Deparment of Health and Human Services

OFFICE 
INSPECTOR GENERAL

INDIAN HEALTH SERVICE

YOUTH ALCOHOL AND

SUBSTANCE ABUSE PROGRAMS

VJCES. 
Richard P. Kusserow 
INSPECTOR GENERAL 
APRi 
1991 
Jy 
;(O'  d:W  Deparment of Health and Human Services

OFFICE 
INSPECTOR GENERAL

INDIAN HEALTH SERVICE

YOUTH ALCOHOL AND

SUBSTANCE ABUSE PROGRAMS

~ Sf.IlVJCES. 
Richard P. Kusserow 
INSPECTOR GENERAL 
+ OEI-
'0  07-89-00940 
;(O'~d:W  EXECUTIVE  SUMMARY

PURPOSE 
The objective of this inspection was to determine the extent to which the Indian Health Service 
progrs 
implemented youth alcohol and substance abuse  funded under Public Law 
(ilS) has 
99-570. 
BACKGROUND 
Over the past two decades, American Indians have recognized the importce of treating their 
alcohol abuse problems, and national attention has been provided to address the situation. 
Reasons attrbuting to this concern include an alcoholism related death rate of over four times 
the age adjusted rates for the U.S. population, and an admssion rate of 34 percent to alcohol and 
drg abuse programs for Indians who are under 25 year of age. For Indians under 35 years of 
age, this statistic increases to almost 70 percent. 
progrs. 
In the late 1960' s, the Offce of Economic Opponunity funded outrach and tratment 
The National Institute on Alcohol Abuse and Alcoholism (NIAA), established in the 1970' 
provided seed monies for treatment of alcohol abuse among the Indians. In the Indian Health 
Care Improvement Act of 1976 (Public Law 94-437), Congress dicted that NIAAAprograms 
be transferred to IRS jurisdiction. 
On October 27, 1986, Congress enacted Public Law 99-570, subtitled the "Indian Alcohol and 
Substance Abuse Prevention and Treatment Act of 1986. " In the fIrst three years of Public Law 
99-570, approximately $50 milion in recurrng funds and $19 millon in nonrecurrng funds 
were appropriated for youth alcohol and substance abuse programs. 
METHODOLOGY 
To secure the information needed to examine operations and activities regarding Public Law 
99-570, data collection instrments were mailed to the 11 ilS area offices. An analysis of the 
information was conducted to determine to what extent each area office had implemented the 
provisions of Public Law 99-570. To verify data received, thre IHS ara offces were selected 
for on-site visits. On-site visits were also made to the two regional treatment centers which were 
operational at the time of our study. Administrative and program sta were interviewed to 
determine the level of operations that the centers had achieved.  FINDINGS

The IHS Headquarers has not completed IHS alcoholism treatment standads. 
The IHS Headquarers has failed to meet quality assurce objectives. 
The current IHS management information system is outmoded and ineffective to 
monitor alcohol program activity. 
The ilS has failed to comply with requirements in Public Law 99-570 to establish 
regional treatment centers in all IRS service areas. 
Nearly two-thirds of alcoholism counselors in the IRS are not cenifed. 
The Bureau of Indian Affais has nOt established emergency shelters as required by 
Public Law 99-570. 
Evidence of inappropriate use of funds has been referred to the OIa Office of Audit 
Services. 
RECOMMENDATIONS 
The ilS should complete and promulgate operating stadads. 
The ilS Headquarers and area offIces should conduct reviews in accordace with 
their own quality assurance goals. 
The ilS should establish a process to review all area offIce program report and 
provide feedback to the ara offces. 
The ilS should develop an adequate management information system which 
provides data on alcohol and substance abuse tratment. 
The ilS should establish regional treatment centers in every ilS service area, or 
advise Congrss of their recommendation for an alternative strategy to provide 
residential services.

The ilS should ensure that all alcoholism counselors become certfIed. 
The IHS should work with the Bureau of Indian Affai to secur the release of funds 
which have been appropriated for emergency shelters and halfway houses.  COMMENTS 
We received comments to the drft of this repon from the Public Health Service (PHS). The 
PHS concurrd with al the recommendations. However, PHS comments state that successful 
implementation of the last two recommendations cannot be assured because those two areas are 
not solely within IRS' s control. 
We agree that programs of the Bureau of Indian Affairs are not under PHS' s diect control. 
However, we believe the IHS should continue coordination effort with the Burau of Indian 
Affairs in order to assure the timely constrction and operation of emergency shelters and 
halfway houses.  .... ...... ................ ........ ,........ ..... ...................................... ............................  ............... ..................... ... ....................  .................. ..................................................  ......................................

