Deparment of Health and Human Services


OFFICE 

INSPECTOR GENERAL


INDIAN HEALTH SERVICE


YOUTH ALCOHOL AND


SUBSTANCE ABUSE PROGRAMS


VJCES. 

Richard P. Kusserow 

INSPECTOR GENERAL 

APRi 1991 Jy ;(O' d:W 
Deparment of Health and Human Services


OFFICE 

INSPECTOR GENERAL


INDIAN HEALTH SERVICE


YOUTH ALCOHOL AND


SUBSTANCE ABUSE PROGRAMS


~ Sf.IlVJCES. 

Richard P. Kusserow 

INSPECTOR GENERAL 

'0 + OEI-07-89-00940 

;(O'~d:W 
EXECUTIVE SUMMARY


PURPOSE 

The objective of this inspection was to determine the extent to which the Indian Health Service 

(ilS) has implemented youth alcohol and substance abuse progrs funded under Public Law 

99-570. 

BACKGROUND 

Over the past two decades, American Indians have recognized the importce of treating their 

alcohol abuse problems, and national attention has been provided to address the situation. 

Reasons attrbuting to this concern include an alcoholism related death rate of over four times 

the age adjusted rates for the U.S. population, and an admssion rate of 34 percent to alcohol and 

drg abuse programs for Indians who are under 25 year of age. For Indians under 35 years of 

age, this statistic increases to almost 70 percent. 

In the late 1960' s, the Offce of Economic Opponunity funded outrach and tratment progrs. 

The National Institute on Alcohol Abuse and Alcoholism (NIAA), established in the 1970' 

provided seed monies for treatment of alcohol abuse among the Indians. In the Indian Health 

Care Improvement Act of 1976 (Public Law 94-437), Congress dicted that NIAAAprograms 

be transferred to IRS jurisdiction. 

On October 27, 1986, Congress enacted Public Law 99-570, subtitled the "Indian Alcohol and 

Substance Abuse Prevention and Treatment Act of 1986. " In the fIrst three years of Public Law 

99-570, approximately $50 milion in recurrng funds and $19 millon in nonrecurrng funds 

were appropriated for youth alcohol and substance abuse programs. 

METHODOLOGY 

To secure the information needed to examine operations and activities regarding Public Law 

99-570, data collection instrments were mailed to the 11 ilS area offices. An analysis of the 

information was conducted to determine to what extent each area office had implemented the 

provisions of Public Law 99-570. To verify data received, thre IHS ara offces were selected 

for on-site visits. On-site visits were also made to the two regional treatment centers which were 

operational at the time of our study. Administrative and program sta were interviewed to 

determine the level of operations that the centers had achieved. 
FINDINGS


The IHS Headquarers has not completed IHS alcoholism treatment standads. 

The IHS Headquarers has failed to meet quality assurce objectives. 

The current IHS management information system is outmoded and ineffective to 

monitor alcohol program activity. 

The ilS has failed to comply with requirements in Public Law 99-570 to establish 

regional treatment centers in all IRS service areas. 

Nearly two-thirds of alcoholism counselors in the IRS are not cenifed. 

The Bureau of Indian Affais has nOt established emergency shelters as required by 

Public Law 99-570. 

Evidence of inappropriate use of funds has been referred to the OIa Office of Audit 

Services. 

RECOMMENDATIONS 

The ilS should complete and promulgate operating stadads. 

The ilS Headquarers and area offIces should conduct reviews in accordace with 

their own quality assurance goals. 

The ilS should establish a process to review all area offIce program report and 

provide feedback to the ara offces. 

The ilS should develop an adequate management information system which 

provides data on alcohol and substance abuse tratment. 

The ilS should establish regional treatment centers in every ilS service area, or 

advise Congrss of their recommendation for an alternative strategy to provide 

residential services.


The ilS should ensure that all alcoholism counselors become certfIed. 

The IHS should work with the Bureau of Indian Affai to secur the release of funds 

which have been appropriated for emergency shelters and halfway houses. 
COMMENTS 

We received comments to the drft of this repon from the Public Health Service (PHS). The 

PHS concurrd with al the recommendations. However, PHS comments state that successful 

implementation of the last two recommendations cannot be assured because those two areas are 

not solely within IRS' s control. 

We agree that programs of the Bureau of Indian Affairs are not under PHS' s diect control. 

