Audit 323095

FY End
2023-12-31
Total Expended
$76.11M
Findings
12
Programs
166
Organization: Lummi Indian Business Council (WA)
Year: 2023 Accepted: 2024-09-30

Organization Exclusion Status:

Checking exclusion status...

Findings

ID Ref Severity Repeat Requirement
500324 2023-002 Material Weakness - AB
500325 2023-002 Material Weakness - AB
500326 2023-003 Significant Deficiency - E
500327 2023-003 Significant Deficiency - E
500328 2023-004 Significant Deficiency - F
500329 2023-004 Significant Deficiency - F
1076766 2023-002 Material Weakness - AB
1076767 2023-002 Material Weakness - AB
1076768 2023-003 Significant Deficiency - E
1076769 2023-003 Significant Deficiency - E
1076770 2023-004 Significant Deficiency - F
1076771 2023-004 Significant Deficiency - F

Programs

ALN Program Spent Major Findings
93.210 Tribal Self-Governance Demonstration Program: Planning and Negotiation Ihs Compacts $18.03M Yes 2
15.022 Tribal Self-Governance $13.33M Yes 1
21.027 Covid-19 - Arpa - Slfrf $10.92M Yes 0
93.600 Head Start Yr 1 $3.90M - 0
15.042 Indian School Equalization Program $2.19M - 0
93.243 Lummi Nation Project Aware Application $1.75M - 0
21.026 Covid-19 - Haf $1.74M Yes 0
93.210 Covid-19 - Testing Ihs and Tribal Operated Programs $1.30M Yes 2
84.027 Idea - Special Educ. $1.28M - 0
93.829 Dhhs Samhsa - Expansion Ln Behavioral Health Svc $1.21M - 0
15.022 Indian Reservation Roads Program $1.06M Yes 1
11.463 South Fork Nooksack River Restoration $937,665 - 0
84.425 Covid-19 - Education Stabilization Fund-Arpa $934,464 - 0
10.912 Salmon Recovery $747,256 - 0
93.563 Child Support Enforcement $715,400 - 0
10.567 Fy20 Net $714,795 - 0
15.046 Administrative Costs $698,160 - 0
93.382 Dhhs - Ln Chap Project $635,242 - 0
93.772 Lummi Nation Public Health Accreditation Project $594,941 - 0
84.010 Title I $495,588 - 0
11.438 Recreation and Conservation (rco) South Fork Upper and Lower Fobes Ph2 Restoration $462,625 - 0
93.575 Covid-19 - Child Care and Development Block Grant $348,225 - 0
16.841 Doj Ovc Tribal Set-Aside Program $333,066 - 0
21.023 Covid-19 - Arpa - Era $297,764 - 0
93.933 Demonstration Projects for Indian Health $283,339 - 0
16.575 Health and Wellness Center Solar Pv Project $282,671 - 0
81.041 Low Income Solar Deployment $282,025 - 0
66.039 Diesel Emissions Reduction Act $271,883 - 0
93.237 Special Diabetes Program for Indians-Diabetes Prevention and Treatment Programs $268,379 - 0
16.608 Lummi Nation Drug Court Program $263,294 - 0
16.587 2021 Ovw Fiscal Year 2021 Grants to Indian Tribal Governments Program Solicitation $259,947 - 0
84.181 Early Learning Part C (3 to Prek) $257,066 - 0
66.121 Lummi Nation Puget Sound Tribal Capacity Building $254,075 - 0
97.036 Fema Shellfish Project D17-153 $200,000 - 0
93.575 Child Care and Development Fund $199,155 - 0
10.567 Fy13 Net $194,113 - 0
11.029 Tribal Broadband Connectivity Program $193,251 - 0
10.567 2020 Fdpir $185,811 - 0
16.575 Fy22 Ocla $166,620 - 0
11.438 Lummi Nation's Pacific Coast Salmon Recovery Grant Program 494.2020 $164,707 - 0
93.581 Dhhs Admin for Children & Families Improving Capability of Indian Tribal Govt to Regulate Envir. Quality $161,922 - 0
16.575 Tribal Government Initiative Year 2 $154,994 - 0
11.454 Covid-19 - Psmfc - Cares Act Funding for States $154,763 - 0
84.287 Early Learning Part B (birth to 3) $151,652 - 0
16.575 Voca by & for Victim Services $148,146 - 0
66.121 Health and Wellness Center Solar Pv Project $145,546 - 0
