O I G   
FFICE OF  NSPECTOR  ENERAL
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect 
the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of 
beneficiaries served by those programs.  This statutory mission is carried out through a nation-wide network of 
audits, investigations, and inspections conducted by the following operating components: 
OFFICE OF AUDIT SERVICES 
The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with its own audit 
resources or by overseeing audit work done by others.  Audits examine the performance of HHS programs and/or 
its grantees and contractors in carrying out their respective responsibilities and are intended to provide 
independent assessments of HHS programs and operations.  These assessments help reduce waste, abuse, and 
mismanagement and promote economy and efficiency throughout HHS. 
OFFICE OF EVALUATION AND INSPECTIONS 
The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the 
public with timely, useful, and reliable information on significant issues.  These evaluations focus on preventing 
fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of departmental programs.  To 
promote impact, OEI reports also present practical recommendations for improving program operations.  
OFFICE OF INVESTIGATIONS 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and misconduct 
related to HHS programs, operations, and beneficiaries.  With investigators working in all 50 States and the District 
of Columbia, OI utilizes its resources by actively coordinating with the Department of Justice and other Federal, 
State, and local law enforcement authorities.  The investigative efforts of OI often lead to criminal convictions, 
administrative sanctions, and/or civil monetary penalties. 
OFFICE OF COUNSEL TO THE INSPECTOR GENERAL 
The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and 
opinions on HHS programs and operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS programs, including False Claims 
Act, program exclusion, and civil monetary penalty cases.  In connection with these cases, OCIG also negotiates and 
monitors corporate integrity agreements.  OCIG renders advisory opinions, issues compliance program guidance, 
publishes fraud alerts, and provides other guidance to the healthcare industry concerning the anti-kickback statute 
and other OIG enforcement authorities. 
    REPORT IN BRIEF
 
Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure 
and Reopening, OEI-06-17-00270 
WHY OIG DID THIS REVIEW 
The Indian Health Service (IHS) provides comprehensive Federal health services to approximately 2.6 million American 
Indians and Alaska Natives.  In 2016, OIG found significant problems in the quality of care and oversight of IHS-
operated hospitals.  Congressional testimonies in recent years and deficiency findings by the Centers for Medicare & 
Medicaid Services (CMS) also raised concerns about quality and patient 
access to care in IHS hospitals. 
KEY TAKEAWAY 
During a 3-year period, IHS temporarily closed the emergency department 
(ED) at 4 of its 24 hospitals.  The Rosebud Hospital ED remained closed for  IHS made significant improvements at 
more than 7 months.  We conducted this study to examine IHSs  Rosebud following the ED closure but 
management of the closure and reopening of the Rosebud Hospital ED to  continues to struggle with securing 
identify lessons learned that IHS could apply should similar situations arise  adequate onsite staffing and 
in the future.  leadership, both of which are critical to 
HOW OIG DID THIS REVIEW  sustaining hospital operations.  
This report provides a chronology of events and identifies factors that led  Enhanced attention and oversight by 
to the closure of the Rosebud Hospital ED, improvement efforts to reopen  IHS and CMS provided momentum for 
the ED, and continued lapses in compliance.  We interviewed leadership  Rosebud to address its problems, but 
and staff at IHS headquarters, the Great Plains Area Office (AO), and  recent deficiencies indicate that IHS did 
Rosebud Hospital, and other stakeholders, including administrators at  not sustain the improvements in 
CMS, receiving hospitals, and the Rosebud Sioux Tribe.  We also reviewed  staffing and leadership after this focus 
both internal and publicly available documents from IHS and stakeholders.  diminished. 
CHRONOLOGY OF EVENTS 
Decision to Close and Impact of Closure  
After receiving citations during a CMS survey deemed of immediate jeopardy (IJ) to ED patients, IHS closed the 
Rosebud Hospital ED in December 2015.  IHS diverted Rosebud patients to the nearest hospitals but did not provide 
the hospitals or the emergency medical services (EMS) adequate time to prepare.  The receiving hospitals were 
overwhelmed by the volume and complexity of patients, and EMS struggled to meet demands with its limited staff and 
longer patient transports.  Our review identified several factors that led to and complicated the closure of the Rosebud 
Hospital ED: 
 Insufficient hospital staffing 
Staffing shortages, particularly in the ED, contributed to findings of noncompliance with the Medicare Conditions 
of Participation and increased dependence on contracted providers rotating in and out. 
 Changing and inconsistent hospital leadership 
Instability and inexperience in key leadership positions made it more difficult for IHS to make strategic, long-term 
improvements at Rosebud Hospital. 
 Inadequate hospital infrastructure 
Rosebud Hospital did not have an adequate infrastructure to ensure basic quality care, including policies and 
procedures, working equipment, and staff training. 
 Lack of oversight by IHS 
IHS officials and staff described poor relationships between the Great Plains AO and Rosebud Hospital, and 
communication breakdowns across IHS, which limited support for identifying and correcting problems. 
 Poor coordination with local partners 
IHS submitted a plan to CMS for operating without an ED but did not adequately communicate with hospital staff, 
EMS, and receiving hospitals, who received little warning and were overwhelmed with demand. 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening         i  REPORT IN BRIEF 
Corrective Action and Reopening  
To correct Rosebud Hospitals deficiencies and re-open the ED, IHS provided additional resources and support from 
across IHS, sought assistance from other agencies, and entered into a Systems Improvement Agreement (SIA) with 
CMS.  IHS made improvements prompted by the SIA, which included updating policies and revising governing board 
bylaws.  Our review identified several factors that led to improvement and reopening of the ED in July 2016: 
 Accountability for compliance and quality 
IHS brought in an accomplished team of clinical and management leaders with experience in solving problems and 
maintaining compliance, holding staff accountable, and fostering a culture of shared responsibility. 
 Systemic changes 
IHS and hospital officials employed systemic methods to identify and address problems, leading to widespread 
change for the hospital and agency. 
 Standardized policies and procedures 
IHS and hospital officials developed and revised hospital policies, delineated clearer roles and responsibilities, and 
streamlined procedures. 
 Investment in staff training 
IHS and hospital officials conducted assessments and training to better ensure that hospital staff were prepared 
and proficient in treating patients. 
 Improved communication and support from IHS 
Rosebud Hospital officials had more frequent communication and closer collaboration with the Great Plains AO 
and IHS headquarters, and additional support across the Department of Health and Human Services. 
Continuing Concerns and Sustainability of Improvements  
IHS completed the SIA to CMSs satisfaction in September 2017, but CMS cited Rosebud Hospital again with ED-related 
IJ deficiencies in July 2018.  Our review identified several factors that led to continued lapses in compliance: 
 Continuing turnover in hospital leadership 
IHS brought strong leadership teams from across IHS and other agencies to correct problems at Rosebud.  
However, those teams were temporary and frequent changes in leadership continued to hamper operations. 
 Insufficient transition of new hospital leaders 
IHS did not build in sufficient overlap and transition of incoming and departing leadership.  This resulted in a lack 
of cohesive strategy, nonadherence to agency priorities, and discontinuation of improvement efforts. 
 Continuing difficulty maintaining staff 
As before, IHS and hospital officials struggled to recruit and retain long-term hospital staff and relied on 
contracted providers to temporarily fill the gaps. 
 Corrective actions not engrained 
Temporary leaders at Rosebud instituted new policies, procedures, and training.  However, those solutions were 
not employed long enough to fully take root with leadership and contracted staff rotating in and out of the 
hospital. 
 IHS could not sustain attention 
Rosebud Hospital and the Great Plains AO received enormous support and focus from IHS and other agencies 
following the ED closure, but this attention could not continue indefinitely. 
WHAT OIG RECOMMENDS 
To correct underlying problems and better serve its beneficiaries, we recommend that IHS, as a management priority, 
develop and implement a staffing program for recruiting, retaining, and training clinical and leadership staff in remote 
hospitals.  This is a necessary first step to addressing quality issues long term; however, other actions are also needed, 
including taking steps to ensure that IHS intervenes early and effectively when problems emerge.  To ensure better 
management of any future ED closures, we also recommend that IHS develop procedures for temporary ED closures 
and communicate those procedures with receiving hospitals and EMS to ensure that they are adequately prepared for 
such events.  IHS concurred with our recommendations.     
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    ii  TABLE OF CONTENTS
 
BACKGROUND .................................................................................................................................................................... 1 
CHRONOLOGY  
Decision to Close and Impact of Closure  
IHSs decision to temporarily close the Rosebud ED in December 2015 was largely due to quality-of- 
care concerns and staffing shortages  ........................................................................................................................... 6 
IHS did not inform Rosebud staff of plans for diverting patients and failed to adequately notify  
receiving hospitals of the ED closure, giving them no time to prepare for an influx of patients  .................................. 8 
IHS opened an urgent-care clinic at Rosebud to meet community needs, but confusion about its  
services led to some emergency patients presenting at the clinic  .............................................................................. 12 
To offset costs for patient diversion, Rosebud received additional PRC and other funds, but receiving  
hospitals and EMS struggled to absorb their increased costs  ..................................................................................... 13 
Key Contributing Factors .............................................................................................................................................. 15 
Corrective Action and Reopening  
Despite HHS-wide assistance, IHS was unable to correct Rosebuds deficiencies and entered into an  
SIA with CMS in April 2016, facing termination from Medicare  .................................................................................. 16 
IHS made improvements at Rosebud prompted by the SIA, some of which resulted in agency-wide  
changes, but struggled to secure staff and resume ED services  ................................................................................. 18 
Prior to the ED reopening, IHS conducted several assessments and trainings to ensure that the ED  
was ready to resume services  ..................................................................................................................................... 23 
IHS reopened the Rosebud ED in July 2016 after correcting its deficiencies, but concerns about  
sustainability remained, primarily because of staffing instability  ............................................................................... 24 
Key Contributing Factors .............................................................................................................................................. 26 
Continuing Concerns and Sustainability of Improvements  
IHS completed the SIA in September 2017, but Rosebud was again cited in July 2018 with an IJ-level  
deficiency in the ED and placed by CMS on a termination track  ................................................................................. 27 
Key Contributing Factors .............................................................................................................................................. 29 
CONCLUSION AND RECOMMENDATIONS 
As a management priority, develop and implement a staffing program for recruiting, retaining, and  
transitioning staff and leadership to remote hospitals ................................................................................................ 30 
Enhance training and orientation for new hospital leaders to ensure that they follow IHS directives and  
continue improvement efforts  .................................................................................................................................... 31 
Continue to take steps to ensure early and effective intervention when IHS identifies problems at hospitals  .......... 31 
Develop procedures for temporary ED closures, and communicate those procedures with receiving hospitals 
and EMS to ensure that they are adequately prepared to receive diverted patients during such events  .................. 31 
AGENCY COMMENTS AND OIG RESPONSE ..................................................................................................................... 33 
APPENDICES 
A: Timeline of Key Events for IHS Closure of the Rosebud ED, 20152018 .................................................................. 34 
B: Agency Comments ................................................................................................................................................... 35 
ACKNOWLEDGMENTS ....................................................................................................................................................... 38 
ENDNOTES ........................................................................................................................................................................ 39
  BACKGROUND
 
OBJECTIVE 
To examine Indian Health Service (IHS) management of and procedures for the temporary closure and subsequent 
reopening of the Rosebud Hospital emergency department (ED), including the agencys collaboration and coordination 
with affected parties. 
BACKGROUND 
IHS is responsible for providing Federal health services to American Indians and Alaska Natives (AI/ANs), and has an 
annual budget of $5.6 billion.1  The Indian Health Care Improvement Act (IHCIA) provides the legal authority for the 
provision of healthcare to AI/ANs.2  In partnership with the 573 federally recognized tribes, IHS provides primary and 
preventative healthcare services to approximately 2.6 million AI/ANs living in the United States.3  IHSs mission is to 
raise the physical, mental, social, and spiritual health of AI/ANs to the highest level. 
However, reports of health disparities and inadequate healthcare services for AI/ANs have been a Federal government 
concern for nearly a century.  In recent years, much attention has focused on inadequacies at IHS hospitals in the 
Great Plains Area, which serves tribes in parts of Iowa, Nebraska, North Dakota, and South Dakota.4, 5, 6  In February 
2016, the Senate Committee on Indian Affairs held a hearing on the substandard quality of care in IHS facilities in the 
Great Plains Area.7  Testimony from the Centers for Medicare & Medicaid Services (CMS) and tribal representatives 
described concerns about several hospitals in the Area, including noncompliance with the Medicare Conditions of 
Participation (CoPs) and the Emergency Medical Treatment and Labor Act (EMTALA) requirements.  During a 
congressional hearing in March 2017, a member of the House Committee on Appropriations Subcommittee on Labor, 
Health and Human Services, Education, and Related Agencies raised similar concerns about quality of care and 
specifically hospital ED closures in the Great Plains Area.8   
Between 2014 and 2016, IHS temporarily closed four hospital EDs, forcing patients to seek treatment elsewhere.9  One 
of theseRosebud Hospitaldiscontinued its emergency services for more than 7 months (December 5, 2015, 
through July 15, 2016).  Rosebud Hospital is a 35-bed medical facility located in the Great Plains Area and is the 
primary source of healthcare for the 
Rosebud Sioux Tribe in South Dakota.10  
Rosebud Hospital 
During the ED closure, patients had to 
travel farther for emergency servicesthe 
nearest emergency rooms were 45 and  
55 miles away.11  An IHS press release 
about the event cited staffing changes 
and limited resources as reasons for the 
closure, while other sources suggested 
that the care was deemed unsafe.12, 13  
After the closure, tribal representatives 
raised allegations that the lengthy 
ambulance transports to other healthcare 
facilities during the closure contributed to 
several patient deaths.  They also 
 
expressed concerns about IHSs decision  Photo: HHS-OIG, 2017 
process, communication, and 
 
