[Senate Hearing 116-76]
[From the U.S. Government Publishing Office]
S. Hrg. 116-76
WHERE ARE THEY NOW: INDIAN PROGRAMS ON THE GAO HIGH RISK LIST
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HEARING
BEFORE THE
COMMITTEE ON INDIAN AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
MARCH 12, 2019
__________
Printed for the use of the Committee on Indian Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
COMMITTEE ON INDIAN AFFAIRS
JOHN HOEVEN, North Dakota, Chairman
TOM UDALL, New Mexico, Vice Chairman
JOHN BARRASSO, Wyoming MARIA CANTWELL, Washington
LISA MURKOWSKI, Alaska JON TESTER, Montana,
JAMES LANKFORD, Oklahoma BRIAN SCHATZ, Hawaii
STEVE DAINES, Montana CATHERINE CORTEZ MASTO, Nevada
MARTHA McSALLY, Arizona TINA SMITH, Minnesota
JERRY MORAN, Kansas
T. Michael Andrews, Majority Staff Director and Chief Counsel
Jennifer Romero, Minority Staff Director and Chief Counsel
C O N T E N T S
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Page
Hearing held on March 12, 2019................................... 1
Statement of Senator Cortez Masto................................ 49
Statement of Senator Hoeven...................................... 1
Statement of Senator Lankford.................................... 44
Statement of Senator Tester...................................... 52
Statement of Senator Udall....................................... 2
Witnesses
Dearman, Tony, Director, Bureau of Indian Education, U.S.
Department of the Interior..................................... 27
Prepared statement........................................... 29
Farb, Jessica, Director, Health Care Team, U.S. Government
Accountability Office.......................................... 4
Prepared statement........................................... 6
LaCounte, Darryl, Acting Director, Bureau of Indian Affairs, U.S.
Department of the Interior..................................... 31
Prepared statement........................................... 33
Weahkee, Rear Admiral Michael, Principal Deputy Director, Indian
Health Service, U.S. Department of Health and Human Services... 36
Prepared statement........................................... 38
Appendix
Response to written questions submitted by Hon. Catherine Cortez
Masto to:
Tony Dearman................................................. 59
Jessica Farb................................................. 60
Darryl LaCounte.............................................. 59
Rear Admiral Michael Weahkee................................. 61
Response to written questions submitted by Hon. Tom Udall to:
Tony Dearman................................................. 64
Rear Admiral Michael Weahkee................................. 65
WHERE ARE THEY NOW: INDIAN PROGRAMS ON THE GAO HIGH RISK LIST
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TUESDAY, MARCH 12, 2019
U.S. Senate,
Committee on Indian Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:47 p.m. in room
628, Dirksen Senate Office Building, Hon. John Hoeven,
Chairman of the Committee, presiding.
OPENING STATEMENT OF HON. JOHN HOEVEN,
U.S. SENATOR FROM NORTH DAKOTA
The Chairman. Good afternoon. I call this oversight hearing
to order.
We are having votes on the Floor right now. That is why I
think it will be a few minutes before more of our Committee
members show up. But we are going to get started, so that the
Vice Chairman and myself can take turns going back and filling
out the votes as well. We appreciate your bearing with us
through that process.
I also want to thank the members for accommodating my
schedule and others so that we could have the hearing this
afternoon instead of tomorrow as originally scheduled. Thank
you to the members for agreeing to do that.
Today, the Committee will examine the Government
Accountability Office report on High Risk Programs published on
March 6th, 2019 as well as the follow-up from the 2017 High
Risk List. Unfortunately, the three Indian programs that we
will discuss today are the same ones we have had on the list
for the past two years. We are working very hard to make sure
they get the issues identified addressed.
This is the fourth hearing for the Committee regarding high
risk Indian programs. Three hearings were held in the 115th
Congress, making today's hearing the first in the new Congress.
I expect we will have more as we continue to work on
outstanding issues.
Every two years during the start of a new Congress, the
Government Accountability Office publishes a report listing
Federal programs deemed high risk. These programs are given the
designation of high risk due to their vulnerability to abuse,
fraud, waste or mismanagement. Three Federal Indian programs,
the Bureau of Indian Education, Indian Energy within the Bureau
of Indian Affairs, and the Indian Health Service have again
been placed on the 2019 High Risk List.
According to the Government Accountability Office, as of
December 2018, these programs have a total of 32 outstanding
recommendations. To monitor a Federal program's progress on the
High Risk List, the Government Accountability Office provides
ratings of not met, partially met, or met.
According to the latest list, each of the three programs
has partially met the five areas of criteria needed to be
addressed to initiate removal from the list. During today's
hearing, I expect to hear from each of the witnesses concerning
where progress has been made and what needs to be done in order
for the three programs to meet all of the criteria.
As Chairman of the Committee, I remain steadfast to holding
these Federal agencies accountable to the millions of American
Indians and Alaska Natives in the Country that receive services
such as education, health care and advancing Indian energy
development projects. The functioning of the Bureau of Indian
Affairs, the Bureau of Indian Education and the Indian Health
Service is important to many, including this Committee, which
has oversight authority to ensure the agencies are meeting
their purposes without abuse, fraud, waste or mismanagement.
Today's hearing is timely with the recent news of former
IHS doctor Stanley Patrick Weber's conviction and sentencing in
Federal District Court in Montana for child sex abuse and the
upcoming start of his second trial in South Dakota on the same
charges. These events must be addressed and we need to get to
the bottom of this ordeal. Indian Country deserves better.
As I have mentioned before, I will continue to hold these
oversight hearings until each Indian program comes off the High
Risk List. I urge all witnesses today to continue working
together in addressing the remaining open recommendations.
I welcome the witnesses today. I look forward to discussing
the remaining GAO recommendations and the timeliness of getting
them addressed.
Before we hear from witnesses, I will turn to Vice
Chairman, Senator Udall, for his opening statement.
STATEMENT OF HON. TOM UDALL,
U.S. SENATOR FROM NEW MEXICO
Senator Udall. Thank you, Chairman Hoeven, for scheduling
today's hearing to discuss the status of Indian programs on the
GAO High Risk List. I appreciate your follow-through on this
important topic.
Last Congress, our Committee held three hearings on the GAO
High Risk Report for Indian Programs. Each hearing demonstrated
that the Federal Government must do better to provide trust and
treaty-based services to American Indian and Alaska Native
tribes.
The GAO reports that high risk Indian programs have made
some notable progress in addressing its open recommendations.
However, members of this Committee and tribal leaders are still
concerned that this progress is not translating into real
change.
Factors such as underfunding, management accountability,
and agency transparency continue to pose barriers to efforts by
the IHS, the BIE, and the BIA to address high risk areas. As a
practical matter, it is reasonable to ask how effective are
IHS, BIE and BIA reforms in response to GAO's High Risk
designation.
As the Ranking Member on the Interior Appropriations
Subcommittee, I understand that underfunding has a direct
impact on nearly every Indian program, but that impact is
particularly acute for programs on the High Risk List. In my
home State of New Mexico, there are still serious facility and
resource issues at a number of BIE, IHS clinics and BIA
programs. I have fought to increase funding at all three
agencies. But without continued meaningful investments and
adequate appropriations, BIE, IHS, and BIA reforms will be less
effective.
At the same time, recent high profile events at the BIE and
the IHS raise serious questions about management accountability
and transparency. At the BIE, the Bureau has a string of
unanswered congressional letters, school closures due to
asbestos, and the lack of compliance with Federal education
laws. It is to the point where I have had to call in BIE and
BIA leadership to submit weekly updates directly to my office.
At the IHS, the Weber incident has alarmed many. To speak
frankly, it has sickened me. For over 20 years, Mr. Weber used
his position of trust and authority as an IHS doctor to prey on
young, innocent victims. What he did is a travesty and what IHS
didn't do intervene to protect Native children who were
patients is unconscionable.
Even though Mr. Weber has been convicted and sentenced for
his crimes in Montana and awaits trial in another Federal court
for similar crimes, questions remain. Who in IHS leadership
failed to document and remove Weber from his position within
the Service? To that end, Chairman Hoeven and I sent a letter
to the HHS Office of Inspector General, asking it to
investigate whether any current or former IHS staff were
complicit in, or had knowledge or involvement with Mr. Weber's
misconduct.
While we wait for concrete answers, I expect IHS leadership
here today to commit to management reform that ensures all
future allegations of abuse by medical professionals at IHS
facilities are properly investigated, reports against IHS
employees who are a danger to patients are not swept under the
rug, whistleblowers do not fear for their reputations or their
livelihoods.
Above all, today's hearing must be more than just hearing
about progress on GAO's recommendations. I need to see evidence
of a cultural shift to improve accountability at the IHS, the
BIE, and the BIA, and I need to see a commitment to
transparency ensuring the Federal Government is upholding trust
and treaty responsibilities.
Finally, I will close by noting that the Committee's newly-
adopted Rule 4(b), this rule states that if the Administration
misses the Committee's 48-hour deadline for submission of
testimony, the Administration witness must state on the record
why the testimony was late.
Thank you, Admiral Weahkee and Ms. Farb, for submitting
your testimony on time. But Mr. Dearman, and Mr. LaCounte,
please be prepared to start your testimony with an explanation
why you did not comply with the Committee's rule.
I thank you, Mr. Chairman. Thank you to our panel for
joining us.
The Chairman. I would like to thank the Ranking Member.
I, too, want to comment on the BIA not submitting their
testimony in a timely way. I was waiting for the introductions
to do that. But both for Director LaCounte and Director
Dearman, I would ask, in your remarks, please indicate why the
testimony wasn't here 48 hours prior as required under the
Committee's rules. I would also like a commitment from you that
in the future, it will be here 48 hours prior to your
testimony. You can respond to those as a part of your
testimony.
With that, again, I appreciate all of you being here. Let's
begin with Ms. Farb, Director of the Health Care Team,
Government Accountability Office here in D.C.
Ms. Farb.
STATEMENT OF JESSICA FARB, DIRECTOR, HEALTH CARE TEAM, U.S.
GOVERNMENT ACCOUNTABILITY OFFICE;
ACCOMPANIED BY FRANK RUSCO. ENERGY GROUP
Ms. Farb. Thank you.
Chairman Hoeven, Vice Chairman Udall and members of the
Committee, thank you for the opportunity to discuss the
progress the agencies within the Department of the Interior and
the Department of Health and Human Services have made since GAO
added management of programs that serve tribes and their
members to its High Risk List in 2017. The High Risk List is
intended to help inform congressional oversight and improve
government performance by calling attention to agencies and
programs that are vulnerable to mismanagement or are in need of
change.
Last week, GAO issued our updated report for 2019. In
summary, officials from Indian Affairs, BIE, BIA, and IHS
continue to express their commitment to addressing issues that
led to the high risk designation. Since we last testified
before this Committee in June 2018, we have met with agency
leaders numerous times and continue to work with each agency to
identify actions they are taking or plan to take to address
GAO's concerns.
For our most recent High Risk Report, we determined that
these agencies have demonstrated some progress to partially
meet each of the criteria for removing a high risk designation.
However, additional progress is needed for the agencies to
fully address these criteria and related management weaknesses.
Since September 2011, GAO has made more than 50
recommendations to improve Federal programs serving tribes and
their members. Thirty-one of these recommendations and one
matter for congressional consideration are still open. The
distribution of these recommendations by issue area, education,
energy, and health care is shown in the figure on display to my
right. As you can see, 20 recommendations have been closed. In
the past few days, the agencies have provided new information
and documentation that may lead to the closure of additional
recommendations.
GAO continues to audit these programs and if deficiencies
are identified, there will likely be additional recommendations
to address. It is important to note that GAO's recommendations
identified in this high risk area reflect management weaknesses
at the Federal level. They do not reflect on the performance of
programs administered by tribes.
Furthermore, closing recommendations is not enough to get
off the High Risk List. Agencies need to identify and address
the root causes of management shortcomings. Since 1990, 26
areas have been removed from the High Risk List. These areas
were on the list for nine years on average after they were
first designated.
As our most recent high risk report indicates, over the
past several months the agencies have demonstrated progress to
partially, but not fully meet, each of the five criteria for
removing a high risk designation. These include leadership
commitment, capacity, developing an action plan, monitoring and
demonstrated progress. Our current assessment of this is shown
in the figure on display to my right.
First, in the area of leadership commitment, leadership at
all of the agencies have been receptive to meeting with GAO
teams regularly and working to develop a better understanding
of what needs to be done to get off the High Risk List. Some of
the agencies have also formed working groups or advisory panels
to assist with strategic direction and implementation of our
recommendations. However, all of the agencies have faced some
issues attaining stable, permanent leadership.
Second, to address capacity issues, BIE hired a full-time
program analyst to coordinate its working group and help
oversee implementation of our recommendations on Indian
education. In February 2019, BIA officials told us they had
drafted a long-range workforce plan to ensure BIA has staff in
place to meet its organizational needs. IHS has established a
new Office of Quality which is expected to develop and monitor
agency-wide quality of care standards.
However, both BIE and IHS continue to face significant
workforce challenges. For example, although BIE is hiring new
staff, about 50 percent of all BIE positions have not been
filled according to recent documentation. Furthermore, GAO's
August 2018 report found that IHS's average overall vacancy
rate for clinical care providers was 25 percent.
With regard to action plans, we found that BIE and IHS both
completed strategic plans, BIE in August 2018 and IHS just this
past month. These plans will provide both agencies with goals
and strategies for improving management and oversight of Indian
education and health care programs.
In terms of monitoring, we found that Indian Affairs has
taken action to monitor corrective measures that address
weaknesses with safety at BIE Schools. IHS has taken steps to
develop patient experience of care surveys as well as standards
for tracking patient wait times.
Finally, despite the increasing number of recommendation
closures, substantial work remains in several key areas,
including accountability for BIE school safety and school
construction projects, continued monitoring of review and
response times for oil and gas leases and agreements, and
persistent monitoring of patient wait time and quality metrics
at IHS. Sustained focus by Interior and HHS in fully
implementing these recommendations and continued oversight by
Congress are essential to achieving progress.
Chairman Hoeven, Vice Chairman Udall and members of the
Committee, this completes my prepared statement. My colleagues
and I would be pleased to respond to any questions you may
have.
[The prepared statement of Ms. Farb follows:]
Prepared Statement of Jessica Farb, Director, Health Care Team, U.S.
Government Accountability Office
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee:
I am pleased to be here today to discuss the status of actions by
the Departments of the Interior (Interior) and Health and Human
Services (HHS) to address issues that led to the high-risk designation
we made related to the federal management of programs that serve tribes
and their members. We added this area to our High-Risk List in February
2017 because of our concern about the ability of agencies within these
departments to manage (1) education and health care programs that serve
tribes and their members and (2) Indian energy resources. \1\ In
particular, our prior work found numerous weaknesses in how Interior's
Bureau of Indian Education (BIE) and Bureau of Indian Affairs (BIA)--
under the office of the Assistant Secretary-Indian Affairs (Indian
Affairs)--managed education and energy resources and how HHS's Indian
Health Service (IHS) managed health care services. We reported that
these management weaknesses jeopardized the health and safety of
American Indians served by these programs and limited opportunities for
tribes and their members to use energy resources to create economic
benefits and improve the well-being of their communities. We expressed
continued concerns about challenges faced by these agencies in our 2019
High-Risk Report. \2\
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\1\ GAO, High-Risk Series: Progress on Many High-Risk Areas, While
Substantial Efforts Needed on Others, GAO-17-317 (Washington, D.C.:
Feb. 15, 2017).
\2\ GAO, High-Risk Series: Substantial Efforts Needed to Achieve
Greater Progress on High-Risk Areas, GAO-19-157SP (Washington, D.C.:
Mar. 6, 2019).
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In 2016, Congress found in the Indian Trust Asset Reform Act that
``through treaties, statutes, and historical relations with Indian
tribes, the United States has undertaken a unique trust responsibility
to protect and support Indian tribes and Indians.'' \3\ As further
stated in that act, the fiduciary responsibilities of the United States
to Indians arise in part from commitments made in treaties and
agreements, in exchange for which Indians surrendered claims to vast
tracts of land. The act notes that this history of federal-tribal
relations and understandings has benefitted the people of the United
States and established ``enduring and enforceable [f]ederal obligations
to which the national honor has been committed.'' Agencies can improve
the efficiency of federal programs under which services are provided to
tribes and their members by making improvements to their management and
oversight of such programs.
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\3\ Pub. L. No. 114-178, 101, 130 Stat. 432 (2016)(codified at 25
U.S.C. 5601).
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Such improvements would be consistent with the expressed view of
Congress as to the federal government's trust responsibilities and
would strengthen confidence in the performance and accountability of
the federal government.
The focus of this high-risk area is on management weaknesses within
federal agencies that administer programs that serve tribes and their
members. However, not all federal programs are administered by federal
agencies. In accordance with federal Indian policy that recognizes the
right of Indian tribes to self-government and that supports tribal
self-determination, a number of tribes have elected to take over the
administration of certain federal programs and services from BIA, BIE,
and IHS. Our recommendations identified in the high-risk area are
neither reflective of the performance of programs administered by
tribes nor directed at any tribally operated programs and activities.
When we added the federal management of programs that serve tribes
and their members to our High-Risk List in February 2017, we cited 39
open recommendations related to this high-risk area. Since then, we
added 13 recommendations in two new reports on BIE school safety and
construction, and a report on IHS provider vacancy rates. \4\ Overall,
as of March 2019, 31 recommendations remain open.
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\4\ See GAO, Indian Affairs: Further Actions Needed to Improve
Oversight and Accountability for School Safety Inspections, GAO-17-421
(Washington, D.C.: May 24, 2017); GAO, Indian Affairs: Actions Needed
to Better Manage Indian School Construction Projects, GAO-17-447
(Washington, D.C.: May 24, 2017); and GAO, Indian Health Service:
Agency Faces Ongoing Challenges Filling Provider Vacancies, GAO-18-580
(Washington, D.C.: Aug. 15, 2018).
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My statement today, which is largely based on our March 2019 High-
Risk Series: Substantial Efforts Needed to Achieve Greater Progress on
High-Risk Areas, will address actions taken and progress made by these
agencies to address the five criteria we use for determining whether to
remove a high-risk designation (leadership commitment, capacity, action
plan, monitoring, and demonstrated progress). For this statement, we
also drew on findings from our reports issued from September 2011
through August 2018 and updated that work by reviewing agency
documentation and interviewing agency officials. To conduct our
previously issued work on which this testimony draws, we reviewed
relevant federal laws, regulations, and policies; reviewed agency
documentation; and interviewed tribal, federal, and industry officials,
among others. More detailed information on the scope and methodology of
our work can be found in each of the reports cited in our High-Risk
Series reports. \5\
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\5\ For a list of related reports, see GAO-17-317 and GAO-19-157SP.
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We conducted the work on which this statement is based in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Background
Since 1990, generally every 2 years at the start of a new Congress,
we call attention to agencies and program areas that are high risk due
to their vulnerability to mismanagement or that are most in need of
transformation. \6\ Our high-risk program is intended to help inform
the congressional oversight agenda and to improve government
performance. Since 1990, a total of 62 different areas have appeared on
the High-Risk List. Of these, 26 areas have been removed, and 2 areas
have been consolidated. On average, the high-risk areas that were
removed from the list had been on it for 9 years after they were
initially added.
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\6\ In our High-Risk List, we also call attention to agencies and
program areas that are high risk due to fraud, waste, and abuse.
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Our experience with the High-Risk List over the past 29 years has
shown that the key elements needed to make progress in high-risk areas
are top-level attention by the administration and agency leaders
grounded in the five criteria for removing high-risk designations,
which we reported on in November 2000. \7\ When legislative and agency
actions, including those in response to our recommendations, result in
our finding significant progress toward resolving a high-risk problem,
we will remove the high-risk designation. However, implementing our
recommendations alone will not result in the removal of the
designation, because the condition that led to the recommendations is
symptomatic of systemic management weaknesses. In cases in which we
remove the high-risk designation, we continue to closely monitor the
areas. If significant problems again arise, we will consider reapplying
the high-risk designation. The five criteria for removing high-risk
designations are as follows:
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\7\ GAO, Determining Performance and Accountability Challenges and
High Risks, GAO-01-159SP (Washington, D.C.: November 2000).
Leadership commitment. Demonstrated strong commitment and
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top leadership support to address the risks.
Capacity. Agency has the capacity (i.e., people and other
resources) to resolve the risk(s).
Action plan. A corrective action plan that defines the root
causes, identifies solutions, and provides for substantially
completing corrective measures in the near term, including
steps necessary to implement solutions we recommended.
Monitoring. A program has been instituted to monitor and
independently validate the effectiveness and sustainability of
corrective measures.
Demonstrated progress. Ability to demonstrate progress in
implementing corrective measures and in resolving the high-risk
area.
These five criteria form a road map for efforts to improve and
ultimately address high-risk issues. Addressing some of the criteria
leads to progress, and satisfying all of the criteria is central to
removal from the list. Figure 1 shows the five criteria for removal for
a designated high-risk area and examples of agency actions leading to
progress toward removal.
Importantly, the actions listed are not ``stand alone'' efforts
taken in isolation of other actions to address high-risk issues. That
is, actions taken under one criterion may be important to meeting other
criteria as well. For example, top leadership can demonstrate its
commitment by establishing a corrective action plan, including long-
term priorities and goals to address the high-risk issue and by using
data to gauge progress--actions that are also vital to addressing the
action plan and monitoring criteria. When an agency meets all five of
these criteria, we can remove the agency from the High-Risk List. We
rate agency progress on the criteria using the following definitions:
Met. Actions have been taken that meet the criterion. There
are no significant actions that need to be taken to further
address this criterion.
Partially met. Some, but not all, actions necessary to meet
the criterion have been taken.
Not met. Few, if any, actions toward meeting the criterion
have been taken.
Agencies Made Some Progress Addressing the Management Weaknesses That
Led to the 2017 High-Risk Designation
Officials from Indian Affairs, BIE, BIA, and IHS expressed their
commitment to addressing the issues that led to the high-risk
designation for federal management of programs that serve tribes and
their members. Since we last testified before this committee on June
13, 2018, we met with agency leaders and worked with each agency to
identify actions the agencies took or plan to take to address the
concerns that contributed to the designation. \8\ We determined that
Indian Affairs, BIE, BIA, and IHS demonstrated some progress to
partially meet each of the criteria for removing a high-risk
designation. However, additional progress is needed for the agencies to
fully address the criteria and related management weaknesses.