However, we believe the IHS should continue coordination effort with the Burau of Indian 

Affairs in order to assure the timely constrction and operation of emergency shelters and 

halfway houses. 
.... ...... .......... .................................. ........ ........ ............ ............ ...,.. ...................... .......... ...... ....................................

.... .......... ........ ...... ................ .............

TABLE OF CONTENTS


EXECUTIVE SUMMARY 

INTR 0 D U CTI 0 N .......... ...... ...... 


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


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


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


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


The IRS Headquarers has not completed ilS alcoholism treatment 

standards................................................................ .............................................. 3


The IRS Headquarers has not met quality assurce objectives.........................


The current ilS management informtion system is outmoded and 

ineffective to monitor alcohol progr activity ................................................


The IRS has nOt complied with requirments in Public Law 99-570 

to establish regional tratment centers in all ilS servce areas ...........................


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


The Bureau of Indian Affais has not established emergency shelters 

as required by Public Law 99-570 .....................................................................


Evidence of inappropriate use of funds has been referred to the 

OIG Offce of Audit Services .............................................................. ................ 8


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


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


.......................................... A­
 APPENDIX A ........ 

INTRODUCTION


PURPOSE 

This inspection was undenaken to determine the extent to which the Indian Health Service (ilS) 

has implemented provisions for youth alcohol and substance abuse programs funded under 

Public Law 99-570. 

BACKGROUND 

The problem of alcoholism among American Indians has existed for many years. Over the past 

two decades, however, Native Americans have recognized the imponance of trating their 

alcohol abuse problems. Reasons attrbuting to this concern include an alcoholism related death 

rate of over four times the age adjusted rates for the U. S. population, and an admssion rate of 

almost 34 percent to alcohol and drg abuse programs for Indians who are under 25 years of age. 

For Indians under 35 years of age, this statistic increases to almost 70 percent. 

National attention began to focus on the problem of alcohol abuse among American Indians in 

the late 1960' s when the Offce of Economic Opponunity (OEO) provided funding for outreach 

and treatment in Indian communities. The National InstitUte on Alcohol Abuse and Alcoholism 

(NIAAA), which was established in the 1970' s, provided seed monies for treatment of alcohol 

abuse among the Indians. The NIAAA funded the OEO-supponed programs and also provided 

star-up or special funding for additional demonstration projects. The NIAAA monies were not 

meant for long-term funding, therefore, Congress created the Indian Health Care Improvement 

Act of 1976 (Public Law 94-437), directing that NIAAA program be transferred to ilS 

jurisdiction. There was a grdual transfer of these progrs betWeen 1978 and 1981. 

638 Most of the grants were convened to contracts, the majority of which were called "

contracts " in line with Public Law 93-638, the Indian Self-Determnation and Education 

Assistance Act. The Self-Determination law, which was reauthorized in October 1988 as Public 

Law 100-472, is currently in effect and represents a subs antial component of the award process. 

The Self-Determination law allows the IHS to contract diectly with Indian trbes for operation 

of their own service programs. The IHS awards and monitors these progrs through its 11 area 

offces. 

On October 27, 1986, Congress enacted Public Law 99-570, the "Indian Alcohol and Substace 

Abuse Prevention and Treatment Act of 1986. " In addition to regular appropriations, this Act 

authorized substantial funds for both IHS and the Bureau of Indian Affais (BIA) for alcohol and 

substance abuse services to the Indian youth population. 

On November 18, 1988, Congress reauthorized and amended Public Law 99-570. SpecifIcally, 

the law authorized appropriations to the Secretar of Health and Human Services for funding to 

implement an Indian Health Service Youth Program. Under this program, the Secretar, acting 
through IHS, was to establish an alcohol and substance abuse program for Indian youth that 

included the following activities: 

Development and implementation of a program for detoxification and treatment for 

Indian youth who are alcohol and substance abusers. This was to include regional 

treatment centers designed to provide detoxification and rehabiltation for both sexes 

on a referral basis. These regional treatment centers ar to be integrated with the 

intake and the rehabiltation programs that exist in the Indian communities. 

Renovation or constrction of a youth regional treatment center in each area under the 

jursdiction of an ilS area office. For the purose of constrcting or renovating these 

regional treatment centers, $6,000,000 was authoried for the fIscal year 1989 and 

$3,000,000 was authorized to be appropriated for fiscal years 1990 and 1991. 

Also, for the purpose of stafng and operating such centers, $3,000,000 was 

authorized for fiscal year 1989 and $11,000,000 for fIscal year 1990. For fUture fiscal 

years, there wil be an amount equal to fIscal year 1990 included in the base budget of 

the IHS. 

