EIN: 275303526
UEI: KFZ5AKUHWH99
Audited by: Cordova CPAs LLC
Oversight agency: 93 [Department of Health and Human Services]
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Data as of September 2, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on June 30, 2026. Under 2 CFR 200.521(d), a pass-through entity that provided federal funds to this organization for this audit period must issue a management decision on these findings by December 30, 2026 (118 days from today).
What is a management decision? →FAC accepted this audit on June 13, 2025 — management decision was due December 13, 2025.
FAC accepted this audit on March 18, 2024 — management decision was due September 18, 2024.
FAC accepted this audit on August 2, 2023 — management decision was due February 2, 2024.
2021-005
FAC accepted this audit on December 12, 2022 — management decision was due June 12, 2023.
2021-005 ? Single Audit Report Submission ? Material Weakness in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination CFDA number: 93.441 Award year: HHSI242202110001C Award period: Fiscal year 2021 Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor?s report or 9 months after the end of the fiscal year, whichever comes first. Condition/Context: The audit package and data collection form was not submitted within the nine months after September 30, 2021. Questioned Costs: None. Cause: The Corporation experienced turnover in key finance department positions which resulted in delays in the completion of its September 30, 2021 audit. Effect: The Corporation is not in compliance with Uniform Guidance 2 CFR 200.512(a). Auditor?s Recommendations: We recommend the Corporation obtain necessary resources to allow for completion of the annual financial report on a timely basis. Management?s Response: The submission did not occur due to turnover in the finance department?s CFO position. The Corporation now has in place the human resources necessary to complete necessary IHS audit compliance reporting requirements going forward.
Show full finding ▾Hide full finding ▴2021-005 ? Single Audit Report Submission ? Material Weakness in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination CFDA number: 93.441 Award year: HHSI242202110001C Award period: Fiscal year 2021 Criteria: The Uniform Guidance 2 CFR 200.512(a) requires the audit package and data collection form be submitted 30 days after receipt of the auditor?s report or 9 months after the end of the fiscal year, whichever comes first. Condition/Context: The audit package and data collection form was not submitted within the nine months after September 30, 2021. Questioned Costs: None. Cause: The Corporation experienced turnover in key finance department positions which resulted in delays in the completion of its September 30, 2021 audit. Effect: The Corporation is not in compliance with Uniform Guidance 2 CFR 200.512(a). Auditor?s Recommendations: We recommend the Corporation obtain necessary resources to allow for completion of the annual financial report on a timely basis. Management?s Response: The submission did not occur due to turnover in the finance department?s CFO position. The Corporation now has in place the human resources necessary to complete necessary IHS audit compliance reporting requirements going forward.
KPHC Management plans to schedule FY22 Audit to occur in February of 2023, which would allow for sufficient time to meet the filing deadline. Person Responsible - Jimmie Kinder, Controller Estimated Completion Date - April 30, 2023
2021-006 ? Activities Allowed/Unallowed and Allowable Costs/Cost Principles (Compensation ? Personal Services) ? Material Weakness in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination Assistance listing number: 93.441 Award number: HHSI242202110001C Award period: Fiscal year 2021 Criteria: The Uniform Guidance 2 CFR 200.430 ? Compensation ? Personal Services (b) states the following: Reasonableness. Compensation for employees engaged in work on federal awards will be considered reasonable to the extent that it is consistent with that paid for similar work in other activities of the nonfederal entity. In cases where the kinds of employees required for federal awards are not found in the other activities of the nonfederal entity, compensation will be considered reasonable to the extent that it is comparable to that paid for similar work in the labor market in which the nonfederal entity competes for the kind of employees involved. Furthermore, 2 CFR 200.430 (f) states the following: Incentive compensation. Incentive compensation to employees based on cost reduction, or efficient performance, suggestion awards, safety awards, etc., is allowable to the extent that the overall compensation is determined to be reasonable and such costs are paid or accrued pursuant to an agreement entered into in good faith between the nonfederal entity and the employees before the services were rendered, or pursuant to an established plan followed by the nonfederal entity so consistently as to imply, in effect, an agreement to make such payment. Condition/Context: Salary increases and retention bonuses were made to certain executive level employees without proper approvals, and without referencing comparable compensation paid for similar work in the Corporation?s local labor market. Additionally, board members also received bonuses and increased stipends without documentation of proper approvals. Finally, hazard pay was approved for all employees, without a hazard pay policy in place and regardless of COVID-19 risk in their position. Questioned Costs: None ? upon subsequent discovery of these items, the Corporation used unrestricted monies to pay for the questionable amounts. Cause: Internal controls for proper approval of salaries and bonuses was overridden by management and the board. Additionally, in some instances the Corporation did not have documented position descriptions which would designate minimum and maximum pay ranges. Finally, a