management of the closure.14 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           1  BACKGROUND 
OVERVIEW OF INDIAN HEALTH SERVICES 
IHS provides healthcare services to AI/ANs directly through IHS-operated facilities or provides financial support for the 
tribes to operate their own healthcare systems.15  In fiscal year (FY) 2019, about 40 percent of IHSs $2 billion 
appropriation to provide healthcare services in hospitals and health clinics was allocated to Federal operations serving 
tribes directly.  The remaining 60 percent was allocated to individual tribes or tribal organizations.16 
IHS Headquarters and Area Offices.  IHS headquarters provides general direction, policy development, and support to 
each of the 12 Area Offices (AOs) and their healthcare delivery sites, which may include hospitals, urgent-care clinics, 
and/or other types of facilities.  AOs oversee the delivery of health services and provide administrative and technical 
support to the federally operated facilities.  The Great Plains AO is responsible for the oversight of five IHS-operated 
hospitals, including Rosebud Hospital, and other direct-service health centers and clinics in the Area.  The Great Plains 
Area covers 17 tribes (approximately 130,000 tribal members) across 4 States (Iowa, Nebraska, North Dakota, and 
South Dakota).17 
IHS maintains its current policies, procedures, and operating standards in the Indian Health Manual (IHM).  IHS policy 
directs that the IHM is the preferred reference for IHS staff regarding IHS-specific policy and procedural 
information.18   
IHS Hospitals.  IHS directly operates 24 acute-care hospitals in 7 Areas, many of which are small and rural.19, 20  Most 
IHS hospitals have fewer than 30 beds.  In FY 2017, the average daily census was 158 inpatients for all IHS-operated 
hospitals and 6 inpatients for individual IHS hospitals.21  IHS hospitals are led by Chief Executive Officers (CEOs) 
responsible for facility management and accountable to IHS AOs.  
Rosebud Hospital.  For Rosebud Hospital, the average daily census was 3 inpatients in FY 2017, and the average 
number of ED encounters was 38 per day (or 14,046 ED patients for the year).22, 23  Rosebud Hospital provides a range 
of services, including obstetric, dental, and pediatric services, for about 35,000 AIs residing in and around the Rosebud 
Indian Reservation.24, 25  The Rosebud Sioux Tribe provides emergency medical services (EMS), which include both air 
and ground transportation.   
Hospital Funding.  In addition to funding appropriated by Congress for healthcare services in hospitals and health 
clinics, IHS hospitals may be reimbursed by Medicare, Medicaid, and private insurance entities for services they 
provide to AI/ANs enrolled in these programs or health plans.26  IHS estimates that it will collect slightly over  
$1 billion from these three sources in FY 2019.27 
Purchased and Referred Care.  In certain circumstances, IHS may supplement the care available in a particular location 
by purchasing services for specific AI/AN patients from non-IHS healthcare entities.  Under this program, known as 
Purchased and Referred Care (PRC), IHS hospitals use PRC funds to refer patients for emergency or specialty care that 
is beyond the scope or capacity of the IHS facility.  However, IHS is the payer of last resort and patients are required to 
exhaust all healthcare resources available to them from private insurance, State health programs, and other Federal 
programs before the PRC program can provide payment.  The PRC program does not have sufficient funds to cover all 
care needs and thus allocates healthcare on the basis of a medical-priority rating system.  In FY 2018, the PRC program 
denied and deferred an estimated 163,058 services needed by eligible AI/ANs, totaling nearly $677 million.28 
Catastrophic Health Emergency Fund.  The PRC program also administers the Catastrophic Health Emergency Fund 
(CHEF), which covers extraordinary medical costs associated with treatment of victims of disasters or catastrophic 
illnesses or injuries, such as those resulting from motor vehicle accidents.  IHS headquarters manages the CHEF funds 
and can use those funds for high-cost cases after a threshold payment amount of $25,000 is met.29 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    2  BACKGROUND 
MEDICARE CONDITIONS OF PARTICIPATION 
IHS requires hospitals to be certified by CMS or accredited by an accrediting organization that supports the 
reimbursement requirements established by CMS.30, 31  Among these requirements are the CoPs, a set of minimum 
quality and safety standards.  The CoPs include requirements such as establishing an effective governing body legally 
responsible for the performance of the hospital, maintaining an organized medical staff that is responsible for the 
quality of patient medical care, and developing and maintaining Quality Assessment and Performance Improvement 
(QAPI) programs.32  A governing body is the only authority that can grant medical staff membership and/or clinical 
privileges through a comprehensive credentials review.33, 34  Each hospital is responsible for ensuring that it meets 
applicable standards and for reporting its certification or accreditation status to the Area Director.  The Area Directors 
are responsible for forwarding this information annually to IHS headquarters.35 
CMS and accrediting organizations monitor IHS hospitals compliance with the CoPs through periodic onsite surveys.36  
Surveyors observe how hospitals provide care to patients, and assess whether that care meets the needs of the 
patients and is in compliance with all requirements.  To indicate noncompliance, surveyors cite hospitals with 
deficiencies that hospitals must correct in a timely manner to continue participating in Medicare.  If surveyors identify 
an immediate jeopardy (IJ), which is noncompliance with one or more requirements that caused, or is likely to cause, 
serious injury, harm, impairment, or death to a patient, the hospital must immediately develop and implement a plan 
of correction to remove the IJ or face termination from the Medicare program by CMS.37  CMS may also terminate 
hospitals if they receive condition-level deficiencies, meaning that one or more deficiencies related to a particular 
CoP are extensive or severe enough that CMS considers the hospital to be out of compliance with the entire condition.  
To avoid termination in the event of condition-level deficiencies, hospitals must submit a plan of correction and, within 
90 days of the survey, implement changes to re-gain compliance.38, 39   
Systems Improvement Agreement.  If a hospital is unable to correct its deficiencies, CMS may terminate the hospitals 
participation in Medicare or enter into a Systems Improvement Agreement (SIA) with the hospital.  The SIA is a binding 
agreement, entered into voluntarily by the hospital and CMS.  Through the SIA, CMS can extend the effective 
termination date to allow the hospital additional time to achieve compliance with the CoPs, contingent on the 
hospitals participation in quality improvement activities and demonstration of improved outcomes.40 
REQUIREMENTS FOR HOSPITAL EMERGENCY SERVICES 
For hospitals that have a dedicated ED (department designated for emergency care), additional requirements apply.  
These hospitals must have appropriate policies and procedures to meet patients emergency needs, integrate 
emergency services with other hospital departments, and ensure adequate medical and nursing staff qualified in 
emergency care, among other requirements.41, 42  Although hospitals are not required to have a dedicated ED, all 
hospitals must provide emergency services, which include initial evaluation, diagnosis, and treatment for medical 
conditions that could place the health of an individual in serious jeopardy or result in serious impairment without 
medical attention.43, 44  EMTALA requires all Medicare-participating hospitals to provide a medical screening exam and 
stabilizing treatment for individuals with potential medical emergencies.45, 46 
Diversion.  When a hospital ED is functioning at, or close to, its maximum capacity, hospitals can invoke diversionary 
status.47  Diversionary status directs ambulances to bypass the hospital ED and transport patients to other nearby 
medical facilities.  Hospitals diverting patients to other facilities must still follow EMTALA requirements to examine and 
stabilize patients who arrive at the hospital.48, 49 
Closure.  IHS has specific requirements pertaining to the closure of a facility or portion of a facility, including the ED.  
The IHCIA requires the Secretary of the Department of Health and Human Services (HHS) to notify Congress at least  
1 year in advance of a permanent closure and to evaluate the closures impact on the community prior to the closure.  
The evaluation must include an analysis of alternative healthcare resources for the affected population, with 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    3  BACKGROUND 
consideration given to cost-effectiveness, quality of care, and the views of the tribes served by the facility.50  These 
requirements do not apply to facilities in which a temporary closure has been deemed necessary for medical, 
environmental, or safety reasons.51 
RELATED WORK 
This study expands on prior and ongoing work by OIG.  In October 2016, OIG issued companion reports describing lack 
of quality oversight and a number of challenges that affect IHS hospitals ability to provide quality care and maintain 
compliance with the Medicare CoPs.52, 53  OIG made several recommendations to IHS, such as implementing a quality-
focused compliance program, establishing standards and expectations for AO/Governing Board oversight activities, 
conducting a needs assessment, and developing an agency-wide strategic plan to address IHS priorities.  OIG also 
recommended that CMS conduct more frequent surveys of non-accredited hospitals and inform IHS leadership when 
citing hospitals with deficiencies.  Additionally, OIG recommended that the Office of the Secretary of HHS lead an 
examination of the quality of care delivered in IHS hospitals through the HHS Executive Council on Quality Care, which 
is currently inactive, and identify and implement innovative strategies to mitigate IHSs longstanding challenges.  In 
response to our recommendations, IHS implemented a Quality Framework to guide the agencys strategic vision for 
quality and patient safety, established a new Office of Quality, and revised the Governing Board structure.   
Prior work by the U.S. Government Accountability Office (GAO) also identified issues in IHS oversight and facility 
operations.  In January 2017, GAO found inconsistencies in governing board meetings, reporting of quality data, and 
reporting of adverse events (harm to a patient because of medical care).54  In a more recent report, in August 2018, 
GAO found that despite IHS recruitment and retention efforts, the agency continued to face significant challenges in 
filling provider vacancies, which affects patient access and quality of care.55   
Ongoing work by OIG includes a medical review that will determine the incidence, preventability, and contributing 
factors of adverse events in IHS hospitals.  OIG is also conducting a management review of IHS headquarters 
operations. 
METHODOLOGY 
Scope.  This study reviews IHS actions and policies regarding the closure and reopening of the Rosebud Hospital ED 
from December 5, 2015, through July 15, 2016.  The report provides a chronology of events and identifies factors that 
contributed to the closure, the closure decision, challenges that IHS and other affected parties experienced during the 
closure, improvement efforts that ultimately led to the ED reopening, and continuing concerns.  The report describes 
communication and collaboration between IHS and the involved parties, including CMS, and the roles and 
responsibilities of each level at IHS, including Rosebud Hospital, Great Plains AO, and IHS headquarters.  See the 
Appendix for a detailed timeline of key events related to the Rosebud ED closure. 
Data Sources.  Report findings are based on data from interviews and document reviews collected between June 2017 
and December 2018.   
Interviews with officials and staff from IHS, CMS, HHS leadership, Rosebud Sioux Tribe, receiving hospitals, and the 
South Dakota Department of Health.  We conducted in-depth onsite and telephone interviews with 53 respondents, 
individually or in small groups, about their roles during the ED closure and in the subsequent reopening.  We present 
interview data in both aggregate analysis and individual quotations. 
  IHS leadership and staff at IHS headquarters, Great Plains AO and Rosebud Hospitalrespondents were the 
Acting Director, Deputy Director, Chief Medical Officer (CMO), former CMO, Acting Deputy Director for Quality 
Health Care, Deputy Director of Field Operations, Director of Office of Public Health Support, former Director 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    4  BACKGROUND 
of Office of Management Services, Acting Area Director, Area CMO, and former and current Acting Hospital 
CEOs, Hospital Clinical Directors, and Federal and contracted hospital staff. 
  CMS leadership and staffrespondents were the Director of the Quality, Safety and Oversight Group, 
Associate Regional Administrator of Survey and Certification, Survey Branch Managers, and surveyor staff. 
  HHS leadership and staffrespondents were a former Acting Secretary of HHS, the Surgeon General, Director 
of the U.S. Public Health Service Commissioned Corps (USPHS) Personnel and Readiness Division, Director of 
the USPHS Readiness and Deployment Operations Group, and other staff. 
  Rosebud Sioux Tribe administratorsrespondents were the Director of the Tribal Health Board and the 
Director of EMS. 
  Receiving hospital leadership and staffrespondents were Administrators/CEOs, Chief Financial Officers, and 
other hospital staff from the two hospitals that received most of Rosebuds ED patients during the closure. 
  South Dakota Department of Healthrespondent was the Assistant Administrator for Rural Health. 
Documents from IHS, CMS, USPHS, Rosebud Sioux Tribe, and receiving hospitals.  We verified issues raised during 
interviews when possible by reviewing selected internal and publicly available documentation obtained from the 
respondents.  The documents included internal management reports, meeting minutes, staffing and patient census 
data summaries, survey deficiency reports, corrective action plans, SIA provisions, CMS monitor reports, and 
documentation exchanged between interview respondents, such as requests for assistance.   
Limitations.  We did not examine the appropriateness of IHSs closure of the Rosebud ED and subsequent reopening or 
whether the closure constituted a permanent closure pursuant to Section 1631(b) of the IHCIA or whether IHSs 
actions were legally compliant with this section of that Act.  Additionally, we did not assess whether any patient deaths 
that occurred during the ED closure were avoidable or whether other patient harm could have occurred if the ED had 
remained open despite quality-of-care problems. 
STANDARDS 
We conducted this study in accordance with the Quality Standards for Inspection and Evaluation issued by the Council 
of the Inspectors General on Integrity and Efficiency. 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    5  CHRONOLOGY 
SECTION 1 
 
