Audit 409364

Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Criteria or Specific Requirement – Performance and Financial Monitoring and Reporting, 2 CFR Section 200.328-329 Condition – The annual Federal Financial Report was not submitted timely and required performance reporting was not completed during the year. Cause – Management turnover caused uncertainty in assigned responsibilities, including this reporting requirement. Effect or Potential Effect – The Medical Center did not comply with federal reporting requirements. Questioned costs – N/A Context – The Federal Financial Report for the reporting period ended September 29, 2025 was due December 28, 2025; however, this was not submitted until May 19, 2026. Additionally, a performance report was due during the year; however, it was not completed. The performance report for the period September 30, 2024–March 31, 2025 was due April 30, 2025. Identification as a Repeat Finding, if applicable – N/A Recommendation – The Medical Center should review reporting requirements in grant award documents for all federal awards to ensure compliance. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The issue was identified in May 2026 and the required reporting was completed and submitted. Going forward management has established a protocol by which reports for federal funding shall be submitted timely.

Congressional Directives Assistance Listing Number 93.493 U.S. Department of Health and Human Services Criteria or Specific Requirement – Procurement and Suspension and Debarment, 2 CFR Sections 200.214 and 200.318-327 Condition – The Medical Center’s Procurement/Contract Management policy does not fully incorporate Uniform Guidance requirements applicable to federal awards. Cause – The Medical Center has established procurement policies designed primarily for general operational purchasing; however, federal procurement requirements were not formally incorporated into the policy framework. Effect or Potential Effect – The Medical Center could potentially enter into transactions that are not conducted in accordance with the Uniform Guidance requirements. Questioned Costs – N/A Context – The exceptions were identified through evaluation of the entity’s procurement policies and application to federal program requirements. The deficiencies are systemic in nature, affecting the design of controls over procurement and suspension and debarment compliance across applicable transactions. Identification as a Repeat Finding, if applicable – N/A Recommendation – The Medical Center should update procurement policies to explicitly incorporate Uniform Guidance including defining and implementing federally compliant procurement methods and thresholds. The Medical Center should implement controls to ensure consistent application of requirements across all federally funded procurements. Views of Responsible Officials and Planned Corrective Actions – Management agrees with the finding. The Medical Center will revise and update its procurement policies and procedures to incorporate applicable federal procurement requirements under the Uniform Guidance.