Audit 360505

FY End

2024-09-30

Total Expended

$80.91M

Findings

1136

Programs

Organization: Bmc Health System, Inc. (MA)

Year: 2024 Accepted: 2025-06-27

Auditor: Kpmg LLP

Organization Exclusion Status:

Checking exclusion status...

Findings

ID	Ref	Severity	Repeat	Requirement
568230	2024-002	Significant Deficiency	Yes	M
568231	2024-002	Significant Deficiency	Yes	M
568232	2024-002	Significant Deficiency	Yes	M
568233	2024-002	Significant Deficiency	Yes	M
568234	2024-002	Significant Deficiency	Yes	M
568235	2024-002	Significant Deficiency	Yes	M
568236	2024-002	Significant Deficiency	Yes	M
568237	2024-002	Significant Deficiency	Yes	M
568238	2024-002	Significant Deficiency	Yes	M
568239	2024-002	Significant Deficiency	Yes	M
568240	2024-002	Significant Deficiency	Yes	M
568241	2024-002	Significant Deficiency	Yes	M
568242	2024-002	Significant Deficiency	Yes	M
568243	2024-002	Significant Deficiency	Yes	M
568244	2024-002	Significant Deficiency	Yes	M
568245	2024-002	Significant Deficiency	Yes	M
568246	2024-002	Significant Deficiency	Yes	M
568247	2024-002	Significant Deficiency	Yes	M
568248	2024-002	Significant Deficiency	Yes	M
568249	2024-002	Significant Deficiency	Yes	M
568250	2024-002	Significant Deficiency	Yes	M
568251	2024-002	Significant Deficiency	Yes	M
568252	2024-002	Significant Deficiency	Yes	M
568253	2024-002	Significant Deficiency	Yes	M
568254	2024-002	Significant Deficiency	Yes	M
568255	2024-002	Significant Deficiency	Yes	M
568256	2024-002	Significant Deficiency	Yes	M
568257	2024-002	Significant Deficiency	Yes	M
568258	2024-002	Significant Deficiency	Yes	M
568259	2024-002	Significant Deficiency	Yes	M
568260	2024-002	Significant Deficiency	Yes	M
568261	2024-002	Significant Deficiency	Yes	M
568262	2024-002	Significant Deficiency	Yes	M
568263	2024-002	Significant Deficiency	Yes	M
568264	2024-002	Significant Deficiency	Yes	M
568265	2024-002	Significant Deficiency	Yes	M
568266	2024-002	Significant Deficiency	Yes	M
568267	2024-002	Significant Deficiency	Yes	M
568268	2024-002	Significant Deficiency	Yes	M
568269	2024-002	Significant Deficiency	Yes	M
568270	2024-002	Significant Deficiency	Yes	M
568271	2024-002	Significant Deficiency	Yes	M
568272	2024-002	Significant Deficiency	Yes	M
568273	2024-002	Significant Deficiency	Yes	M
568274	2024-002	Significant Deficiency	Yes	M
568275	2024-002	Significant Deficiency	Yes	M
568276	2024-002	Significant Deficiency	Yes	M
568277	2024-002	Significant Deficiency	Yes	M
568278	2024-002	Significant Deficiency	Yes	M
568279	2024-002	Significant Deficiency	Yes	M
568280	2024-002	Significant Deficiency	Yes	M
568281	2024-002	Significant Deficiency	Yes	M
568282	2024-002	Significant Deficiency	Yes	M
568283	2024-002	Significant Deficiency	Yes	M
568284	2024-002	Significant Deficiency	Yes	M
568285	2024-002	Significant Deficiency	Yes	M
568286	2024-002	Significant Deficiency	Yes	M
568287	2024-002	Significant Deficiency	Yes	M
568288	2024-002	Significant Deficiency	Yes	M
568289	2024-002	Significant Deficiency	Yes	M
568290	2024-002	Significant Deficiency	Yes	M
568291	2024-002	Significant Deficiency	Yes	M
568292	2024-002	Significant Deficiency	Yes	M
568293	2024-002	Significant Deficiency	Yes	M
568294	2024-002	Significant Deficiency	Yes	M
568295	2024-002	Significant Deficiency	Yes	M
568296	2024-002	Significant Deficiency	Yes	M
568297	2024-002	Significant Deficiency	Yes	M
568298	2024-002	Significant Deficiency	Yes	M
568299	2024-002	Significant Deficiency	Yes	M
568300	2024-002	Significant Deficiency	Yes	M
568301	2024-002	Significant Deficiency	Yes	M
568302	2024-002	Significant Deficiency	Yes	M
568303	2024-002	Significant Deficiency	Yes	M
568304	2024-002	Significant Deficiency	Yes	M
568305	2024-002	Significant Deficiency	Yes	M
568306	2024-002	Significant Deficiency	Yes	M
568307	2024-002	Significant Deficiency	Yes	M
568308	2024-002	Significant Deficiency	Yes	M
568309	2024-002	Significant Deficiency	Yes	M
568310	2024-002	Significant Deficiency	Yes	M
568311	2024-002	Significant Deficiency	Yes	M
568312	2024-002	Significant Deficiency	Yes	M
568313	2024-002	Significant Deficiency	Yes	M
568314	2024-002	Significant Deficiency	Yes	M
568315	2024-002	Significant Deficiency	Yes	M
568316	2024-002	Significant Deficiency	Yes	M
568317	2024-002	Significant Deficiency	Yes	M
568318	2024-002	Significant Deficiency	Yes	M
568319	2024-002	Significant Deficiency	Yes	M
568320	2024-002	Significant Deficiency	Yes	M
568321	2024-002	Significant Deficiency	Yes	M
568322	2024-002	Significant Deficiency	Yes	M
568323	2024-002	Significant Deficiency	Yes	M
568324	2024-002	Significant Deficiency	Yes	M
568325	2024-002	Significant Deficiency	Yes	M
568326	2024-002	Significant Deficiency	Yes	M
568327	2024-002	Significant Deficiency	Yes	M
568328	2024-002	Significant Deficiency	Yes	M
568329	2024-002	Significant Deficiency	Yes	M
568330	2024-002	Significant Deficiency	Yes	M
568331	2024-002	Significant Deficiency	Yes	M
568332	2024-002	Significant Deficiency	Yes	M
568333	2024-002	Significant Deficiency	Yes	M
568334	2024-002	Significant Deficiency	Yes	M
568335	2024-002	Significant Deficiency	Yes	M
568336	2024-002	Significant Deficiency	Yes	M
568337	2024-002	Significant Deficiency	Yes	M
568338	2024-002	Significant Deficiency	Yes	M
568339	2024-002	Significant Deficiency	Yes	M
568340	2024-002	Significant Deficiency	Yes	M
568341	2024-002	Significant Deficiency	Yes	M
568342	2024-002	Significant Deficiency	Yes	M
568343	2024-002	Significant Deficiency	Yes	M
568344	2024-002	Significant Deficiency	Yes	M
568345	2024-002	Significant Deficiency	Yes	M
568346	2024-002	Significant Deficiency	Yes	M
568347	2024-002	Significant Deficiency	Yes	M
568348	2024-002	Significant Deficiency	Yes	M
568349	2024-002	Significant Deficiency	Yes	M
568350	2024-002	Significant Deficiency	Yes	M
568351	2024-002	Significant Deficiency	Yes	M
568352	2024-002	Significant Deficiency	Yes	M
568353	2024-002	Significant Deficiency	Yes	M
568354	2024-002	Significant Deficiency	Yes	M
568355	2024-002	Significant Deficiency	Yes	M
568356	2024-002	Significant Deficiency	Yes	M
568357	2024-002	Significant Deficiency	Yes	M
568358	2024-002	Significant Deficiency	Yes	M
568359	2024-002	Significant Deficiency	Yes	M
568360	2024-002	Significant Deficiency	Yes	M
568361	2024-002	Significant Deficiency	Yes	M
568362	2024-002	Significant Deficiency	Yes	M
568363	2024-002	Significant Deficiency	Yes	M
568364	2024-002	Significant Deficiency	Yes	M
568365	2024-002	Significant Deficiency	Yes	M
568366	2024-002	Significant Deficiency	Yes	M
568367	2024-002	Significant Deficiency	Yes	M
568368	2024-002	Significant Deficiency	Yes	M
568369	2024-002	Significant Deficiency	Yes	M
568370	2024-002	Significant Deficiency	Yes	M
568371	2024-002	Significant Deficiency	Yes	M
568372	2024-002	Significant Deficiency	Yes	M
568373	2024-002	Significant Deficiency	Yes	M
568374	2024-002	Significant Deficiency	Yes	M
568375	2024-002	Significant Deficiency	Yes	M
568376	2024-002	Significant Deficiency	Yes	M
568377	2024-002	Significant Deficiency	Yes	M
568378	2024-002	Significant Deficiency	Yes	M
568379	2024-002	Significant Deficiency	Yes	M
568380	2024-002	Significant Deficiency	Yes	M
568381	2024-002	Significant Deficiency	Yes	M
568382	2024-002	Significant Deficiency	Yes	M
568383	2024-002	Significant Deficiency	Yes	M
568384	2024-002	Significant Deficiency	Yes	M
568385	2024-002	Significant Deficiency	Yes	M
568386	2024-002	Significant Deficiency	Yes	M
568387	2024-002	Significant Deficiency	Yes	M
568388	2024-002	Significant Deficiency	Yes	M