TABLE OF CONTENTS

EXECUTIVE SUMMARY 
INTR 0 D U CTI 0 N .......... ...... ...... 

PURPOSE............ ........ 

BACKGROUND ................................ ........ 

MEll ODO LOG Y ..............................................................................................

FIND IN G S .................................................................................................................. 3

treatment 
The IRS Headquarers has not completed ilS alcoholism 
standards................................................................ .............................................. 3

assurce objectives.........................

The IRS Headquarers has not met quality 
system is outmoded and 
The current ilS management informtion 
progr 
ineffective to monitor alcohol  activity ................................................

The IRS has nOt complied with requirments in Public Law 99-570 
to establish regional tratment centers in all ilS servce areas ...........................

Nearly two-thirds of alcoholism counselors in the ilS are not cenied.............

The Bureau of Indian Affais has not established emergency shelters 
as required by Public Law 99-570 .....................................................................

Evidence of inappropriate use of funds has been referred to the 
OIG Offce of Audit Services .............................................................. ................ 8

RECO MMEND A TI 0 NS .................................. ................ ........ .................................

A G EN CY CO MMENTS ........................................................................................

.......................................... A

APPENDIX A ........ 
 INTRODUCTION

PURPOSE 
(ilS) 
This inspection was undenaken to determine the extent to which the Indian Health Service 
has implemented provisions for youth alcohol and substance abuse programs funded under 
Public Law 99-570. 
BACKGROUND 
Over the past 
The problem of alcoholism among American Indians has existed for many years. 
trating their 
two decades, however, Native Americans have recognized the imponance of 
concern include an alcoholism related death 
alcohol abuse problems. Reasons attrbuting to this 
S. population, and an admssion rate of 
rate of over four times the age adjusted rates for the U. 
drg abuse programs for Indians who are under 25 years of age. 
almost 34 percent to alcohol and 
For Indians under 35 years of age, this statistic increases to almost 70 percent. 
National attention began to focus on the problem of alcohol abuse among American Indians in 
outreach 
the late 1960' s when the Offce of Economic Opponunity (OEO) provided funding for 
Alcohol Abuse and Alcoholism 
and treatment in Indian communities. The National InstitUte on 
s, provided seed monies for treatment of alcohol 
(NIAAA), which was established in the 1970' 
abuse among the Indians. The NIAAA funded the OEO-supponed programs and also provided 
demonstration projects. The NIAAA monies were not 
star-up or special funding for additional 
meant for long-term funding, therefore, Congress created the Indian Health Care Improvement 
ilS 
Act of 1976 (Public Law 94-437), directing that NIAAA program be transferred to 
progrs 
jurisdiction. There was a grdual transfer of these  betWeen 1978 and 1981. 
638
Most of the grants were convened to contracts, the majority of which were called "
contracts" in line with Public Law 93-638, the Indian Self-Determnation and Education 
Assistance Act. The Self-Determination law, which was reauthorized in October 1988 as Public 
antial component of the award process. 
Law 100-472, is currently in effect and represents a subs 
The Self-Determination law allows the IHS to contract diectly with Indian trbes for operation 
progrs 
through its 11 area 
of their own service programs. The IHS awards and monitors these 
offces. 
570, the "Indian Alcohol and Substace 
On October 27, 1986, Congress enacted Public Law 99-
Act 
" In addition to regular appropriations, this 
Abuse Prevention and Treatment Act of 1986.
Affais (BIA) for alcohol and 
authorized substantial funds for both IHS and the Bureau of Indian 
substance abuse services to the Indian youth population. 
570. SpecifIcally, 
On November 18, 1988, Congress reauthorized and amended Public Law 99-
of Health and Human Services for funding to 
the law authorized appropriations to the Secretar 
implement an Indian Health Service Youth Program. Under this program, the Secretar, acting  through IHS, was to establish an alcohol and substance abuse program for Indian youth that 
included the following activities: 
Development and implementation of a program for detoxification and treatment for 
Indian youth who are alcohol and substance abusers. This was to include regional 
treatment centers designed to provide detoxification and 
rehabiltation for both sexes 
on a referral basis. These regional treatment centers 
ar to be integrated with the 
intake and the rehabiltation programs that exist in the Indian communities. 
Renovation or constrction of a youth regional treatment center in each area under the 
jursdiction of an ilS area office. For the purose of constrcting or renovating these 
regional treatment centers, $6,000,000 was authoried for the fIscal year 1989 and 
$3,000,000 was authorized to be appropriated for fiscal years 1990 and 1991. 
Also, for the purpose of stafng and operating such centers, $3,000,000 was 
authorized for fiscal year 1989 and $11,000,000 for fIscal year 1990. For fUture fiscal 
years, there wil be an amount equal to fIscal year 1990 included in the base budget of 
the IHS. 
Cooperation with the BIA in developing and implementing community-based 
rehabilitation and follow-up services for Indian youth who are alcohol or substance 
abusers. These services ar to be designed to integrte long-term treatment and to 
retu 
monitor and suppon the Indian youth after their  to their home communities. 
Inclusion of family members of the youth in the tratment programs or 
other services. 
METHODOLOGY 
The 11 ilS area offces were the primar soure of informtion for this review. Offce staf 
directly involved with or knowledgeable of the varous inspection topics were asked to complete 
data collection instrments designed to secure the information needed to exame operations and 
activities. The questions included in the data collection instrments addssed varous topics, 
including guidelines and procedures, programs and services, regional tratment centers, fInancial 
accountability, operational monitorig, and the ilS management information system. 
An analysis of the information was conducted to determne to what extent each area offce had 
implemented the provisions of Public Law 99-570. To verify data received, three ilS area 
offices were selected for on-site visits. 
On-site visits were also made to the two regional tratment centers which were operational at the 
time of our study. Administrative and program staff were intervewed to determine the level of 
operation that the centers had achieved.  FINDINGS

