Armed Forces Retirement Home
Health Care Oversight Should Be Strengthened Gao ID: GAO-07-790R May 30, 2007The Armed Forces Retirement Home (AFRH), an independent executive branch entity, operates two continuing care retirement communities (CCRC). 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 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 (1) identified existing standards applicable to health services in the three settings at AFRH and similar facilities; (2) discussed accreditation process and follow-up between accreditation surveys with officials from standard-setting organizations; (3) reviewed the statutory oversight structure for AFRH; (4) reviewed relevant DOD and AFRH reports related to oversight issues, including complaints; (5) interviewed DOD, DOD inspector general (IG), and service IG officials involved in oversight, including the Under Secretary's Principal Deputy (PDUS); (6) interviewed two civilian experts in health care for the elderly and retirement home administration serving on the AFRH-Washington Local Advisory Board; and (7) compared health care-related problems identified during Joint Commission accreditation reviews with those identified during service IG inspections.
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.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-790R, Armed Forces Retirement Home: Health Care Oversight Should Be Strengthened
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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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