The Pleasant Point Health Center (PPHC) did not meet a number of federal and tribal health and safety requirements for quality of care during the period from 2014 through 2016, according to a report issued in July by the U.S. Department of Health and Human Services' Office of Inspector General.
     Brian Altvater, who is currently the health director and was for most of the period covered by the report, acknowledges that the violations are serious and the health center has to take corrective action to rectify them. "It's like a report card. If it's not good, you have to bring your grades up." Altvater, though, says that a high turnover rate among health care providers, lack of staff in key positions and a hostile relationship with the tribal government all contributed to the health center's poor performance.
     The review found that the health center did not always have: a physician who provided medical direction for the health center; clear lines of authority and responsibility between medical and administrative decision‑making; written medical policies and procedures, including pain‑management treatment prioritization for opioid prescription and compliance monitoring; written policies and procedures for medical documentation and complete patient health records; an annual quality assurance evaluation of patient health care; complete preemployment screening, including fingerprinting of employees who come in contact with children; and a safe, clean accessible environment and a preventative maintenance program for the health care facility and medical equipment.
     The report states, "Because the Passamaquoddy Tribe at Pleasant Point did not provide adequate oversight and implement policies and procedures for its health center, PPHC did not always meet federal and tribal requirements, which increased the risk that patients did not always receive quality health care and PPHC may hire unqualified medical providers and administrative staff."

Lack of medical director
     Specifically, the report states that during the audit period the health center had a single health director "who did not have a medical education or medical training, but exercised some roles reserved for a physician or other licensed medical provider." The report continues, "In certain circumstances, he also intervened with medical providers on the behalf of patients dissatisfied with their pain-management treatment. In certain instances, medical staff indicated that they felt pressured by the health director to change a patient's prescription, which they felt was inappropriate because the health director did not have medical training."
     Altvater says there were periods when the health center did not have a physician who could serve as medical director, and without a medical director "the continuity of care was nonexistent. We were struggling to get providers on staff." The health center often used temporary locum tenens providers instead, and he says, "Many of them stayed only for a couple of months or less. We got some that were less than average, and we got some that were outright bad." The health center is still using locum providers now while continuing to try to recruit physicians to the staff.
     Concerning the audit's finding that there were not always clear lines of responsibility between medical and administrative decision‑making, Altvater says that "has a lot to do with the turnover in providers. In my job description it says I hear complaints. I have to walk a fine line between helping them and not crossing over the line to making medical decisions." He adds, "If we had a medical director, then the administrators wouldn't be as intimately involved." The health center is still looking for a medical director, but Altvater notes that the lack of medical staff is not just a problem at Pleasant Point. The issue is seen nationwide, and more so in rural communities Downeast.
     He says that some providers crossed a line themselves and "got in the middle of tribal politics." He comments, "Politics should be left up to the tribe and not to people who are non-tribal members."

Pain medication issues
     According to the audit, the health director also placed significant limits on patient lab testing, and the report states that a significant reduction in compliance monitoring urine drug tests for patients on an opioid treatment plan was noted in November 2016, with no evidence that patients received this test in December.
     In addition, the report states that the health center did not have written medical policies and procedures because it was not under the medical direction of a physician and because of staff turnover. A total of 11 of 14 medical providers worked at the health center for less than a year during the review period, and the report states, "Some health care staff expressed concerns that patients with opioid prescriptions made threats of violence against them."
     The auditors also found inconsistencies in the medical providers' pain-management treatment plans used to monitor patients with opioid prescriptions. For instance, in a review of selected medical records, six of 30 patients who received both opioid prescriptions and urine drug tests had not signed a Controlled Substance Agreement to comply with their opioid treatment plan. For six of the 30 patients, medical providers did not incorporate any drug test findings into the patients' treatment plans. Without written policies in place, the health center "did not have sufficient guidance to facilitate day-to-day decision-making related to patient care and opioid prescribing practices."
     Altvater says that pain management depends on the providers' philosophy, with some not prescribing pain medication and others doing so more readily. "With the great turnover in staff and different philosophies, it's hard to get them all on the same page. Probably we weren't paying close enough attention to the amount of pain medication [prescribed], but it's their call, not mine."
     He says providers were not consistent in how they enforced pain medication agreements, with some patients being screened repeatedly and some not tested as frequently. Because funding has been tight and the health center was spending "tens of thousands on drug screening," he says the center had to cut back some on the amount of screening.