The IHS Headquarters has not completed IHS alcoholism treatment standards. 
The Public Law 99-570 was passed in October 1986, and the IHS Alcohol and Substace Abuse 
Programs branch issued draft stadards in Februar 1988. These standards were revised in 
September 1988 and, as of July 1990, were still in draft. The thee offces we visited indicated 
that faiure to fInalze the guidelines created operational problems. For example, staff at one area 
offce said that they feel no compulsion to follow the IHS draf alcoholism stadards because 
they are not in final and ilS Headquarers, based on past experience, wil not enforce them. 
Employees at a second area offce said that little diection and lack of approved standads caused 
gaps in tratment services and weakened IHS Headquarrs ' crdibility on alcoholism. The third 
area office visited developed its own alcoholism stadads, based in pan on ilS's draft 
progr 
standards. This area offce follows these guidelines, in addition to aftercare  guidelies, 
which were developed by area offce staf. 
According to the three area offces, the ilS Headquarers has provided very little guidance to 
IHS area offices in development and implementation of Public Law 99-570 programs. The IRS 
Headquarers has not provided enough technical assistance to the ara offces nor do they have 
enough hands-on knowledge of the day-to-day operations at the area offces, according to the 
area office interviewees. 
The IHS Headquarters has failed to meet quality assurance objectives. 
The IRS Headquarers did not conduct reviews of area offices every two years. 
Progrs 
According to IRS Headquarers directives, the ilS Alcohol and Substace Abuse 
branch is to review ara offces once every two years. Although IHS reviewed six area offices in 
1988, only one area office was reviewed in 1989. Four area offIces have not had a formal 
Progrs 
quality assurance review from the IRS Alcohol and Substace  branch in the last two 
years. 
Because of lack of guidance and approved standards, area offIce sta are uncenan about the 
appropriateness of funding decisions made for cenain activities. For example, within one area 
office s service area, at least two activities appeared to be inappropriately funded under the youth 
alcoholism programs. One was a " Sober Rodeo " in which pancipants and the audience were 
banned from bringing alcohol onto the premises, and the other was an elaborate renovation of a 
camping site in which substance-free lifestyles were only a small par of the campout s agenda. 
Area office staf doubted the validity of these alcoholism treatment program, stating that they 
now question whether this was an appropriate utilization of Public Law 99-570 funds.  g., 
Area offices did not conduct reviews of trbal programs in accordance with their own 
goals. 
The IRS draft alcoholism standards indicate that periodic quality assurance reviews should be 
conducted. To check the extent to which quality assurance reviews monitored the programs, a 
copy of each quality assurance review conducted in calenda year 1989 by area offIce staff was 
requested. An analysis of these reviews revealed that each area offce performed the reviews in 
their own manner with their own evaluation instrment 
All IRS ara offices had different quality assurance objectives. We found varance between 
these objectives and the number of reviews actually conducted. Eight of eleven ara offices had 
established their own goals for annual reviews of al their tratment programs. Two area offIces 
had a goal for every other year reviews, while another ara office attempted reviews twice 
annually. Only one area had successfully met their goal. 
The IRS did not make effective use of information obtained in the reviews which they 
did conduct. 
Many common weakesses were noted among the numerous tratment programs in the area 
progrs 
offce review repons. Severa trbal alcoholism  did not have established policies or 
drt 
procedures, nor did they follow the IHS  alcoholism standads. According to many of the 
reviews, the forms comprising the management information system (the Alcohol Treatment 
Guidance System) were not being fIlled out or were not completely filled out. Case fIe 
organization was a serious problem among severa trbal alcoholism programs. Also, treatment 
plans were often incomplete and unclear. 
cenied. 
The IRS area offIce reviews mentioned that few of the alcoholism counselors were 
Some reviews said that sporadic counseling among tratment providers crated gaps in services, 
and that some youth were not receiving enough periodic individual or group counseling (e. 
L. 99-570 youth counselors were being used at a few treatment sites to provide counseling to 
clients in the adult residential treatment program, resulting in less time available to spend with 
the youth). A positive factor noted in the reviews is that cogent recommendations were almost 
always given, as well as follow-up site visits being scheduled if problems were discovered. 
progr 
In discussion with staff from three area offces, we found that the ara offce  review 
repons are not requested by nor submitted to IRS Headq  arrs. There is apparently no process 
. in place for IRS Headquarers to utilize information from the area offce program review report 
to provide feedback to all the area offces on common program defIciencies. 
The current IHS management information system is outmoded and ineffective to monitor 
alcohol program activity. 
Data submitted from the 11 area offices indicated that the Alcohol Treatment Guidance System 
served its purpose in the past, but has not been updated to fully serve curent program 
management needs. The area offce staff interviewed said that they did not trst the data  produced by the management information system. Among the weakesses pointed out, al area 
the accurcy, reliabilty, and effIciency of the management 
offces rased questions about 
information system. A few offIces also expressed concerns about the outdated mode of entering 