D C I C  
ECISION TO  LOSE AND  MPACT OF  LOSURE
 
IHSs decision to temporarily close the Rosebud ED in December 2015 was largely 
due to quality-of-care concerns and staffing shortages 
CMS cited Rosebud Hospital with IJ and condition-level deficiencies after failing to provide 
Immediate Jeopardy is 
the most serious deficiency  adequate emergency services.  During an onsite survey in November 2015, CMS found both 
categorization based on the  quality-of-care and operational problems across Rosebud Hospital departments and cited the 
scope and severity of the  hospital for noncompliance with nearly one-third (7 of 23) of the Medicare CoPs.  Surveyors 
actual or potential harm to 
identified condition-level deficiencies related to the Governing Board, Patient Rights, QAPI 
patients.   
program, Medical Staff, Medical Record Service, Physical Environment, and Emergency 
Services.  CMS found the deficiencies in the ED to be particularly problematic, and cited them 
at the IJ level, an immediate jeopardy to patient health and safety.  The ED deficiencies 
involved failure to provide adequate and timely treatment for four patients:  
  A patient with chest pain who did not receive a timely medical screening exam, and 
had a delayed transfer to another facility better equipped to treat the condition;    
  A pediatric patient with a possible head injury from a car accident who did not receive 
appropriate care or monitoring;  
  A patient with chest pain who was not triaged appropriately and did not receive 
adequate monitoring or timely care; and 
  A patient who delivered a pre-term baby unattended on the ED bathroom floor.  
IHS officials and staff attributed Rosebuds deficiencies to longstanding problems with 
insufficient staffing, rotating leadership, and equipment issues.  In interviews, IHS officials and 
staff reported that the deficiencies CMS found in the November 2015 survey were evidence of 
deeper problems with the hospital, including difficulty in filling vacancies, leadership 
instability, outdated equipment, and limited clinical support and oversight by the Great Plains 
AO.  Respondents reported that IHS has struggled for years to recruit and retain sufficient 
numbers of providers (physicians, nurses, 
and other clinical staff) at Rosebud because 
Hospital leadership sometimes kept 
of the hospitals remoteness, and relied on 
poorly performing contracted staff 
contracted providers to fill critical gaps, 
around just as warm bodies.   
particularly in the ED.  Furthermore, hospital 
staff reported that these contracted  Rosebud staff member 
providers did not always meet the hospitals 
needs or acceptable standards.   
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           6  DECISION TO CLOSE AND IMPACT OF CLOSURE 
Staff reported that they voiced concerns about insufficient staffing to hospital leadership to 
no avail and recalled several occasions when the ED had few staff and no supervisor available 
on call.  At the time of the CMS survey, the Rosebud Hospital ED had only one physician 
assistant on duty and no physician, as required.  Area staff noted that to be fully staffed, 
Rosebud should have at least one physician and one midlevel provider (e.g., nurse 
practitioner, physician assistant) per shift, in addition to three nurses.     
Changing Leadership  Leadership.  According to an IHS official, Rosebud Hospital had 27 CEOs over a 9-year period, 
In the 9 years leading up to  averaging 3 CEOs per year.  Many of these CEOs served in an acting capacity and lasted only a 
the ED closure, Rosebud  few months before they left voluntarily, were fired by IHS, or were removed by a tribal 
Hospital had 27 CEOs. 
resolution.  Although many of these CEOs may have initially appeared to be a good fit, several 
IHS officials indicated that the CEOs often lacked experience and were ill-equipped to fulfill 
that role.  One official described how some CEOs, due to their inexperience and lack of 
knowledge about hospital operations, depended on Clinical Directors to run the hospital, 
meaning that the CEO position sometimes added little value to hospital management.  Shortly 
after the November 2015 survey, both the CEO and the Clinical Director left Rosebud.  
Interview respondents reported that these leadership changes and voids resulted in a lack of 
oversight to ensure that other hospital functions ran smoothly, such as ensuring staff training 
and the adequacy of equipment.     
Equipment.  CMS surveyors found several equipment issues, including an oxygen leak in the 
ED, problems with the phone and call light system, and broken steam autoclaves (used to 
sterilize surgical instruments).  Hospital staff indicated that equipment was often broken or 
lacking in the ED, with examples including equipment considered critical to daily ED 
operations, such as suction tubes (used to remove secretions) and heart monitors.   
Breakdowns in communication between the hospital, Great Plains AO, and IHS headquarters 
further exacerbated the issues at Rosebud and limited IHS oversight and support.  IHS officials 
indicated that the relationships between officials at Rosebud Hospital and the Great Plains AO 
were at times strained, and that breakdowns in communication limited AO support to address 
problems.  IHS officials described the relationship between the AO and the Great Plains 
hospitals as lacking trust and clear roles and responsibilities.  Hospitals operated on their own, 
with little support or input from the AO, and there was a lot of finger pointing and 
disagreement about who was responsible for 
addressing issues that arose at the hospital 
level.  One official noted that although the  There was no cohesive ownership in 
AO was aware of Rosebuds longstanding  Great Plains... Hospitals ran their own 
issues, Rosebud received little support or 
thing, independent of the AO.   
assistance because Area leadership did not 
IHS official 
believe it was their responsibility to correct 
hospital deficiencies.   
According to interviews, the AO may have been more active in the past, conducting mock 
surveys of Rosebud and other Great Plains hospitals to provide hospital leadership and staff 
experience with the survey process and give the AO an interim assessment of hospital 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    7  DECISION TO CLOSE AND IMPACT OF CLOSURE 
operations.  Mock surveys simulate the actual survey process and typically include direct 
observation, policy reviews, and medical record reviews.56  Although the surveys identified a 
wide range of problems, including quality-of-care issues in the Rosebud ED, an Area staff 
member reported that the AO medical team stopped them a few years before the Rosebud ED 
closure.  According to the staff member, the AO team limited their scrutiny to only medical 
record reviews following significant occurrences, such as a patient death or other sentinel 
(serious or widespread) event.  IHS officials also reported that the AO provided little 
information to IHS headquarters about the problems in the Great Plains, including Rosebud 
Hospital.  Although IHS headquarters leadership were aware of problems and asked questions, 
they did not know the extent or severity of the problems. 
IHSs inability to remove the IJ deficiencies in the Rosebud ED and secure sufficient staffing 
prompted IHS leadership to suspend Rosebuds emergency services.  Following the survey, it 
quickly became clear to both IHS and CMS that Rosebud was unable to resolve the IJ, primarily 
due to staffing shortages in the ED.  When the Area CMO went onsite shortly after the CMS 
survey to review Rosebuds plan of correction, the one doctor on duty in the ED had been on 
call for 36 hours.  The Area CMO reached out to other contractors and hospitals in the Great 
Plains but was unable to acquire additional providers.   
Given that IHS was unable to correct the deficiencies in the Rosebud ED, CMS issued a letter 
Hospital termination 
of termination to Rosebud in December 2015.  The same day, the Great Plains Area Director 
from Medicare is rare.  In 
2017, CMS terminated        a  nd Area CMO, with support from IHS headquarters leadership, temporarily closed the ED.  
four hospitals for failure to  IHS did not conduct an analysis of the impact of the ED closure on the community prior to this 
meet health and safety 
temporary closure (such an analysis is only required by the IHCIA for a permanent closure).  
requirements.   
Instead, Area leadership met with the tribal council and the tribally operated EMS to inform 
them that the ED diversion would begin the following day.  IHS also issued a press release on 
its website about the closure.  Shortly after the ED closed and patient diversion began, the 
Great Plains Area Director and the Area CMO left their positions at IHS.  Once the ED was on 
diversion, CMS suspended the deficiencies related to emergency services and excluded the ED 
from its surveys until Rosebud was ready to resume those services. 
IHS did not inform Rosebud staff of plans for diverting patients and failed to 
adequately notify receiving hospitals of the ED closure, giving them no time to 
prepare for an influx of patients 
IHS did not adequately notify its own staff or surrounding hospitals that it planned to close the 
ED, causing confusion from the onset of the closure.  Within a week of the closure, the Area 
CMO submitted a written plan to CMS to operate Rosebud Hospital without a dedicated ED, as 
required.  However, in interviews, we found that Rosebud staff were unaware of the plan or 
its details.  The hospital also lacked agreements and memoranda of understanding (MOUs) 
with neighboring hospitals for diverting emergency patients, despite Rosebud Hospital 
frequently using diversion in the past for specialty services, such as obstetrics and surgery.  
Rosebud staff also reported that they did not receive any training or information about ED 
diversion prior to the closure, and noted that Area leadership was slow to notify them of the 
decision to close.  Some Rosebud staff reported that they learned about the closure only 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    8  DECISION TO CLOSE AND IMPACT OF CLOSURE 
when the hospitals that received Rosebuds emergency patients began contacting them with 
inquiries about the closure.  Area leadership eventually held a staff meeting to inform 
Rosebud staff about its decision to close, but IHSs lack of guidance on roles and procedures 
during ED diversion caused confusion among staff.   
Receiving hospitals learned about the ED diversion through non-IHS sources shortly before it 
began and were quickly overwhelmed by the volume and complexity of Rosebud patients.  
Despite IHSs attempts to publicize the closure on its website and directly notify the receiving 
hospitals, administrators from the two non-IHS hospitals that received most of Rosebuds 
patients reported that IHS failed to alert them of the ED diversion.  One of the administrators 
stated that the hospital learned about the closure from a local radio station that had tuned 
into the broadcasted tribal council meeting, during which IHS announced the ED diversion.  
Shortly after the broadcast, the tribally operated EMS notified the hospital that ambulances 
were en route to the facility with patients.  An administrator from the second receiving 
hospital reported that they received a letter from IHS about the diversion nearly 2 weeks after 
the Rosebud ED closed.  The lack of notification prevented the receiving hospitals from 
preparing for the incoming patients.  Furthermore, confusion about the actual start time of 
the diversion resulted in ambulances diverting patients several hours before the ED was set to 
close, giving receiving hospitals even less time to prepare.   
In addition, the receiving hospitals struggled to receive sufficient notice from EMS about 
incoming patients throughout the closure.  An administrator from one of the receiving 
hospitals reported that ambulances often notified the hospital only a few minutes before they 
arrived or sometimes they showed up without warning.  The small window of notice made it 
difficult for hospital staff to adequately prepare for the patients, particularly in the event of 
complex cases such as premature infants.  An administrator from the South Dakota 
Department of Health, who communicated regularly with the tribally operated EMS, reported 
that EMS staff sometimes did not contact the receiving hospitals in advance of transporting 
patients due to fear of being diverted again. 
The receiving hospitals experienced a significant increase in the number and case mix of 
emergency patients and reported struggling to meet patient needs.  These hospitals are both 
fairly small (25-bed) facilities located in communities with fewer than 3,000 people, about an 
hour away from Rosebud Hospital.  One of the hospital administrators described this event as 
an avalanche.  Within the first 6 weeks of the closure, the number of ED patients increased 
by 67 percent and the intensity of demand tested the hospitals capabilities.  The hospital saw 
substantial increases in particular of mental health patients, drug overdoses, shootings, and 
sexual assaultsareas in which staff had limited experience.  Drug overdoses were especially 
difficult for the hospital to treat because patients needed multiple supports that relied on 
continual staff monitoring and equipment, including airway support, IV fluids, and kidney 
dialysis (which the hospital typically provided only to stable outpatients with chronic illness).  
The acuity of the incoming patients often required a transfer to a larger hospital farther away.  
An administrator from the other receiving hospital reported that its ED visits increased by  
38 percent during the Rosebud ED closure, which had a trickle-down effect on the other 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    9  DECISION TO CLOSE AND IMPACT OF CLOSURE 
hospital departments.  For example, the hospitals inpatient and obstetrics admissions 
increased by 51 and 21 percent, respectively, during the closure. 
The influx of emergency patients was taxing on staff, and receiving hospitals reported losing 
staff as a result.  Administrators from the receiving hospitals reported that when the diversion 
first began, they did not have sufficient staff to handle the volume and complexity of the ED 
patients, which took a toll on staff who worked many overtime hours trying to fill the gaps.  
Both hospitals indicated that they lost staff as a result of the influx of patients.  The ED 
diversion affected all hospital operations, from billing to housekeeping.  One administrator 
questioned why IHS did not send any Rosebud staff to assist with the patient influx given that 
the ED was closed.  Both hospitals reported that they contracted with additional providers and 
security staff to address the increased needs of their EDs. 
IHSs short notice of the ED diversion also made it difficult for tribal EMS to mobilize and meet 
27%  
demands with its staffing shortages and longer transports of patients.  The ED closure had a 
of EMS transports  significant impact on the tribally operated EMS, which was understaffed.  The EMS Director 
to receiving facilities took  explained that IHSs short notice prevented EMS from mobilizing and adequately preparing for 
more than 5 hours to 
the closure.  EMS received 2,867 dispatch calls during the months that the ED was closed, and 
complete. 
more than half of those calls (1,514) resulted in patient transports to other facilities.  
Ambulances had to travel longer distances, often with high-acuity patients, which resulted in 
delays in EMS response time to emergency 
calls.  Many of these transports took several 
If patients were truly having a cardiac 
hours to complete.  Of the 1,514 patient 
transports conducted by local EMS during  event, the heart muscles would be 
Rosebuds ED closure, 32 percent of  damaged during the long route to the 
transports (481) took between 3 and             receiving hospitals.   
5 hours to complete, roundtrip, and            EMS Director 
27 percent of transports (403) took more 
than 5 hours to complete.   
To manage the workload, EMS hired eight additional staff, revised shifts, and worked 
overtime.  Despite these additional hires, EMS was short-staffed throughout the closure and 
posted multiple job advertisements for drivers, paramedics, and emergency medical 
technicians that it was unable to fill.  As described by one of the receiving hospital 
administrators, EMS had ambulances but not enough staff to sufficiently meet the needs.  
According to the EMS Director, the closure was also emotionally hard on EMS staff, who felt 
they were carrying the weight of the diversion on their own with no backup, and some staff 
left as a result.  The South Dakota Department of Health administrator who communicated 
regularly with EMS explained that ambulance staff not only had to manage what was going on 
at the scene when they picked up a patient, but also assess the patients needs during long 
transits and decide which of the two overrun facilities was best-suited at that time to accept 
the patient.   
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    10  DECISION TO CLOSE AND IMPACT OF CLOSURE 
IHSs lack of communication with receiving hospitals and EMS continued throughout the 
closure and made it difficult for these entities to anticipate staffing needs.  Administrators 
from the receiving hospitals reported that communication with IHS was insufficient during the 
months that the ED was closed.  They noted that it was difficult to find a person in charge 
either at Rosebud or at the AO because of constant leadership changes.  The Tribal Health 
Board Director also reported difficulty in receiving timely updates from IHS during the closure 
and noted that Rosebud Hospital staff would turn off the ringer when EMS tried to call the 
hospital.  IHS later addressed this issue when it provided EMS with its own direct line to the 
hospital.  An administrator at one of the receiving hospitals expressed that they expected IHS 
leadership to reach out to the receiving hospitals and discuss the terms of the closure, but 
that never happened.  The administrator noted that it was not clear when the Rosebud ED 
would reopen or whether it would reopen as an outpatient clinic or an ED.  Without knowing 
the length of the closure, it was difficult for the hospital to anticipate staffing needs and 
determine whether or not to renew its contracted staff.   
An administrator from the other receiving hospital reported that IHS initially told the hospital 
that the Rosebud ED would be back up and running within 30 days.  The administrator 
periodically contacted Rosebud for updates on the reopening date, but the date kept changing 
and the administrator had a hard time finding anyone to talk to other than PRC staff.  The 
administrator stated that not knowing how long Rosebuds ED diversion would last was the 
worst part.   
Receiving hospitals and tribal EMS met weekly to discuss diversion-related issues, and 
expressed frustration over IHSs absence.  Shortly after IHS closed the Rosebud ED, an 
administrator in the South Dakota Department of Health began coordinating weekly calls with 
all the receiving hospitals in Nebraska and South Dakota and the tribal EMS.  According to the 
administrator, the purpose of the calls was to open channels of communication to mitigate 
challenges and share concerns and updates among the affected parties.  An administrator 
from one of the receiving hospitals reported that although these calls were helpful for sharing 
needs and identifying available hospital beds, IHS was not present during the calls.  The EMS 
Director also noted IHSs absence on the 
calls but recalled two occasions during 
which IHS listened into the calls.  The  We needed boots on the ground, but 
administrator from the South Dakota 
no one offered to help... This was IHSs 
Department of Health indicated that he 
crisis, but to find anyone willing to talk 
inquired about having someone from the 
with us was difficult.   
AO participate on the calls, but he was 
Receiving hospital administrator 
never able to locate anyone.  Once the ED 
reopened, these calls discontinued. 
Some of these communication gaps during the closure may have emerged due to changing 
leadership, with no one person or group following through to ensure that communication with 
receiving hospitals was widespread and continuous.  During our interviews, IHS officials and 
Rosebud staff reported that communication with the receiving hospitals improved in the 
weeks leading up to the ED reopening and in the months that followed.  During our onsite 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    11  DECISION TO CLOSE AND IMPACT OF CLOSURE 
review in August 2017, Rosebud staff reported that they held weekly calls with the receiving 
hospitals to provide status updates and discuss any issues that could potentially affect the 
receiving hospitals.  
IHS opened an urgent-care clinic at Rosebud to meet community needs, but 
confusion about its services led to some emergency patients presenting at the clinic 
On the same day that the ED closed, Rosebud Hospital began providing 24-hour urgent-care 
services by using the ED staff and contracted providers.  The purpose of the urgent-care clinic 
was to increase the availability of primary care services and to minimize the number of 
patients that sought care at receiving hospital EDs for non-emergencies.  According to an IHS 
official, many of the patients in the IHS hospital EDs are the worried wellpatients who 
need primary care but present in the ED instead of the outpatient clinic. 
IHS announced the opening of the urgent-care clinic through a press release on its website on 
the day of the closure.  A CMS official and staff who were onsite when the Rosebud ED closed 
reported that they conducted a walkthrough of the hospital to ensure that the ED was not 
being used.  Hospital staff covered the ED signs and posted urgent-care signs throughout the 
facility.  As the CMS official noted, IHS was still responsible for providing first aid at Rosebud 
but could not use the ED or exceed the capabilities of an urgent-care clinic. 
Although EMS transported most emergency patients to the receiving hospitals, EMS staff and 
tribal members continued to bring some patients to Rosebud after the ED closed, and hospital 
staff struggled to care for those patients in the urgent-care setting.  Despite IHSs 
announcement of its ED closure and the opening of the urgent-care clinic, confusion about the 
types of services provided by urgent care resulted in emergency patients continuing to arrive 
at Rosebud.  Hospital staff described the onset of the closure as chaotic and reported 
receiving large volumes of high-acuity patients at the urgent-care clinic.  Cases ranged from 
heart attacks, women in labor, and car accidents to snake bites.  According to the EMS 
Director, IHS did not specify what services Rosebud would provide during the closure, and the 
community continued to perceive the urgent-care clinic as an ED because the staff and the 
physical space of the ED were still intact.  Rosebud staff eventually clarified to EMS that 
ambulances could not bring any emergency patients to the urgent-care clinic or drop them off 
near the hospital.  Instead, they had to transport all emergency patients to the receiving 
hospitals for treatment.   
EMS eventually stopped bringing patients to Rosebud, but tribally operated transportation 
services and family members continued to drop emergency patients off at the urgent-care 
clinic.  The EMS Director explained that if an ambulance picked up a patient who was stable 
enough and wanted to go to Rosebud, EMS would contact tribal transportation services and 
have them take the patient to Rosebuds urgent-care clinic.  According to Rosebud staff, some 
of the patients who arrived in the vans operated by the tribe had acute medical needs beyond 
the capability of an urgent-care facility and had to be flown out to other facilities.   
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    12  DECISION TO CLOSE AND IMPACT OF CLOSURE 
Although the ED was not supposed to be in use, Rosebud staff reported that some staff 
continued to sneak patients into the ED to provide emergency services.  This stopped when 
IHS began renovating the ED, and staff 
could only stabilize and transfer emergency 
The closure increased risks for patients.  
patients who arrived at the hospital.  
When you cant use the ED and you try 
Rosebud staff described how caring for 
to take care of an emergency in an 
high-acuity patients in the urgent-care 
urgent-care setting, youre tying the 
setting was challenging because the rooms 
were not equipped to treat emergency  arm on the providers back.   
patients and lacked appropriate monitors,  IHS official 
oxygen equipment, and lighting.   
Many patients sought emergency treatment during the closure, but some patients who 
needed emergency treatment did not seek care.  According to Rosebud staff, some patients 
feared being unable to find their way back to the reservation after treatment at the receiving 
hospital.  Or, they feared receiving a medical bill that they could not afford to pay if the PRC 
program declined to cover their expenses. 
To offset costs for patient diversion, Rosebud received additional PRC and other 
funds, but receiving hospitals and EMS struggled to absorb their increased costs 
The closure quickly depleted Rosebuds PRC program, but the Great Plains AO and IHS 
headquarters provided additional funds to cover some of the expenses.  According to Rosebud 
and Area staff, the hospitals PRC program was stretched thin prior to the closure, and once 
the ED diversion began, patient needs further exceeded available funds and depleted the PRC 
program.  Rosebud staff noted that the hospital typically ran out of PRC funds several months 
before the new PRC budget cycle began, which resulted in large numbers of deferred cases.  
To offset some of the diversion-related costs, the Great Plains AO and IHS headquarters 
provided additional funds to Rosebud during the closure.  The AO has an emergency fund 
from which Great Plains facilities can make requests.  Area staff reported that over the years 
Rosebud received more assistance from this fund than many other Great Plains facilities.  
Rosebud also received additional funds from IHS headquarters to cover PRC needs during the 
closure, in addition to CHEF funds that assisted Rosebud in covering patient cases with 
extraordinary medical costs.   
Although Rosebud received additional funds during the closure, it struggled to handle the 
administrative workload of the PRC program.  According to staff, the workload quadrupled as 
a result of the ED diversion and caused a backlog.  Rosebud staff who normally only processed 
PRC payments now also had to track diverted patients, which rapidly became an 
overwhelming task due the large volume of patients.  Staff also noted that there was no 
preparation, guidance, or protocol for the PRC program to handle the ED diversion, and that 
Rosebud staff, receiving hospitals, and patients were confused about what services PRC would 
cover during the closure.   
At the onset of the closure, the Area Director incorrectly stated that IHS would cover all ED-
related costs, regardless of whether patients conditions met Rosebuds PRC criteria, which 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    13  DECISION TO CLOSE AND IMPACT OF CLOSURE 
included only emergent or acutely urgent-care services (i.e., services necessary to prevent the 
immediate threat to life, limb, or senses).  Shortly thereafter, IHS clarified that the Rosebud 
PRC program would continue to follow the same guidelines used under normal circumstances 
and only cover life-or-limb cases, which raised concerns in the tribal community.  The Tribal 
Health Board Director stated that IHSs decision to cover only life-or-limb cases sent a 
message to the community to triage themselves during the closure.  If a tribal member 
presented at one of the receiving hospital EDs with a condition that the patient believed was 
emergent but turned out to be non-emergent, the medical services would typically not be 
covered by PRC.  Instead, the patient would be responsible for the medical expenses.  
However, if the same patient had presented at the Rosebud ED, if it had remained open, the 
costs for the medical services would have been covered by IHS regardless of whether the 
condition was emergent.  
Receiving hospital administrators reported that the closure was costly, and that IHS did not 
always provide reimbursements in a timely manner.  The receiving hospitals were accustomed 
to receiving patients from Rosebud during other types of diversions (e.g., surgery, obstetrics), 
but the ED closure was different and posed a greater burden on these hospitals.  The length of 
the closure and the large number of emergency patients arriving in their EDs resulted in 
greater expenses for the receiving hospitals.  For example, one of the receiving hospital 
administrators explained that in addition to the costs associated with the services provided to 
the diverted emergency patients, the hospital accrued expenses related to staff overtime 
hours, salaries for new hires brought onboard to handle the patient influx, and air transports 
for the diverted patients whom the receiving hospital was unable to care for.  The 
administrator also noted that the hospital covered other costs, such as patient co-pays, 
medications, and transportation of discharged patients. 
Although Rosebud received additional funds during the ED closure, administrators from the 
receiving hospitals reported that IHS was sometimes slow to reimburse the hospitals for their 
medical expenses associated with the diverted patients.  The receiving hospitals often waited 
several years to get paid for services provided to Rosebud patients.  The administrator at one 
of the receiving hospitals noted that IHSs payment system is complex as it does not cover all 
costs and often runs out of money, causing reimbursement delays. 
IHS provided some additional funds to EMS, but the tribe reported that these funds were 
insufficient to cover all the costs associated with the closure.  According to the EMS Director, 
the EMS fleet and personnel budget incurred substantial extra costs as a result of the closure.  
EMS had to hire additional staff and work many overtime hours to transport the high volume 
of emergency patients to other facilities.  Although IHS provided some additional funds to 
reduce the burden on the tribally operated EMS program, the EMS Director reported that 
these funds did not cover all of the additional expenses resulting from the closure.   
 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    14  DECISION TO CLOSE AND IMPACT OF CLOSURE 
Section 1: Key Contributing Factors 
Factors that led to and complicated the ED closure 
Insufficient hospital staffing 
Staffing shortages at Rosebud Hospital, particularly in the ED, contributed to findings of 
noncompliance with the Medicare CoPs and increased dependence on contracted providers 
rotating in and out. 
Changing and inconsistent hospital leadership 
Instability and inexperience in key leadership positions made it more difficult for IHS to make 
strategic, long-term improvements at Rosebud Hospital. 
Inadequate hospital infrastructure 
Rosebud Hospital did not have an adequate infrastructure to ensure basic quality care, 
including policies and procedures, working equipment, and staff training. 
Lack of oversight by IHS 
IHS officials and staff described poor relationships between the Great Plains AO and Rosebud 
Hospital, and communication breakdowns across IHS, which limited support for identifying 
and correcting problems. 
Poor coordination with local partners 
IHS submitted a plan to CMS for operating without an ED but did not adequately communicate 
with hospital staff, EMS, and receiving hospitals, who received little warning and were 
overwhelmed with demand. 
 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    15  CHRONOLOGY
 
