Corrective Action Plan
Finding # 1 SPECIAL TESTS AND PROVISIONS Title 42 of the Code of Federal Regulations (CFR), Subpart K - Indian Child Protection and Family Violence Prevention, §136.404, states that "All Indian Tribes or Tribal organization receiving funds under the authority of the I...
Corrective Action Plan
Finding # 1 SPECIAL TESTS AND PROVISIONS Title 42 of the Code of Federal Regulations (CFR), Subpart K - Indian Child Protection and Family Violence Prevention, §136.404, states that "All Indian Tribes or Tribal organization receiving funds under the authority of the ISDEA must identify those positions that permit regular contact with or control over Indian children; conduct an investigation of the character of each individual who is employed or is being considered for employment in a position that involves regular contact with or control over Indian children; and employ only individuals who meet standards of character that are no less stringent that those prescribed by regulations in this subpart." §136.406 goes on to clarify that "the minimum standards of
character shall be considered met only after the individual has been the subject of a satisfactory background investigation" which must include "a criminal background check, which includes a fingerprint check through the Criminal Justice Information Services Division of the Federal Bureau of Investigation (FBI), under procedures approved by the FBI." It was noted during testing performed over Chapa-De Indian Health Program, Inc.’s (the Organization) compliance with the provisions of its IHS Compact funding agreement, that no employees underwent a fingerprint check through the Criminal Justice Information Services Division of the FBI either before hiring, or during the year under audit because its application to gain access through fingerprinting to FBI
criminal records was denied by the California Attorney General’s Office due to lack of statutory authority that allows the Organization to receive such information. Recommendation - On January 11, 2023, the Organization obtained approval from the California Attorney General’s Office to receive federal criminal offender record information. However, identification of covered individuals, and actual fingerprinting did not begin until after the year under audit. It appears that the Organization has been granted the access required to comply with 42 CFR §136.406. We recommend that the Organization establish written policies for determining which employees and applicants should undergo fingerprinting, and adopt and implement policies and procedures for performing an FBI fingerprinting check during the hiring process going forward. Organization’s Corrective Action Plan: Background -Chapa-De has faced challenges obtaining authorization from the Department of Justice (DOJ) to access the required FBI fingerprint criminal record information. After multiple denials, Chapa-De sought legal counsel assistance and successfully obtained authorization from the DOJ on January 11, 2023, granting access to federal criminal records. The initiation of the FBI fingerprinting process took time due to the intricate procedures involved in training, handling, and securing criminal records. Chapa-De is actively working to ensure compliant systems and security measures are in place for the management of access and security of criminal records. Completed Actions - Chapa-De has identified all Native American minor patients and subsequently identified medical and behavioral health providers who had interactions with these patients, tallying the number of in-person visits. Among the 68 providers, 26 medical and behavioral health providers had at least one in-person visit with a Native American minor patient in the last year. All 26 providers have undergone the live scan FBI fingerprint background check. As of December 12, 2023, thirty (30) staff have completed the FBI fingerprint background checks. The definition of regular contact with or control over an Indian child includes responsibility for an Indian child within the scope of the individual’s duties and responsibilities or contact with an Indian child on a recurring and foreseeable basis (42 CFR 136.403). In determining recurring and foreseeable, we assess the number of Native minor patients a provider has and the frequency of encounters each year. If a provider sees any number of Native minor patients more than once a year, we consider it as regular contact. Conversely, if a provider only sees one Native minor patient once in a particular year, we would not consider that recurring. Planned Actions - To enhance our processes and align with regulatory expectations, Chapa-De is actively implementing an organization-wide fingerprinting initiative. This initiative mandates that all patient-interfacing staff, whether employed, contracted, or volunteered at Chapa-De, undergo live scan DOJ/FBI fingerprint background checks to ensure patient safety and security. This requirement is in addition to our current background checks and credentialing processes. In response to the auditor’s recommendation, Chapa-De is currently formulating comprehensive written policies to determine which personnel and applicants may qualify for exemption from the fingerprint background checks. Temporary staff, not directly involved in patient interactions or patient care settings, may be eligible for exemption, subject to a case-by-case evaluation and approval by authorized representatives. This exception is designed to provide flexibility while upholding our commitment to patient safety, overall security, and the protection of resources. The decision to grant an exception will be based on the specific circumstances and responsibilities of the individual in question. Simultaneously, Chapa-De will continue to identify and establish a monitoring process or system to identify individuals who are in a provisional status and are required to be supervised and in sight of a staff person who has completed the background investigation, including the FBI fingerprint background checks whenever minor patients are in their care, custody, or control. Projected Completion Date - We anticipate completing the organization-wide fingerprinting initiative and resolving any issues identified in the audit finding by March 31, 2024. Contact Person - Anthony Reyes, Chief Administrative Officer, will oversee this plan.