568389	2024-002	Significant Deficiency	Yes	M
568390	2024-002	Significant Deficiency	Yes	M
568391	2024-002	Significant Deficiency	Yes	M
568392	2024-002	Significant Deficiency	Yes	M
568393	2024-002	Significant Deficiency	Yes	M
568394	2024-002	Significant Deficiency	Yes	M
568395	2024-002	Significant Deficiency	Yes	M
568396	2024-002	Significant Deficiency	Yes	M
568397	2024-002	Significant Deficiency	Yes	M
568398	2024-002	Significant Deficiency	Yes	M
568399	2024-002	Significant Deficiency	Yes	M
568400	2024-002	Significant Deficiency	Yes	M
568401	2024-002	Significant Deficiency	Yes	M
568402	2024-002	Significant Deficiency	Yes	M
568403	2024-002	Significant Deficiency	Yes	M
568404	2024-002	Significant Deficiency	Yes	M
568405	2024-002	Significant Deficiency	Yes	M
568406	2024-002	Significant Deficiency	Yes	M
568407	2024-002	Significant Deficiency	Yes	M
568408	2024-002	Significant Deficiency	Yes	M
568409	2024-002	Significant Deficiency	Yes	M
568410	2024-002	Significant Deficiency	Yes	M
568411	2024-002	Significant Deficiency	Yes	M
568412	2024-002	Significant Deficiency	Yes	M
568413	2024-002	Significant Deficiency	Yes	M
568414	2024-002	Significant Deficiency	Yes	M
568415	2024-002	Significant Deficiency	Yes	M
568416	2024-002	Significant Deficiency	Yes	M
568417	2024-002	Significant Deficiency	Yes	M
568418	2024-002	Significant Deficiency	Yes	M
568419	2024-002	Significant Deficiency	Yes	M
568420	2024-002	Significant Deficiency	Yes	M
568421	2024-002	Significant Deficiency	Yes	M
568422	2024-002	Significant Deficiency	Yes	M
568423	2024-002	Significant Deficiency	Yes	M
568424	2024-002	Significant Deficiency	Yes	M
568425	2024-002	Significant Deficiency	Yes	M
568426	2024-002	Significant Deficiency	Yes	M
568427	2024-002	Significant Deficiency	Yes	M
568428	2024-002	Significant Deficiency	Yes	M
568429	2024-002	Significant Deficiency	Yes	M
568430	2024-002	Significant Deficiency	Yes	M
568431	2024-002	Significant Deficiency	Yes	M
568432	2024-002	Significant Deficiency	Yes	M
568433	2024-002	Significant Deficiency	Yes	M
568434	2024-002	Significant Deficiency	Yes	M
568435	2024-002	Significant Deficiency	Yes	M
568436	2024-002	Significant Deficiency	Yes	M
568437	2024-002	Significant Deficiency	Yes	M
568438	2024-002	Significant Deficiency	Yes	M
568439	2024-002	Significant Deficiency	Yes	M
568440	2024-002	Significant Deficiency	Yes	M
568441	2024-002	Significant Deficiency	Yes	M
568442	2024-002	Significant Deficiency	Yes	M
568443	2024-002	Significant Deficiency	Yes	M
568444	2024-002	Significant Deficiency	Yes	M
568445	2024-002	Significant Deficiency	Yes	M
568446	2024-002	Significant Deficiency	Yes	M
568447	2024-002	Significant Deficiency	Yes	M
568448	2024-002	Significant Deficiency	Yes	M
568449	2024-002	Significant Deficiency	Yes	M
568450	2024-002	Significant Deficiency	Yes	M
568451	2024-002	Significant Deficiency	Yes	M
568452	2024-002	Significant Deficiency	Yes	M
568453	2024-002	Significant Deficiency	Yes	M
568454	2024-002	Significant Deficiency	Yes	M
568455	2024-002	Significant Deficiency	Yes	M
568456	2024-002	Significant Deficiency	Yes	M
568457	2024-002	Significant Deficiency	Yes	M
568458	2024-002	Significant Deficiency	Yes	M
568459	2024-002	Significant Deficiency	Yes	M
568460	2024-002	Significant Deficiency	Yes	M
568461	2024-002	Significant Deficiency	Yes	M
568462	2024-002	Significant Deficiency	Yes	M
568463	2024-002	Significant Deficiency	Yes	M
568464	2024-002	Significant Deficiency	Yes	M
568465	2024-002	Significant Deficiency	Yes	M
568466	2024-002	Significant Deficiency	Yes	M
568467	2024-002	Significant Deficiency	Yes	M
568468	2024-002	Significant Deficiency	Yes	M
568469	2024-002	Significant Deficiency	Yes	M
568470	2024-002	Significant Deficiency	Yes	M
568471	2024-002	Significant Deficiency	Yes	M
568472	2024-002	Significant Deficiency	Yes	M
568473	2024-002	Significant Deficiency	Yes	M
568474	2024-002	Significant Deficiency	Yes	M
568475	2024-002	Significant Deficiency	Yes	M
568476	2024-002	Significant Deficiency	Yes	M
568477	2024-002	Significant Deficiency	Yes	M
568478	2024-002	Significant Deficiency	Yes	M
568479	2024-002	Significant Deficiency	Yes	M
568480	2024-002	Significant Deficiency	Yes	M
568481	2024-002	Significant Deficiency	Yes	M
568482	2024-002	Significant Deficiency	Yes	M
568483	2024-002	Significant Deficiency	Yes	M
568484	2024-002	Significant Deficiency	Yes	M
568485	2024-002	Significant Deficiency	Yes	M
568486	2024-002	Significant Deficiency	Yes	M
568487	2024-002	Significant Deficiency	Yes	M
568488	2024-002	Significant Deficiency	Yes	M
568489	2024-002	Significant Deficiency	Yes	M
568490	2024-002	Significant Deficiency	Yes	M
568491	2024-002	Significant Deficiency	Yes	M
568492	2024-002	Significant Deficiency	Yes	M
568493	2024-002	Significant Deficiency	Yes	M
568494	2024-002	Significant Deficiency	Yes	M
568495	2024-002	Significant Deficiency	Yes	M
568496	2024-002	Significant Deficiency	Yes	M
568497	2024-002	Significant Deficiency	Yes	M
568498	2024-002	Significant Deficiency	Yes	M
568499	2024-002	Significant Deficiency	Yes	M
568500	2024-002	Significant Deficiency	Yes	M
568501	2024-002	Significant Deficiency	Yes	M
568502	2024-002	Significant Deficiency	Yes	M
568503	2024-002	Significant Deficiency	Yes	M
568504	2024-002	Significant Deficiency	Yes	M
568505	2024-002	Significant Deficiency	Yes	M
568506	2024-002	Significant Deficiency	Yes	M
568507	2024-002	Significant Deficiency	Yes	M
568508	2024-002	Significant Deficiency	Yes	M
568509	2024-002	Significant Deficiency	Yes	M
568510	2024-002	Significant Deficiency	Yes	M
568511	2024-002	Significant Deficiency	Yes	M
568512	2024-002	Significant Deficiency	Yes	M
568513	2024-002	Significant Deficiency	Yes	M
568514	2024-003	Significant Deficiency	Yes	P
568515	2024-003	Significant Deficiency	Yes	P
568516	2024-003	Significant Deficiency	Yes	P
568517	2024-003	Significant Deficiency	Yes	P
568518	2024-003	Significant Deficiency	Yes	P
568519	2024-003	Significant Deficiency	Yes	P
568520	2024-003	Significant Deficiency	Yes	P
568521	2024-003	Significant Deficiency	Yes	P
568522	2024-003	Significant Deficiency	Yes	P
568523	2024-003	Significant Deficiency	Yes	P
568524	2024-003	Significant Deficiency	Yes	P
568525	2024-003	Significant Deficiency	Yes	P
568526	2024-003	Significant Deficiency	Yes	P
568527	2024-003	Significant Deficiency	Yes	P
568528	2024-003	Significant Deficiency	Yes	P
568529	2024-003	Significant Deficiency	Yes	P
568530	2024-003	Significant Deficiency	Yes	P
568531	2024-003	Significant Deficiency	Yes	P
568532	2024-003	Significant Deficiency	Yes	P
568533	2024-003	Significant Deficiency	Yes	P
568534	2024-003	Significant Deficiency	Yes	P
568535	2024-003	Significant Deficiency	Yes	P
568536	2024-003	Significant Deficiency	Yes	P
568537	2024-003	Significant Deficiency	Yes	P
568538	2024-003	Significant Deficiency	Yes	P
568539	2024-003	Significant Deficiency	Yes	P
568540	2024-003	Significant Deficiency	Yes	P
568541	2024-003	Significant Deficiency	Yes	P
568542	2024-003	Significant Deficiency	Yes	P
568543	2024-003	Significant Deficiency	Yes	P
568544	2024-003	Significant Deficiency	Yes	P
568545	2024-003	Significant Deficiency	Yes	P
568546	2024-003	Significant Deficiency	Yes	P
568547	2024-003	Significant Deficiency	Yes	P
568548	2024-003	Significant Deficiency	Yes	P
568549	2024-003	Significant Deficiency	Yes	P
568550	2024-003	Significant Deficiency	Yes	P
568551	2024-003	Significant Deficiency	Yes	P
568552	2024-003	Significant Deficiency	Yes	P
568553	2024-003	Significant Deficiency	Yes	P