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\8\ GAO, High Risk: Agencies Need to Continue Efforts to Address
Management Weaknesses of Federal Programs Serving Indian Tribes GAO-18-
616T (Washington D.C.: June 13, 2018).
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Overall Rating for Improving Federal Management of Programs That Serve
Tribes and Their Members
As we reported in the March 2019 high-risk report, when we applied
the five criteria for High-Risk List removal to each of the three
segments--education, energy, and health care--we determined that Indian
Affairs, BIE, BIA, and IHS have each demonstrated some progress.
Overall, the agencies have partially met the leadership commitment,
capacity, action plan, monitoring, and demonstrated progress criteria
for the education, health care, and energy areas. However, the agencies
continue to face challenges, particularly in retaining permanent
leadership and a sufficient workforce.
The following is a summary of the progress that Indian Affairs,
BIE, BIA, and IHS have made in addressing the five criteria for removal
from the High-Risk List.
Leadership Commitment
To meet the leadership commitment criterion for removal of a high-
risk designation, an agency needs to have demonstrated strong
commitment and top leadership support to address management weaknesses.
The following examples show actions Indian Affairs, BIE, BIA, and IHS
took to partially meet the leadership commitment criterion.
Education. Indian Affairs' leaders have demonstrated
commitment to addressing key weaknesses in the management of
BIE schools in several ways. For example, the BIE Director
formed an internal working group, convened meetings with other
senior leaders within Indian Affairs, and publicly stated that
his agency is committed to ensuring implementation of our
recommendations on Indian education. In addition, the BIE
Director and other Indian Affairs leaders and senior managers
have met with us frequently to discuss outstanding
recommendations, actions they have taken to address these
recommendations, and additional actions they could take. We
also met with the new Assistant Secretary-Indian Affairs, who
expressed her commitment to supporting the agency's efforts to
address weaknesses in the management of BIE schools. However,
it is important that Indian Affairs leaders be able to sustain
this level of commitment to solving problems in Indian
education. Since 2012, there have been seven Assistant-
Secretaries of Indian Affairs and five BIE Directors. There has
also been leadership turnover in other key offices responsible
for implementing our recommendations on Indian education. We
have previously reported that leadership turnover hampered
Indian Affairs' efforts to make improvements to Indian
education. \9\ We believe that ensuring stable leadership and a
sustained focus on needed changes is vital to the successful
management of BIE schools.
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\9\ GAO, Indian Affairs: Better Management and Accountability
Needed to Improve Indian Education, GAO-13-774 (Washington, D.C.: Sept.
24, 2013).
Energy. BIA officials demonstrated leadership commitment by,
among other things, meeting with us to discuss the agency's
progress in addressing our recommendations. In June 2018, a
permanent Assistant Secretary for Indian Affairs was confirmed.
This action provided an opportunity to improve Indian Affair's
oversight of federal actions associated with energy
development. According to the BIA Acting Director and the
Acting Director for Trust Services, BIA held a number of
meetings with the Assistant Secretary to discuss agency action
plans for our recommendations. However, BIA does not have a
permanent Director, and BIA's Office of Trust Service--which
has significant responsibility over Indian energy activities--
does not have a permanent Director or Deputy Director. We have
seen turnover in these leadership positions as officials have
been brought in to temporarily fill these roles. As officials
are brought in temporarily, previously identified plans and
timeframes for completing some activities have changed, and BIA
has found itself starting over on the process to identify or
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implement corrective actions.
Health Care. IHS officials demonstrated leadership
commitment by regularly meeting with us to discuss the agency's
progress in addressing our recommendations. In addition, IHS
has chartered a policy advisory council that will focus on
issues related to strategic direction, recommended policy, and
organizational adjustments. According to IHS, this advisory
council will, among other things, serve as a liaison among IHS
leadership for issues involving strategic direction and policy,
as well as monitor and facilitate related policy workgroups.
However, IHS still does not have permanent leadership-including
a Director of IHS-which is necessary for the agency to
demonstrate its commitment to improvement. Additionally, since
2012, there have been five IHS Acting Directors, and there has
been leadership turnover in other key positions, such as area
directors. \10\
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\10\ IHS oversees its health care facilities through a
decentralized system of area offices, which are led by area directors.
To fully meet the leadership commitment criterion, all agencies
will need, among other things, stable, permanent leadership that has
assigned the tasks needed to address weaknesses and that holds those
assigned accountable for progress. For a timeline of senior leadership
turnover in Indian Affairs, BIE, BIA, and IHS from 2012 through March
2019, see Figure 3.
Capacity
To meet the capacity criterion, an agency needs to demonstrate that
it has the capacity (i.e., people and other resources) to resolve its
management weaknesses. Indian Affairs, BIE, BIA, and IHS each made some
progress in identifying capacity and resources to implement some of our
recommendations, but BIE and IHS continue to face significant workforce
challenges. The following examples show actions Indian Affairs, BIE,
BIA, and IHS took to partially meet the capacity criterion.
Education. BIE and other Indian Affairs offices that support
BIE schools have made some progress in demonstrating capacity
to address risks to Indian education. For example, BIE hired a
full-time program analyst to coordinate its working group and
help oversee the implementation of our recommendations on
Indian education. This official has played a key role in
coordinating the agency's implementation efforts and has
provided us with regular updates on the status of these
efforts. BIE has also conducted hiring in various offices in
recent years as part of a 2014 Secretarial Order to reorganize
the bureau. \11\ For example, it has hired school safety
officers and personnel in offices supporting the oversight of
school spending. However, about 50 percent of all BIE positions
have not been filled, including new positions that have been
added as a result of the agency's restructuring, according to
recent BIE documentation. Moreover, the agency reported that it
has not filled the position of Chief Academic Officer, a top-
level BIE manager responsible for providing leadership and
direction to BIE's academic programs. Furthermore, BIE has not
completed a strategic workforce plan to address staffing and
training gaps with key staff, which we previously recommended.
Such a plan is important to allow BIE and other Indian Affairs
offices to better understand workforce needs and leverage
resources to meet them. In February 2019, BIE drafted a
strategic workforce plan and reported it is currently gathering
feedback on the plan from internal stakeholders. BIE officials
indicated they are planning to finalize and implement the plan
in 2019.
---------------------------------------------------------------------------
\11\ U.S. Department of the Interior, Secretarial Order 3334:
Restructuring the Bureau of Indian Education (Washington, D.C.: June
16, 2014).
Energy. In November 2016, we recommended that BIA establish
a documented process for assessing the workforce at its agency
offices. \12\ BIA has taken a number of actions, such as
conducting an internal survey to identify general workforce
needs related to oil and gas development. This survey
information supported staffing decisions for the recently
created Indian Energy Service Center. In February 2019, BIA
officials told us they have drafted a long-range workforce plan
to ensure BIA has staff in place to meet its organizational
needs. We will review the plan to determine if the planned
actions will help BIA identify critical skills and competencies
related to energy development and identify potential gaps.
---------------------------------------------------------------------------
\12\ GAO, Indian Energy Development: Additional Actions by Federal
Agencies Needed to Overcome Factors Hindering Development, GAO-17-43
(Washington, D.C.: Nov. 17, 2016).
Health Care. IHS has made some progress in demonstrating it
has the capacity and resources necessary to address the program
risks we identified in our reports. For example, among other
actions, IHS officials stated that the agency is expanding the
role of internal audit staff within its enterprise risk
management program to augment internal audits and complement
audits by the HHS Inspector General and GAO. In addition, IHS
has developed a new Office of Quality, which is expected to
develop and monitor agency-wide quality of care standards.
However, IHS officials told us there are still vacancies in
several key positions, including the Director of the Office of
Resource Access and Partnerships, and the Office of Finance and
Accounting. Additionally, our August 2018 report found that
IHS's overall vacancy rate for clinical care providers was 25
percent. \13\
---------------------------------------------------------------------------
\13\ GAO-18-580.
To fully meet the capacity criterion, all of the agencies need to
assess tradeoffs between these and other administration priorities in
terms of people and resources, and the agencies should provide to
decision makers key information on resources needed to address
management weaknesses.
Action Plan
To meet the action plan criterion, an agency needs to have a
corrective action plan that defines the root causes, identifies
solutions, and provides for substantially completing corrective
measures in the near term, including steps necessary to implement the
solutions we recommended. The following examples show actions Indian
Affairs, BIE, BIA, and IHS took to partially meet the action plan
criterion.
Education. Among other actions, BIE implemented a new action
plan for overseeing BIE school spending, including written
procedures and risk criteria, which fully addressed two
priority recommendations. Also, BIE completed a strategic plan
in August 2018, which we recommended in September 2013. \14\
The plan provides the agency with goals and strategies for
improving its management and oversight of Indian education, and
establishes detailed actions and milestones for the
implementation. However, Indian Affairs has not provided
documentation that it has completed action plans on other
important issues, such as a comprehensive, long-term capital
asset plan to inform its allocation of school facility funds,
which we recommended in May 2017. \15\
---------------------------------------------------------------------------
\14\ GAO-13-774.
\15\ GAO-17-447.
Energy. In meetings, BIA officials identified actions they
have taken towards implementing our recommendations. For
instance, BIA officials told us they have recently completed
modifications to BIA's database for recording and maintaining
historical and current data on ownership and leasing of Indian
land and mineral resources--the Trust Asset and Accounting
Management System (TAAMS). The officials said that the
modifications incorporate the key identifiers and data fields
needed to track and monitor review and response times for oil
and gas leases and agreements. BIA officials we met with have
demonstrated an understanding that addressing long--standing
management weaknesses is not accomplished through a single
action but through comprehensive planning and continued
movement toward a goal. However, the agency does not have a
comprehensive action plan to identify the root causes of all
---------------------------------------------------------------------------
identified management weaknesses and address the problems.
Health Care. In February 2019, IHS finalized its strategic
plan for fiscal years 2019 through 2023, and is developing a
related work plan to address certain root causes of management
challenges and define solutions and corrective measures for the
agency. The strategic plan divides these challenges into three
categories: (1) access to care, (2) quality of care, and (3)
program management and operations. We will examine the
strategic plan and IHS's work plan, once issued, to determine
whether they contain the needed elements of an action plan.
To fully meet the action plan criterion, a comprehensive plan that
identifies actions to address the root causes of its management
shortcomings would have to come from top leadership with a commitment
to provide sufficient capacity and resources to take the necessary
actions to address management shortcomings and risks.
Monitoring
To meet the monitoring criterion, an agency needs to demonstrate
that a program has been instituted to monitor and independently
validate the effectiveness and sustainability of corrective measures.
We have been working with the agencies to help clarify the need to
establish a framework for monitoring progress that includes goals and
performance measures to track their efforts and ultimately verify the
effectiveness of their efforts. The following examples show actions
Indian Affairs, BIE, BIA, and IHS took to partially meet the monitoring
criterion.
Education. Indian Affairs, in consultation with Department
of Interior's Office of Occupational Safety and Health, has
taken actions to monitor corrective measures that address
weaknesses with the agency's safety program--which covers
safety at BIE schools. However, the agency has not yet
demonstrated that it is monitoring several other areas, such as
whether relevant employees are being held to the agency's
required performance standards for safety inspections.
Energy. BIA has taken steps to improve monitoring by holding
frequent meetings to assess its progress in implementing our
recommendations. However, BIA has not yet taken needed steps to
monitor its progress in addressing the root causes of
management weaknesses.
Health Care. IHS has taken some steps toward monitoring the
agency's progress in addressing the root causes of their
management weaknesses. In addition to developing its new Office
of Quality, IHS has taken steps to develop a patient experience
of care survey, as well as standards for tracking patient wait
times. These efforts should be reflected in the agency's
corrective plan, as part of an overall framework for monitoring
progress that includes goals and performance measures to track
their efforts and ultimately verify the effectiveness of their
efforts.
To fully meet the monitoring criterion, the agencies need to
establish goals and performance measures as they develop action plans
and take further actions to monitor the effectiveness of actions to
address root causes of identified management shortcomings.
Demonstrated Progress
To meet the demonstrated progress criterion, an agency needs to
demonstrate progress in implementing corrective measures and in
resolving the high-risk area. The following examples show actions
Indian Affairs, BIA, and IHS took to partially meet the demonstrated
progress criterion.
Education. As of February 2019, Indian Affairs had addressed
11 of the 23 outstanding education recommendations we
identified in our September 2017 testimony. Three of these
recommendations were closed after the June 2018 hearing,
including a recommendation from our 2013 report for BIE to
develop a strategic plan and two recommendations from our 2017
report on improving the oversight and accountability for BIE
school safety inspections. \16\ Overall, Indian Affairs'
efforts since we issued our High-Risk List update in February
2017 represent a significant increase in activity implementing
our recommendations. \17\ Substantial work, however, remains to
address our outstanding recommendations in several key areas,
such as in accountability for BIE school safety and school
construction projects. For example, Indian Affairs has not
provided documentation that the inspection information its
personnel collect on the safety of BIE schools is complete and
accurate. \18\ As of late February 2019, 12 recommendations
related to this high-risk area remain open and Indian Affairs
concurred with all 12 recommendations. For a full description
of the status of these open recommendations, see in table 1 in
appendix I.
---------------------------------------------------------------------------
\16\ GAO-13-774, GAO-17-421.
\17\ GAO-17-317.
\18\ GAO, Indian Affairs: Key Actions Needed to Ensure Safety and
Health at Indian School Facilities, GAO-16-313 (Washington, D.C.: Mar.
10, 2016).
Energy. BIA has shown significant progress developing data
collection instruments and processes needed to track and review
response times for a number of different actions associated
with energy development. For example, in our June 2015 report,
we recommended that BIA take steps to improve its geographic
information system (GIS) capabilities to ensure it can verify
ownership in a timely manner. \19\ We closed this
recommendation as BIA has made significant progress in
enhancing its GIS capabilities by integrating map-viewing
technology and capabilities into its land management data
system. In addition, we recommended that BIA take steps to
identify cadastral survey needs. \20\ BIA's enhanced map-
viewing technology allows the bureau to identify land boundary
discrepancies, which can then be researched and corrected. To
address the recommendation, BIA identified unmet survey needs
that were contained within the defunct cadastral request
system. BIA developed a new mechanism for its regions and
agency offices to make survey requests and a new database to
maintain survey requests. In fall 2018, BIA completed
enhancements to TAAMS that will allow the agency to track
timeframes and status of oil and gas revenue-sharing
agreements-called communitization agreements (CA) through the
review process. BIA held training on the enhancements in
November 2018 and requested staff input information on any
newly submitted CAs in the system. In a meeting on February 25,
2019, the Acting Director of BIA said that BIA had also
completed efforts to modify TAAMS, incorporating the key
identifiers and data fields needed to track and monitor review
and response times for oil and gas leases and agreements. We
believe these actions show significant progress in addressing
management weaknesses associated with outdated technology and
data limitations for tracking and monitoring the review and
approval of energy related documents. However, BIA needs to
collect data from its updated system, develop timeframes, and
monitor agency performance to close open recommendations. For a
full description of the status of the agency's open
recommendations, see in table 2 in appendix II.
---------------------------------------------------------------------------
\19\ GAO, Indian Energy Development: Poor Management by BIA Has
Hindered Energy Development on Indian Lands, GAO-15-502 (Washington,
D.C.: June 15, 2015).
\20\ A cadastral survey is, in effect, the public record of the
extent, value, and ownership of land.
Health Care. IHS has made progress in implementing
corrective actions related to the management of health care
programs. Specifically, since our 2017 High-Risk Report, IHS
implemented four of our 13 open recommendations. For example,
in response to our April 2013 recommendation, to ensure that
IHS's payment rates for contracted services do not impede
patient access to physician and other nonhospital care, IHS
developed an online tool that enables the agency to track
providers that do not accept IHS's payment rates. As of March
2019, six out of the 13 recommendations in our 2017 High-Risk
Report remain open, and we have added one additional
recommendation--for a total of seven open recommendations
related to this high-risk area. IHS officials told us that they
plan to complete the implementation of additional
recommendations in 2019. For a full description of the status
of the agency's open recommendations, see in table 3 in
---------------------------------------------------------------------------
appendix III.
To fully meet the demonstrating progress criterion, agencies need
to continue taking actions to ensure sustained progress and show that
management shortcomings are being effectively managed and root causes
are being addressed.
In conclusion, we see some progress in meeting all of the criteria,
at all agencies, especially related to education programs. However,
permanent leadership that provides continuing oversight and
accountability is needed. We also see varying levels of progress at all
of the agencies in understanding what they need to do to be removed
from the High-Risk List, and identifying steps that can be incorporated
into corrective action plans. We look forward to working with the
agencies to track their progress in implementing a framework for
monitoring and validating the effectiveness of planned corrective
actions. Among the greatest continuing challenges for the agencies is
developing sufficient capacity, including demonstrating that they have
the people and other resources required to address the deficiencies in
their programs and activities. This challenge cannot be overcome by the
agencies without a commitment from their leadership and the
administration to prioritize fixing management weaknesses in programs
and activities that serve tribes and their members. Sustained
congressional attention to these issues will help ensure that the
agencies continue to achieve progress in these areas.
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
this completes my prepared statement. I would be pleased to respond to
any questions that you may have.
Appendix I: Status of Open Recommendations to the Department of the
Interior on Indian Education
As of late February 2019, 12 of the 23 recommendations to the
Department of the Interior on Indian education we identified in our
September 13, 2017, testimony remain open.
Table 1: The Status of Open Recommendations in Prior GAO Reports to the
Department of the Interior (Interior) on Management and Oversight of
Indian Education
------------------------------------------------------------------------
Category and Report number
recommendation and date Status
------------------------------------------------------------------------
Management challenges GAO-13-774 Interior agreed with this
facing Bureau of Indian September 2013 recommendation. In
Education (BIE) The February 2019, BIE
Secretary of the Interior drafted a strategic
should direct the workforce plan and
Assistant Secretary- reported it is currently
Indian Affairs to revise gathering feedback on the
its strategic workforce plan from various
plan to ensure that internal offices. BIE
employees providing officials indicated they
administrative support to are planning to finalize
BIE have the requisite and implement the plan in
knowledge and skills to 2019. BIE developed the
help BIE achieve its draft plan to also
mission and are placed in address another workforce
the appropriate offices plan recommendation in
to ensure that regions our November 2014 report
with a large number of (see below). We will
BIE schools have continue to monitor the
sufficient support. agency's efforts to
implement these
recommendations.
BIE's oversight of school GAO-15-121 Interior agreed with this
spending The Secretary of November 2014 recommendation. In
the Interior should February 2019, BIE
direct the Assistant drafted a strategic
Secretary-Indian Affairs workforce plan and
to develop a reported it is currently
comprehensive workforce gathering feedback on the
plan to ensure that BIE plan from internal
has an adequate number of offices. BIE officials
staff with the requisite indicated they are
knowledge and skills to planning to finalize and
effectively oversee BIE implement the plan in
school expenditures. 2019. BIE developed the
draft plan to also
address another workforce
plan recommendation in
our September 2013 report
(see above). We will
continue to monitor the
agency's efforts to
implement these
recommendations.
Safety and health at GAO-16-313 March Interior agreed with this
Indian school facilities 2016 recommendation. In
To support the collection September 2018, Indian
of complete and accurate Affairs provided
safety and health documentation that it had
information on the completed fiscal year
condition of BIE school 2018 safety inspections
facilities nationally, of all BIE schools. The
the Secretary of the agency also reported that
Interior should direct it is taking steps to
the Assistant Secretary- oversee the quality of
Indian Affairs to ensure school inspections, but
that all BIE schools are it has not provided us
annually inspected for with documentation that
safety and health, as indicates inspection
required by its policy, information agency
and that inspection personnel collect and
information is complete report to schools is
and accurate. complete and accurate. We
will continue to monitor
the agency's performance
in this area.
To ensure that all BIE GAO-16-313 March Interior agreed with this
schools are positioned to 2016 recommendation. In June
address safety and health 2018, Indian Affairs
problems with their provided us with
facilities and provide documentation on its
student environments that efforts to build schools'
are free from hazards, capacity to address
the Secretary of the safety and health
Interior should direct problems with their
the Assistant Secretary- facilities. In
Indian Affairs to develop particular, the agency
a plan to build schools' updated its Service Level
capacity to promptly Agreement between BIA and
address safety and health BIE, which details their
problems with facilities. roles and
Such a plan could responsibilities for
prioritize assistance to inspecting and providing
schools to improve the technical assistance to
expertise of facility BIE schools, among other
staff to maintain and areas. However, Indian
repair school buildings. Affairs' documents
provided little
information on how it
plans to support BIE
school personnel in
fixing safety hazards in
their facilities. In our
2016 report, we found
that school personnel
often lack the necessary
technical expertise to
address safety hazards in
school buildings.
Further, the agency did
not include information
on whether it has staffed
regional offices with
specialists to assist
schools with safety and
facility issues. In
September 2018, we
requested additional
information from Indian
Affairs on this
recommendation but the
agency had not provided
it as of February 2019.
We will continue to
monitor its efforts on
this recommendation.
The Secretary of the GAO-17-421 May Interior agreed with this
Interior should direct 2017 recommendation.In August
the Assistant Secretary- 2018, Indian Affairs
Indian Affairs to develop reported that it
and take corrective developed a corrective
actions, in consultation action plan, in
with Interior's consultation with
Designated Agency Safety Interior's Designated
and Health Official, to Agency Safety and Health
address BIA safety Official, and taken some
program weaknesses corrective actions
identified in prior identified in the plan.
Interior evaluations. However, it did not
provide documentation
that correction actions
in other important areas
had been completed, such
as signed management
statements of commitment
to safety and regional
analysis and plans for
correcting safety
deficiencies. In
September 2018, we
requested additional
information from Indian
Affairs on this
recommendation but the
agency had not provided
it as of February 2019.
We will continue to
monitor its efforts on
this recommendation.
The Secretary of the GAO-17-421 May Interior agreed with this
Interior should direct 2017 recommendation.In May
the Assistant Secretary- 2018, Indian Affairs
Indian Affairs to assign reported that it had
responsibility to a completed a draft
specific office or training plan and noted
official to develop and that it had submitted the
implement a plan to plan to management for
assess employees' safety review. In February 2019,
training needs and Indian Affairs reported
monitor employees' that its training plan
compliance with Indian for safety personnel was
Affairs' safety training waiting to be approved
requirements. and signed by management.