hazard pay policy was not developed and implemented to define what roles and positions would receive additional pay based on COVID-19 risk for their position. Effect: The Corporation paid out salaries, bonuses and hazard pay that was not properly authorized and/or supported. Auditor?s Recommendations: The Corporation should consider significant improvements in formalizing employment policies and related documentation. We suggest that the following recommendations be given consideration: ? Position descriptions should be made for all positions within the Corporation and include designated pay range amounts based on wage and salary surveys that are updated at least every two years. ? Salary levels of officers should always be approved by the Board of Directors and should be in writing in all cases. ? Employment contracts should be executed with all key employees, setting forth compensation levels and terms of employment. ? Board approvals should be required for all bonus amounts that exceed a designated percentage and internal policies should be updated to reflect this requirement. Documentation of all approvals should be retained. ? Hazard pay policies should be developed and pay range increases should align with levels of risk to the employee based on job function. Management?s Response: It was discovered that the prior administration, both the senior management and the board, overrode internal controls for prover approval of salaries and bonuses. and the bonuses themselves were not checked for reasonableness by current market comparison. The senior management involved have been replaces and the board has been disbanded. The approvals process for bonuses has been modified to address the override of internal controls.
Show full finding ▾Hide full finding ▴2021-006 ? Activities Allowed/Unallowed and Allowable Costs/Cost Principles (Compensation ? Personal Services) ? Material Weakness in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination Assistance listing number: 93.441 Award number: HHSI242202110001C Award period: Fiscal year 2021 Criteria: The Uniform Guidance 2 CFR 200.430 ? Compensation ? Personal Services (b) states the following: Reasonableness. Compensation for employees engaged in work on federal awards will be considered reasonable to the extent that it is consistent with that paid for similar work in other activities of the nonfederal entity. In cases where the kinds of employees required for federal awards are not found in the other activities of the nonfederal entity, compensation will be considered reasonable to the extent that it is comparable to that paid for similar work in the labor market in which the nonfederal entity competes for the kind of employees involved. Furthermore, 2 CFR 200.430 (f) states the following: Incentive compensation. Incentive compensation to employees based on cost reduction, or efficient performance, suggestion awards, safety awards, etc., is allowable to the extent that the overall compensation is determined to be reasonable and such costs are paid or accrued pursuant to an agreement entered into in good faith between the nonfederal entity and the employees before the services were rendered, or pursuant to an established plan followed by the nonfederal entity so consistently as to imply, in effect, an agreement to make such payment. Condition/Context: Salary increases and retention bonuses were made to certain executive level employees without proper approvals, and without referencing comparable compensation paid for similar work in the Corporation?s local labor market. Additionally, board members also received bonuses and increased stipends without documentation of proper approvals. Finally, hazard pay was approved for all employees, without a hazard pay policy in place and regardless of COVID-19 risk in their position. Questioned Costs: None ? upon subsequent discovery of these items, the Corporation used unrestricted monies to pay for the questionable amounts. Cause: Internal controls for proper approval of salaries and bonuses was overridden by management and the board. Additionally, in some instances the Corporation did not have documented position descriptions which would designate minimum and maximum pay ranges. Finally, a hazard pay policy was not developed and implemented to define what roles and positions would receive additional pay based on COVID-19 risk for their position. Effect: The Corporation paid out salaries, bonuses and hazard pay that was not properly authorized and/or supported. Auditor?s Recommendations: The Corporation should consider significant improvements in formalizing employment policies and related documentation. We suggest that the following recommendations be given consideration: ? Position descriptions should be made for all positions within the Corporation and include designated pay range amounts based on wage and salary surveys that are updated at least every two years. ? Salary levels of officers should always be approved by the Board of Directors and should be in writing in all cases. ? Employment contracts should be executed with all key employees, setting forth compensation levels and terms of employment. ? Board approvals should be required for all bonus amounts that exceed a designated percentage and internal policies should be updated to reflect this requirement. Documentation of all approvals should be retained. ? Hazard pay policies should be developed and pay range increases should align with levels of risk to the employee based on job function. Management?s Response: It was discovered that the prior administration, both the senior management and the board, overrode internal controls for prover approval of salaries and bonuses. and the bonuses themselves were not checked for reasonableness by current market comparison. The senior management involved have been replaces and the board has been disbanded. The approvals process for bonuses has been modified to address the override of internal controls.