568554	2024-003	Significant Deficiency	Yes	P
568555	2024-003	Significant Deficiency	Yes	P
568556	2024-003	Significant Deficiency	Yes	P
568557	2024-003	Significant Deficiency	Yes	P
568558	2024-003	Significant Deficiency	Yes	P
568559	2024-003	Significant Deficiency	Yes	P
568560	2024-003	Significant Deficiency	Yes	P
568561	2024-003	Significant Deficiency	Yes	P
568562	2024-003	Significant Deficiency	Yes	P
568563	2024-003	Significant Deficiency	Yes	P
568564	2024-003	Significant Deficiency	Yes	P
568565	2024-003	Significant Deficiency	Yes	P
568566	2024-003	Significant Deficiency	Yes	P
568567	2024-003	Significant Deficiency	Yes	P
568568	2024-003	Significant Deficiency	Yes	P
568569	2024-003	Significant Deficiency	Yes	P
568570	2024-003	Significant Deficiency	Yes	P
568571	2024-003	Significant Deficiency	Yes	P
568572	2024-003	Significant Deficiency	Yes	P
568573	2024-003	Significant Deficiency	Yes	P
568574	2024-003	Significant Deficiency	Yes	P
568575	2024-003	Significant Deficiency	Yes	P
568576	2024-003	Significant Deficiency	Yes	P
568577	2024-003	Significant Deficiency	Yes	P
568578	2024-003	Significant Deficiency	Yes	P
568579	2024-003	Significant Deficiency	Yes	P
568580	2024-003	Significant Deficiency	Yes	P
568581	2024-003	Significant Deficiency	Yes	P
568582	2024-003	Significant Deficiency	Yes	P
568583	2024-003	Significant Deficiency	Yes	P
568584	2024-003	Significant Deficiency	Yes	P
568585	2024-003	Significant Deficiency	Yes	P
568586	2024-003	Significant Deficiency	Yes	P
568587	2024-003	Significant Deficiency	Yes	P
568588	2024-003	Significant Deficiency	Yes	P
568589	2024-003	Significant Deficiency	Yes	P
568590	2024-003	Significant Deficiency	Yes	P
568591	2024-003	Significant Deficiency	Yes	P
568592	2024-003	Significant Deficiency	Yes	P
568593	2024-003	Significant Deficiency	Yes	P
568594	2024-003	Significant Deficiency	Yes	P
568595	2024-003	Significant Deficiency	Yes	P
568596	2024-003	Significant Deficiency	Yes	P
568597	2024-003	Significant Deficiency	Yes	P
568598	2024-003	Significant Deficiency	Yes	P
568599	2024-003	Significant Deficiency	Yes	P
568600	2024-003	Significant Deficiency	Yes	P
568601	2024-003	Significant Deficiency	Yes	P
568602	2024-003	Significant Deficiency	Yes	P
568603	2024-003	Significant Deficiency	Yes	P
568604	2024-003	Significant Deficiency	Yes	P
568605	2024-003	Significant Deficiency	Yes	P
568606	2024-003	Significant Deficiency	Yes	P
568607	2024-003	Significant Deficiency	Yes	P
568608	2024-003	Significant Deficiency	Yes	P
568609	2024-003	Significant Deficiency	Yes	P
568610	2024-003	Significant Deficiency	Yes	P
568611	2024-003	Significant Deficiency	Yes	P
568612	2024-003	Significant Deficiency	Yes	P
568613	2024-003	Significant Deficiency	Yes	P
568614	2024-003	Significant Deficiency	Yes	P
568615	2024-003	Significant Deficiency	Yes	P
568616	2024-003	Significant Deficiency	Yes	P
568617	2024-003	Significant Deficiency	Yes	P
568618	2024-003	Significant Deficiency	Yes	P
568619	2024-003	Significant Deficiency	Yes	P
568620	2024-003	Significant Deficiency	Yes	P
568621	2024-003	Significant Deficiency	Yes	P
568622	2024-003	Significant Deficiency	Yes	P
568623	2024-003	Significant Deficiency	Yes	P
568624	2024-003	Significant Deficiency	Yes	P
568625	2024-003	Significant Deficiency	Yes	P
568626	2024-003	Significant Deficiency	Yes	P
568627	2024-003	Significant Deficiency	Yes	P
568628	2024-003	Significant Deficiency	Yes	P
568629	2024-003	Significant Deficiency	Yes	P
568630	2024-003	Significant Deficiency	Yes	P
568631	2024-003	Significant Deficiency	Yes	P
568632	2024-003	Significant Deficiency	Yes	P
568633	2024-003	Significant Deficiency	Yes	P
568634	2024-003	Significant Deficiency	Yes	P
568635	2024-003	Significant Deficiency	Yes	P
568636	2024-003	Significant Deficiency	Yes	P
568637	2024-003	Significant Deficiency	Yes	P
568638	2024-003	Significant Deficiency	Yes	P
568639	2024-003	Significant Deficiency	Yes	P
568640	2024-003	Significant Deficiency	Yes	P
568641	2024-003	Significant Deficiency	Yes	P
568642	2024-003	Significant Deficiency	Yes	P
568643	2024-003	Significant Deficiency	Yes	P
568644	2024-003	Significant Deficiency	Yes	P
568645	2024-003	Significant Deficiency	Yes	P
568646	2024-003	Significant Deficiency	Yes	P
568647	2024-003	Significant Deficiency	Yes	P
568648	2024-003	Significant Deficiency	Yes	P
568649	2024-003	Significant Deficiency	Yes	P
568650	2024-003	Significant Deficiency	Yes	P
568651	2024-003	Significant Deficiency	Yes	P
568652	2024-003	Significant Deficiency	Yes	P
568653	2024-003	Significant Deficiency	Yes	P
568654	2024-003	Significant Deficiency	Yes	P
568655	2024-003	Significant Deficiency	Yes	P
568656	2024-003	Significant Deficiency	Yes	P
568657	2024-003	Significant Deficiency	Yes	P
568658	2024-003	Significant Deficiency	Yes	P
568659	2024-003	Significant Deficiency	Yes	P
568660	2024-003	Significant Deficiency	Yes	P
568661	2024-003	Significant Deficiency	Yes	P
568662	2024-003	Significant Deficiency	Yes	P
568663	2024-003	Significant Deficiency	Yes	P
568664	2024-003	Significant Deficiency	Yes	P
568665	2024-003	Significant Deficiency	Yes	P
568666	2024-003	Significant Deficiency	Yes	P
568667	2024-003	Significant Deficiency	Yes	P
568668	2024-003	Significant Deficiency	Yes	P
568669	2024-003	Significant Deficiency	Yes	P
568670	2024-003	Significant Deficiency	Yes	P
568671	2024-003	Significant Deficiency	Yes	P
568672	2024-003	Significant Deficiency	Yes	P
568673	2024-003	Significant Deficiency	Yes	P
568674	2024-003	Significant Deficiency	Yes	P
568675	2024-003	Significant Deficiency	Yes	P
568676	2024-003	Significant Deficiency	Yes	P
568677	2024-003	Significant Deficiency	Yes	P
568678	2024-003	Significant Deficiency	Yes	P
568679	2024-003	Significant Deficiency	Yes	P
568680	2024-003	Significant Deficiency	Yes	P
568681	2024-003	Significant Deficiency	Yes	P
568682	2024-003	Significant Deficiency	Yes	P
568683	2024-003	Significant Deficiency	Yes	P
568684	2024-003	Significant Deficiency	Yes	P
568685	2024-003	Significant Deficiency	Yes	P
568686	2024-003	Significant Deficiency	Yes	P
568687	2024-003	Significant Deficiency	Yes	P
568688	2024-003	Significant Deficiency	Yes	P
568689	2024-003	Significant Deficiency	Yes	P
568690	2024-003	Significant Deficiency	Yes	P
568691	2024-003	Significant Deficiency	Yes	P
568692	2024-003	Significant Deficiency	Yes	P
568693	2024-003	Significant Deficiency	Yes	P
568694	2024-003	Significant Deficiency	Yes	P
568695	2024-003	Significant Deficiency	Yes	P
568696	2024-003	Significant Deficiency	Yes	P
568697	2024-003	Significant Deficiency	Yes	P
568698	2024-003	Significant Deficiency	Yes	P
568699	2024-003	Significant Deficiency	Yes	P
568700	2024-003	Significant Deficiency	Yes	P
568701	2024-003	Significant Deficiency	Yes	P
568702	2024-003	Significant Deficiency	Yes	P
568703	2024-003	Significant Deficiency	Yes	P
568704	2024-003	Significant Deficiency	Yes	P
568705	2024-003	Significant Deficiency	Yes	P
568706	2024-003	Significant Deficiency	Yes	P
568707	2024-003	Significant Deficiency	Yes	P
568708	2024-003	Significant Deficiency	Yes	P
568709	2024-003	Significant Deficiency	Yes	P
568710	2024-003	Significant Deficiency	Yes	P
568711	2024-003	Significant Deficiency	Yes	P
568712	2024-003	Significant Deficiency	Yes	P
568713	2024-003	Significant Deficiency	Yes	P
568714	2024-003	Significant Deficiency	Yes	P
568715	2024-003	Significant Deficiency	Yes	P
568716	2024-003	Significant Deficiency	Yes	P
568717	2024-003	Significant Deficiency	Yes	P
568718	2024-003	Significant Deficiency	Yes	P
