SIOUX FALLS, S.D. — The internal watchdog of the U.S. Department of Health and Human Services says the often-substandard quality of care at hospitals serving Native Americans is the result of outdated equipment and technology, lack of resources and difficulty attracting and keeping skilled staff.

The Office of Inspector General on Friday released two reports that look into the longstanding challenges of the 28 hospitals directly operated by the federal Indian Health Service. The OIG, which acknowledged that reports of inadequate health care services for Native Americans have been of concern to the federal government for almost a century, criticized the agency’s limited oversight regarding compliance with federal regulations and quality of care, detailing how the agency’s regional administrators have few sources of information to assess the services provided at the facilities.

The Indian Health Service, commonly referred to as IHS, is responsible for providing health care services to enrolled tribal members as part of the government’s treaty obligations to Native American tribes. But the agency has faced challenges for decades, and within the past year it has been under increased scrutiny from Congress after inspections of hospitals in the Great Plains uncovered severe deficiencies.

The OIG says IHS’s eight regional offices conduct activities to monitor the quality of the facilities, but those efforts are minimal in some areas. One of the reports states that the primary source of information that the regional offices use to detect quality problems is a small number of complaints and patient harm reports.

“However, according to hospital administrators, most patient complaints relate to customer service and wait times, rather than medical care,” according to the report. “Further, most hospitals (20 of 28) receive fewer than 100 complaints per year for inpatient and outpatient visits combined, averaging about 1 complaint per 1,000 patient visits. … Considering the quantity and subject matter of complaints and patient harm reports, they are unlikely to provide hospital staff with the breadth of information needed to identify and diagnose systemic quality or compliance breakdowns.”

The OIG, which gathered the information for the reports between April and October 2014, also said that only half of the regional offices conducted mock inspection surveys that could provide insight regarding the facilities’ quality practices. The watchdog also faulted the IHS for staggering findings of outdated facilities and the weekslong process that job applicants must follow, even when the physician vacancy rate was 33 percent at the time the information for the reports was gathered.

According to the report, in 15 of the 28 hospitals, administrators reported that aging or inadequate physical environments affected their ability to give quality care. Corroded pipes in one hospital caused sewage to leak into the operating room.

The IHS has now been under scrutiny for more than a year after inspectors from the Centers for Medicare and Medicaid Services, known as CMS, found several quality-of-care deficiencies at hospitals in South Dakota and Nebraska. At one facility, the alarming conditions of its emergency room led officials to close it for seven months.

The OIG on Friday recommended that CMS inspectors survey IHS facilities more frequently.

The IHS in a statement Friday concurred with recommendations made by the OIG, including the need for more training for staffers and new ways to monitor hospital quality. The IHS also said it began a mock survey initiative at 26 hospitals in May 2016 to assess compliance with the standards that facilities must meet to be able to participate in the Medicare program.

The IHS’s statement also highlighted a team that was formed in February 2016 “to ensure that dependable, quality care is delivered consistently across IHS facilities.”

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Associated Press writer James Nord contributed to this report from Pierre, South Dakota.