SECTION 2 
 
C A R  
ORRECTIVE  CTION AND  EOPENING
 
Despite HHS-wide assistance, IHS was unable to correct Rosebuds deficiencies and 
entered into an SIA with CMS in April 2016, facing termination from Medicare 
IHS developed a plan of correction and obtained assistance from other IHS hospitals and 
Commissioned Corps officers, but CMS found continued noncompliance during a revisit.  
Shortly after the CMS onsite survey in November 2015, which led to the ED closure, IHS 
submitted a plan of correction to CMS to address Rosebuds noncompliance with the CoPs and 
temporarily reassigned staff from other facilities to assist at the hospital.  Rosebud Hospital 
staff reported that these reassignments sometimes placed undue burden on other facilities 
because those facilities already struggled to ensure sufficient staffing levels.  In the days that 
followed, the former IHS Principal Deputy Director, with assistance from the former Acting 
Deputy Secretary of HHS at the time, made a special request to the Office of the Surgeon 
General and the USPHS for deployments of Commissioned Corps officers to assist Rosebud 
and other Great Plains facilities.  USPHS, which comprises approximately 6,500 licensed, public 
health and safety professionals (e.g., doctors, nurses, and mental health providers), assigned 
to over 20 Federal agencies, is available to the President and the HHS Secretary to rapidly 
respond to any public health emergency or crisis within or outside the United States.   
In early January 2016, USPHS deployed its first officers to Rosebudincluding three nurses, an 
ED physician, and an occupational therapistto provide healthcare facility leadership, direct 
patient care, clinical quality management, and other professional services.  According to Great 
Plains Area staff, the primary task for these officers, who were onsite for approximately  
6 weeks, was to help Rosebud staff develop and implement policies across the hospital (e.g., 
nursing, ED) to meet the CoP requirements.   
Despite IHSs plan of correction and 
reassignment of staff, and USPHSs  Everything was broken, knowing 
deployment of Commissioned Corps officers,  what I know now... We were creating 
IHS was unable to achieve compliance with 
task-oriented solutions to address 
the CoPs at Rosebud Hospital.  During a 
deficiencies, but the problems were 
followup survey in February 2016, CMS 
bigger than the tasks.   
found continued noncompliance with five 
IHS official 
CoPs: Governing Board, QAPI, Medical Staff, 
Medical Record Service, and Physical 
Environment.  CMS also found 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           16  CORRECTIVE ACTION AND REOPENING 
noncompliance with an additional CoP, Nursing Services.  A CMS official acknowledged that 
IHS attempted to make corrections but indicated that leadership churn and staffing shortages 
plagued the hospitals ability to sustain those corrections.  The official also noted an apparent 
lack of urgency for IHS to properly address the problems at Rosebud.   
CMS entered into an SIA with IHS after recognizing the impact the termination would have on 
SIA agreements are 
the community, and outlined specific tasks for IHS to achieve compliance and reopen the ED.  
fairly rare, and typically 
reserved for serious and  CMS granted IHS several extensions to the termination date of Rosebud, while exploring the 
longstanding problems.   option of developing an SIA.  After considering the impact that the termination would have on 
CMS reported to OIG that  
the Rosebud Sioux Tribe, CMS entered into an SIA with IHS in April 2016 and suspended the 
during 2016, only                 
termination pending Rosebuds fulfillment of the agreement.57  A few days before the SIA was 
four hospitals nation-wide 
signed, AO staff met with the tribe to inform them of the agreement.  These meetings 
were under SIAs. 
continued through the duration of the SIA, during which IHS provided the tribe with updates 
on Rosebuds improvement activities.  IHS also communicated regularly with CMS, both at the 
regional and headquarters level, about Rosebuds progress on SIA-related tasks.   
The SIA outlined an actionable plan with descriptive tasks for IHS to address Rosebuds 
compliance issues.  Those tasks were as follows: 
  Update hospital policies, procedures, and processes;  
  Design and implement an effective and sustainable QAPI program;  
  Improve Rosebuds governing body;   
  Improve privileging and credentialing processes of medical staff; and  
  Develop recruitment, integration, and retention strategies to address vacancies.   
An IHS official explained that the SIA put the deficiencies and corresponding tasks into an 
understandable and user-friendly format.  The SIA laid out specific tasks for reopening the ED 
and ensuring safe provision of emergency care.  To reopen the ED, IHS had to evaluate and 
address resources needed for safe operation (e.g., staffing, equipment); supplement qualified 
and credentialed IHS staff with contracted 
providers until IHS could recruit an experienced 
The SIA focused on the efforts 
and qualified ED staffing contractor to operate the 
that needed to be addressed 
ED; conduct a mock survey to ensure compliance 
with the CoPs and EMTALA requirements; and  and put them into practice.   
notify CMS of its intent to reopen the ED at least   IHS official 
10 days in advance of the reopening. 
As part of the SIA, CMS contracted with an independent quality monitor who provided onsite 
observations and evaluations of Rosebuds progress in meeting the terms of the SIA.  The 
monitor worked directly with Rosebud leadership and staff and provided CMS with monthly 
summary reports of the onsite visits and quarterly reports of Rosebuds overall progress.  CMS 
shared these reports with IHS and the tribe throughout the SIA.  Rosebud and Area staff noted 
that having the monitor onsite was helpful and reinforced the importance of making changes.  
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    17  CORRECTIVE ACTION AND REOPENING 
IHS made improvements at Rosebud prompted by the SIA, some of which resulted 
in agency-wide changes, but struggled to secure staff and resume ED services 
The SIA was a turning point for Rosebud and intensified IHSs focus to make systemic 
improvements and reopen the ED.  According to Rosebud staff, there was no structure prior 
to the SIA to address deficiencies systemically.  To meet the demands of the SIA and to reopen 
the ED, IHS reassigned experienced and highly qualified staff from across the agency for 
temporary duty assignments at Rosebud, requested additional deployments of Commissioned 
Corps officers, and contracted with a staffing company to operate the ED once it reopened. 
IHS assigned a leadership team to direct the improvement efforts at Rosebud, which included 
addressing personnel issues, policies, QAPI, governing body, and renovations.   
A month after signing the SIA, IHS assembled a team of experts from across the agency, 
known as the SIA Phase 1 team (SIA team) and sent them to Rosebud to provide immediate 
onsite management, leadership, and support.  The SIA team members served in acting 
capacity as the CEO, Chief Operations Officer, Chief Information Officer, CMO, Director of 
Nursing (DON), and Director of QAPI at Rosebud.  They were tasked with mitigating risk 
factors, preventing deficiencies identified by CMS, and reopening the ED.   
The SIA team remained at Rosebud until it was replaced by another team a few months after 
the ED resumed its services.  Rosebud and Area staff noted that the SIA team was key to 
turning the hospital around and reopening the ED.  Upon arrival, the team began making 
immediate changes, including activating a hospital incident command system (HICS); 
addressing personnel issues; developing, updating, and implementing policies, procedures, 
and processes; designing and implementing a QAPI program; developing a robust governing 
body; and directing renovations in the ED. 
HICS.  Within a week of arriving at Rosebud Hospital, the SIA team activated the HICS, a 
management system designed to deal with an event that challenges or exceeds the medical 
infrastructure (such as an emergency or a disaster).  The HICS structure establishes a clear 
chain of command, allows collaboration across departments and delegation of responsibilities, 
provides logistical and administrative support to operational personnel, and ensures coverage 
of key functions.58  A member of the SIA team reported frequent meetings (twice per day) 
with hospital staff under the HICS structure to assign tasks and monitor the progress of the SIA 
activities.  The team also held weekly meetings to review the SIA plan in its entirety and 
discuss any challenges or possible barriers. 
Personnel issues.  The SIA team took immediate action to instill a culture of trust within the 
hospital and the community by addressing personnel misconduct and building rapport with 
staff through open communication and behavior modeling.  An IHS official, who served on the 
SIA team, reported that there was a significant amount of personnel-related fraud, waste, and 
abuse at Rosebud (e.g., staff not reporting to work or staff clocking in, leaving, and later 
returning to the hospital to clock out).  IHS terminated several hospital staff during the teams 
first month onsite.  The IHS official emphasized the importance of setting the tone early on 
about acceptable and unacceptable conduct, and for leadership to model and not just 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    18  CORRECTIVE ACTION AND REOPENING 
verbalize appropriate behavior.  According to the official, with the many changes in leadership 
over the years, Rosebud staff had not seen what appropriate leadership looked like. 
Policies.  To address systemic issues, the SIA team completely overhauled Rosebuds policies, 
6,500  
procedures, and processes, which were in disarray after years of poor management and lack 
hospital policies  of policy review.  Rosebud staff and SIA team members reported that the absence of clear 
removed  ownership of policies, and of a sufficient cataloging system of hospital policies, procedures, 
that were obsolete or 
and processes, had resulted in duplications and multiple revised versions of the same 
duplicative. 
documents, which made it difficult for anyone to identify current policies.  These documents 
resided on a shared drive without any access control, which meant that anyone could modify 
the documents without approval.  To address this problem, Rosebud acquired a web-based 
management software tool and spent many hours reviewing, updating, approving, and 
implementing policies, procedures, and processes.  The SIA team began this effort in the ED, 
but eventually all hospital departments were included in the effort.  The result was a 
significant reduction in the number of policy, procedure, and process documentsfrom 
approximately 8,000 to 1,500.  At the time of our onsite review, in August 2017, nearly all IHS-
operated hospitals in the Great Plains had begun using this same web-based management 
software tool. 
The SIA team also implemented an approval process for revising or adding policies.  Any policy 
changes now had to go through the committee of the department from where the policy 
originated (e.g., ED committee reviewed ED policy) and obtain approval from the medical 
executive, hospital leadership, and occasionally the governing board.  To ensure that Rosebud 
staff were aware of policy changes, staff received an email notification if a document was 
revised or added, which required their review and signature. 
QAPI.  To improve quality of care and oversight, the SIA team established a QAPI program 
across the hospital departments, which other facilities later adopted.  Although Rosebud had 
some semblance of a QAPI program, the program lacked the capability to detect and resolve 
issues.  Hospitals may customize QAPI programs to best suit their individual needs, but the 
programs should be data-driven, hospital-wide, and result in specific interventions designed to 
improve health outcomes for patients.59  Rosebud staff noted that past leadership did not 
understand the importance of the QAPI program and lacked knowledge to implement the 
needed structure.  Staff had previously requested assistance to improve the QAPI program but 
reported that they never received a well-suited person for that role.  With the SIA team 
onsite, Area and Rosebud staff stated that the hospital was able to establish a functioning 
QAPI program by using the SIA teams expertise and assistance from across IHS to identify 
appropriate metrics.  Rosebud primarily based its QAPI goals on each departments plan of 
correction.  These plans were developed in response to the CMS deficiency citations. 
As part of the QAPI program, the team implemented daily quality assurance meetings.  Also, 
once the ED reopened, Rosebud began conducting trigger chart reviews and remediation if 
any issues were identified.  According to an IHS official, Rosebuds QAPI improvement efforts 
eventually spread throughout the Great Plains and other Areas.  The AO also began to have a 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    19  CORRECTIVE ACTION AND REOPENING 
larger role in the hospitals QAPI program.  At the time of our onsite review, Area staff were 
meeting monthly with Rosebud staff to discuss QAPI-related issues.   
Governing body.  Prior to the arrival of the SIA team, Rosebud did not have a rigorous 
governing body to provide sufficient oversight.  Area staff described how the governing body 
was disproportionately heavy in AO representation and disconnected from the issues that 
arose at Rosebud.  To prevent further failure to recognize and address problems at Rosebud, 
the SIA team leveraged their expertise and lessons learned from other facilities to create a 
more robust governing body.  An IHS official reported that Rosebuds revised approach served 
as the model for IHSs standardization of governing board bylaws across all IHS-operated 
hospitals, which went into effect in January 2017. 
Under the revised structure, the Area Director served as the chair of the governing board and 
ensured adequate representation of disciplines to carry out the required activities.  All 
governing board members had a vote and although the majority of voting members had to 
represent the AO, the governing board could include similar representation from the hospital.  
Tribal leaders no longer had a vote on the governing board, but AO staff noted that tribal 
leaders were encouraged to participate and present tribal reports during governing board 
meetings, except when personnel issues or patient data were on the agenda.  The new bylaws 
required that governing board meetings, at a minimum, included topics of quality of care, 
patient safety, and hospital operations.  The bylaws also required that the governing board 
met twice per year, but at the time of our onsite review, Area staff noted that the governing 
board convened quarterly, twice onsite to allow more interaction with the tribe and twice by 
phone.   
Rosebud could also request ad hoc governing board meetings, which occurred frequently, to 
discuss incidents or to initiate the credentialing process of a provider.  Rosebud staff reported 
that the credentialing process improved with the revised governing board.  Before the new 
bylaws, Rosebud had frequently used 120-day temporary credentialing approvals to bring staff 
onboard quicker because the credentialing process at the AO was slow.  This practice stopped 
once the new structure was put into place. 
Renovations.  Rosebud had not undergone a major renovation in 26 years and hospital staff 
  No Renovation 
for Years   reported that the ED was not well laid out.  The location of certain walls affected accessibility 
Prior to 2016, Rosebud  and separated staff, which ultimately affected the oversight of both patients and staff.  To 
went 26 years without a  optimize and improve the physical space of the ED, IHS seized the occasion to reconstruct the 
major renovation. 
space while it was closed, and remodeled the nurses station, triage, and trauma, using funds 
from IHS headquarters.  IHS also repaired and replaced some equipment, and Rosebud 
provided training to ensure that staff knew how to operate the equipment. 
The Great Plains AO and IHS headquarters also undertook improvement efforts while assisting 
and supporting Rosebud.  At the time of the ED closure, it became apparent to IHS leadership 
that the Great Plains AO also needed to make improvements to restore collaboration and to 
provide better monitoring of Rosebud and other facilities.  An IHS official indicated that if the 
AO had been functioning properly, then Rosebud could have received more support and 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    20  CORRECTIVE ACTION AND REOPENING 
guidance, which in turn may have prevented the hospital from ending up in such a dire 
situation.  To address the issues at the AO, IHS temporarily assigned experienced staff from 
across the agency who worked on improving all aspects of Area operations, from finance to 
acquisition to human resources.  An IHS official reported that these changes were initially 
resisted by some of the existing staff, and as with Rosebud, the temporarily assigned staff had 
to address several performance and conduct issues shortly after arriving at the AO.  
IHS headquarters also made some changes during the closure, which it launched in the 
months following the ED reopening.  In November 2016, IHS launched the IHS Quality 
Framework and undertook several improvement efforts following the launch.  These efforts 
included: (1) awarding a master contract for accreditation of hospitals; (2) acquiring a 
credentialing software system to standardize the credentialing process; (3) implementing a 