568719	2024-003	Significant Deficiency	Yes	P
568720	2024-003	Significant Deficiency	Yes	P
568721	2024-003	Significant Deficiency	Yes	P
568722	2024-003	Significant Deficiency	Yes	P
568723	2024-003	Significant Deficiency	Yes	P
568724	2024-003	Significant Deficiency	Yes	P
568725	2024-003	Significant Deficiency	Yes	P
568726	2024-003	Significant Deficiency	Yes	P
568727	2024-003	Significant Deficiency	Yes	P
568728	2024-003	Significant Deficiency	Yes	P
568729	2024-003	Significant Deficiency	Yes	P
568730	2024-003	Significant Deficiency	Yes	P
568731	2024-003	Significant Deficiency	Yes	P
568732	2024-003	Significant Deficiency	Yes	P
568733	2024-003	Significant Deficiency	Yes	P
568734	2024-003	Significant Deficiency	Yes	P
568735	2024-003	Significant Deficiency	Yes	P
568736	2024-003	Significant Deficiency	Yes	P
568737	2024-003	Significant Deficiency	Yes	P
568738	2024-003	Significant Deficiency	Yes	P
568739	2024-003	Significant Deficiency	Yes	P
568740	2024-003	Significant Deficiency	Yes	P
568741	2024-003	Significant Deficiency	Yes	P
568742	2024-003	Significant Deficiency	Yes	P
568743	2024-003	Significant Deficiency	Yes	P
568744	2024-003	Significant Deficiency	Yes	P
568745	2024-003	Significant Deficiency	Yes	P
568746	2024-003	Significant Deficiency	Yes	P
568747	2024-003	Significant Deficiency	Yes	P
568748	2024-003	Significant Deficiency	Yes	P
568749	2024-003	Significant Deficiency	Yes	P
568750	2024-003	Significant Deficiency	Yes	P
568751	2024-003	Significant Deficiency	Yes	P
568752	2024-003	Significant Deficiency	Yes	P
568753	2024-003	Significant Deficiency	Yes	P
568754	2024-003	Significant Deficiency	Yes	P
568755	2024-003	Significant Deficiency	Yes	P
568756	2024-003	Significant Deficiency	Yes	P
568757	2024-003	Significant Deficiency	Yes	P
568758	2024-003	Significant Deficiency	Yes	P
568759	2024-003	Significant Deficiency	Yes	P
568760	2024-003	Significant Deficiency	Yes	P
568761	2024-003	Significant Deficiency	Yes	P
568762	2024-003	Significant Deficiency	Yes	P
568763	2024-003	Significant Deficiency	Yes	P
568764	2024-003	Significant Deficiency	Yes	P
568765	2024-003	Significant Deficiency	Yes	P
568766	2024-003	Significant Deficiency	Yes	P
568767	2024-003	Significant Deficiency	Yes	P
568768	2024-003	Significant Deficiency	Yes	P
568769	2024-003	Significant Deficiency	Yes	P
568770	2024-003	Significant Deficiency	Yes	P
568771	2024-003	Significant Deficiency	Yes	P
568772	2024-003	Significant Deficiency	Yes	P
568773	2024-003	Significant Deficiency	Yes	P
568774	2024-003	Significant Deficiency	Yes	P
568775	2024-003	Significant Deficiency	Yes	P
568776	2024-003	Significant Deficiency	Yes	P
568777	2024-003	Significant Deficiency	Yes	P
568778	2024-003	Significant Deficiency	Yes	P
568779	2024-003	Significant Deficiency	Yes	P
568780	2024-003	Significant Deficiency	Yes	P
568781	2024-003	Significant Deficiency	Yes	P
568782	2024-003	Significant Deficiency	Yes	P
568783	2024-003	Significant Deficiency	Yes	P
568784	2024-003	Significant Deficiency	Yes	P
568785	2024-003	Significant Deficiency	Yes	P
568786	2024-003	Significant Deficiency	Yes	P
568787	2024-003	Significant Deficiency	Yes	P
568788	2024-003	Significant Deficiency	Yes	P
568789	2024-003	Significant Deficiency	Yes	P
568790	2024-003	Significant Deficiency	Yes	P
568791	2024-003	Significant Deficiency	Yes	P
568792	2024-003	Significant Deficiency	Yes	P
568793	2024-003	Significant Deficiency	Yes	P
568794	2024-003	Significant Deficiency	Yes	P
568795	2024-003	Significant Deficiency	Yes	P
568796	2024-003	Significant Deficiency	Yes	P
568797	2024-003	Significant Deficiency	Yes	P
1144672	2024-002	Significant Deficiency	Yes	M
1144673	2024-002	Significant Deficiency	Yes	M
1144674	2024-002	Significant Deficiency	Yes	M
1144675	2024-002	Significant Deficiency	Yes	M
1144676	2024-002	Significant Deficiency	Yes	M
1144677	2024-002	Significant Deficiency	Yes	M
1144678	2024-002	Significant Deficiency	Yes	M
1144679	2024-002	Significant Deficiency	Yes	M
1144680	2024-002	Significant Deficiency	Yes	M
1144681	2024-002	Significant Deficiency	Yes	M
1144682	2024-002	Significant Deficiency	Yes	M
1144683	2024-002	Significant Deficiency	Yes	M
1144684	2024-002	Significant Deficiency	Yes	M
1144685	2024-002	Significant Deficiency	Yes	M
1144686	2024-002	Significant Deficiency	Yes	M
1144687	2024-002	Significant Deficiency	Yes	M
1144688	2024-002	Significant Deficiency	Yes	M
1144689	2024-002	Significant Deficiency	Yes	M
1144690	2024-002	Significant Deficiency	Yes	M
1144691	2024-002	Significant Deficiency	Yes	M
1144692	2024-002	Significant Deficiency	Yes	M
1144693	2024-002	Significant Deficiency	Yes	M
1144694	2024-002	Significant Deficiency	Yes	M
1144695	2024-002	Significant Deficiency	Yes	M
1144696	2024-002	Significant Deficiency	Yes	M
1144697	2024-002	Significant Deficiency	Yes	M
1144698	2024-002	Significant Deficiency	Yes	M
1144699	2024-002	Significant Deficiency	Yes	M
1144700	2024-002	Significant Deficiency	Yes	M
1144701	2024-002	Significant Deficiency	Yes	M
1144702	2024-002	Significant Deficiency	Yes	M
1144703	2024-002	Significant Deficiency	Yes	M
1144704	2024-002	Significant Deficiency	Yes	M
1144705	2024-002	Significant Deficiency	Yes	M
1144706	2024-002	Significant Deficiency	Yes	M
1144707	2024-002	Significant Deficiency	Yes	M
1144708	2024-002	Significant Deficiency	Yes	M
1144709	2024-002	Significant Deficiency	Yes	M
1144710	2024-002	Significant Deficiency	Yes	M
1144711	2024-002	Significant Deficiency	Yes	M
1144712	2024-002	Significant Deficiency	Yes	M
1144713	2024-002	Significant Deficiency	Yes	M
1144714	2024-002	Significant Deficiency	Yes	M
1144715	2024-002	Significant Deficiency	Yes	M
1144716	2024-002	Significant Deficiency	Yes	M
1144717	2024-002	Significant Deficiency	Yes	M
1144718	2024-002	Significant Deficiency	Yes	M
1144719	2024-002	Significant Deficiency	Yes	M
1144720	2024-002	Significant Deficiency	Yes	M
1144721	2024-002	Significant Deficiency	Yes	M
1144722	2024-002	Significant Deficiency	Yes	M
1144723	2024-002	Significant Deficiency	Yes	M
1144724	2024-002	Significant Deficiency	Yes	M
1144725	2024-002	Significant Deficiency	Yes	M
1144726	2024-002	Significant Deficiency	Yes	M
1144727	2024-002	Significant Deficiency	Yes	M
1144728	2024-002	Significant Deficiency	Yes	M
1144729	2024-002	Significant Deficiency	Yes	M
1144730	2024-002	Significant Deficiency	Yes	M
1144731	2024-002	Significant Deficiency	Yes	M
1144732	2024-002	Significant Deficiency	Yes	M
1144733	2024-002	Significant Deficiency	Yes	M
1144734	2024-002	Significant Deficiency	Yes	M
1144735	2024-002	Significant Deficiency	Yes	M
1144736	2024-002	Significant Deficiency	Yes	M
1144737	2024-002	Significant Deficiency	Yes	M
1144738	2024-002	Significant Deficiency	Yes	M
1144739	2024-002	Significant Deficiency	Yes	M
1144740	2024-002	Significant Deficiency	Yes	M
1144741	2024-002	Significant Deficiency	Yes	M
1144742	2024-002	Significant Deficiency	Yes	M
1144743	2024-002	Significant Deficiency	Yes	M
1144744	2024-002	Significant Deficiency	Yes	M
1144745	2024-002	Significant Deficiency	Yes	M
1144746	2024-002	Significant Deficiency	Yes	M
1144747	2024-002	Significant Deficiency	Yes	M
1144748	2024-002	Significant Deficiency	Yes	M
1144749	2024-002	Significant Deficiency	Yes	M
1144750	2024-002	Significant Deficiency	Yes	M
1144751	2024-002	Significant Deficiency	Yes	M
1144752	2024-002	Significant Deficiency	Yes	M
1144753	2024-002	Significant Deficiency	Yes	M
1144754	2024-002	Significant Deficiency	Yes	M
1144755	2024-002	Significant Deficiency	Yes	M
