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