Cooperation with the BIA in developing and implementing community-based 

rehabilitation and follow-up services for Indian youth who are alcohol or substance 

abusers. These services ar to be designed to integrte long-term treatment and to 

monitor and suppon the Indian youth after their retu to their home communities. 

Inclusion of family members of the youth in the tratment programs or other services. 

METHODOLOGY 

The 11 ilS area offces were the primar soure of informtion for this review. Offce staf 

directly involved with or knowledgeable of the varous inspection topics were asked to complete 

data collection instrments designed to secure the information needed to exame operations and 

activities. The questions included in the data collection instrments addssed varous topics, 

including guidelines and procedures, programs and services, regional tratment centers, fInancial 

accountability, operational monitorig, and the ilS management information system. 

An analysis of the information was conducted to determne to what extent each area offce had 

implemented the provisions of Public Law 99-570. To verify data received, three ilS area 

offices were selected for on-site visits. 

On-site visits were also made to the two regional tratment centers which were operational at the 

time of our study. Administrative and program staff were intervewed to determine the level of 

operation that the centers had achieved. 
FINDINGS


The IHS Headquarters has not completed IHS alcoholism treatment standards. 

The Public Law 99-570 was passed in October 1986, and the IHS Alcohol and Substace Abuse 

Programs branch issued draft stadards in Februar 1988. These standards were revised in 

September 1988 and, as of July 1990, were still in draft. The thee offces we visited indicated 

that faiure to fInalze the guidelines created operational problems. For example, staff at one area 

offce said that they feel no compulsion to follow the IHS draf alcoholism stadards because 

they are not in final and ilS Headquarers, based on past experience, wil not enforce them. 

Employees at a second area offce said that little diection and lack of approved standads caused 

gaps in tratment services and weakened IHS Headquarrs ' crdibility on alcoholism. The third 

area office visited developed its own alcoholism stadads, based in pan on ilS's draft 

standards. This area offce follows these guidelines, in addition to aftercare progr guidelies, 

which were developed by area offce staf. 

According to the three area offces, the ilS Headquarers has provided very little guidance to 

IHS area offices in development and implementation of Public Law 99-570 programs. The IRS 

Headquarers has not provided enough technical assistance to the ara offces nor do they have 

enough hands-on knowledge of the day-to-day operations at the area offces, according to the 

area office interviewees. 

The IHS Headquarters has failed to meet quality assurance objectives. 

The IRS Headquarers did not conduct reviews of area offices every two years. 

According to IRS Headquarers directives, the ilS Alcohol and Substace Abuse Progrs 

branch is to review ara offces once every two years. Although IHS reviewed six area offices in 

1988, only one area office was reviewed in 1989. Four area offIces have not had a formal 

quality assurance review from the IRS Alcohol and Substace Progrs branch in the last two 

years. 

Because of lack of guidance and approved standards, area offIce sta are uncenan about the 

appropriateness of funding decisions made for cenain activities. For example, within one area 

office s service area, at least two activities appeared to be inappropriately funded under the youth 

alcoholism programs. One was a " Sober Rodeo " in which pancipants and the audience were 

banned from bringing alcohol onto the premises, and the other was an elaborate renovation of a 

camping site in which substance-free lifestyles were only a small par of the campout s agenda. 

Area office staf doubted the validity of these alcoholism treatment program, stating that they 

now question whether this was an appropriate utilization of Public Law 99-570 funds. 
g., 

Area offices did not conduct reviews of trbal programs in accordance with their own 

goals. 

The IRS draft alcoholism standards indicate that periodic quality assurance reviews should be 

conducted. To check the extent to which quality assurance reviews monitored the programs, a 

copy of each quality assurance review conducted in calenda year 1989 by area offIce staff was 

requested. An analysis of these reviews revealed that each area offce performed the reviews in 

their own manner with their own evaluation instrment 

All IRS ara offices had different quality assurance objectives. We found varance between 

these objectives and the number of reviews actually conducted. Eight of eleven ara offices had 

established their own goals for annual reviews of al their tratment programs. Two area offIces 

had a goal for every other year reviews, while another ara office attempted reviews twice 

annually. Only one area had successfully met their goal. 

The IRS did not make effective use of information obtained in the reviews which they 

did conduct. 