information into the system (i.e., keypunching). They felt that there are numerous errors 
associated with this type of process crating a lack  system. 
of trst in this 
While the DIG is awar that the IRS has been developing a new management information 
system over the last fIve years to track data on alcohol and substance abuse treatment, the system 
has yet to be implemented. The review team has leared that full implementation of the system 
at all area offIces wil not occur until 1995. 
The IHS has not complied with requirements in Public Law 99-570 to establish regional 
treatment centers in all IHS service areas. 
Public Law 99-570 provides for the constrction or renovation of a youth regional treatment 
center (RTC) in each of the 11 IRS service areas. While presently six RTC' s are reponed 
two were operational at the time of the study. The two RTC' s were the 
operational by ilS, only 
New Sunrse Regional Treatment Center in Acoma, New Mexico and the Jack Brown Center in 
Tahlequah, Oklahoma. In those areas where an RTC is not operational, the area offces indicated 
thauesidential treatment is generally purchased from commercial programs using P.L. 99-570 
funds. 
Problems were cited as reasons for noncompliance with the law. These include historical 
animosities among trbes causing an unwilingness to come to a consensus on the location of a 
facility, the purchase of comparble treatment services from the private sector, and the failure to 
find a suitable facility which would serve as a treatment center. 
Disagreement exists among some IHS components over the effcacy of RTC's. One area offce 
prefers to use only commercially purchased treatment. Two area offices felt that one regional 
treatment center per ara offce region is insuffcient. These tWO offces said more RTC' s are 
necessar to deal with the diversity of trbes and because of geogrphical limitations. 
In one area with an ilS-operated RTC, the average cost of treatment of a youth was 
000. In contrst, the average cost of residential treatment in a commercial 
approximately $20,
program was approximately $6 300 per individual. This is primarly due to the fact that the 
average stay in the IHS-operated RTC is considerably longer than the commercial progrs. We 
recognize that there may be a difference in kinds and qualities of services. Also, according to 
IHS officials, the RTC deals with many cultural needs and issues that ar not addrssed by 
commercial programs. 
The second regional treatment center, which was a trbally-operated facilty, had provided 
treatment for 53 youth between the ages of 13 and 18. The average cost of treatment was about 
$14 150 per youth for 122 days of inpatient treatment at $116 a day. Discussions held with area 
office staf indicated that the concept of the RTC could be very successful as long as provisions 
are made to address multiple diagnostic issues, and to include family involvement as part of 
residential treatment. They also indicated that this is not always par of the treatment process in  a commercial program. In addition to the RTC, however, they noted that referr agencies such 
as Alcoholics Anonymous should be utilized in an effon to unite community resources in the 
development of aftercare teams to maintan progression made by youth and their families in 
treatment. 
Nearly two-thirds of alcoholism counselors in the IRS are not certified. 
drt 
The IHS  operating standards, which ar the only operating rules curently in existence, 
require counselors who provide tratment services though IHS-funded programs to be cenified 
as substance abuse counselors. Information provided by most of the ara offces indicated that 
they rely on the State s rules to determne counselor certfIcation requirements. 
stadads 
The IRS draft alcoholism  lists thee classifIcations of counselors and counselor interns. 
fit 
The intern must be in a course leading towards cenication; the  level counselor shall be 
certfIed but not necessarly have any practical experience; and the second level counselor must 
be cenified as a substance abuse counselor and have two years counseling experience in a 
substace abuse program or counseling agency. One year of this counseling experience must 
have been with youths with alcoholism/substace abuse problems and must have provided an 
opponunity to demonstrate knowledge of counseling theory, techniques, and practices specific to 
Indi.an youth. 
tie fre 
The draft alcoholism standads do not provide a  for certfication of all IRS 
counselors. At one area office site which we visited, the OIG review team was told that by the 
end of a counselor s first year, that individual had to be cenied or workig toward eventual 
certfIcation. The IRS employee admitted that by using ths crteria any counselor could fall into 
the latter category, which was labeled "certfIable. " A recovering alcoholic would fIt into this 
category. It was explained to us that this is how ilS retans its non-qualfIed and largely 
uncertfIed counseling staff. 
As of sprig 1990, approximately 62 percent of all counselors were uncenied. According to 
primar reason for this high figur is that the individuals simply 
area office staf interviewed, the 
could not pass the cenifIcation examination. In addition, those who do pass the exam frequently 
leave for more lucrative positions. 
One area offce site visited decided not to retain its uncertfied sta. Alcoholism counselors 
were given three opponunities to pass the certfication examnation. Within one service unit in 
this Area, all alcoholism counselors "flunked" the certfication exam 3 times, and were dismissed 
by the area diector. The area office indicated that this maner of "gettg tough" is resulting in 
higher competence among treatment staff and better-quality treatment programs. The following 
graph displays the number of cenifIed and uncertfied counselors by area offices.  .. .. .. .. . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . ... . . . . . . . ... . .. . .. . . . '. . . .  . .... ..  . . . . . ... .. . . . .
Alcoholism Counselors

