Audit 301158

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-005 – Cash Management Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.007, 84.063, and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have review controls in place over cash management. Effect or potential effect: There is no consistent documentation to support the timely performance of internal controls at Good Samaritan College of Nursing & Health Science. There is no consistent documentation to support the performance of internal controls at CHI Health School of Radiologic Technology. Questioned costs: None. Context: We issued a material weakness for Good Samaritan College of Nursing & Health Science related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. CHI Health School of Radiologic Technology did not have review controls in place over cash management. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $0.2 million, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science– Finding 2022-004 and 2021-004. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should continue to perform and improve its processes and retain documentation to evidence performance of internal controls over cash management. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over cash management. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.063, 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Title 2, Subtitle A Chapter II Part 200 Subpart F Section 200.510(b) Schedule of expenditures of Federal awards. The auditee must prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with Section 200.502. Section 200.502(a) states the determination of when a federal award is expended must be based on when the activity related to the federal award occurs. Condition: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted an overstatement of the SFA expenditures reported in the SEFA. Cause: Management did not reconcile amounts reported on the SEFA for the SFA program to the underlying detail to ensure accurate and complete reporting of the federal program in the SEFA. Effect or potential effect: Certain amounts in the SEFA were reported incorrectly or omitted. Questioned costs: None. Context: During our testing for Good Samaritan College of Nursing & Health Science, we obtained a population of disbursements and reconciled the total payments to the SEFA. Disbursements totaled $3,538,116 compared to the amount reported in the SEFA of $4,627,538. This resulted in an overstatement of SFA expenditures reported in the SEFA of $1,089,372 for Good Samaritan College of Nursing & Health Science. The amounts reported in the final SEFA in this report for SFA expenditures for Good Samaritan College of Nursing & Health Science have been corrected to $3,538,116. Management’s control regarding the review of the SEFA did not identify this error. SFA expenditures for Good Samaritan College of Nursing & Health Science of $3.5 million represent 85% of total SFA expenditures of $4.2 million and 1% of total SEFA expenditures of $309.9 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls to ensure the completeness and accuracy of the SEFA and review applicable guidance prior to finalization. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2024.

Finding 2023-005 – Cash Management Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.007, 84.063, and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have review controls in place over cash management. Effect or potential effect: There is no consistent documentation to support the timely performance of internal controls at Good Samaritan College of Nursing & Health Science. There is no consistent documentation to support the performance of internal controls at CHI Health School of Radiologic Technology. Questioned costs: None. Context: We issued a material weakness for Good Samaritan College of Nursing & Health Science related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. CHI Health School of Radiologic Technology did not have review controls in place over cash management. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $0.2 million, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science– Finding 2022-004 and 2021-004. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should continue to perform and improve its processes and retain documentation to evidence performance of internal controls over cash management. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over cash management. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-006 – Reporting – Common Origination and Disbursement (COD) System Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Institutions submit Direct Loan, Pell Grant, TEACH Grant, and IASG origination records and disbursement records to the COD system. Origination records can be sent well in advance of any disbursements, as early as the institution chooses to submit them for any student the institution reasonably believes will be eligible for a payment. An institution follows up with a disbursement record for that student no earlier than (1) seven calendar days prior to the disbursement date under the Advance or Heightened Cash Monitoring 1 payment methods, or (2) the date of the disbursement under the Reimbursement or Heightened Cash Monitoring 2 Payment Method (see Federal Register, Volume 86, Number 119, June 24, 2021). The disbursement record reports the actual disbursement date and the amount of the disbursement. ED processes origination and/or disbursement records and returns acknowledgments to the institution. The acknowledgments identify the processing status of each record: Rejected, Accepted with Corrections, or Accepted. In testing the origination and disbursement data, the auditor should be most concerned with the data ED has categorized as accepted or accepted with corrections. Institutions must report student disbursement data within 15 calendar days after the institution makes a disbursement or becomes aware of the need to make an adjustment to previously reported student disbursement data or expected student disbursement data. Institutions may do this by reporting once every 15 calendar days, biweekly or weekly, or may set up their own system to ensure that changes are reported in a timely manner.  Condition: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan payment data to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have processes and internal controls in place to ensure that COD disbursement information was updated and accurate. Effect or potential effect: Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be identified and resolved in a timely manner. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be identified and resolved in a timely manner. Questioned costs: None.   Context: We issued a material weakness related to internal controls in the prior year for Good Samaritan College of Nursing & Health Science. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. For CHI Health School of Radiologic Technology, EY selected 17 student disbursements of Pell and Direct Loans from a population of 105 disbursements. For each of the 17 disbursements, the disbursement date reported in COD was not the actual disbursement date but was the “assumed” or “expected” date per discussion with management. This resulted in a finding of noncompliance for CHI Health School of Radiologic Technology. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Findings 2022-003, 2021-003, 2020-004, and 2019-008. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should ensure that all monthly grant reconciliations are being performed, reviewed, and approved, with documentation being retained in its internal records. The accuracy of the disbursement data should also be validated. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over reporting in the COD system. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.16(e) states: “For purposes of determining student eligibility for assistance under a title IV, HEA program, establishes, publishes, and applies reasonable standards for measuring whether an otherwise eligible student is maintaining satisfactory academic progress in his or her educational program. The Secretary considers an institution’s standards to be reasonable if the standards are in accordance with the provisions specified in § 668.34.” 34 CFR 668.34 states: “An institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under the title IV, HEA programs.” The Secretary considers the institution’s policy to be reasonable if it meets the specified requirements in 34 CFR 668.34, including the following, for which we noted noncompliance by CHI Health School of Radiologic Technology.   (1) The policy provides that a student’s academic progress is evaluated— (i) At the end of each payment period if the educational program is either one academic year in length or shorter than an academic year Or (ii) For all other educational programs, at the end of each payment period or at least annually to correspond with the end of a payment period (2) The policy specifies— (i) For all programs, the maximum timeframe as defined in paragraph (b) of this section (ii) For a credit hour program using standard or nonstandard terms that is not a subscription-based program, the pace, measured at each evaluation, at which a student must progress through his or her educational program to ensure that the student will complete the program within the maximum timeframe, calculated by either dividing the cumulative number of hours the student has successfully completed by the cumulative number of hours the student has attempted or by determining the number of hours that the student should have completed by the evaluation point in order to complete the program within the maximum timeframe (3) If the institution places students on financial aid warning, or on financial aid probation, as defined in paragraph (b) of this section, the policy describes these statuses. (4) If the institution permits a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy describes— (i) How the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (ii) The basis on which a student may file an appeal: The death of a relative, an injury or illness of the student, or other special circumstances   (iii) Information the student must submit regarding why the student failed to make satisfactory academic progress, and what has changed in the student’s situation that will allow the student to demonstrate satisfactory academic progress at the next evaluation (5) If the institution does not permit a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy must describe how the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (6) The policy provides for notification to students of the results of an evaluation that impacts the student’s eligibility for title IV, HEA program funds Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding the satisfactory academic progress (SAP) policy. During our testing, we noted that the policy does not contain specific procedures related to the following components: (1) The policy does not specify the frequency of evaluation of SAP for purposes of Title IV assistance; (2) The policy does not specify the maximum timeframe or the pace at which the student must progress through the program; (3) No specific procedures exist related to disbursements to students on financial aid warning status; (4) No specific procedures exist related to appeal and reinstatement process; and (5) No specific procedures exist related to the notification to students of the evaluation process. Additionally, we noted there was no documentation retained to evidence that a review of the SAP policy was performed to ensure compliance with federal regulations. Cause: CHI Health School of Radiologic Technology did not have effective internal controls to ensure compliance with SAP requirements and did not retain sufficient documentation of review procedures over the SAP Policy. Effect or potential effect: The published SAP policy does not comply with federal requirements. Questioned costs: None. Context: CHI Health School of Radiologic Technology’s SAP policy did not include required elements according to federal regulations and there was no evidence that the SAP policy was reviewed and approved by management. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure the SAP policy includes all required elements and is reviewed and approved on an annual basis with supporting documentation of the review retained. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-009 – Activities Allowed or Unallowed/Eligibility Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Cause: Due to the size of the program, CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Effect or potential effect: Students receiving federal aid could be ineligible or receive the incorrect amount of federal student financial assistance. Questioned costs: None.   Context: Although CHI Health School of Radiologic Technology has processes in place related to Activities Allowed or Unallowed and Eligibility, internal controls were not documented and there was no evidence that internal controls were performed. Total SFA expenditures for CHI Health School of Radiologic Technology were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls related to Activities Allowed or Unallowed and Eligibility and retain evidence that internal controls were performed throughout the year. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-010 – Special Tests and Provisions – Enrollment Reporting Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have internal controls in place over enrollment reporting.   Effect or potential effect: Lack of internal controls over timely and accurate enrollment reporting could result in inaccurate enrollment status. A student’s enrollment status determines eligibility for in-school status, deferment, and grace periods. Enrollment reporting in a timely and accurate manner is critical for effective management of the programs. Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be timely identified and resolved. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be timely identified and resolved. Questioned costs: None. Context: We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding. Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $3.5 million, which makes up 85% of total SFA Cluster expenditures of approximately $4.2 million. Total federal expenditures for CHI Health School of Radiologic Technology Assistance were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Finding 2022-005 & 2021-006. This is not a repeat finding for CHI Health School of Radiologic Technology. Recommendation: Good Samaritan College of Nursing & Health Science should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. CHI Health School of Radiologic Technology should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.063, 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Title 2, Subtitle A Chapter II Part 200 Subpart F Section 200.510(b) Schedule of expenditures of Federal awards. The auditee must prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with Section 200.502. Section 200.502(a) states the determination of when a federal award is expended must be based on when the activity related to the federal award occurs. Condition: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted an overstatement of the SFA expenditures reported in the SEFA. Cause: Management did not reconcile amounts reported on the SEFA for the SFA program to the underlying detail to ensure accurate and complete reporting of the federal program in the SEFA. Effect or potential effect: Certain amounts in the SEFA were reported incorrectly or omitted. Questioned costs: None. Context: During our testing for Good Samaritan College of Nursing & Health Science, we obtained a population of disbursements and reconciled the total payments to the SEFA. Disbursements totaled $3,538,116 compared to the amount reported in the SEFA of $4,627,538. This resulted in an overstatement of SFA expenditures reported in the SEFA of $1,089,372 for Good Samaritan College of Nursing & Health Science. The amounts reported in the final SEFA in this report for SFA expenditures for Good Samaritan College of Nursing & Health Science have been corrected to $3,538,116. Management’s control regarding the review of the SEFA did not identify this error. SFA expenditures for Good Samaritan College of Nursing & Health Science of $3.5 million represent 85% of total SFA expenditures of $4.2 million and 1% of total SEFA expenditures of $309.9 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls to ensure the completeness and accuracy of the SEFA and review applicable guidance prior to finalization. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2024.

