While the department was taking steps to address the issues uncovered on May 25, 2010, two Yadkin County commissioners, Brady Wooten and Kevin Austin began raising questions about the administration and management of the department.
Their questions led Wooten and Austin to attempt during the Wednesday, Aug. 8, regular meeting of the Yadkin County Commissioners to authorize the county to spend over $20,000 to have an outside consulting firm conduct a performance review of the health department.
Their attempt failed on a 3-2 vote during the commission meeting with commissioners David Moxley, Tommy Garner, and Commission Chairman Chad Wagoner voting against the performance audit.
Prior to the meeting last week, Austin, during an interview with the Ripple, expressed his reaction to learning about the possibility Yadkin County women might have developed cancer as a result of not being notified about an abnormal pap smear.
“I’m horrified. I can’t begin to express my feelings…if it was my wife or my daughter.(,) I don’t know what I would do,” said Austin on Friday, Sept. 3.
“They failed to do anything. They should have acted,” said Austin.
However, Yadkin County Health Department Director J. Michael Reavis and the department’s Director of Nursing Martha Powell counter they took steps to identify those possibly at risk once the notification issues were identified after an internal audit. While the internal (audit) was underway, said Reavis, the department requested the state also audit the records, policies and procedures for the pap smear follow-ups.
“Once the problem was identified, we responded appropriately to protect our clients,” said, Reavis Tuesday.
During an interview Monday at the department’s offices in Yadkinville, Reavis offered what the department has done and is doing to address the notification issues.
“We’ve gone back three years,” said Reavis Monday, “to make every reasonable attempt to locate any and all women whose pap smears returned from state testing with abnormal results.”
To accomplish this, said Reavis, the department has begun reviewing one by one the approximately 1,800 pap smears provided to clients over the last three years. The department is awaiting its request of the state to provide all abnormal pap smear results during the same time period.
Of those approximately 1,800 paps, said Powell, at least 30 abnormal results are returned requiring the initiation of a notification procedure.
There is no notification from the department for a normal pap smear unless the patient requests it, Reavis and Powell said.
However, in every case audited by the state, there was an initial attempt to notify the client of an abnormal pap, either by a telephone call or mail.
The notification issue was raised, said Reavis, once there was no contact with the woman after the initial attempt to alert her (of a potentially problematic result) that lead to the potential problems.
When the state conducted its on-site audit on Aug. 12-13, the department supplied 26 charts for the women whose pap smears had been returned with abnormal results between August 2009 and May 2010.
Of those, the state reported in its audit, 13 had received appropriate follow up based on a June 2009 policy, which created some of the notification issues raised on May 25, 2010. That June 2009 policy did not have a “documented time frame” in which to notify a woman with an abnormal pap.
The audit, which was conducted by Patricia Horton, RN, MPH and representing the Women & Children’s Health Section of the N.C. Department of Health and Human Services Division of Public Health, also found that:
• three of the 26 charts received follow up at four months
• one of the 26 charts received follow up at five months
• two of the 26 charts received follow up at six months • one of the 26 charts received follow up at 10 and a half months According to the audit reports “Some significant observations were made during the review.” They were:
• One patient was notified of abnormal pap on Feb. 12, 2010 and again by certified letter on June 2, 2010 by the Director of Nursing.
• Certified letters or patient notification were not provided to patients/clients based on no supporting documentation. In some of the records, some of the follow up was done three to four months later by the Director of Nursing.
• There were “patient aware” notes but no method of notification documented. Addressing those issues, Reavis and Powell have recommended to the Yadkin County Board of Health that “all clients will receive a second notification for abnormal pap smear results in the form of a certified letter (within a) in four to eight week period if there has been no response from client from initial notification.”
They have also recommended “all health department programs will continue with at least two people doing chart/program reviews. This is being done as a learning tool for staff and to ensure chart review is a shared event.”
Powell made it clear the Yadkin County Health Department will make every effort to find any and all the women over the last three years that had abnormal paps.
“If the circumstances dictate that we go out in the field and find that person, we will do what is beneficial for our client and the department,” said Powell.
Resignations, retirement, allegations of inappropriate e-mails and conflicts of interests
While the health department was attempting to address the potential problems with the pap notifications, other issues raised by Commissioners Brady Wooten and Austin have prompted action, and inaction, by the Yadkin County Board of Commissioners.