By IHS Area Office 
# of Counselors

160 
40  ..... . .. .. n. n .. ...0.  ..... .. . n ..
120 no. 
100 
IHS Area Offices 
Legend 
lI 
Noncertified
Certified 
The Bureau of Indian Affairs has not established emergency shelters as required by Public 
Law 99-570. 
Public Law 99-570 provides for the establishment of emergency shelters or halfway houses by 
the Bureau of Indian Affais for Indi(U youth who are alcohol or substance abusers, including 
youth who have been 31ested for offenses dictly or indictly related to alcohol or substace 
abuse. Regardig the latter, the law stipulates that when an Indian youth is 31ested for an 
alcoholism related offense and parntal custody is not possible, "  such youth shal be referrd to 
such facilty in lieu of incarceration... 
In addition to a referral facilty for youth who are arsted for 
alcohol related offenses, 
emergency shelters and halway houses also provide an alcohol-free environment for youth who 
have undergone residential tratment for alcoholism or substace abuse and cannot retur to 
their community immediately. 
At the time of the review, only one emergency shelter and no halfway houses had been 
established. Through September 1990, $8 millon has been appropriated for constrction of 
emergency shelters for fiscal years 1987-90, but approximately $5 milion has been actually 
millon was authorized for operation and stafng of emergency 
distrbuted. Also, although $12 
shelters for fiscal years 1987-90, only $1 milion was actualy appropriated, with $926,000 
actually distrbuted in fiscal year 1990.  Regional treatment center and ara offce sta who were interviewed said that the lack of these 
lapse, and severely limits the impact of
transitional living centers results in a high incidence of 

dollars spent on residential tratment. They indicated that the absence of these facilities also 
prevents youth who have received residential treatment frm returning to an alcohol- and 
drug-free environment after discharge. Therefore, youth ar forced to return to the same setting 
which may have initially contrbuted to their alcohol or substace abuse. 
EJ'idellce of ill appropriate use of funds has been referred to the DIG Office of Audit Services. 
Our inspection included a review of documentation and interviews with IRS employees. Based 
on information obtained in our review, we have made a referr of a possible misappropriation of 
L. 99-570 funds to the OIG Office of Audit Services for a financial audit.  RECOMMENDATIONS