Finding 2023-005 – Cash Management Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.007, 84.063, and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have review controls in place over cash management. Effect or potential effect: There is no consistent documentation to support the timely performance of internal controls at Good Samaritan College of Nursing & Health Science. There is no consistent documentation to support the performance of internal controls at CHI Health School of Radiologic Technology. Questioned costs: None. Context: We issued a material weakness for Good Samaritan College of Nursing & Health Science related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. CHI Health School of Radiologic Technology did not have review controls in place over cash management. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $0.2 million, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science– Finding 2022-004 and 2021-004. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should continue to perform and improve its processes and retain documentation to evidence performance of internal controls over cash management. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over cash management. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-006 – Reporting – Common Origination and Disbursement (COD) System Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Institutions submit Direct Loan, Pell Grant, TEACH Grant, and IASG origination records and disbursement records to the COD system. Origination records can be sent well in advance of any disbursements, as early as the institution chooses to submit them for any student the institution reasonably believes will be eligible for a payment. An institution follows up with a disbursement record for that student no earlier than (1) seven calendar days prior to the disbursement date under the Advance or Heightened Cash Monitoring 1 payment methods, or (2) the date of the disbursement under the Reimbursement or Heightened Cash Monitoring 2 Payment Method (see Federal Register, Volume 86, Number 119, June 24, 2021). The disbursement record reports the actual disbursement date and the amount of the disbursement. ED processes origination and/or disbursement records and returns acknowledgments to the institution. The acknowledgments identify the processing status of each record: Rejected, Accepted with Corrections, or Accepted. In testing the origination and disbursement data, the auditor should be most concerned with the data ED has categorized as accepted or accepted with corrections. Institutions must report student disbursement data within 15 calendar days after the institution makes a disbursement or becomes aware of the need to make an adjustment to previously reported student disbursement data or expected student disbursement data. Institutions may do this by reporting once every 15 calendar days, biweekly or weekly, or may set up their own system to ensure that changes are reported in a timely manner.  Condition: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan payment data to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have processes and internal controls in place to ensure that COD disbursement information was updated and accurate. Effect or potential effect: Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be identified and resolved in a timely manner. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be identified and resolved in a timely manner. Questioned costs: None.   Context: We issued a material weakness related to internal controls in the prior year for Good Samaritan College of Nursing & Health Science. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. For CHI Health School of Radiologic Technology, EY selected 17 student disbursements of Pell and Direct Loans from a population of 105 disbursements. For each of the 17 disbursements, the disbursement date reported in COD was not the actual disbursement date but was the “assumed” or “expected” date per discussion with management. This resulted in a finding of noncompliance for CHI Health School of Radiologic Technology. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Findings 2022-003, 2021-003, 2020-004, and 2019-008. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should ensure that all monthly grant reconciliations are being performed, reviewed, and approved, with documentation being retained in its internal records. The accuracy of the disbursement data should also be validated. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over reporting in the COD system. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-007 – Special Tests and Provisions – Disbursements to or on Behalf of Students Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.165 Notices, requires the following: (1) Before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. If those funds include Direct Loan program funds, the notice must indicate which funds are from subsidized loans, which are from unsubsidized loans, and which are from PLUS loans.   (2) Except in the case of a post-withdrawal disbursement made in accordance with § 668.22(a)(5), if an institution credits a student ledger account with Direct Loan, Federal Perkins Loan, or TEACH Grant program funds, the institution must notify the student or parent of – (i) The anticipated date and amount of the disbursement (ii) The student’s or parent’s right to cancel all or a portion of that loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement and have the loan proceeds or TEACH Grant proceeds returned to the Secretary (iii) The procedures and time by which the student or parent must notify the institution that he or she wishes to cancel the loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement (3) The institution must provide the notice described in paragraph (a)(2) of this section in writing – (i) No earlier than 30 days before, and no later than 30 days after, crediting the student’s ledger account at the institution, if the institution obtains affirmative confirmation from the student under paragraph (a)(6)(i) of this section Or (ii) No earlier than 30 days before, and no later than seven days after, crediting the student’s ledger account at the institution, if the institution does not obtain affirmative confirmation from the student under paragraph (a)(6)(i) of this section Condition: Good Samaritan College of Nursing & Health Science did not send loan notifications to 3 of 30 students selected for disbursement testing for direct loans within +/- 30 days of the funds being disbursed. CHI Health School of Radiologic technology did not send loan notifications to 14 of 14 students selected for disbursement testing with direct loans within +/- 30 days of the funds being disbursed. Cause: Internal controls over direct loan notifications were not designed or operating effectively at Good Samaritan College of Nursing & Health Science and CHI Health School of Radiologic Technology. Effect or potential effect: Good Samaritan College of Nursing & Health Science was noncompliant with regards to direct loan notification requirements which could impact a student’s ability to cancel the loan timely. CHI Health School of Radiologic Technology was noncompliant with regards to loan notification requirements which could impact a student’s ability to cancel the loan timely. Questioned costs: None. Context: For Good Samaritan College of Nursing & Health Science, we issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over disbursements to or on behalf of students were operating effectively during the year. As such, we did not test the operating effectiveness of this control. For Good Samaritan College of Nursing & Health Science, for 3 of 30 students selected for testing that received direct loans, notifications were not sent to the students for direct loan disbursements. The three disbursements were made in September 2022 and totaled $6,680. Direct loans totaling $87,326 were disbursed to the 30 selected students receiving direct loans during the year. Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.5 million, representing 72% of Good Samaritan College of Nursing & Health Science’s SFA Cluster expenditures of approximately $3.5 million, and 61% of total SFA Cluster expenditures of approximately $4.2 million. For CHI Health School of Radiologic Technology, for 14 of 14 students selected for testing that received direct loans, notifications were not sent to the students for direct loan disbursements. For the 14 students, the total net disbursements for direct loans totaled $24,940. Total direct loans for CHI Health School of Radiologic Technology are approximately $171 thousand, representing 86% of CHI Health School of Radiologic SFA Cluster expenditures of approximately $198 thousand, and 4% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Finding 2022-017. This is not a repeat finding for CHI Health School of Radiologic Technology. Recommendation: Good Samaritan College of Nursing & Health Science should establish procedures to ensure that loan notifications are sent for all loan disbursements, as required. CHI Health School of Radiologic Technology should establish procedures to ensure that loan notifications are sent for all loan disbursements, as required. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.16(e) states: “For purposes of determining student eligibility for assistance under a title IV, HEA program, establishes, publishes, and applies reasonable standards for measuring whether an otherwise eligible student is maintaining satisfactory academic progress in his or her educational program. The Secretary considers an institution’s standards to be reasonable if the standards are in accordance with the provisions specified in § 668.34.” 34 CFR 668.34 states: “An institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under the title IV, HEA programs.” The Secretary considers the institution’s policy to be reasonable if it meets the specified requirements in 34 CFR 668.34, including the following, for which we noted noncompliance by CHI Health School of Radiologic Technology.   (1) The policy provides that a student’s academic progress is evaluated— (i) At the end of each payment period if the educational program is either one academic year in length or shorter than an academic year Or (ii) For all other educational programs, at the end of each payment period or at least annually to correspond with the end of a payment period (2) The policy specifies— (i) For all programs, the maximum timeframe as defined in paragraph (b) of this section (ii) For a credit hour program using standard or nonstandard terms that is not a subscription-based program, the pace, measured at each evaluation, at which a student must progress through his or her educational program to ensure that the student will complete the program within the maximum timeframe, calculated by either dividing the cumulative number of hours the student has successfully completed by the cumulative number of hours the student has attempted or by determining the number of hours that the student should have completed by the evaluation point in order to complete the program within the maximum timeframe (3) If the institution places students on financial aid warning, or on financial aid probation, as defined in paragraph (b) of this section, the policy describes these statuses. (4) If the institution permits a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy describes— (i) How the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (ii) The basis on which a student may file an appeal: The death of a relative, an injury or illness of the student, or other special circumstances   (iii) Information the student must submit regarding why the student failed to make satisfactory academic progress, and what has changed in the student’s situation that will allow the student to demonstrate satisfactory academic progress at the next evaluation (5) If the institution does not permit a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy must describe how the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (6) The policy provides for notification to students of the results of an evaluation that impacts the student’s eligibility for title IV, HEA program funds Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding the satisfactory academic progress (SAP) policy. During our testing, we noted that the policy does not contain specific procedures related to the following components: (1) The policy does not specify the frequency of evaluation of SAP for purposes of Title IV assistance; (2) The policy does not specify the maximum timeframe or the pace at which the student must progress through the program; (3) No specific procedures exist related to disbursements to students on financial aid warning status; (4) No specific procedures exist related to appeal and reinstatement process; and (5) No specific procedures exist related to the notification to students of the evaluation process. Additionally, we noted there was no documentation retained to evidence that a review of the SAP policy was performed to ensure compliance with federal regulations. Cause: CHI Health School of Radiologic Technology did not have effective internal controls to ensure compliance with SAP requirements and did not retain sufficient documentation of review procedures over the SAP Policy. Effect or potential effect: The published SAP policy does not comply with federal requirements. Questioned costs: None. Context: CHI Health School of Radiologic Technology’s SAP policy did not include required elements according to federal regulations and there was no evidence that the SAP policy was reviewed and approved by management. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure the SAP policy includes all required elements and is reviewed and approved on an annual basis with supporting documentation of the review retained. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-009 – Activities Allowed or Unallowed/Eligibility Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Cause: Due to the size of the program, CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Effect or potential effect: Students receiving federal aid could be ineligible or receive the incorrect amount of federal student financial assistance. Questioned costs: None.   Context: Although CHI Health School of Radiologic Technology has processes in place related to Activities Allowed or Unallowed and Eligibility, internal controls were not documented and there was no evidence that internal controls were performed. Total SFA expenditures for CHI Health School of Radiologic Technology were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls related to Activities Allowed or Unallowed and Eligibility and retain evidence that internal controls were performed throughout the year. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-010 – Special Tests and Provisions – Enrollment Reporting Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have internal controls in place over enrollment reporting.   Effect or potential effect: Lack of internal controls over timely and accurate enrollment reporting could result in inaccurate enrollment status. A student’s enrollment status determines eligibility for in-school status, deferment, and grace periods. Enrollment reporting in a timely and accurate manner is critical for effective management of the programs. Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be timely identified and resolved. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be timely identified and resolved. Questioned costs: None. Context: We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding. Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $3.5 million, which makes up 85% of total SFA Cluster expenditures of approximately $4.2 million. Total federal expenditures for CHI Health School of Radiologic Technology Assistance were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Finding 2022-005 & 2021-006. This is not a repeat finding for CHI Health School of Radiologic Technology. Recommendation: Good Samaritan College of Nursing & Health Science should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. CHI Health School of Radiologic Technology should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.063, 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Title 2, Subtitle A Chapter II Part 200 Subpart F Section 200.510(b) Schedule of expenditures of Federal awards. The auditee must prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with Section 200.502. Section 200.502(a) states the determination of when a federal award is expended must be based on when the activity related to the federal award occurs. Condition: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted an overstatement of the SFA expenditures reported in the SEFA. Cause: Management did not reconcile amounts reported on the SEFA for the SFA program to the underlying detail to ensure accurate and complete reporting of the federal program in the SEFA. Effect or potential effect: Certain amounts in the SEFA were reported incorrectly or omitted. Questioned costs: None. Context: During our testing for Good Samaritan College of Nursing & Health Science, we obtained a population of disbursements and reconciled the total payments to the SEFA. Disbursements totaled $3,538,116 compared to the amount reported in the SEFA of $4,627,538. This resulted in an overstatement of SFA expenditures reported in the SEFA of $1,089,372 for Good Samaritan College of Nursing & Health Science. The amounts reported in the final SEFA in this report for SFA expenditures for Good Samaritan College of Nursing & Health Science have been corrected to $3,538,116. Management’s control regarding the review of the SEFA did not identify this error. SFA expenditures for Good Samaritan College of Nursing & Health Science of $3.5 million represent 85% of total SFA expenditures of $4.2 million and 1% of total SEFA expenditures of $309.9 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls to ensure the completeness and accuracy of the SEFA and review applicable guidance prior to finalization. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2024.

Finding 2023-012 – Special Tests and Provisions – Return of Title IV Funds Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR section 668.173(b) requires timely return of title IV, HEA program funds. “In accordance with procedures established by the Secretary or FFEL Program lender, an institution returns unearned title IV, HEA program funds timely if – (1) The institution deposits or transfers the funds into the bank account it maintains under § 668.163 no later than 45 days after the date it determines that the student withdrew; (2) The institution initiates an electronic funds transfer (EFT) no later than 45 days after the date it determines that the student withdrew; (3) The institution initiates an electronic transaction, no later than 45 days after the date it determines that the student withdrew, that informs a FFEL lender to adjust the borrower’s loan account for the amount returned; or (4) The institution issues a check no later than 45 days after the date it determines that the student withdrew. An institution does not satisfy this requirement if – (i) The institution’s records show that the check was issued more than 45 days after the date the institution determined that the student withdrew or (ii) The date on the cancelled check shows that the bank used by the Secretary or FFEL Program lender endorsed that check more than 60 days after the date the institution determined that the student withdrew.”   Condition: Good Samaritan College of Nursing & Health Science did not provide evidence of an effective review process to ensure the timely calculation and return of Title IV funds to the U.S. Department of Education. Good Samaritan College of Nursing & Health Science did not calculate and return Title IV funds in a timely manner to the U.S. Department of Education, within 45 days after the date the institution determined that a student withdrew. Cause: Good Samaritan College of Nursing & Health Science did not have effective internal controls and procedures in place over the return of Title IV funds to prevent noncompliance. Effect or potential effect: Good Samaritan College of Nursing & Health Science is not returning Title IV funds within the required timeframe to the U.S. Department of Education, resulting in noncompliance. Questioned costs: None. Context: After obtaining an understanding of the internal controls over return of Title IV funds, we determined internal controls were not designed sufficiently to ensure compliance with timely calculation and returns of Title IV funds. EY selected and tested 5 students from the population of 20 students that withdrew during the year ended June 30, 2023. Of the 5 students selected, returns of Title IV funds were required for 3 students, with no returns required for 2 students. For 1 of the 3 students which required a return, Good Samaritan College of Nursing & Health Science calculated and returned the funds after 45 days from the date Good Samaritan College of Nursing & Health Science determined the student withdrew. The return of Title IV funds for that student was made in 63 days and totaled $2,780 and consisted of Direct Loans.   Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.5 million, representing 72% of Good Samaritan College of Nursing & Health Science’s SFA Cluster expenditures of approximately $3.5 million, and 61% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should review and revise its internal controls and procedures in place over the return of Title IV funds to ensure that the returns of Title IV funds are made within the required timeframe. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-013 – Activities Allowed or Unallowed Identification of the federal program: U.S. Department of Health and Human Services Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) Assistance Listing No. 93.498 Catholic Health Initiatives Colorado (CHIC) Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Cause: CHIC has processes in place to ensure that expenditures charged to the PRF program were allowable; however, evidence of controls for certain individual invoices with purchase orders that were charged to a COVID-19 cost center could not be obtained. CHIC’s purchase order process does not require approval of purchase orders for standard items that the organization regularly utilizes. These items are preapproved for order based on an initial clinical and financial review and do not require additional approval each time they are ordered. CHIC implemented a sign-on bonus program to retain and hire employees in response to the COVID-19 pandemic. Certain of these bonuses were already being paid out over time and to incentivize employees, the payout was accelerated. The review to determine the employee's eligibility for this program was performed by the former Director of Human Resources Operations and Compensation (the Director) and the review was evidenced by the Director sending an email attaching the spreadsheet of eligible participants and their payout balance, indicating the review was complete and the employee met the criteria. The Director had since left CHIC and not all emails could be located to evidence this review. Effect or potential effect: Expenditures could be reimbursed that are not allowed under the program. Questioned costs: None. Context: EY Selected and tested 25 invoices totaling $1,224,624 from a population of 206 invoices totaling $4.6 million. Of the 25 invoices selected for testing, evidence of invoice approval was not available for 6 of the 25 invoices totaling $466,950. The lack of evidence of approval was limited to those selections associated with purchase orders. Total PRF expenditures related to invoices were $4.6 million, representing 3% of total PRF expenditures reported on the SEFA of $177.1 million. EY selected and tested 25 sign-on bonus payments totaling $197,000 from a population of 691 bonus payments totaling $5.7 million. Of the 25 bonus payments selected for testing, for 1 bonus payment totaling $12,000, the email evidencing the review that the employee was eligible for the bonus program could not be located. Although sign-on bonuses paid were $5.7 million, total bonus payments, including the sign-on bonuses, charged to the program were $3.8 million, representing 2% of total PRF expenditures reported on the SEFA of $177.1 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure evidence is retained to support the execution of internal controls. Views of responsible officials: Management agrees with the finding and will work to retain all documentation in the future.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-001 – Eligibility Identification of the federal program: U.S. Department of Health and Human Services Medical Assistance Program (Medicaid Cluster) Assistance Listing No. 93.778 Pass Through Number Pass Through Entity Grant Period 7202400-23-179 County of Sacramento (7/1/2022 – 6/30/2023) Dignity Health Medical Foundation Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided. Cause: Dignity Health Medical Foundation management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to lack of understanding of the documentation retention needed. Effect or potential effect: Ineligible individuals may be provided services. Questioned costs: None.  Context: We selected 40 patients to test eligibility, noting that for three patients, documentation was not retained to evidence that Medicaid eligibility was reviewed prior to patient services being provided. All three instances occurred in one location (Valley Hi) and for the months of July and August 2022. Identification of a repeat finding: This is a repeat finding for Dignity Health Medical Foundation – Finding 2022-012 and 2021-013. Recommendation: We recommend management implement a process and internal controls to retain appropriate documentation that participants are eligible to receive services prior to providing services under the Medical Assistance Program. Views of responsible officials: Management agrees with the finding and implemented corrective action in September 2022.

