Report | July 23, 2014

Inspection of the Armed Forces Retirement Home


Who Should Read This Report

Personnel 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 report.


Section 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 U.S.C. § 418) requires that the Inspector General of the Department of Defense perform a comprehensive inspection of all aspects of the AFRH every three years.

What We Did

In 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.  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, D.C. (AFRH-W) Resident Advisory Committee (RAC), and
  • AFRH Gulfport (AFRH-G) RAC.

The DoD IG Inspection Team developed the scope and methodology for this inspection based on discussions with representatives from the OUSD (P&R) and Office of 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 RACs.

We also took into consideration observations and recommendations from its previous AFRH inspection, described in the 2010 DoD Inspector General report (No. IE-2010-002), “Inspection of the Armed Forces Retirement Home,” February 25, 2010 (hereafter referred to as the 2010 DoD IG Inspection Report). 

The DoD IG Inspection Team inspected various areas of AFRH operations and management, as listed in the Objectives section of this report. 

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 inspection.


Notable Progress/Accomplishments

AFRH management has effectively managed the construction of major facilities:

  • The new AFRH-G facility, with impressive 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 shut down, demolished, or being 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 savings.

We found that AFRH personnel gave adequate due diligence and care to facility engineering and safety issues.  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-Centered  Long-Term Care Community, Continuing Care Retirement Community, and Dementia Care Specialty Program.

Other areas where AFRH made significant progress include:

  • screening new applicants,
  • prioritizing applicants on the waiting list,
  • developing a contract with the U.S. Department of Interior, National Business Center for information technology management, and
  • adjudicating and ensuring the integrity of veterans’ preference.

We found that, despite the concerns passed on to them during the inspection, most residents of the retirement home were pleased to be living there, particularly the residents of the Independent Living units.  The quality of life for the Independent Living residents, with numerous recreational activities planned by the Resident Recreational Services office, was quite high.


The DoD IG Inspection Team inspected 13 different areas of AFRH operations and management, to include medical operations.  A summary of important observations concerning the 13 areas is provided below.  The report itself provides a detailed description of all observations and discussions on those observations which is essential for obtaining a comprehensive picture of the AFRH enterprise.

Medical (Tab A)

  • AFRH was not accredited by a recognized civilian accrediting organization in the areas of medical care, dental care, rehabilitation, and pharmacy services even though the DoD IG recommended accreditation of these areas in the 2010 inspection report.
  • Medical record documentation, nursing notes, and documentation of medication were incomplete.
  • Short acting opioids, instead of more appropriate long acting opioids, were being used to manage chronic pain.
  • There was no documentation of counseling of Coumadin patients on drug interactions and some providers did not have access to necessary information at Coumadin Clinics.
  • There was no routine interaction between the SMA and the USD (P&R) on AFRH operations, except in times of crisis.  In addition, there was no effective system in place for the SMA to raise the issue with the USD (P&R) when the SMA disagreed with, or was concerned by, a decision made by the AFRH COO.
  • Credentialing and privileging processes included the following deficiencies:
    • lack of definition of qualification requirements,
    • lack of appropriate training for the credentialing and privileging personnel,
    • lack of data tracking necessary for re-privileging, and
    • the granting of privileges for services that were out of scope for the AFRH. 
  • AFRH had numerous standard operating procedures (SOPs), many of which were contradictory, difficult to understand, and/or used references that were not pertinent to the subject.  Many SOPs were also markedly out of date.  Additionally, no SOPs existed for two high-risk activities:  (1) the Coumadin Clinic, and (2) end-of-shift narcotic counts.
  • AFRH Agency and AFRH-W lacked sufficient/competent physician leadership.  Personnel practices at the AFRH tended to promote from within rather than open the positions to outside physicians who may be more qualified.  The DoD IG Inspection Team also noted that the position description, in at least one case, was altered to allow selection of an internal candidate who did not meet the original qualification requirements.  These and other issues contributed significantly to the questionable quality of medical operations, particularly at the AFRH-W facility.
  • The DoD IG Inspection Team found the employee occupational health program was generally ineffective.  The AFRH Agency and the two facilities were not fully complying with AFRH Agency directives on “Medical Qualification Determination” and the “AFRH Reasonable Accommodation Policy and Plan.”  As a result, some of the nursing staff were incapable of performing the duties that required certain physical and medical fitness.
  • AFRH Agency and AFRH-W lacked personnel with adequate training in quality management and performance improvement.
  • Both the AFRH clinical performance improvement and quality management programs were in their infancies.  Performance improvement (PI) metrics, many of which were not meaningful, were imposed from the AFRH Agency down to the respective facilities.  In addition, peer reviews were not routinely conducted and data was not tracked for re-privileging. 

