Audit 334164

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.

2023-002 — Eligibility – Material Weakness in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: In accordance with the Center’s policy and federal guidelines, to be eligible for healthcare services under the Urban Indian Health Service program, an adult individual must provide documentation to the Center that would indicate that they are an enrolled member of a federally recognized Tribe. An individual could prove their enrollment status by submitting a copy of their tribal identification card or certificate of degree of Indian blood (CDIB). Condition: Five of the twenty-five individual files reviewed did not contain valid documentation of Tribal identification that would indicate that these five individuals are members of a federally recognized Tribe. Questioned Costs: None. Cause: The Center did not have a process in place that requires individuals to submit their eligibility documentation during their initial visit. As a result, healthcare services were provided to the five individuals without having their eligibility documents on file. Effect: Without a process in place that requires obtaining and reviewing eligibility documents for all applicants prior to providing healthcare services under the Urban Indian Health Services Program, the risk of noncompliance with eligibility requirements increases. Auditor’s Recommendations: We recommend developing and implementing internal control policies and procedures to ensure that healthcare services under the Urban Indian Health Services Program are not provided until all required eligibility documents have been obtained, verified, and filed. In addition, we recommend training to staff and clear communication to applicants regarding documentation requirements. Management Response: All Nations Health Center recognizes this material weakness as part of the insufficient training of all front desk staff. All Nations has reviewed the policies and procedures for front staff duties and responsibilities and has re-trained its staff to ensure we collect all pertinent documentation for all patients classified as “beneficiaries.” If the proper documentation is not obtained, the patient status will remain as “nonbeneficiary".

2023-003 — Allowable Cost/Allowable Activities – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Urban Indian Health Service ALN number: 93.193 Award years and number: 1/1/2018–12/31/2022, 75H70921C00004 & H722IHS0138-20-00 Pass-through entity: (if applicable) N/A Criteria: According to the Uniform Guidance (2 CFR § 200.303 - Internal Controls) and the Center’s internal control policies, adequate documentation must be maintained to support all transactions, including evidence of approval and authorization by designated personnel. Condition: 2 of the 25 nonpayroll transactions tested did not have the required approval and authorization forms retained, thus, the auditor could not verify if the expenses were properly approved and authorized. Questioned Costs: None. Cause: Management has not designed a proper system of internal control to ensure that all nonpayroll disbursements have authorized supporting documentation. Effect: Without a proper authorization process, unallowable costs or activities may be charged to the federal program, which could lead to the withdrawal of funding from the federal government. Auditor’s Recommendations: Management should design and implement an internal control system that properly maintains the required documentation. Management Response: All Nations Health Center has a more lenient approval process for must have charges that are under the “auto-pay” status. All Nations has moved away from this leniency and will require all “auto-pay” must have charges to go through the regular approval process.

2023-004 — Single Audit Report Submission – Significant Deficiency in Internal Controls Over Compliance and Noncompliance Federal program information: Funding agency: All Major Programs Title: All Major Programs ALN number: All Major Programs Award years and number: All Major Programs Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor’s report or 9 months after the end of the fiscal year, whichever comes first. Condition: The Center’s fiscal year 2023 single audit reporting package was not submitted within nine months after the end of the audit period. Questioned Costs: None. Cause: The Center did not have appropriate internal control policies and procedures in place to ensure accounting records and financial statements were reconciled timely and the audit conducted to meet compliance requirements. Effect: As a result of not timely reconciling accounting records and financial statements, the single audit reporting package was submitted after the required reporting time period. Auditor’s Recommendations: To ensure compliance with the Uniform Guidance, the Center should prepare accurate, complete and timely financial statements and ensure an audit is performed to ensure the timely submission of the Single Audit reporting package. Management Response: The Center concurs with this finding, and intends to identify appropriate resources and implement procedures necessary for timely submission of the Single Audit report in the future.