Many common weakesses were noted among the numerous tratment programs in the area 

offce review repons. Severa trbal alcoholism progrs did not have established policies or 

procedures, nor did they follow the IHS drt alcoholism standads. According to many of the 

reviews, the forms comprising the management information system (the Alcohol Treatment 

Guidance System) were not being fIlled out or were not completely filled out. Case fIe 

organization was a serious problem among severa trbal alcoholism programs. Also, treatment 

plans were often incomplete and unclear. 

The IRS area offIce reviews mentioned that few of the alcoholism counselors were cenied. 

Some reviews said that sporadic counseling among tratment providers crated gaps in services, 

and that some youth were not receiving enough periodic individual or group counseling (e. 

L. 99-570 youth counselors were being used at a few treatment sites to provide counseling to 

clients in the adult residential treatment program, resulting in less time available to spend with 

the youth). A positive factor noted in the reviews is that cogent recommendations were almost 

always given, as well as follow-up site visits being scheduled if problems were discovered. 

In discussion with staff from three area offces, we found that the ara offce progr review 

repons are not requested by nor submitted to IRS Headq arrs. There is apparently no process 

. in place for IRS Headquarers to utilize information from the area offce program review report 

to provide feedback to all the area offces on common program defIciencies. 

The current IHS management information system is outmoded and ineffective to monitor 

alcohol program activity. 

Data submitted from the 11 area offices indicated that the Alcohol Treatment Guidance System 

served its purpose in the past, but has not been updated to fully serve curent program 

management needs. The area offce staff interviewed said that they did not trst the data 
produced by the management information system. Among the weakesses pointed out, al area 

offces rased questions about the accurcy, reliabilty, and effIciency of the management 

information system. A few offIces also expressed concerns about the outdated mode of entering 

information into the system (i.e., keypunching). They felt that there are numerous errors 

associated with this type of process crating a lack of trst in this system. 

While the DIG is awar that the IRS has been developing a new management information 

system over the last fIve years to track data on alcohol and substance abuse treatment, the system 

has yet to be implemented. The review team has leared that full implementation of the system 

at all area offIces wil not occur until 1995. 

The IHS has not complied with requirements in Public Law 99-570 to establish regional 

treatment centers in all IHS service areas. 

Public Law 99-570 provides for the constrction or renovation of a youth regional treatment 

center (RTC) in each of the 11 IRS service areas. While presently six RTC' s are reponed 

operational by ilS, only two were operational at the time of the study. The two RTC' s were the 

New Sunrse Regional Treatment Center in Acoma, New Mexico and the Jack Brown Center in 

Tahlequah, Oklahoma. In those areas where an RTC is not operational, the area offces indicated 

thauesidential treatment is generally purchased from commercial programs using P.L. 99-570 

funds. 

Problems were cited as reasons for noncompliance with the law. These include historical 

animosities among trbes causing an unwilingness to come to a consensus on the location of a 

facility, the purchase of comparble treatment services from the private sector, and the failure to 

find a suitable facility which would serve as a treatment center. 

Disagreement exists among some IHS components over the effcacy of RTC's. One area offce 

prefers to use only commercially purchased treatment. Two area offices felt that one regional 

treatment center per ara offce region is insuffcient. These tWO offces said more RTC' s are 

necessar to deal with the diversity of trbes and because of geogrphical limitations. 

In one area with an ilS-operated RTC, the average cost of treatment of a youth was 

approximately $20,000. In contrst, the average cost of residential treatment in a commercial 

program was approximately $6 300 per individual. This is primarly due to the fact that the 

average stay in the IHS-operated RTC is considerably longer than the commercial progrs. We 

recognize that there may be a difference in kinds and qualities of services. Also, according to 

IHS officials, the RTC deals with many cultural needs and issues that ar not addrssed by 

commercial programs. 

The second regional treatment center, which was a trbally-operated facilty, had provided 

treatment for 53 youth between the ages of 13 and 18. The average cost of treatment was about 

$14 150 per youth for 122 days of inpatient treatment at $116 a day. Discussions held with area 

office staf indicated that the concept of the RTC could be very successful as long as provisions 

are made to address multiple diagnostic issues, and to include family involvement as part of 

residential treatment. They also indicated that this is not always par of the treatment process in 
a commercial program. In addition to the RTC, however, they noted that referr agencies such 

as Alcoholics Anonymous should be utilized in an effon to unite community resources in the 

development of aftercare teams to maintan progression made by youth and their families in 

treatment. 

Nearly two-thirds of alcoholism counselors in the IRS are not certified. 