quality assurance accountability dashboard to improve transparency on access to and quality 
of care; (4) establishing patient wait time standards for primary- and urgent-care settings;  
(5) developing a standard patient experience of care survey; and (6) implementing ED 
telehealth consultation in the Great Plains and Billings Areas to provide access to specialized 
emergency medicine doctors and nurses.60  In December 2018, IHS announced a 
reorganization plan that included a new Office of Quality, which would be responsible for the 
agencys quality and safety-related work.  This reorganization became effective in January 
2019, and the Office of Quality is now led by the Deputy Director of Quality Health Care.61  
Under this structure, each AO has a Chief Quality Officer and each facility has a QAPI Officer.62   
Additionally, with assistance from agencies represented on the HHS Executive Council on 
Quality Care, IHS implemented several recruitment and retention strategies to better attract 
qualified candidates.  Through its partnership with USPHS, IHS now had priority access to 
Commissioned Corps applicants.  IHS also exercised its partnership with HRSA to recruit and 
retain primary-care providers, using HRSAs National Health Service Corps scholarship and 
loan repayment incentives.  IHS also utilized global recruitment, which allowed applicants to 
apply to a single job posting and be considered for multiple positions at different locations.  To 
prepare individuals selected to serve in leadership positions at the different levels of the 
agency, IHS developed leadership training, which it launched a month prior to the ED 
reopening.63 
Throughout the closure and following the reopening, the AO and IHS headquarters 
communicated with Rosebud about the improvement activities at the hospital, AO, and IHS 
headquarters.  An IHS official who served on the SIA team reported that Rosebud met weekly 
with IHS headquarters and Area leadership to discuss the progress and any challenges they 
faced in fulfilling the SIA and reopening the ED.  The official stated that the AO and IHS 
headquarters initially requested an overwhelming amount of reporting, which hindered the 
team from effectively working on tasks.  The SIA team voiced this concern and, given that the 
requests often overlapped, IHS leadership agreed to reduce and compile the reporting.   
For the weekly meetings with IHS leadership and the AO, the SIA team developed and 
presented a briefing document, which typically covered five key focus areas for that week.  
The team also did a walkthrough of any recent updates to the SIA work plan during those 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    21  CORRECTIVE ACTION AND REOPENING 
meetings.  Rosebud staff and SIA team members alike said that they felt supported by IHS 
leadership throughout this event.  One SIA team member said that IHS leadership tried to find 
solutions to help close every gap that the team identified.  An IHS official who was temporarily 
assigned to the AO noted that, prior to the ED closure, IHS leadership did not fully grasp the 
needs and challenges in Great Plains or at Rosebud.  With first-hand experience, IHS 
leadership now has a better understanding of the situation, the IHS official said. 
IHS requested additional deployments of Commissioned Corps officers who, despite their short 
stays, were key for getting the ED ready for reopening.  In 2016, USPHS deployed  
193 Commissioned Corps officers to the Great Plains, at the request of IHS and HHS 
leadership.  A total of 52 officers were assigned to assist at Rosebud Hospital.  They filled 
various non-medical and medical roles, ranging from facility managers to safety officers to 
physicians.  A USPHS official noted that officers were deployed on the basis of IHSs request 
for specific professions or tasks.  Many officers who were sent to Rosebud had medical 
backgrounds but had not practiced medicine for some time and were not clinically current.  
The SIA team assigned those officers to administrative functions such as revising policies and 
procedures, conducting quality assurance checks, implementing processes, developing QAPI 
dashboard systems, establishing infection control program, and mentoring staff.  The officers 
who were still practicing medicine assisted with clinical care throughout the hospital 
departments, including inpatient and urgent care.   
Although IHS wanted longer deployments, the Commissioned Corps officers generally rotated 
in and out of Rosebud every 24 weeks.  A USPHS official explained that deployments were 
designed to be short-term so that officers could assist at other locations because there were 
not enough officers to meet the national and global demands.  The official stated that USPHS 
previously had an Inactive Reserve Corps, comprising 10,000 inactive officers, who could be 
called on to assist during an event.  However, the Inactive Reserve Corps was abolished under 
the Affordable Care Act in 2010, which significantly reduced the number of available officers.64  
Rosebud staff reported that the short stints of the deployments were sometimes disruptive 
and difficult to work around, particularly if the officers were unfamiliar with IHS and needed 
time to learn the system.  Yet, staff noted that these officers played a crucial role in ramping 
up the improvement efforts needed to reopen the ED.  As described by an IHS official, 
Rosebud was able to stop the bleeding with the help of the Commissioned Corps officers.  
The deployments of the Commissioned Corps officers continued for several months after the 
ED reopened.  This arrangement was unusual and somewhat challenging for USPHS because 
the deployment request did not have an end date.  A USPHS official explained that 
deployments are typically based on a public health emergency declaration, which has a built-
in timeframe that can be extended if needed.  The deployments to the Great Plains were 
different because the directive came from the HHS Office of the Secretary without a 
declaration of a public health emergency.  A few months after the Rosebud ED reopened, 
USPHS began to look for an exit strategy, and together with IHS leadership established an end 
date for December 2016. 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    22  CORRECTIVE ACTION AND REOPENING 
IHS awarded a staffing contract for the ED but struggled to obtain qualified providers.  Around 
the time that the SIA went into effect, IHS awarded a contract for a private staffing company 
to staff the ED.  Although IHS had prior experience working with this contractor both in the 
Great Plains and in other Areas, an IHS official noted that this was the first time that IHS had 
ever outsourced an entire ED, including management, which proved to be a challenging task.  
The contractor had difficulty delivering enough qualified providers in a timely manner.  An IHS 
official who was part of the SIA team acknowledged that the contractor worked hard to fulfill 
the contract but noted that IHS was ultimately responsible for ensuring that providers were 
qualified.   
A former IHS official who was involved in the vetting and credentialing process of providers at 
the AO reported rejecting many of the providers forwarded by the contractor because of 
problematic backgrounds or insufficient qualifications.  For example, the official recalled 
rejecting a provider who failed to disclose a DUI (driving under the influence) arrest on the 
application.  Another prospective provider, whom IHS also rejected, had a record of sexual 
abuse.  Furthermore, some providers in the contractors staffing pool had worked at Rosebud 
in the past but had been removed due to performance or conduct issues.   
The first contracted staff began to arrive at Rosebud about a week before the ED reopened, 
but it soon became clear to IHS that the contractor would not be able to fully staff the ED by 
the expected reopening date as promised.  IHS had already delayed the reopening date 
several times due to staffing shortages and was set on keeping its July 2016 reopening date.  
To keep the date and adequately staff the ED, IHS had to find another solution.  IHS officials 
reported that this involved supplementing the contracted ED providers with existing Federal 
staff, including former Rosebud ED nurses, and providers from the urgent-care clinic who 
were under different contracts.  This arrangement, and the staggered arrival of contracted 
providers, continued long after the ED reopened. 
Prior to the ED reopening, IHS conducted several assessments and trainings to 
ensure that the ED was ready to resume services 
In the weeks leading up to the reopening, IHS conducted and contracted numerous 
assessment, analysis, and training activities to ensure that the ED was survey-ready for CMS 
and capable of caring for emergency patients.  The SIA team reported performing mock 
surveys, sometimes with the assistance of staff from across the agency.  During the ED mock 
surveys, the SIA team checked crash carts to ensure that they were easily accessible and fully 
stacked with essential medications and equipment, and assessed both Federal and contracted 
hospital staffs ability to operate the crash 
carts.  The mock drills also included trial runs 
We had to make sure we were ready 
with EMS during which an ambulance would 
because if we failed, that would be 
bring a mannequin (patient) on a stretcher 
hard to recover from.   
into the ED.  If the team identified 
inadequacies during a mock survey, it would  IHS official 
rectify the problems and provide additional 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    23  CORRECTIVE ACTION AND REOPENING 
training to staff.  According to an SIA team member, Rosebud ran these drills until a couple of 
days before the reopening. 
In addition to the mock surveys, the SIA team conducted tabletop exercises.  These exercises 
are meetings during which hospital leadership and staff typically review and discuss roles and 
responsibilities during an imagined scenario, which may identify gaps in planning and 
communication.65  The SIA team also conducted multi-week failure mode and effects analysis, 
a proactive method for identifying and addressing potential problems or failures and their 
resulting effects on the system or process before an undesirable event occurs.66  The failure 
mode and effects analysis at Rosebud included all hospital departments and looked for failure 
process points in every part of the hospital.  As directed under the SIA, IHS also contracted 
with an accrediting organization to conduct gap analysis at Rosebud to inform the SIA team of 
the hospitals readiness for a CMS survey.  Similar to the other assessment and analysis 
activities, the SIA team worked on addressing any deficiencies identified in the gap analysis. 
IHS reopened the Rosebud ED in July 2016 after correcting its deficiencies, but 
concerns about sustainability remained, primarily because of staffing instability 
Seven months after IHS closed the ED and after numerous improvement efforts and 
ED Critical to  
Rosebud Operations   assessments, the SIA Acting CEO determined that the hospital was ready to resume 
During the first 2 weeks  emergency services.  This decision, approved by IHS leadership, came after CMS conducted a 
after the ED reopening,  walkthrough of the ED and confirmed that Rosebud had cleared the ED-related deficiencies 
Rosebud had 732 ED 
found during the November 2015 survey.  Prior to resuming services, IHS notified the tribe of 
patients. 
its decision to reopen the ED and issued a press release on its website.  The ED immediately 
began treating patients once it reopened, but it continued to experience staffing challenges.  
During the 16 days that remained in July, Rosebud reported 732 ED visits, averaging 46 ED 
visits per day.  In following months, IHS continued working on the improvement efforts laid 
out by the SIA, but frequent shift in leadership sometimes caused confusion and disruption.  
The improvement efforts eventually led to the completion of the SIA and CMSs removal of 
Rosebuds pending termination from Medicare; however, continued leadership instability 
raised concerns about the sustainability of those improvements 
The preparedness efforts in the ED were put to the test immediately after the reopening, and 
Rosebud experienced challenges with the staffing contract and frequent changes in leadership.  
The ED began seeing patients on the first day it reopened, and within the first week, a nearby 
fatal car collision, involving eight people, tested Rosebuds capabilities.  EMS transported all 
victims to the Rosebud ED, which at the time was staffed with a mixture of Federal and 
contracted providers.  The EMS Director described the event as chaotic and indicated that 
although there were many medical staff present in the ED, some of the new contracted staff 
were ineffective because they were unfamiliar with the hospital.   
Although the SIA called for a contractor to operate and manage the ED, IHS officials and staff 
reported that the outsourcing of the ED was a challenge because not only was the contractor 
unable to fill all shifts until nearly a year after the ED reopened, some of the contracted 
providers struggled to keep up with Rosebud policies and procedures.  For example, Rosebud 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    24  CORRECTIVE ACTION AND REOPENING 
staff stated that some providers failed to consistently document their medical decisions in the 
medical records and did not participate in remediation activities when issues were identified.  
The CMS monitor, who frequently visited and observed Rosebuds progress as directed by the 
SIA, also noted in her reports to CMS that staffing continued to be a problem in the ED after it 
reopened.  Some of the issues that the monitor observed related to contracted staff not 
showing up for work or leaving without notice, forcing IHS to try to backfill staffing at the last 
minute.  The staffing shortages sometimes resulted in longer wait times for patients or 
patients leaving without being seen by a healthcare provider.   
An IHS official who served on the SIA team said 
that it was a mistake to have a contractor  In hindsight, the agency should 
manage the ED.  With contracted staff  never have entered into a 
overseeing other contracted staff, IHS had to 
management contract in the ED.   
follow the contractors processes when dealing  IHS official 
with performance issues in the ED.  An Area 
staff member underscored the importance of 
having a strong Federal presence in the ED because IHS was ultimately responsible for the 
care provided at Rosebud.  
To ensure that the quality and safety in the ED were satisfactory, an IHS official reported that 
the SIA team implemented several monitoring tools after the reopening.  The team held daily 
ED-specific meetings and developed an ED dashboard with various data analytics for daily 
review.  The team also implemented comprehensive chart reviews of every new provider for 
the providers first 30 days.  To ensure that medical staff were familiar with hospital policies, 
procedures, and processes, Rosebud established a 3-day orientation for new staff and a 1-day 
orientation for returning staff who had not worked at the hospital in the last 30 days, given 
that many contracted staff rotated between facilities.  In addition to these oversight and 
training activities, IHS continued to work on the hospital-wide improvement efforts outlined 
by the SIA. 
Despite the many improvements at Rosebud, staff reported concerns about the frequent 
rotation in hospital leadership.  After the SIA Phase 1 team departed a few months after the 
ED reopened, several other SIA teams came and left, which staff explained caused confusion 
and frustration because each team would change direction and focus, often without any input 
from permanent staff.  A Rosebud staff member indicated that there was a clear separation 
between the temporary leadership teams and the rest of the hospital staff.  The staff member 
questioned how the hospital could sustain improvements without stable leadership and 
inclusion and mentoring of permanent staff.  A CMS official also expressed concerns about the 
leadership churn impacting Rosebuds ability to achieve and maintain compliance with the 
CoP requirements.  A CMS surveyor reported that every time the survey team went onsite, 
they were greeted by a new, acting leadership team at Rosebud and they would find 
deficiencies that had not been addressed or corrected. 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    25  CORRECTIVE ACTION AND REOPENING 
Section 2: Key Contributing Factors 
Factors that led to improvements and reopening of the ED 
Accountability for compliance and quality  
IHS brought in an accomplished team of clinical and management leaders with experience in 
solving problems and maintaining compliance, holding staff accountable, and fostering a 
culture of shared responsibility. 
Systemic changes 
IHS and hospital officials employed systemic methods to identify and address problems, 
leading to widespread change for the hospital and agency. 
Standardized policies and procedures 
IHS and hospital officials developed and revised hospital policies, delineated clearer roles and 
responsibilities, and streamlined procedures. 
Investment in staff training 
IHS and hospital officials conducted assessments and training to better ensure that hospital 
staff were prepared and proficient in treating patients. 
Improved communication and support from IHS 
Rosebud Hospital officials had more frequent communication and closer collaboration with 
the Great Plains AO and IHS headquarters, and additional support across HHS. 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    26  CHRONOLOGY 
 