Finding 2023-002 – Allowable Costs/Cost Principles Identification of the federal program: U.S. Department of Health and Human Services Medical Assistance Program (Medicaid Cluster) Assistance Listing No. 93.778 Passed through County of Sacramento Pass Through Number Pass Through Entity Grant Period 7202100-23-096 County of Sacramento (7/1/2022 – 12/10/2022) Mercy San Juan Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing.  Cause: Mercy San Juan Medical Center management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 2 of 25 payroll expenditures selected for testing, Mercy San Juan Medical Center did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Mercy San Juan Medical Center. Total non-service-based payroll expenditures for Mercy San Juan Medical Center were approximately $0.3 million and represent 5% of the total Medicaid Cluster expenditures of approximately $6.5 million. Identification of a repeat finding: This is not a repeat finding. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-005 – Cash Management Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.007, 84.063, and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have review controls in place over cash management. Effect or potential effect: There is no consistent documentation to support the timely performance of internal controls at Good Samaritan College of Nursing & Health Science. There is no consistent documentation to support the performance of internal controls at CHI Health School of Radiologic Technology. Questioned costs: None. Context: We issued a material weakness for Good Samaritan College of Nursing & Health Science related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. CHI Health School of Radiologic Technology did not have review controls in place over cash management. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $0.2 million, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science– Finding 2022-004 and 2021-004. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should continue to perform and improve its processes and retain documentation to evidence performance of internal controls over cash management. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over cash management. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.063, 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Title 2, Subtitle A Chapter II Part 200 Subpart F Section 200.510(b) Schedule of expenditures of Federal awards. The auditee must prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with Section 200.502. Section 200.502(a) states the determination of when a federal award is expended must be based on when the activity related to the federal award occurs. Condition: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted an overstatement of the SFA expenditures reported in the SEFA. Cause: Management did not reconcile amounts reported on the SEFA for the SFA program to the underlying detail to ensure accurate and complete reporting of the federal program in the SEFA. Effect or potential effect: Certain amounts in the SEFA were reported incorrectly or omitted. Questioned costs: None. Context: During our testing for Good Samaritan College of Nursing & Health Science, we obtained a population of disbursements and reconciled the total payments to the SEFA. Disbursements totaled $3,538,116 compared to the amount reported in the SEFA of $4,627,538. This resulted in an overstatement of SFA expenditures reported in the SEFA of $1,089,372 for Good Samaritan College of Nursing & Health Science. The amounts reported in the final SEFA in this report for SFA expenditures for Good Samaritan College of Nursing & Health Science have been corrected to $3,538,116. Management’s control regarding the review of the SEFA did not identify this error. SFA expenditures for Good Samaritan College of Nursing & Health Science of $3.5 million represent 85% of total SFA expenditures of $4.2 million and 1% of total SEFA expenditures of $309.9 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls to ensure the completeness and accuracy of the SEFA and review applicable guidance prior to finalization. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2024.

Finding 2023-005 – Cash Management Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.007, 84.063, and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have review controls in place over cash management. Effect or potential effect: There is no consistent documentation to support the timely performance of internal controls at Good Samaritan College of Nursing & Health Science. There is no consistent documentation to support the performance of internal controls at CHI Health School of Radiologic Technology. Questioned costs: None. Context: We issued a material weakness for Good Samaritan College of Nursing & Health Science related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. CHI Health School of Radiologic Technology did not have review controls in place over cash management. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $0.2 million, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science– Finding 2022-004 and 2021-004. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should continue to perform and improve its processes and retain documentation to evidence performance of internal controls over cash management. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over cash management. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-006 – Reporting – Common Origination and Disbursement (COD) System Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Institutions submit Direct Loan, Pell Grant, TEACH Grant, and IASG origination records and disbursement records to the COD system. Origination records can be sent well in advance of any disbursements, as early as the institution chooses to submit them for any student the institution reasonably believes will be eligible for a payment. An institution follows up with a disbursement record for that student no earlier than (1) seven calendar days prior to the disbursement date under the Advance or Heightened Cash Monitoring 1 payment methods, or (2) the date of the disbursement under the Reimbursement or Heightened Cash Monitoring 2 Payment Method (see Federal Register, Volume 86, Number 119, June 24, 2021). The disbursement record reports the actual disbursement date and the amount of the disbursement. ED processes origination and/or disbursement records and returns acknowledgments to the institution. The acknowledgments identify the processing status of each record: Rejected, Accepted with Corrections, or Accepted. In testing the origination and disbursement data, the auditor should be most concerned with the data ED has categorized as accepted or accepted with corrections. Institutions must report student disbursement data within 15 calendar days after the institution makes a disbursement or becomes aware of the need to make an adjustment to previously reported student disbursement data or expected student disbursement data. Institutions may do this by reporting once every 15 calendar days, biweekly or weekly, or may set up their own system to ensure that changes are reported in a timely manner.  Condition: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan payment data to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have processes and internal controls in place to ensure that COD disbursement information was updated and accurate. Effect or potential effect: Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be identified and resolved in a timely manner. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be identified and resolved in a timely manner. Questioned costs: None.   Context: We issued a material weakness related to internal controls in the prior year for Good Samaritan College of Nursing & Health Science. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. For CHI Health School of Radiologic Technology, EY selected 17 student disbursements of Pell and Direct Loans from a population of 105 disbursements. For each of the 17 disbursements, the disbursement date reported in COD was not the actual disbursement date but was the “assumed” or “expected” date per discussion with management. This resulted in a finding of noncompliance for CHI Health School of Radiologic Technology. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Findings 2022-003, 2021-003, 2020-004, and 2019-008. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should ensure that all monthly grant reconciliations are being performed, reviewed, and approved, with documentation being retained in its internal records. The accuracy of the disbursement data should also be validated. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over reporting in the COD system. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.16(e) states: “For purposes of determining student eligibility for assistance under a title IV, HEA program, establishes, publishes, and applies reasonable standards for measuring whether an otherwise eligible student is maintaining satisfactory academic progress in his or her educational program. The Secretary considers an institution’s standards to be reasonable if the standards are in accordance with the provisions specified in § 668.34.” 34 CFR 668.34 states: “An institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under the title IV, HEA programs.” The Secretary considers the institution’s policy to be reasonable if it meets the specified requirements in 34 CFR 668.34, including the following, for which we noted noncompliance by CHI Health School of Radiologic Technology.   (1) The policy provides that a student’s academic progress is evaluated— (i) At the end of each payment period if the educational program is either one academic year in length or shorter than an academic year Or (ii) For all other educational programs, at the end of each payment period or at least annually to correspond with the end of a payment period (2) The policy specifies— (i) For all programs, the maximum timeframe as defined in paragraph (b) of this section (ii) For a credit hour program using standard or nonstandard terms that is not a subscription-based program, the pace, measured at each evaluation, at which a student must progress through his or her educational program to ensure that the student will complete the program within the maximum timeframe, calculated by either dividing the cumulative number of hours the student has successfully completed by the cumulative number of hours the student has attempted or by determining the number of hours that the student should have completed by the evaluation point in order to complete the program within the maximum timeframe (3) If the institution places students on financial aid warning, or on financial aid probation, as defined in paragraph (b) of this section, the policy describes these statuses. (4) If the institution permits a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy describes— (i) How the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (ii) The basis on which a student may file an appeal: The death of a relative, an injury or illness of the student, or other special circumstances   (iii) Information the student must submit regarding why the student failed to make satisfactory academic progress, and what has changed in the student’s situation that will allow the student to demonstrate satisfactory academic progress at the next evaluation (5) If the institution does not permit a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy must describe how the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (6) The policy provides for notification to students of the results of an evaluation that impacts the student’s eligibility for title IV, HEA program funds Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding the satisfactory academic progress (SAP) policy. During our testing, we noted that the policy does not contain specific procedures related to the following components: (1) The policy does not specify the frequency of evaluation of SAP for purposes of Title IV assistance; (2) The policy does not specify the maximum timeframe or the pace at which the student must progress through the program; (3) No specific procedures exist related to disbursements to students on financial aid warning status; (4) No specific procedures exist related to appeal and reinstatement process; and (5) No specific procedures exist related to the notification to students of the evaluation process. Additionally, we noted there was no documentation retained to evidence that a review of the SAP policy was performed to ensure compliance with federal regulations. Cause: CHI Health School of Radiologic Technology did not have effective internal controls to ensure compliance with SAP requirements and did not retain sufficient documentation of review procedures over the SAP Policy. Effect or potential effect: The published SAP policy does not comply with federal requirements. Questioned costs: None. Context: CHI Health School of Radiologic Technology’s SAP policy did not include required elements according to federal regulations and there was no evidence that the SAP policy was reviewed and approved by management. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure the SAP policy includes all required elements and is reviewed and approved on an annual basis with supporting documentation of the review retained. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-009 – Activities Allowed or Unallowed/Eligibility Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Cause: Due to the size of the program, CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Effect or potential effect: Students receiving federal aid could be ineligible or receive the incorrect amount of federal student financial assistance. Questioned costs: None.   Context: Although CHI Health School of Radiologic Technology has processes in place related to Activities Allowed or Unallowed and Eligibility, internal controls were not documented and there was no evidence that internal controls were performed. Total SFA expenditures for CHI Health School of Radiologic Technology were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls related to Activities Allowed or Unallowed and Eligibility and retain evidence that internal controls were performed throughout the year. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-010 – Special Tests and Provisions – Enrollment Reporting Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have internal controls in place over enrollment reporting.   Effect or potential effect: Lack of internal controls over timely and accurate enrollment reporting could result in inaccurate enrollment status. A student’s enrollment status determines eligibility for in-school status, deferment, and grace periods. Enrollment reporting in a timely and accurate manner is critical for effective management of the programs. Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be timely identified and resolved. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be timely identified and resolved. Questioned costs: None. Context: We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding. Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $3.5 million, which makes up 85% of total SFA Cluster expenditures of approximately $4.2 million. Total federal expenditures for CHI Health School of Radiologic Technology Assistance were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Finding 2022-005 & 2021-006. This is not a repeat finding for CHI Health School of Radiologic Technology. Recommendation: Good Samaritan College of Nursing & Health Science should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. CHI Health School of Radiologic Technology should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.063, 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Title 2, Subtitle A Chapter II Part 200 Subpart F Section 200.510(b) Schedule of expenditures of Federal awards. The auditee must prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with Section 200.502. Section 200.502(a) states the determination of when a federal award is expended must be based on when the activity related to the federal award occurs. Condition: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted an overstatement of the SFA expenditures reported in the SEFA. Cause: Management did not reconcile amounts reported on the SEFA for the SFA program to the underlying detail to ensure accurate and complete reporting of the federal program in the SEFA. Effect or potential effect: Certain amounts in the SEFA were reported incorrectly or omitted. Questioned costs: None. Context: During our testing for Good Samaritan College of Nursing & Health Science, we obtained a population of disbursements and reconciled the total payments to the SEFA. Disbursements totaled $3,538,116 compared to the amount reported in the SEFA of $4,627,538. This resulted in an overstatement of SFA expenditures reported in the SEFA of $1,089,372 for Good Samaritan College of Nursing & Health Science. The amounts reported in the final SEFA in this report for SFA expenditures for Good Samaritan College of Nursing & Health Science have been corrected to $3,538,116. Management’s control regarding the review of the SEFA did not identify this error. SFA expenditures for Good Samaritan College of Nursing & Health Science of $3.5 million represent 85% of total SFA expenditures of $4.2 million and 1% of total SEFA expenditures of $309.9 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls to ensure the completeness and accuracy of the SEFA and review applicable guidance prior to finalization. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2024.

Finding 2023-005 – Cash Management Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.007, 84.063, and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science has processes in place for determining the amount of student financial aid to be drawn down and disbursed; however, management did not perform internal controls over cash management throughout the year. CHI Health School of Radiologic Technology has processes in place for determining the amount of Direct Loans and Pell grants to be drawn down and disbursed; however, there is no review control in place over the disbursement amounts before funds are drawn down from the G5 system. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have review controls in place over cash management. Effect or potential effect: There is no consistent documentation to support the timely performance of internal controls at Good Samaritan College of Nursing & Health Science. There is no consistent documentation to support the performance of internal controls at CHI Health School of Radiologic Technology. Questioned costs: None. Context: We issued a material weakness for Good Samaritan College of Nursing & Health Science related to internal controls in the prior year. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. CHI Health School of Radiologic Technology did not have review controls in place over cash management. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $0.2 million, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science– Finding 2022-004 and 2021-004. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should continue to perform and improve its processes and retain documentation to evidence performance of internal controls over cash management. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over cash management. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-006 – Reporting – Common Origination and Disbursement (COD) System Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Institutions submit Direct Loan, Pell Grant, TEACH Grant, and IASG origination records and disbursement records to the COD system. Origination records can be sent well in advance of any disbursements, as early as the institution chooses to submit them for any student the institution reasonably believes will be eligible for a payment. An institution follows up with a disbursement record for that student no earlier than (1) seven calendar days prior to the disbursement date under the Advance or Heightened Cash Monitoring 1 payment methods, or (2) the date of the disbursement under the Reimbursement or Heightened Cash Monitoring 2 Payment Method (see Federal Register, Volume 86, Number 119, June 24, 2021). The disbursement record reports the actual disbursement date and the amount of the disbursement. ED processes origination and/or disbursement records and returns acknowledgments to the institution. The acknowledgments identify the processing status of each record: Rejected, Accepted with Corrections, or Accepted. In testing the origination and disbursement data, the auditor should be most concerned with the data ED has categorized as accepted or accepted with corrections. Institutions must report student disbursement data within 15 calendar days after the institution makes a disbursement or becomes aware of the need to make an adjustment to previously reported student disbursement data or expected student disbursement data. Institutions may do this by reporting once every 15 calendar days, biweekly or weekly, or may set up their own system to ensure that changes are reported in a timely manner.  Condition: Good Samaritan College of Nursing & Health Science did not perform its internal control over the requirement to submit Pell and Direct Loan payment data to the Department of Education through the COD system, which consists of monthly COD reconciliations. CHI Health School of Radiologic Technology does not have a process in place for updating the COD system for actual disbursement dates. The COD disbursement information reported by CHI Health School of Radiologic Technology was based on “assumed” and “expected” disbursement dates and amounts, but is never updated for actual disbursement dates. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the entire period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have processes and internal controls in place to ensure that COD disbursement information was updated and accurate. Effect or potential effect: Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be identified and resolved in a timely manner. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be identified and resolved in a timely manner. Questioned costs: None.   Context: We issued a material weakness related to internal controls in the prior year for Good Samaritan College of Nursing & Health Science. Based upon the implementation date for the corrective action provided by management, the finding related to this internal control had not been remediated for the full period under audit. As such, we did not test the operating effectiveness of this control and are issuing a material weakness consistent with the prior year finding. Total federal expenditures for Good Samaritan College of Nursing & Health Science are approximately $3.5 million, representing 85% of total SFA Cluster expenditures of approximately $4.2 million. For CHI Health School of Radiologic Technology, EY selected 17 student disbursements of Pell and Direct Loans from a population of 105 disbursements. For each of the 17 disbursements, the disbursement date reported in COD was not the actual disbursement date but was the “assumed” or “expected” date per discussion with management. This resulted in a finding of noncompliance for CHI Health School of Radiologic Technology. Total federal expenditures for CHI Health School of Radiologic Technology are approximately $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Findings 2022-003, 2021-003, 2020-004, and 2019-008. This is not a repeat finding for CHI Health School of Radiologic Technology.   Recommendation: Good Samaritan College of Nursing & Health Science should ensure that all monthly grant reconciliations are being performed, reviewed, and approved, with documentation being retained in its internal records. The accuracy of the disbursement data should also be validated. CHI Health School of Radiologic Technology should refine its process and retain documentation to evidence performance of internal controls over reporting in the COD system. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-007 – Special Tests and Provisions – Disbursements to or on Behalf of Students Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.165 Notices, requires the following: (1) Before an institution disburses title IV, HEA program funds for any award year, the institution must notify a student of the amount of funds that the student or his or her parent can expect to receive under each title IV, HEA program, and how and when those funds will be disbursed. If those funds include Direct Loan program funds, the notice must indicate which funds are from subsidized loans, which are from unsubsidized loans, and which are from PLUS loans.   (2) Except in the case of a post-withdrawal disbursement made in accordance with § 668.22(a)(5), if an institution credits a student ledger account with Direct Loan, Federal Perkins Loan, or TEACH Grant program funds, the institution must notify the student or parent of – (i) The anticipated date and amount of the disbursement (ii) The student’s or parent’s right to cancel all or a portion of that loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement and have the loan proceeds or TEACH Grant proceeds returned to the Secretary (iii) The procedures and time by which the student or parent must notify the institution that he or she wishes to cancel the loan, loan disbursement, TEACH Grant, or TEACH Grant disbursement (3) The institution must provide the notice described in paragraph (a)(2) of this section in writing – (i) No earlier than 30 days before, and no later than 30 days after, crediting the student’s ledger account at the institution, if the institution obtains affirmative confirmation from the student under paragraph (a)(6)(i) of this section Or (ii) No earlier than 30 days before, and no later than seven days after, crediting the student’s ledger account at the institution, if the institution does not obtain affirmative confirmation from the student under paragraph (a)(6)(i) of this section Condition: Good Samaritan College of Nursing & Health Science did not send loan notifications to 3 of 30 students selected for disbursement testing for direct loans within +/- 30 days of the funds being disbursed. CHI Health School of Radiologic technology did not send loan notifications to 14 of 14 students selected for disbursement testing with direct loans within +/- 30 days of the funds being disbursed. Cause: Internal controls over direct loan notifications were not designed or operating effectively at Good Samaritan College of Nursing & Health Science and CHI Health School of Radiologic Technology. Effect or potential effect: Good Samaritan College of Nursing & Health Science was noncompliant with regards to direct loan notification requirements which could impact a student’s ability to cancel the loan timely. CHI Health School of Radiologic Technology was noncompliant with regards to loan notification requirements which could impact a student’s ability to cancel the loan timely. Questioned costs: None. Context: For Good Samaritan College of Nursing & Health Science, we issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over disbursements to or on behalf of students were operating effectively during the year. As such, we did not test the operating effectiveness of this control. For Good Samaritan College of Nursing & Health Science, for 3 of 30 students selected for testing that received direct loans, notifications were not sent to the students for direct loan disbursements. The three disbursements were made in September 2022 and totaled $6,680. Direct loans totaling $87,326 were disbursed to the 30 selected students receiving direct loans during the year. Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.5 million, representing 72% of Good Samaritan College of Nursing & Health Science’s SFA Cluster expenditures of approximately $3.5 million, and 61% of total SFA Cluster expenditures of approximately $4.2 million. For CHI Health School of Radiologic Technology, for 14 of 14 students selected for testing that received direct loans, notifications were not sent to the students for direct loan disbursements. For the 14 students, the total net disbursements for direct loans totaled $24,940. Total direct loans for CHI Health School of Radiologic Technology are approximately $171 thousand, representing 86% of CHI Health School of Radiologic SFA Cluster expenditures of approximately $198 thousand, and 4% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Finding 2022-017. This is not a repeat finding for CHI Health School of Radiologic Technology. Recommendation: Good Samaritan College of Nursing & Health Science should establish procedures to ensure that loan notifications are sent for all loan disbursements, as required. CHI Health School of Radiologic Technology should establish procedures to ensure that loan notifications are sent for all loan disbursements, as required. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-008 – Special Tests and Provisions – Satisfactory Academic Progress Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR 668.16(e) states: “For purposes of determining student eligibility for assistance under a title IV, HEA program, establishes, publishes, and applies reasonable standards for measuring whether an otherwise eligible student is maintaining satisfactory academic progress in his or her educational program. The Secretary considers an institution’s standards to be reasonable if the standards are in accordance with the provisions specified in § 668.34.” 34 CFR 668.34 states: “An institution must establish a reasonable satisfactory academic progress policy for determining whether an otherwise eligible student is making satisfactory academic progress in his or her educational program and may receive assistance under the title IV, HEA programs.” The Secretary considers the institution’s policy to be reasonable if it meets the specified requirements in 34 CFR 668.34, including the following, for which we noted noncompliance by CHI Health School of Radiologic Technology.   (1) The policy provides that a student’s academic progress is evaluated— (i) At the end of each payment period if the educational program is either one academic year in length or shorter than an academic year Or (ii) For all other educational programs, at the end of each payment period or at least annually to correspond with the end of a payment period (2) The policy specifies— (i) For all programs, the maximum timeframe as defined in paragraph (b) of this section (ii) For a credit hour program using standard or nonstandard terms that is not a subscription-based program, the pace, measured at each evaluation, at which a student must progress through his or her educational program to ensure that the student will complete the program within the maximum timeframe, calculated by either dividing the cumulative number of hours the student has successfully completed by the cumulative number of hours the student has attempted or by determining the number of hours that the student should have completed by the evaluation point in order to complete the program within the maximum timeframe (3) If the institution places students on financial aid warning, or on financial aid probation, as defined in paragraph (b) of this section, the policy describes these statuses. (4) If the institution permits a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy describes— (i) How the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (ii) The basis on which a student may file an appeal: The death of a relative, an injury or illness of the student, or other special circumstances   (iii) Information the student must submit regarding why the student failed to make satisfactory academic progress, and what has changed in the student’s situation that will allow the student to demonstrate satisfactory academic progress at the next evaluation (5) If the institution does not permit a student to appeal a determination by the institution that he or she is not making satisfactory academic progress, the policy must describe how the student may reestablish his or her eligibility to receive assistance under the title IV, HEA programs (6) The policy provides for notification to students of the results of an evaluation that impacts the student’s eligibility for title IV, HEA program funds Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding the satisfactory academic progress (SAP) policy. During our testing, we noted that the policy does not contain specific procedures related to the following components: (1) The policy does not specify the frequency of evaluation of SAP for purposes of Title IV assistance; (2) The policy does not specify the maximum timeframe or the pace at which the student must progress through the program; (3) No specific procedures exist related to disbursements to students on financial aid warning status; (4) No specific procedures exist related to appeal and reinstatement process; and (5) No specific procedures exist related to the notification to students of the evaluation process. Additionally, we noted there was no documentation retained to evidence that a review of the SAP policy was performed to ensure compliance with federal regulations. Cause: CHI Health School of Radiologic Technology did not have effective internal controls to ensure compliance with SAP requirements and did not retain sufficient documentation of review procedures over the SAP Policy. Effect or potential effect: The published SAP policy does not comply with federal requirements. Questioned costs: None. Context: CHI Health School of Radiologic Technology’s SAP policy did not include required elements according to federal regulations and there was no evidence that the SAP policy was reviewed and approved by management. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure the SAP policy includes all required elements and is reviewed and approved on an annual basis with supporting documentation of the review retained. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-009 – Activities Allowed or Unallowed/Eligibility Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing Nos. 84.063 and 84.268 CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Cause: Due to the size of the program, CHI Health School of Radiologic Technology did not have adequate internal controls in place surrounding Activities Allowed or Unallowed and Eligibility. Effect or potential effect: Students receiving federal aid could be ineligible or receive the incorrect amount of federal student financial assistance. Questioned costs: None.   Context: Although CHI Health School of Radiologic Technology has processes in place related to Activities Allowed or Unallowed and Eligibility, internal controls were not documented and there was no evidence that internal controls were performed. Total SFA expenditures for CHI Health School of Radiologic Technology were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls related to Activities Allowed or Unallowed and Eligibility and retain evidence that internal controls were performed throughout the year. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-010 – Special Tests and Provisions – Enrollment Reporting Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.063 and 84.268 Good Samaritan College of Nursing & Health Science CHI Health School of Radiologic Technology Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Good Samaritan College of Nursing & Health Science did not have internal controls over enrollment reporting. CHI Health School of Radiologic Technology did not have internal controls over enrollment reporting. Cause: Good Samaritan College of Nursing & Health Science has been developing and implementing internal controls in response to the prior year finding; however, controls were not implemented during the period under audit. Due to the size of the program, CHI Health School of Radiologic Technology did not have internal controls in place over enrollment reporting.   Effect or potential effect: Lack of internal controls over timely and accurate enrollment reporting could result in inaccurate enrollment status. A student’s enrollment status determines eligibility for in-school status, deferment, and grace periods. Enrollment reporting in a timely and accurate manner is critical for effective management of the programs. Discrepancies between the U.S. Department of Education’s systems and Good Samaritan College of Nursing & Health Science’s internal records may not be timely identified and resolved. Discrepancies between the U.S. Department of Education’s systems and CHI Health School of Radiologic Technology’s internal records may not be timely identified and resolved. Questioned costs: None. Context: We issued a significant deficiency related to internal controls in the prior year. The finding related to this internal control was not remediated for the period under audit. Good Samaritan College of Nursing & Health Science did not have evidence of whether the internal controls over enrollment reporting were operating effectively during the year. As such, we did not test the operating effectiveness of this control and are issuing a significant deficiency consistent with the prior year finding. Good Samaritan College of Nursing & Health Science has SFA Cluster expenditures of approximately $3.5 million, which makes up 85% of total SFA Cluster expenditures of approximately $4.2 million. Total federal expenditures for CHI Health School of Radiologic Technology Assistance were $198 thousand, representing 5% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is a repeat finding for Good Samaritan College of Nursing & Health Science – Finding 2022-005 & 2021-006. This is not a repeat finding for CHI Health School of Radiologic Technology. Recommendation: Good Samaritan College of Nursing & Health Science should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. CHI Health School of Radiologic Technology should refine processes and develop internal controls over enrollment reporting requirements and retain evidence of performance of internal controls. Views of responsible officials: Management at Good Samaritan College of Nursing & Health Science agrees with the finding and implemented corrective action in April 2023. Management at CHI Health School of Radiologic Technology agrees with the finding and will implement corrective action by June 2024.