The IHS drt operating standards, which ar the only operating rules curently in existence, 

require counselors who provide tratment services though IHS-funded programs to be cenified 

as substance abuse counselors. Information provided by most of the ara offces indicated that 

they rely on the State s rules to determne counselor certfIcation requirements. 

The IRS draft alcoholism stadads lists thee classifIcations of counselors and counselor interns. 

The intern must be in a course leading towards cenication; the fit level counselor shall be 

certfIed but not necessarly have any practical experience; and the second level counselor must 

be cenified as a substance abuse counselor and have two years counseling experience in a 

substace abuse program or counseling agency. One year of this counseling experience must 

have been with youths with alcoholism/substace abuse problems and must have provided an 

opponunity to demonstrate knowledge of counseling theory, techniques, and practices specific to 

Indi.an youth. 

The draft alcoholism standads do not provide a tie fre for certfication of all IRS 

counselors. At one area office site which we visited, the OIG review team was told that by the 

end of a counselor s first year, that individual had to be cenied or workig toward eventual 

certfIcation. The IRS employee admitted that by using ths crteria any counselor could fall into 

the latter category, which was labeled "certfIable. " A recovering alcoholic would fIt into this 

category. It was explained to us that this is how ilS retans its non-qualfIed and largely 

uncertfIed counseling staff. 

As of sprig 1990, approximately 62 percent of all counselors were uncenied. According to 

area office staf interviewed, the primar reason for this high figur is that the individuals simply 

could not pass the cenifIcation examination. In addition, those who do pass the exam frequently 

leave for more lucrative positions. 

One area offce site visited decided not to retain its uncertfied sta. Alcoholism counselors 

were given three opponunities to pass the certfication examnation. Within one service unit in 

this Area, all alcoholism counselors "flunked" the certfication exam 3 times, and were dismissed 

by the area diector. The area office indicated that this maner of "gettg tough" is resulting in 

higher competence among treatment staff and better-quality treatment programs. The following 

graph displays the number of cenifIed and uncertfied counselors by area offices. 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. .. . . .... 

. .. .. . . . . . ... .. . . . .

Alcoholism Counselors


By IHS Area Office 

# of Counselors


160 

..... . .. .. n. n .. ...0. ..... .. . n .. 40 

120 no. 

100 

IHS Area Offices 

Legend 

lI Certified Noncertified

The Bureau of Indian Affairs has not established emergency shelters as required by Public 

Law 99-570. 

Public Law 99-570 provides for the establishment of emergency shelters or halfway houses by 

the Bureau of Indian Affais for Indi(U youth who are alcohol or substance abusers, including 

youth who have been 31ested for offenses dictly or indictly related to alcohol or substace 

abuse. Regardig the latter, the law stipulates that when an Indian youth is 31ested for an 

alcoholism related offense and parntal custody is not possible, " such youth shal be referrd to 

such facilty in lieu of incarceration... 

In addition to a referral facilty for youth who are arsted for alcohol related offenses, 

emergency shelters and halway houses also provide an alcohol-free environment for youth who 

have undergone residential tratment for alcoholism or substace abuse and cannot retur to 

their community immediately. 

At the time of the review, only one emergency shelter and no halfway houses had been 

established. Through September 1990, $8 millon has been appropriated for constrction of 

emergency shelters for fiscal years 1987-90, but approximately $5 milion has been actually 

distrbuted. Also, although $12 millon was authorized for operation and stafng of emergency 

shelters for fiscal years 1987-90, only $1 milion was actualy appropriated, with $926,000 

actually distrbuted in fiscal year 1990. 
Regional treatment center and ara offce sta who were interviewed said that the lack of these 

transitional living centers results in a high incidence of 
 lapse, and severely limits the impact of

dollars spent on residential tratment. They indicated that the absence of these facilities also 

prevents youth who have received residential treatment frm returning to an alcohol- and 

drug-free environment after discharge. Therefore, youth ar forced to return to the same setting 

which may have initially contrbuted to their alcohol or substace abuse. 

EJ'idellce of ill appropriate use of funds has been referred to the DIG Office of Audit Services. 

Our inspection included a review of documentation and interviews with IRS employees. Based 

on information obtained in our review, we have made a referr of a possible misappropriation of 

L. 99-570 funds to the OIG Office of Audit Services for a financial audit. 
RECOMMENDATIONS


The IHS should complete and promulgate operating standards. 

