Audit 342683

Criteria: An individual must meet the eligibility requirements as defined by Federal regulations published in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health Services, Part 2, Chapter 3, “Contract Health Services” dated January 5, 1998. Condition: Of the 60 participant files reviewed, the following was noted: • 60 samples out of 60 did not have record of review and approval separate from the person entering the information. • 6 samples out of 60 did not have proper proof of tribal membership to receive medical services and/or proper proof of residence covering the testing period to receive medical services. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period, along with lack of management oversight. Effect: By not ensuring proper reviews are occurring by a supervisor or other authorized individual, inaccurate information may have been entered into the online system, and ineligible participants could be receiving benefits. Questioned Costs: Not applicable. Repeat Finding: Yes, 2022-004 and 2023-001. Recommendation: We recommend that the Clinic adhere to program policies and procedures as documented and the files are reviewed annually for completeness, and that review of the online checklist is reviewed by someone other than the Patient Care Representative, and that this review is documented and maintained for review at a later date. Views of Responsible Officials and Planned Corrective Action: The Clinic will review all patient files to ensure all applicable documentation is located within each file. Any applicable documentation that is missing from the file will be requested from the patient to verify continued eligibility or services will be terminated. The Clinic will also implement an approval process for new patients to ensure patient eligibility is reviewed and approved prior to providing services.

Criteria: An individual must meet the eligibility requirements as defined by Federal regulations published in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health Services, Part 2, Chapter 3, “Contract Health Services” dated January 5, 1998. Condition: Of the 60 participant files reviewed, the following was noted: • 60 samples out of 60 did not have record of review and approval separate from the person entering the information. • 6 samples out of 60 did not have proper proof of tribal membership to receive medical services and/or proper proof of residence covering the testing period to receive medical services. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period, along with lack of management oversight. Effect: By not ensuring proper reviews are occurring by a supervisor or other authorized individual, inaccurate information may have been entered into the online system, and ineligible participants could be receiving benefits. Questioned Costs: Not applicable. Repeat Finding: Yes, 2022-004 and 2023-001. Recommendation: We recommend that the Clinic adhere to program policies and procedures as documented and the files are reviewed annually for completeness, and that review of the online checklist is reviewed by someone other than the Patient Care Representative, and that this review is documented and maintained for review at a later date. Views of Responsible Officials and Planned Corrective Action: The Clinic will review all patient files to ensure all applicable documentation is located within each file. Any applicable documentation that is missing from the file will be requested from the patient to verify continued eligibility or services will be terminated. The Clinic will also implement an approval process for new patients to ensure patient eligibility is reviewed and approved prior to providing services.

Criteria: Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR Part 200. Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the suspension and debarment standards set out at 2 CFR Part 180, which implements Executive Orders 12549 and 12689, “Debarment and Suspension,” federal awarding agency regulations in Title 2 of the CFR adopting/implementing the OMB guidance in 2 CFR Part 180; program legislation; and the terms and conditions of the award. Condition: During transactional testing, the following was noted: • 93.441 – 4 out of 6 vendors reviewed did not have evidence of multiple competitive bids being obtained. Additionally, there are no consistent processes in place to check to ensure vendors are not suspended or debarred prior to conducting business. • 93.441 – 4 out of 6 vendors reviewed did not have evidence or processes in place to check to ensure vendors were not suspended or debarred prior to conducting business. None of the 6 vendors were suspended of debarred. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period over procurement, along with lack of management oversight. Effect: The Clinic is not enacting fair competition in the procurement process nor are they following their policies by making sure bidding support is provided before the appropriate officials sign the Purchase Order. Additionally, the Clinic may be paying vendors that are suspended and debarred which would be an unallowable cost. Questioned Costs: AL#: 93.441 Known: Procurement- $71,963. Repeat Finding: Yes, 2022-007 and 2023-004. Recommendation: We recommend the Clinic conduct training for staff and program managers to review the Clinic’s procurement and suspension and debarment policies and procedures along with federal regulations. Views of Responsible Officials and Planned Corrective Action: The Clinic will review the procurement standards set forth at 2 CFR part 200 and will update the procurement and purchasing policies to comply with all required purchasing standards. All vendors will be required to submit and certify a statement regarding debarment and suspension prior to contract award.