The IHS should complete and promulgate operating standards. 
The IRS should act expeditiously to finalize the existing draft operatig standads for youth 
alcohol and substance abuse programs. Approved operating stadards would enable the area 
offices to reference specific guidelines in implementing and monitoring requirements of Public 
Law 99-570. 
The IHS Headquarters and area offices should conduct reviews in accordance with their own 
quality assurance goals. 
The IRS Headquarers and IHS area offces should come to a consensus as to what is needed by 
way of program performance reviews and commit the appropriate resources to accomplish this. 
PrOtocols should be reviewed and modified to assure the most appropriate timing and content of 
reviews and mae. up of review teams. 
The IHS should establish a process to review all area offce program reports and provide 
to the area offices. 
. feedback 
The IRS Headquarers should establish a process to review all area office program review 
repons to identify common progrm weakesses and systematically communicate them to the 
area offices. This would permt ilS Headquarters to specify areas of program priorities, needs, 
or deficiencies for area office follow up. 
The IHS should develop an adequate management information system which provides data on 
alcohol and substance abuse treatment. 
It is imperative that the IHS complete, as soon as possible, a comprehensive management 
information system which can appropriately distinguish between and follow all clients 
participating in the alcoholism programs, and the extent and nature of services that were 
received. The management information system should be fully developed to handle youth 
alcoholism program data and modern treatment methodologies. 
We also recommend that the new system provide a capabilty for trbal input and access. This 
would provide timely information at the trbal level to follow clients and conduct composite 
analyses on the trbal caseload.

The IHS should establish regional treatment centers in .every IHS service area, or advise 
Congress of their recommendation  to provide residential services. 
for an alternative strategy 
The IRS should increase effons to see that service areas without a regional treatment center 
establish such a facility as mandated by Public Law 99-570. As some service areas have 
encountered barers in attempting to establish regional treatment centers, the ilS should  coordinate with the ara offices to addrss the problems that hinder timely establishment of 
regional treatment centers. 
Since some disagreement exists among ara office constituents over the effcacy of regional 
treatment centers, the IHS should formally assess the regional tratment center issue and advise 
Congress of their recommendation on any new strtegies. 
The IHS should ensure that all alcoholism counselors become certfied. 
ar 
The IHS should ensure that al alcoholism counselors  certfied, as required by the IHS draft 
operating standads. If the alcohol and substace abuse treatment of Indian youth is to be 
effective, qualifed counselors ara of prima importce. Ara offces should do everything 
possible to promote cenmcation of and professionalism among alcoholism counselors. 
The IHS should work with the Bureau of Indian Affairs to assure the timely construction and 
operation of emergency shelters and halfway houses. 
Since treatment of the adolescent abuser often requirs alcohol- and drg-free transitional living 
quarters, the effectiveness of the residential treatment program is impaid when there are no 
emergency shelters or halfway houses. 
retu 
Without trsitional living centers, youth must  to an environment which may have 
precipitated the problem. Considerable tie has elapsed since the appropriation of these funds, 
and it is imperative that IRS enhance effons to see that establishment of these facilties takes 
place. 
To ensure effective utilzation of these facilities when established, provisions should be 
developed for adequate and timely monitoring of these facilties. 
We recommend that the ilS reexamine the Memoradum of Agrement with the Bureau of 
Indian Affai (BIA) to establish a management framework for the stang and operation of 
emergency shelters and halway houses that results in an effective coordination of resources and 
programs of IHS and BIA components. A modifIcation of the Marh 1987 Memoradum of 
Agreement may be necessar in order for tratment goals to be met.  AGENCY COMMENTS

The Public Health Service (PHS) concurrd with all the recommendations in the OIG draft 
repon. However, PHS stated that successful implementation of the last two recommendations 
s control. 
cannot be assured because those two areas are not solely within ilS'
We agree that programs of the Bureau of Indian Affais are not dictly under PHS's control. 
However, we believe the IRS should continue coordination effort with the Bureau of Indian 
Affais (BIA) in order to assure timely constrction and operation of emergency shelters and 
halfway houses. In a recent contact with BIA staf, we were advised that the constrction of 
emergency shelters and halway houses would slip from the present schedule to a completion 
date in fiscal year 1992. 
While agreeing to emphasize the importnce of having all counselors cenifed, PHS believes that 
a more realistic and practical goal is to certfy 80 percent of counselors by 1991, and then retain 
that level. We agree that such a program would be responsive to our recommendation.  APPENDIX A

PUBLIC HEALTH SERVICE COMMENTS  &.  '-- -- '.\..;'   -._,.._-  ,_-,'" -". -(- , "' . ..
REm 
DEPARTMENT OF  HUMA SERVICE  Pulic He 
Memorandum
JA 2 
1991 
Dae 
Assistant Secretary 
From  for Rea 1 t 
,,); "l  '9
Subjec  PRS Comments on Office of Inspector(i  eral Draft Report