We will continue to
monitor Indian Affairs'
efforts to implement this
recommendation.
The Secretary of the GAO-17-421 May Interior agreed with this
Interior should direct 2017 recommendation. In
the Assistant Secretary- February 2019, Indian
Indian Affairs to ensure Affairs reported that the
that BIA's employee appraisal plans for
performance standards on agency safety personnel
inspections are responsible for
consistently incorporated inspecting BIE schools
into the appraisal plans had been updated with the
of all BIA personnel with agency's performance
safety program standards for
responsibilities. inspections. However, it
did not provide
documentation that this
action was taken per our
request. We will continue
to monitor Indian
Affairs' efforts to
implement this
recommendation.
The Secretary of the GAO-17-421 May Interior agreed with this
Interior should direct 2017 recommendation. In May
the Assistant Secretary- 2018, Indian Affairs
Indian Affairs to use reported that its Safety
information gathered from Office will assist safety
monitoring the timeliness supervisors in tracking
of school safety inspectors' performance
inspection reports to on report timeliness,
assess the performance of consistency and
employees with safety accountability of
program responsibilities inspection services. As
and hold them of February 2019, we have
accountable. not received
documentation that the
agency is taking this
action. We will continue
to monitor Indian
Affairs' efforts to
implement this
recommendation.
Oversight of BIE school GAO-17-447 May Interior agreed with this
construction projects To 2017 recommendation. In August
ensure accountability for 2017, Indian Affairs
BIE school facility reported that its Office
funds, the Secretary of of Facilities, Property,
the Interior should and Safety Management was
direct the Assistant undergoing a
Secretary-Indian Affairs reorganization to
to develop a establish a work group
comprehensive long-term focused on asset
capital asset plan to management and will
inform its allocation of continue to work with the
school facility funds. Office of Management and
Such a plan should Budget to develop a
include a prioritized capital asset management
list of school repair and plan. Indian Affairs
maintenance projects with reported a target date of
the greatest need for June 30, 2018, for
funding. implementing this
recommendation. As of
February 2019, the agency
had not provided
documentation that it had
completed a comprehensive
long-term capital asset
plan. We will continue to
monitor Indian Affairs'
efforts to implement this
recommendation.
To ensure accountability GAO-17-447 May Interior agreed with this
for BIE school facility 2017 recommendation. In August
funds, the Secretary of 2017, Indian Affairs
the Interior should reported that it had
direct the Assistant taken several actions,
Secretary-Indian Affairs including establishing
to develop and implement new oversight mechanisms,
guidance for its project hiring staff with
managers and contracting expertise in construction
officers regarding contracting, and
effective use of administering training
accountability measures. for contracting staff,
among other actions to
enhance the use of
accountability measures
in contracting. In
October 2018, Indian
Affairs reported that it
had taken additional
actions, including
providing formal meeting
and training events on
construction and project
management and conducting
a review of contracting
warrants to ensure that
those possessing
construction capability
had obtained necessary
training. Indian Affairs
also requires additional
management and legal
reviews of certain
construction contracts
and has established
multiple award
construction contracts to
streamline the
construction contracting
process and ensure that
accountability measures
are included in the base
contracts. Indian Affairs
adopted a construction
contract checklist to aid
the construction
contracting team and
developed a new letter
outlining roles and
responsibilities for the
project managers. As of
February 2019, we were
evaluating the agency's
documentation regarding
the implementation of
this recommendation.
To ensure accountability GAO-17-447 May Interior agreed with this
for BIE school facility 2017 recommendation. In August
funds, the Secretary of 2017, Indian Affairs
the Interior should reported that its
direct the Assistant Division of Facilities
Secretary-Indian Affairs Management and
to improve oversight and Construction will develop
technical assistance to a project tracking and
tribal organizations to monitoring process for
enhance tribal capacity all projects above a
to manage major certain monetary
construction projects. threshold. Additionally,
Indian Affairs reported
that this office will
work with BIA and BIE
officials to identify
common challenges that
tribes face in managing
projects and provide
appropriate technical
assistance. Indian
Affairs reported a target
date of June 30, 2018,
for implementing this
recommendation. As of
February 2019, the agency
had not provided
documentation that it had
taken these steps. We
will continue to monitor
Indian Affairs' efforts
to implement this
recommendation.
To ensure accountability GAO-17-447 May Interior agreed with this
for BIE school facility 2017 recommendation. In
funds, the Secretary of February 2019, Indian
the Interior should Affairs reported that it
direct the Assistant drafted an internal
Secretary-Indian Affairs policy and guidance on
to develop and implement maintaining contract
guidance for maintaining files, which were
complete contract and undergoing internal
grant files for all BIE review. We will continue
school construction to monitor Indian
projects. Affairs' efforts to
implement this
recommendation.
------------------------------------------------------------------------
Source: GAO-19-445T
Appendix II: Status of Open Recommendations to the Department of
Interior on Indian Energy
As of February 2019, 12 of the 14 recommendations to the Department
of Interior's Bureau of Indian Affairs cited in our 2017 High-Risk
Report remain open.
Table 2: The Status of Open Recommendations in Prior GAO Reports to the
Department of the Interior's (Interior) Bureau of Indian Affairs (BIA)
on Management and Oversight of Indian Energy Resources
------------------------------------------------------------------------
Category and Report number
recommendation and date Status
------------------------------------------------------------------------
BIA's data and technology GAO-15-502 June BIA requested each of its
BIA should work with the 2015 12 regions to review and
Bureau of Land Management identify historic survey
(BLM) to identify requests that were
cadastral survey needs. contained within a
defunct cadastral request
system to determine if
the requests are still
valid. According to BIA
officials, BIA and BLM
identified about 1,900
survey requests that were
not funded. BIA developed
a new database that
includes this inventory
and new survey requests
since 2015. BIA also
developed a mechanism for
its regions and agency
offices to make new
survey requests.
According to BIA
officials, the agency has
limited funding for
cadastral surveys and
conduct surveys that are
needed for litigation
purposes and those
surveys that are
mandated. Officials said
that BIA and BLM
coordinators meet bi-
monthly. We believe these
actions address the
recommendation and are in
the process of closing
this recommendation.
BIA's oversight of its GAO-15-502 June In a meeting on February
review process for energy 2015 25, 2019, the Acting
related documents BIA Director of BIA said that
should develop a the agency had completed
documented process to efforts to modify TAAMS,
track its review and incorporating the key
response times. identifiers and data
fields needed to track
and monitor review and
response times for oil
and gas leases and
agreements and
communitization
agreements (CA). BIA is
also in the process of
revising its Fluid
Minerals Handbook to
establish a standard
methodology for
processing new leases. We
have meetings planned
with BIA to observe the
tracking and reporting
capabilities of the
updated system. We also
will discuss the status
of actions to track and
monitor realty
transactions and other
energy-related documents,
such as rights of way
agreements.
BIA should enhance data GAO-15-502 June BIA identified the same
collection efforts to 2015 actions to implement this
ensure it has data needed recommendation as the
to track its review and prior recommendation, and
response times. we will be reviewing
these actions.
BIA should establish GAO-16-553 June In a meeting on February
required timeframes for 2016 25, 2019, BIA officials
the review and approval told us the agency has
of Indian CAs to ensure a drafted suggested
more timely CA process. timeframes for the review
and approval for the
Indian CAs for both BIA
and BLM. BIA is revising
the Onshore Energy and
Mineral Lease Management
Interagency Standard
Operating Procedures to
include these timeframes.
The officials said that
the Indian Energy and
Minerals Steering
Committee (IEMSC) will
meet in May 2019 and
discuss the proposed
timeframes. IEMSC is a
committee within Interior
that includes senior
managers from BIA, BLM,
and other agencies with a
focus on Indian trust
energy and mineral
policies and issues. When
BIA establishes required
timeframes for the review
approval of CAs, this
recommendation will be
closed.
BIA should develop a GAO-16-553 June In April 2017, BIA began
systematic mechanism for 2016 tracking CAs through the
tracking Indian CAs review and approval
through the review and process in a centralized
approval process to spreadsheet while the
determine, among other agency modified TAAMS. In
things, whether the the fall of 2018, BIA
revised CA process meets completed enhancements to
newly established TAAMS that will allow the
timeframes. agency to track
timeframes and status of
Indian CAs through the
review process. BIA held
training on the
enhancements with realty
staff in November 2018
and requested staff input
information on any newly
submitted CAs in the
system. We believe these
actions address most of
the recommendation. Once
timeframes have been
established and
monitored, we believe
this will be fully
addressed.
BIA should assess whether GAO-16-553 June In a meeting on February
the revised CA process is 2016 25, 2019, the BIA Acting
achieving its objective Director and other
to improve the timeliness officials said that they
of the review and have collected data since
approval of Indian CAs, April 2017 on the
and if not, make changes timeframes of the review
as appropriate. and approval of CAs and
have been assessing
efforts to streamline the
process. In addition, the
officials said that the
Indian Energy and
Minerals Steering
Committee (IEMSC) will
meet in May 2019 and this
topic will be discussed.
When BIA provides
documentation on their
assessment of the revised
process, we will be able
to close this
recommendation.
BIA's collaboration and GAO-17-43 In a meeting on February
communication BIA should November 2016 25, 2019, the BIA Acting
include the other Director said the agency
regulatory agencies in has formal agreements
the Service Center, such with Interior's Fish and
as FWS, EPA, and the Wildlife Service (FWS),
Corps, so that the Indian the Environmental
Energy Service Center Protection Agency (EPA)
(Service Center) can act and the U.S. Army Corps
as a single point of of Engineers (Corps). We
contact or a lead agency plan to obtain and review
to coordinate and these agreements. In
navigate the regulatory addition, we plan to
process. visit the Service Center
to discuss agency roles
and coordination.
BIA should establish GAO-17-43 BIA prepared an addendum
formal agreements with November 2016 to expand an existing
Interior's Office of memorandum of
Indian Energy and understanding between DOE
Economic Development and IEED to include the
(IEED) and the Department Service Center. DOE has
of Energy (DOE) that not yet approved the
identify, at a minimum, agreement. However, the
the advisory or support existing memorandum of
role of each office understanding between DOE
involved with the Service and IEED does not
Center. identify the role for
these agencies as related
to the Service Center. We
plan to visit the Service
Center to discuss agency
roles and coordination.
BIA should establish a GAO-17-43 On June 13, 2018, the
documented process for November 2016 Acting Director of BIA
seeking and obtaining testified before the
input from key Senate Committee on
stakeholders, such as BIA Indian Affairs that the
employees, on the Service Service Center developed
Center activities. a process that allows key
agencies to provide input
and requests for service.
The Acting Director
reported that the process
includes guidance on the
prioritization of task
orders and that Service
Center officials began
using an intake form in
August 2017 to obtain
input regularly from
stakeholders. We plan to
visit the Service Center
to learn about this
process and any others
the Service Center may
have to obtain input
regularly from
stakeholders.
BIA should document the GAO-17-43 BIA reported it has taken
rationale for key November 2016 actions needed to
decisions related to the implement our
establishment of the recommendation. On May
Service Center, such as 17, 2017, the Acting
alternatives and tribal Assistant Secretary-
requests that were Indian Affairs testified
considered. before the Senate
Committee on Indian
Affairs that Interior
considers this
recommendation
implemented because (1)
the development of the
Service Center was the
result of a concept paper
produced by a multi-
agency team and (2) a
multi-agency team held a
tribal listening session,
received written
comments, and conducted
conference calls in an
effort to gather input
from relevant
stakeholders. BIA's
actions have not resulted
in documentation on the
alternatives considered,
whether tribal input and
requests were considered,
and the rationale for not
incorporating key
suggestions. Without
documentation on
alternatives considered
in establishing the
Service Center, it is
unclear whether requests
from stakeholders were
appropriately considered.
Since BIA has not
provided this
documentation, we plan to
close this recommendation
as unimplemented.
BIA's workforce planning GAO-17-43 BIA has taken a number of
BIA should incorporate November 2016 actions, such as
effective workforce conducting an internal
planning standards by survey to identify
assessing critical skills general workforce needs
and competencies needed related to oil and gas
to fulfill BIA's development. This survey
responsibilities related information supported
to energy development and staffing decisions for
by identifying potential the Indian Energy Service
gaps. Center. On June 13, 2018,
the Acting Director of
BIA testified before the
Senate Committee on
Indian Affairs that the
BIA conducted a multi-
agency survey to collect
workforce data on needs
for energy and minerals
management. According to
the Acting Director of
BIA, the survey
information confirmed
needs across agencies in
the areas of engineering,
engineering technicians
and environmental science
disciplines. He also
stated that BIA would
work to develop effective
workforce standards to
address the need for the
skills and competencies
needed for energy
development. In a meeting
on February 25, 2019, BIA
officials said that the
Office of Trust Service
has developed a long-
range workforce action
plan. The plan includes
proposed actions to
identify potential gaps
in the workforce and
determine future needs.
We plan to gather
additional information
and review the workforce
action plan to determine
if these actions result
in BIA identifying
critical skills and
competencies needed to
fulfill BIA's
responsibilities related
to energy development and
identifying potential
gaps agency offices.
BIA should establish a GAO-17-43 We plan to gather
documented process for November 2016 additional information
assessing BIA's workforce and review the workforce
composition at agency action plan to determine
offices taking into if it establishes a
account BIA's mission, process for assessing
goals, and tribal BIA's workforce
priorities. composition at agency
offices.
------------------------------------------------------------------------
Source: GAO-19-445T
Appendix III: Status of Open Recommendations to HHS on the Indian
Health Service
As of March 2019, six out of the 13 recommendations in our 2017
High-Risk Report remain open, and we have added one additional
recommendation-for a total of seven open recommendations related to
this high-risk area.
Table 3: Status of Open Recommendations in Prior GAO Reports to the
Department of Health and Human Services (HHS) on Management and
Oversight of the Indian Health Service (IHS)
------------------------------------------------------------------------
Category and Report number
recommendation and date Status
------------------------------------------------------------------------
Estimating Purchased/ GAO-11-767 HHS agreed with our
Referred Care (PRC) September 2011 recommendation. In March
program needs To develop 2019, IHS officials
more accurate data for reported that updates to
estimating the funds the PRC chapter of the
needed for the PRC Indian Health Manual had
program and improving IHS been completed that
oversight, the Secretary address this
of Health and Human recommendation, and that
Services should direct the updated manual would
the Director of IHS to be posted to the IHS
develop a written policy website shortly. We will
documenting how IHS review the updated PRC
evaluates need for the chapter of the Indian
PRC program and Health Manual once it is
disseminate it to area posted.
offices and PRC programs
to ensure they understand
how unfunded services
data are used to estimate
overall program needs.
To develop more accurate GAO-11-767 HHS agreed with our
data for estimating the September 2011 recommendation. In March
funds needed for the PRC 2019, IHS officials
program and improving IHS reported that updates to
oversight, the Secretary the PRC chapter of the
of Health and Human Indian Health Manual had
Services should direct been completed that
the Director of IHS to address this
provide written guidance recommendation, and that
to PRC programs on a the updated manual would
process to use when funds be posted to the IHS
are depleted and there is website shortly. We will
a continued need for review the updated PRC
services, and monitor to chapter of the Indian
ensure that appropriate Health Manual once it is
actions are taken. posted. We will also
review IHS's monitoring
of actions taken after
this guidance is issued.
Ensuring equitable GAO-12-446 June HHS agreed with our
allocation of PRC program 2012 recommendation. In March
funds To make IHS's 2019, IHS officials
allocation of PRC program reported that updates to
funds more equitable, the the PRC chapter of the
Secretary of Health and Indian Health Manual had
Human Services should been completed that
direct the Director of address this
the Indian Health Service recommendation, and that
to develop written the updated manual would
policies and procedures be posted to the IHS
to require area offices website shortly. We will
to notify IHS when review the updated PRC
changes are made to the chapter of the Indian
allocations of funds to Health Manual once it is
PRC programs. posted.
Improving IHS's PRC GAO-14-57 HHS agreed with the first
program In an effort to December 2013 part of this
ensure that IHS has recommendation. As of
meaningful information on December 2018, IHS
the timeliness with which officials told us that it
it issues purchase orders had implemented the first
authorizing payment under part of this
the PRC program and to recommendation by
improve the timeliness of developing two new
payments to providers, Government Performance
the Secretary of the and Results Act (GPRA)
Department of Health and measures that recognize
Human Services should the differences in
direct the Director of payment processes for the
IHS to: (1) modify IHS's two types of referrals in
claims data system to the PRC program.
separately track IHS Officials reported that
referrals and self- IHS is tracking and
referrals, revise the monitoring progress
Government Performance towards reaching both
Results Act measure for these targets, and will
the PRC program so that report its performance
it distinguishes between annually in the
these two types of Congressional
referrals, and establish Justification. Regarding
separate timeframe the second part of this
targets for these recommendation, in March
referral types; and (2) 2019, IHS officials
improve the alignment reported that updates to
between PRC staffing the PRC chapter of the
levels and workloads by Indian Health Manual had
revising its current been completed that
practices, where address this
appropriate, to allow recommendation, and that
available funds to be the updated manual would
used to pay for PRC be posted to the IHS
program staff. website shortly. We will
review the updated PRC
chapter of the Indian
Health Manual once it is
posted.
Improving IHS oversight of GAO-16-333 March HHS agreed with our
patient wait times To 2016 recommendation. IHS
help ensure that timely officials stated in March
primary care is available 2019 that they were
and accessible to updating the agency's
American Indian and patient wait time
Alaska Native people, the standards to include
Secretary of HHS should emergency department wait
direct the Director of times, and the agency was
IHS to monitor patient working to develop system-
wait times in its wide capacity for data
federally operated measurement and
facilities and ensure monitoring. Once the
corrective actions are standards are fully
taken when standards are developed and monitoring
not met. is underway, IHS will
also need to ensure
corrective actions are
taken when standards are
not met. We will review
IHS's monitoring of
patient wait times, as
well as corrective
actions taken, after
these procedures have
been established and
implemented.
Improving IHS oversight of GAO-17-181 HHS agreed with this
quality of care To help January 2017 recommendation and
ensure that quality care reported that agency-wide
is provided to American measures, goals and
Indian and Alaska Native benchmarks have been
people, the Secretary of developed, and that they
HHS should direct the build on best practices
Director of IHS to, as and external benchmarks
part of the from comparable
implementation of its organizations. HHS also
quality framework, ensure has a system-wide
that agency-wide dashboard of performance
standards for the quality accountability metrics,
of care provided in its for use at the
federally operated enterprise, area, and
facilities are developed, facility levels. In
that facility performance addition, IHS awarded a
in meeting these contract to a software
standards is development firm in
systematically monitored December 2018 to design a
over time, and that new adverse event
enhancements are made to reporting and tracking
its adverse event system for the agency. We
reporting system. will review IHS's
monitoring of facility
performance, and its new
adverse event reporting
system when they are
completed.
Improving IHS GAO-18-580 HHS agreed with this
decisionmaking about August 2018 recommendation. In its
resource allocation and comments on our report,
provider staffing The HHS stated that IHS plans
Director of IHS should to update its policies to
obtain, on an agency-wide include a centralized
basis, information on reporting mechanism
temporary provider requirement for all
contractors, including temporary contracts
their associated cost and issued for providers. HHS
number of full-time also stated that, upon
equivalents, and use this finalization of the
information to inform policy, IHS will broadly
decisions about resource incorporate and implement
allocation and provider the reporting mechanism
staffing. agency-wide and maintain
it on an annual basis. We
will update the status of
this recommendation when
we receive additional
information.
------------------------------------------------------------------------
Note: IHS's PRC program, as it is currently known, was previously
referred to as the Contract Health Services (CHS) program in prior GAO
reports. Source: GAO-19-445T
The Chairman. Thank you, Director Farb. We appreciate it.
Director Dearman.
STATEMENT OF TONY DEARMAN, DIRECTOR, BUREAU OF INDIAN
EDUCATION, U.S. DEPARTMENT OF THE INTERIOR
Mr. Dearman. Good afternoon Chairman Hoeven, Vice Chairman
Udall and members of the Committee.
Thank you for the invitation to appear again on behalf of
the Bureau of Indian Education to discuss our ongoing work to
address the high risk designation from the Government
Accountability Office.
As of today, I am happy to report that BIE has closed nine
of the thirteen overdue recommendations since the first high
risk hearing in 2017. The BIE has also closed two
recommendations from GAO-17-421, for a total of eleven
recommendation closures. The BIE continues to work
collaboratively with our GAO colleagues to address all
remaining recommendations, including those issued in 2017.
As I have testified before, the BIE views the GAO reports
as a constructive tool to improve our agency and help the
students we are committed to serve. Today, I would like to
update you on our progress and provide you with our plans to
address the remaining outstanding recommendations. Regarding
GAO Report 13-774, BIE has completed implementation of all but
one recommendation in this report, including the BIE's first
ever five-year strategic direction. The direction is a
culmination of a year of hard work, planning and substantive
consultation with tribes and will, for the first time, provide
a comprehensive road map for BIE.
BIE purposely delayed implementation of the two outstanding
recommendations regarding a strategic workforce plan until
finalizing the direction. Following publishing of the direction
in mid-August, the BIE conducted an exhaustive analysis of its
available human resources data to create a working draft of the
workforce plan.
In an ongoing effort to work early and often with GAO on
all of our high risk-related projects, we provided GAO with the
draft in mid-February. I am happy to report that the BIE
received GAO's feedback last week and we are working to
incorporate their expert input.
BIE initially anticipated completing the workforce plan
prior to the hearing. However, the recent shutdown delayed the
completion date. We expect to complete this process in the
coming weeks and look forward to formally closing the two
workforce plan recommendations soon thereafter.
It is worth highlighting here that the department
previously considered BIE's workforce plan recommendation in
13-774 closed. However, following BIE's meeting with GAO on
June 17th and August 16th of 2017, GAO provided clarification
regarding its expectations. As a result, the BIE and the
department agreed that its previous work did not fully address
GAO's recommendation and agreed to reinitiate work on its
strategic workforce plan.
Regarding GAO-16-313, BIE successfully implemented
Recommendations II and IV, and GAO permanently closed the
recommendations in early 2018.
BIE and its Indian Affairs partners continue to work
implementing GAO's two remaining recommendations. In addition,
BIE and BIA once again administered safe school audits with a
100 percent completion rate in 2018. We are on track to
complete 100 percent of the inspections in 2019 and are
monitoring whether schools have established required safety
committees.
