 
(codified, as amended, at 24 U.S.C. §§ 411-423). 

[6] Prior to the NDAA for Fiscal Year 2002, the Local Boards exercised 
operational oversight over AFRH campuses. 

[7] 24 U.S.C. §§ 418, 411(f). 

[8] Previously, the vehicles owned and operated by AFRH lacked 
restrooms. 

[9] Cody v. Rumsfeld, 450 F. Supp. 2d 5 (D.D.C. 2006). In dismissing 
the lawsuit, the court cited the NDAA for Fiscal Year 2006, which 
required the availability of a physician and dentist during daily 
business hours, daily scheduled transportation to nearby medical 
facilities, and establishment by the COO of uniform standards for 
access to health care services. 

[10] The current PDUS has been in this position since July 2006. 

[11] Service IGs examined health care in clinics and all three care 
settings while the Joint Commission's inspections were more limited. 

[12] 24 U.S.C. § 411(g). 

[13] All data on this slide are as of 2006. 

[14] Pub. L. No. 107-107, §§ 1401-1410, 115 Stat. 1012, 1257-67 (2001) 
(codified, as amended, at 24 U.S.C. §§ 411-423). 

[15] Previously, Local Boards exercised operational oversight. 

[16] 24 U.S.C. §§ 418, 411(f). 

[17] Previously, the vehicles owned and operated by AFRH lacked 
restrooms. 

[18] 24 U.S.C. § 413(b). 

[19] U.S. Census Bureau, 2002 Economic Census. 

[20] The current PDUS has been in this position since July 2006. 

[21] The Commission on Accreditation of Rehabilitation Facilities 
purchased the Continuing Care Accreditation 18 Commission in 2003. 

[22] RFIs may be appealed. 

[23] Statewide average interval must not exceed 12 months and maximum 
interval between inspections may not exceed 15 months. 

[24] CARF-CCAC accredits about 300 of the approximately 4,000 CCRCs 
nationwide. 

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