Wooten, as well as the Yadkin Ripple and another media outlet, has formally requested over 500 e-mails exchanged between Reavis and Health Board Chairman Dr. Keith Phillips from the time the pap issues were raised in May 2010 and through August 2010.
While there has been much speculation about the content of the e-mails, only Reavis, who according to state open records statutes is the custodian of the e-mails and ultimately responsible for their release, or not, to the public knows if the information is inappropriate.
On Tuesday, Reavis said he is working on preparing the over 600 e-mails in question for release. Acknowledging he hasn’t released the e-mails as quickly as some had hoped, Reavis said he has had to thoroughly examine the e-mails and redact any information that involved department personnel issues or patient/client information.
The county commission, however, convened an emergency meeting on Aug. 12, to authorize the hiring of attorneys from Womble Carlyle to inspect the e-mails in question and offer the county advice on how to archive and secure all of the electronic information stored on county computers in accordance with state statute. During the commission meeting last week, Womble Carlyle attorney Rick Rice was asked by Commissioner Tommy Garner about the e-mails. “Have you seen the e-mails in question?” asked Garner who then wanted to know what Rice had found. Rice responded, “I’m in no position to say that there was no criminal activity, but there are no violations of state or federal law.”
At the request of the commissioners, Yadkin County Manager Aaron Church had the e-mails in question compiled by a Yadkin County information technology specialist and saved on to six thumb or flash drives.
The thumb drives, said Church are stored in a secure location. At the meeting last week, Wooten offered commissioners a motion to have those e-mails examined during a closed board session. Austin seconded the motion. “We need to review this to do our job correctly,” said Wooten after he offered his motion to examine the e-mails.
Then Austin addressed the commission. “We ask(ed) the manager to provide the information on the thumb drives…so we can only view these e-mails in closed session so commission members don’t have possession of the e-mails.” Austin added, “I have no desire to view these e-mails…the intention is to view the relevant e-mails.”
Commission Chairman Wagoner then offered opinion on the e-mails and his view of the commission’s responsibility. “(We) do not have policing authority over the board of health.” Womble Carlyle’s Rice agreed. “We don’t have the authority. This (the e-mails) is an issue for the board of health” said Wagoner.
Austin disagreed by asking if the board of health was involved in a lawsuit and ordered to pay damages who would pay? Rice said the county would be the responsible party.
When the issue of reviewing the e-mails was put to a vote, Austin and Wooten voted to examine the e-mails. Wagoner, Garner and Moxley voted against the motion by Wooten.
But the questions raised about the content of the e-mail resulted in the resignation of Health Board Chairman Dr. Keith Phillips, Phillips in his resignation letter to the county commission wrote “Apparently forwarding emails that some may find offensive has had a negative impact on my ability to function as the chairman of this important board. The wrangling over these issues has deflected the focus from issues crucial to the health and safety of Yadkin County residents toward completely unrelated activities--and that is simply unacceptable.”
The commission accepted Dr Phillips resignation during its meeting last week.
And, while according to Reavis unrelated and coincidental, he announced his retirement as health department director on Aug. 18.
He said Monday that he and his wife had been looking for three years for the perfect retirement home, found it and recently closed on the property.
At least one member of the health board asked Wooten to be replaced as a health board member. “It appears to me that the representation from the Commissioners on the Health Board has a conflict of interest that has the potential to impact the judgement of that representation and ultimate decisions of the group. I believe that it will be in the best interests of the citizens of Yadkin County for the Commissioners to appoint an alternate Commissioner to serve on the Health Board other than Mr. Wooten,” wrote Vice Chairman of the Health Board Anne Watkins in an e-mail sent to Wooten.
Watkins also voiced the same concerns during the meeting last week. In the e-mail to Wooten and others obtained by the Ripple, Watkins offered the “factors that support this position (that Wooten should be replaced).” “Mr. Wooten was citied for environmental regulation violations several years ago, by the Department of Environmental Health and a significant fine was imposed upon Mr. Wooten as a result. The current Health Director had a role in generating those citations,” wrote Watkins. She also wrote of actions taken by Wooten attempting to gain access to Phillips’ e-mails and his attempt to have a performance review of the department before the commissioners heard from the health board about the results of the internal audit and the state audit concerning the pap smears. “It is my opinion that continued service as a member of the group to which the Health Director reports is a conflict of interest for Mr. Wooten,” wrote Watkins.
The issue of the audit is likely to appear again at the next Yadkin County Commission meeting on Sept. 20. The results of the investigation into the pap smear problems will be formally heard by the commissioners.