Indian Health and Human Services
Planned Work
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The Indian Health Service (IHS) Sanitation Facilities Construction (SFC) Program works in partnership with Tribes to prevent the spread of disease by providing American Indian and Alaska Native homes and communities with essential water supply, sewage disposal, and solid waste disposal facilities. In fiscal year 2021, IHS identified a need of more than $3.4 billion for SFC projects affecting more than 248,000 new and existing homes. To address that need, Congress appropriated $3.5 billion to the SFC Program through the Infrastructure Investment and Jobs Act. We will assess IHS's capacity to establish agreements and contracts for administering the supplemental $3.5 billion, and to oversee the construction of projects paid for using that funding.
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The Indian Health Service (IHS) provides a comprehensive health service delivery system for approximately 2.6 million American Indians and Alaska Natives who belong to 574 federally recognized Tribes in 37 States. IHS has a decentralized management structure that consists of two major components: headquarters offices in Rockville, Maryland, and 12 area offices.
IHS's National Supply Service Center (NSSC) serves as the distribution warehouse and supply distribution management center for IHS by providing supply support services and medical supplies to IHS Federal and Tribal Hospitals, Tribal health programs, and Urban Indian Organization health care centers in all 12 IHS areas. The NSSC Director reports to the Area Director of the Oklahoma City Area. Within IHS, but separate from NSSC, the Navajo Area operates a Regional Supply Service Center (RSSC), located in Gallup, New Mexico. The RSSC Director reports to the Area Director of the Navajo Area and has no reporting relationship to NSSC. RSSC provides medical supplies to the Navajo, Albuquerque, and Phoenix IHS areas. Facilities in these three areas can order and receive supplies from both NSSC and RSSC. In a related audit, we are examining NSSC's distribution of medical supplies and equipment during the COVID-19 pandemic.
Our objective is to determine whether IHS coordinated NSSC and RSSC operations to distribute supplies to facilities in an effective manner from January 1, 2019, through March 31, 2022.
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The COVID-19 pandemic response has included a significant increase in the use of telehealth technologies to provide access to health care. The dramatic growth in telehealth utilization has introduced new cybersecurity risks to medical facilities, including Indian Health Service (IHS) facilities, that use these technologies. We will perform an audit to determine whether IHS has implemented select cybersecurity controls to protect its telehealth technologies from these emerging cybersecurity risks. Read the Work Plan Summary
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COVID-19 has created unprecedented challenges for the U.S. hospital system, including Indian Health Service (IHS), Tribal, and Urban Indian Health Program (UIHP) facilities. American Indians and Alaska Natives (AI/AN) are particularly vulnerable to COVID-19 due to the relatively high rates of diabetes, cancer, heart disease, and asthma among these populations. These vulnerabilities can be heightened by the strong familial structures in AI/AN communities, in which families commonly live in multigenerational homes. Such socially cohesive communities provide a broad range of benefits to their members, but paradoxically these strong structures make it all the more difficult to maintain physical distancing during a pandemic.
IHS has received funding for medical supplies and equipment through the COVID-19 relief bills allocated to IHS, Tribal, and UIHP facilities. The objective of this audit is to determine whether IHS had adequate internal controls to ensure that medical supplies and equipment were effectively distributed to the National Supply Service Center's customers in response to the COVID-19 pandemic. Read the Work Plan Summary
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The Indian Child Protection and Family Violence Prevention Act (P.L. No. 101-630) requires background checks, including Federal Bureau of Investigation fingerprinting, for individuals whose duties involve contact with children. Furthermore, Indian Health Service (IHS) appropriated funds may not be used to pay for services provided by individuals excluded from federally funded health care programs. Prior OIG audit work identified IHS and Tribal health facilities that did not meet Federal requirements for background verifications of employees in contact with children. We will determine whether IHS-operated health facilities met Federal requirements for background verifications of employees, contractors, and volunteers in contact with Indian children served by the facilities, and whether health care providers treating these children were appropriately licensed. Read the Work Plan Summary
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The COVID-19 pandemic has disproportionately affected American Indian and Alaska Native (AI/AN) populations nationwide. The Centers for Disease Control and Prevention (CDC) reported that the age-adjusted AI/AN population's mortality rate from COVID-19 was 1.8 times higher than that among non-Hispanic whites as of December 2020. The Indian Health Service (IHS) has issued its COVID-19 Pandemic Vaccine Plan detailing how the IHS health care system will distribute, allocate, and administer the COVID-19 vaccine. The CDC recommended that all jurisdictions be prepared to immediately vaccinate identified critical populations as the earliest COVID-19 vaccine doses became available and were granted emergency use authorization. IHS is recognized as a "coordinator," similar to a State or other jurisdiction, for vaccine distribution. Tribal Health Programs and Urban Indian Organizations had the option to receive vaccines through either the IHS or their State. IHS direct facilities receive the vaccine through IHS. Approximately 338 facilities elected to receive vaccines through the IHS (including IHS direct facilities, Tribal Health Programs, and Urban Indian Organizations). We will focus on IHS's coordination of the distribution, allocation, and administration of the vaccine to Tribal Health Programs. Read the Work Plan Summary
