EIN: 911004074
UEI: TP4UB9N6TSA5
Audited by: Stauffer & Associates PLLC
Cognizant agency: 93 [Department of Health and Human Services]
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Data as of September 7, 2026
Management decision deadline — for entities that funded this organization
The FAC accepted this audit on September 30, 2025. 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 March 30, 2026 (166 days ago).
What is a management decision? →FAC accepted this audit on September 30, 2024 — management decision was due March 30, 2025.
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1) Condition/Context: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. [ ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: High staff turnover and lack of qualified personnel. Effect: Without proper supervisor approval, unallowable entries could be posted to the program. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend the Department to follow their policy and procedures that all journal entries are reviewed and approved by management prior to posting. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Show full finding ▾Hide full finding ▴Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1) Condition/Context: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. [ ] Compliance Finding [ ] Significant Deficiency [ X ] Material Weakness Cause: High staff turnover and lack of qualified personnel. Effect: Without proper supervisor approval, unallowable entries could be posted to the program. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend the Department to follow their policy and procedures that all journal entries are reviewed and approved by management prior to posting. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: During transactional testing, 11 of 16 individually important items (IIIs) were journal entries with no documented review and approval process. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart E, §200.405 Allocable costs, manual adjustments will be defined as reasonable and allocable as defined within existing governing statues, regulations, or terms and conditions of the award. Levels of delegation of staff administering these regulatory activities will utilize the appropriate credentials request cost adjustments and use prudent judgment to determine those costs are necessary and do not deviate from the Department’s established practices and policies. Final review of cost adjustment requests will be reviewed by Department’s OMB and once approved a signature of review and approval will be documented. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025
Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: The Department must establish and maintain internal controls designed to reasonably ensure compliance with eligibility. The Department must also establish policies and procedures related to eligibility requirements. Condition/Context: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There was a lack of record retention and the ability to locate information from prior years. Effect: Individuals that are not eligible for services may have received services. Questioned Costs: None. Repeat Finding: No. Recommendation: Management should reexamine processes and controls over participant eligibility to ensure all documentation is obtained and retained for all participants, regardless of whether the program staff are familiar with the program participant or not. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Show full finding ▾Hide full finding ▴Program Information: Assistance Listing #: 93.210 U.S. Department of Health and Human Services Tribal Self-Governance Demonstration Program: Planning and Negotiation IHS Compacts/COVID-19 - Testing IHS and Tribal Operated Programs Award Numbers: 64G940011 Award Periods: 10/1/21-9/30/24 Criteria: The Department must establish and maintain internal controls designed to reasonably ensure compliance with eligibility. The Department must also establish policies and procedures related to eligibility requirements. Condition/Context: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. [ X ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: There was a lack of record retention and the ability to locate information from prior years. Effect: Individuals that are not eligible for services may have received services. Questioned Costs: None. Repeat Finding: No. Recommendation: Management should reexamine processes and controls over participant eligibility to ensure all documentation is obtained and retained for all participants, regardless of whether the program staff are familiar with the program participant or not. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: 2 out of 40 samples were missing proof of insurance in the patient’s file, which is a requirement under the Department's eligibility policy. Solution: Implement a standardized process for verifying, documenting, and maintaining proof of required documents (e.g. proof of residency, insurance, etc.) in the patient's file during each visit. This will involve revising and implementing the new procedures manual to verify and document patient intake. The procedures manual will support appropriate communication from data collection to when information is uploaded into EPIC to verify if clients have insurance. Our training plan will incorporate these new methods of collecting data from the clients and outline regular internal auditing of patient files to assist the Tribal Assisters to properly verify documents and communicate with providers to assist clients in enrolling with insurance providers such as but not limited to Washington Apple Health (WAH). Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. Responsible: Kathryn Halverson, Health and Human Services CEO, Lummi Indian Business Council Anticipated completion date: 06/30/2025