1144756	2024-002	Significant Deficiency	Yes	M
1144757	2024-002	Significant Deficiency	Yes	M
1144758	2024-002	Significant Deficiency	Yes	M
1144759	2024-002	Significant Deficiency	Yes	M
1144760	2024-002	Significant Deficiency	Yes	M
1144761	2024-002	Significant Deficiency	Yes	M
1144762	2024-002	Significant Deficiency	Yes	M
1144763	2024-002	Significant Deficiency	Yes	M
1144764	2024-002	Significant Deficiency	Yes	M
1144765	2024-002	Significant Deficiency	Yes	M
1144766	2024-002	Significant Deficiency	Yes	M
1144767	2024-002	Significant Deficiency	Yes	M
1144768	2024-002	Significant Deficiency	Yes	M
1144769	2024-002	Significant Deficiency	Yes	M
1144770	2024-002	Significant Deficiency	Yes	M
1144771	2024-002	Significant Deficiency	Yes	M
1144772	2024-002	Significant Deficiency	Yes	M
1144773	2024-002	Significant Deficiency	Yes	M
1144774	2024-002	Significant Deficiency	Yes	M
1144775	2024-002	Significant Deficiency	Yes	M
1144776	2024-002	Significant Deficiency	Yes	M
1144777	2024-002	Significant Deficiency	Yes	M
1144778	2024-002	Significant Deficiency	Yes	M
1144779	2024-002	Significant Deficiency	Yes	M
1144780	2024-002	Significant Deficiency	Yes	M
1144781	2024-002	Significant Deficiency	Yes	M
1144782	2024-002	Significant Deficiency	Yes	M
1144783	2024-002	Significant Deficiency	Yes	M
1144784	2024-002	Significant Deficiency	Yes	M
1144785	2024-002	Significant Deficiency	Yes	M
1144786	2024-002	Significant Deficiency	Yes	M
1144787	2024-002	Significant Deficiency	Yes	M
1144788	2024-002	Significant Deficiency	Yes	M
1144789	2024-002	Significant Deficiency	Yes	M
1144790	2024-002	Significant Deficiency	Yes	M
1144791	2024-002	Significant Deficiency	Yes	M
1144792	2024-002	Significant Deficiency	Yes	M
1144793	2024-002	Significant Deficiency	Yes	M
1144794	2024-002	Significant Deficiency	Yes	M
1144795	2024-002	Significant Deficiency	Yes	M
1144796	2024-002	Significant Deficiency	Yes	M
1144797	2024-002	Significant Deficiency	Yes	M
1144798	2024-002	Significant Deficiency	Yes	M
1144799	2024-002	Significant Deficiency	Yes	M
1144800	2024-002	Significant Deficiency	Yes	M
1144801	2024-002	Significant Deficiency	Yes	M
1144802	2024-002	Significant Deficiency	Yes	M
1144803	2024-002	Significant Deficiency	Yes	M
1144804	2024-002	Significant Deficiency	Yes	M
1144805	2024-002	Significant Deficiency	Yes	M
1144806	2024-002	Significant Deficiency	Yes	M
1144807	2024-002	Significant Deficiency	Yes	M
1144808	2024-002	Significant Deficiency	Yes	M
1144809	2024-002	Significant Deficiency	Yes	M
1144810	2024-002	Significant Deficiency	Yes	M
1144811	2024-002	Significant Deficiency	Yes	M
1144812	2024-002	Significant Deficiency	Yes	M
1144813	2024-002	Significant Deficiency	Yes	M
1144814	2024-002	Significant Deficiency	Yes	M
1144815	2024-002	Significant Deficiency	Yes	M
1144816	2024-002	Significant Deficiency	Yes	M
1144817	2024-002	Significant Deficiency	Yes	M
1144818	2024-002	Significant Deficiency	Yes	M
1144819	2024-002	Significant Deficiency	Yes	M
1144820	2024-002	Significant Deficiency	Yes	M
1144821	2024-002	Significant Deficiency	Yes	M
1144822	2024-002	Significant Deficiency	Yes	M
1144823	2024-002	Significant Deficiency	Yes	M
1144824	2024-002	Significant Deficiency	Yes	M
1144825	2024-002	Significant Deficiency	Yes	M
1144826	2024-002	Significant Deficiency	Yes	M
1144827	2024-002	Significant Deficiency	Yes	M
1144828	2024-002	Significant Deficiency	Yes	M
1144829	2024-002	Significant Deficiency	Yes	M
1144830	2024-002	Significant Deficiency	Yes	M
1144831	2024-002	Significant Deficiency	Yes	M
1144832	2024-002	Significant Deficiency	Yes	M
1144833	2024-002	Significant Deficiency	Yes	M
1144834	2024-002	Significant Deficiency	Yes	M
1144835	2024-002	Significant Deficiency	Yes	M
1144836	2024-002	Significant Deficiency	Yes	M
1144837	2024-002	Significant Deficiency	Yes	M
1144838	2024-002	Significant Deficiency	Yes	M
1144839	2024-002	Significant Deficiency	Yes	M
1144840	2024-002	Significant Deficiency	Yes	M
1144841	2024-002	Significant Deficiency	Yes	M
1144842	2024-002	Significant Deficiency	Yes	M
1144843	2024-002	Significant Deficiency	Yes	M
1144844	2024-002	Significant Deficiency	Yes	M
1144845	2024-002	Significant Deficiency	Yes	M
1144846	2024-002	Significant Deficiency	Yes	M
1144847	2024-002	Significant Deficiency	Yes	M
1144848	2024-002	Significant Deficiency	Yes	M
1144849	2024-002	Significant Deficiency	Yes	M
1144850	2024-002	Significant Deficiency	Yes	M
1144851	2024-002	Significant Deficiency	Yes	M
1144852	2024-002	Significant Deficiency	Yes	M
1144853	2024-002	Significant Deficiency	Yes	M
1144854	2024-002	Significant Deficiency	Yes	M
1144855	2024-002	Significant Deficiency	Yes	M
1144856	2024-002	Significant Deficiency	Yes	M
1144857	2024-002	Significant Deficiency	Yes	M
1144858	2024-002	Significant Deficiency	Yes	M
1144859	2024-002	Significant Deficiency	Yes	M
1144860	2024-002	Significant Deficiency	Yes	M
1144861	2024-002	Significant Deficiency	Yes	M
1144862	2024-002	Significant Deficiency	Yes	M
1144863	2024-002	Significant Deficiency	Yes	M
1144864	2024-002	Significant Deficiency	Yes	M
1144865	2024-002	Significant Deficiency	Yes	M
1144866	2024-002	Significant Deficiency	Yes	M
1144867	2024-002	Significant Deficiency	Yes	M
1144868	2024-002	Significant Deficiency	Yes	M
1144869	2024-002	Significant Deficiency	Yes	M
1144870	2024-002	Significant Deficiency	Yes	M
1144871	2024-002	Significant Deficiency	Yes	M
1144872	2024-002	Significant Deficiency	Yes	M
1144873	2024-002	Significant Deficiency	Yes	M
1144874	2024-002	Significant Deficiency	Yes	M
1144875	2024-002	Significant Deficiency	Yes	M
1144876	2024-002	Significant Deficiency	Yes	M
1144877	2024-002	Significant Deficiency	Yes	M
1144878	2024-002	Significant Deficiency	Yes	M
1144879	2024-002	Significant Deficiency	Yes	M
1144880	2024-002	Significant Deficiency	Yes	M
1144881	2024-002	Significant Deficiency	Yes	M
1144882	2024-002	Significant Deficiency	Yes	M
1144883	2024-002	Significant Deficiency	Yes	M
1144884	2024-002	Significant Deficiency	Yes	M
1144885	2024-002	Significant Deficiency	Yes	M
1144886	2024-002	Significant Deficiency	Yes	M
1144887	2024-002	Significant Deficiency	Yes	M
1144888	2024-002	Significant Deficiency	Yes	M
1144889	2024-002	Significant Deficiency	Yes	M
1144890	2024-002	Significant Deficiency	Yes	M
1144891	2024-002	Significant Deficiency	Yes	M
1144892	2024-002	Significant Deficiency	Yes	M
1144893	2024-002	Significant Deficiency	Yes	M
1144894	2024-002	Significant Deficiency	Yes	M
1144895	2024-002	Significant Deficiency	Yes	M
1144896	2024-002	Significant Deficiency	Yes	M
1144897	2024-002	Significant Deficiency	Yes	M
1144898	2024-002	Significant Deficiency	Yes	M
1144899	2024-002	Significant Deficiency	Yes	M
1144900	2024-002	Significant Deficiency	Yes	M
1144901	2024-002	Significant Deficiency	Yes	M
1144902	2024-002	Significant Deficiency	Yes	M
1144903	2024-002	Significant Deficiency	Yes	M
1144904	2024-002	Significant Deficiency	Yes	M
1144905	2024-002	Significant Deficiency	Yes	M
1144906	2024-002	Significant Deficiency	Yes	M
1144907	2024-002	Significant Deficiency	Yes	M
1144908	2024-002	Significant Deficiency	Yes	M
1144909	2024-002	Significant Deficiency	Yes	M
1144910	2024-002	Significant Deficiency	Yes	M
1144911	2024-002	Significant Deficiency	Yes	M
1144912	2024-002	Significant Deficiency	Yes	M
1144913	2024-002	Significant Deficiency	Yes	M
1144914	2024-002	Significant Deficiency	Yes	M
1144915	2024-002	Significant Deficiency	Yes	M
1144916	2024-002	Significant Deficiency	Yes	M