We are also working to ensure employee performance
standards regarding inspections are consistently incorporated
into the appraisal plans of personnel with safety program
responsibilities. Personnel are on schedule to require safety
inspectors to formally document when inspection reports are
delivered to schools, as well as establish a process to
routinely monitor the timeliness of such reports.
Further, BIE staff and its Indian Affairs partners drafted
and recently implemented the Indian Affairs Safety, Health and
Accessibility Inspection Evaluation Guidelines, which will
comprehensively address many of the GAO safety-related
recommendations outlined in subsequent reports released in
2017.
Chairman Hoeven, Vice Chairman Udall and members of the
Committee, thank you for the opportunity to present testimony
today and to provide the Committee an update regarding our work
with GAO. Work remains. The BIE continues to make progress and
is committed to addressing all GAO recommendations to improve
services to our students.
Thank you for your time and I would be honored to answer
any questions.
[The prepared statement of Mr. Dearman follows:]
Prepared Statement of Tony Dearman, Director, Bureau of Indian
Education, U.S. Department of the Interior
Good afternoon Chairman Hoeven, Vice Chairman Udall, and Members of
the Committee. Thank you for the invitation to appear again on behalf
of the Bureau of Indian Education (BIE) to discuss our ongoing work to
address the high-risk designation from the Government Accountability
Office (GAO) in the High Risk Report (GAO-17-317 High Risk Series).
GAO's recently issued report, GAO-19-157SP,provides the updated status
of the Department's efforts to address these recommendations.
Since the first High Risk hearing in 2017, the BIE has worked to
address all outstanding recommendations, with nine of the thirteen
overdue recommendations permanently closed. Additionally, the BIE has
closed two separate recommendations from GAO-17-421, for a total of
eleven recommendation closures. The BIE continues to work
collaboratively with our GAO colleagues to address all remaining GAO
recommendations, including those issued in 2017, to improve our
services to Indian students. Such work has already proven effective as
evidenced by our newly implemented Strategic Direction and
comprehensive fiscal monitoring policy, both of which have
substantially improved our managerial effectiveness and our ability to
serve schools and Indian students.
As I previously testified, the BIE team views the GAO reports as a
constructive tool to improve our agency and help the students we are
committed to serve. As such, I will update you on headway made in the
following areas:
1. GAO High Risk Status for BIE
2. GAO Recommendations: Status & BIE Next Steps
GAO High Risk Status for BIE
In February 2017, the GAO released its High Risk Report (GAO-17-317
High Risk Series) designating BIE as a high-risk agency. The GAO
highlighted persistent weaknesses noted in previous reports that
inhibit the agency from efficiently executing its mission to serve
Indian students:
Indian Affairs' (IA) oversight of school safety and
construction, as well as how BIE monitors the way schools use
Interior funds;
The impact of limited workforce planning in several key
areas related to BIE schools;
The effects of aging BIE school facilities and equipment and
how such facilities contribute to degraded and unsafe
conditions for students and staff; and
How the lack of internal controls and other weaknesses
hinder IA's ability to collect complete and accurate
information on the physical conditions of BIE schools.
BIE considers GAO recommendations a roadmap to establish and
maintain comprehensive internal policies and procedures that support
service delivery, ensure accountability, and provide organizational
stability.
GAO Recommendations: Status and BIE Next Steps
Since I started as the Director, BIE has prioritized resources and
critical personnel to refocus our efforts in addressing the
longstanding, systemic issues outlined in GAO reports that will
ultimately improve our ability to serve Indian students.
GAO-13-774-INDIAN AFFAIRS: Better Management and Accountability Needed
to Improve Indian Education (September 2013).
GAO made five recommendations:
I.) Develop and implement decisionmaking procedures, which are
documented in management directives, administrative policies,
or operating manuals;
II.) Develop a communication strategy;
III.) Appoint permanent members to the BIE-Education committee
and meet on a quarterly basis;
IV.) Draft and implement a strategic plan with stakeholder
input; and
V.) Revise the BIE strategic workforce plan.
BIE completed implementation of all but one recommendation in this
report, recommendation five, including the BIE's first five-year
Strategic Direction (Direction). The BIE designed the Direction to
increase BIE's ability to improve its services to Indian students by
organizing management activities, setting priorities, and ensuring
efficient and effective utilization of staff and resources, while also
working collaboratively with Tribes, school boards, employees, and
other stakeholders. As BIE implements the Direction, it is providing
quarterly updates online regarding progress and will institute a mid-
cycle status update during Year Three of the implementation. As part of
each yearly evaluation of milestones and actions, the BIE will notify
Tribes, school boards, employees and other stakeholders about annual
reporting to inform their feedback and gather input for the mid-cycle
status update during Year Three.
Recommendation V--BIE purposefully delayed implementation of
recommendation five until finalizing the Direction to ensure alignment
of the two planning documents. Following publication of the Direction,
the BIE initiated the collection and analysis of its available human
resources data. BIE initially projected its completion date by this
hearing. However, the recent shutdown delayed the completion date. We
provided a first draft to our GAO colleagues to review and provide
substantive edits on February 19, 2019. GAO provided us with their
comments and feedback on March 4, 2019. We are now working to
incorporate feedback into the final plan. We expect to complete this
process in the coming weeks and look forward to formally closing this
recommendation soon thereafter.
GAO-15-121-INDIAN AFFAIRS: Bureau of Indian Education Needs to Improve
Oversight of School Spending (November 2014).
GAO made four recommendations:
I.) Develop a comprehensive workforce plan;
II.) Implement an information sharing procedure;
III.) Draft a written procedure for making major program
expenditures; and
IV.) Create a risk-based approach in managing BIE school
expenditures.
As is the case with the previous GAO report, the BIE completed
implementation of all but recommendation one. It is worth highlighting
the recently published BIE High Risk Fiscal Oversight Policy and
Handbook. For the first time, the BIE established a comprehensive
fiscal monitoring protocol, which coordinates efforts and technical
assistance to schools across the organization. As a result, GAO
permanently closed recommendations two, three, and four.
Recommendation I--During the early stages of the current BIE
reform, IA conducted an initial workforce study. Following BIE's
meetings with GAO on June 17, 2017 and August 16, 2017, GAO provided
clarification regarding its expectations. As a result, the BIE's
strategic workforce plan referenced under GAO-13-774 will fully address
recommendation five from GAO-13-774 as well as recommendation one from
GAO-15-121. As such, the BIE plans to formally close this
recommendation in the coming weeks.
GAO-16-313-INDIAN AFFAIRS: Key Actions Needed to Ensure Safety and
Health at Indian School Facilities (March 2016)
GAO made four recommendations:
I.) Ensure that all BIE schools are inspected as well as
implement a plan to mitigate challenges;
II.) Prioritize inspections at schools where facility
conditions may pose a greater risk to students;
III.) Develop a plan to build schools' capacity to promptly
address safety and health problems with facilities and improve
the expertise of facility staff to maintain and repair school
buildings; and
IV.) Consistently monitor whether schools have established
required safety committees.
BIE successfully implemented recommendations two and four, and GAO
permanently closed the recommendations in early 2018. BIE and its IA
partners continue its work implementing GAO's two remaining
recommendations contained in GAO-16-313.
Recommendations I and III--BIE is collaborating with partners from
across IA to address its remaining safety-related GAO recommendations.
Through an IA collaborative working group to address outstanding safety
issues, BIE and IA administered safe school audits with a 100 percent
completion rate in 2016, 2017, and 2018. We are on track to complete
100 percent of inspections in 2019 and are monitoring whether schools
have established required safety committees.
Regarding 16-313 recommendation one, the IA Deputy Assistant
Secretary--Management (DAS-M) has provided a closure package to GAO.
GAO has communicated to DAS-M that it will monitor implementation of
the submitted plan over the remainder of 2019 and will provide final
closure by December 31, 2019. Regarding 16-313 recommendation three,
DASM plans to submit a formal closure package to GAO by March 29, 2019.
We are also working to ensure that employee performance standards
regarding inspections are consistently incorporated into the appraisal
plans of personnel with safety program responsibilities. Personnel are
on schedule to require safety inspectors to formally document when
inspection reports are delivered to schools as well as establish a
process to routinely monitor the timeliness of such reports. Further,
BIE staff and its IA partners drafted and recently implemented the
``Indian Affairs Safety Health and Accessibility Inspection/Evaluation
Guidelines'', which will comprehensively address many of GAO's safety-
related recommendations outlined in subsequent GAO reports released in
2017.
Conclusion
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee,
thank you for the opportunity to present testimony today and provide
the Committee an update regarding our work with GAO. Work remains, but
BIE continues to make progress and is committed to addressing all GAO
recommendations to improve services to our students. Thank you for your
time, and I would be honored to answer any questions you may have.
The Chairman. How about in regard to the lateness of your
testimony? Would you comment in that regard?
Mr. Dearman. Senator, we apologize for the lateness of our
testimony. We have a lot of moving parts right now in making
sure that the recommendations are closed, because there are a
lot of departments and Indian Affairs partners that are
included in assisting in closing the GAO's recommendations. We
wanted to make sure that the information provided was accurate.
We do have a review process with the department.
I will definitely take back the concern with the
department. I will make certain we meet the deadline for the
next hearing.
The Chairman. Thank you.
Director LaCounte.
STATEMENT OF DARRYL LaCOUNTE, ACTING DIRECTOR,
BUREAU OF INDIAN AFFAIRS, U.S. DEPARTMENT OF THE
INTERIOR
Mr. LaCounte. Good afternoon, Chairman Hoeven and Vice
Chairman Udall. Thank you for the opportunity to present a new
update on behalf of the Department of the Interior regarding
Indian Affairs' role in the development of Indian energy and
our continued commitment to address the high risk designation
in the Government Accountability Office High Risk Report. Thank
you.
I apologize, too, on behalf of the department for our late
submission of the written testimony. The department has been
working hard right up to the last evening to include all
actions taken to address the GAO recommendations in order to
give the Committee the most up-to-date, accurate picture.
There are some new folks involved in the process and I am
confident everyone involved will learn from this. I am really
confident that when I am the witness, I will speak a little
louder as the deadline nears. But to be honest with you, I
really don't know why it is late.
Approximately one year ago in February 2018, I began in an
acting capacity as the Deputy Bureau Director for Trust
Services and soon transitioned into the Acting Bureau Director.
As I stated in my testimony in June 2018, my priority was not
just to address the GAO recommendations in the High Risk
Report, but to ensure we fully enhance our systems, so that
implementation has proven significant results well into the
future.
The Indian Energy Service Center has processed 21 new
communitization agreements as recommended in GAO's 16-553 since
September of 2018, which is a reflection of our dedication and
commitment to assure we advance economic opportunities and
technical support in full partnership with tribes and tribal
members developing their energy resources.
My staff and I have also worked diligently to reestablish
and improve communications with GAO. I feel we have been very
successful in developing a productive relationship with our
newly-designated point of contact at GAO. Regular communication
with a consistent staff provides much needed coordination to
close the High Risk List recommendations as well as improve the
overall process to address other issues.
We agreed to meet with GAO at the Indian Energy Service
Center for a site visit later this month to demonstrate our
system enhancements and streamlined processes related to those
recommendations. I will go off my script a little bit and
invite anyone from this Committee to join in that. We look
forward to progressing together.
As the Committee is aware, the GAO made 14 recommendations
to the Bureau of Indian Affairs within three separate reports.
The department agreed with GAO's recommendations and endeavored
to address them by committing to and implementing widespread
reform to help foster energy independence among tribes who are
interested in developing their resources. We are confident that
all 14 recommendations have been addressed and believe they
should be closed as our solutions to these findings have been
implemented throughout the Bureau.
As indicated in my previous update, the BIA had closed
Recommendations 1 and 5 and really, the GAO has closed 1 and 5.
I also indicated I was aggressively prioritizing the closing
out of Recommendations 2, 3, 4 and 6 by the end of September
2018. Our goal was to close the remaining Recommendations 7
through 14 by the end of the calendar year.
We provided closure packages for all of the outstanding
recommendations to the Indian Affairs Division of Internal
Evaluation and Assessment by the end of September 2018. We also
provided follow-up information as requested for closure by the
end of December 2018. We will work with our partners to ensure
the process is complete for closure. Additionally, we look
forward to improving our own evaluation and reporting capacity
and structure within Indian Affairs through this process.
Again, thank you for the opportunity to provide an update
on our progress in addressing the GAO recommendations from past
reports and the GAO-17-317 high risk series. I would be glad to
answer any questions the Committee may have.
[The prepared statement of Mr. LaCounte follows:]
Prepared Statement of Darryl LaCounte, Acting Director, Bureau of
Indian Affairs, U.S. Department of the Interior
Chairman Hoeven, Vice Chairman Udall, and Members of the Committee.
Thank you for the opportunity to provide an update on behalf of the
Department regarding Indian Affairs' role in the development of Indian
energy and our continued commitment to address the high risk
designation in the Government Accountability Office (GAO) High Risk
Report (GAO-17-317 High Risk Series). GAO's recently issued report,
GAO-19-157SP, provides the updated status of the Department's efforts
to address these recommendations.
As the Committee is aware, the Department agreed with GAO's
recommendations and we continue to address the recommendations by
implementing widespread reform to help foster energy independence among
Tribes who are interested in developing their resources. As the High
Risk report notes, GAO made fourteen recommendations to the Bureau of
Indian Affairs (BIA), in three reports. As of June 13, 2018,
Recommendations 1 and 5 had been closed. BIA made a commitment to close
Recommendations 2, 3, 4, and 6, by the end of September 2018, and
Recommendations 7, 8, 9, 13, and 14 by the end of the calendar year.
The GAO recommendations are incorporated into our operations and
have proven to benefit our modernization initiatives and improve
efficiencies while building progressive relationships in collaboration
with parties engaged in Indian energy.
GAO 15-502
Recommendation 1: To ensure it can verify ownership in a timely
manner and identify resources available for development, BIA should
take steps to complete its GIS mapping module in TAAMS.
As announced in my last visit on June 13, 2018, the Indian Affairs
GIS Map Viewer has been deployed as of August 31, 2017. BIA addressed
the requirements for this Recommendation, and is closed as of February
22, 2018.
Recommendation 2: To ensure it can verify ownership in a timely
manner and identify resources available for development, BIA should
work with Bureau of Land Management (BLM) to identify cadastral survey
needs.
The BIA and the BLM established a Reimbursable Service Agreement
between the two agencies to deliver the much needed survey-related
products and services. BLM and BIA established a database that contains
the information necessary to identify ownership. An intake mechanism
was developed by the Indian Energy Service Center for making new survey
requests.
Specifically, BIA and BLM established a Reimbursable Service
Agreement (RSA) for Cadastral Surveys complete for Fiscal Years 2015,
2016, 2017, and 2018; established the Cadastral Survey Inventory
established in 2015, completed the BIA Guidance on October 10, 2018;
and completed the Cadastral Survey Implementation on October 1, 2018.
Implementation and full deployment of the cadastral survey process was
complete in 2018.
Recommendation 3: To improve the efficiency and transparency of its
review process, BIA should develop a documented process to track its
review and response times.
System enhancements in the Trust Asset and Accounting Management
Systems (TAAMS) were developed to track Mineral Leases from submission,
approval, and recordation. As of September 30, 2018, the module was
complete and implemented in the suite of TAAMS Modules. The module
provides transparency in tracking and monitoring the status of a
Mineral Lease throughout the review and approval process. In addition
BIA provided TAAMS Minerals Module Training Guides and Webex Training,
where we tracked attendance to ensure delivery of information and
support.
The BIA updated the 2012 Fluid Minerals Handbook (52 IAM X-H, to
assist Staff in the review and approval of new Oil and Gas Leases. The
Handbook establishes a standard for processing new leases, whether the
result of a lease advertisement and sale or the result of negotiations
between the parties to the lease. It includes new or updated flowcharts
and templates, language and content updates and corrections. The
Handbook is complete and currently in the final stages of clearance for
release by our Regulatory Affairs office, which is expected in early
May 2019.
Recommendation 4: To improve the efficiency and transparency of its
review process, BIA should enhance data collection efforts to ensure it
has data needed to track its review and response times.
As in Recommendation 3, BIA developed system enhancements to TAAMS
and updated the Fluid Minerals Handbook. TAAMS can now track mineral
leases from submittal to approval and recordation. This tool adds to
the BIA agencies' transparency in identifying the status of a mineral
lease throughout the review and approval process. Management can also
access TAAMS and determine the status of a lease. The TAAMS Enhancement
request was approved by the TAAMS Change Management Board (TCMB) in
2017, and the enhancements were incorporated into the system by
September 30, 2018.
The BIA has the capability of capturing key dates along the review
and approval process for a lease package, including, but not limited
to, the initial receipt, confirmation of a complete lease package,
approval and recording of the leases. This module has been completed
and added to the suite of modules in TAAMS as of September 30, 2018.
Recommendation 5: Provide additional energy development-specific
guidance on provisions of Tribal Energy Resource Agreement (TERA)
regulations that tribes have identified to Interior as unclear.
In the last testimony, we reported that our Department's Office of
Indian Energy and Economic Development (IEED) placed on its web site
guidance to tribes seeking an approved TERA or which seek to assume
energy-related administrative functions under Public Law 93-638 on
August 31, 2017. As a result, the GAO closed Recommendation 5 on March
8, 2018.
GAO 16-553
Recommendation 1: Establish required timeframes for the review and
approval of an Indian Communitization Agreement (CA) to ensure a more
timely CA process.
As communicated previously, the Department continues its work to
ensure timely review and approval of Indian Communization Agreements
(CA). A National Policy Memorandum (Memorandum) was issued that
establishes a tracking mechanism to monitor the existing timeframes for
review and approval of Indian CAs. The TAAMS CA system enhancements
were completed by September 30, 2018.
The process is outlined in the Standard Operating Procedure (SOP)
and supported by the intent of the Interagency Agreement. The
Interagency Agreement is signed by BIA, BLM, OST, ONRR and IEED to
process federal Indian energy transactions. SOP training specific to
Indian Oil and Gas Leasing Activities was held on June 12-13, 2018, at
the National Indian Training Center in Albuquerque, New Mexico.
Additionally, we held another training on December 11-12, 2018, at the
Federal Center in Lakewood, Colorado.
Recommendation 2: Develop a systematic mechanism for tracking
Indian CAs through the review and approval process to determine, among
other things, whether the revised CA process meets newly established
timeframes.
A national tracking mechanism was established to identify
timeframes and captures the status of transactions in the system of
record, TAAMS. This tool adds to the agencies' transparent
identification of the status of any CA application within the review
process. The system has the capability of capturing key dates along the
review and approval process for a CA package, including, but not
limited to, the initial receipt, confirmation of a complete package,
technical review request sent to BLM, and the recommendation received
from BLM.
BIA developed and implemented the tracking functionality Bureau-
wide through TAAMS effective September 30, 2018. With the system
enhancements in TAAMS, BIA tracks CAs from submittal to approval and
recordation. This CA suite of modules in TAAMS is complete as of
September 30, 2018.
Recommendation 3a: Assess whether the revised CA process is
achieving its objective to improve the timeliness of the review and
approval of Indian CAs, and if not, make changes as appropriate.
This recommendation is consistent with activity completed in
relation to other recommendations. As of September 30, 2018, the
Communitization Agreement (CA) tracking module was added to the Trust
Asset and Accounting Management System (TAAMS) to expedite the review
and approval of Indian CA's. The CA module provides agency wide
transparency on the status of any CA application process.
The BIA has the capability of capturing key dates during the review
and approval process, including, but not limited to, the initial
receipt, confirmation of a complete package, technical review request
sent to the Bureau of Land Management (BLM), and recommendations
received from BLM. SOP training specific to Indian Oil and Gas Leasing
Activities was held on June 12--13, 2018, and December 11-12, 2018.
As previously reported, since 2017, BIA has utilized a Google
Tracking Sheet to track national Indian CA's from submission to
approval. The Google Tracking Sheet was BIA's interim approach to track
the approval of CA's, gather information on timeframes and status, and
establish a baseline to ensure improvement of timeliness of the Indian
CA review and approval process. Data from the Google Tracking Sheet is
important and utilized to track timeframes in TAAMS to assist in
establishing metrics for processing agreements.
GAO 17-43
Recommendation 3: Include the other regulatory agencies in the
Service Center, such as FWS, EPA, and the Army Corps of Engineers, so
that the Service Center can act as a single point of contact or a lead
agency to coordinate and navigate the regulatory process.
The Indian Energy Service Center (IESC) fosters and establishes
working relationships with other federal agencies to enhance Indian
Energy opportunities. The BIA is committed to collaborating and
establishing formal Memorandum of Understanding (MOUs) with other
federal agencies to expedite oil and gas development. The purpose of
the MOU is to enhance cooperation, efficiency, and effectiveness of
Energy and Mineral issues.
In 2017, the IESC submitted formal invitations to each agency
regarding the implementation of MOUs with the United States Fish &
Wildlife Service (USFWS), Environmental Protection Agency (EPA), and
United States Army Corps of Engineers (USACE). As a result of the
formal invitations, IESC participated in several conference calls and
meetings with each agency to discuss the request of the Government
Accountability Office (GAO) and the benefits of the formal MOUs.
On January 10, 2018, the United States Army Corps of Engineers
(USACE) signed the MOU with IESC. On June 1, 2018, the U.S. Fish and
Wildlife Service's Principal Deputy Director also signed the MOU with
IESC. On June 14, 2018, the Environmental Protection Agency approved
the MOU with IESC.
Recommendation 4: Establish formal agreements with IEED and DOE
that identify, at a minimum, the advisory or support role of each
office.
A formal MOU was established between the Office of Indian Energy
and Economic Development (IEED) and the Department of Energy (DOE) on
June 21, 2016. On August 9, 2018, an Addendum to the MOU between IEED
and DOE was approved by myself, the Acting Director of the Bureau of
Indian Affairs. On September 5, 2018, the Addendum to the MOU with IEED
and DOE was approved by the Assistant Secretary--Indian Affairs. The
purpose of the addendum was to invite the Bureau of Indian Affairs--
Indian Energy Service Center to participate in the MOU between IEED and
DOE.
Recommendation 5: Establish a documented process for seeking and
obtaining input from key stakeholders, such as BIA employees, on the
Service Center activities.
