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The Indian Health Service Did Not Ensure That Commissioned Corps Officers’ Background Investigations Complied With Federal Requirements

Issued on  | Posted on  | Report number: A-01-24-01500

Why OIG Did This Audit

  • The Indian Child Protection and Family Violence Act (ICPFVPA) established minimum character standard requirements for Federal background investigations for individuals in contact with Indian children and the Crime Control Act established requirements for supervision of such individuals pending the completion of background investigations. Prior OIG work in this area found gaps in compliance with these requirements.
  • This audit assessed whether Commissioned Corps Officers (Officers) assigned to provide health care services to Tribal and Indian Health Service (IHS) operated health programs received background investigations in accordance with Federal requirements.

What OIG Found

Officers assigned to provide health care services to Tribal and IHS-operated health programs did not receive background investigations in accordance with Federal requirements. We found that:

  • IHS did not ensure that the background investigations for any of the 100 Officers in our sample considered the minimum character standard requirements of the ICPFVPA.
  • IHS did not provide evidence for 59 Officers in our sample with pending background investigations that the Officers were within the sight and under the supervision of staff members with satisfactory background investigations or communicated to Tribes that the Officers had pending background investigations and required supervision when children are in their care.
  • IHS did not ensure that background investigations for 39 Officers in our sample that needed reinvestigations were initiated within the standard timeframe.

Commissioned Corps and IHS relied on the Office of National Security (ONS) adjudicated background investigations, but they were not aware that these background investigations were based on Federal guidelines that did not assess an individual’s criminal history results against the minimum character standards of the ICPFVPA.

What OIG Recommends

We made nine recommendations, including that IHS and the Commissioned Corps work with the Office of National Security to develop policies and procedures to ensure that all Officers assigned to IHS have background investigations adjudicated according to the requirements in the ICPFVPA. The full recommendations are in the report.

In written comments to our draft report, IHS concurred with our recommendations and the Commissioned Corps concurred with our report.

26-A-01-022.01 to IHS - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Indian Health Service work with the Office of National Security to develop policies and procedures to ensure that all Officers assigned to IHS have background investigations adjudicated according to the requirements of the ICPFVPA.

26-A-01-022.02 to IHS - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Indian Health Service work with ONS to evaluate the most recent background investigation results for all Officers assigned to IHS and determine whether the individuals meet the minimum character standards of the ICPFVPA to allow the individuals to be in contact with Indian children.

26-A-01-022.03 to IHS - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Indian Health Service determine which Officers have pending background investigations and take immediate action to ensure the supervision of these individuals when children are in their care.

26-A-01-022.04 to IHS - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Indian Health Service develop policies and procedures to communicate provisional clearance status of Officers assigned to Tribal health programs to Tribes.

26-A-01-022.05 to IHS - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Indian Health Service work with ONS to obtain full access to all Officers' background investigation data in the Security Manager system that includes criminal history results to enable a determination of the schedule for reinvestigations.

26-A-01-022.06 to IHS - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Indian Health Service develop and implement policies and procedures to identify and track when Officers background reinvestigations will expire and initiate reinvestigations within the standard timeframe.

26-A-01-022.07 to OASH - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Commissioned Corps of the United States Public Health Service work with the Office of National Security to develop policies and procedures to ensure that all Officers assigned to IHS have background investigations adjudicated according to the requirements of the ICPFVPA.

26-A-01-022.08 to OASH - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Commissioned Corps of the United States Public Health Service communicate an Officer's provisional clearance status at the time the individual is assigned to a Division and the final determination of the background investigation adjudication to Divisions.

26-A-01-022.09 to OASH - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Commissioned Corps of the United States Public Health Service maintain documentation of provisional clearance status and final determination of background investigations in Officers' eOPFs to facilitate use of the Officers' personnel records in the redetermination of their eligibility for a position.

26-A-01-022.10 to OASH - Open Unimplemented
Update expected on 06/08/2026
We recommend that the Commissioned Corps of the United States Public Health Service collect at least annually, background investigations that have been adjudicated and enter the COIs into the Officers' eOPF.

View in Recommendation Tracker