1144917	2024-002	Significant Deficiency	Yes	M
1144918	2024-002	Significant Deficiency	Yes	M
1144919	2024-002	Significant Deficiency	Yes	M
1144920	2024-002	Significant Deficiency	Yes	M
1144921	2024-002	Significant Deficiency	Yes	M
1144922	2024-002	Significant Deficiency	Yes	M
1144923	2024-002	Significant Deficiency	Yes	M
1144924	2024-002	Significant Deficiency	Yes	M
1144925	2024-002	Significant Deficiency	Yes	M
1144926	2024-002	Significant Deficiency	Yes	M
1144927	2024-002	Significant Deficiency	Yes	M
1144928	2024-002	Significant Deficiency	Yes	M
1144929	2024-002	Significant Deficiency	Yes	M
1144930	2024-002	Significant Deficiency	Yes	M
1144931	2024-002	Significant Deficiency	Yes	M
1144932	2024-002	Significant Deficiency	Yes	M
1144933	2024-002	Significant Deficiency	Yes	M
1144934	2024-002	Significant Deficiency	Yes	M
1144935	2024-002	Significant Deficiency	Yes	M
1144936	2024-002	Significant Deficiency	Yes	M
1144937	2024-002	Significant Deficiency	Yes	M
1144938	2024-002	Significant Deficiency	Yes	M
1144939	2024-002	Significant Deficiency	Yes	M
1144940	2024-002	Significant Deficiency	Yes	M
1144941	2024-002	Significant Deficiency	Yes	M
1144942	2024-002	Significant Deficiency	Yes	M
1144943	2024-002	Significant Deficiency	Yes	M
1144944	2024-002	Significant Deficiency	Yes	M
1144945	2024-002	Significant Deficiency	Yes	M
1144946	2024-002	Significant Deficiency	Yes	M
1144947	2024-002	Significant Deficiency	Yes	M
1144948	2024-002	Significant Deficiency	Yes	M
1144949	2024-002	Significant Deficiency	Yes	M
1144950	2024-002	Significant Deficiency	Yes	M
1144951	2024-002	Significant Deficiency	Yes	M
1144952	2024-002	Significant Deficiency	Yes	M
1144953	2024-002	Significant Deficiency	Yes	M
1144954	2024-002	Significant Deficiency	Yes	M
1144955	2024-002	Significant Deficiency	Yes	M
1144956	2024-003	Significant Deficiency	Yes	P
1144957	2024-003	Significant Deficiency	Yes	P
1144958	2024-003	Significant Deficiency	Yes	P
1144959	2024-003	Significant Deficiency	Yes	P
1144960	2024-003	Significant Deficiency	Yes	P
1144961	2024-003	Significant Deficiency	Yes	P
1144962	2024-003	Significant Deficiency	Yes	P
1144963	2024-003	Significant Deficiency	Yes	P
1144964	2024-003	Significant Deficiency	Yes	P
1144965	2024-003	Significant Deficiency	Yes	P
1144966	2024-003	Significant Deficiency	Yes	P
1144967	2024-003	Significant Deficiency	Yes	P
1144968	2024-003	Significant Deficiency	Yes	P
1144969	2024-003	Significant Deficiency	Yes	P
1144970	2024-003	Significant Deficiency	Yes	P
1144971	2024-003	Significant Deficiency	Yes	P
1144972	2024-003	Significant Deficiency	Yes	P
1144973	2024-003	Significant Deficiency	Yes	P
1144974	2024-003	Significant Deficiency	Yes	P
1144975	2024-003	Significant Deficiency	Yes	P
1144976	2024-003	Significant Deficiency	Yes	P
1144977	2024-003	Significant Deficiency	Yes	P
1144978	2024-003	Significant Deficiency	Yes	P
1144979	2024-003	Significant Deficiency	Yes	P
1144980	2024-003	Significant Deficiency	Yes	P
1144981	2024-003	Significant Deficiency	Yes	P
1144982	2024-003	Significant Deficiency	Yes	P
1144983	2024-003	Significant Deficiency	Yes	P
1144984	2024-003	Significant Deficiency	Yes	P
1144985	2024-003	Significant Deficiency	Yes	P
1144986	2024-003	Significant Deficiency	Yes	P
1144987	2024-003	Significant Deficiency	Yes	P
1144988	2024-003	Significant Deficiency	Yes	P
1144989	2024-003	Significant Deficiency	Yes	P
1144990	2024-003	Significant Deficiency	Yes	P
1144991	2024-003	Significant Deficiency	Yes	P
1144992	2024-003	Significant Deficiency	Yes	P
1144993	2024-003	Significant Deficiency	Yes	P
1144994	2024-003	Significant Deficiency	Yes	P
1144995	2024-003	Significant Deficiency	Yes	P
1144996	2024-003	Significant Deficiency	Yes	P
1144997	2024-003	Significant Deficiency	Yes	P
1144998	2024-003	Significant Deficiency	Yes	P
1144999	2024-003	Significant Deficiency	Yes	P
1145000	2024-003	Significant Deficiency	Yes	P
1145001	2024-003	Significant Deficiency	Yes	P
1145002	2024-003	Significant Deficiency	Yes	P
1145003	2024-003	Significant Deficiency	Yes	P
1145004	2024-003	Significant Deficiency	Yes	P
1145005	2024-003	Significant Deficiency	Yes	P
1145006	2024-003	Significant Deficiency	Yes	P
1145007	2024-003	Significant Deficiency	Yes	P
1145008	2024-003	Significant Deficiency	Yes	P
1145009	2024-003	Significant Deficiency	Yes	P
1145010	2024-003	Significant Deficiency	Yes	P
1145011	2024-003	Significant Deficiency	Yes	P
1145012	2024-003	Significant Deficiency	Yes	P
1145013	2024-003	Significant Deficiency	Yes	P
1145014	2024-003	Significant Deficiency	Yes	P
1145015	2024-003	Significant Deficiency	Yes	P
1145016	2024-003	Significant Deficiency	Yes	P
1145017	2024-003	Significant Deficiency	Yes	P
1145018	2024-003	Significant Deficiency	Yes	P
1145019	2024-003	Significant Deficiency	Yes	P
1145020	2024-003	Significant Deficiency	Yes	P
1145021	2024-003	Significant Deficiency	Yes	P
1145022	2024-003	Significant Deficiency	Yes	P
1145023	2024-003	Significant Deficiency	Yes	P
1145024	2024-003	Significant Deficiency	Yes	P
1145025	2024-003	Significant Deficiency	Yes	P
1145026	2024-003	Significant Deficiency	Yes	P
1145027	2024-003	Significant Deficiency	Yes	P
1145028	2024-003	Significant Deficiency	Yes	P
1145029	2024-003	Significant Deficiency	Yes	P
1145030	2024-003	Significant Deficiency	Yes	P
1145031	2024-003	Significant Deficiency	Yes	P
1145032	2024-003	Significant Deficiency	Yes	P
1145033	2024-003	Significant Deficiency	Yes	P
1145034	2024-003	Significant Deficiency	Yes	P
1145035	2024-003	Significant Deficiency	Yes	P
1145036	2024-003	Significant Deficiency	Yes	P
1145037	2024-003	Significant Deficiency	Yes	P
1145038	2024-003	Significant Deficiency	Yes	P
1145039	2024-003	Significant Deficiency	Yes	P
1145040	2024-003	Significant Deficiency	Yes	P
1145041	2024-003	Significant Deficiency	Yes	P
1145042	2024-003	Significant Deficiency	Yes	P
1145043	2024-003	Significant Deficiency	Yes	P
1145044	2024-003	Significant Deficiency	Yes	P
1145045	2024-003	Significant Deficiency	Yes	P
1145046	2024-003	Significant Deficiency	Yes	P
1145047	2024-003	Significant Deficiency	Yes	P
1145048	2024-003	Significant Deficiency	Yes	P
1145049	2024-003	Significant Deficiency	Yes	P
1145050	2024-003	Significant Deficiency	Yes	P
1145051	2024-003	Significant Deficiency	Yes	P
1145052	2024-003	Significant Deficiency	Yes	P
1145053	2024-003	Significant Deficiency	Yes	P
1145054	2024-003	Significant Deficiency	Yes	P
1145055	2024-003	Significant Deficiency	Yes	P
1145056	2024-003	Significant Deficiency	Yes	P
1145057	2024-003	Significant Deficiency	Yes	P
1145058	2024-003	Significant Deficiency	Yes	P
1145059	2024-003	Significant Deficiency	Yes	P
1145060	2024-003	Significant Deficiency	Yes	P
1145061	2024-003	Significant Deficiency	Yes	P
1145062	2024-003	Significant Deficiency	Yes	P
1145063	2024-003	Significant Deficiency	Yes	P
1145064	2024-003	Significant Deficiency	Yes	P
1145065	2024-003	Significant Deficiency	Yes	P
1145066	2024-003	Significant Deficiency	Yes	P
1145067	2024-003	Significant Deficiency	Yes	P
1145068	2024-003	Significant Deficiency	Yes	P
1145069	2024-003	Significant Deficiency	Yes	P
1145070	2024-003	Significant Deficiency	Yes	P
1145071	2024-003	Significant Deficiency	Yes	P
1145072	2024-003	Significant Deficiency	Yes	P
1145073	2024-003	Significant Deficiency	Yes	P
1145074	2024-003	Significant Deficiency	Yes	P
1145075	2024-003	Significant Deficiency	Yes	P
1145076	2024-003	Significant Deficiency	Yes	P
1145077	2024-003	Significant Deficiency	Yes	P
1145078	2024-003	Significant Deficiency	Yes	P
