TOIYABE INDIAN HEALTH PROJECT, INC.Tribal Government

U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Federal Financial Assistance Listing Number 93.441 Indian Self-Determination Equipment and Real Property Management Material Noncompliance and Material Weakness in Internal Control over Compliance Grant Award Number - Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria - Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires property records 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 sale price of the property. Condition - Property records were not maintained in accordance with Uniform Guidance for all property and equipment purchased. Cause - The Organization did not have adequate internal controls to ensure its property records included all the requirements under Uniform Guidance or properly identify all property and equipment purchased with federal funds. Effect - Property records were not adequately maintained. Questioned Costs - None. Context/Sampling - No sampling was used. We examined the Organization’s property records in total. Repeat Finding From Prior Year - Yes; finding 2022-004. Recommendation - We recommend the Organization enhance internal controls to ensure its property records include all the requirements under Uniform Guidance and properly identify all property and equipment purchased with federal funds. Views of Responsible Officials - Management agrees with this finding.

2021-004 U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Federal Financial Assistance Listing/ CFDA Number 93.441 Indian Self-Determination Equipment and Real Property Management Material Noncompliance and Material Weakness in Internal Control over Compliance Grant Award Number - Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria - Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires property records 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 sale price of the property. Condition - Property records were not maintained in accordance with Uniform Guidance for all property and equipment purchased. Cause - The Organization did not have adequate internal controls to ensure its property records included all the requirements under Uniform Guidance or properly identify all property and equipment purchased with federal funds. Effect - Property records were not adequately maintained. Questioned Costs - None. Context/Sampling - No sampling was used. We examined the Organization?s property records in total. Repeat Finding From Prior Year - Yes; prior year finding 2020-007. Recommendation - We recommend the Organization enhance internal controls to ensure its property records include all the requirements under Uniform Guidance and properly identify all property and equipment purchased with federal funds. Views of Responsible Officials - Management agrees with this finding.

2021-005 U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Federal Financial Assistance Listing/ CFDA Number 93.441 Indian Self-Determination Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Grant Award Number - Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria - Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that indirect costs be applied in accordance with the approved rate agreement. Condition - The approved indirect cost rate was not applied accurately as it included the indirect cost rate being incorrectly applied to purchases of fixed assets. Cause - The Organization did not have adequate internal controls to ensure the indirect cost rate was applied accurately. Effect - Prior to adjustment, indirect costs were over allocated to the grant by $175,515. Questioned Costs - None. Context/Sampling - No sampling was used. The application of the indirect cost rate was tested in total. Repeat Finding From Prior Year - Yes; Prior year finding 2020-005. Recommendation - We recommend the Organization enhance internal controls to ensure the indirect cost rate is applied accurately. Views of Responsible Officials - Management agrees with this finding.

2021-006 U.S. Department of Health and Human Services Federal Financial Assistance Listing/CFDA Number 93.498 COVID-19 - Provider Relief Fund and American Rescue Plan General and Targeted Distributions Reporting Material Noncompliance and Material Weakness in Internal Control over Compliance Criteria - 2 CFR 200.33(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations and conditions of the federal grant. The Organization selected Option iii to calculate lost revenue which consists of a comparison of actual results during the period of availability to the actual results in calendar 2019. The Organization excluded dialysis net revenue from the calculation due to historical issues with the billing of these services which resulted in significant issues with year over year comparisons of this revenue stream. Pharmacy revenue was also excluded. Condition - Due to the Organization utilizing various contracted billing companies and errors in the billing process due to the contracted billing companies, the month-to-month financial information is known to be incorrect. Significant year-end adjustments were proposed for fiscal years 2019, 2020, and 2021 financial statement audits. These adjustments were reflected in September of each year, when the adjustments actually impacted the entire fiscal year and should have been reflected as such in the calculation. In addition, the Organization did not include bad debt expense, which should have been included to arrive at net revenue. Cause - The Organization did not have adequate internal controls to ensure the lost revenue calculation was done in accordance with guidance. Effect - The lost revenue reported on the HHS reporting portal for Period 1 included amounts for the periods from April through June 2020 and July through September 2020 and totaled $2,100,495. Had the year-end adjustments been allocated and bad debts properly included in the calculation, the lost revenue reported on the HHS reporting portal would have included amounts for the periods from April through June 2020, July through September 2020, October through December 2020 and January through March 2021 and totaled $1,808,666. Questioned Costs - None. Had the Organization allocated the year-end adjustments and included bad debt expense, the amount of lost revenue exceeded the Provider Relief Funds received by $140,000. Context/Sampling - Key line items were tested on the Period 1 Department of Human Services special report. Repeat Finding From Prior Year - No

