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1 INTEGRITY EFFICIENCY ACCOUNTABILITY EXCELLENCEI nspector General Department of DefenseReport No. DODIG-2014-093 JULY 23, 2014 Inspection of the Armed Forces Retirement HomeVisionOur vision is to be a model oversight organization in the Federal Government by leading change, speaking truth, and promoting excellence a diverse organization, working together as one professional team, recognized as leaders in our more information about whistleblower protection, please see the inside back EFFICIENCY ACCOUNTABILITY | of DefenseFra ud, Waste & AbuseMissionOur mission is to provide independent, relevant, and timely oversight of the Department of Defense that supports the warfighter; promotes accountability, integrity, and efficiency; advises the Secretary of Defense and Congress; and informs the (Project No.)

2 IExecutive SummaryInspection of the Armed Forces Retirement HomeVisit us at Should Read This ReportPersonnel in the Office of the Secretary of Defense, the Defense Health Agency (formerly TRICARE Management Activity), and the Armed Forces Retirement Home (AFRH) who are responsible for and engaged in oversight, management, and operations of the AFRH should read this 1518 of the Armed Forces Retirement Home Act of 1991, November 15, 1990, as amended by Public Law 112-81, National Defense Authorization Act for FY 2012, December 31, 2011 (24 418) legislates that:Not less often than once every three years, the Inspector General of the Department of Defense shall perform a comprehensive inspection of all aspects of each facility of the Retirement Home, including independent living, assisted living, long term care , medical and dental care , pharmacy, financial and contracting records, and any aspect of either facility on which the Advisory Council or the Resident Advisory Committee of the facility recommends b(2) of the amended 24 418 (2012)

3 Also states that The Inspector General shall be assisted in inspections under this subsection by a medical inspector general July 23, 2014of a military department designated for purposes of this subsection by the Secretary of Defense. (See Appendix B for project announcement.)The Office of the Under Secretary of Defense for Personnel and Readiness [OUSD (P&R)] designated the Army Medical Command (MEDCOM) to provide medical inspection assistance for this inspection. Subsequently, the DoD Inspector General (IG) entered into a memorandum of understanding (MOU) with Army MEDCOM to delineate each agency s role in the conduct of this inspection. (See Appendix C for DoD IG/Army MEDCOM MOU.)What We DidIn preparation for the inspection, the DoD IG Inspection Team discussed the general scope of the inspection with the Chief Operating Officer (COO) of the AFRH, representatives from the OUSD (P&R) and Assistant Secretary of Defense (Health Affairs)/Defense Health Agency (ASD(HA)/DHA), and the AFRH IG.

4 In addition, we met with the Deputy Director of the Defense Health Agency, who is the Senior Medical Advisor (SMA) to AFRH. We also contacted the chairpersons of the following council and committees to ascertain their concerns or desired focus areas for inclusion within the DoD IG s inspection scope: AFRH Advisory Council, AFRH Washington, (AFRH-W) Resident Advisory Committee (RAC), and AFRH Gulfport (AFRH-G) RAC. The DoD IG s Inspection Team developed the scope and methodology for this inspection based on discussions with representatives from the OUSD (P&R) and Office of Background (cont d)ii DODIG-2014-093 (Project No. )Exective SummaryInspection of the Armed Forces Retirement Home What We Did (cont d)the Deputy Director of the Defense Health Agency, as well as written input received from the Chairman of the AFRH Advisory Council, and chairpersons of the two also took into consideration observations and recommendations from its previous AFRH inspection, described in the 2010 DoD Inspector General report (No.)

5 IE-2010-002), Inspection of the Armed Forces Retirement Home, February 25, 2010 (hereafter referred to as the 2010 DoD IG Inspection Report). Our objectives and methodology are discussed in the subsequent sections of this report. Upon review of all relevant research data, we conducted the on-site inspections and reviews of the AFRH management programs, the AFRH medical programs, and facilities of AFRH-W and AFRH-G during the weeks of August 27-31 and September 10-14, 2012. Multiple follow-on discussions were held with the AFRH-W staff. During the on-site phase of the inspection, we also conducted employee sensing sessions and DoD IG confidential feedback sessions to ascertain employee perceptions of quality-of-work life for the staff and to receive confidential feedback from residents and DoD IG Inspection Team inspected various areas of AFRH operations and management, as listed in the Objectives section of this report.