Criteria: Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR Part 200. Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the suspension and debarment standards set out at 2 CFR Part 180, which implements Executive Orders 12549 and 12689, “Debarment and Suspension,” federal awarding agency regulations in Title 2 of the CFR adopting/implementing the OMB guidance in 2 CFR Part 180; program legislation; and the terms and conditions of the award. Condition: During transactional testing, the following was noted: • 93.441 – 4 out of 6 vendors reviewed did not have evidence of multiple competitive bids being obtained. Additionally, there are no consistent processes in place to check to ensure vendors are not suspended or debarred prior to conducting business. • 93.441 – 4 out of 6 vendors reviewed did not have evidence or processes in place to check to ensure vendors were not suspended or debarred prior to conducting business. None of the 6 vendors were suspended of debarred. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period over procurement, along with lack of management oversight. Effect: The Clinic is not enacting fair competition in the procurement process nor are they following their policies by making sure bidding support is provided before the appropriate officials sign the Purchase Order. Additionally, the Clinic may be paying vendors that are suspended and debarred which would be an unallowable cost. Questioned Costs: AL#: 93.441 Known: Procurement- $71,963. Repeat Finding: Yes, 2022-007 and 2023-004. Recommendation: We recommend the Clinic conduct training for staff and program managers to review the Clinic’s procurement and suspension and debarment policies and procedures along with federal regulations. Views of Responsible Officials and Planned Corrective Action: The Clinic will review the procurement standards set forth at 2 CFR part 200 and will update the procurement and purchasing policies to comply with all required purchasing standards. All vendors will be required to submit and certify a statement regarding debarment and suspension prior to contract award.

Criteria: An individual must meet the eligibility requirements as defined by Federal regulations published in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health Services, Part 2, Chapter 3, “Contract Health Services” dated January 5, 1998. Condition: Of the 60 participant files reviewed, the following was noted: • 60 samples out of 60 did not have record of review and approval separate from the person entering the information. • 6 samples out of 60 did not have proper proof of tribal membership to receive medical services and/or proper proof of residence covering the testing period to receive medical services. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period, along with lack of management oversight. Effect: By not ensuring proper reviews are occurring by a supervisor or other authorized individual, inaccurate information may have been entered into the online system, and ineligible participants could be receiving benefits. Questioned Costs: Not applicable. Repeat Finding: Yes, 2022-004 and 2023-001. Recommendation: We recommend that the Clinic adhere to program policies and procedures as documented and the files are reviewed annually for completeness, and that review of the online checklist is reviewed by someone other than the Patient Care Representative, and that this review is documented and maintained for review at a later date. Views of Responsible Officials and Planned Corrective Action: The Clinic will review all patient files to ensure all applicable documentation is located within each file. Any applicable documentation that is missing from the file will be requested from the patient to verify continued eligibility or services will be terminated. The Clinic will also implement an approval process for new patients to ensure patient eligibility is reviewed and approved prior to providing services.

Criteria: An individual must meet the eligibility requirements as defined by Federal regulations published in Code of Federal Regulations (CFR), at Title 42, Section 136.21 through 136.25, and Indian Health Services, Part 2, Chapter 3, “Contract Health Services” dated January 5, 1998. Condition: Of the 60 participant files reviewed, the following was noted: • 60 samples out of 60 did not have record of review and approval separate from the person entering the information. • 6 samples out of 60 did not have proper proof of tribal membership to receive medical services and/or proper proof of residence covering the testing period to receive medical services. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period, along with lack of management oversight. Effect: By not ensuring proper reviews are occurring by a supervisor or other authorized individual, inaccurate information may have been entered into the online system, and ineligible participants could be receiving benefits. Questioned Costs: Not applicable. Repeat Finding: Yes, 2022-004 and 2023-001. Recommendation: We recommend that the Clinic adhere to program policies and procedures as documented and the files are reviewed annually for completeness, and that review of the online checklist is reviewed by someone other than the Patient Care Representative, and that this review is documented and maintained for review at a later date. Views of Responsible Officials and Planned Corrective Action: The Clinic will review all patient files to ensure all applicable documentation is located within each file. Any applicable documentation that is missing from the file will be requested from the patient to verify continued eligibility or services will be terminated. The Clinic will also implement an approval process for new patients to ensure patient eligibility is reviewed and approved prior to providing services.

