A report released Thursday by the city’s auditor found the D.C. fire department hasn’t implemented most of the recommended revisions that came down in 2006 after a New York Times editor was mugged, and eventually died, but emergency crews mistook him as drunk and didn’t treat him as a top priority.

After David Rosenbaum’s death in 2006, then-Mayor Adrian Fenty initiated a task force that came up with 36 individual recommendations for D.C. Fire and Emergency Medical Services to adhere to.

Since that time, just 11 recommendations have been implemented, six have been partially implemented, four were largely implemented but then later rescinded, and 15 have not been implemented.

Chief among the issues not yet addressed after Rosenbaum’s death is that firefighters and paramedics were supposed to be cross-trained in both fields. All employees at the agency need to be trained in basic levels of EMS and fire rescue tactics, per the recommendations of the mayor.

That standard was put in place, but was not adhered to. According to the auditor’s report, in 2013, DCFEMS hired 23 single-role providers in violation of the policy.

The city also was supposed to establish and clarify what role its police department should play in the treatment and transportation of uninjured, intoxicated people and where those people should be held.

The audit found the city has no sobering centers willing to accept intoxicated patients transported by the agency, so they are forced to take the people to area hospitals.

In response to the audit, acting DCFEMS Chief Gregory M. Dean said in a statement that the agency has done a lot of things to enhance its systems, like increasing the number of ambulances during peak demand hours and creating new management positions to better handle patient care.

“I am committed to taking a collaborative approach, with the support of the broader community and the council to achieve our goal of providing the highest quality of professional and compassionate pre-hospital care to people who need it,” Dean said.

The auditor’s office launched the investigation in February after a few high profile incidents brought the DCFEMS under the microscope.

In January, a man died across the street from a fire station after suffering a heart attack and firefighters in the station neglected to come to his aid.

That same month, a Metro train stopped in a tunnel and filled with smoke, killing a woman and hurting many others. Fire fighters sent to free the passengers from the stuck train had to use their cell phones to communicate with each other because their radios wouldn’t work in the tunnel.

In her conclusion, auditor Kathleen Patterson said with a new administration and leadership, the agency has the ability to “improve the management, training, operations, and culture of the EMS,” though it doesn’t appear they are acting on that opportunity.

During a budget oversight hearing in April, Interim Chief Edward Mills told the city council the agency’s preventative maintenance program basically consisted of one person, and a lot of the city’s ambulances and firetrucks were not functional.

Mills said the city’s fleet of ambulances consisted of 98 ambulances, but just 49 of those were in service and many of those were “in a state of disrepair.”

The firetrucks weren’t in much better shape. Just 29 of the city’s 63 pump trucks were certified for use and only 11 of the city’s 26 ladder trucks were certified.

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