Finding 1227060 (2025-003)

Material Weakness Repeat Finding
Requirement
I
Questioned Costs
-
Year
2025
Accepted
2026-08-17

AI Summary

  • Core Issue: The Hospital lacks a compliant procurement policy and did not follow required procurement processes.
  • Impacted Requirements: Noncompliance with 2 CFR 200.303(a) and 2 CFR 200.318 regarding internal controls and documented procurement policies.
  • Recommended Follow-Up: Update the procurement policy to meet Uniform Guidance standards and implement procedures to ensure compliance and proper documentation.

Finding Text

U.S Department of Health and Human Services Federal Financial Assistance Listing #93.493 Congressional Directives Procurement, Suspension & Debarment Material Weakness in Internal Control Over Compliance and Material Noncompliance Criteria: 2 CFR 200. 303(a) establishes that the auditee must establish and maintain effective internal control over the federal award that provides assurance that the entity is managing the federal award in compliance with federal statutes, regulations, and the terms and conditions of the federal award. 2 CFR 200.318 maintains that recipients must have and use documented procurement policies and must conform procurement standards to Uniform Guidance standards in sections 2 CFR 200.317 through 200.327. Additionally, 2 CFR 200 Appendix II requires certain provisions be included in contracts if criteria are applicable. Condition: Testing of the federal program identified the following: 􀁸 The Hospital’s formally documented procurement policy was missing the required elements detailed under Uniform Guidance. 􀁸 Instances where the Hospital did not follow the procurement process, and/or retain documentation for reasoning of selection of vendor. Cause: The Hospital was not aware of the federal procurement requirements and did not have an established policy. Contract provisions were not evaluated compared to Uniform Guidance contract requirements and documentation was not retained to support procurement and selection of vendors. Effect: The Hospital was not in compliance with the procurement standards for their purchases and are not in compliance with the requirement to have a written policy in accordance with Uniform Guidance. Questioned Costs: None reported. Context: A nonstatistical sample of 4 out of 14 vendors were selected for testing. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital update their procurement policy to ensure it includes all the required elements in accordance with Uniform Guidance. In addition, we suggest that management implement procedures and control processes related to the review of procurement to ensure the procurement methods are being followed and documentation is retained to support compliance. Views of Responsible Officials: Management agrees with the finding.

Corrective Action Plan

Finding 2025-003 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: Testing of the federal program identified the following: 􀁸 The Hospital’s formally documented procurement policy was missing the required elements detailed under Uniform Guidance. 􀁸 Instances where the Hospital did not follow the procurement process, and/or retain documentation for reasoning of selection of vendor. Corrective Action Plan: For Finding 2025-003, the Hospital has updated and approved its Federal Procurement Policy and Procedure to incorporate all required elements of Uniform Guidance and strengthen compliance with federal grant requirements. In addition, the Hospital revised its Capital Request process to include formal procurement requirements, vendor selection documentation, and approval workflows. Effective immediately, no federal funds will be expended until the procurement process has been fully completed and documented in accordance with the revised policy. Management has implemented controls to ensure procurement records are maintained, including documentation supporting vendor selection and purchasing decisions. To support compliance and consistent application of the new requirements, education and training on the revised procurement and capital request processes will be provided to all managers on August 5, 2026. Hospital leadership will monitor adherence to these procedures through ongoing review and oversight to ensure compliance with federal regulations and prevent future occurrences of this finding. Responsible Individuals: Wesley Babers, Chief Executive Officer and Ashley Jaramillo, Chief Financial Officer Anticipated Completion Date: August 2026

Categories

Procurement, Suspension & Debarment

Other Findings in this Audit

  • 1227061 2025-004
    Material Weakness Repeat

Programs in Audit

ALN Program Name Expenditures
93.493 CONGRESSIONAL DIRECTIVES $2.43M
93.301 SMALL RURAL HOSPITAL IMPROVEMENT GRANT PROGRAM $11,041