Indian Health Service 
(IRS) Youth Al
 hol and Substance Abu

Programs 
Inspector General 
, OS

Attached are the PHS comments on the findings and

report. 
recommendations contained in the subject draft  Though
we cone ur wi t h all of the re commenda t ions) the following
comments explain why 
recommendations is notsuc cesssfuol ilmeplemleynta tiwon ofi tthhe in IRS' control.  ast
First 
, since IRS is outside the certification process, and
because there is wide variance in the certification proe

among the States , there are legitimate reasons that restrict 
IRS from ensuring continuous certification of all alcoholism

counselors employed in Indian alcohol programs. Second 
, though

IRS has a positive working relationship with 
staff in the

Bureau of Indian Affairs (BIA), Department of Interior ,  the 
eventual construction of emergency shelters and halfway houses
using BIA appropriated 
funds is not under IRS control. 
6. Ik
Mason , M.  ) Dr. 
Attachment 
I . 
, r 
i 'U  ...1  .Ji 
) ::::;:.;f 
i - . I 
 1-' .
 COMMS 
PUBLIC HEATH SERVICE (PHS)  ON OFFICE OF INSPECTOR 
GENERA ( OIG ) DRAT REPORT II INDIA HEATH SERVICE YOUTH ALCOHOL 
AND SUBSTANCE ABUSE PROGRAS, " OEI-07-89-00940 
OIG Recommendation

We recommend that the Indian Health Service  ms ) : 
standars for youth
Complete and promulgate operating 
alco 
l and substance abuse programs. 
PHS Comment

We concur. On  1990, the operating standards were
August  20,
submi tted to the IHS Division of Management Policy fpr
approval. It is 
expected that the standards will be' approved 
1991. 
by the end of March  Upon approval of the standards, 
instructions will be developed and sent to the 12 IRS Area

plementation in

Alcoholism/Substance Abuse Coordinators for 

their area wi thin one month of the approval of the standards.

Monthly follow-up calls will be placed to each IRS Area

plementing the 
Coordinator to check on the progress in 
 standards 
operating procedures. Full imlementation of the 
should be completed by the end of fiscal year (FY) 1991.

Sumary reports 
plementation will be 
on the progress of 
submitted to the Associate Director, Office of Health Programs

( OHP ), IHS, on a monthly basis. 
OIG Recommendation

Headquarters and Area Offices conduct reviews in

ow quality assurance goals. 
accordance with their 
PHS Cornen 
We concur. A renewed emphasis has been initiated to improve

Areas. 
quality assurance site reviews in each of the 12 IHS 
the IHS Area Alcoholism/Substance Abuse

Decemer 6,  1990, 
Coordinators, IHS Headquarters Alcoholism and Substance Abuse

Program Branch (ASAPB) staff, and tribal representatives formed

a workgroup to implement a plan for reviewing Area Office

alcoholism progr  s using a newly revised protocol. The 
workgroup will finalize the review protocol by the end of

February 1991. A schedule namng the sites to be reviewed and 
the dates of the review will be completed and distributed to

1991. In the interim, 
each Area Office by the end of March 
review teams consisting of IHS employees, tribal

and, 
representatives, and alcoholism staff will be formed 
beginning in May 1991, these teams will be sent to each Area to

review these programs. A report on the findings and 
the reviews will be completed by October

recommenda tions of 
1991.  sumrizing 
Monthly follow-up reports  the progress of reviews 
will be submitted to the IHS Area Directors; Associate

Director, OHP; and Area Alcoholism/Substance Abuse Coordinators

beginning in January 1992. 
eIG Recommendation

Establish a process to review all Area Office program

reports and provide feedback to the Area Offices.

PHS Comment

We concur. On Decemer 6, 1990, an IRS/tribal workgroup to

provide oversight for this activity was established. The 
workgroup will establish a process and fo  t for reporting

1991. 
data concefronirn.gt  program admnistration by February  The 
proposed 
will be presented to the Area 
Alcoholism/Substance Abuse Coordinators for their review,

comment and approval at their next meeting scheduled for March

1991. Area Coordinators will be trained on this process in

order to have it implemented in all Areas by the end of April

1991. 
Follow-up training on the use of the process will be 
provided to all Area Coordinators to ensure unifo:m

plementation by the end of May 1991. 
eIG Recommendation

infor.tion 
Develop an adequate management  system which 
treatment. 
provides data on alcohol and substance abuse 
PHS Comment

We concur. In Decemer 1990 a workgroup was fo  ed to 
establish a workplan for revising the activities for the

System. This 
modification of the Alcoholism Treatment Guidance 
workplan was developed and presented to Area

Alcoholism/Substance Abuse Coordinators and tribal

representatives. Area Coordinators were provided copies of the

plementation plan and were asked to submit a corresponding

Chemical Dependency Management Info  tion System (CDMIS) for

their Area by January 31, 1991. The Area CDMIS implementation

plans will be consolidated into a master CDMIS plan. The Beta

testing of CDMIS in selected Areas will be completed in August

1991, and full-scale implementation of CDMIS in all Areas will

1992. Smmry reports on the 
begin in the first quarter of FY  subtted 
status of the progress of the CDMIS activity will be 
to the Associate Director, OHP; Area Directors; and Area

monthly basis 
Alcoholism/Substance Abuse Coordinators on a 
beginning January 1992.  eIG Recommendation