66.121 Fy-20 Epa Puget Sound Partnership Implementation $142,939 - 0
93.243 Lummi Nation Strategic Prevention Framework (spf) Project Grant $132,557 - 0
93.612 Lummi Nation Young People Re-Engagement Program (yrep) $127,171 - 0
16.024 Tribal Sexual Assault Services Program $120,447 - 0
16.585 Lummi Nation's Family Drug Court Grant Program $118,272 - 0
17.277 Wioa - Dislocated Workers $116,161 - 0
20.U03 Implement Gps Tracking of Lummi Transit Vehicles and New Bus Shelters $113,172 - 0
16.587 Violence Against Women (discretionary Grants for Tribal Governments) $112,856 - 0
16.838 Comprehensive Opioid, and Substance Abuse Program $112,404 - 0
81.041 Dept. of Energy-Low Income Community Solar Deployment $110,169 - 0
11.438 Fy19 Pcsrf $106,928 - 0
93.054 Native American Caregiver Support Program $105,991 - 0
16.320 Lummi Nation Services for Victims of Human Trafficking $102,987 - 0
16.841 Transforming Lummi Nation's Response to Elder Abuse $94,692 - 0
11.438 Fy19 Hatchery Genetic Management Plan $93,243 - 0
93.778 Hca Funding $91,945 - 0
11.307 Lummi Vendor Marketplace $90,570 - 0
15.663 National Fish and Wildlife $90,524 - 0
93.600 Head Start $88,652 - 0
97.036 Fema Lummi Nation Pump Repair $85,771 - 0
93.072 Fy21 Kinship Navigator $84,954 - 0
84.425 Covid-19 - Cares Act -Doe/geer I $79,811 - 0
93.071 Nutrition Services Incentive Program $79,076 - 0
93.958 State - Youth Mentoring Program $77,928 - 0
15.631 Srfb $76,987 - 0
15.044 Transportation $71,490 - 0
10.594 Fy22 Fdpir Nutrition Education $63,031 - 0
93.072 Fy19 Kinship Navigator $61,360 - 0
16.841 Lummi Nation Ctas PA 7- Lvoc Grant Program $58,532 - 0
84.250 Vocational Rehabilitation $56,382 - 0
93.959 Supported Housing and Employment $55,782 - 0
84.060 Indian Education - Grants to Local Educational Agencies $53,608 - 0
84.336 Title IV-B $52,238 - 0
11.438 Nwifc - Evaluation of Temporal & Spatial Distribution of Returning S. Fork Chinook Adults $49,895 - 0
84.424 Education Stabilization Fund-Arpa Geer III $47,838 - 0
11.302 Conduct and Implement Economic Development Strategies $47,823 - 0
10.557 Special Supplemental Nutrition Program for Women, Infants and Children (wic) $45,486 - 0
11.438 Recreation and Conservation (rco) Sf Nooksack Skookum Edfro Ph 3 Design $42,125 - 0
11.477 Fishery Disaster Funding $41,390 - 0
15.148 Energy Department Capacity Project $40,866 - 0
15.639 South Fork Cavanaugh Island Restoration $40,000 - 0
15.069 Zoonoic Disease Initiative $38,579 - 0
66.605 Performance Partnership Grant $38,091 - 0
20.205 St Wa Wsdot Lummi Transit Infrastructure for Bus Shelters $37,973 - 0
10.567 Op Council, Emergency Rental Assistance $36,453 - 0
10.594 Fy21 Fdpir Nutrition Education $31,874 - 0
11.U01 Interagency Agreement $31,668 - 0
93.047 Title Vi, Part A & B $29,563 - 0
15.531 Wria 1 Lead Entity $29,000 - 0
93.568 Dhhs Admin for Children & Families Low Income Home Energy Asst. Prgrm $28,257 - 0
10.567 Fy18 Net $24,728 - 0
10.567 Covid-19 - Fdpir: Cares Act: Facility Improvements & Equipment Upgrades $24,662 - 0
97.036 Fema - Disaster Declaration $23,167 - 0
66.121 Epa Puget Sound Partnership Implementation $21,818 - 0
15.631 Psar-Lead Entity Contracts $21,122 - 0
20.U02 Fy17-19 Public Transportation on Indian Reservations Formula Apportionments $20,424 - 0
93.596 Child Care and Development Fund $19,724 - 0
20.509 Covid-19 - Cares Act 5311 Ttp Formula Grant $17,307 - 0
11.473 National Fish and Wildlife Creating Resilience Plan for Lummi Reservation $16,872 - 0