Addressing addiction
     As for drug addiction caused by prescription pain medication, Altvater notes that other methods such as acupuncture and chiropractic treatment are now being used instead to alleviate pain. For those who have become addicted through prescriptions, some have been shut off from addictive pain medications so quickly by providers that they "end up on the street. The doctor can't monitor street drugs. You don't know what's on the street." He adds, "We don't have adequate programs for those withdrawing. The demand is high, and help is limited."
     "We don't have adequate dollars to provide health care in the community. When you add the addiction element, it only amplifies and magnifies that. The existing problem of people who were used to getting a certain amount of pain meds with the big push nationwide to change that -- that causes problems." He adds, "It's heartbreaking to see people struggling. They come into my office crying and feel trapped, but addiction doesn't give you choice once you're in the midst of your disease. We owe it to all the people who reach out for help to do everything we can."
     He notes that the tribal government has set aside $500,000 to combat the opioid epidemic at Sipayik, but the money has not yet been used.

'System is broken'
     Altvater says many of the issues are caused both by the turnover in providers and by the vacancies in key positions at the health center, including the lack of a full-time health planner. The clinic also lacks a health board, with the tribal council acting as one. Altvater notes, though, that some councillors have little experience in the health care field, yet they oversee the health center.
     "This system is broken," he says, referring to the relationship between the health center and the tribal government. "There has been a lot of political interference with me doing my job. I would accept 100% of the blame for the OIG report if I were 100% in control of the clinic, which I've never had."
     Although he's been health director for a total of 18 years, his most recent tenure has been for four years. He says during that time he's seen four tribal chiefs, several tribal managers and several chief financial officers in tribal government. "There's no stability there. We've always asked for more support from the tribal administration. When some tribal leaders micromanage, it's counterproductive to what I'm trying to do as health director. I need support from them. We need to sit down and meet, preferably on a quarterly basis, so we can be on the same team and so we can provide good quality health care to the people at Sipayik."
     According to Altvater, at times money has been committed from the health center's budget by the tribal administration and "I have been totally bypassed. Yet I deal with the fallout of those actions."
He says his relationship with the tribal government has left him in a hostile work environment that has made it difficult for him to do his job.

Other issues identified in audit
     The audit also found incomplete patient health records, noting that one medical provider did not write notes for 526 out of 1,762 patient visits during an 11-month period; a second provider did not write notes for 23 out of 36 visits during a two-week period; and a third did not write notes for 67 out of 1,382 visits during an eight-month period. Altvater points out that one provider "left a lot of open charts. He didn't complete them, and that put a strain on the whole system."
     Because the health center did not carry out an annual program evaluation, it did not "take corrective actions to improve health care in areas, such as opioid prescribing and compliance monitoring," the report states. The health center is now in the process of conducting annual program evaluations, with the Indian Health Service assisting. A corrective action plan also is being worked on.
     Concerning preemployment review, the audit found that, of 27 employees who had regular contact with children, none had evidence of fingerprinting or an FBI background check, per federal requirements. Also, the files for 44 of the 53 employees did not have evidence of preemployment drug testing and 32 did not have documentation of three reference checks, as required by tribal policies. Preemployment review is done by the tribal government administration, and "they're working on fixing" the issues, says Altvater.
     As for the health center's environment, the audit found cracked linoleum flooring, ripped vinyl on an exam table, rusted medical instruments, expired medical supplies and an unclean medical instrument tray. Telehealth equipment was not operational, and patient care areas had nonfunctioning alarms that are meant to alert emergency responders of agitated patients. According to Altvater, many of those equipment issues have been fixed.
    The Office of Inspector General made several recommendations to the Passamaquoddy Tribe at Pleasant Point, including that it ensures PPHC is under the medical direction of a physician; establishes clear lines of authority and responsibility between medical and administrative decision‑making; and develops and implements medical policies and procedures to comply with health and safety requirements.
     In written comments on the draft report, tribal Chief Ralph Dana and Vice Chief Elizabeth Dana concurred with the recommendations and described actions that the tribe has taken or planned to take to address them. For example, the health center has solicited assistance from Indian Health Services to recruit a medical director to fulfill required physician responsibilities and has updated its position descriptions for health director and medical director to emphasize the separate administrative and medical roles.
     The tribe receives about $3.4 million under its annual Title 1 contract with Indian Health Services to operate the health center, which provides outpatient care to approximately 1,000 tribal members.