In my last report, I testified the IESC developed a process that
allows key agencies to provide input and requests for service received
on behalf of tribes from the IESC. The process includes guidance on the
prioritization of task orders. The Executive Management Group of the
IESC is comprised of the directors of the BIA, BLM, ONRR, and Office of
the Special Trustee for American Indians (OST). The IESC began
utilizing the intake forms in August 2017 to obtain input regularly
from stakeholders. IESC is on target to close this recommendation. This
process is still in use, and this recommendation can be closed.
Recommendation 6: Document the rationale for key decisions related
to the establishment of the Service Center, such as alternatives and
tribal requests that were considered.
The Department created the Indian Energy & Minerals Steering
Committee (IEMSC), which is a group that helps to ensure that the
Department meets its trust responsibility to federally recognized
Indian tribes and the individual Indian mineral owners. The IEMSC is an
inter-agency forum for Indian energy and mineral resource development,
royalty management coordination, and information exchange. This
committee is comprised of senior representatives from the BIA, BLM,
ONRR, OST, and the Solicitor's Office.
Recommendation 7: Incorporate effective workforce planning
standards by assessing critical skills and competencies needed to
fulfill BIA's responsibilities related to energy development and by
identifying potential gaps.
As the Acting Director, I identified the top workforce planning
priorities with the goal of the most effective development and
execution of workforce planning, so that the organization is able to
leverage its human capital to accomplish its strategic goals. The
Office of Trust Services (OTS) developed metrics to capture benefits or
challenges in workforce planning.
To ensure the most efficient and cost-effective workforce, the BIA
requires competent staff with technical skills for Energy and Mineral
Development on Indian lands. As previously reported, a multi-agency
survey was collected in order to better understand and to align with
workforce needs for energy and minerals management. The information
gleaned from the survey confirmed common needs across agencies in the
areas of engineering, engineering technicians and environmental science
disciplines at the forefront of identifying the availability of the
resources for economic development.
Based on responses to the survey and current data, BIA attrition
over the past five years has resulted in a potential gap of 33 to 50
Engineers, Engineering Technicians, and Environmental Scientists in BIA
Trust operations. Current retirement statistics project that 59 percent
of the employees who occupy these positions are eligible for retirement
now or within 5 years.
The OTS workforce planning consists of developing and implementing
an Energy and Minerals Student Internship Program. The purpose is to
address skills gaps across Indian country. This will contribute to an
overall national strategy to attract, recruit, train, develop, and
retain highly qualified Indian and Alaskan Natives within the BIA,
Tribes, or Tribal Enterprises.
Approximately 20 Pathways Student internship positions for
engineering and engineering technician career fields have been approved
and will be funded by the OTS this Fiscal Year. Selections and
recruitment is targeted for March 29, 2019.
Recommendation 8: Establish a documented process for assessing
BIA's workforce composition at agency offices taking into account BIA's
mission, goals, and tribal priorities.
In previous testimony, we indicated it was assessing the BIA Indian
energy and mineral workforce composition using the same process as
described in Recommendation 13. The BIA continues to identify and
assess its energy and minerals workforce composition using data
collected from a multi-agency survey to develop a strategy to implement
a large scale process that ensures that current decisions and actions
impacting the workforce are aligned with short and long-term strategic
needs for energy and minerals management. OTS prepared an Indian Energy
and Minerals Workforce Planning Action Plan dated August 9, 2018 and is
prepared to close this recommendation.
Conclusion
Thank you for the opportunity to present an update on our progress
in addressing the GAO recommendations from past reports and the GAO
High Risk Report. The BIA is confident that all of these
recommendations have been addressed and believe they should be closed.
We look forward to improving our own evaluation and reporting capacity
and structure within Indian Affairs through this process. I would be
glad to answer any questions the Committee may have.
The Chairman. Thank you, Director LaCounte.
Admiral Weahkee.
STATEMENT OF REAR ADMIRAL MICHAEL WEAHKEE,
PRINCIPAL DEPUTY DIRECTOR, INDIAN HEALTH SERVICE, U.S.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Mr. Weahkee. Good afternoon, Chairman Hoeven, Vice Chairman
Udall and members of the Committee.
I am Rear Admiral Michael Weahkee, Principal Deputy
Director of the Indian Health Service. I am pleased to appear
before this Committee again to provide testimony regarding IHS
programs identified by the U.S. Government Accountability
Office's 2019 High Risk Report that was just released last
week.
I would like to take this opportunity to restate that our
continued priority and goal at IHS is to provide high quality
health care for American Indians and Alaska Natives. IHS is
committed to making improvements and ultimately, to being
removed from the GAO's High Risk List.
Although IHS is still on the list, we have made significant
progress since the GAO's 2017 Report was published. Since that
time, GAO has closed seven of their recommendations to IHS.
Earlier this month, IHS requested closure of an additional four
open recommendations after issuing updates to our Indian Health
Manual's Purchased and Referred Care Chapter.
Since June 2018, IHS has realized significant progress in
making improvements to quality care for American Indians and
Alaska Natives. These improvements include implementing
credentialing and privileging software agency-wide for all
providers and awarding a new contract for an adverse events
reporting and tracking system that replaces an older legacy
system. IHS also started work on modernizing our electronic
health record system. In collaboration with the Department of
Health and Human Services' Office of the Chief Technology
Officer, we are completing a Health Information Technology
Modernization Research Project to inform us about options to
replace or modernize our existing infrastructure.
In February of 2019, IHS released a new strategic plan for
fiscal years 2019 to 2023, which will help guide ongoing
efforts to provide health care for American Indians and Alaska
Natives throughout the United States. This plan details how the
IHS will achieve its mission through three strategic goals,
which are each supported by several objectives and dozens upon
dozens of strategies. This plan continues to elevate and
institutionalize the work that was previously included in the
IHS Quality Improvement framework.
Our Indian Health Service's new Office of Quality was
formally established in January 2019, and our new Deputy
Director for Quality Healthcare was selected and on-boarded at
IHS headquarters in November of 2018. The Office of Quality
will include four divisions: Enterprise Risk Management,
Quality Assurance, Innovation and Improvement, and Patient
Safety and Clinical Risk Management. The Office of Quality
supports IHS hospitals and health centers by providing
resources and tools for quality assurance and improvement to
attain and maintain compliance with CMS certification standards
and with Joint Commission accreditations.
Accreditation and certification surveys have been conducted
at 26 IHS facilities in nine IHS areas. As a result, as of the
third quarter of 2018, 96 percent of IHS hospitals were fully
accredited or CMS certified, and 97 percent of our Indian
Health Service health centers were accredited.
IHS understands the importance of having permanent
leadership in key positions throughout the agency. In the past
year, the Indian Health Service has filled eight Senior
Executive Service positions, which includes two headquarters
senior leadership positions, two area director positions, and
four headquarters office director positions.
As the Committee knows, recruitment and retention of health
care professionals is a challenge for the Indian Health Service
and other health care organizations serving rural and remote
locations. To meet these challenges, the IHS has offered
legislative proposals in the fiscal year 2019 IHS Congressional
Justification for discretionary use of all Title 38 personnel
authorities, half-time obligations for loan repayment and
scholarship recipients, and tax exemption for these recipients.
Since implementation of the PRC rates regulations in
October 2016, the PRC program has realized a $1.188 billion
increase in purchasing power according to our fiscal
intermediary. This purchasing power has allowed our PRC
programs to pay for additional services and fund more medical
priority levels than ever before, which improves access to care
for our patients.
In closing, there are a few updates regarding the Pine
Ridge Indian Hospital that I believe are important to mention
to this Committee. On February 26, 2019, the Joint Commission
Resources was onsite at the Pine Ridge Hospital to conduct a
review of compliance in preparation for an accreditation
survey. IHS is preparing to send a request by the end of March
to CMS for a recertification survey visit at the Pine Ride
Hospital.
As the Acting Principal Deputy Director and the lead of the
agency, I am very proud of the dedication and commitment of our
IHS team at all levels of the agency who have focused on and
accomplished the objectives of the action plan during this past
year. These actions demonstrate that the IHS is taking its
challenges seriously, and is continuing to take assertive and
proactive steps to address them.
I want to thank you for your commitment to improving
quality, safety and access to health care for American Indians
and Alaska Natives.
I am happy to answer questions you might have.
[The prepared statement of Mr. Weahkee follows:]
Prepared Statement of Rear Admiral Michael Weahkee, Principal Deputy
Director, Indian Health Service, U.S. Department of Health and
Human Services
Good afternoon, Chairman Hoeven, Vice-Chairman Udall, and Members
of the Senate Committee on Indian Affairs. I am RADM Michael D.
Weahkee, Principal Deputy Director of the Indian Health Service (IHS).
I am pleased to appear before this Committee again to provide testimony
regarding IHS programs identified by the U.S. Government Accountability
Office (GAO) High Risk Report recently released on March 6, 2019. Our
continued priority and goal at IHS is to provide quality care.
IHS is a unique agency within the Department of Health and Human
Services (HHS). It is the only HHS agency whose primary function is
direct health care delivery. IHS was established to carry out the
responsibilities, authorities, and functions of the United States in
providing health care services to American Indians and Alaska Natives.
The mission, in partnership with American Indian and Alaska Native
people, is to raise the physical, mental, social, and spiritual health
of American Indians and Alaska Natives to the highest level. The IHS
system consists of 12 area offices, which oversee 170 service units
that provide care at the local level. Health services are provided
through facilities managed by IHS, by Tribes and tribal organizations
under authorities of the Indian Self-Determination and Education
Assistance Act, and through contracts and grants awarded to urban
Indian organizations authorized by the Indian Health Care Improvement
Act.
Demonstrated Progress
IHS is committed to making improvements and ultimately to being
removed from the GAO's High Risk list. The GAO released its most recent
High Risk Report on March 6, 2019. Although IHS is still on the list,
we have made significant progress since the GAO's High Risk report
published on February 15, 2017. Since that time, GAO has closed seven
recommendations. Earlier this month, IHS requested closure of four
recommendations after issuing updates to the Indian Health Manual,
Purchased/Referred Care (PRC) chapter. The remaining two
recommendations cited in the 2017 report require continued IHS
monitoring of the actions implemented before we formally ask the GAO to
close them. In the March 6, 2019 report, GAO cites one additional
recommendation that was not cited in the 2017 report, and IHS is moving
forward with actions to implement this recommendation.
Since June 2018, IHS has realized significant improvements to
quality care for American Indians and Alaska Natives. These
improvements include developing and implementing an IHS Strategic Plan
for Fiscal Year 2019-2023, establishing an Office of Quality,
implementing credentialing and privileging software agency-wide for all
applicants, and awarding a new contract for an adverse events reporting
and tracking system that replaces an older legacy system.
IHS also started work on modernizing our electronic health record
system. In collaboration with the HHS Office of the Chief Technology
Officer, we are completing a Health Information Technology (HIT)
Modernization Research Project to inform IHS regarding options to
replace or modernize our existing HIT infrastructure.
Leadership Commitment
IHS leadership is committed to making progress on addressing GAO's
recommendations and continues to press forward in working partnership
with GAO. Since last June, IHS has met four times with key GAO
officials to describe action plans for closing-out the recommendations
and to review our activities to meet the criteria to be removed from
the High Risk list. IHS is focused on implementing change across the
agency to strengthen our ability to ensure quality health care.
In February 2019, IHS released the Strategic Plan for Fiscal Years
2019-2023. The Strategic Plan will help guide ongoing efforts to
provide health care for American Indians and Alaska Natives throughout
the United States. The plan details how the IHS will achieve its
mission through three strategic goals, which are each supported by
objectives and strategies.
Goal 1: To ensure that comprehensive, culturally appropriate
personal and public health services are available and
accessible to American Indian and Alaska Native people.
Goal 2: To promote excellence and quality through innovation
of the Indian health system into an optimally performing
organization.
Goal 3: To strengthen IHS program management and operations.
This Strategic Plan reflects the feedback received from Tribes,
tribal organizations, urban Indian organizations, IHS staff, and other
stakeholders. This plan continues to elevate and institutionalize the
work previously included in the IHS Quality Improvement framework.
IHS leadership, along with HHS, seeks to innovate the delivery of
care the IHS provides to meet the health needs of tribal communities
not fully addressed by the traditional hospital model in some locations
IHS serves. Our facilities are predominately in rural locations with
limited access to services for the population, or in urban areas where
the services provided are duplicative of those available in private
sector facilities. As a result, our hospitals tend to have low
utilization of inpatient services. To address this, we could transition
from full hospital services to an ambulatory care center with 24/7
urgent care or to a critical access hospital where appropriate. Through
this transition we could reallocate staff and resources from expensive
and lightly used inpatient services to more cost-effective and heavily
used primary care services.
Last month, I participated in the first HHS Intradepartmental
Council on Native American Affairs meeting under the current
administration. The council is comprised of HHS Operating Division and
Staff Division senior officials. The council discusses strategies,
priorities and recommendations on new partnerships and
intradepartmental collaboration relating to American Indians and Alaska
Natives. This is an exciting step in broadening our partnership
throughout the Department and with other Federal agencies outside of
HHS.
Progress on Improvements in Quality Care
IHS's new Office of Quality was formally established in January
2019 and our new Deputy Director for Quality Healthcare was selected
and on-boarded in November 2018. The Office of Quality will include
four divisions: Enterprise Risk Management (ERM), Quality Assurance,
Innovation and Improvement, and Patient Safety and Clinical Risk
Management. Six current staff in quality assurance, quality
improvement, patient safety and clinical risk management roles are
transitioning to the new Office of Quality. ERM has begun transitioning
to the new Office of Quality, which will be completed by the end of
fiscal year 2019. Five new positions for the Office of Quality have
been announced, and IHS plans to interview and hire within the next two
months. During the transition of staff and ERM, IHS anticipates all
current work will continue without disruption.
The Office of Quality supports IHS hospitals and health centers by
providing resources and tools for quality assurance and improvement to
attain and maintain compliance with Centers for Medicare & Medicaid
Services (CMS) regulations and accreditation standards. Accreditation
and Certification surveys have been conducted at 26 IHS facilities in
nine IHS areas. As a result, in the third quarter of 2018, 96 percent
of IHS hospitals were fully accredited or CMS certified, and 97 percent
of IHS health centers were accredited.
Improving access to care is a top priority for the agency. Wait
times are one component of access to care, and an important measure of
the patient experience. In 2017, IHS published IHS Circular Number 17-
11 establishing wait time standards for direct care IHS facilities.
Facilities are already using data to drive measureable improvements in
wait times. The published IHS Wait Time Standards are undergoing
improvement to add wait time standards for emergency department
settings. IHS is working toward further automating data collection and
reporting capabilities to improve monitoring and accountability.
Monitoring
As mentioned in prior testimony to this Committee, IHS finalized
the National Accountability Dashboard for Quality (NADQ) on February
20, 2018. Since finalization, we've completed a Fiscal Year (FY) 2018
Quarter 3 report that was released October 9, 2018. With the release of
the 2018 Quarter 4 report in March 2019, the NADQ will have
successfully completed a full year of reporting. The dashboard is a
valuable reporting tool that enables IHS headquarters and area offices
to have a near real-time view of health care hospitals and health
centers functioning across the system. Over time, this will facilitate
implementation and monitoring of quality care measures. As IHS
continues to implement the NADQ, we anticipate the results will
demonstrate sustained improvements in the nine key metrics tracked in
the dashboard including accreditation and an active quality improvement
program.
Organizational Capacity
IHS understands the importance of having permanent leadership in
key positions throughout the agency. In the past year, IHS has filled
eight Senior Executive Service positions, which includes two senior
staff positions, two area director positions, and four headquarter
office director positions. In addition, IHS continues its leadership
training program designed to prepare selected IHS individuals to serve
in leadership positions at the service unit, area, and headquarters
levels. The leadership training program has had three cohorts since the
summer of 2017 with nearly 100 total participants completing the
training. The next cohort starts in March 2019.
Recruitment and retention of health care professionals is a
challenge for IHS and other health care organizations serving rural
locations. To meet these challenges, IHS offered legislative proposals
in the FY 2019 IHS Congressional Justification for discretionary use of
all Title 38 personnel authorities, half-time obligations for loan
repayment and scholarship recipients, and tax exemption for these
recipients.
Purchased/Referred Care Improvements
IHS continues to improve and increase access to care for our
beneficiaries through outreach, education, and enrollment activities.
The national PRC program set targets for local programs to ensure that
IHS is able to provide access to our patients in the most cost
effective manner. All levels of PRC management frequently monitor
progress towards meeting these targets, and IHS started doing internal
quarterly monitoring in September 2018 to look at root causes for not
meeting the targets. Initial analysis identified two caveats to the
measure that are beyond IHS control: 1) the time it takes from
authorization to appointment availability is significant, and 2) the
time it takes for a provider to file a claim is significant.
Since implementation of the PRC rates regulations in October 2016,
the PRC program has realized a $1.188 billion increase in purchasing
power according to the fiscal intermediary. This purchasing power has
allowed PRC programs to pay for additional services and fund more
medical priority levels than ever before, which improves access to care
for our patients.
In closing, there are a few updates regarding the Pine Ridge and
Rosebud IHS Hospitals that are important to mention to this Committee.
On February 26, 2019, The Joint Commission Resources was onsite at the
Pine Ridge Hospital to conduct a review of compliance in preparation
for an accreditation survey. IHS is preparing to send a request by the
end of March to CMS for a recertification survey of the Pine Ridge
Hospital. There are a few recent key personnel changes at the Pine
Ridge Hospital. We have hired a full time Clinical Director as of
January 20, 2019. We have also put in place an acting Director of
Nursing and an acting Administrative Officer in the past month.
At the Rosebud Hospital, we hired a new Chief Medical Officer,
Chief Nurse Officer, Chief Quality Manager, and a Federal Emergency
Department Nurse supervisor. We have two additional Nurse Case managers
awaiting acceptance of employment offers, and three new Registered
Nurses, an OB/GYN physician, and a psychologist on board. We have also
made improvements in Outpatient Clinic access at the Rosebud Hospital,
which include extending outpatient hours, a workflow redesign to gain
efficiency, and tele-health for outpatient clinics including Emergency
Department, Cardiology, Endocrinology, Behavioral Health, Rheumatology,
and Neurology. Also, facility projects for improvements include the
following: dental renovation, HVAC system replacement with a start date
Summer 2019, and a 19 unit housing complex with a completion date
projected for May 2019.
We have improved our tribal consultation at Rosebud with weekly
meetings between the Rosebud Sioux Tribe (RST) Health Administrator,
RST Health board members, and Rosebud Hospital leadership. The RST
Council and health board attend hospital meetings monthly.
We have also continued to reach out and support our tribal partners
in the Winnebago Tribe of Nebraska and the Omaha Tribe of Nebraska. IHS
has offered the Winnebago Tribe technical assistance since it assumed
control of the hospital in June 2018. In December 2018, I traveled
along with other senior IHS staff to meet with both Tribes for a tour
of the Twelve Clans Unity Hospital.
I am very proud of the dedication and commitment of our IHS team at
all levels of the agency; who have focused on and accomplished the
objectives of the action plan during this past year. These actions
demonstrate that IHS is taking its challenges seriously, and is
continuing to take assertive and proactive steps to address them.
Thank you for your commitment to improving quality, safety, and
access to health care for American Indians and Alaska Natives. I am
happy to answer your questions.
Senator Udall. [Presiding.] Thank you to the panel for your
testimony today.
Admiral, I do not think you mentioned anything about the
Dr. Weber incident in your testimony, is that correct?
Mr. Weahkee. Yes, sir, that is correct.
Senator Udall. I wanted to focus on that for a little bit.
First of all, I believe there is a documentary that has
come out. I asked my Indian Affairs staff if they had watched
it. I was wondering if you had watched it. It is a Wall Street
Journal, PBS, I think, yes a Frontline, PBS, Wall Street J
Journal documentary that came out on February 12th.
Mr. Weahkee. Yes, sir, I have seen it, and actually took
part as an interviewee with the Wall Street Journal and PBS.
Senator Udall. So you are very familiar with it. I am going
to see it. I haven't seen it yet but they told me it was very
hard to watch. I think that is consistent with some of the
questions I think I am going to ask.
As I stated in my opening, I find the failure of IHS to
address the multiple reports of Dr. Weber's abhorrent conduct
with young IHS patients appalling. IHS officials reportedly
ignored reports, retaliated against employees who tried to
raise the alarm, and left Native children in the hands of a
predator.
Has the Service determined why Dr. Weber wasn't fired after
the Billings Area leadership became aware of his misconduct?
Why was he allowed to remain an IHS employee and transfer to
the Great Plains Area?
Mr. Weahkee. Thank you, Senator, for the question.
The Indian Health Service has been working hard to gather
as many facts as we have access to about Dr. Weber's tenure
with the agency. It stretches all the way back to 1986, so we
are talking about 33 years in the past. The particular time
when he was in Montana was 1992 to 1995, so even that, we are
looking back 25 or so years ago. Many of the employees who were
in place at the time have since retired or moved on.
We have committed to conducting, via a third party
contractor or vendor, what we are framing as a medical quality
assurance review. We are going to have somebody who can come in
and look objectively not only at the Indian Health Service
records. We know who the people were in charge at the time in
these various places, but we would like somebody to come in and
interview not only our own employees, but community members,
tribal members, law enforcement, and others.
Much of what we learned about the case we learned from our
partners at the Office of Inspector General and through the
investigations conducted by the Federal Bureau of Investigation
and the South Dakota Medical Board. We are gathering as much
information as we can but we do not have the answers to those
types of questions yet at this time.
Senator Udall. So the two questions that I asked, why he
wasn't fired after the Billings Area leadership became aware of
his misconduct, you don't know the answer to that yet?
Mr. Weahkee. Not yet, sir.
Senator Udall. But you are going to get an answer for me.
Mr. Weahkee. Absolutely.
Senator Udall. Why was he allowed to remain an IHS employee
and transfer to the Great Plains Area? Do you have an answer
for that?
Mr. Weahkee. Well, we do know there were a couple of
investigations conducted previously, again, one of those by the
FBI themselves. There was not enough evidence gathered at the
time to substantiate allegations. So we want to look back and
really determine who knew what. And getting back to the issue
of the culture of the agency, if there were individuals who
knew and they didn't push that information out to either law
enforcement or to others within the supervisory chain, why.
As I had mentioned in the PBS Frontline story, I would
consider those individuals who may have had knowledge and
didn't push that forward as being complicit in the actions of
Dr. Weber.