97.036 Fema-Building Resilient Infrastructure/communities $15,299 - 0
11.438 Fy20 Pcsrf $14,254 - 0
16.710 Tribal Resources Grant Program- Equipment $14,246 - 0
15.904 Historic Preservation Fund Grants-in-Aid $14,029 - 0
93.959 Indian Child Welfare Services $13,225 - 0
10.912 Wetland Restoration Agreement $13,190 - 0
11.438 Nwifc-Hatchery Reform Contract $12,711 - 0
93.671 Covid-19 - Arp Fvpvs $12,124 - 0
20.205 Highway Planning and Construction $11,641 - 0
15.032 Indian Economic Development $10,810 - 0
93.788 Dhhs Samhsa - Ln Opioid Grant Prevention Treatment & Aftercare $10,615 - 0
93.054 Covid-19 - Tcc6 American Resuce Plan (arp) for Oaa Title Vi Part C $9,927 - 0
11.429 Lummi Nation Pacific Northwest Bwet $9,085 - 0
93.590 Tribal Fatherhood Support Programs $9,060 - 0
84.299 Lummi Marine Trades Nycp $8,942 - 0
15.130 Jom $8,225 - 0
93.569 Community Services Block Grant $7,052 - 0
93.047 Covid-19 - Arp for Oaa Title Vi Part A/b $6,906 - 0
10.565 Fy22 Csfp $6,770 - 0
93.671 Family Violence Prevention & Services $5,764 - 0
93.791 Money Follows the Person Tribal Initiative $5,013 - 0
10.565 Wa State Department of Agriculture Food Assistance $4,872 - 0
93.069 Public Health Emergency Preparedness $4,507 - 0
93.053 Nutrition Services Incentive Program $4,417 - 0
15.148 Tribal Energy Development Capacity Grants $4,000 - 0
11.438 Nooksack River Early Chinook $3,901 - 0
20.U01 Covid-19 - Y21 Arp Tribal Transit Program $3,643 - 0
93.575 Construction and Renovation of Childcare Facilities $2,949 - 0
11.438 Mf Porter Creek Reach Ph2 Restoration $2,836 - 0
15.151 Enhancement Funds $2,797 - 0
16.710 Ctas Purpose Area #1: Cops Office Tribal Resources Grant Program $2,476 - 0
11.438 Engineering Services for Lummi Bay Hatchery Raceways $1,892 - 0
15.149 Focus $1,670 - 0
10.565 Fy21 Csfp $1,533 - 0
93.047 Nutrition Services Incentive Program $1,346 - 0
10.567 Fy19 Net $1,192 - 0
84.358 Idea - Small, Rural School Achievement Program $1,083 - 0
93.594 Native Employment Works Program $1,030 - 0
93.788 Lummi Nation's Tribal Opioid Response Program Application $1,014 - 0
93.243 Dhhs Samhsa Native Connections Project $861 - 0
16.025 Special Domestic Violence Criminal Jurisdiction Program $384 - 0
11.438 Wria 1 Salmon Recovery Board Lead Entity $380 - 0
93.243 Lummi Nation Medication Assisted Treatment Expansion Project $364 - 0
11.454 Covid-19 - Psmfc - Cares Act Funding $250 - 0
16.585 Fy16 Family Drug Court Implementation & Enhancement Program $104 - 0
84.181 Idea - Special Educ. $19 - 0
15.U01 Forestry on Indian Lands $-2 - 0
93.421 Nihb Climate Ready Tribes $-123 - 0
21.019 Covid-19 - Federal Coronavirus Relief Funds (crf) for Tribal Governments $-2,426 - 0
11.438 Fy12 Pcsrf $-3,118 - 0
10.567 Covid-19 - Fy21 Fdpir-Cares Act Supplemental Admin Grant $-3,600 - 0
11.307 Covid-19 - Cares Eda Economic Adjustment Assistance $-5,463 - 0
11.438 Fy15 Pcsrf $-5,775 - 0
93.587 Lummi Nation Language Instruction $-6,420 - 0
93.047 Covid-19 - Families First Coronavirus Response Act $-11,387 - 0
16.588 Fy20 Stop $-11,806 - 0
11.438 Fy16 Pcsrf $-12,885 - 0
11.438 Lummi Nation's South Fork Nooksack Chinook Rescue Program $-28,501 - 0
93.047 Covid-19 - (nac3) Cares Act for Nutrition Services for Native American Programs Under Title Vi of the Oaa $-28,721 - 0
93.391 Covid-19 - Supporting Tribal Public Health Capacity in Coronavirus Preparedness and Response $-36,269 - 0
93.568 Low-Income Home Energy Assistance $-160,244 - 0