The IRS should act expeditiously to finalize the existing draft operatig standads for youth 

alcohol and substance abuse programs. Approved operating stadards would enable the area 

offices to reference specific guidelines in implementing and monitoring requirements of Public 

Law 99-570. 

The IHS Headquarters and area offices should conduct reviews in accordance with their own 

quality assurance goals. 

The IRS Headquarers and IHS area offces should come to a consensus as to what is needed by 

way of program performance reviews and commit the appropriate resources to accomplish this. 

PrOtocols should be reviewed and modified to assure the most appropriate timing and content of 

reviews and mae. up of review teams. 

The IHS should establish a process to review all area offce program reports and provide 

. feedback to the area offices. 

The IRS Headquarers should establish a process to review all area office program review 

repons to identify common progrm weakesses and systematically communicate them to the 

area offices. This would permt ilS Headquarters to specify areas of program priorities, needs, 

or deficiencies for area office follow up. 

The IHS should develop an adequate management information system which provides data on 

alcohol and substance abuse treatment. 

It is imperative that the IHS complete, as soon as possible, a comprehensive management 

information system which can appropriately distinguish between and follow all clients 

participating in the alcoholism programs, and the extent and nature of services that were 

received. The management information system should be fully developed to handle youth 

alcoholism program data and modern treatment methodologies. 

We also recommend that the new system provide a capabilty for trbal input and access. This 

would provide timely information at the trbal level to follow clients and conduct composite 

analyses on the trbal caseload.


The IHS should establish regional treatment centers in .every IHS service area, or advise 

Congress of their recommendation for an alternative strategy to provide residential services. 

The IRS should increase effons to see that service areas without a regional treatment center 

establish such a facility as mandated by Public Law 99-570. As some service areas have 

encountered barers in attempting to establish regional treatment centers, the ilS should 
coordinate with the ara offices to addrss the problems that hinder timely establishment of 

regional treatment centers. 

Since some disagreement exists among ara office constituents over the effcacy of regional 

treatment centers, the IHS should formally assess the regional tratment center issue and advise 

Congress of their recommendation on any new strtegies. 

The IHS should ensure that all alcoholism counselors become certfied. 

The IHS should ensure that al alcoholism counselors ar certfied, as required by the IHS draft 

operating standads. If the alcohol and substace abuse treatment of Indian youth is to be 

effective, qualifed counselors ara of prima importce. Ara offces should do everything 

possible to promote cenmcation of and professionalism among alcoholism counselors. 

The IHS should work with the Bureau of Indian Affairs to assure the timely construction and 

operation of emergency shelters and halfway houses. 

Since treatment of the adolescent abuser often requirs alcohol- and drg-free transitional living 

quarters, the effectiveness of the residential treatment program is impaid when there are no 

emergency shelters or halfway houses. 

Without trsitional living centers, youth must retu to an environment which may have 

precipitated the problem. Considerable tie has elapsed since the appropriation of these funds, 

and it is imperative that IRS enhance effons to see that establishment of these facilties takes 

place. 

To ensure effective utilzation of these facilities when established, provisions should be 

developed for adequate and timely monitoring of these facilties. 

We recommend that the ilS reexamine the Memoradum of Agrement with the Bureau of 

Indian Affai (BIA) to establish a management framework for the stang and operation of 

emergency shelters and halway houses that results in an effective coordination of resources and 

programs of IHS and BIA components. A modifIcation of the Marh 1987 Memoradum of 

Agreement may be necessar in order for tratment goals to be met. 
AGENCY COMMENTS


The Public Health Service (PHS) concurrd with all the recommendations in the OIG draft 

repon. However, PHS stated that successful implementation of the last two recommendations 

cannot be assured because those two areas are not solely within ilS's control. 

We agree that programs of the Bureau of Indian Affais are not dictly under PHS's control. 

However, we believe the IRS should continue coordination effort with the Bureau of Indian 

Affais (BIA) in order to assure timely constrction and operation of emergency shelters and 

halfway houses. In a recent contact with BIA staf, we were advised that the constrction of 

emergency shelters and halway houses would slip from the present schedule to a completion 

date in fiscal year 1992. 

While agreeing to emphasize the importnce of having all counselors cenifed, PHS believes that 

a more realistic and practical goal is to certfy 80 percent of counselors by 1991, and then retain 

that level. We agree that such a program would be responsive to our recommendation. 
APPENDIX A


PUBLIC HEALTH SERVICE COMMENTS 
&. 

\.. . ;__, .,. _,.( , . ..