1145079	2024-003	Significant Deficiency	Yes	P
1145080	2024-003	Significant Deficiency	Yes	P
1145081	2024-003	Significant Deficiency	Yes	P
1145082	2024-003	Significant Deficiency	Yes	P
1145083	2024-003	Significant Deficiency	Yes	P
1145084	2024-003	Significant Deficiency	Yes	P
1145085	2024-003	Significant Deficiency	Yes	P
1145086	2024-003	Significant Deficiency	Yes	P
1145087	2024-003	Significant Deficiency	Yes	P
1145088	2024-003	Significant Deficiency	Yes	P
1145089	2024-003	Significant Deficiency	Yes	P
1145090	2024-003	Significant Deficiency	Yes	P
1145091	2024-003	Significant Deficiency	Yes	P
1145092	2024-003	Significant Deficiency	Yes	P
1145093	2024-003	Significant Deficiency	Yes	P
1145094	2024-003	Significant Deficiency	Yes	P
1145095	2024-003	Significant Deficiency	Yes	P
1145096	2024-003	Significant Deficiency	Yes	P
1145097	2024-003	Significant Deficiency	Yes	P
1145098	2024-003	Significant Deficiency	Yes	P
1145099	2024-003	Significant Deficiency	Yes	P
1145100	2024-003	Significant Deficiency	Yes	P
1145101	2024-003	Significant Deficiency	Yes	P
1145102	2024-003	Significant Deficiency	Yes	P
1145103	2024-003	Significant Deficiency	Yes	P
1145104	2024-003	Significant Deficiency	Yes	P
1145105	2024-003	Significant Deficiency	Yes	P
1145106	2024-003	Significant Deficiency	Yes	P
1145107	2024-003	Significant Deficiency	Yes	P
1145108	2024-003	Significant Deficiency	Yes	P
1145109	2024-003	Significant Deficiency	Yes	P
1145110	2024-003	Significant Deficiency	Yes	P
1145111	2024-003	Significant Deficiency	Yes	P
1145112	2024-003	Significant Deficiency	Yes	P
1145113	2024-003	Significant Deficiency	Yes	P
1145114	2024-003	Significant Deficiency	Yes	P
1145115	2024-003	Significant Deficiency	Yes	P
1145116	2024-003	Significant Deficiency	Yes	P
1145117	2024-003	Significant Deficiency	Yes	P
1145118	2024-003	Significant Deficiency	Yes	P
1145119	2024-003	Significant Deficiency	Yes	P
1145120	2024-003	Significant Deficiency	Yes	P
1145121	2024-003	Significant Deficiency	Yes	P
1145122	2024-003	Significant Deficiency	Yes	P
1145123	2024-003	Significant Deficiency	Yes	P
1145124	2024-003	Significant Deficiency	Yes	P
1145125	2024-003	Significant Deficiency	Yes	P
1145126	2024-003	Significant Deficiency	Yes	P
1145127	2024-003	Significant Deficiency	Yes	P
1145128	2024-003	Significant Deficiency	Yes	P
1145129	2024-003	Significant Deficiency	Yes	P
1145130	2024-003	Significant Deficiency	Yes	P
1145131	2024-003	Significant Deficiency	Yes	P
1145132	2024-003	Significant Deficiency	Yes	P
1145133	2024-003	Significant Deficiency	Yes	P
1145134	2024-003	Significant Deficiency	Yes	P
1145135	2024-003	Significant Deficiency	Yes	P
1145136	2024-003	Significant Deficiency	Yes	P
1145137	2024-003	Significant Deficiency	Yes	P
1145138	2024-003	Significant Deficiency	Yes	P
1145139	2024-003	Significant Deficiency	Yes	P
1145140	2024-003	Significant Deficiency	Yes	P
1145141	2024-003	Significant Deficiency	Yes	P
1145142	2024-003	Significant Deficiency	Yes	P
1145143	2024-003	Significant Deficiency	Yes	P
1145144	2024-003	Significant Deficiency	Yes	P
1145145	2024-003	Significant Deficiency	Yes	P
1145146	2024-003	Significant Deficiency	Yes	P
1145147	2024-003	Significant Deficiency	Yes	P
1145148	2024-003	Significant Deficiency	Yes	P
1145149	2024-003	Significant Deficiency	Yes	P
1145150	2024-003	Significant Deficiency	Yes	P
1145151	2024-003	Significant Deficiency	Yes	P
1145152	2024-003	Significant Deficiency	Yes	P
1145153	2024-003	Significant Deficiency	Yes	P
1145154	2024-003	Significant Deficiency	Yes	P
1145155	2024-003	Significant Deficiency	Yes	P
1145156	2024-003	Significant Deficiency	Yes	P
1145157	2024-003	Significant Deficiency	Yes	P
1145158	2024-003	Significant Deficiency	Yes	P
1145159	2024-003	Significant Deficiency	Yes	P
1145160	2024-003	Significant Deficiency	Yes	P
1145161	2024-003	Significant Deficiency	Yes	P
1145162	2024-003	Significant Deficiency	Yes	P
1145163	2024-003	Significant Deficiency	Yes	P
1145164	2024-003	Significant Deficiency	Yes	P
1145165	2024-003	Significant Deficiency	Yes	P
1145166	2024-003	Significant Deficiency	Yes	P
1145167	2024-003	Significant Deficiency	Yes	P
1145168	2024-003	Significant Deficiency	Yes	P
1145169	2024-003	Significant Deficiency	Yes	P
1145170	2024-003	Significant Deficiency	Yes	P
1145171	2024-003	Significant Deficiency	Yes	P
1145172	2024-003	Significant Deficiency	Yes	P
1145173	2024-003	Significant Deficiency	Yes	P
1145174	2024-003	Significant Deficiency	Yes	P
1145175	2024-003	Significant Deficiency	Yes	P
1145176	2024-003	Significant Deficiency	Yes	P
1145177	2024-003	Significant Deficiency	Yes	P
1145178	2024-003	Significant Deficiency	Yes	P
1145179	2024-003	Significant Deficiency	Yes	P
1145180	2024-003	Significant Deficiency	Yes	P
1145181	2024-003	Significant Deficiency	Yes	P
1145182	2024-003	Significant Deficiency	Yes	P
1145183	2024-003	Significant Deficiency	Yes	P
1145184	2024-003	Significant Deficiency	Yes	P
1145185	2024-003	Significant Deficiency	Yes	P
1145186	2024-003	Significant Deficiency	Yes	P
1145187	2024-003	Significant Deficiency	Yes	P
1145188	2024-003	Significant Deficiency	Yes	P
1145189	2024-003	Significant Deficiency	Yes	P
1145190	2024-003	Significant Deficiency	Yes	P
1145191	2024-003	Significant Deficiency	Yes	P
1145192	2024-003	Significant Deficiency	Yes	P
1145193	2024-003	Significant Deficiency	Yes	P
1145194	2024-003	Significant Deficiency	Yes	P
1145195	2024-003	Significant Deficiency	Yes	P
1145196	2024-003	Significant Deficiency	Yes	P
1145197	2024-003	Significant Deficiency	Yes	P
1145198	2024-003	Significant Deficiency	Yes	P
1145199	2024-003	Significant Deficiency	Yes	P
1145200	2024-003	Significant Deficiency	Yes	P
1145201	2024-003	Significant Deficiency	Yes	P
1145202	2024-003	Significant Deficiency	Yes	P
1145203	2024-003	Significant Deficiency	Yes	P
1145204	2024-003	Significant Deficiency	Yes	P
1145205	2024-003	Significant Deficiency	Yes	P
1145206	2024-003	Significant Deficiency	Yes	P
1145207	2024-003	Significant Deficiency	Yes	P
1145208	2024-003	Significant Deficiency	Yes	P
1145209	2024-003	Significant Deficiency	Yes	P
1145210	2024-003	Significant Deficiency	Yes	P
1145211	2024-003	Significant Deficiency	Yes	P
1145212	2024-003	Significant Deficiency	Yes	P
1145213	2024-003	Significant Deficiency	Yes	P
1145214	2024-003	Significant Deficiency	Yes	P
1145215	2024-003	Significant Deficiency	Yes	P
1145216	2024-003	Significant Deficiency	Yes	P
1145217	2024-003	Significant Deficiency	Yes	P
1145218	2024-003	Significant Deficiency	Yes	P
1145219	2024-003	Significant Deficiency	Yes	P
1145220	2024-003	Significant Deficiency	Yes	P
1145221	2024-003	Significant Deficiency	Yes	P
1145222	2024-003	Significant Deficiency	Yes	P
1145223	2024-003	Significant Deficiency	Yes	P
1145224	2024-003	Significant Deficiency	Yes	P
1145225	2024-003	Significant Deficiency	Yes	P
1145226	2024-003	Significant Deficiency	Yes	P
1145227	2024-003	Significant Deficiency	Yes	P
1145228	2024-003	Significant Deficiency	Yes	P
1145229	2024-003	Significant Deficiency	Yes	P
1145230	2024-003	Significant Deficiency	Yes	P
1145231	2024-003	Significant Deficiency	Yes	P
1145232	2024-003	Significant Deficiency	Yes	P
1145233	2024-003	Significant Deficiency	Yes	P
1145234	2024-003	Significant Deficiency	Yes	P
1145235	2024-003	Significant Deficiency	Yes	P
1145236	2024-003	Significant Deficiency	Yes	P
1145237	2024-003	Significant Deficiency	Yes	P
1145238	2024-003	Significant Deficiency	Yes	P
1145239	2024-003	Significant Deficiency	Yes	P