Contacts

Name Title Type
TP4UB9N6TSA5 Anthony Madera Auditee
3603847181 Shane Cox Auditor
No contacts on file

Notes to SEFA

Title: BASIS OF PRESENTATION Accounting Policies: Expenditures reported on the Schedule are reported on the modified accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. Pass-through entity identifying numbers are presented where available. De Minimis Rate Used: N Rate Explanation: The Department has elected to not use the 10-percent de minimis indirect cost rate allowed under the Uniform Guidance. The accompanying schedule of expenditures of federal and nonfederal awards (the Schedule) includes the federal award activity of the Governmental Department (the Department) of the Lummi Indian Business Council under programs of the federal government (as well as programs funded by nonfederal grantor sources) for the year ended December 31, 2023. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Because the Schedule presents only a selected portion of the operations of the Department, it is not intended to and does not present the financial position, changes in net position, or cash flows of the Department.
Title: ASSISTANCE LISTING NUMBERS Accounting Policies: Expenditures reported on the Schedule are reported on the modified accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. Pass-through entity identifying numbers are presented where available. De Minimis Rate Used: N Rate Explanation: The Department has elected to not use the 10-percent de minimis indirect cost rate allowed under the Uniform Guidance. Every attempt has been made to determine the correct Assistance Listing (AL) and award numbers for the federal award programs reported on this Schedule. When the federal agency making the award has not provided the AL number and when the appropriate number has not been determined, the number in the AL number column represents the two-digit federal department number as the prefix of the AL number and the suffix has been listed as unknown (UNK). When an award number for a grant could not be obtained, the column for the award number was left blank for the particular award.
Title: NONCASH AWARDS Accounting Policies: Expenditures reported on the Schedule are reported on the modified accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. Pass-through entity identifying numbers are presented where available. De Minimis Rate Used: N Rate Explanation: The Department has elected to not use the 10-percent de minimis indirect cost rate allowed under the Uniform Guidance. The amount of commodities reported on the Schedule for AL #10.567 (no grant identification number provided) is the value of $194,113 distributed by the Department during the current year and priced as prescribed by value at the time of distribution.
Title: DONATED PERSONAL PROTECTIVE EQUIPMENT (UNAUDITED) Accounting Policies: Expenditures reported on the Schedule are reported on the modified accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. Pass-through entity identifying numbers are presented where available. De Minimis Rate Used: N Rate Explanation: The Department has elected to not use the 10-percent de minimis indirect cost rate allowed under the Uniform Guidance. The Department did not receive any donated Personal Protective Equipment (PPE) during the year ended December 31, 2023.