Finding 2023-011 – Schedule of Expenditures of Federal Awards (SEFA) Preparation Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.007, 84.063, 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Title 2, Subtitle A Chapter II Part 200 Subpart F Section 200.510(b) Schedule of expenditures of Federal awards. The auditee must prepare a schedule of expenditures of Federal awards for the period covered by the auditee’s financial statements which must include the total federal awards expended as determined in accordance with Section 200.502. Section 200.502(a) states the determination of when a federal award is expended must be based on when the activity related to the federal award occurs. Condition: Management did not have effective internal controls in place to ensure accurate and complete reporting of federal programs on the SEFA. This resulted an overstatement of the SFA expenditures reported in the SEFA. Cause: Management did not reconcile amounts reported on the SEFA for the SFA program to the underlying detail to ensure accurate and complete reporting of the federal program in the SEFA. Effect or potential effect: Certain amounts in the SEFA were reported incorrectly or omitted. Questioned costs: None. Context: During our testing for Good Samaritan College of Nursing & Health Science, we obtained a population of disbursements and reconciled the total payments to the SEFA. Disbursements totaled $3,538,116 compared to the amount reported in the SEFA of $4,627,538. This resulted in an overstatement of SFA expenditures reported in the SEFA of $1,089,372 for Good Samaritan College of Nursing & Health Science. The amounts reported in the final SEFA in this report for SFA expenditures for Good Samaritan College of Nursing & Health Science have been corrected to $3,538,116. Management’s control regarding the review of the SEFA did not identify this error. SFA expenditures for Good Samaritan College of Nursing & Health Science of $3.5 million represent 85% of total SFA expenditures of $4.2 million and 1% of total SEFA expenditures of $309.9 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should develop and implement internal controls to ensure the completeness and accuracy of the SEFA and review applicable guidance prior to finalization. Views of responsible officials: Management agrees with the finding and implemented corrective action in February 2024.

Finding 2023-012 – Special Tests and Provisions – Return of Title IV Funds Identification of the federal program: U.S. Department of Education Office of Federal Student Aid Student Financial Assistance Cluster Assistance Listing No. 84.268 Good Samaritan College of Nursing & Health Science Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 34 CFR section 668.173(b) requires timely return of title IV, HEA program funds. “In accordance with procedures established by the Secretary or FFEL Program lender, an institution returns unearned title IV, HEA program funds timely if – (1) The institution deposits or transfers the funds into the bank account it maintains under § 668.163 no later than 45 days after the date it determines that the student withdrew; (2) The institution initiates an electronic funds transfer (EFT) no later than 45 days after the date it determines that the student withdrew; (3) The institution initiates an electronic transaction, no later than 45 days after the date it determines that the student withdrew, that informs a FFEL lender to adjust the borrower’s loan account for the amount returned; or (4) The institution issues a check no later than 45 days after the date it determines that the student withdrew. An institution does not satisfy this requirement if – (i) The institution’s records show that the check was issued more than 45 days after the date the institution determined that the student withdrew or (ii) The date on the cancelled check shows that the bank used by the Secretary or FFEL Program lender endorsed that check more than 60 days after the date the institution determined that the student withdrew.”   Condition: Good Samaritan College of Nursing & Health Science did not provide evidence of an effective review process to ensure the timely calculation and return of Title IV funds to the U.S. Department of Education. Good Samaritan College of Nursing & Health Science did not calculate and return Title IV funds in a timely manner to the U.S. Department of Education, within 45 days after the date the institution determined that a student withdrew. Cause: Good Samaritan College of Nursing & Health Science did not have effective internal controls and procedures in place over the return of Title IV funds to prevent noncompliance. Effect or potential effect: Good Samaritan College of Nursing & Health Science is not returning Title IV funds within the required timeframe to the U.S. Department of Education, resulting in noncompliance. Questioned costs: None. Context: After obtaining an understanding of the internal controls over return of Title IV funds, we determined internal controls were not designed sufficiently to ensure compliance with timely calculation and returns of Title IV funds. EY selected and tested 5 students from the population of 20 students that withdrew during the year ended June 30, 2023. Of the 5 students selected, returns of Title IV funds were required for 3 students, with no returns required for 2 students. For 1 of the 3 students which required a return, Good Samaritan College of Nursing & Health Science calculated and returned the funds after 45 days from the date Good Samaritan College of Nursing & Health Science determined the student withdrew. The return of Title IV funds for that student was made in 63 days and totaled $2,780 and consisted of Direct Loans.   Total direct loans for Good Samaritan College of Nursing & Health Science are approximately $2.5 million, representing 72% of Good Samaritan College of Nursing & Health Science’s SFA Cluster expenditures of approximately $3.5 million, and 61% of total SFA Cluster expenditures of approximately $4.2 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should review and revise its internal controls and procedures in place over the return of Title IV funds to ensure that the returns of Title IV funds are made within the required timeframe. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-013 – Activities Allowed or Unallowed Identification of the federal program: U.S. Department of Health and Human Services Provider Relief Fund and American Rescue Plan (ARP) Rural Distributions (PRF) Assistance Listing No. 93.498 Catholic Health Initiatives Colorado (CHIC) Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303 requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be compliance with guidance in “Standards for Internal Control the Federal Government” issued by the Comptroller General the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: Management did not consistently retain evidence to support that internal controls were in place and operating effectively for approval of invoices with purchase orders and to ensure that bonuses paid to employees related to COVID-19 were eligible to receive the bonus. Cause: CHIC has processes in place to ensure that expenditures charged to the PRF program were allowable; however, evidence of controls for certain individual invoices with purchase orders that were charged to a COVID-19 cost center could not be obtained. CHIC’s purchase order process does not require approval of purchase orders for standard items that the organization regularly utilizes. These items are preapproved for order based on an initial clinical and financial review and do not require additional approval each time they are ordered. CHIC implemented a sign-on bonus program to retain and hire employees in response to the COVID-19 pandemic. Certain of these bonuses were already being paid out over time and to incentivize employees, the payout was accelerated. The review to determine the employee's eligibility for this program was performed by the former Director of Human Resources Operations and Compensation (the Director) and the review was evidenced by the Director sending an email attaching the spreadsheet of eligible participants and their payout balance, indicating the review was complete and the employee met the criteria. The Director had since left CHIC and not all emails could be located to evidence this review. Effect or potential effect: Expenditures could be reimbursed that are not allowed under the program. Questioned costs: None. Context: EY Selected and tested 25 invoices totaling $1,224,624 from a population of 206 invoices totaling $4.6 million. Of the 25 invoices selected for testing, evidence of invoice approval was not available for 6 of the 25 invoices totaling $466,950. The lack of evidence of approval was limited to those selections associated with purchase orders. Total PRF expenditures related to invoices were $4.6 million, representing 3% of total PRF expenditures reported on the SEFA of $177.1 million. EY selected and tested 25 sign-on bonus payments totaling $197,000 from a population of 691 bonus payments totaling $5.7 million. Of the 25 bonus payments selected for testing, for 1 bonus payment totaling $12,000, the email evidencing the review that the employee was eligible for the bonus program could not be located. Although sign-on bonuses paid were $5.7 million, total bonus payments, including the sign-on bonuses, charged to the program were $3.8 million, representing 2% of total PRF expenditures reported on the SEFA of $177.1 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: Management should ensure evidence is retained to support the execution of internal controls. Views of responsible officials: Management agrees with the finding and will work to retain all documentation in the future.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-001 – Eligibility Identification of the federal program: U.S. Department of Health and Human Services Medical Assistance Program (Medicaid Cluster) Assistance Listing No. 93.778 Pass Through Number Pass Through Entity Grant Period 7202400-23-179 County of Sacramento (7/1/2022 – 6/30/2023) Dignity Health Medical Foundation Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: The Dignity Health Medical Foundation did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided. Cause: Dignity Health Medical Foundation management did not retain evidence of Medicaid eligibility being reviewed prior to patient services being provided due to lack of understanding of the documentation retention needed. Effect or potential effect: Ineligible individuals may be provided services. Questioned costs: None.  Context: We selected 40 patients to test eligibility, noting that for three patients, documentation was not retained to evidence that Medicaid eligibility was reviewed prior to patient services being provided. All three instances occurred in one location (Valley Hi) and for the months of July and August 2022. Identification of a repeat finding: This is a repeat finding for Dignity Health Medical Foundation – Finding 2022-012 and 2021-013. Recommendation: We recommend management implement a process and internal controls to retain appropriate documentation that participants are eligible to receive services prior to providing services under the Medical Assistance Program. Views of responsible officials: Management agrees with the finding and implemented corrective action in September 2022.

