Dec. 14, 2017 —
Section 411, title 24, United States Code, established the Armed Forces Retirement Home (AFRH) as an independent establishment in the executive branch. The AFRH consists of two facilities – Gulfport, Mississippi (AFRH‑Gulfport) and Washington, D.C. (AFRH‑Washington) – as well as the corporate headquarters, collocated at the Washington campus. Both AFRH facilities designate residential units by graduated levels of care for those residents who require additional healthcare services. These levels consist of independent living, independent living plus, assisted living, long-term care, and memory support. The head of the A FRH is the Chief Operating Officer, who is subject to the authority, direction, and control of the Secretary of Defense. The Deputy Director, Defense Health Agency, serves as the Senior Medical Advisor (SMA) for the AFRH. The SMA provides advice to the Secretary of Defense, the Deputy Chief Management Officer, and the Chief Operating Officer, AFRH, about the direction and
• medical administrative matters at each facility of the Retirement Home; and
• the provision of medical care, preventive mental health, and dental-care services at each facility of the Retirement Home.
We found that the AFRH medical staff generally provided healthcare services that met national healthcare standards and the quality-of-life needs of residents. However, AFRH medical providers did not conduct provider visits to residents in long-term-care units at the frequency required by national healthcare standards. Additionally, AFRH medical administrators did not effectively implement all facility-level controls to identify deficiencies in healthcare practices, such as documenting medication and treatment administration, documenting infection-control rounds, and recording temperatures for refrigerators where resident medications were stored.
AFRH Wellness Centers demonstrated adequate physical controls over controlled substances handled and stored by Wellness Center personnel. However, the Wellness Centers did not have adequate administrative controls to demonstrate accountability of controlled substances transported, handled, and stored by Wellness Center personnel. Additionally, the Wellness Centers did not have adequate administrative controls to ensure that access to medication-storage areas was limited to authorized personnel only.
We recommend that the Chief Operating Officer, Armed Forces Retirement Home, require that the
Chief, Healthcare Services, at each facility:
• develop and implement a process for regular reviews of medical provider visits,
• review and align current healthcare practices with approved facility-level standard operating procedures, and
• develop and implement administrative controls over controlled substances at the AFRH Wellness Centers. We recommend that the Deputy Director, Defense Health Agency, in accordance with their responsibilities as the Senior Medical Advisor:
• advise the Chief, Healthcare Services, of each facility on the development and implementation of the recommendations; and
• review identified deficiencies as a part of their quarterly oversight responsibilities.
Management Comments and Our Response:
The Acting Chief Operating Officer, Armed Forces Retirement Home, agreed with our findings and recommendations. He agreed to develop and implement a process for regular reviews of provider visits; provide education to ensure clinical staff understand their roles regarding the completion of documentation; ensure that the Infection Control Nurse documents, tracks, and collects data for further analysis; and develop and implement temperature logs and conduct staff education on protocols related to cold storage of medication.
Further, the Chief Operating Officer agreed to develop and implement a controlled-substance tracking log; add an inventory-control procedure to facility-level standard operating procedures; create a restricted list of positions that have supervised and unsupervised access to medication storage areas; and update facility-level standard operating procedures accordingly.
The Deputy Director, Defense Health Agency, agreed with our findings and recommendations. In response to both recommendations, the Deputy Director agreed to provide oversight of the AFRH corrective actions through regular site visits, quarterly updates with AFRH leadership, and a review of the AFRH policies and procedures. The Deputy Director agreed also to engage the AFRH leadership, as needed, to address any issue or concern that may arise.
Comments from the Acting Chief Operating Officer, AFRH, and the Deputy Director, Defense Health Agency, addressed the specifics of the recommendations. Therefore, the recommendations are resolved but will remain open. We will close the recommendations after we verify that the actions described in the responses have been implemented.
This report is a result of Project No. D2017-D00SPO-0002.000.