2020-005 U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Grant Award Number ? Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that indirect costs be applied in accordance with the approved rate agreement. Condition ? The approved indirect cost rate was not applied accurately. Cause ? The Organization did not have adequate internal controls to ensure the indirect cost rate was applied accurately. Effect ? Prior to an adjustment to correct, indirect costs were over allocated to the grant by $619,525. Questioned Costs ? None. Context/Sampling ? No sampling was used. The application of the indirect cost rate was tested in total. Repeat Finding From Prior Year ? Yes; Prior year finding 2019-006. Recommendation ? We recommend the Organization enhance internal controls to ensure the indirect cost rate is applied accurately. Views of Responsible Officials ? Management agrees with this finding.

2020-006 U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Allowable Costs/Cost Principles Significant Deficiency in Internal Control over Compliance Grant Award Number ? Affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that costs must be adequately documented. In addition, charges for salaries and wages must be based on records that accurately reflect the work performed. Condition ? Salaries and wages were charged to the programs without documentation to support the percentage of salaries and wages allocated. Cause ? The Organization did not have adequate internal controls to ensure salaries and wages for employees who work on multiple grant activities were allocated to reflect the work performed. Effect ? Salaries and wages could be charged to the federal program that were unallowable. Questioned Costs ? Undetermined. Context/Sampling ? A nonstatistical sample of 60 from a population of 1,022 employee pay periods was selected for testing under the Indian Self-Determination program. The sample of 60 included pay periods from 29 employees. 3 employee pay periods were allocated without appropriate support. Repeat Finding From Prior Year ? Yes; prior year finding 2019-005. Recommendation ? We recommend the Organization enhance internal controls to ensure salaries and wages for employees who work on multiple grant activities were allocated to reflect the work performed. Views of Responsible Officials ? Management agrees with this finding.

2020-007 U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Equipment and Real Property Management Material Noncompliance and Material Weakness in Internal Control over Compliance Grant Award Number ? Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires property records 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 sale price of the property. Condition ? Property records were not maintained in accordance with Uniform Guidance for all property and equipment purchased. Cause ? The Organization did not have adequate internal controls to ensure its property records included all the requirements under Uniform Guidance or properly identify all property and equipment purchased with federal funds. Effect ? Property records were not adequately maintained. Questioned Costs ? None. Context/Sampling ? No sampling was used. We examined the Organization?s property records in total. Repeat Finding From Prior Year ? Yes; prior year finding 2019-008. Recommendation ? We recommend the Organization enhance internal controls to ensure its property records include all the requirements under Uniform Guidance and properly identify all property and equipment purchased with federal funds. Views of Responsible Officials ? Management agrees with this finding.

2020-008 U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Procurement Significant Deficiency in Internal Control over Compliance Grant Award Number ? Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires contracts contain the applicable provisions described in Appendix II to Part 200 for contracts under federal awards. Condition ? Certain applicable provisions described in Appendix II to Part 200 were not included in contracts as required. Cause ? The Organization did not have adequate internal controls to ensure contracts under federal awards contained all of the applicable provisions were included prior to entering into all covered transactions. Effect ? The Organization has not precisely followed the requirements described in Appendix II to Part 200 which include administrative, contractual, or legal remedies in instances where contractors violate or breach contract terms . Questioned Costs ? None. Context/Sampling ? A nonstatistical sample of 40 from a population of 799 procurement transactions was selected for testing under the Indian Self-Determination program. Three of the procurement transactions were missing certain applicable provisions. Repeat Finding From Prior Year ? No. Recommendation ? We recommend the Organization enhance internal controls to ensure all contracts under federal awards contain the applicable provisions prior to entering into all covered transactions. Views of Responsible Officials ? Management agrees with this finding.

