Finding 2025-001 – Eligibility (Significant Deficiency in Internal Control Over Compliance and Instance of Noncompliance) Planned Corrective Action: The Seattle Indian Health Board is implementing enhanced corrective actions to ensure full compliance with Indian Health Service eligibility requirements, specifically related to documentation of Tribal enrollment. While prior corrective actions established foundational training and audit processes, management has identified the need for stronger front-end controls, clearer accountability, and system-based safeguards to prevent recurrence. Seattle Indian Health Board will implement the following actions: 1. Strengthen Front-End Eligibility Controls - Eligibility verification protocols will be updated to require complete Tribal enrollment documentation prior to scheduling non-urgent appointments. - A standardized eligibility checklist will be embedded into intake workflows to ensure all required documentation is identified and collected before services are rendered. 2. System Enhancement and Documentation Tracking - Electronic health record workflows will be enhanced to include required fields and alters for missing eligibility documentation, including Tribal enrollment. - Patients with incomplete eligibility records will be flagged, and services will be limited to allowable scenarios until documentation is obtained. 3. Targeted Training and Competency Validation - All registration and front desk staff will undergo mandatory retraining focused specifically on Tribal enrollment documentation requirements and compliance standards. - Staff competency will be validated through post-training assessments and periodic spot checks. 4. Enhanced Monitoring and Internal Audit - Monthly eligibility audits will be expanded to include a statistically valid sample size and documented review of Tribal enrollment verification. - Audit results will be formally reported to executive leadership, with identified deficiencies tracked through resolution. - Repeat errors or noncompliance will be addressed through corrective coaching and performance management, as appropriate. Management believes these enhanced corrective actions directly address the root cause of the finding by strengthening preventive controls, improving staff competency, and increasing oversight and accountability. Name of Responsible Party: Tempest Dawson, Director of Clinic Operations Anticipated Completion Date: December 31, 2026.