Current KPHC Senior management & New Board will ensure that existing policy is enforced. More stringent reviews and increased approvals will be required. Person Responsible - Jonathan Trujillo, Interim CEO, Jimmie Charlie, CMO & Acting COO, Jimmie Kinder, Controller and Victoria Acosta, HR Manager Estimated Completion Date November 21, 2022.
2021-007 ? Eligibility - Significant Deficiency in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination Assistance listing number: 93.441 Award number: HHSI242202110001C Award period: Fiscal year 2021 Criteria: Requirements contained in 42 CFR Part 136, Subparts B (for direct care) and C (for purchased/referred care) specify that services are available to persons of Indian descent belonging to the Indian community served by the local facilities and program. Condition/Context: The Corporation failed to obtain and maintain adequate supporting documentation verifying eligibility for 4 of the 25 patients tested. Questioned Costs: None. Cause: The Corporation did not require patients seeking program assistance to submit all required documentation verifying that the patient was eligible under the grant?s eligibility requirements to receive assistance. Effect: Failure to maintain required supporting documents to verify eligibility could result in ineligible individuals receiving benefits under the grant. In addition, inadequate controls in this area of compliance could result in the Corporation not being able to detect and correct this situation in a timely manner. Auditor?s Recommendations: Corporation management should implement control procedures to ensure that all patients seeking assistance covered by the grants submit all required supporting documentation verifying eligibility prior to receiving program assistance. In addition, management should implement procedures to ensure all existing patients have the required supporting documentation verifying eligibility. Management?s Response: As part of the patient registration/ intake process, new patients are required to certify their eligibility for treatment at the Corporation by providing a Certificate of Indian Blood as certifying documentation. Patient?s that do not currently have a CIB on file, are being further investigated by contacting the appropriate Tribal Entity and getting the CIB.
Show full finding ▾Hide full finding ▴2021-007 ? Eligibility - Significant Deficiency in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination Assistance listing number: 93.441 Award number: HHSI242202110001C Award period: Fiscal year 2021 Criteria: Requirements contained in 42 CFR Part 136, Subparts B (for direct care) and C (for purchased/referred care) specify that services are available to persons of Indian descent belonging to the Indian community served by the local facilities and program. Condition/Context: The Corporation failed to obtain and maintain adequate supporting documentation verifying eligibility for 4 of the 25 patients tested. Questioned Costs: None. Cause: The Corporation did not require patients seeking program assistance to submit all required documentation verifying that the patient was eligible under the grant?s eligibility requirements to receive assistance. Effect: Failure to maintain required supporting documents to verify eligibility could result in ineligible individuals receiving benefits under the grant. In addition, inadequate controls in this area of compliance could result in the Corporation not being able to detect and correct this situation in a timely manner. Auditor?s Recommendations: Corporation management should implement control procedures to ensure that all patients seeking assistance covered by the grants submit all required supporting documentation verifying eligibility prior to receiving program assistance. In addition, management should implement procedures to ensure all existing patients have the required supporting documentation verifying eligibility. Management?s Response: As part of the patient registration/ intake process, new patients are required to certify their eligibility for treatment at the Corporation by providing a Certificate of Indian Blood as certifying documentation. Patient?s that do not currently have a CIB on file, are being further investigated by contacting the appropriate Tribal Entity and getting the CIB.