Senator Udall. As far as I am concerned, management at
every level failed to do their jobs and their duties under
Federal law. This is unconscionable and unacceptable.
Now, something similar has happened before that I want to
just note here. This failure aligns with the concerns raised in
this Committee's report of 2010 called the Dorgan Report, that
IHS management does not follow Federal employee misconduct
procedures and instead, transfers problem employees and assists
in a system colloquially referred to as pass the lemon.
What that report looked at is, the idea that you see some
misconduct and rather than dealing with it, it is just passed
on to someplace else in the system. So I hope when you come
back and answer those questions that I have just asked, that we
are not finding ourselves in that situation.
How is IHS working to make sure service units and area
management do their job to document and address Federal
employee misconduct?
Mr. Weahkee. Thank you, Senator Udall.
What we have done, and I would just first like to start by
committing to you that it will not be tolerated to pass that
bad lemon while I am in this seat. We are going to put the
infrastructure in place to ensure that is sustainable for the
agency moving forward.
Senator Udall. Will you also commit that you are going to
protect whistleblowers, and make sure if they come forward,
that they are not retaliated against? Now is your opportunity
to talk to all of your employees, the ones that not only watch
you today, but hear through various channels in the Indian
Health Service as to what has happened here. Will you commit to
that?
Mr. Weahkee. Absolutely, yes, sir. We have been messaging
that since the sentencing took place when Dr. Weber was
convicted and sentenced. We have made sure that messaging has
gone out broadly.
We envision over this next year conducting a series of town
halls throughout the Indian Health Service, so that I can meet
directly with employees and relay that message personally. We
will also be shooting videos so that we capture as many of our
15,400 employees as possible.
Some of the other actions that we have taken, we have
implemented new policies which provide even higher ethical
standards for our health care providers and others. We have
also made it mandatory that not only are licensed health care
providers who, as a part of their licensing requirements are
mandatory reporters, we have made every single Indian Health
Service employee a mandatory reporter. And with that goes the
protection.
We want to institute what is called a just culture, so that
every employee not only feels that they can bring issues
forward and not fear retaliation or reprisal, but that they are
actually celebrated when they do so, when they point something
out that does not quite look right, needs to be fixed, that
they bring those items forward. We dedicate the resource and
time to fix them, and that those individuals are thanked for
doing that.
We have also, as I had mentioned in the opening testimony,
implemented the National Credentialing Software System. That
enables us to have quick, ready access to our physicians' and
other providers' medical credential files. Those files can be
viewed not just at the location to which they are assigned, but
at the area offices and headquarters level as well and there is
portability of those records. A number of actions are underway.
Senator Udall. Thank you. I appreciate that.
Senator Lankford, you are up in the questioning box.
STATEMENT OF HON. JAMES LANKFORD,
U.S. SENATOR FROM OKLAHOMA
Senator Lankford. Thank you. By the way, I think Senator
Daines from Montana set the temperature in this room today to a
temperature that is close to his preference on that. I don't
know if you have noticed, but it is definitely north of
Oklahoma temperature in here.
Senator Daines. It is refreshing.
Senator Lankford. It is refreshing and keeps everybody
going.
Thank you all for being here. Thanks for the ongoing work.
Obviously, we have questions, as we should. GAO has brought up
some good things to be able to bring for conversation. I am
going to bring a couple of them as well.
Let me ask the question that is really my favorite that
some of you have not heard me ask before. For GAO, tell me
where it is working. You are identifying areas where it is
incomplete. Where is it working in the Country? Where do you
see coordination and cooperation really happening or making
progress?
Ms. Farb. I will start and I may invite my colleagues up to
join me, because I focus on the health care area.
Where it is working for us with regard to IHS is the
regular meeting to talk about the recommendations, to have the
time to explain to them what we are seeing and sort of the
underlying root cause problems that lead to the
recommendations, so having that ability. We are not just
focused on closing recommendations. We are focused on improving
the management and oversight. So what has been working for us
is in the last year and a half, they have been doing a number
of things that Admiral Weahkee mentioned to address the
recommendations, but also to sort of address the broader
management challenges.
Senator Lankford. Do you see progress?
Ms. Farb. Yes, we see progress, but there is still, as a
classic GAO statement, there is work remaining to be done.
Senator Lankford. I just met with Gene Dodaro last week. I
said do as much as you can to make your statements as blunt as
possible and so they are clear, not safe, but clear.
Where do you see, whether it be energy, education, or in
health care, the greatest amount of progress or a success story
that GAO can tell? This is an area that was raised; this is a
success story to tell.
Ms. Farb. I think on the quality front as well as the
patient wait time front, the two systems that IHS has now put
in place, those are addressing problems we found historically
to be an issue. And so those two efforts, I think, again, we
have to watch over time to see how that plays out, but those
are addressing it. I do not know if my colleagues want to
address that or energy.
Senator Lankford. Just identify your name when you step up.
Mr. Rusco. My name is Frank Rusco. I am in the Energy Group
at GAO.
Where we see the most progress, and what I would call
hopefulness, is where tribes have been able to take more
control and more self-determination over the process. For
example, I think we are going to see for the first time a tribe
enter into a full TERA agreement.
Senator Lankford. How long has that taken to have the first
tribe do that?
Mr. Rusco. This will be the first and it hasn't happened
for, I don't know, nine years. I don't know when that was.
Mr. LaCounte. It was 2005.
Mr. Rusco. In 2005, okay, thank you. Thirteen years.
Senator Lankford. So yes, fourteen years, let's say.
Mr. Rusco. Yes.
Senator Lankford. And it is not done yet. It is getting
close?
Mr. Rusco. It is not done. Yes.
Senator Lankford. So the question is, how do we have a
second one and does it take another 14 years to have a second
one? Do you feel like the process is in place and the test has
been done for the first one to have kind of autonomy to be able
to make those decisions? Is the bureaucracy resolved enough
that it a second one would take less than 14 years?
Mr. Rusco. I hope so. I think the bureaucracy still needs
work. The tribe that is going to do this has a huge amount of
experience in the oil and gas business, and the tribe has huge
experience in self-determination mechanisms. Both of those need
to happen.
Senator Lankford. Do you think I should bug the Acting
Director about that and see what he thinks?
Mr. Rusco. Absolutely.
Senator Lankford. I think I am going to. What do you guess,
because the energy side is one of the areas that I have several
tribes in my State that really want to increase their energy
footprint and be able to engage in this. But the bureaucracy
has been so difficult for them that they just do not know if it
is worth it to be able to go through it.
How does this get better and how does a second tribe go
through this in less than 14 years?
Mr. LaCounte. Congress just made it better, to where I
don't think that that is going to happen. The amendments to the
TERA Act itself, I think, are going to take care of that
problem. In speaking with Senator Hoeven's assistant just
earlier, I was surprised to hear that the Osage Nation is
looking at a TERA agreement.
Senator Lankford. The Osage Nation has looked at that for a
very long time, though. It has been something they have looked
at and decided, not worth the trouble. They are one of those
folks that I hope can lean and actually execute it.
Mr. LaCounte. I am pretty familiar with the Osage and I am
surprised to see that is the place they are going to try it.
But I am excited to see it too, and we will do everything we
can to help them out.
Senator Lankford. That would be terrific. Let us know what
we can do to be able to help on the other end of that as well,
to be able to stay productive and engaged through the process.
Admiral, I do want to be able to ask you a question as
well. On the health care side, some of the tribes are doing
joint ventures. In my State, if you want to go to a really
beautiful new hospital, I can take you to some of the joint
venture hospitals that some of the tribes have built in
cooperation with the communities and municipalities around
them. They are phenomenal facilities.
The question becomes how frequently tribes can engage in
that contract relationship, how often they can come back and
say, we want to do another joint venture? Is there flexibility
in that? Or is there the ability to say, I am sorry, you can do
one or so every four or five years, but we do not really want
to come back? Are there that many requests coming in for joint
ventures on health care facilities that it is bogging down the
system?
Mr. Weahkee. Thank you, Senator Lankford.
With regard to the joint venture program, I completely
agree. The Cherokee Nation is building a beautiful outpatient
facility. Muskogee Creek just completed a facility. Joint
ventures are absolutely a great program.
There is a correlation between the amount of funds that we
receive through our health care facility construction program
and the number of joint venture projects that we can fund. It
has been about every two to three years that we will put out a
solicitation and requests for proposals.
I do believe, in speaking with our Office of Environmental
Health and Engineering director, Gary Hartz, this year that we
will likely put out a solicitation in 2019. We do receive many
more applications than we can fund. There is always a surplus
of applications or projects that we cannot get to because of
lack of funds for that program. But I would agree, a very
successful program. We go into an agreement for 20 years that
we will staff that project, and we have many success stories
out there as a result.
Senator Lankford. We would like to be able to maintain
those success stories.
Mr. Chairman, may I ask one final question?
Senator Udall. Please.
Senator Lankford. Thank you.
Mr. Dearman, can I ask about deferred maintenance and what
you need? In BIE, that has been one of the concerns, the amount
of deferred maintenance that is kind of scattered around the
Country and the process to actually get to it.
Is there a prioritization, is it each facility has a
priority list, is there a national priority list, is there,
basically, a check-off list to say, we know this is coming five
years from now, or we know this is ten years overdue, twenty
years overdue and we are working through that process? How do
you prioritize those things on deferred maintenance?
Mr. Dearman. Thank you, Senator.
I am really thankful that Assistant Secretary Tara Sweeney,
when she came in, she really sat all of us down, she sat us
down, BIE and BIA and DASM down. And we really started looking
at who has their hands in our facilities. As you are well
aware, BIE has always worked with BIA and DASM to address
facility issues.
Right now we are looking at streamlining all the services
to our schools. But to get to that point, we have to make sure
the data is in our system. We call that our Maximo system, that
all those schools enter their deferred maintenance or projects
that need to be done.
DASM has actually started pulling all the what we call
facility condition index reports where the schools enter it,
and we are starting to prioritize our schools based on that.
However, as we are going around doing the safety inspections,
and this is the first year that BIE is doing all the safety
inspections, we are really working with the schools to make
sure that all the data is entered in the Maximo system along
with working with BIA's regional facilities.
Before we prioritize any school replacement, we have heard
loud and clear our tribes want to be involved in that. They
want to have consultation. But we are really starting to
compile the data right now and looking at all the needs.
Senator Lankford. What are you using as your safety
standard? Is that a national standard you are using, or is that
State fire code? What is the standard you are choosing to use
for your safety standard?
Mr. Dearman. That is a very good question, because that is
part of the GAO findings and recommendations. We are working
again with the Deputy Assistant Secretary of Management, their
shop, to make sure that the policy set forward is for BIE and
BIA. So there is policy that we are putting out. I am not real
familiar with what standards they are utilizing to create the
policy, but we are creating policy and putting it in our Indian
Affairs manual.
Senator Lankford. Obviously, it helps on a national level
or even on the State level, where there are multiple campuses
in the State, that there is a consistency of what is considered
safe and what is not, and what is a fire code violation, an
electrical violation, plumbing or whatever it may be, to be
able to know where to prioritize that, having either a national
standard or at least a State fire marshal type standard to say,
we are all going to work from a common set looking around the
entire State or region to be able to know what we are dealing
with. At times, there has been some pushback to having that,
just saying, hey, this doesn't necessarily apply in different
places. But we have to have some standard that we are working
with that is consistent or you cannot prioritize the projects.
Mr. Dearman. Yes.
Senator Lankford. We look forward to maintaining that
dialogue and seeing where that goes. What is the time period
when you think that is done?
Mr. Dearman. I would have to go back to the department and
find out.
Senator Lankford. Please just contact us and let us know
what the date is when you look like you are going to have all
that information, and then start to be able to make the
decisions from there.
Mr. Dearman. Okay.
Senator Lankford. Thank you. Thank you, Mr. Chairman.
Senator Udall. Thank you, Senator Lankford.
Ms. Farb, you heard the discussion about the Indian Health
Service doctor and what happened in terms of abuse. Referring
to that and thinking of that, has the GAO ever done a review of
IHS's management's documentation of employee misconduct and use
of transfers, administrative leave and duty reassignments?
Ms. Farb. Not to my knowledge have we done that kind of
study. We have definitely looked at, in other programs, issues
like credentialing like Admiral Weahkee referred to. We looked
at that in the VA program and found lots of issues. We have a
whole body of work on that.
For IHS specifically, we have not looked at transfers of
employees or documentation of those types of issues, but we
would be happy to take a look into that if that is something
that the Committee is interested in.
Senator Udall. And you would be willing to work with my
staff to start on that work?
Ms. Farb. Absolutely.
Senator Udall. Great. Thank you.
Mr. Dearman and Mr. LaCounte, between 2012 and 2018, the
Department of Interior spent $1.2 million to fix the fire alarm
and lighting protection systems at the Pine Hill School in New
Mexico. It's my understanding the major contributing factor for
these costs and timeline overages was inaccurate project
scoping and contracting. GAO documented similar issues with
contracting in a 2017 report.
What is Interior doing to increase management oversight of
procurement personnel and contracting officers?
Mr. LaCounte. I am not aware of the $1.2 million. I almost
wonder if that is the $1.2 million provided to the school for
maintenance. Whether it was used on those systems or not, I
don't know the answer to that.
To address the contracting issues in this particular
situation, obviously, you are very familiar with, we have put
that process directly at the central office to handle the Pine
Hill School at this time. Going down the road, in the future,
the BIE will have its own administrative staff, including
contracting officers, which I believe will make that much more
effective, because they will be directly responsible to the BIE
as opposed to having a layer between BIE and BIA. Even though
Mr. Dearman and I work very well together, in the past, we know
that was not the case. I think that, in and of itself, will
make things much stabler into the future. To that, I would
defer to Mr. Dearman.
Mr. Dearman. Senator Udall, thank you for the question.
I really think it is a lack of communication and
understanding the system that goes all the way back to 2012.
Again, like I said earlier, Assistant Secretary Sweeney sat us
all down and really started looking at who does what within our
system to take care of our schools.
It was a learning process. It was a very good process, and
I really appreciate your support in making sure things are
getting done. But things are getting done now because of the
leadership she has provided BIA and BIE that should have been
done years ago.
As far as going back, we have been communicating with the
school board, with the school leaders. We have to really make
sure that we are coordinating the communication between bureaus
as well. We have actually been meeting with Ramah School, we
had a meeting with them last week and we met with your staff.
One of the things they are requesting is to be able to handle
their own contracts. We are discussing that, we have had BIA
involved and we are working with the school.
I really think improving communication and making sure we
are there to assist the tribes that may need a little bit more
help with contracting would eliminate that, really being at the
table with them. And we have increased our regular meetings
with Ramah, the school board and the school leaders. I know BIA
is meeting with them, BIE is meeting with them. We at least
touch base bi-weekly and as needed. DASM is going down as well.
So that kind of communication is needed and is established now.
Senator Udall. Great.
Mr. LaCounte, the June 2018 DOI-OIG report revealed that
the BIE and BIA spent $1.2-plus million. That was documented in
their report. Will both of you commit that you will meet with
my staff this month to discuss contracting oversight for BIE
facilities projects?
Mr. Dearman. Yes.
Mr. LaCounte. Yes.
Senator Udall. Thank you.
Mr. Dearman. Senator, may I update you on one thing?
Senator Udall. Please, go ahead.
Mr. Dearman. We are in the process of taking over contracts
within BIE. That is also really going to help us. It will help
us establish timelines and more consistency in servicing our
schools.
I know Mr. LaCounte alluded to that. We have been working
with GAO and discussing that. We are in the process of taking
over contracting.
Senator Udall. Great. Thank you both very much.
Mr. Chairman, I yield back.
The Chairman. [Presiding.] Senator Cortez Masto.
STATEMENT OF HON. CATHERINE CORTEZ MASTO,
U.S. SENATOR FROM NEVADA
Senator Cortez Masto. Thank you.
Let me also echo some of the concerns I heard from the
Ranking Member earlier with respect to Dr. Weber. I am hoping
we are having a hearing on this. It is outrageous to me that it
went on so long, the predatory nature of this doctor, nobody
came forward, and it continued over so many years. I just want
to put that on the record. I am looking forward to further
hearing, understanding what happened, and the accountability
and how we are going to prevent this from happening in the
future.
Let me jump back to the working relationship between BIE
and IHS. Director Dearman, in previous testimonies, you have
mentioned that your office is diligently working to address the
varying and developing needs of our students, including
behavioral and mental health support services. Can you please
talk a little bit further about this partnership with IHS and
how you are planning to overcome some of the IHS limitations
that were outlined in the GAO report?
Mr. Dearman. Yes. Thank you, Senator.
We have established meetings with IHS. As a matter of fact,
two weeks ago, we were at IHS discussing the MOA that is
servicing our schools. As you are well aware, a lot of our
schools are so isolated, one size does not fit all. We really
have to go in and work with IHS to see what resources are
available, whether they be tribal or government resources, and
providing training. For example, right now we are working on
regional training to really deal with suicidal ideations or
behavioral health within our system.
Last year alone, we had 26 suicide attempts. That was just
captured with our BIA-operated and maybe a few of our tribally-
controlled that choose to report to us. We had two suicide
completions.
As we have stated, until we get our emotionally and
physically our students healthy, they are not going to learn.
We really are establishing strong rapport and strong
relationships to where we are individualizing the services that
each school and region receives from IHS.
Senator Cortez Masto. Admiral, can you elaborate a little
bit more on the IHS involvement?
Mr. Weahkee. Yes, ma'am. So, the umbrella agreement that we
have here at the national level enables local level agreements
to be made. As Mr. Dearman mentioned about one size not fitting
all, we do really need to look at and tailor the services as
best meets the needs for the Supai in the bottom of the Grand
Canyon or those living in Riverside County, Los Angeles, which
is an urban site in metropolitan LA. The needs are very
different and the settings. So really tailoring those
agreements at the local level is vitally important.
Senator Cortez Masto. I do not mean to interrupt but I only
have so much time.
So you are in the process of setting forth those strategic
plans, and you are working with local law enforcement, and
local mental health and whoever else is necessary to address
this issue, if it exists? And I realize not all of our Native
American communities have law enforcement.
Are you putting in place those strategic plans? And do you
have, looking at the map as a region and actually going after
and addressing all of those concerns with respect to our
students?
Mr. Dearman. As far as the schools what we are doing,
Senator, is, matter of fact, right before the meeting, I met
with Charlie Addington, who is the Director of OJS, Bureau of
Indian Affairs. We are looking at our schools, and who has
jurisdiction, and what law enforcement services they have.
We are also looking at some of our security contracts that
some of our schools utilize. Instead of using them for
contracts outside of the government, but utilizing our own OJS
officers and hiring to where we have more control. We are
addressing that. We have been questioned, too, that as part of
our strategic direction, that was not one of the six goals
identified through tribal consultation. But that does not mean
we are not addressing it, because we are.
Senator Cortez Masto. Okay. I appreciate that.
And do you have the resources? Does the current budget that
the Administration has put forth, does it provide the resources
that are necessary to achieve this goal you have set?
Mr. Dearman. With the current budget, the way it will work
with our schools is the schools will take it from their
budgets. An example would be that some of the schools receive
funding for security purposes. And some of the schools, we have
a line item just for school security and safety that we really
distribute out to the schools that will identify a need. But it
depends on the amount of resources that the schools generate,
based on the ADM, student enrollment.
Senator Cortez Masto. So let me just say this. There are
two BIE schools in Nevada, the Duck Water Shoshone Elementary
School and the Pyramid Lake Junior-Senior High School. If I
come and talk with them about their needs, will they tell me
that you have reached out to them on this very issue when it
comes to mental health and behavioral health issues for their
students?
Mr. Dearman. I am not sure if the two sides would, because
they are both tribally-controlled. We assist tribally-
controlled as needed. Anytime anything happens, we try to reach
out to the tribally-controlled schools and see if they want our
assistance.
Senator Cortez Masto. Thank you. I appreciate that.
I notice my time is up.
The Chairman. Admiral Weahkee, in information you provided
to this Committee regarding Dr. Weber, you included hiring of
an independent contractor to review the agency and its
personnel involvement in handling of the matter. Can you
explain to the Committee what the Indian Health Service intends
to do with the findings of this investigation, and how Indian
patients can be assured that they will receive safe, reliable
health care going forward and that we don't have a repeat of
this incident?
Mr. Weahkee. Thank you, Senator Hoeven.
What we hope to do, objectively, again, with the third-
party eye, is to have somebody look back and determine where
the missed opportunities took place. We want to make sure that
we gauge things against the policies that were in place at the
time. Were those policies followed? If not, where the
breakdowns occurred and who should be held accountable for
those policies not being put into place.
Ultimately, the goal is to fill in those gaps, make sure
that we have policies, that people know what the policies are,
that we are training on them, and that we are creating the
culture of accountability and the just culture I mentioned of
people not fearing retaliation for reporting up.
The Chairman. Are you confident you are taking all
necessary steps to make sure you do not have a repeat, that if
you have any issues right now going on right that you may not
be aware of, and that you don't have a repeat of this type of
instance in the future?
Mr. Weahkee. Senator, I do know as a result of the scrutiny
and the level of marketing, if you will, that we have done to
our complaint hotline, we have become aware of additional
instances of issues that needed to be resolved. And we have
moved forward on several termination actions as a result. We
have made several referrals to the IG in the last several
months about matters that have come to our attention after
identifying the issues needed to be reported immediately.
The Chairman. And you will provide that information to our
Committee, make sure they are fully addressed, and that you
have all necessary systems in place to avoid any repeat of this
type of incident to the maximum extent possible?
Mr. Weahkee. We absolutely do, sir, yes, sir.
The Chairman. According to the March 2019 High Risk Series
Report, the Indian Health Service planned to complete
implementation of all of the outstanding recommendations by
2019. So these have been open for two years. As you know, this
is our fourth hearing on these findings.
Please detail for me when you expect to have those closed
out. As I have said, we will have hearings until they are all
closed out. What do you anticipate the timeline to be for the
remaining findings?
Mr. Weahkee. Thank you, Senator.
Many of the older recommendations were from our Purchased
and Referred Care Program or what was previously known as our
Contract Health Service Program. Those were the oldest of our
recommendations. The vast majority of those have been
addressed.
With the publication of our revised policy, we have made
the request to GAO that they close those out. When those are
closed out, we are basically left with three open
recommendations, two of those being patient wait times and
quality care initiatives that we have put into place that just
need to be monitored over time to ensure the changes we have
made are sustained and lasting.
