Finding 386902 (2021-005)

Significant Deficiency
Requirement
L
Questioned Costs
-
Year
2021
Accepted
2024-03-28

AI Summary

  • Core Issue: CBNHC failed to submit required quarterly and annual reports for the Indian Self-Determination program due to operational disruptions.
  • Impacted Requirements: Non-compliance with the Annual Funding Agreement's reporting deadlines for SF-425 and narrative reports.
  • Recommended Follow-Up: CBNHC should establish internal controls to ensure timely completion and submission of all program reports moving forward.

Finding Text

2021-005 — Reporting Federal/state program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination ALN: 93.441 Award period: 10/1/2020 – 9/30/2021 Criteria: The Annual Funding Agreement (AFA) with I.H.S. requires CBNHC to submit Federal Financial Reports (SF-425) within 30 days after the close of each quarter, except for the fourth quarter, which will be submitted within 90 days after the close of the federal fiscal year. Additionally, a brief annual narrative report will also be submitted within 90 days after the close of the federal fiscal year. Condition: The quarterly SF-425 reports for all quarters of fiscal year 2021 were not prepared or submitted to I.H.S. Additionally, the annual narrative report was not prepared or submitted for fiscal year 2021. Context: All four quarterly SF-425 reports and the annual narrative report for the Indian Self-Determination program. Questioned Costs: None Cause: CBNHC was significantly impacted by the COVID-19 pandemic, which impacted the preparation and submission of required reports. Effect: CBNHC is not in compliance with reporting requirements for the Indian Self-Determination program. Auditor’s Recommendations: CBNHC should develop internal controls to ensure all program reports are properly completed and submitted by the required due dates. Management’s Response: CBNHC continued to experience operational disruptions caused by turnover of key administrative positions and the COVID-19 pandemic. In addition to staff shortages, CBNHC’s priority was on emergency response to the To’Hajiilee community. These events caused CBNHC to fall behind in maintaining its financials and other administrative tasks. The SF-425 and narrative reporting as required under the I.H.S. Annual Funding Agreement were not submitted. CBNHC takes seriously its contractual obligations and is actively working toward compliance in its reporting requirements.

Corrective Action Plan

2021-005 – Reporting Corrective Action: CBNHC will implement the following corrective actions: • CBNHC will immediately complete the annual narrative reports for all fiscal years through September 30, 2023. • CBNHC will immediately complete the SF-425 financial reports for all fiscal years through September 30, 2023, and thereafter, every quarter through the current fiscal year. • CBNHC will actively communicate its status with the IHS Area Office regarding its progress towards the required deliverables. • CBNHC will implement an executive leadership team who are collectively responsible for assuring regulatory compliance for the entity, which will be achieved through the timely sharing of important information. • CBNHC’s Board of Directors will serve as governance over these requirements. Person Responsible: The following individuals will be responsible for the above corrective action plan: • Chief Executive Officer (Derrick Watchman) – Is responsible for ensuring that the annual narrative reports are submitted to IHS according to the AFA. In addition, the CEO will initiate monthly progress meetings with IHS. • Interim Finance Director (Volelle Zamora) – Is responsible for ensuring that the SF-425 financial reports are submitted to IHS according to the AFA. • Chief Executive Officer (Derrick Watchman), Chief Medical Officer (Sheryl O’Shea MD), Chief Operations Officer (Volelle Zamora), Executive Administrative Assistant (Ophelia Mace), and Human Resource Director (Christina Chavez) – Will serve as the CBNHC executive leadership team and are collectively responsible for assuring that the required reporting and other compliance are achieved. • Board of Directors (Kimberly Bruce, Harrison Platero, Lester Secatero) – Are responsible for CBNHC’s governance and will monitor required completion of reporting. Completion Date: The annual narrative reports for fiscal years 2021, 2022, and 2023 were completed as of December 31, 2023. The SF-425 reports will be completed and submitted to IHS by March 31, 2024. CBNHC is conducting monthly progress meetings with IHS regarding its requirements for financial reporting. CBNHC has implemented an executive leadership team, and they meet regularly, to share information and establish timelines for the completion and submission of its required reporting.

Categories

Reporting

Other Findings in this Audit

  • 386898 2021-004
    Material Weakness Repeat
  • 386899 2021-004
    Material Weakness Repeat
  • 386900 2021-004
    Material Weakness Repeat
  • 386901 2021-004
    Material Weakness Repeat
  • 386903 2021-006
    Significant Deficiency
  • 386904 2021-007
    Significant Deficiency
  • 386905 2021-004
    Material Weakness Repeat
  • 386906 2021-004
    Material Weakness Repeat
  • 963340 2021-004
    Material Weakness Repeat
  • 963341 2021-004
    Material Weakness Repeat
  • 963342 2021-004
    Material Weakness Repeat
  • 963343 2021-004
    Material Weakness Repeat
  • 963344 2021-005
    Significant Deficiency
  • 963345 2021-006
    Significant Deficiency
  • 963346 2021-007
    Significant Deficiency
  • 963347 2021-004
    Material Weakness Repeat
  • 963348 2021-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.441 Indian Self-Determination $8.23M
93.391 Activities to Support State, Tribal, Local and Territorial (stlt) Health Department Response to Public Health Or Healthcare Crises $242,298
93.237 Special Diabetes Program for Indians_diabetes Prevention and Treatment Projects $197,623
21.019 Coronavirus Relief Fund $118,317
93.772 Tribal Public Health Capacity Building and Quality Improvement Umbrella Cooperative Agreement $63,745
93.228 Indian Health Service_health Management Development Program $-53,186