Establish regional treatment centers 
(RTCs) in every IHS 
service area or advise Congress of their recommendation

for an alternative strategy to provide residential

services. 
PHS Comment

We concur. The ASAPB Medical Advisor and the Alcoholism

Program Specialist are responsible for maag  g ths acti vi ty . 
The Medical Advisor will direct those activities related to

programng and treatment contaed in the RTCs. The 
Alcoholism Program Specialist monitors issues related to

meeting the legal requirements for construction of RTCs under

Public Law (P.  ) 99-570.

In Decemer 1990, a workgroup comprised of the Directors of

existing RTCs was appointed to develop guidance progr  g and 
mm; 
treatment services in newly constructed or proposed RTCs, and

problem during the constrction phase of 
to identify common 
RTCs . A report on the workplan will be completed at the first

meeting of this workgroup scheduled for January 28, 1991. A

plan 
matrix which graphically depicts the  g, construction and 
coordina tion phases for completing the construction of RTCs

will be developed by this workgroup by the end of Mach 1991. 
ASAPB has developed, in conjunction with the Office of the

General Counsel, a policy that specifies the conditions in

which IHS will construct RTCs. It is expected that this policy

plementation by the end of March 1991. 
will be approved for 

Beginning in January 1991, a monthly consolidated report will

be prepared to address the completion of all RTCs currently in

the planning and development phase and to report on problems

from programs now serving clients. The reports will be

submi tted to the Area Directors, Area Alcoholism/Substance 
Abuse Coordinators, and the Associate Director, OEP.

eIG Recommendation

certified. 
Ensure that all alcoholism counselors become 
PHS Comment

We concur with the intent of this recommendation. However, 
there are legitimate reasons that restrict IRS from ensuring

continuous certification of all alcoholism counselors employed

in Indian alcoholism programs. 
The IHS is outside the 
certification 
certification process and must rely upon existing 
or credentialing entities. There is wide variance in the
 py 
mechanism, as 
certification process among States who have such 
bodies. 
well as among national tcareed entialing  Some States 
require counselors to  one year of non-paid, scuepretrfviiesded.  
employment in State certified agencies to becomer eqement. 
comly with 
IHS cannot require tribes to  such a 
To do so, would result in no service delivery in some tribal

communi ti

howver, ensure an emhasis 
IRS can,  be established on the 100
percent certification of certifiable counselors. 
An IRS/tribal 
Decemer 
workgroup was for.ed in  1990 to assist in developing
he first

the mechanism for certifying alcoholism counselors. 

meeting of this workgroup is scheduled for January 1991, and it

the
is expected that work on the proje1ct w9ill9 be 1com.pl eted 

end of April  IRS' goal is to certify 80 percent of all 
program under 
alcoholism counselors employed in alcohol 
contract to IRS by the end of 1991 and to maintain the 80

rate. 
percent certification 
A plan for certifying alcoholism counselors was developed in

plemented in 1988. Since 1988,

each IHS Area and 

P . L. 99-570 training funds have been allocated to each Area for
the puroses of 
preparing alcoholism counselors to meet
certifica tion  continuig 
requirements and for providing 
education to certified counselors. IHS' Headquarers ASAPB 
staff will provide technical assistance to the Area

Alcoholism/Substance Abuse Program to enhance training 
endeavors through consultation with treatment programs such as

Hazelden, the Betty Ford Center, and the Commssion on the 
Headquarters 
Accreditation of Rehabilitation Facilities. 
basis. 
consultation to the Areas has been provided on a monthly 
A monthly progress report on the certification activities will

subtted 
be 
to the Area Directors, the Area 
Alcoholism/Substance Abuse Coordinators, and the Associate

Director, OHP.

eIG Recommendation

(BIA), Departent 
Work with the Bureau of Indian Affairs 
of Interior, to secure the release of funds that have been

houses. 
appropriated for emergency shelters and halfway 
PHS Comment

We concur. In Septemer 1990, the Assistant Secretary, BIA,

appointed a director of the Alcoholism and Substance Abuse

Program for that agency. Since this appointment, staff from

thee  director. 
IHS' ASAPB have held  meetings with this new  We have been info  ed that funds were released to the Division

BIA, for distribution to tribes for

of Social Services 
 1989. Of 
construction of emergency shelters in  the 20 grant 
six tribal groups have completed construction and these

awards  operational. 
emergency shelters are  Construction of the
remining  exected to be comleted by the end of 
14 shelters is 
FY 1991.