Representative Kristi Noem today sought information about the quality of care provided at Indian Health Service (IHS) facilities in South Dakota.  In a letter to IHS Principal Deputy Director Robert McSwain, Noem discusses documented instances where patients were put in serious danger when receiving care at an IHS service unit and raises concerns about losing accreditation from the Center for Medicare and Medicaid Services (CMS).  Noem also solicits information about what steps are being taken to correct the problems.

This letter comes in the wake of IHS service units in Rosebud and Pine Ridge being notified that they are at risk of losing CMS accreditation, which would force many tribal members to find help miles and miles away from their homes. 

“Safe and efficient Indian Health Service medical facilities are critical to the well-being of the more than 100,000 Native Americans in the Great Plains Area. For Tribal members who live in rural areas, IHS hospitals are the only health care facilities within a hundred miles or more. Sadly, the experiences of my constituents in South Dakota indicate that IHS Great Plains Area facilities are failing to provide quality care, and Tribal members are paying the price,” wrote Noem.

Noem further details problems discovered at the IHS Service Unit in Rosebud recently:

  • Staff washed surgical instruments by hand because the sterilization machine had been broken for six months;
  • No infection control measures were taken for a patient with a history of an untreated highly infectious disease. When the patient was transferred, no documentation was created to inform the accepting facility of his history with the disease;
  • Staff left a pregnant patient unattended and she delivered her premature baby on the floor of a hospital bathroom. The baby was initially not breathing. Staff intervened, but when the doctor arrived 20-30 minutes later, staff did not notify the doctor that the baby was premature or that it had been found on the floor. No equipment was available to deal with the situation. While staff obtained equipment, the baby was not placed in a warmer and was not given oxygen.

Noem also outlines problems of Schedule II drug theft that were discovered in a 2010 Senate Indian Affairs Committee report.

In light of this, Noem has requested a robust report from IHS by January 31, 2016, that details:

  • Which IHS facilities are facing CMS termination notices and why;
  • What reforms IHS and the Great Plains Area have taken in response to a 2010 Senate report outlining many underlying problems in the Great Plains Area;
  • Instances of Schedule II drug theft;
  • Instances where a health care provider offered care while under the influence of drugs or alcohol;
  • Instances where a health care provider was practicing with a lapsed license, accreditation, or certification; and
  • The total amount spent in the Great Plains Area on administrative expenses.

A full copy of the letter can be found below.

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Mr. Robert G. McSwain
Principal Deputy Director
Indian Health Service
Department of Health and Human Services
The Reyes Building
801 Thompson Avenue
Rockville, MD 20852

Dear Mr. McSwain,

Safe and efficient Indian Health Service (IHS) medical facilities are critical to the well-being of the more than 100,000 Native Americans in the Great Plains Area. For Tribal members who live in rural areas, IHS hospitals are the only health care facilities within a hundred miles or more. Sadly, the experiences of my constituents in South Dakota indicate that IHS Great Plains Area facilities are failing to provide quality care, and Tribal members are paying the price.

The Center for Medicare and Medicaid Services (CMS) recently notified the Pine Ridge and Rosebud IHS service units that they did not meet basic CMS guidelines in terms of quality care. If the hospitals do not fix the problems CMS identified in its review, their agreements with CMS will be terminated. Disturbingly, this is not the first time CMS has raised concerns about Great Plains Area hospitals. These notices come on the heels of CMS’ termination of its agreement with the Winnebago IHS service unit in Nebraska, also located in the Great Plains Area.

The CMS termination notices are not the only urgent problems facing my constituents. Just over a week ago, the people of the Rosebud Sioux Tribe were blindsided with the sudden closure of their hospital’s Emergency Department (ED) on the grounds that it was simply too dangerous to treat patients there. It is my understanding that, the weekend the ED closed, three rape patients and one stabbing patient were forced to travel an hour away to Nebraska for care.

The lack of quality health care for Tribal members in the Great Plains Area is not a new problem. As I visit reservations across South Dakota, my constituents share all manner of anecdotes describing negative experiences with IHS facilities. Their stories are backed by congressional oversight work. In September 2010, Byron Dorgan, then-Chairman of the Senate Indian Affairs Committee, convened a hearing titled, “In Critical Condition: The Urgent Need to Reform the Indian Health Service’s Aberdeen Area,” for which your predecessor, Dr. Yvette Roubideaux, provided testimony. At the hearing, and in the subsequent December 2010 Committee report of the same title (see attached), the Committee depicted the frightening reality that Native Americans in the Great Plains Area face when they rely on IHS for medical care.

The Committee’s work detailed the Aberdeen office’s lack of coherent policies and procedures governing even the simplest activities across the Great Plains Area, resulting in bureaucratic paralysis at best and a physical danger to patients at worst. The report contains a litany of instances in which the Aberdeen office’s lack of guidance and oversight facilitated low standards in facilities across its jurisdiction. According to the report, for example, Great Plains Area facilities failed to secure narcotic drugs, which contributed to employee thefts of pills by the thousands and the dispensing of powerful Schedule II drugs almost indiscriminately. Additionally, the Committee found Great Plains Area facilities engaged in substantial amount of diversions or reduced services, resulting in unnecessary costs and potentially affecting health care access for numerous Native Americans. Most shockingly, the Committee found that employees at Great Plains Area facilities put patients in serious danger by conducting surgical procedures under the influence of controlled substances.