Finding Details

Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1) Condition/Context: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. [ ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: High staff turnover and lack of qualified personnel. Effect: Without proper supervisor approval, unallowable entries could be posted to the program. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend the Department to follow their policy and procedures that all journal entries are reviewed and approved by management prior to posting. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1) Condition/Context: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. [ ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: High staff turnover and lack of qualified personnel. Effect: Without proper supervisor approval, unallowable entries could be posted to the program. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend the Department to follow their policy and procedures that all journal entries are reviewed and approved by management prior to posting. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: The Department must establish and maintain internal controls designed to reasonably ensure compliance with eligibility. The Department must also establish policies and procedures related to eligibility requirements. Condition/Context: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There was a lack of record retention and the ability to locate information from prior years. Effect: Individuals that are not eligible for services may have received services. Questioned Costs: None. Repeat Finding: No. Recommendation: Management should reexamine processes and controls over participant eligibility to ensure all documentation is obtained and retained for all participants, regardless of whether the program staff are familiar with the program participant or not. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: The Department must establish and maintain internal controls designed to reasonably ensure compliance with eligibility. The Department must also establish policies and procedures related to eligibility requirements. Condition/Context: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There was a lack of record retention and the ability to locate information from prior years. Effect: Individuals that are not eligible for services may have received services. Questioned Costs: None. Repeat Finding: No. Recommendation: Management should reexamine processes and controls over participant eligibility to ensure all documentation is obtained and retained for all participants, regardless of whether the program staff are familiar with the program participant or not. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 15.022 U.S. Department of the Interior Tribal Self-Governance/Indian Reservation Roads Program Award Numbers: GT-OSGT107-10/A16AP00068 Award Periods: 1/1/2011 – 12/31/2023 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1). Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal award identification number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). A physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years (2 CFR section 200.313(d)(2)). A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR section 200.313(d)(3)). Condition/Context: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. [ ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Turnover in key personnel, lack of internal controls, and the inability to provide supporting documentation. Effect: Without review and approval of the physical inventory listing, it is possible the reconciliation to property records may not occur. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend that physical inventory is taken, that the results are reconciled with the property records at least once every 2 years, and that documentation of this process is stored for review at a later date. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 15.022 U.S. Department of the Interior Tribal Self-Governance/Indian Reservation Roads Program Award Numbers: GT-OSGT107-10/A16AP00068 Award Periods: 1/1/2011 – 12/31/2023 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1). Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal award identification number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). A physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years (2 CFR section 200.313(d)(2)). A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR section 200.313(d)(3)). Condition/Context: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. [ ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Turnover in key personnel, lack of internal controls, and the inability to provide supporting documentation. Effect: Without review and approval of the physical inventory listing, it is possible the reconciliation to property records may not occur. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend that physical inventory is taken, that the results are reconciled with the property records at least once every 2 years, and that documentation of this process is stored for review at a later date. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1) Condition/Context: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. [ ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: High staff turnover and lack of qualified personnel. Effect: Without proper supervisor approval, unallowable entries could be posted to the program. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend the Department to follow their policy and procedures that all journal entries are reviewed and approved by management prior to posting. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1) Condition/Context: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. [ ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: High staff turnover and lack of qualified personnel. Effect: Without proper supervisor approval, unallowable entries could be posted to the program. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend the Department to follow their policy and procedures that all journal entries are reviewed and approved by management prior to posting. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: The Department must establish and maintain internal controls designed to reasonably ensure compliance with eligibility. The Department must also establish policies and procedures related to eligibility requirements. Condition/Context: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There was a lack of record retention and the ability to locate information from prior years. Effect: Individuals that are not eligible for services may have received services. Questioned Costs: None. Repeat Finding: No. Recommendation: Management should reexamine processes and controls over participant eligibility to ensure all documentation is obtained and retained for all participants, regardless of whether the program staff are familiar with the program participant or not. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: The Department must establish and maintain internal controls designed to reasonably ensure compliance with eligibility. The Department must also establish policies and procedures related to eligibility requirements. Condition/Context: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There was a lack of record retention and the ability to locate information from prior years. Effect: Individuals that are not eligible for services may have received services. Questioned Costs: None. Repeat Finding: No. Recommendation: Management should reexamine processes and controls over participant eligibility to ensure all documentation is obtained and retained for all participants, regardless of whether the program staff are familiar with the program participant or not. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 15.022 U.S. Department of the Interior Tribal Self-Governance/Indian Reservation Roads Program Award Numbers: GT-OSGT107-10/A16AP00068 Award Periods: 1/1/2011 – 12/31/2023 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1). Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal award identification number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). A physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years (2 CFR section 200.313(d)(2)). A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR section 200.313(d)(3)). Condition/Context: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. [ ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Turnover in key personnel, lack of internal controls, and the inability to provide supporting documentation. Effect: Without review and approval of the physical inventory listing, it is possible the reconciliation to property records may not occur. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend that physical inventory is taken, that the results are reconciled with the property records at least once every 2 years, and that documentation of this process is stored for review at a later date. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Program Information: Assistance Listing #: 15.022 U.S. Department of the Interior Tribal Self-Governance/Indian Reservation Roads Program Award Numbers: GT-OSGT107-10/A16AP00068 Award Periods: 1/1/2011 – 12/31/2023 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1). Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal award identification number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). A physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years (2 CFR section 200.313(d)(2)). A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR section 200.313(d)(3)). Condition/Context: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. [ ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Turnover in key personnel, lack of internal controls, and the inability to provide supporting documentation. Effect: Without review and approval of the physical inventory listing, it is possible the reconciliation to property records may not occur. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend that physical inventory is taken, that the results are reconciled with the property records at least once every 2 years, and that documentation of this process is stored for review at a later date. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.