DEPARTMENT OF REm HUMA SERVICE Pulic He 

Memorandum JA 2 1991 

Dae 

From Assistant Secretary for Rea 1 t 

'9 ,,); "l 

Subjec PRS Comments on Office of Inspector(i eral Draft Report
 Indian Health Service (IRS) Youth Al
 hol and Substance Abu
 Programs 

Inspector General , OS


Attached are the PHS comments on the findings and


recommendations contained in the subject draft report. Though we cone ur wi t h all of the re commenda t ions) the following comments explain why successful implementation of the ast recommendations is not solely within IRS' control. 

First , since IRS is outside the certification process, and because there is wide variance in the certification proe
 among the States , there are legitimate reasons that restrict IRS from ensuring continuous certification of all alcoholism


counselors employed in Indian alcohol programs. Second , though
 IRS has a positive working relationship with staff in the
 Bureau of Indian Affairs (BIA), Department of Interior , the eventual construction of emergency shelters and halfway houses using BIA appropriated funds is not under IRS control. 

6. Ik

Mason , M. ) Dr. 

Attachment 

I . 

i 'U , r ...1 .Ji 

) ::::;:.;f . I 


i - 1-' .

PUBLIC HEATH SERVICE (PHS) COMMS ON OFFICE OF INSPECTOR 

GENERA ( OIG ) DRAT REPORT II INDIA HEATH SERVICE YOUTH ALCOHOL 

AND SUBSTANCE ABUSE PROGRAS, " OEI-07-89-00940 

OIG Recommendation


We recommend that the Indian Health Service ms ) : 

Complete and promulgate operating standars for youth alco l and substance abuse programs. 

PHS Comment


We concur. On August 20, 1990, the operating standards were

submi tted to the IHS Division of Management Policy fpr approval. It is expected that the standards will be' approved 

by the end of March 1991. Upon approval of the standards, 

instructions will be developed and sent to the 12 IRS Area


Alcoholism/Substance Abuse Coordinators for 
 plementation in


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


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


Coordinator to check on the progress in 
 plementing the operating procedures. Full imlementation of the standards 

should be completed by the end of fiscal year (FY) 1991.


Sumary reports on the progress of plementation will be 

submitted to the Associate Director, Office of Health Programs


( OHP ), IHS, on a monthly basis. 

OIG Recommendation


Headquarters and Area Offices conduct reviews in


accordance with their ow quality assurance goals. 

PHS Cornen 

We concur. A renewed emphasis has been initiated to improve


quality assurance site reviews in each of the 12 IHS Areas. Decemer 6, 1990, the IHS Area Alcoholism/Substance Abuse


Coordinators, IHS Headquarters Alcoholism and Substance Abuse


Program Branch (ASAPB) staff, and tribal representatives formed


a workgroup to implement a plan for reviewing Area Office


alcoholism progr s using a newly revised protocol. The 

workgroup will finalize the review protocol by the end of


February 1991. A schedule namng the sites to be reviewed and 

the dates of the review will be completed and distributed to


each Area Office by the end of March 1991. In the interim, 

review teams consisting of IHS employees, tribal


representatives, and alcoholism staff will be formed and, 

beginning in May 1991, these teams will be sent to each Area to


review these programs. A report on the findings and 

recommenda tions of the reviews will be completed by October


1991. 
Monthly follow-up reports sumrizing the progress of reviews 

will be submitted to the IHS Area Directors; Associate


Director, OHP; and Area Alcoholism/Substance Abuse Coordinators


beginning in January 1992. 

eIG Recommendation


Establish a process to review all Area Office program


reports and provide feedback to the Area Offices.


PHS Comment


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


provide oversight for this activity was established. The 

workgroup will establish a process and fo t for reporting


data concerning program admnistration by February 1991. The 

proposed for.t will be presented to the Area 

Alcoholism/Substance Abuse Coordinators for their review,


comment and approval at their next meeting scheduled for March


1991. Area Coordinators will be trained on this process in


order to have it implemented in all Areas by the end of April
 1991. Follow-up training on the use of the process will be 

provided to all Area Coordinators to ensure unifo:m


plementation by the end of May 1991. 

eIG Recommendation


Develop an adequate management infor.tion system which 

provides data on alcohol and substance abuse treatment. 