KPHC is certifying patient eligibility on a going-forward by checking for CIBs for every patient scheduled. Patient?s that do not have a CIB on file, are being further investigated by contacting the appropriate Tribal Entity and getting the CIB. KPHC is also researching the current patient database and ensuring that CIBs are on file. Person Responsible - Nohemy Rosales, HIMS Director Estimated Completion Date - February 28, 2023
2021-008 ? Activities Allowed/Unallowed and Allowable Costs/Cost Principles ? Significant Deficiency in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination Assistance listing number: 93.441 Award number: HHSI242202110001C Award period: Fiscal year 2021 Criteria: According to Title 2, U.S. Code of Federal Regulations Part 200 (2 CFR 200), Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Subpart D, Section 200.303), the nonfederal entity must establish and maintain effective internal controls over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition/Context: A Personnel Action Form validating the accuracy of an amount paid to an employee could not be located (one out of 25 tested). Questioned Costs: None. Cause: The Corporation failed to obtain and maintain adequate supporting documentation verifying compensation for 1 of the 25 employees tested. Effect: Failure to maintain required supporting documents to verify compensation could result in inaccurate payment to employees receiving benefits under the grant. Auditor?s Recommendations: We recommend management design and implement secondary monitoring internal controls that will ensure proper approval and documentation for any costs charged to the federal program. Management?s Response: Going forward, a ?PAR Pending? log is being utilized by the HR department to track the processing and disposition of all PARs, which should result in all PARs being effectively processed and filed.
Show full finding ▾Hide full finding ▴2021-008 ? Activities Allowed/Unallowed and Allowable Costs/Cost Principles ? Significant Deficiency in Internal Controls over Compliance and Noncompliance Federal program information: Funding agency: U.S. Department of Health and Human Services Title: Indian Self-Determination Assistance listing number: 93.441 Award number: HHSI242202110001C Award period: Fiscal year 2021 Criteria: According to Title 2, U.S. Code of Federal Regulations Part 200 (2 CFR 200), Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, (Subpart D, Section 200.303), the nonfederal entity must establish and maintain effective internal controls over the federal award that provides reasonable assurance that the nonfederal entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. Condition/Context: A Personnel Action Form validating the accuracy of an amount paid to an employee could not be located (one out of 25 tested). Questioned Costs: None. Cause: The Corporation failed to obtain and maintain adequate supporting documentation verifying compensation for 1 of the 25 employees tested. Effect: Failure to maintain required supporting documents to verify compensation could result in inaccurate payment to employees receiving benefits under the grant. Auditor?s Recommendations: We recommend management design and implement secondary monitoring internal controls that will ensure proper approval and documentation for any costs charged to the federal program. Management?s Response: Going forward, a ?PAR Pending? log is being utilized by the HR department to track the processing and disposition of all PARs, which should result in all PARs being effectively processed and filed.
Going forward, KPHC will be revising their credit card purchase policy and procedures that no lapse in adequate transaction documentation will occur. Person Responsible - Jimmie Kinder, Controller and Victoria Acosta, HR Manager Estimated Completion Date - February 28, 2023
FAC accepted this audit on June 22, 2021 — management decision was due December 22, 2021.
FAC accepted this audit on August 19, 2020 — management decision was due February 19, 2021.
FAC accepted this audit on May 21, 2019 — management decision was due November 21, 2019.
FAC accepted this audit on May 16, 2018 — management decision was due November 16, 2018.
FAC accepted this audit on June 21, 2017 — management decision was due December 21, 2017.
Data source: This information comes from the Federal Audit Clearinghouse, the official repository of Single Audit data. All data is public domain. Verify this organization's audit history at fac.gov.
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