Finding Text
Criteria: The Indian Child Protection and Family Violence Prevention Act (25 USC 3201 et seq.) requires
Tribal Organizations that receive funds under the ISDEAA to conduct an investigation of the character of
each individual who is employed or is being considered for employment by such Tribal Organization in a
position that involves regular contact with, or control over, Indian children. The Act further states that the
Tribal Organization may employ only individuals in those positions if they meet standards of character
that are no less stringent than those prescribed by the regulations, which are outlined in 42 CFR 136.405,
and only after an individual has been the subject of a satisfactory background investigation as described
in 42 CFR 136.406.
Condition and Context: For 25 out of 25 employees tested, the Hospital was not able to provide
sufficient documentation to support that a background check was completed prior to the employee's start
date or within five years for existing employees per the Hospital’s Human Resources policy. For 12 out of
25 employees tested, the Hospital was not able to provide support that the background check results
were reviewed by the appropriate authority prior to the employee being onboarded or within five years for
existing employees per the Hospital’s Human Resources policy.
Cause: Policies and procedures were not well defined or communicated to staff to ensure documentation
was retained to support the required background checks were completed or reviewed and approved prior
to an employee’s start date or within the previous five years for existing employees.
Effect: The Hospital does not have sufficient documentation to evidence background checks were
completed for new hires in the fiscal year or within the previous five years for existing employees.
Questioned Cost: None
Repeat Finding: No
Recommendation: We recommend the Hospital provide additional training to ensure employees are
properly documenting the background checks process and retaining evidence to support background
checks were completed, reviewed and approved prior to an employee’s start date or within the previous
five years for existing employees.
Views of Responsible Officials: The Human Resources (HR) team of the Chief Human Resources
Officer and the HR Generalists are responsible for completing background checks for existing new
employees. The HR team will ensure proper and required background checks are completed, reviewed
and approved for all new and existing employees. Proper documentation and results of all background
checks will be reviewed and filed accordingly.