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The Families First Coronavirus Response Act provided $64 million in additional resources for COVID-19 response activities through the Indian Health Service (IHS) and requires coverage, without cost-sharing, for COVID-19 testing for American Indians/Alaska Natives, who receive health services. The Paycheck Protection Program and Health Care Enhancement Act provided $750 million for COVID-19 testing and testing-related services through IHS. From these two Acts, funding for COVID-19 testing to urban Indian organizations total $53 million and funding to IHS Federal health programs and Tribal health programs total $611 million. We will audit IHS's allocation and utilization of funding to urban Indian organizations, IHS Federal health programs and Tribal health programs. Specifically, our objectives will be to determine whether: (1) IHS allocated the COVID-19 funds to ensure that testing supplies were available to meet community needs, and (2) COVID-19 funds were used by IHS and grantees for testing, including other testing-related services, in accordance with Federal requirements. Read the Work Plan Summary
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The Substance Abuse and Mental Health Services Administration (SAMHSA) has awarded a series of grants to combat opioid use disorder. These grants include State Targeted Response to the Opioid Crisis grants (Opioid STR) with approximately half of $970 million awarded in fiscal year (FY) 2017 and the other half awarded in FY 2018. In FY 2018, SAMHSA also awarded more than $930 million in the State Opioid Response grants (SOR) and approximately $50 million in Tribal Opioid Response grants (TOR). The purpose of the Opioid STR, SOR, and TOR grants are to increase access to treatment, reduce unmet treatment need, and reduce opioid overdose related deaths. This post-award audit will determine how select States or Tribal agencies implemented programs under the Opioid STR, SOR, or TOR grants. We will also determine whether the activities of these agencies and subrecipients responsible for implementing the programs complied with Federal regulations and met grant program goals. Read the Work Plan Summary
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The Indian Health Service's (IHS's) mission is to partner with American Indians and Alaska Natives to elevate their physical, mental, social, and spiritual health to the highest level. The goal of IHS is to ensure that comprehensive, culturally acceptable personal and public health services are available and accessible to all of the approximately 2.6 million members of the 573 federally recognized Tribes. In 1975, Congress recognized the importance of Tribal decision making in Tribal affairs and the nation-to-nation relationship between the United States and Tribes through the passage of the Indian Self-Determination and Education Assistance Act (ISDEAA) (P.L. No. 93-638). Under ISDEAA, federally recognized Tribes administer their own healthcare programs and services that IHS would otherwise provide through P.L. No. 93-638 funding agreements with IHS. In 2019, a pediatrician who worked at several IHS health facilities during a 21-year period was convicted of sexually abusing children served at these facilities. Congressional officials have expressed concerns about safeguards for Indian children and specifically about IHS failing to address this pediatrician's history of offenses at the various IHS health facilities where he was employed. The Indian Child Protection and Family Violence Prevention Act (P. L. No. 101-630), requires background checks, including Federal Bureau of Investigation fingerprinting, for employees whose job duties involve contact with children. Prior OIG audit work identified two Tribal health facilities that did not meet Federal requirements for background verifications for employees in contact with children. We will determine whether the tribally operated health facilities met Federal and Tribal requirements for background verification of employees, contractors, and volunteers in contact with children served by the facilities. Read the Work Plan Summary
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The Federal government pays its share of a State's Medicaid expenditures based on the Federal Medical Assistance Percentage (FMAP), which varies depending on the State's relative per capita income. States' regular FMAPs range from a low of 50 percent to a high of 83 percent; however, States receive a 100-percent FMAP for expenditures related to services received through Indian Health Service (IHS) facilities. In Federal fiscal years 2016 through 2018, States claimed $6.6 billion in expenditures at the IHS services FMAP, all of which was federally funded. We will analyze selected States' methodologies for identifying expenditures claimed at the IHS services FMAP and determine whether the States claimed these expenditures in accordance with Federal requirements. Read the Work Plan Summary
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IHS provides a comprehensive health service delivery system for approximately 2 million American Indians and Alaska Natives either by operating health facilities directly or by funding tribes through contracts or compacts to operate health facilities themselves. In certain cases, tribes may operate a facility known as a Federally Qualified Health Center (FQHC), which is certified by CMS to provide outpatient health services to rural areas or underserved populations. In addition to funding from IHS, the tribes may also receive health care funding from the Medicaid or Medicare programs. This report will build on OIG’s body of work identifying longstanding challenges that likely impact the quality of health care services provided to American Indians and Alaska Natives. We will review a tribally operated FQHC that is funded by IHS, to determine whether health services delivered to American Indians and Alaska Natives met applicable Federal requirements. Read the Work Plan Summary