U.S. Department of Agriculture Community Facilities Loans and Grants, CFDA 10.766 Special Tests and Provisions ? Protection and Disposition of Funds Material Weakness in Internal Control over Compliance Grant Award Number ? Affects all loans included under CFDA 10.766 on the Schedule of Expenditures of Federal Awards. Criteria ? The OMB Compliance Supplement requires borrowers to establish accounts into which borrower funds, agency loan proceeds, the revenues of the facility financed, and any other income that shall be deposited in accordance with the loan resolutions authorization the incurrence of indebtedness related to the agency loan proceeds. The loan resolutions require the establishment of a general account and a reserve account. The reserve account is required to accumulate $5,884 each month until the required reserve amount is met. Condition ? Evidence of review and approval of the reserve account?s bank reconciliation was not available. Cause ? The Organization did not have internal controls to ensure appropriate review of the reserve account?s bank reconciliation was documented. Effect ? Compliance with the reserve requirement may not be monitored. Questioned Costs ? None. Context/Sampling ? No sampling was used. We examined the March 2019 bank reconciliation, as that was the month that had activity in the reserve account. Review and approval were not evident on the bank reconciliation; however, it was noted that the reserve requirement was met. Repeat Finding From Prior Year ? No Recommendation ? We recommend the Organization implement internal controls to ensure appropriate review of the reserve account?s bank reconciliation is documented. Views of Responsible Officials ? Management agrees with this finding.

U.S. Department of Health and Human Services Health Center Program Cluster: Grants for New and Expanded Services Under the Health Center Program, CFDA 93.527 Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Allowable Costs/Cost Principles Material Noncompliance and Material Weakness in Internal Control over Compliance Grant Award Number ? Affects all grant awards included under CFDA 93.527 and grant award included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that costs must be adequately documented. In addition, charges for salaries and wages must be based on records that accurately reflect the work performed. Condition ? Salaries and wages were charged to the programs without documentation to support the percentage of salaries and wages allocated. Cause ? The Organization did not have adequate internal controls to ensure salaries and wages for employees who work on multiple grant activities were allocated to reflect the work performed. Effect ? Salaries and wages could be charged to the federal program that were unallowable. Questioned Costs ? Undetermined Context/Sampling ? A nonstatistical sample of 63 from a population of 224 employee pay periods was selected for testing under the Health Center program. The sample of 63 included pay periods from 18 employees. 18 employee pay periods which represented nine employees were allocated without appropriate support. A nonstatistical sample of 60 from a population of 1,094 employee pay periods was selected for testing under the Indian Self-Determination program. The sample of 60 included pay periods from 37 employees. 17 employee pay periods which represented ten employees were allocated without appropriate support. Repeat Finding From Prior Year ? Yes; prior year finding 2018-006. Recommendation ? We recommend the Organization enhance internal controls to ensure salaries and wages for employees who work on multiple grant activities were allocated to reflect the work performed. Views of Responsible Officials ? Management agrees with this finding.

U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Allowable Costs/Cost Principles Material Weakness in Internal Control over Compliance Grant Award Number ? Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires that indirect costs be applied in accordance with the approved rate agreement. Condition ? The approved indirect cost rate was not applied accurately. Cause ? The Organization did not have adequate internal controls to ensure the indirect cost rate was applied accurately. Effect ? Indirect costs were under allocated to the grant by $885,538. Questioned Costs ? None Context/Sampling ? No sampling was used. The application of the indirect cost rate was tested in total. Repeat Finding From Prior Year ? No Recommendation ? We recommend the Organization enhance internal controls to ensure the indirect cost rate is applied accurately. Views of Responsible Officials ? Management agrees with this finding.