SECTION 3 
	
C C S
ONTINUING 	 ONCERNS 	AND 	 USTAINABILITY 	OF	
I 	
MPROVEMENTS
 
IHS completed the SIA in September 2017, but Rosebud was again cited in July 2018 
with an IJlevel deficiency in the ED and placed by CMS on a termination track    
Vacancies in ED  Despite earlier progress and extensive support from IHS and other HHS agencies, the Rosebud 
In September 2018,  Hospital  continued to  struggle  to remain in compliance with the  Medicare  CoPs.  In 
Rosebud Hospital had        September 2017, CMS determined that Rosebud met all CoPs  and provisions outlined in the 
69 vacancies and 7 of  
SIA, and rescinded  the hospitals pending termination  from Medicare.  However,  in the  
these  were in the ED.  
following months, IHS  continued to have difficulty securing longterm hospital  staff and 
adequate leadership at Rosebud.  In September 2018, Rosebud Hospital had  69 vacancies  
(7 were in the  ED) that  were mostly  filled by contracted providers, and between July 2016 (the 
ED reopening) and September 2018, Rosebud had 6 CEOs, 3 Clinical Directors, and 9 DONs.   
Less than a year after IHS completed the SIA, in July 2018, CMS found new  compliance issues  
in the ED during a complaint survey.  These  compliance issues involved an IJ for  failing to 
ensure that  the ED call system was working and failing to  provide emergency care for two 
patients who presented in the ED with behavioral health needs:    
  A pediatric  patient with alcohol  intoxication who was left unattended  in a separate 
room during  which the patient attempted suicide; and 
  An adult  patient  suffering from paranoia and with methamphetamine in  the system
who died after being chemically and physically restrained.
To remove  the IJ, IHS provided Rosebud Hospital staff with additional training  on  the ED  call 
system and reeducated staff on hospital policies.  During a followup survey  in August 2018, 
CMS determined that IHS  had corrected the IJ deficiency in the  ED.  However,  in conducting  
the followup survey, CMS surveyors found other issues and cited Rosebud for conditionlevel  
deficiencies with five CoPs: Governing Body, QAPI, Radiological Services, Utilization Review, 
and Infection  Control.  Two of these CoPs, Governing  Body and QAPI, were CoPs for which the  
hospital had previously  been cited in November 2015 and February  2016.  Given that these 
were conditionlevel deficiencies, Rosebud Hospital was again placed by CMS on  a track 
toward termination from  the Medicare program.    
   