6 Following the on-site inspections, the Inspection Team area leads reviewed all the documents and information collected during the on-site inspection and requested additional documents from the AFRH points of contacts (POCs) for various phases. Some of the DoD IG inspectors, particularly the medical inspectors, sought additional data and clarifications. In October 2012, as the inspectors were analyzing data from field work, we received a confidential communication regarding a case of patient neglect allegedly caused by the failure of AFRH staff to meet standards of oral care at the AFRH-W facility. We consulted other relevant components in the DoD Office of the Inspector General (DoD OIG), including the Directorate for Investigations of Senior Officials, Office of Whistleblower Protection, and the DoD IG Hotline office.

7 After a series of DoD OIG multi-component meetings and additional data collection, the DoD IG Deputy Inspector General for Special Plans and Operations sent a Notice of Concern regarding the oral care negligence case to the Principal Deputy Under Secretary of Defense, Personnel & Readiness [PDUSD[(P&R)] on November 20, mid-January of 2013, the DoD OIG was informed about the death of one of the residents at the AFRH-W facility. There were questions raised about the cause of the resident s death and AFRH had begun a root cause analysis investigation. Although the AFRH COO stated that the investigation report would be shared with the DoD IG, the AFRH General Counsel later refused to provide the report to DoD OIG, citing protection from disclosure, as stated in DoD Directive , Confidentiality of Medical Quality Assurance Records, July 9, 1996.]

8 In late February 2013, DoD OIG received additional communications regarding alleged deteriorating conditions of nursing and medical care at the AFRH-W facility that were increasing the risk of patient neglect and patient injury due to inadequate nursing and medical staff. The DoD OIG decided to bring the issue to DODIG-2014-093 (Project No. ) iiiExecutive SummaryInspection of the Armed Forces Retirement HomeWhat We Did (cont d)the attention of the Acting Under Secretary for Personnel and Readiness [USD[(P&R)]. On March 21, 2013, the DoD OIG provided a briefing to the Acting USD (P&R) and recommended that the Acting USD (P&R) send a team of medical professionals to review the quantitative and qualitative aspects of nursing and medical operations at the AFRH-W facility.]

9 Parts A through O of this report provide more detailed information about the specific activities performed by the DoD IG Inspection Team on each of the identified areas of Progress/AccomplishmentsAFRH management has effectively managed the construction of major facilities: The new AFRH-G facility, with state-of-the-art features and amenities, was reopened on October 4, 2010, as scheduled. The AFRH-W facility Scott Building demolition and re-building was nearing completion on schedule. Other old, unusable buildings and structures in the AFRH-W facility were either being shut down, demolished, or considered for demolition. AFRH management was focused on development and execution of long-range facility management programs, including potential use of vacant land on the AFRH-W facility, energy savings, and operational cost found that AFRH personnel gave adequate due diligence and care to facility engineering and safety issues.

10 The modern, interconnected three-tower building of the Gulfport facility, with numerous in-house amenities, was a state-of-the-art retirement facility. The new Scott Building at the AFRH-W facility will significantly enhance the quality of life for the residents, particularly the residents of the Assisted Living and Long-Term care units. AFRH has been accredited under the Commission on Accreditation of Rehabilitation Facilities (CARF) Aging Services programs that included the Assisted Living, Person-Centered1 Long-Term care Community, Continuing care Retirement Community, and Dementia care Specialty areas where AFRH made significant progress include: screening new applicants, prioritizing applicants on the waiting list, developing a contract with the Department of Interior, National Business Center for information technology management, and adjudicating and ensuring the integrity of veterans found that, despite the concerns expressed by them during the inspection, most residents of the retirement home were pleased to be living there, particularly the residents of the Independent Living units.