Criteria: Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR Part 200. Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the suspension and debarment standards set out at 2 CFR Part 180, which implements Executive Orders 12549 and 12689, “Debarment and Suspension,” federal awarding agency regulations in Title 2 of the CFR adopting/implementing the OMB guidance in 2 CFR Part 180; program legislation; and the terms and conditions of the award. Condition: During transactional testing, the following was noted: • 93.441 – 4 out of 6 vendors reviewed did not have evidence of multiple competitive bids being obtained. Additionally, there are no consistent processes in place to check to ensure vendors are not suspended or debarred prior to conducting business. • 93.441 – 4 out of 6 vendors reviewed did not have evidence or processes in place to check to ensure vendors were not suspended or debarred prior to conducting business. None of the 6 vendors were suspended of debarred. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period over procurement, along with lack of management oversight. Effect: The Clinic is not enacting fair competition in the procurement process nor are they following their policies by making sure bidding support is provided before the appropriate officials sign the Purchase Order. Additionally, the Clinic may be paying vendors that are suspended and debarred which would be an unallowable cost. Questioned Costs: AL#: 93.441 Known: Procurement- $71,963. Repeat Finding: Yes, 2022-007 and 2023-004. Recommendation: We recommend the Clinic conduct training for staff and program managers to review the Clinic’s procurement and suspension and debarment policies and procedures along with federal regulations. Views of Responsible Officials and Planned Corrective Action: The Clinic will review the procurement standards set forth at 2 CFR part 200 and will update the procurement and purchasing policies to comply with all required purchasing standards. All vendors will be required to submit and certify a statement regarding debarment and suspension prior to contract award.

Criteria: Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the procurement standards set out at 2 CFR Sections 200.318 through 200.326. They must use their own documented procurement procedures, which reflect applicable state and local laws and regulations, provided that the procurements conform to applicable Federal statutes and the procurement requirements identified in 2 CFR Part 200. Nonfederal entities other than States, including those operating Federal programs as subrecipients of States, must follow the suspension and debarment standards set out at 2 CFR Part 180, which implements Executive Orders 12549 and 12689, “Debarment and Suspension,” federal awarding agency regulations in Title 2 of the CFR adopting/implementing the OMB guidance in 2 CFR Part 180; program legislation; and the terms and conditions of the award. Condition: During transactional testing, the following was noted: • 93.441 – 4 out of 6 vendors reviewed did not have evidence of multiple competitive bids being obtained. Additionally, there are no consistent processes in place to check to ensure vendors are not suspended or debarred prior to conducting business. • 93.441 – 4 out of 6 vendors reviewed did not have evidence or processes in place to check to ensure vendors were not suspended or debarred prior to conducting business. None of the 6 vendors were suspended of debarred. Context: The audit findings represent a systematic problem, see condition above. Cause: There were ineffective controls in place during the period over procurement, along with lack of management oversight. Effect: The Clinic is not enacting fair competition in the procurement process nor are they following their policies by making sure bidding support is provided before the appropriate officials sign the Purchase Order. Additionally, the Clinic may be paying vendors that are suspended and debarred which would be an unallowable cost. Questioned Costs: AL#: 93.441 Known: Procurement- $71,963. Repeat Finding: Yes, 2022-007 and 2023-004. Recommendation: We recommend the Clinic conduct training for staff and program managers to review the Clinic’s procurement and suspension and debarment policies and procedures along with federal regulations. Views of Responsible Officials and Planned Corrective Action: The Clinic will review the procurement standards set forth at 2 CFR part 200 and will update the procurement and purchasing policies to comply with all required purchasing standards. All vendors will be required to submit and certify a statement regarding debarment and suspension prior to contract award.