PHS Comment


We concur. In Decemer 1990 a workgroup was fo ed to 

establish a workplan for revising the activities for the


modification of the Alcoholism Treatment Guidance System. This 

workplan was developed and presented to Area


Alcoholism/Substance Abuse Coordinators and tribal


representatives. Area Coordinators were provided copies of the


plementation plan and were asked to submit a corresponding


Chemical Dependency Management Info tion System (CDMIS) for


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


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


testing of CDMIS in selected Areas will be completed in August


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


begin in the first quarter of FY 1992. Smmry reports on the 

status of the progress of the CDMIS activity will be subtted 

to the Associate Director, OHP; Area Directors; and Area


Alcoholism/Substance Abuse Coordinators on a monthly basis 

beginning January 1992. 
eIG Recommendation


Establish regional treatment centers (RTCs) in every IHS 

service area or advise Congress of their recommendation


for an alternative strategy to provide residential
 services. 

PHS Comment


We concur. The ASAPB Medical Advisor and the Alcoholism


Program Specialist are responsible for maag g ths acti vi ty . 

The Medical Advisor will direct those activities related to


programng and treatment contaed in the RTCs. The 

Alcoholism Program Specialist monitors issues related to


meeting the legal requirements for construction of RTCs under


Public Law (P. ) 99-570.


In Decemer 1990, a workgroup comprised of the Directors of


existing RTCs was appointed to develop guidance progr mm; g and 

treatment services in newly constructed or proposed RTCs, and


to identify common problem during the constrction phase of 

RTCs . A report on the workplan will be completed at the first


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


matrix which graphically depicts the plan g, construction and 

coordina tion phases for completing the construction of RTCs


will be developed by this workgroup by the end of Mach 1991. 

ASAPB has developed, in conjunction with the Office of the


General Counsel, a policy that specifies the conditions in


which IHS will construct RTCs. It is expected that this policy
 will be approved for 
 plementation by the end of March 1991. 

Beginning in January 1991, a monthly consolidated report will


be prepared to address the completion of all RTCs currently in


the planning and development phase and to report on problems


from programs now serving clients. The reports will be


submi tted to the Area Directors, Area Alcoholism/Substance 

Abuse Coordinators, and the Associate Director, OEP.


eIG Recommendation


Ensure that all alcoholism counselors become certified. 

PHS Comment


We concur with the intent of this recommendation. However, 

there are legitimate reasons that restrict IRS from ensuring


continuous certification of all alcoholism counselors employed
 in Indian alcoholism programs. The IHS is outside the 

certification process and must rely upon existing certification 

or credentialing entities. There is wide variance in the

py 

certification process among States who have such mechanism, as 

well as among national credentialing bodies. Some States 

require counselors to tae one year of non-paid, supervised 

employment in State certified agencies to become certfied. 

IHS cannot require tribes to comly with such a reqement. 

To do so, would result in no service delivery in some tribal


communi ti


IRS can, howver, ensure an emhasis be established on the 100 percent certification of certifiable counselors. An IRS/tribal 

workgroup was for.ed in Decemer 1990 to assist in developing

the mechanism for certifying alcoholism counselors. 
 he first


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


is expected that work on the project will be completed 
 the

end of April 1991. IRS' goal is to certify 80 percent of all 

alcoholism counselors employed in alcohol program under 

contract to IRS by the end of 1991 and to maintain the 80


percent certification rate. 

A plan for certifying alcoholism counselors was developed in


each IHS Area and 
 plemented in 1988. Since 1988,


P . L. 99-570 training funds have been allocated to each Area for the puroses of preparing alcoholism counselors to meet certifica tion requirements and for providing continuig 

education to certified counselors. IHS' Headquarers ASAPB 

staff will provide technical assistance to the Area


Alcoholism/Substance Abuse Program to enhance training 

endeavors through consultation with treatment programs such as


Hazelden, the Betty Ford Center, and the Commssion on the 

Accreditation of Rehabilitation Facilities. Headquarters 

consultation to the Areas has been provided on a monthly basis. 

A monthly progress report on the certification activities will
 be subtted to the Area Directors, the Area 

Alcoholism/Substance Abuse Coordinators, and the Associate


Director, OHP.


eIG Recommendation


Work with the Bureau of Indian Affairs (BIA), Departent 

of Interior, to secure the release of funds that have been


appropriated for emergency shelters and halfway houses. 

PHS Comment


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


appointed a director of the Alcoholism and Substance Abuse


Program for that agency. Since this appointment, staff from


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


of Social Services 
 BIA, for distribution to tribes for


construction of emergency shelters in 1989. Of the 20 grant 

awards six tribal groups have completed construction and these


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

FY 1991.