Finding 2023-002 – Allowable Costs/Cost Principles Identification of the federal program: U.S. Department of Health and Human Services Medical Assistance Program (Medicaid Cluster) Assistance Listing No. 93.778 Passed through County of Sacramento Pass Through Number Pass Through Entity Grant Period 7202100-23-096 County of Sacramento (7/1/2022 – 12/10/2022) Mercy San Juan Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” 2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At Mercy San Juan Medical Center, internal controls over the required allowability criteria with regard to payroll expense were not performed for 2 of 25 employees selected for testing.  Cause: Mercy San Juan Medical Center management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 2 of 25 payroll expenditures selected for testing, Mercy San Juan Medical Center did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Mercy San Juan Medical Center. Total non-service-based payroll expenditures for Mercy San Juan Medical Center were approximately $0.3 million and represent 5% of the total Medicaid Cluster expenditures of approximately $6.5 million. Identification of a repeat finding: This is not a repeat finding. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-004 – Subrecipient Monitoring Identification of the federal program: U.S. Department of Defense U.S. Department of Health and Human Services Research and Development Cluster Assistance Listing Nos. 12.420, 93.394, 93.650, 93.853, and 93.866 Federal Award Numbers: Grant Period 1PiCMS331609-01-00 (05/01/2019 – 07/31/2022) W81XWH1710429 (09/30/2017 – 09/29/2024) 1U24NS107204 (07/15/2018 – 06/30/2024) 1R01NS109382 (09/01/2019 – 08/31/2024) R01NS109584 (12/01/2019 – 11/30/2024) 2P01AG014449-23 (04/01/2021 – 03/31/2025) 1UG3CA247606 (07/01/2020 – 06/30/2024) 1R21NS116385 (09/01/2020 – 05/31/2023) 1R56AG068630 (09/15/2020 – 08/31/2022) R01AG057708 (12/15/2020 – 11/31/2022) W81XWH2110145 (04/01/2021 – 03/31/2023) 2R01ZVS213158 (07/01/2021 – 06/30/2026) 1R01NS115815 (04/01/2021 – 04/30/2026) R01NS120331 (09/01/2021 – 08/30/2026) R21NS125861 (09/29/2021 – 03/19/2023) R01CA264992 (03/01/2022 – 02/28/2023) R21NS128550A (08/15/2022 – 07/30/2024) Pass Through Number Pass Through Entity Grant Period 232828 Massachusetts General Hospital (07/01/2018 – 06/30/2023) St. Joseph’s Hospital and Medical Center Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).” Condition: While St. Joseph’s Hospital and Medical Center has controls in place to review and approve invoices prior to payment, the review was not precise enough to ensure duplicate invoices were not paid to subrecipients. Cause: St. Joseph’s Hospital and Medical Center did not have effective controls in place to ensure duplicate payments were not made to their subrecipients. Effect or potential effect: Subrecipients may be overpaid resulting in questioned costs. Additionally, amounts paid to subrecipients may be inaccurate and in excess of the subrecipient’s actual and immediate cash requirements for carrying out the purpose of the program. Questioned costs: $5,514   Context: We selected 35 payments to subrecipients totaling $607,117. For 2 of the 35 subrecipient expenditures selected for testing, from the same subrecipient, St. Joseph’s Hospital and Medical Center received and paid duplicate invoices totaling $5,514. St. Joseph’s Hospital and Medical Center’s subrecipient expenditures totaled $4.0 million during the period, which represented 31% of St. Joseph’s Hospital and Medical Center’s total research and development expenditures of $12.8 million and 5.6% of total Research and Development cluster expenditures of $71.3 million. Identification as a repeat finding, if applicable: This is not a repeat finding. Recommendation: We recommend St. Joseph’s Hospital and Medical Center implement controls over payments to subrecipients to ensure that duplicate invoices are not paid. Views of responsible officials: Management agrees with the finding and will implement corrective action by June 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.

Finding 2023-003 – Allowable Costs/Cost Principles Identification of the federal program: Health Resources and Services Administration HIV Emergency Relief Project Grants Assistance Listing No. 93.914 Pass Through Numbers Pass Through Entity Grant Period PH-002898 County of Los Angeles (1/1/2011 – 2/28/2023) PH-002375 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003746 County of Los Angeles (12/1/2012 – 6/30/2025) PH-003802 County of Los Angeles (1/1/2013 – 6/30/2025) H-208518 County of Los Angeles (4/1/2006 – 7/31/2025) PH-004205 County of Los Angeles (6/1/2020 – 2/28/2023) 8198 PREV King County Public Health (3/1/2022 – 2/28/2023) 10126 PREV King County Public Health (3/1/2022 – 2/28/2024) St. Mary Medical Center – Long Beach Bailey-Boushay House Criteria or specific requirement (including statutory, regulatory, or other citation): 2 CFR 200.303(a) requires that a non-federal entity must “(a) establish and maintain effective internal control over the Federal award that provides reasonable assurance that the non-Federal entity is managing the Federal award in compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. These internal controls should be in compliance with guidance in “Standards for Internal Control in the Federal Government” issued by the Comptroller General of the United States and the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO).”   2 CFR 200.430 (i) states “Standards for Documentation of Personnel Expenses (1) Charges to Federal awards for salaries and wages must be based on records that accurately reflected the work performed. These records must: (i) be supported by a system of internal control which provides reasonable assurance that the charges are accurate, allowable, and properly allocated; (ii) be incorporated into the official records of the non-Federal entity; (iii) reasonably reflect the total activity for which the employee is compensated by the non-Federal entity, not exceeding 100% of compensated activities; (iv) encompass both federal assisted and all other activities compensated by the non-Federal entity on an integrated basis, but may include the use of subsidiary records as defined in the non-Federal entity’s written policy; (v) comply with the established accounting policies and practices of the non-Federal entity.” Condition: At St. Mary Medical Center – Long Beach, internal controls with regard to approving timecards were not performed for 3 of 40 employee timecards selected for testing. At Bailey-Boushay House, internal controls with regard to approving timecards were not performed for 6 out of 40 employee timecards selected for testing. Cause: St. Mary Medical Center – Long Beach and Bailey-Boushay House management did not consistently perform the necessary internal control procedures addressing the requirements of 2 CFR 200.303(a) and 2 CFR 200.430. Effect or potential effect: Unallowable and/or inaccurate payroll expenditures could be charged to the federal program. Questioned costs: None. Context: For 3 of 40 payroll expenditures selected for testing, St. Mary Medical Center – Long Beach did not properly approve the employee timecard for time charged to the grant in accordance with the practices of St. Mary Medical Center – Long Beach. For 6 out of 40 payroll expenditures selected for testing, Bailey-Boushay House did not properly approve the employee timecard for time charged to the grant in accordance with the practices of Bailey-Boushay House. Total payroll expenditures for St. Mary Medical Center – Long Beach were approximately $1.3 million and represent 32% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Total payroll expenditures for Bailey-Boushay House were approximately $1.1 million and represent 25% of the total HIV Emergency Relief Project Grants expenditures of approximately $4.2 million. Identification of a repeat finding: This is not a repeat finding for St. Mary Medical Center – Long Beach. This is a repeat finding for Bailey-Boushay House – Finding 2022-007 and 2021-008. Recommendation: We recommend management execute its processes to properly approve all time charged to federal grants in accordance with 2 CFR 200.430. Additionally, we recommend management execute and retain evidence of its internal controls over the allowability of payroll expenditures. Views of responsible officials: Management agrees with the finding and will implement corrective action in April 2024.