U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Eligibility Significant Deficiency in Internal Control over Compliance Grant Award Number ? Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 42 Part 136 indicates that to be eligible for purchase referred care (PRC), individuals must be eligible for direct care and either: reside within the U.S. on a Federal recognized Indian reservation; or reside within a PRCDA and; are members of the Tribe or Tribes located on that reservation; or maintain close economic and social ties with that Tribe or Tribes. Condition ? A tribal membership card to ensure eligibility for a beneficiary who received PRC was maintained on file; however, it was not legible and the identity on the card could not be read. Cause ? The Organization did not have adequate internal controls to ensure appropriate documentation was maintained to support eligibility. Effect ? Services may be paid for on behalf of an ineligible participant. Questioned Costs ? Less than $25,000. Context/Sampling ? A nonstatistical sample of 62 from a population of approximately 3,800 transactions was selected for testing. Documentation to support eligibility was not available for one individual. We noted there were nine total transactions on behalf of this individual and the total charges were $3,034. Repeat Finding From Prior Year ? No Recommendation ? We recommend the Organization enhance internal controls to ensure appropriate documentation is maintained to support eligibility. Views of Responsible Officials ? Management agrees with this finding.

U.S. Department of Health and Human Services Passed Through California Rural Indian Health Board Indian Self-Determination, CFDA 93.441 Equipment and Real Property Management Material Noncompliance and Material Weakness in Internal Control over Compliance Grant Award Number ? Potentially affects all grant awards included under CFDA 93.441 on the Schedule of Expenditures of Federal Awards. Criteria ? Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance) requires property records 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 sale price of the property. Condition ? Property records were not maintained in accordance with Uniform Guidance for all property and equipment purchased. Cause ? The Organization did not have adequate internal controls to ensure its property records included all the requirements under Uniform Guidance or properly identify all property and equipment purchased with federal funds. Effect ? Property records were not adequately maintained. Questioned Costs ? None Context/Sampling ? No sampling was used. We examined the Organization?s property records in total. Repeat Finding From Prior Year ? Yes; prior year finding 2018-010. Recommendation ? We recommend the Organization enhance internal controls to ensure its property records include all the requirements under Uniform Guidance and properly identify all property and equipment purchased with federal funds. Views of Responsible Officials ? Management agrees with this finding.

U.S. Department of Health and Human Services Health Center Program Cluster: Grants for New and Expanded Services Under the Health Center Program, CFDA 93.527 Reporting Material Noncompliance and Material Weakness in Internal Control over Compliance Grant Award Number ? Affects all grant awards included under CFDA 93.527 on the Schedule of Expenditures of Federal Awards. Criteria ? The OMB Compliance Supplement requires reports submitted to the Federal awarding agency include all activity of the reporting period, are supported by applicable accounting or performance records, and are presented in accordance with program requirements. Condition ? During our testing of the 2018 Uniform Data System Report (UDS), we noted amounts were reported based on allocations that were judgmentally estimated and not based on the instructions indicated in the UDS Reporting Manual. Cause ? The Organization did not have internal controls to ensure the UDS report was supported by the applicable records in accordance with the UDS Reporting Manual. Effect ? Inaccurate information was reported to the federal awarding agency. Questioned Costs ? None Context/Sampling ? No sampling was used; the entire population of one annual UDS report was tested. We were unable to verify the accuracy of Table 8a as the amounts were allocated from pooled cost centers from a cost center that is not reported under the grant program using estimated percentages rather than a percentage of full-time equivalents or patient visits as required by the UDS Reporting Manual. Repeat Finding From Prior Year ? Yes; prior year finding 2018-011. Recommendation ? We recommend the Organization implement internal controls to ensure the UDS report is reviewed and supported by the applicable records in accordance with the UDS Reporting Manual. Views of Responsible Officials ? Management agrees with this finding.

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