The third is a relatively new recommendation that we
received related to workforce and the need to look at how much
resource we are spending on contract providers. We are putting
in place the ability to track how much we are spending on
contract providers versus bringing those providers on full
time.
Hopefully, with the GAO seeing our good progress, we will
have all of those closed within a very short few months. We
have been monitoring patient wait times for almost a year now,
but they need to see that we have some sustainability there.
The Chairman. Director Farb, does that square with what you
anticipate is realistic for addressing those recommendations?
Ms. Farb. Yes, sir. They submitted documentation during the
course of planning for this hearing. We have not reviewed all
of it. I believe it is possible that three of those
recommendations may be ready to be closed.
There is another one that involves some monitoring. We want
to make sure we understand what is being done to address that.
What Real Admiral Weahkee mentioned in terms of the remaining
three recommendations, that is correct. That is what we are
looking for, sort of monitoring over time to make sure we are
doing what we say we are doing.
The Chairman. I have some additional questions but I am
going to turn to Senator Tester at this point.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Mr. Chairman and Ranking Member,
for having this hearing.
I am going to talk about staffing for a second with Tony
and the Admiral. I will start with Tony.
How would you assess your overall staffing and education in
the schools?
Mr. Dearman. At the school level, that fluctuates, that
varies. Above the school, what I call our support, our
technical assistance, we are at 49 percent. But I would have to
go back, Senator, and get you the exact numbers.
Senator Tester. Teachers in the classroom?
Mr. Dearman. I would have to go back and get the figures.
Senator Tester. Would it be, do you think, higher than 49
percent?
Mr. Dearman. Yes, it would definitely be higher than 49
percent. The thing with that is we would only be able to
capture the BIE-operated. But yes, it would be higher than 49
percent.
Senator Tester. That is all I want, the BIE staff. The
other guys, that is your problem. The others is their problem.
I would love to know where it is at for a couple of reasons. If
you don't have teachers in the classrooms, and good teachers in
the classrooms, we have a problem.
Have you guys been able to do any sort of assessment as to
the teachers you have and their ability to relate with Native
American culture?
Mr. Dearman. Thank you, Senator. That is one of the
problems that we have been discussing with our tribes. We
really feel like that is one of the reasons we have such a high
turnover, because a lot of the teachers don't understand the
community or culture that they are going into. As we have been
meeting with tribes and our schools, we really encourage our
teachers to get involved in the community actions. We have
developed, working with GAO, and we are fixing to submit by the
end of this month, the workforce plan which really takes a deep
dive into our entire workforce.
Senator Tester. And I am assuming, I mean, the President's
budget just came out yesterday, but I am assuming that we will
probably have a hearing on that budget at some point in time. I
am assuming you are not at 100 percent on your teachers.
Mr. Dearman. No, sir, we are not.
Senator Tester. Okay. That budget going forward, and you
can say, I do not know, we will look into it, if you don't
know, because we will have a hearing on it. Did you make
allowances to make sure you had the budget to be able to hire
100 percent of what you need?
Mr. Dearman. The majority of our staff at the school level
is hired through ISEP. Looking at the current budget, we are
looking at about $1 less WSU that is submitted for our schools.
Senator Tester. Tell me what ISEP is.
Mr. Dearman. ISEP is what a majority of our schools would
utilize.
Senator Tester. What does that mean? What is that acronym?
Mr. Dearman. Indian Student Equalization Program. That is
what the majority of our schools would utilize to hire staff.
Senator Tester. Gotcha. That is the line item. You said
that line item is what?
Mr. Dearman. With the feds and its proposed budget?
Senator Tester. Yes.
Mr. Dearman. It is about $1 less than last year per
student, WSU.
Senator Tester. Okay. Does that get you where you need to
be?
Mr. Dearman. We can, we are, again, Senator --
Senator Tester. So, this is not the Appropriations
Committee but this is the authorizing, I believe, the last time
I checked. We kind of need that stuff. And I will tell you why
it is so important.
The Chairman. You are on the Approps Committee.
Senator Tester. I am and so are you. So we can work
together on that.
But why it is important, is that if we want to, in my
opinion, if we want to get poverty out of Indian Country, one
of the foundational blocks is a good education. If we do not
have that foundational block, it doesn't matter what we do. I
believe we are still going to have problems. So take a look at
that.
As long as I have you and the mic is hot, what about the
construction budget? Is that in your bailiwick too? Is that in
your oversight or purview?
Mr. Dearman. It is not. We work with DASM.
Senator Tester. Okay. Darryl, is that part of yours? No? I
can hear that sigh of relief now. Okay, go ahead.
Mr. Dearman. I can address part of that, Senator. Again,
the department supports the President's budget, as you are
aware. We realize that with the shortcomings in the
construction piece with the proposed budget, we really are
looking forward to working with Congress with the
infrastructure.
Senator Tester. Here is the deal. You have to support the
President's budget; he is your direct boss. We are over here as
one of those branches of government that you have to deal with.
But we cannot fix it unless we know why to fix it. We are not
going to just throw a number at the wall. And by the way, I
would love to have, if you could just get back to us on where
you are for teacher staffing, not talking aides, secretaries,
just classroom teachers, that would be great.
Admiral, good to see you again. Kind of the same question.
How are you on staffing, where are you? Are you at 50 percent
or 75 percent? If you do not have it, I will make the same
request to you.
Mr. Weahkee. Thank you, Senator Tester.
Overall, our vacancy rate is 20 percent across all job
categories in the agency. When we speak specifically about
health care providers, we get up into the 30 to 32 percent
depending on which profession we are talking about. Our hardest
to fill are our physicians, nurse practitioners, physician
assistants.
Senator Tester. Let me ask a couple things on that. Do you
have the numbers on your general practitioners, where they
would be?
Mr. Weahkee. I would say 29 percent.
Senator Tester. I am sorry I am going over time. You can
gavel me out at any time.
Are you guys able to use physician assistants and nurse
practitioners to fill some of those slots?
Mr. Weahkee. We have used that strategy to the extent that
we are able. There are instances where you must have a
physician to provide oversight for a PA and in some States, a
nurse practitioner as well.
Senator Tester. Depending on the State or are they all that
way?
Mr. Weahkee. Depending on the State for the nurse
practitioners.
Senator Tester. I serve on the VA Committee and they are
always talking about by the time we get done hiring, getting
all the questions asked on a doc, several months have passed
and that doc already has a job somewhere else, getting a
paycheck.
Do you also have that problem at IHS?
Mr. Weahkee. We have had that problem historically. Some of
the quality improvement efforts that we are putting in place,
like the credentialing software system, it is helping to
alleviate that, especially for those providers already in-
house.
Senator Tester. So average time, and I could ask this
question of Tony also. You can get me this if you can, Tony.
Average time it costs from the time a job opens and you get
applicants to the time you get it filled, any metrics on that?
Mr. Weahkee. We use an 80-day benchmark for the hiring
process, but when you build in the required background
investigations and the credentialing process, six months is a
best-case scenario.
Senator Tester. Are there things we can do as Congress to
help cut that time down, to cut some of the red tape? Docs are
hard to get. They are hard to get in the private sector, they
are hard to get everywhere. I can't imagine a doctor standing
around for six months waiting for IHS, VA or any other Federal
agency, as far as that goes, to say, yes, we are going to hire
you.
Mr. Weahkee. We can look to what the private sector does.
They send individuals out to job fairs and they have a contract
in hand. They can negotiate a salary and get a signature on the
spot. We don't necessarily have that ability within the Federal
Government.
Senator Tester. Assuming it is welcome if we could cut down
some of the time, though, right?
Mr. Weahkee. I am sorry, sir?
Senator Tester. You would welcome the opportunity if we
could cut down some of the time?
Mr. Weahkee. Absolutely.
Senator Tester. I want to thank you all. Jessica and
Darryl, I am sorry I didn't pick on you guys. I appreciate you
all being here. Thank you very much for the work you do. We
will follow up later on the budget. Thank you very much.
The Chairman. Did you get in all your questions?
Senator Tester. Yes. I never get all my questions in, but I
am done.
The Chairman. I have just a couple more. Then I will turn
to Senator Cortez Masto to finish up.
Director Dearman, I think Senator Tester was getting at the
same thing I wanted to address. That is your staffing and your
vacancies. Do you feel like you are making progress on filling
those vacancies? The other thing is, do you feel you are on top
of any work environment issues as far as any concerns about
hostile work environment or any of those things, which may go
to turnover? So if you could kind of you address both those.
Mr. Dearman. We are working on capacity. When I became
director, I believe we were at about 43 percent staff. Right
now, we are about 49. We are thinking out of the box and
looking at ways of how we can actually recruit and retain
people. And we are looking at incentives as far as recruitment
and retention incentives. We are looking at advertising
positions outside of areas, out in the communities where we
actually have more Indian applicants.
And where we really don't have capacity, we are actually
utilizing contracts. An example of that, Senator, is, one of
the issues we are talking about is bringing on people. In one
of the OIG findings, they documented that we were not
completing our background checks.
What we have done is we have contracted with the Interior
Business Center, which is really coming in, helping us get
caught back up while we build up our capacity. So we are not
using our capacity as an excuse, by no means, but we are
continuing to work on our capacity through the hiring process.
The Chairman. Any work environment issues, do you feel you
are addressing them fully and properly and expeditiously?
Mr. Dearman. I really feel like we are on top of that
issue. The department has actually mandated that all of our
employees go through harassment training. We are constantly
getting out there and making sure that our employees are aware
that if they feel they are harassed or in a bad environment,
there is a process of reporting. So all of our employees, all
the way down to the school level, are aware of that.
The Chairman. Thank you.
Director LaCounte, we just passed the Tribal Resource
Energy Agreement about helping our tribes across the Country
develop their energy resources, traditional, renewable or
whatever, based on what they want to do. It is up to you to
help them implement that. How is that proceeding?
Mr. LaCounte. Within Indian Affairs, there is a branch that
is called Indian Energy and Economic Development. They work
directly for the Assistant Secretary. It is their charge to get
out and work hand in hand with any tribes who have applied for
any type of TERA agreement or even go out and promote.
They don't work directly for me but they do work for Indian
Affairs and the Assistant Secretary. It is their charge to do
it. That is probably their priority right now, to take what you
have done and share the knowledge, provide the training and the
assistance to help tribes if they are interested in doing so,
but more so, making them aware of the changes that have been
made and why it is much more attractive than it was prior to
the amendments.
The Chairman. You have 12 outstanding findings from the GAO
High Risk Report. Obviously, that is a concern. Tell me how you
are going to get those resolved and in what kind of timeline?
Mr. LaCounte. I will do the best I can to get them
resolved. I am fully confident that we have done everything
that we can within BIA, including implementing the solutions in
the field. They are actually using them.
Unfortunately, I understand that no job is finished until
the paperwork is done, but I had no idea the paperwork was
going to be as big as the job itself. That is what I am finding
out. But I am fully confident we have done what we need to do
and it is working in the field. I am going to do what we can.
I talked with Mr. Rusco from GAO earlier today. We met with
them the week before last. He advised me that I was not so good
at hiding my frustration as I thought I was within that
meeting. I will work harder on that, but I am going to work
hard on getting these things closed out because I am very
frustrated.
The Chairman. I share the concern on paperwork sometimes,
but it is very important that the underlying issue is fully
addressed and that we know it is fully addressed.
So with that, I will turn to Director Farb, your sense of
the timeline to get these 12 remaining findings resolved? Are
you making progress and what is your sense of what the
realistic timeframe is to get them addressed and the paperwork
done?
Ms. Farb. I am going to ask my colleague, Frank Rusco, who
represents the Indian Energy Issue Portfolio to come and answer
that question.
Mr. Rusco. Thank you. I am Frank Rusco.
We got, I will call it an avalanche of paperwork about two
weeks ago from the department. We looked through a lot of it.
We still have some questions about whether the intent of the
recommendation has fully been met. We do need to go out in the
field and see, as Mr. LaCounte says, how it is working in
practice.
We saw a number of things that we are still concerned
about. We need to see timelines set for certain activities.
Then we need to see monitoring to make sure the different
offices and agencies are meeting the timelines that they have
set.
The Chairman. Do you have an estimate as to what is
realistic to wrap up these 12?
Mr. Rusco. I don't. We are going out at the end of the
month to the Indian Energy Service Center. We will also talk to
the Indian Energy and Economic Development folks and we will
ask them how things are working in the field. If they are, then
there are a number of those recommendations that will be
closed. I am going to say four or five. The other things, we
just need to sit down and talk further with BIA to see if they
can show us how things are actually implemented.
The Chairman. As you get a sense of that, would you please
provide a follow-up summary to our staff, our Committee?
Mr. Rusco. Absolutely. Will do.
The Chairman. Thank you.
With that, Senator Cortez Masto.
Senator Cortez Masto. Actually, I am good. I will submit my
question for the record. Thank you.
The Chairman. All right. Then if there are no more
questions for today, members may also submit follow-up
questions for the record. The hearing record will be open for
two weeks.
I appreciate your being here. It is very important that we
get these remaining issues addressed. They are important.
Obviously, we will do everything we can to get them done in a
timely way, as well as making sure they are fully covered.
Thank you to the GAO for your work and being here today as
well.
With that, our hearing is adjourned.
[Whereupon, at 4:08 p.m., the Committee was adjourned.]
A P P E N D I X
Response to Written Questions Submitted by Hon. Catherine Cortez Masto
to Tony Dearman
Questions. Director Dearman has previously mentioned that his
office is diligently working to address the varying and developing
needs of students in the two BIE schools in Nevada, including
behavioral and mental health support services. Explain further about
this partnership with IUS and how you're planning to overcome some of
the IHS limitations that were outlined in the GAO report?
How did the shutdown affect your ability to address the challenges
raised by GAO? Are there any long-term ramifications that we should be
watching out for?
Answers. The Bureau of Indian Education (BIE) is committed to
creating positive, safe, and culturally relevant learning environments
where students gain the knowledge, skills, and behaviors necessary for
physical, mental, and emotional well-being. BIE recognizes the
importance of student mental and behavioral health and has identified
it as one of its six Strategic Direction goals. BIE is especially proud
that the final student mental and behavioral health goal includes
several action items that were offered by Tribes and Indian Country
leaders during the Tribal consultation process last year.
One critical component of Goal Two of the Strategic Direction is
mental and behavioral health professional development and training.
Over the course of the last year of implementation of Goal Two, the BIE
has certified approximately 329 staff members in Youth Mental Health
First Aid. The Youth Mental Health First Aid training consists of an 8-
hour public education program that introduces participants to the
unique risk factors and warning signs of mental health problems in
adolescents, builds understanding of the importance of early
intervention, and teaches individuals how to help an adolescent in
crisis or experiencing a mental health challenge. The training utilizes
real world role-playing and simulations to demonstrate how to assess a
mental health crisis; select interventions and provide initial help;
and connect young people to professional, peer, social, and self-help
care.
Additionally, in December 2016, the Indian Health Service (IHS) and
BIE entered into an interagency agreement intended to increase access
to mental and behavioral health services for students attending BIE-
funded schools. Under this 1 0-year agreement, the agencies will work
collaboratively to establish local partnerships through Memoranda of
Agreement among local IHS mental health programs and BIE-funded schools
in order to provide on-site mental health assessment and counseling
services to BIE students.
With regard to the recent lapse in appropriations and subsequent
shutdown, work related to GAO closures and the Strategic Direction
paused for the duration of the lapse. This resulted in a delay to GAO
and Strategic Direction work. Specifically, during the month prior to
the shutdown, five percent ofBIE's Strategic Direction actions were
reported as being behind schedule. In the month following the closure,
36 percent of Strategic Direction actions were reported as behind
schedule, an increase of 31 percent. However, the BIE has refocused its
efforts and is working to catch up on its Strategic Direction work
commitments as quickly as possible. Currently, 28 percent of Strategic
Direction actions are behind schedule and the BIE is continuing to work
hard every day to close this gap and deliver on its year-one Strategic
Direction milestones.
______
Response to Written Questions Submitted by Hon. Catherine Cortez Masto
to Darryl LaCounte
Question 1. According to GAO, ``BIA officials said the agency does
not have the staff or resources to implement a comprehensive workforce
planning system to ensure it has staff in place at its agency offices
to meet its organization needs.'' Does the President's budget include
the resources that you need to make those assessments? If not, why not?
If so, when can we expect this workforce evaluation?
Answer. As indicated during the March 2019 SCIA Hearing on the GAO
High Risk Designation ofBIA, the BIA continues to prioritize filling
vacancies. Workforce planning is ongoing. We have worked closely with
Indian Affairs Human Capital and Budget staff, as well as BIA subject
matter experts, to conduct an assessment. As with any budget scenario,
resources are identified for priorities.
The BIA Office of Trust Services, and Indian Energy Service Center
have finalized the draft workforce evaluation, which will be the
guiding comprehensive internal document by calendar year end.
Question 2. How did the shutdown affect your ability to address the
challenges raised by GAO? Are there any long-term ramifications that we
should be watching out for?
Answer. The shutdown did not create long-term ramifications for the
Indian Energy Service Center. Some activities, like the Mineral User
Group meeting, which was scheduled for January 2019, had to be
rescheduled. In addition, the processing of permits and leases were
halted, but activities resumed when the shutdown ended. While the
shutdown did create a backlog of work, the backlog is being addressed
and the staff is attempting to resume a normal workload.
______
Response to Written Questions Submitted by Hon. Catherine Cortez Masto
to Jessica Farb
Questions. In its 2017 High Risk Report, GAO noted that
insufficient reimbursements for health services delivered by providers
outside ofiHS led to ``gaps in services (that] sometimes delay
diagnoses and treatments, which can exacerbate the severity of a
patient's condition and necessitate more intensive treatment.'' The
2019 High Risk Report says IHS has taken steps to identify providers
who don't accept the Service's low reimbursement rates. To what portion
of the underlying issue do you attribute awareness of providers who
don't accept IHS rates, versus low reimbursement rates that have
created narrow networks of providers? How much would IHS have to
increase reimbursements to address the issue? When you're evaluating
the progress of these agencies in meeting their targets, how do you
measure or account for the sustainability of their solutions? How do we
make sure that agencies don't backtrack in areas where they've made
improvements?
How did the shutdown affect your ability to address the challenges
raised by GAO? Are there any long-term ramifications that we should be
watching out for?
Answers:
GAO has recommended that IHS increase reimbursements and decrease
payments
Increasing third-party reimbursements. When services are not
available at federally operated or tribally operated facilities, the
Indian Health Service (IHS) may pay for services provided through
external providers through its Purchased/Referred Care (PRC) program.
The PRC program is funded through annual appropriations and must
operate within the limits of available appropriated funds. In our 2017
High Risk Report, we reported that although funding appropriated for
the PRC program had recently increased, the program is unable to pay
for all eligible services. We also reported that gaps in services
sometimes delay diagnoses and treatments, which can exacerbate the
severity of a patient's condition and necessitate more intensive
treatment. We concluded that one way for IHS to increase the funding
available for eligible services was to increase its third-party
reimbursements from programs such as Medicaid. \1\ The Patient
Protection and Affordable Care Act (PPACA) expanded or created new
health care coverage options, including a state option to expand
Medicaid eligibility to individuals with incomes at or below 138
percent of the federal poverty level. We estimated that PPACA's new
coverage options may allow hundreds of thousands of American Indian/
Alaska Native people to obtain health care benefits for which they were
not previously eligible, assuming all states expanded their Medicaid
programs. We reported that, if American Indian/Alaska Native people
enroll in one of these options and choose to receive care through IHS,
increased revenue from third party payers such as Medicaid could free
up IHS resources and help alleviate pressure on the IHS budget.
---------------------------------------------------------------------------
\1\ Indian Health Service: Most American Indians and Alaska Natives
Potentially Eligible for Expanded Health Coverage, but Action Needed to
Increase Enrollment. GAO-13-553. Washington, D.C.: September 5, 2013.
---------------------------------------------------------------------------
Reducing payment rates. In addition to the potential financial
benefits of increasing its third-party reimbursements, in 2013, we
found that IHS could achieve cost savings that it could then direct
toward additional patient care if it reduced its PRC payment rates for
physician and nonhospital care. We found that in 2010, the PRC program
primarily paid physicians at their billed charges, which were
significantly higher than what Medicare and private insurers would have
paid for the same services. \2\ Specifically, we estimated that the PRC
program paid twice as much as what Medicare would have paid and about
one and a quarter times as much as what private insurers would have
paid for the same physician services provided in 2010. We concluded
that setting PRC program physician and other nonhospital payments at
rates consistent with Medicare would enable IHS to achieve needed
savings that could be used to expand patient access to health care. In
response, the Department of Health and Human Services issued a final
rule on March 21, 2016 to apply Medicare payment rates to all
physicians and other nonhospital services provided through PRC--saving
the agency over $18 million. Given the possibility this change could
affect access to care in certain areas if providers do not accept the
lower payment rates, we recommended that IHS monitor PRC program
patient access to physician and other nonhospital care. In response to
this recommendation, IHS developed an online tool that enables the
agency to track providers that do not accept IHS's payment rates. While
we have not done work to address the issue of lower payment rates
creating narrow provider networks, we recommended that IHS monitor
patient access in order to help ensure that does not happen. We also
have ongoing work looking at how Medicaid expansion has affected health
care coverage and services for American Indians and Alaska Natives.
---------------------------------------------------------------------------
\2\ Indian Health Service: Capping Payment Rates for Nonhospital
Services Could Save Millions of Dollars for Contract Health Services.
GAO-13-272. Washington, D.C.: April 11, 2013.
---------------------------------------------------------------------------
GAO's recommendation follow-up procedures
Agencies have a responsibility to monitor and maintain accurate
records on the status of our recommendations. These requirements are
detailed in two OMB circulars--OMB Circular A-50 and OMB Circular A-
123. Among the requirements included are that the agencies (1) appoint
a top-level audit follow-up official, (2) maintain accurate records on
the status of recommendations, and (3) assign a high priority to
following up on audit recommendations.
Although agency officials are responsible for resolving audit
findings and recommendations, GAO's continued attention to
recommendations can help bring about the benefits of the audit work. We
actively monitor the status of our open recommendations--those that
remain valid but have not yet been implemented--and post our findings
to a recommendations database, which is updated regularly and publicly
available at https://www.gao.gov. The database records information on
recommendations and on whether timely and appropriate corrective
actions have been taken.
