Finding 1227061 (2025-004)

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

AI Summary

  • Core Issue: The Hospital lacks an internal control policy to verify that vendors are not suspended or debarred from federal assistance programs.
  • Impacted Requirements: Non-compliance with 2 CFR 200.303(a) and 2 CFR 200.214 regarding vendor eligibility for federal awards.
  • Recommended Follow-Up: Update the procurement policy to include suspension and debarment checks, and ensure documentation is retained for compliance verification.

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 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. Additionally, 2 CFR 200.214 requires recipients to restrict the subawards and contracts with certain parties that are debarred, suspended, or excluded from ineligible participation in Federal assistance programs or activities. Condition: The Hospital does not have an internal control policy in place to ensure covered transactions are with vendors that are not suspended or debarred, and no evidence was retained regarding ensuring the vendor was not suspended or debarred. Cause: The Hospital does not have an internal control policy or procedures to ensure compliance and was not aware of options available for monitoring to ensure compliance. Effect: The Hospital may enter into a covered transaction with a vendor that is suspended or debarred. Questioned Costs: None reported. Context: A nonstatistical sample of 3 out of 13 covered transactions were selected for testing. Repeat Finding from Prior Years: No Recommendation: We recommend the Hospital update their procurement policy to ensure it includes suspension and debarment requirements. Additionally, we recommend management complete a review to ensure vendors are not suspended or debarred from doing business with the federal government prior to entering into a procurement transaction and retain documentation to support that these procedures are being performed. Views of Responsible Officials: Management agrees with the finding.

Corrective Action Plan

Finding 2025-004 Federal Agency Name: United States Department of Health and Human Services Program Name: Congressional Directives FFAL #93.493 Finding Summary: The Hospital does not have an internal control policy in place to ensure covered transactions are with vendors that are not suspended or debarred, and no evidence was retained regarding ensuring the vendor was not suspended or debarred. Corrective Action Plan: For Finding 2025-004, the Hospital has implemented corrective actions to address the lack of internal controls related to suspended and debarred vendor verification. The Hospital revised its Capital Request Form to require documented verification that vendors involved in federally funded procurements are not suspended or debarred prior to contract award or purchase. Additionally, the Federal Procurement Policy and Procedure was updated to establish formal internal controls for screening vendors against applicable federal exclusion lists and retaining evidence of the verification process. Effective immediately, no procurement involving federal funds will be approved until suspended and debarred status verification has been completed and documented. Management will provide education to all managers on August 5, 2026, regarding the revised requirements and documentation standards. Hospital leadership will conduct ongoing monitoring and review of procurement files to ensure compliance with federal regulations and to prevent recurrence 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 Subrecipient Monitoring

Other Findings in this Audit

  • 1227060 2025-003
    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