Armed Forces Retirement Home: Health Care Oversight Should Be Strengthened (30-MAY-07, GAO-07-790R). The 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. -------------------------Indexing Terms------------------------- REPORTNUM: GAO-07-790R ACCNO: A70081 TITLE: Armed Forces Retirement Home: Health Care Oversight Should Be Strengthened DATE: 05/30/2007 SUBJECT: Agency evaluation Elder care Health care facilities Health care services Home health care services Nursing homes Patient care services Retirement Standards Institution accreditation Executive agency oversight ****************************************************************** ** This file contains an ASCII representation of the text of a ** ** GAO Product. ** ** ** ** No attempt has been made to display graphic images, although ** ** figure captions are reproduced. Tables are included, but ** ** may not resemble those in the printed version. ** ** ** ** Please see the PDF (Portable Document Format) file, when ** ** available, for a complete electronic file of the printed ** ** document's contents. ** ** ** ****************************************************************** GAO-07-790R * [1]PDF6-Ordering Information.pdf * [2]Order by Mail or Phone 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).^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.^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.^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.^4 The Joint Commission accredits the nursing home and the AFRH clinic, which provides physician and routine dental services. ^1Hurricane Katrina destroyed the AFRH Gulfport, Mississippi, facility in 2005 and many residents now live at the AFRH Washington, D.C., campus. ^2Pub. L. No. 109-163, S 909(b), 119 Stat. 3136, 3405. 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.^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.^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.^7 ^3AFRH 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. ^4The 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. ^5Pub. L. No. 107-107, SS 1401-1410, 115 Stat. 1012, 1257-67 (2001) (codified, as amended, at 24 U.S.C. SS 411-423). ^6Prior to the NDAA for Fiscal Year 2002, the Local Boards exercised operational oversight over AFRH campuses. 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.^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.^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 o identified existing standards applicable to health services in the three settings at AFRH and similar facilities; o discussed accreditation process and follow-up between accreditation surveys with officials from standard-setting organizations; o reviewed the statutory oversight structure for AFRH; o reviewed relevant DOD and AFRH reports related to oversight issues, including complaints; o interviewed DOD, DOD IG, and service IG officials involved in oversight, including the PDUS;^10 o interviewed two civilian experts in health care for the elderly and retirement home administration serving on the AFRH-Washington Local Advisory Board; and o compared health care-related problems identified during Joint Commission accreditation reviews with those identified during service IG inspections. ^724 U.S.C. SS 418, 411(f). ^8Previously, the vehicles owned and operated by AFRH lacked restrooms. ^9Cody 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. ^10The current PDUS has been in this position since July 2006. 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 Standards applied Independent living None Assisted living None Nursing home Joint Commission standards Clinics Joint Commission standards Source: GAO. 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.^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. ^11Service IGs examined health care in clinics and all three care settings while the Joint Commission's inspections were more limited. 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: o refocus service IG inspections on health care, particularly in the independent and assisted living settings, which are not covered by external accreditation; o ensure that service IG inspections do not occur in the same year as Joint Commission accreditation; o ensure that service IGs have access to all relevant data on Joint Commission inspections; and o 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 [email protected] . 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. Kathleen King Director, Health Care Enclosures - 2 Enclosure II Comments from the Department of Defense (290588) GAO's Mission The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. 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