Finding Text
2021-006 — Special Tests and Provisions – Background Checks
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 AFA with I.H.S. requires CBNHC to conduct fingerprinting and background checks of employees, contractors, and patient care providers as required by applicable law (including 25 U.S.C. Section 3207 and 1647 (a)(b) and 42 C.F.R. Sections 136.401 to 136.418) and in accordance with the policies and procedures of CBNHC.
Condition: CBNHC did not maintain records of the start/hire date, fingerprint charts, completed background check, and the suitability determination/adjudication for one employee. For one other employee, the suitability determination/adjudication was not completed until almost five years after their hire date (although the background check was completed within three months of their hire date).
Context: Two of six employees tested for the Indian Self-Determination program.
Questioned Costs: None
Cause: CBNHC was significantly impacted by the COVID-19 pandemic, which caused turnover in the Human Resources department at CBNHC.
Effect: CBNHC is not in compliance with background check requirements for the Indian Self-Determination program.
Auditor’s Recommendations: CBNHC should implement its policies and procedures regarding background checks to ensure that all employees and contractors are subject to fingerprinting and background checks.
Management’s Response: CBNHC experienced substantial staffing shortages and struggled with the impacts of the COVID-19 pandemic throughout fiscal year 2021. During this time, CBNHC continued with its recruiting of staff to carry out the human resource duties and responsibilities required for regulatory compliance; however, continued management vacancies and COVID-19 severely impacted its ability to obtain necessary human resources and other key staff. The Controller continued in the role of Acting CEO for the first half of fiscal year 2021 and formally assumed the CEO position as of March 18, 2021. The Acting CEO remained responsible for operations of the organization, the Finance Department, and Human Resources during this time. The Human Resources Director position was vacant throughout most of fiscal year 2021 and was finally filled in August 2021. The recruiting challenges and continued effects of the pandemic left CBNHC leadership severely short-staffed, causing significant delays in processing required background checks. The status of the approved Human Resources and associated administrative positions and their status at the close of fiscal year 2021 is summarized as follows:
• Chief Executive Officer (Position Status: Vacant from June 11, 2020 – March 18, 2021) – Responsible for providing administrative oversight for all aspects of the efficient operations of CNBHC and serves as the administrative authority for the organization and its health programs. Interim CEO duties were assigned to the Controller, who formally accepted the position in March 2021.
• Controller (Position Status: Vacant from March 18, 2021 – September 30, 2021) – Responsible for management, oversight, and administration of the CBNHC accounting, finance, payroll and tax functions, advises executive leadership on financial management and strategic planning; develops, modifies and enforces financial accounting safeguards. The Acting CEO was serving as Acting Controller. The Controller was appointed Acting CEO in February 2020 and formally accepted the position in March 2021.
• Human Resource Director (Position Status: Vacant from October 1, 2020 – August 30, 2021) – Guides and manages the overall provision of Human Resources services, policies, and benefit programs for CBNHC. The Human Resources Director will assist in confirming payroll set-up, including rates and deductions, and will participate in reviewing benefit invoices to ensure accuracy. As noted above, the Human Resources Director (previously Manager) was vacant for most of fiscal year 2021, with the Controller maintaining responsibilities of the CEO, Controller, and Human Resources Director.
Additionally, vendors that process and finalize CBNHC background checks experienced severe backlogs due to delays across the nation’s court systems in the aftermath of the pandemic and associated shutdowns. These delays contributed to further delays in CBNHC receiving adjudication and background results.