Because agency personnel serve as a primary source of information
on the status of recommendations, we request that the agency also
provide us with a copy of the agency's statement of action to serve as
preliminary information on the status of open recommendations. We
follow up by discussing the status of recommendations with cognizant
agency officials; obtaining copies of agency documents supporting the
recommendations' implementation; and performing sufficient work to
verify that the recommended actions are being taken and, to the extent
possible, that the desired results are being achieved.
A recommendation is closed when it has been implemented, when
actions have been taken that essentially meet the recommendation's
intent, or when circumstances have changed and the recommendation is no
longer valid. GAO staff obtain verification, with sufficient supporting
documentation, that an agency's reported actions are being implemented
adequately before closing out a recommendation. GAO staff may interview
agency officials, obtain agency documents, access agency databases, or
obtain information from the agency's Office of the Inspector General.
Follow-up records are retained for 5 fiscal years from the fiscal year
that a product's last recommendation is closed. However, sustained
congressional attention is needed to ensure initial agency
implementation and to prevent agencies from backsliding.
______
Response to Written Questions Submitted by Hon. Catherine Cortez Masto
to Rear Admiral Michael Weahkee
Question 1. In its 2017 report, GAO noted that insufficient
reimbursements for health services delivered by providers outside of
IHS led to ``gaps in services [that] sometimes delay diagnoses and
treatments, which can exacerbate the severity of a patient's condition
and necessitate more intensive treatment.'' The 2019 report says IHS
has taken steps to identify providers who don't accept the Service's
low reimbursement rates. What else is IHS doing to address this access
question? Has IHS considered increasing reimbursements for these
services?
Answer. The 2017 GAO report quoted in the question explains that
Purchased/Referred Care (PRC) funding is provided through annual
appropriations, which has increased in recent years. However, despite
these increases, GAO states, ``the [PRC] program is unable to pay for
all eligible services, and that these gaps in services sometimes delay
diagnoses and treatments, which can exacerbate the severity of a
patient's condition and necessitate more intensive treatment.'' See GAO
report 17-317, page 209-210, available at https://www.gao.gov/assets/
690/682765.pdf. The GAO did not identify insufficient reimbursements
for non-IHS provided health care as the cause for the gaps in service.
In May 2016, IHS established a regulation on capping payment rates
for physicians. See 42 C.F.R. Part 136, Subpart I--Limitation on
Charges for Health Care Professional Services and Non-Hospital-Based
Care. This rule implemented a methodology and payment rates for the IHS
PRC to apply Medicare payment methodologies to all physician and other
health care professional services and non-hospital-based services.
Specifically, it allows health programs operated by IHS, tribes, tribal
organizations, and urban Indian organizations (collectively known as I/
T/U programs) to negotiate or pay non-I/T/U providers based on the
applicable Medicare fee schedule, prospective payment system, and
Medicare Rate in accordance with a Medicare waiver, the amount
negotiated by a repricing agent, or the provider or supplier's most
favored customer rate. In accordance with this new regulation, I/T/U
programs may negotiate a higher rate with those providers that refuse
to accept Medicare methodology for payment, using the providers most
favored customer rate as a ceiling in most cases.
Question 2. In view of issues faced by providers like the Paiutes
in Nevada, IHS has started work on modernizing s its electronic health
record system. While the Paiute clinic in my state is not an IHS
clinic, they do utilize the electronic records system which, from their
perspective, has been slow to see improvements. When should facilities
expect to see positive changes or improvements to the existing HIT
infrastructure? What is IHS doing to ensure that input from tribes
running their own facilities is taken into account?
Answer. The IHS uses the Resource and Patient Management System
(RPMS) to manage clinical, financial, and administrative information in
federal hospitals and clinics, as well as in some tribal and urban
health programs. The RPMS is currently installed in over 400 separate
locations and is patched by local staff who are responsible for
maintaining the system. Enhancements are provided by IHS Office of
Information Technology (OIT) through a combination of federal staff,
contract developers, and shared code made available from the Department
of Veterans Affairs through a memorandum of understanding.
In RPMS development, requests for changes to the software are
evaluated by informatics staff, subject matter experts, and the IHS
Chief Medical Officer to address requested improvements, regulatory
compliance, and audit findings. New software is released to the over
400 locations incrementally throughout the year as individual update
packages are released. The most recent package was released in December
2018. In FY 2018, OIT released 110 minor enhancements and 5
comprehensive software package releases. A new Electronic Prescribing
of Controlled Substances package will be released in the summer of 2019
that creates new functionality to support the IHS Opioid initiatives.
IHS has started efforts to modernize its health information
technology (HIT) infrastructure. This effort will include substantial
changes to the existing RPMS, or purchasing and implementing a
commercial option. This first step for IHS is completing the HHS
sponsored IHS HIT Modernization Research Project that began in October
2018 and will conclude in September 2019. The research project will
inform IHS about the requirements and challenges that IHS needs to
address in order to modernize its HIT system. The IHS is developing a
modernization plan that addresses the technical design, operating plan,
and funding strategy. The IHS will continue to support the current RPMS
as well as develop a long-term plan to modernize and sustain its HIT
investments.
Additionally, the FY 2020 Budget proposes $25 million for IHS to
begin transition to a new and modernized Electronic Health Record
system. This funding will lay the groundwork to improve the quality of
care, reduce the cost of care, promote interoperability, simplify IT
service management, increase the security of patient data, enhance
cybersecurity, and update infrastructure across rural locations to
enable a successful Electronic Health Record transformation.
The IHS has established and funds advisory committees composed of
members of tribes, tribal organizations, and representatives of the
Federal Government to ensure participation on addressing issues such as
RPMS and the HIT modernization effort, including the Direct Service
Tribal Advisory Committee and the Tribal Self-Governance Advisory
Council. In addition, IHS established the Information System Advisory
Council (ISAC) to guide the development of a co-owned and co-managed
Indian health information infrastructure and information systems.
With tribal partners, the ISAC examines the larger question of our
HIT platforms. The ISAC has a chartered responsibility to make
technology recommendations and priorities to the IHS Director. IHS
concurrently engages in tribal consultation and urban confer to gather
input and assist our decisionmaking process. This process has included
several listening sessions combined with a broad array of stakeholder
and community engagements. Feedback from the ISAC, listening sessions,
and engagement with HHS and other Federal programs will ultimately
converge to provide the IHS with good information to help determine a
best path forward.
Question 3. The report discussed the importance of appropriate and
level staffing, particularly the need to efficiently replace key
personnel as vacancies become apparent. Health workforce issues as a
significant challenge across all of our rural communities. The
President's budget that was released yesterday included ``investments
in new programs to improve patient care through recruitment and
retention of health care professionals.'' Please provide additional
detail on those programs and how they will help bring health care
providers to rural communities like those in Nevada. What actions can
we take in Congress to help you meet those needs?
Answer. Investments in new programs will be used to support a range
of recruitment and retention strategies aimed to enhance and support
the IHS mission. Initiatives include, but are not limited to, housing
subsidies, U.S. Code Title 38 compensation, increases in the number of
IHS loan repayment and scholarship awards, use of other Federal loan
repayment programs, and the expansion of IHS recruitment and outreach
activities.
Recruitment and retention of employees is a high priority for the
IHS. To successfully recruit and retain health care professionals, IHS
must provide competitive employment packages. As requested in the
Fiscal Year 2020 Budget, IHS could use housing subsidies for civilian
health professionals that are assigned or accept staff quarters. A
housing subsidy would be offered equivalent to the amount charged by
General Services Administration (GSA). Health professionals not
assigned to staff quarters would be offered housing subsidies based on
a mileage rate of the nearest location where housing is available as
determined by the agency. The housing subsidy is designed to offset GSA
rental rates or to reduce the cost of commuting and renting homes in
adjacent communities. This subsidy will be a significant tool to aid in
the overall recruitment and retention of civilian health professionals
and aligns with the basic allowance for housing program that is offered
to U.S. Public Health Service Commissioned Corps officers assigned to
the IHS.
IHS has the delegated authority to use Title 38 of the U.S. Code,
Chapter 74--Veterans Health Administration--Personnel, for compensation
purposes, including IHS-developed Title 38 pay tables. IHS currently
has ten Title 38 pay tables. Consistent with the Fiscal Year 2020
Budget request, IHS can develop additional Title 38 pay tables or
increase current pay. More competitive pay can help reduce IHS vacancy
and turnover rates.
Recruitment and retention of health care professionals is a
challenge for IHS and other health care organizations serving rural
locations. To address these challenges, the FY 2020 Budget for IHS
includes legislative proposals to provide IHS discretionary use of all
U.S. Code Title 38 personnel authorities, half-time obligations for
loan repayment and scholarship recipients, and tax exemption for these
recipients.
Question 4. How did the shutdown affect your ability to address the
challenges raised by GAO? Are there any long-term ramifications that we
should be watching out for?
Answer. Over the 35-day lapse in appropriations that started on
December 22, 2018 and ended January 25, 2019, IHS continued to provide
direct clinical health care services as well as referrals for
contracted services that cannot be provided through IHS clinics.
However, IHS could only perform national policy development and
issuance, oversight, and other functions necessary to meet the
immediate needs of the patients, medical staff, and medical facilities.
IHS was unable to provide the majority of funds to Tribes and Urban
Indian Health programs. The government lapse in appropriations created
multiple disruptions to direct operations of IHS facilities including
delay in training staff on various clinical and administrative topics,
staffing critical clinical and administrative vacancies at IHS
facilities, recruitment of health care professionals, facility
maintenance and repair, and the inability to restock critical medical
supplies and services at various health care facilities.
In addition to the operational impacts listed here, the lapse in
appropriations significantly impacted IHS health care team morale,
among other psychological impacts. Employees across the Indian health
care system were concerned about how to pay their rent, how to feed
their families, how to pay for gas to get to work, how to pay their
childcare costs, etc.
Despite these setbacks, the IHS health care team is resilient,
dedicated to our mission, and will continue to work to mitigate any and
all impacts experienced by the government lapse in appropriations. We
are focused on our priority and goal to provide quality care.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Tony Dearman
Elementary and Secondary Education Act Compliance
Question 1. As part of the BIE's efforts to develop a 'state plan'
to define standards, assessments, and accountability systems for BIE-
funded schools consistent with Section 1111 of the Elementary and
Secondary Education Act, the Bureau established a Standards,
Assessments, and Accountability System Negotiated Rulemaking Committee.
The BIE's website indicated that the Committee would meet four times,
but the recent partial government shutdown caused a delay in the final
meeting. Will the Bureau's delay of the final meeting of the Committee
result in any complications with completing the rulemaking process in
time to meet the deadlines agreed upon by the Department of the
Interior and the Department of Education?
Answer. The partial appropriations lapse did not further delay the
implementation of the rulemaking process. The Committee met four times
in person and numerous times as subcommittees and in April 2019
delivered a Final Consensus Report to the Bureau of Indian Education
that summarizes recommendations for regulations to implement the
unified requirements for standards, assessments, and accountability
systems for BIE-funded schools and other aJternative requirements.
Presently, the Bureau of Indian Education (BIE) is completing the
rulemaking process. BIE is coordinating regularly scheduled meetings
with the Department of Education (ED) and working with ED-funded
comprehensive centers to ensure that ED is aware of expected
deliverables and timelines for implementation. BIE estimates a 3-month
review process prior to publication of the final rule. As such, BIE
estimates publication of the Final Rule within a December 2019 to
January 2020 timeframe. While the BIE's anticipated timeframe for full
implementation of its standards, assessments, and accountability system
will not occur until school year 2020-2021, ED understands that is now
the timeframe and is providing technical assistance and recommendations
for implementation, as well as support to BIE as it works with its
schools to ensure that schools, tribes, and local stakeholders are
properly notified and prepared for the planned rollout of
implementation.
Question 1a. When does the Bureau anticipate publishing or making
public the recommendations of the Committee?
Answer. The Committee's recommendations were published on the BIE
website in April 2019 and are publicly available at https://
www.bia.gov/sites/bia.gov/files/assets/as-ia/raca/pdf/BIE-NRM-Final-
Report-V8_508.pdf.
Question 1b. Will tribal leaders, tribal school board officials,
BIE student families, and other relevant stakeholders have an
opportunity to provide feedback or suggestions to improve any newly
proposed standards, assessments, and accountability systems?
Answer. BIE published the proposed Standards, Assessments, and
Accountability System rule on June 10, 2019. See 84 F.R. 26785. The
proposed rule provided 30 days for submission of public comments. In
addition, BIE held 6 tribal consultation sessions at locations around
the country. The BIE is currently analyzing the comments that were
received concerning the proposed rule and anticipates publication of a
final rule that takes those comments into consideration within three
months. Beyond the stakeholder engagement throughout the rulemaking
process, as the BIE develops and finalizes plans for requirements for
standards, assessments, and accountability system, including an agency
``State Plan'' pursuant to the final rule, BIE intends to solicit input
from stakeholders through focus groups and consultation with Tribes and
other stakeholders.
______
Response to Written Questions Submitted by Hon. Tom Udall to
Rear Admiral Michael Weahkee
Management Accountability
Question 1. During the hearing, I asked you about IHS's failure to
address the widespread reports of abuse of Native American children and
misconduct by one of its former employees, Dr. Stanley Weber. At the
time, you could not provide me with an explanation of why IHS's allowed
Dr. Weber to transfer from the IHS Billings Area to the IHS Great
Plains Area after leadership became aware of his misconduct. Please
provide the Committee with any known facts surrounding Dr. Weber's move
from the Billings Area to the Great Plains Area;
Answer. Dr. Weber transferred from the Billings Community Hospital
in Browning, Montana, to the Pine Ridge Service Unit in South Dakota,
on June 8, 1995. The Indian Health Service (IHS) is organizing an
intensive medical quality assurance review of internal IHS past actions
related to this provider. Questions involving historical issues and
facts will be fully addressed through this review.
Question 1a. Please provide the Committee with an update on IHS's
investigation on the Dr. Weber case.
Answer. On February 22, 2019, IHS posted a solicitation for a
medical quality assurance review of IHS policies and procedures with
respect to reporting allegations of sexual abuse of IHS patients by IHS
clinical staff. IHS intended to post this solicitation much sooner, but
the timeline was extended as a result of the lapse in appropriations
that started on December 22, 2018 and ended January 25, 2019. IHS is
proceeding through the required acquisition process and anticipates
awarding a contract in May 2019. The contractor will be required to
submit a final written report, with recommendations for improvement, to
IHS within 180 days of the contract award date.
Question 1b. Please provide the Committee with a description of
current Service Area and Service Unit procedures for documenting and
addressing federal employee misconduct, including any safeguards that
would prevent the transfer of federal employees suspected of misconduct
from one Service Area or Unit to another.
Answer. IHS health care providers are Federal employees and are
therefore required to adhere to all Federal laws, regulations, rules,
and standards of conduct. When established standards of conduct are
violated, or the rules of the workplace are disregarded, corrective
action is warranted to motivate employees to conform to acceptable
standards of behavior and prevent prohibited and/or unsafe activities.
Depending on the level of misconduct, the preponderance of evidence to
support the misconduct, and the nexus between the misconduct and the
employee's job and the IHS mission, we will remove a health care
provider that has committed any egregious and/or abusive misconduct.
The IHS follows the Department of Health and Human Services (HHS)
policy Chapter 5-10: Responsibility and Procedure for Reporting
Misconduct and Criminal Offenses, which outlines policies, procedures,
and assignments of responsibility for reporting allegations of criminal
offenses committed at any location within IHS. The IHS reports any
allegations of criminal misconduct to the HHS Office of Inspector
General (OIG) and cooperates during any investigation initiated by the
OIG. The IHS works in partnership with the OIG to ensure Area and
Service Unit leaders are informed of any allegations of criminal
misconduct and take any immediate actions necessary, such as removing
an employee from the facility while an investigation is conducted.
The IHS policy, ``Ethical and Professional Conduct of Health Care
Providers'' (IHM Part 3, Chapter 23, established in 2004), establishes
the policy, procedures, and responsibilities for IHS personnel,
supervisors, and management officials regarding the conduct of health
care providers https://www.ihs.gov/IHM/pc/part-3/p3c23/. This policy
serves as an adjunct to, and not as a substitute for, ``The Standards
of Ethical Conduct of Employees of the Executive Branch,'' the HHS
``Supplemental Standards of Ethical Conduct for Employees,'' and the
Commissioned Corps ``Standards of Conduct.''
All IHS employees are required to complete the Notification and
Federal Employee Anti-Discrimination and Retaliation Act (No FEAR Act)
training. This mandatory training provides notice to federal employees
of the rights and protections available to them under federal
antidiscrimination, whistleblower protection, and retaliation laws. The
course is available to all employees, on-line, through the HHS Learning
Management System. The No FEAR Act of 2002 requires that each federal
agency be accountable for violations of anti-discrimination and
whistleblower protection laws and provide mandatory training to
employees every two years and within ninety days of entering on duty
for new employees regarding their rights under the law.
On February 20, 2019, IHS issued a new policy, ``Protecting
Children from Sexual Abuse by Health Care Providers'' (available at
https://www.ihs.gov/ihm/pc/part-3/p3c20/), that expands and reiterates
existing policy to require any IHS staff member to report any incident
or reasonable suspicion of sexual abuse of a child by a health care
provider directly to the proper child protective and/or law enforcement
authorities. It also requires any IHS staff member to report any
incident or reasonable suspicion of sexual abuse of a child directly to
their supervisor, the Chief Executive Officer, or alert the next
supervisor in the chain of command if the first line supervisor is the
one suspected of child sexual abuse. The new policy specifically
outlines a supervisor's responsibilities for protecting children from
sexual abuse by health care providers.
Additionally, this section also directs all IHS Staff to document a
report they make in the IHS Incident Reporting System within five
business days. In short, this requires all IHS employees to report any
incident or reasonable suspicion of sexual abuse of a child by a health
care provider that they observe or reasonably suspect.
Allegations brought to the attention of medical staff are recorded
in the provider's credentialing file, then evaluated and managed in
accordance with the facility's bylaws, which adhere to the Centers for
Medicare & Medicaid Services (CMS) Conditions of Participation. 42
C.F.R. 482.22 (a)(2) states that medical staff must examine the
credentials of all eligible candidates for medical staff membership and
make recommendations to the hospital's governing body on the
appointment of these candidates in accordance with state law, including
scope-of-practice laws, and the medical staff bylaws, rules, and
regulations. A candidate who has been recommended by medical staff and
has been appointed by the governing body is subject to all medical
staff bylaws, rules, and regulations, in addition to CMS regulations.
Under CMS rules, the hospital's governing body is responsible for
organization and conduct of the medical staff.
The transfer of an IHS provider, or any IHS employee, from one IHS
facility to another is not a valid solution for misconduct within the
federal employee discipline system. The IHS relies on the HHS
Instruction 752, ``Corrective Action, Discipline and Adverse Actions,''
dated March 20, 2009. This instruction clarifies roles and
responsibilities for managers when addressing employee misconduct in
the workplace. It also establishes guidance and criteria to ensure that
corrective action is consistent with good management practices.
For Commissioned Corps officers, reasons for transfer have not been
tracked, and are therefore not available. In recent history, since
2017, Corps officers at IHS who have sustained allegations of serious
misconduct have not been permitted to transfer within the IHS and have
been referred to Commissioned Corps Headquarters for potential adverse
action, up to and including involuntary termination (if active duty
service is less than 20 years) or retirement (if active duty service is
over 20 years).
Staffing Recruitment and Retention
Question 2. Last September, GAO released a new report on staffing
challenges at IHS. This report confirms the concerns I raised at our
last high risk hearing about the high clinical vacancy levels in the
Navajo and Albuquerque Areas. It also concluded that the Service has
trouble developing competitive salary packages and attracting new staff
because of facility conditions. Does IHS have the resources it needs to
offer more competitive salaries in these high-vacancy areas?
Answer. Recruitment and retention of health care professionals is a
challenge for IHS and other health care organizations serving rural
locations. To address these challenges, the FY 2020 Budget for IHS
includes legislative proposals to provide IHS discretionary use of all
U.S. Code Title 38 personnel authorities, half-time obligations for
loan repayment and scholarship recipients, and tax exemption for these
recipients.
The IHS is working with the HHS Office of the Assistant Secretary
for Health to improve the recruitment and retention of U.S. Public
Health Service Commissioned Corps officers using existing authorities.
Question 2a. Are there enough human resource personnel to develop
special pay tables for these regions?
Answer. The IHS is committed to authorizing Title 38 pay tables, as
necessary, to recruit and retain quality medical providers. Currently,
there are ten IHS Title 38 pay tables. Additional OHR staff would be
needed to develop and manage a larger number of pay tables.
Question 2b. Do you agree with the report's conclusion that aging
facilities and medical equipment frustrate the Service's recruitment
efforts?
Answer. There are specific instances in which the age of our
facilities and outdated medical equipment have been pointed to as
factors in candidates' decisions not to pursue employment with our
Agency. In addition, other contributory factors include remote
locations, lack of suitable housing options, family requirements,
spousal employment opportunities, and local amenities.
Question 2c. Are there any Office of Management and Budget employee
rules and regulations that limit the ability of the Service to recruit
and retain clinical personnel (e.g., prohibitions on utilizing three
day, 12-hour shift schedules commonly utilized in the healthcare
industry for nurses)?
Answer. The IHS is not aware of any Office of Management and Budget
employee rules and regulations that limit our ability to recruit and
retain clinical personnel. IHS has the authority to use U.S. Code Title
5 (Government Organization and Employees) and Title 38 (Veterans'
Benefits) work schedules for our clinical personnel. Under Title 38,
there is flexibility for clinical personnel work schedules to include
the Baylor plan for nurses (i.e., 24 hours over a weekend equals a 40
hour schedule).
The challenge comes with the additional administrative burden
required by the IHS to exercise the Title 38 authorities that have been
delegated to HHS. Currently, the Agency must submit individual requests
to exercise a specific authority delegated to the Department, which in
some cases requires months of work to develop and justify the request.
This work would be alleviated with the direct delegation of Title 38
authority to the Agency.
IHS does not have the authority to use Title 38 for employee leave
of absence, e.g., annual leave accrual. However, the Department of
Veterans Affairs provides an automatic one day of annual leave accrual
per pay period for physicians, dentists, podiatrists, and optometrists
regardless of their work history. Nurses, nurse anesthetists, physician
assistants, and expanded-function dental auxiliaries also earn eight
hours of annual leave per pay period under Title 38.
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