Human Resources (Tab B)

  • AFRH could not verify that the Career Transition Assistance Plan (CTAP)   was cleared during the application process or that well-qualified CTAP candidates received priority over non-CTAP candidates in the selection process as directed by 5 CFR (1999).
  • The AFRH Agency administration was not accurately following required Human Resources procedures, Office of Personnel Management guidelines, or effectively communicating its hiring practices to employees. 

Financial Management (Tab C)

  • A purchase card holder had utilized convenience checks for improper transactions that were prohibited by the U.S. Department of Treasury and were in violation of AFRH Agency Directive 3-1, “Financial Management,” July 18, 2012.
  • Although required by AFRH-W SOPs, AFRH-W Business Center personnel were not conducting required audits/cash counts of some of the AFRH funds.

Armed Forces Retirement Home Inspector General (Tab D)

  • The COO assigned the AFRH Public Affairs Officer the additional duties of the AFRH IG, relegating the AFRH IG position to a dual-hatted position with other primary responsibilities.  As a result, there is a possibility of conflict of interest between the duties of the IG and the duties of the Public Affairs Officer when the issues under investigation pertain to the Public Affairs office.
  • The AFRH IG program may lack credibility because it does not have quality standards defined for AFRH IG audits and investigations.

Admissions and Eligibility (Tab E)

  • The AFRH Pre-admission Team was not using financial factors to determine whether an applicant was eligible under the “Incapable of Earning a Livelihood” category, as directed by AFRH Agency Directive 8-13, “Incapable of Earning a Livelihood Designation,”  July 3, 2012.
  • Current methods used to screen and verify eligibility may not adequately eliminate applicants who have a drug abuse problem.
  • AFRH personnel were not accurately following agency directives or facility SOPs in conducting the pre-admissions function. 

Facilities Engineering and Safety (Tab F)

  • AFRH-W was not performing adequate testing/monitoring of the “Home Free” devices to identify any defects or issues with the system.  This created an unsecured area at the AFRH-W where monitored residents at risk of wandering could leave without the knowledge of AFRH-W personnel. 
  • The CISCOR Resident Monitoring System (RMS) at AFRH-G experienced at least 39 outages from June 5, 2012 to September 12, 2012.  Because the RMS system produced such a high number of outages in a 3-month period, the system may be unreliable. 

Information Assurance (Tab G)

  • More than 50 high and moderate security control weaknesses were identified in the AFRH System Security Plan (SSP) and Plan of Actions and Milestones (POA&M).
  • The General Support System (GSS) did not comply with the National Institute of Standards and Technology (NIST) SP 800-53 Revision 3, “Recommended Security Controls for Federal Information Systems,” May 1, 2010.

Resident / Recreation Services (Tab H)

  • AFRH-W personnel could not provide evidence that they were following all SOPs in a manner sufficient to meet the criteria addressed in the 2012 Inspection Checklist. 
  • AFRH-W personnel were not conducting daily walk-through inspections,  as required by established SOPs.  Additionally, inspection documentation lacked consistency.

