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

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

Issued on 12/09/2025 | Posted on 12/12/2025 | Report number: A-01-24-01500

Report Materials

• Full Report (PDF, 5.0 MB)
• Report Highlights (PDF, 360.6 KB)

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.