OEI061700270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening            27  CONTINUING CONCERNS AND SUSTAINABILITY OF IMPROVEMENTS 
IHS officials and staff attributed the recent deficiencies to a new hospital leadership team, 
installed at Rosebud in December 2017, not following IHS directives and discontinuing 
improvement efforts and processes established during the SIA.  IHS officials reported that In 
February 2018, Rosebud Hospital leadership failed to submit performance data and 
documentation on hospital improvement activities during a governing board meeting.  Shortly 
after that meeting, the AO began providing enhanced guidance to the hospital leadership 
team, but the problems continued.  In April 2018, the Acting Area Director ordered an 
independent mock survey of the hospital to further assess its performance and provide 
additional oversight.  The mock survey team found an array of problems, including 
documentation issues; failure to update, implement, and train staff on policies; lack of 
adherence to QAPI processes; and deterioration of care, particularly related to infection 
control.  The Acting Area Director informed hospital leadership of the findings and requested 
immediate correction but to no avail.  IHS finally removed the leadership team, around the 
time of the CMS survey in July 2018, and sent AO staff with previous Acting leadership 
experience at Rosebud Hospital to resolve the deficiencies and achieve compliance with the 
Medicare CoPs.  
The termination from Medicare was initially set for August 2018, but CMS reported that it 
IHS Corrected 
Deficiencies  extended the termination date to November 2018 after IHS submitted a plan of correction.  A 
Two weeks before the  couple of weeks before the termination date, CMS revisited Rosebud Hospital and determined 
expected termination date,   that IHS had corrected the deficiencies, and that the hospital was in compliance with all 
Rosebud came back into 
Medicare CoPs.  However, in a subsequent interview with OIG, CMS survey staff expressed 
compliance with the CoPs. 
concerns about the sustainability of those corrections, given that IHS continued to rely on 
short-term contracted providers to fill vacancies and temporarily reassigned agency staff to fill 
leadership positions.  Over the years, CMS surveyors noticed a pattern when citing Rosebud 
Hospital with deficiencies: IHS would reassign top-performing teams from across the agency 
to quickly resolve the deficiencies at the hospital, but once these teams were replaced with 
new and often inexperienced leadership, the problems would resurface.  CMS staff suggested 
that the cyclical compliance issues may have been further affected by IHSs lack of training and 
transition of new leadership and staff.  Insufficient overlap between incoming and departing 
staff likely prevented new staff from effectively understanding their roles and fully grasping 
IHSs priorities and the hospitals improvement activities and processes. 
During CMSs revisit in November 2018, several key leadership positions had new Acting 
personnel, including the CEO, Clinical Director, DON, and the ED Nurse Supervisor.  An IHS 
official reported that the agency was in the process of posting new job announcements for 
these positions, but emphasized that IHS continued to face challenges recruiting and retaining 
permanent leadership and staff, primarily due to the remote location of Rosebud Hospital and 
IHSs limited compensation packages.  
 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    28  CONTINUING CONCERNS AND SUSTAINABILITY OF IMPROVEMENTS 
Section 3: Key Contributing Factors 
Factors that led to continued lapses in compliance 
Continuing turnover in hospital leadership 
IHS brought strong leadership teams from across IHS and other agencies to correct problems 
at Rosebud.  However, those teams were temporary and frequent changes in leadership 
continued to hamper operations.  
Insufficient transition of new hospital leaders 
IHS did not build in sufficient overlap and transition of incoming and departing leadership.  
This resulted in lack of a cohesive strategy, nonadherence to agency priorities, and 
discontinuation of improvement efforts.  
Continuing difficulty maintaining staff 
As before, IHS and hospital officials struggled to recruit and retain long-term hospital staff and 
relied on contracted providers to temporarily fill the gaps. 
Corrective actions not engrained 
Temporary leaders at Rosebud instituted new policies, procedures, and training.  However, 
those solutions were not employed long enough to fully take root with leadership and 
contracted staff rotating in and out of the hospital. 
IHS could not sustain attention 
Rosebud Hospital and the Great Plains AO received enormous support and focus from IHS and 
 
other agencies following the ED closure, but this attention could not continue indefinitely.
 
 
 
 
 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    29  CONCLUSION and RECOMMENDATIONS
 
The problems at Rosebud Hospital that led to the closure of the ED were manifold and systemic.  To resolve those 
problems, IHS leadership had to make changes at the hospital, AO, and headquarters levels, which required extensive 
assistance and support from across the agency and other stakeholders, including CMS, USPHS, tribal EMS, and 
surrounding community hospitals.  IHSs longstanding problems at Rosebud Hospital, including provider recruitment 
and retention challenges and frequent changes in leadership, were evident throughout this time period and remain a 
concern.   
Following the closure, IHS and CMS focused substantial resources on improving the quality and safety of care in the 
Rosebud ED and throughout the hospital.  This focus came at a cost to other IHS hospitals in leadership, staffing, and 
other resources.  The SIA was a turning point for IHS to address the problems at Rosebud, and the SIA team in 
particular played a key role in correcting the deficiencies in Rosebuds ED and across the hospital.  The team addressed 
personnel issues, revised policies, established a QAPI program, and restructured the governing body, among other 
efforts.  IHS made many improvements at Rosebud and has continued to make changes throughout the agency.   
Still, CMS found a new IJ deficiency and condition-level deficiencies in the Rosebud ED during JulyAugust 2018, which 
raises the question of whether the improvements were sustainable.  Despite the intense focus of the SIA and other 
efforts, leadership and staffing instability continues to affect hospital operations. 
There is little question that IHS's handling of the ED closure was problematic and had negative consequences for the 
affected parties.  But it is important to recognize that the closure was preceded by Rosebuds inability to remain in 
compliance with the Medicare CoPs.  The factors that contributed to the noncompliance, including staffing 
inadequacies and changing leadership, were longstanding and occurred before, during, and after the closure.  These 
issues will require IHSs continued focus.  Innovative solutions are needed to avoid cyclical noncompliance by Rosebud 
and prevent residual impact of that instability on the hospital and the overall agency. 
To address the problems that we identified in this case study of Rosebud Hospital, and to avoid and minimize similar 
problems across IHS hospitals, we make four recommendations to IHS: 
As a management priority, develop and implement a staffing program for recruiting, retaining, and 
transitioning staff and leadership to remote hospitals 
IHS had difficulty maintaining an adequate workforce and consistent leadership at Rosebud before, during, and after 
the ED closure, which affected the hospitals ability to maintain compliance.  Frequent changes led to confusion about 
the roles and responsibilities, instability among staff and the hospital culture, and continuing shifts in management 
strategies for improving operations.  The impact of these longstanding challenges, particularly inadequate staffing, is 
profound and inhibits progress in correcting all other problems.   
As such, IHS should intensify efforts and build on the goals and objectives of its strategic plan to stabilize staffing and 
leadership at Rosebud and other remote hospitals.  IHS's top priority should be to find innovative ways to recruit and 
retain permanent providers and long-term hospital leaders, which includes establishing tangible targets for filling 
staffing and leadership positions.  This alone will not solve all of Rosebuds challenges, but it is necessary for long-term 
success.  Without addressing this staffing issue, it is difficult to envision how IHS could achieve sufficient and lasting 
clinical improvements.   
IHS should maximize opportunities to access Departmental resources and experts, and continue to look for new 
partnerships both within and outside of HHS to identify and implement additional recruitment and retention tools.  
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           30  CONCLUSION AND RECOMMENDATIONS 
Possibilities include working with the Office of Personnel Management to develop a new model for staffing remote IHS 
facilities, and looking at how other Federal agencies, such as the Department of Defense, and private healthcare 
organizations have structured programs to address similar staffing challenges.  IHS should also consider seeking the 
necessary regulatory and/or legislative changes to implement a new sustainable plan for staffing remote IHS facilities.   
Enhance training and orientation for new hospital leaders to ensure that they follow IHS directives and 
continue improvement efforts  
IHS launched a leadership training, shortly before it reopened the Rosebud ED, to prepare new leaders at different 
levels of IHS for their new roles.  However, it is unclear whether IHS continued this training effort after its initial launch 
and whether the training addressed hospital-specific needs.  To counter confusion about the roles and expectations of 
new hospital leaders, IHS should continue to provide leadership training that includes specific instructions and 
information related to hospital management.   
IHS should also establish longer transition periods and overlap between incoming and departing leadership to ensure 
that new hospital management teams understand the priorities and directives of IHS.  This action could include having 
experienced leadership and staff from other facilities and AOs working side-by-side with new hospital leaders for an 
extended period of time to provide mentoring and guidance on IHS improvement efforts and hospital policies, 
procedures, and processes. 
Continue to take steps to ensure early and effective intervention when IHS identifies problems at 
hospitals  
Given the frequent change in hospital leadership and contracted providers, it is crucial for IHS to closely monitor 
hospitals performance and intervene early and effectively to correct problems before they reach a level of 
noncompliance.  IHS revised the governing board structure to improve AO oversight of hospitals, and following the 
revelation of renewed problems at Rosebud in February 2018, the Great Plains AO took quick and substantial action to 
make changes and improve practices.  This quick turnaround appears to have been supported throughout the AO and 
IHS headquarters.  To ensure that IHS policies outline the necessary steps for closer monitoring and quicker 
intervention by AO and headquarters leadership, IHS should assess its policies and revise them as needed.  Close 
monitoring and quick action could avoid a potential crisis and ensure that IHS addresses problems that may arise at its 
hospitals in a timely and consistent manner.   
Develop procedures for temporary ED closures and communicate those procedures with receiving 
hospitals and EMS to ensure that they are adequately prepared to receive diverted patients during such 
events 
IHS and Rosebud Hospital leadership did not effectively plan for, coordinate, or communicate the ED closure, which 
caused confusion among some staff and had serious ramifications for surrounding hospitals and the community.  The 
receiving hospitals and EMS received little warning about the closure and were quickly overwhelmed with demand.  
IHSs lack of problem management continued throughout the closure and afterward.  An administrator from one of the 
receiving hospitals reported continuing uncertainty about who to contact at IHS if a future ED closure occurs.  Despite 
lessons learned from problems caused at the closure, Rosebud and IHS continued to be slow in supporting its partners 
and failed to substantially improve its transparency and communication.  Given that IHS temporarily suspended 
emergency services in several hospitals in recent years, it is incumbent on IHS to ensure that hospitals are adequately 
prepared to handle any future ED closures.  
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    31  CONCLUSION AND RECOMMENDATIONS 
To ensure preparedness, IHS should develop plans, procedures, and training that clearly define leadership and staff 
roles and responsibilities at all levels of IHS (hospital, AO, and headquarters) during an ED closure, all of which were 
lacking at Rosebud.  Such efforts could include activating the HICS, which could assist hospitals in managing the closure 
and addressing the problems needed to resume services.  Each hospital should tailor its plans and procedures to the 
hospital-specific needs and environment, and could include forming MOUs with surrounding hospitals and EMS, likely 
to be affected by the ED closure and diversion of emergency patients.  The plans should also include instructions for 
notifying affected parties of the temporary closure, including the IHS hospital staff, tribes, receiving hospitals, and 
EMS.  Inconsistent notifications during IHSs closure of the Rosebud ED caused confusion and hindered adequate 
preparation among the affected parties.   
To ensure that IHS hospitals are familiar with the plans and procedures, IHS should provide training to all staff.  Prior to 
the closure, Rosebud staff had no information or knowledge about the procedures or expectations during an ED 
closure.  Considering that some hospitals and AOs struggle with frequent staff and leadership turnover, IHS should 
ensure that all new staff are aware of the plans and procedures for ED closures, and that plans are reviewed and 
updated regularly.  As part of the training, IHS could share lessons learned across the facilities, including its 
experiences in closing and reopening the Rosebud ED.  IHS should also communicate the plans and procedures with 
the receiving hospitals and EMS, to ensure that the affected healthcare providers can plan and prepare accordingly. 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    32  AGENCY COMMENTS and OIG RESPONSE
 
 
IHS concurred with all four recommendations and stated that it will use the findings and recommendations in this 
report to improve its management and operations.  In its comments, IHS provided actions taken and planned as of 
May 2019.  
In response to our first recommendation to develop and implement a staffing program for recruiting, retaining, and 
transitioning staff and leadership to remote hospitals, IHS stated that it has outlined the agencys commitment to 
recruit and retain quality staff across IHS in the IHS Strategic Plan FY 20192023, released in February 2019.67  IHS 
stated that it will assemble a multidisciplinary, senior-level workgroup tasked with developing a comprehensive 
workforce plan.  The workforce plan, which IHS expects to complete by May 2020, will address recruitment, training, 
and placement of staff into leadership positions, particularly in remote locations, as well as succession planning. 
In response to our second recommendation to enhance training and orientation for new hospital leaders to ensure 
that they follow IHS directives and continue improvement efforts, IHS stated that it has implemented an agency-wide 
leadership training program for all leaders across IHS, including hospital leaders.  IHS also stated that it will establish a 
workgroup, comprising experienced AO management and operational staff, to identify and share best practices for 
training and orienting new hospital leadership.  IHS will incorporate the best practices into a training policy, required 
for all new hospital leadership, which IHS expects to complete by March 2020.  
In response to our third recommendation to continue steps to ensure early and effective intervention when IHS 
identifies problems at hospitals, IHS stated that it is working to improve governance and accountability and provided a 
list of efforts undertaken.  These efforts include establishing the Office of Quality, launching a national accountability 
dashboard for quality to measure outcomes, contracting with Joint Commission Resources for consultation services 
and mock surveys of IHS hospitals, implementing a new credentialing software, awarding a contract to develop a new 
adverse events reporting system, enhancing collaboration with CMS, and further training staff in quality improvement.      
Lastly, in response to our fourth recommendation to develop procedures for temporary ED closures, and communicate 
those procedures with receiving hospitals and EMS to ensure that they are adequately prepared to receive diverted 
patients during such events, IHS stated that it has developed a preliminary outline of considerations and procedures 
when closing an ED under various scenarios.  IHS will form a multidisciplinary workgroup that will use the outline to 
develop an ED closure procedure, which hospitals will incorporate into their respective emergency management plans.  
IHS expects to complete the ED closure procedure by December 2019. 
OIG values the steps that IHS has taken, and will continue to assess updates from IHS regarding progress in 
implementing these recommendations. 
For the full text of IHSs comments, see Appendix B. 
 
 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           33  APPENDIX A
 
TIMELINE OF KEY EVENTS FOR IHS CLOSURE OF THE ROSEBUD ED, 20152018 
2015  November 19 CMS cited Rosebud with seven CoP deficiencies, including IJ in the ED. 
  December 4 CMS issued termination letter to IHS with an effective date of February 17, 2016. 
  December 5 IHS closed Rosebud ED and opened 24-hour urgent-care clinic. 
  December IHS requested deployments from USPHS. 
   
2016  January USPHS began deployments of Commissioned Corps officers to Rosebud. 
  February 12 CMS revisited Rosebud and cited five CoP deficiencies and extended termination to March 16, 2016. 
  March 4 CMS extended termination date to April 29, 2016, to explore possibility of formulating an SIA with IHS. 
  April 30 IHS entered into an SIA with CMS and extended the termination date to May 16, 2017. 
  May 17 IHS awarded Rosebud ED staffing contract. 
  May 31 IHS assembled SIA Phase 1 team at Rosebud. 
  June 6 SIA team activated HICS at Rosebud. 
  June 16 IHS finalized revised Rosebud ED policies. 
  June 16-23 IHS provided Rosebud staff training on emergency services. 
  June 24 IHS conducted mock survey to assess Rosebud ED readiness. 
  June 26 IHS conducted risk management review of Rosebud. 
  June 29 Rosebud began daily tabletop exercises for the ED using failure mode and effects analysis. 
  June 30 IHS completed ED renovations. 
  July 1 IHS conducted risk management review of Rosebud. 
  July 5 IHS notified CMS of its intent to reopen the ED. 
  July Contracted ED staff began to arrive at Rosebud. 
  July 12 CMS cleared ED for reopening. 
  July 14 IHS conducted mock survey of the Rosebud ED. 
  July 15 Rosebud resumed ED services and closed urgent-care clinic. 
   