Among the more disturbing South Dakota-based anecdotes listed in the report:

The [Rapid City IHS Hospital] pharmacy submitted a report of theft or loss of controlled substances dated March 19, 2008, which indicates that 5,569 Hydrocodone tablets were missing due to employee pilferage. On that same day, the pharmacy issued an amended report indicating the loss of 5,417 Hydrocodone tablets; 965 Darvocet tablets; and 187 Xanax tablets, totaling 6,569 missing controlled substances in one day. The report identified employee theft as the reason for loss [sic] pills.

The [pregnant] patient arrived at the [Rosebud Hospital] ER with contractions every five minutes and was triaged as urgent. One and a half hours later, she was discharged from the ER. The patient proceeded to the outpatient department due to her continued contractions and was told to walk around and go to the bathroom for a urinalysis. Forty-one minutes after the patient was discharged from the ER, she delivered the baby in the outpatient clinic bathroom.

The following is a summary of the key issues identified [at the Rapid City IHS Hospital]:

  • Two medical doctors with expired state licenses;
  • Six doctors and family nurse practitioners with expired CPR certifications;
  • Eight family nurse practitioners and physicians with lapsed ACLS [Advanced Cardiovascular Life Support] certifications; and
  • One family nurse practitioner with an expired DEA [Drug Enforcement Agency] license.

 

Five years have passed since Sen. Dorgan released his report, more than enough time for the IHS and the Aberdeen office to make the changes that were desperately needed. Nevertheless, my constituents’ experiences and CMS’ recent findings at the Pine Ridge and Rosebud IHS Hospitals suggest little has changed. For example, among the myriad problems discovered at Rosebud in recent weeks:

  • Staff washed surgical instruments by hand because the sterilization machine had been broken for six months;
  • No infection control measures were taken for a patient with a history of an untreated highly infectious disease. When the patient was transferred, no documentation was created to inform the accepting facility of his history with the disease;
  • Staff left a pregnant patient unattended and she delivered her premature baby on the floor of a hospital bathroom. The baby was initially not breathing. Staff intervened, but when the doctor arrived 20-30 minutes later, staff did not notify the doctor that the baby was premature or that it had been found on the floor. No equipment was available to deal with the situation. While staff obtained equipment, the baby was not placed in a warmer and was not given oxygen.

In testimony at the Senate Indian Affairs Committee’s 2010 hearing, Dr. Roubideaux acknowledged the challenges facing the Great Plains Area, and noted that funding levels are not solely to blame. Rather, she said, “we [IHS] can and we must make meaningful progress toward addressing these issues utilizing the resources we currently have.” I agree with her assessment and hope you do too.

In light of the appalling situation in some of South Dakota’s IHS service units and to help me determine what meaningful systematic changes IHS has made since the 2010 report, please provide the following information by January 31, 2016:

1)     An exhaustive list of IHS facilities that have been served with CMS termination notices for the time period January 1, 2012 to present. In providing this information, please include:

The facilities whose CMS contracts were terminated and of those, the facilities that are currently in good standing with CMS.

2)     Describe in detail the reforms IHS and the Great Plains Area made in response to the Senate Indian Affairs Committee report titled “In Critical Condition: The Urgent Need to Reform the Indian Health Service’s Aberdeen Area,” as well as any supporting documentation;

3)     A list of any instances of Schedule II drug theft from any facility in the Great Plains Area for the time period January 1, 2012 to present. In providing this information, please include:

The kind and amount of drug involved;

Whether an IHS employee was found responsible for the theft;

If an employee was responsible for the theft:

List whether the employee was disciplined;

Describe the nature of the discipline;

4)     A list of any instances in which any health care provider employed by any facility in the Great Plains Area was found to have been under the influence of drugs or alcohol in the conduct of their job for the time period January 1, 2012 to present. In providing this information, please include:

Whether the employee was disciplinedl;

Describe the nature of the discipline;

5)     A list of any instances in which any health care provider employed by any facility in the Great Plains Area was found to have lapsed in any license, accreditation, or certification for the time period January 1, 2012 to present. In providing this information, please include:

The provider’s job title;

The facility where the provider was posted at the time of the lapse;

The type of license, accreditation, or certification that lapsed;

The amount of time the license, accreditation, or certification had been lapsed before it was reinstated;

6)     Provide a full accounting of funding allotted to the Great Plains Area, as well as the total amount spent by the Aberdeen office on administrative expenses (including administrator salaries and bonuses), each year for the time period January 1, 2012 to present.

Thank you for your assistance in this matter. If you have questions about my request, please contact my staff at 202-225-2801.

Sincerely,

KRISTI NOEM
Member of Congress

CC:      

The Honorable Sylvia Burwell, Secretary, HHS

Mr. Andy Slavitt, Acting Administrator, CMS

Mr. Ron Cornelius, Great Plains Area Director, IHS

Mr. Gary Cantrell, Deputy Inspector General for Investigations, HHS OIG

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