Program Information: Assistance Listing #: 15.022 U.S. Department of the Interior Tribal Self-Governance/Indian Reservation Roads Program Award Numbers: GT-OSGT107-10/A16AP00068 Award Periods: 1/1/2011 – 12/31/2023 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1). Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal award identification number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). A physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years (2 CFR section 200.313(d)(2)). A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR section 200.313(d)(3)). Condition/Context: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. [ ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Turnover in key personnel, lack of internal controls, and the inability to provide supporting documentation. Effect: Without review and approval of the physical inventory listing, it is possible the reconciliation to property records may not occur. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend that physical inventory is taken, that the results are reconciled with the property records at least once every 2 years, and that documentation of this process is stored for review at a later date. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Show full finding ▾Hide full finding ▴Program Information: Assistance Listing #: 15.022 U.S. Department of the Interior Tribal Self-Governance/Indian Reservation Roads Program Award Numbers: GT-OSGT107-10/A16AP00068 Award Periods: 1/1/2011 – 12/31/2023 Criteria: Internal control is a process, effected by an entity’s…[governing body], management and other personnel, designed to provide reasonable assurance regarding the achievement of objectives relating to operations, reporting, and compliance: (Internal Control – Integrated Framework, Committee of Sponsoring Organizations of the Treadway Commission, © May 2013, p.1). Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the Federal award identification number), who holds title, the acquisition date, cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sales price of the property (2 CFR section 200.313(d)(1)). A physical inventory of the property must be taken and the results reconciled with the property records at least once every 2 years (2 CFR section 200.313(d)(2)). A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated (2 CFR section 200.313(d)(3)). Condition/Context: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. [ ] Compliance Finding [ X ] Significant Deficiency [ ] Material Weakness Cause: Turnover in key personnel, lack of internal controls, and the inability to provide supporting documentation. Effect: Without review and approval of the physical inventory listing, it is possible the reconciliation to property records may not occur. Questioned Costs: None. Repeat Finding: No. Recommendation: We recommend that physical inventory is taken, that the results are reconciled with the property records at least once every 2 years, and that documentation of this process is stored for review at a later date. View of Responsible Officials and Planned Corrective Action: Management agrees with the finding and has prepared corrective action as detailed in its Corrective Action Plan.
Person responsible for corrective action plan: Anthony Madera, CFO Lummi Indian Business Council 2665 Kwina Road Bellingham, WA 98226 (360) 384-7181 Condition: Management completed a physical inventory in 2022-2023, but was not able to provide support showing management review and approval. Solution: With the guidance and authority outlined in the Department’s internal policies and in accordance with 2 CFR, Part 200, Subpart D, Property Standards, The non-Federal entity must submit annually an inventory listing of federally-owned property in its custody to the Federal awarding agency as defined within existing governing statues, regulations, or terms and conditions of the award. Procedures for the delegated staff administering these regulatory activities will follow the minimum requirements of maintaining property records. Final review of inventory will have final reviewed by Department’s CFO of approval and will be documented annually. Corrective action plan will be in accordance with c CFR, Part 200, Subpart F, §200.511 Audit findings follow-up. The Department entered into a professional agreement with Financial Service Advisors, LLC to assess current policies to update standards of management by identifying credentials and experience of senior finance staff who will oversee these activities. Revisions to the policies will provide the Department’s government an extensive manual that will be developed into a fiscal management training. Training will include but not be limited to reviewing procurement methods, fiscal review of ledger activity, and audit responsibility on a quarterly basis and reporting to tribal council. Responsible: Anthony Madera, Chief Financial Officer, Lummi Indian Business Council Anticipated completion date: 06/30/2025
FAC accepted this audit on September 28, 2023 — management decision was due March 28, 2024.
FAC accepted this audit on December 1, 2022 — management decision was due June 1, 2023.
FAC accepted this audit on March 14, 2022 — management decision was due September 14, 2022.
FAC accepted this audit on December 30, 2020 — management decision was due June 30, 2021.
FAC accepted this audit on September 26, 2019 — management decision was due March 26, 2020.
GSA_MIGRATION
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GSA_MIGRATION
FAC accepted this audit on September 27, 2018 — management decision was due March 27, 2019.
FAC accepted this audit on September 28, 2017 — management decision was due March 28, 2018.
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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