Corrective Action Plan Action Item Responsible Party Monitoring Require that procurement transactions be properly identified and tracked by federal program to ensure completeness and traceability. CFO / Procurement Staff Monthly review Maintain complete procurement documentation, including records of competition, procurement method, and verification of suspension and debarment in accordance with federal requirements. CFO / Procurement Department Periodic internal review Reconcile procurement-related expenditures to the SEFA and underlying accounting records to ensure a reliable population for compliance testing. CFO Documented reconciliation In FY 2026, management developed and implemented a formal Records Retention Policy to ensure that accounting records, supporting documentation, and organizational records are properly maintained and retained in accordance with applicable regulatory and audit requirements CFO Management oversight Implement supervisory review of procurement activity to ensure compliance with federal procurement requirements. CFO / Board Finance Committee Quarterly review ________________________________________ Management Response Management notes that no additional federal grants, other than the HRSA Section 330 program grant (Assistance Listing 93.224), were received in FY2025 or FY2026. Prior management did not provide a reconciled SEFA schedule for earlier reporting periods, which contributed to the documentation limitations identified during the audit. Beginning in FY2026, management has developed a detailed SEFA tracking schedule for the HRSA Section 330 grant that identifies the date federal funds were drawn down, the amount received, the related expenditures, and the corresponding disbursement dates. This schedule is maintained to improve reconciliation between drawdowns, expenditures, and the general ledger and to ensure documentation is readily available for audit and compliance purposes. In FY2026, management implemented an updated and comprehensive set of policies and procedures designed to strengthen internal controls and promote consistent, standardized accounting and administrative practices. These updates establish clearer documentation requirements, defined responsibilities, and improved oversight to ensure compliance with applicable regulations and the safeguarding of organizational records and financial information. ________________________________________ Responsible Official: Chief Financial Officer Expected Completion Date: FY 2026