2017  September 1 IHS completed SIA and CMS removed pending termination. 
   
2018  July 26 CMS cited Rosebud with IJ deficiencies in the ED. 
  August 7 CMS issued termination letter to IHS with an effective date of August 30, 2018. 
  August 17 CMS revisited Rosebud and found that the IJ was resolved but cited five CoP deficiencies. 
  September 24 CMS extended termination date to November 26, 2018. 
  September 28 CMS accepted IHS plan of correction. 
  November 20 CMS removed pending termination after a revisit that found Rosebud compliant with all CoPs. 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           34  APPENDIX B
 
IHS COMMENTS 
 
 
   
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           35  APPENDIX B 
 
   
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    36  APPENDIX B 
 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    37  ACKNOWLEDGMENTS
 
Petra Nealy served as the team leader for this case study.  Others in the Office of Evaluation and Inspections who 
contributed to the case study include Amy Ashcraft, Patricia Chen, Ben Gaddis, and Anthony Soto McGrath.  Office of 
Evaluation and Inspections staff who provided support include Kevin Farber and Joe Chiarenzelli.  
This report was prepared under the direction of Ruth Ann Dorrill, Regional Inspector General for Evaluation and 
Inspections in the Dallas regional office, and Amy Ashcraft and Petra Nealy, Deputy Regional Inspectors General.
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           38  ENDNOTES
 
  
 
1 IHS, Justification of Estimates for Appropriate Committees, Fiscal Year 2020, p. CJ-7. Accessed at 
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY2020CongressionalJustificati
on.pdf on June 28, 2019. 
2 P.L. No. 94-437, Indian Health Care Improvement Act.  25. U.S.C.  1601.  The IHCIA identifies a major national goal to provide 
the quantity and quality of health services which will permit the health status of Indians to be raised to the highest possible level 
and to encourage the maximum participation of Indians in the planning and management of those services. 
3 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2020, p. CJ-1-2.  Accessed at  
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY2020CongressionalJustificati
on.pdf on June 28, 2019. 
4 U.S. Senate Committee on Indian Affairs, In Critical Condition: The Urgent Need to Reform the Indian Health Services Aberdeen 
Area, December 28, 2010.  Accessed at https://www.indian.senate.gov/sites/default/files/upload/files/Chairman-s-Report-In-
Critical-Condition-12-28-10.pdf on June 28, 2019. 
5 U.S. Commission on Civil Rights, Broken Promises: Evaluating the Native American Health Care System, September 2004.  
Accessed at http://www.usccr.gov/pubs/docs/nabroken.pdf on June 28, 2019. 
6 The Institute for Government Research, The Problem of Indian Administration, February 21, 1928, Ch. I.  Accessed at 
http://www.alaskool.org/native_ed/research_reports/IndianAdmin/Indian_Admin_Problms.html on June 28, 2019. 
7 U.S. Senate Committee on Indian Affairs, Reexamining the Substandard Quality of Indian Health Care in the Great Plains, February 
3, 2016.  Accessed at https://www.indian.senate.gov/hearing/oversight-hearing-reexamining-substandard-quality-indian-health-
care-great-plains on June 28, 2019. 
8 U.S. House of Representatives Committee on Appropriations, Management Challenges at the Departments of Labor, Health and 
Human Services, and Education and the Social Security Administration: Views from the Inspectors General, March 9, 2017.  
Accessed at https://www.govinfo.gov/content/pkg/CHRG-115hhrg27208/pdf/CHRG-115hhrg27208.pdf on June 28, 2019. 
9 IHS temporarily closed Acoma-Canoncito-Laguna Service Unit ED on multiple occasions during a 5-month period in 2014, 
Crownpoint Hospital ED for approximately 2 months in 2015, and Rosebud Hospital ED for 7 months in 20152016.  Sioux San 
Hospital ED has remained closed since September 2016.  In July 2017, IHS submitted a report to Congress to permanently 
discontinue emergency and inpatient services at Sioux San Hospital by July 2018.  OIG email correspondence with IHS officials on 
February 14, 2017.  IHS, Indian Health Service Report on Proposed Closure of the Sioux San Hospital Emergency and Inpatient 
Departments, July 2017.   
10 IHS, Rosebud Service Unit.  Accessed at https://www.ihs.gov/greatplains/healthcarefacilities/rosebud/ on June 28, 2019. 
11 Indianz.com, Rosebud Sioux Tribe sues Indian Health Service over crisis in care, April 28, 2016.  Accessed at 
http://www.indianz.com/News/2016/04/28/rosebud-sioux-tribe-sues-india.asp?print=1 on June 28, 2019. 
12 IHS, Press Release, Rosebud Hospital Diverts Emergency Room Services, December 4, 2015.  Accessed at 
https://www.ihs.gov/newsroom/index.cfm/pressreleases/2015pressreleases/rosebud-hospital-diverts-emergency-room-services/ 
on June 28, 2019. 
13 Letter from Representative Kristi Noem to (former) IHS Principal Deputy Director Robert McSwain, December 18, 2015.  
Accessed at http://dakotawarcollege.com/noem-seeks-information-on-critical-conditions-within-indian-health-service-facilities/ 
on June 28, 2019. 
14 In July 2016, then IHS Acting Director testified before the Indian, Insular, and Alaska Native Affairs Subcommittee of the House 
Natural Resources Committee that she would join committee members in asking OIG to investigate deaths considered related to 
the Rosebud ED closure.  Following the testimony, IHS forwarded to OIG a letter sent by the Rosebud Sioux Tribe president to IHS, 
dated August 9, 2016.  In the letter, tribal leadership requested an OIG investigation into deaths that occurred during the ED 
closure.  In subsequent conversations with OIG, tribal representatives raised additional concerns about IHSs management and 
handling of the closure. 
15 Pursuant to the Indian Self-Determination and Education Assistance Act, P.L. No. 93-638, IHS contracts and/or compacts with 
tribes or tribal organizations to deliver services.  IHS, Fact Sheets: A Quick Look.  Accessed at 
https://www.ihs.gov/newsroom/factsheets/quicklook/ on June 28, 2019. 
16 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2020, p. CJ-7, CJ-56.  Accessed at   
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY2020CongressionalJustificati
on.pdf on June 28, 2019.  In addition to the $2 billion appropriated for hospitals and health clinics, IHS supports programs such as 
dental services and public health, among others. 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening           39  ENDNOTES 
 
17 IHS, Great Plains Area.  Accessed at https://www.ihs.gov/greatplains/ on June 28, 2019.  The number of hospitals operated by 
IHS in the Great Plains Area decreased from seven to five hospitals after the Winnebago Tribe assumed operations of Winnebago 
Hospital in July 2018 and IHS converted Rapid City Hospital to a health center in 2019.  OIG email correspondence with IHS official 
on January 24, 2019 and July 1, 2019. 
18 IHS, Indian Health Manual, pt. 1; Ch. 1; section 1-1.2 (Indian Health Manual). 
19 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2020, p. CJ-57.  Accessed at  
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY2020CongressionalJustificati
on.pdf on June 28, 2019.  The number of hospitals operated by IHS decreased from 26 to 25 hospitals in 2018 after the Winnebago 
Tribe assumed operations of Winnebago Hospital.  OIG email correspondence with IHS official on January 24, 2019.  In 2019, the 
number IHS-operated hospitals decreased from 25 to 24 hospitals after IHS converted Rapid City Hospital to a health center.  OIG 
email correspondence with IHS official on July 1, 2019. 
20 IHS, Internal document, Inpatient Summary Data for Indian Health Service Hospitals by Area and Facility  October through 
September Fiscal Year 2017, April 9, 2018. 
21 Ibid. 
22 Ibid. 
23 OIG email correspondence with IHS officials on February 21, 2018.  
24 Ibid. 
25 IHS, Rosebud Service Unit.  Accessed at https://www.ihs.gov/greatplains/healthcarefacilities/rosebud/ on June 28, 2019. 
26 Social Security Act  1880(a) and 1911(a), P.L. No. 94-437, Indian Health Care Improvement Act (codified at 25 U.S.C.  
1621(e)). 
27 IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2020, p. CJ-7.  Accessed at  
https://www.ihs.gov/sites/budgetformulation/themes/responsive2017/display_objects/documents/FY2020CongressionalJustificati
on.pdf on June 28, 2019.   
28 Ibid, pp. CJ-115-117.   
29 Ibid, p. CJ-116.   
30 IHS, Circular No. 97-01.  Accessed at https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_circ_mainandcirc=ihm_circ_9701 on 
June 28, 2019.  On September 29, 2017, IHS awarded a contract to The Joint Commission for accreditation of all IHS direct-service 
hospitals.  IHS, Justification of Estimates for Appropriations Committees, Fiscal Year 2020, p. CJ-58.   
31 Social Security Act  1880(a) and 1865(a)(1).   
32 42 CFR  482.1, 482.12, 482.21, and 482.22. 
33 42 CFR  482.12. 
34 IHS, Indian Health Manual, pt. 3; Ch. 1; section 3-1.2B (Governing Body). 
35 IHS, Circular No. 97-01.  Accessed at https://www.ihs.gov/ihm/index.cfm?module=dsp_ihm_circ_mainandcirc=ihm_circ_9701 on 
June 28, 2019. 
36 CMS, State Operations Manual (SOM), Ch. 1  1018A. 
37 CMS, SOM, Appendix QGuidelines for Determining Immediate Jeopardy. 
38 CMS, SOM, Appendix ASurvey Protocol, Regulations and Interpretive Guidelines for Hospitals.  CMS, Schedule of Termination 
ProceduresNoncompliance With One or More CoPs or Conditions for Coverage Cited Deficiencies Limit Capacity of 
Provider/Supplier to Furnish Adequate Level or Quality of Care (Medicare).  Accessed at https://www.cms.gov/Medicare/Provider-
Enrollment-and-Certification/SurveyCertificationEnforcement/Downloads/Schedule-of-Termination-Procedures.pdf on June 28, 
2019. 
39 42 CFR  489.53. 
40 Compass Clinical Consulting, FAQ: What is a CMS Systems Improvement Agreement?  July 10, 2017.  Accessed at 
https://www.compass-clinical.com/what-is-a-systems-improvement-agreement/ on June 28, 2019. 
41 42 CFR  482.55.  
42 CMS, Provision of Emergency Services  Important Requirements for Hospitals, S&C-07-19, April 26, 2007.  Accessed  
at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter07-
19.pdf on June 28, 2019.  
43 42 CFR  482.55.  42 CFR  489.24(b) defines dedicated emergency department. 
44 SSA  1867(e)(1). 
45 P.L. No. 99-272, Emergency Medical Treatment and Active Labor Act, 100 Stat. 164 (1980).  SSA  1867(e).  42 U.S.C.  1393dd et 
seq. 
46 CMS, SOM, Appendix VInterpretive GuidelinesResponsibilities of Medicare Participating Hospitals in Emergency Cases.   
47 CMS, State Operations Provider Certification, Pub. 100-07, May 29, 2009, p. 22.  Accessed at https://www.cms.gov/Regulations-
and-Guidance/Guidance/Transmittals/downloads/R46SOMA.pdf on June 28, 2019. 
 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    40  ENDNOTES 
 
48 Ibid. 
49 42 CFR  489.24(b)(4). 
50 P.L. No. 94-437, Indian Health Care Improvement Act.  25 U.S.C.  1631(b)(1). 
51 P.L. No. 94-437, Indian Health Care Improvement Act.  25 U.S.C.  1631(b)(2). 
52 OIG, Indian Health Service Hospitals: More Monitoring Needed to Ensure Quality Care, OEI-06-14-00010, October 2016. 
53 OIG, Indian Health Service Hospitals: Longstanding Challenges Warrant Focused Attention to Support Quality Care, OEI-06-14-
00011, October 2016. 
54 GAO, Indian Health Service: Actions Needed to Improve Oversight of Quality of Care, GAO-17-181, January 2017.  Accessed at 
https://www.gao.gov/assets/690/681951.pdf on June 28, 2019.  
55 GAO, Indian Health Service: Agency Faces Ongoing Challenges Filling Provider Vacancies, GAO-18-580, August 2018.  Accessed at 
https://www.gao.gov/assets/700/693940.pdf on June 28, 2019. 
56 Joint Commission International, Prepare for Accreditation.  Accessed at 
https://www.jointcommissioninternational.org/improve/prepare-for-accreditation/ on June 28, 2019.  CMS, SOM, Appendix A.   
57 IHS, Systems Improvement Agreement for Rosebud Public Health Service Indian Hospital, April 30, 2016.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/RosebudSIAsigned.pdf on June 28, 
2019. 
58 Hospital Incident Command System, HICS Guidebook, August 2006.  Accessed at https://emsa.ca.gov/wp-
content/uploads/sites/71/2017/07/Guidebook_Glossary.pdf on June 28, 2019. 
59 42 CFR  482.21. 
60 IHS, Quality at IHS.  Accessed at https://www.ihs.gov/quality/ on June 28, 2019. 
61 IHS, Press Release, Indian Health Service Announces New Office of Quality, December 21, 2018.  Accessed at 
https://www.ihs.gov/newsroom/pressreleases/2018pressreleases/indian-health-service-announces-new-office-of-quality/ on June 
28, 2019. 
62 IHS, Indian Health Service Quality Framework 2016-2017, October 2016.   
63 Testimony of RADM Chris Buchanan, Deputy Director for IHS, before Subcommittee on Indian, Insular and Alaska Native Affairs 
Committee on Natural Resources, June 21, 2017.  Accessed at 
https://www.ihs.gov/sites/newsroom/themes/responsive2017/display_objects/documents/testimony/115/115th-June-21-
2017.pdf on June 28, 2019. 
64 P.L. No. 111-148, Patient Protection and Affordable Care Act, Sec. 5210.  U.S. Public Health Service Commissioned Corps, Office 
of the Ready Reserve AffairsReady Reserve Corps Update, September 2, 2010.  Accessed at 
https://dcp.psc.gov/ccbulletin/articles/Reserve_Update.aspx on June 28, 2019. 
65 Federal Emergency Management Agency, Lesson 6: Staying Prepared.   
66 CMS, Guidance for Performing Failure Mode and Effects Analysis with Performance Improvement Projects.  Accessed at 
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/QAPI/downloads/GuidanceForFMEA.pdf on June 28, 2019. 
67 IHS, IHS Strategic Plan FY 2019-23, updated February 27, 2019.  Accessed at 
https://www.ihs.gov/sites/strategicplan/themes/responsive2017/display_objects/documents/IHS_Strategic_Plan_FY%202019-
2023.pdf on June 28, 2019. 
OEI-06-17-00270         Case Study: Indian Health Service Management of Rosebud Hospital Emergency Department Closure and Reopening    41