Contracts Management (Tab I)

  • Thirty-two of the 47 contracts inspected did not have Independent Government Cost Estimates (IGCE) or supporting documentation with enough clarity to articulate how the estimate was ascertained.
  • The market research was not consistently documented in a manner appropriate to the size and complexity of the acquisition.
  • At least 6 of the 47 contracts inspected did not have a recommendation for award memorandum (or a similar document) on file describing how the contracting officer determined the award outcome.
  • AFRH Contracting Officer’s Representatives (CORs) lacked documentation to support modification transactions.
  • AFRH facilities were not consistently managing or providing oversight to interagency agreements between AFRH and other Federal agencies.  The interagency agreements did not clearly define whether the Bureau of Public Debt (BPD) or AFRH was required to monitor over interagency agreements.
  • AFRH Contracting Officer’s Technical Representative (COTR) background/experience was not adequate to support all the contracts they were managing and COTR responsibility was not evenly distributed.
  • The contract files reviewed lacked documented Quality Assurance Surveillance Plans (QASP), as directed by corresponding contracts, and, in several cases, contract files lacked documentation of evidence that COTRs were providing oversight over the contractor performance.

Security (Tab J)

  • Security of the AFRH-W Scale Gate facility entrance, controlled by Department of Veterans Affairs (VA) Police, did not meet the security standards established in SOP No. W-OA-SEC-5-27, “Perimeter Security,” July 6, 2012.
  • Although a baseline security training program with SOPs and a master training task list existed, the AFRH-W and AFRH-G guards were not adequately trained nor empowered to provide traditional Federal security services according to recognized Federal standards. 

Estate Matters and Disposition of Effects (Tab K)

  • AFRH could not assure the delivery of decedent’s wills to the appropriate court of record, as specified by section 420 (a)(1), title 24, United States Code (24 U.S.C § 420(a)(1) [FY 2012]). 
  • AFRH employees involved in the disposition of effects and estates were not accurately following AFRH Agency Directive 8-8, “Estate Matters,” September 2, 2008, or AFRH facility SOPs.  There was potential for lawsuits against AFRH for failing to properly handle the decedents’ belongings.
  • AFRH-G employees were unprepared in cases where the retirement home may have had a legal interest, as described in section 420(b)(1)(C), title 24, United States Code, (24 U.S.C § 420(b)(1)(C) [2012]).

AFRH Hotline Activity (Tab L)

  • AFRH IG did not issue implementing guidance for the Hotline program as required by AFRH Agency Directive 1-9, “AFRH Inspector General Program,” June 2, 2009.  As a result, AFRH’s Hotline investigations could not be evaluated against any AFRH-identified/developed standards.

Senior Management (Tab O)

  • DoD Instruction 1000.28, “Armed Forces Retirement Home,” February 1, 2010, did not address the amendments to the Armed Forces Retirement Home Act introduced by Public Law 112-81, “National Defense Authorization Act FY 2012,” December 31, 2011. 
  • The AFRH COO hired insufficiently competent medical personnel to run the medical operations of the agency and the facilities and did not fill two key supervisory nursing positions at the AFRH-W facility for approximately 6 months.
  • The SMA from DHA lacked clear authority and responsibility to effectively address medical operations issues at the AFRH. 
  •  The SMA was not aware of many important medical operational issues at AFRH and was unable to decisively intervene in AFRH management decisions related to medical operations. 
  • USD (P&R) did not identify the specific DoD and/or VA policies, procedures, and guidelines that were appropriate for the AFRH, as recommended in the 2010 DoD IG Inspection report, and did not direct the AFRH to follow those policies, procedures, and guidelines. 
  • There was frustration among some of the AFRH employees, particularly the nursing staff at the AFRH-W facility, about working conditions and the fear of retaliation if they voiced opinions at odds with management.  Some senior officials also expressed fear of retaliation from upper management. 
  • The combined position of Deputy COO and the Chief Financial Officer (CFO) had been vacant for more than 2 years.  The AFRH COO was simultaneously performing these duties.
  • The lower-level staff, particularly the nursing assistants at the AFRH-W facility, expressed their frustrations about lack of assistance from upper management for professional development or advancement at the AFRH.
  • The AFRH COO created an unmandated agency-level Ombudsman position which will divert funds needed to hire competent medical and nursing personnel.

Recommendations, Management Comments, and Our Response

This report contains 131 recommendations addressing issues in the 13 management areas described in this Executive Summary.  A summary of management’s comments and our response are immediately after each recommendation.  The full set of management’s comments are at the end of the report.