Programs

ALN	Program	Spent	Major	Findings
93.279	Drug Abuse and Addiction Research Programs	$17.85M	Yes	2
93.847	Diabetes, Digestive, and Kidney Diseases Extramural Research	$4.54M	Yes	2
93.940	Hiv Prevention Activities Health Department Based	$3.47M	-	0
93.855	Allergy and Infectious Diseases Research	$3.42M	Yes	2
93.273	Alcohol Research Programs	$2.72M	Yes	2
93.213	Research and Training in Complementary and Integrative Health	$1.92M	Yes	2
93.242	Mental Health Research Grants	$1.91M	Yes	2
93.945	Assistance Programs for Chronic Disease Prevention and Control	$1.64M	-	0
93.110	Maternal and Child Health Federal Consolidated Programs	$1.48M	-	0
93.839	Blood Diseases and Resources Research	$1.46M	Yes	2
93.226	Research on Healthcare Costs, Quality and Outcomes	$1.39M	Yes	2
93.837	Cardiovascular Diseases Research	$1.32M	Yes	2
93.997	Assisted Outpatient Treatment	$1.01M	-	0
93.732	Mental and Behavioral Health Education and Training Grants	$912,672	-	0
93.121	Oral Diseases and Disorders Research	$781,277	Yes	2
12.420	Military Medical Research and Development	$777,634	Yes	2
93.865	Child Health and Human Development Extramural Research	$683,686	Yes	2
93.396	Cancer Biology Research	$639,308	Yes	2
93.959	Block Grants for Prevention and Treatment of Substance Abuse	$638,382	-	0
93.884	Primary Care Training and Enhancement	$576,992	-	0
93.604	Assistance for Torture Victims	$423,079	-	0
93.153	Coordinated Services and Access to Research for Women, Infants, Children, and Youth	$372,876	Yes	2
93.073	Birth Defects and Developmental Disabilities - Prevention and Surveillance	$369,507	-	0
93.243	Substance Abuse and Mental Health Services Projects of Regional and National Significance	$362,184	-	0
93.928	Special Projects of National Significance	$351,018	-	0
93.853	Extramural Research Programs in the Neurosciences and Neurological Disorders	$347,219	Yes	2
93.788	Opioid Str	$328,526	-	0
93.989	International Research and Research Training	$306,781	Yes	2
93.117	Preventive Medicine Residency	$306,337	-	0
93.186	National Research Service Award in Primary Care Medicine	$288,326	Yes	2
16.753	Congressionally Recommended Awards	$285,351	-	0
93.088	Advancing System Improvements for Key Issues in Women's Health	$277,234	-	0
93.225	National Research Service Awards Health Services Research Training	$253,419	Yes	2
93.394	Cancer Detection and Diagnosis Research	$184,584	Yes	2
93.136	Injury Prevention and Control Research and State and Community Based Programs	$167,874	-	0
93.RD	Centers for Disease Control and Prevention	$162,926	Yes	2
93.217	Family Planning Services	$159,618	-	0
93.113	Environmental Health	$149,008	Yes	2
93.866	Aging Research	$129,541	Yes	2
12.RD	National Defense, Emergency Preparedness, and Energy Program	$118,676	Yes	2
10.569	Emergency Food Assistance Program (food Commodities)	$109,957	-	0
93.307	Minority Health and Health Disparities Research	$97,140	Yes	2
93.958	Block Grants for Community Mental Health Services	$96,999	-	0
93.817	Hospital Preparedness Program (hpp) Ebola Preparedness and Response Activities	$94,336	-	0
93.994	Maternal and Child Health Services Block Grant to the States	$86,450	-	0
93.RD	National Institutes of Health	$82,526	Yes	2
94.013	Americorps Volunteers in Service to America 49.013	$74,931	-	0
10.331	Gus Schumacher Nutrition Incentive Program	$65,539	-	0
93.846	Arthritis, Musculoskeletal and Skin Diseases Research	$58,391	Yes	2
10.001	Agricultural Research Basic and Applied Research	$58,351	Yes	2
93.926	Healthy Start Initiative	$56,777	-	0
47.074	Biological Sciences	$56,204	Yes	2
94.006	Americorps State and National 94.006	$49,575	-	0
93.334	The Healthy Brain Initiative: Technical Assistance to Implement Public Health Actions Related to Cognitive Health, Cognitive Impairment, and Caregiving at the State and Local Levels	$43,646	-	0
93.395	Cancer Treatment Research	$41,300	Yes	2
16.745	Criminal and Juvenile Justice and Mental Health Collaboration Program	$29,833	-	0
93.310	Trans-Nih Research Support	$29,696	Yes	2
93.898	Cancer Prevention and Control Programs for State, Territorial and Tribal Organizations	$29,046	Yes	2
93.592	Family Violence Prevention and Services/discretionary	$26,286	Yes	2
93.778	Medical Assistance Program	$25,755	-	0
93.173	Research Related to Deafness and Communication Disorders	$22,772	Yes	2
93.353	21st Century Cures Act - Beau Biden Cancer Moonshot	$16,986	Yes	2
93.397	Cancer Centers Support Grants	$13,285	Yes	2
93.368	21st Century Cures Act - Precision Medicine Initiative	$12,767	Yes	2
93.172	Human Genome Research	$12,582	Yes	2
47.049	Mathematical and Physical Sciences	$10,387	Yes	2
93.365	Sickle Cell Treatment Demonstration Program	$8,705	Yes	2
93.239	Policy Research and Evaluation Grants	$5,593	-	0
93.838	Lung Diseases Research	$5,046	Yes	2
93.877	Autism Collaboration, Accountability, Research, Education, and Support	$3,008	Yes	2
93.194	Community Prevention Coalitions (partnership) Demonstration Grant	$2,472	-	0
10.253	Consumer Data and Nutrition Research	$1,133	Yes	2
93.011	National Organizations of State and Local Officials	$651	-	0
93.084	Prevention of Disease, Disability, and Death by Infectious Diseases	$577	-	0
93.360	Biomedical Advanced Research and Development Authority (barda), Biodefense Medical Countermeasure Development	$101	Yes	2
93.361	Nursing Research	$17	Yes	2
94.021	Americorps Volunteer Generation Fund 94.021	$-6	-	0
93.914	Hiv Emergency Relief Project Grants	$-117	-	0
16.575	Crime Victim Assistance	$-909	-	0
93.421	Strengthening Public Health Systems and Services Through National Partnerships to Improve and Protect the Nation’s Health	$-2,198	-	0
93.350	National Center for Advancing Translational Sciences	$-5,734	Yes	2
93.044	Special Programs for the Aging, Title Iii, Part B, Grants for Supportive Services and Senior Centers	$-6,253	-	0
16.588	Violence Against Women Formula Grants	$-6,666	-	0
14.231	Emergency Solutions Grant Program	$-12,642	-	0
93.495	Community Health Workers for Public Health Response and Resilient	$-13,947	-	0
93.867	Vision Research	$-15,894	Yes	2
93.840	Translation and Implementation Science Research for Heart, Lung, Blood Diseases, and Sleep Disorders	$-17,661	Yes	2
93.393	Cancer Cause and Prevention Research	$-24,472	Yes	2
19.040	Public Diplomacy Programs	$-58,955	Yes	2

Contacts

Name	Title	Type
JZ8RQC4EMDZ5	Tyler Flack	Auditee
6174142864	Martin Dunbar	Auditor
No contacts on file

Notes to SEFA

Title: Basis of Presentation Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: The Health System applies its predetermined approved facilities and administrative rate when charging indirect costs to federal awards rather than the 10% de minims cost rate as described in Section 200.414 of the Uniform Guidance. The accompanying supplementary schedule of expenditures of federal awards (the Schedule) includes the federal award activity of the Health System under programs of the federal government for the year ended September 30, 2024. The information in this Schedule is presented in accordance with the requirements of Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards (Uniform Guidance). Because the Schedule presents only a selected portion of the operations of the Health System, it is not intended to and does not present the consolidated financial position, changes in net assets, or cash flows of the Health System.

Title: Summary of Significant Accounting Policies Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: The Health System applies its predetermined approved facilities and administrative rate when charging indirect costs to federal awards rather than the 10% de minims cost rate as described in Section 200.414 of the Uniform Guidance. Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years.

Title: Indirect Cost Rate Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: The Health System applies its predetermined approved facilities and administrative rate when charging indirect costs to federal awards rather than the 10% de minims cost rate as described in Section 200.414 of the Uniform Guidance. The Health System applies its predetermined approved facilities and administrative rate when charging indirect costs to federal awards rather than the 10% de minims cost rate as described in Section 200.414 of the Uniform Guidance.

Title: Noncash Assistance Accounting Policies: Expenditures reported on the Schedule are reported on the accrual basis of accounting. Such expenditures are recognized following the cost principles contained in the Uniform Guidance, wherein certain types of expenditures are not allowable or are limited as to reimbursement. Negative amounts shown on the Schedule represent adjustments or credits made in the normal course of business to amounts reported as expenditures in prior years. De Minimis Rate Used: N Rate Explanation: The Health System applies its predetermined approved facilities and administrative rate when charging indirect costs to federal awards rather than the 10% de minims cost rate as described in Section 200.414 of the Uniform Guidance. In 2024, $109,957 of U.S. Department of Agriculture (USDA) was received from the Greater Boston Food Bank (ALN #10.569) and distributed to program participants through the Boston Medical Center Food Bank. This noncash assistance amount represents the fair value of the product at the time of receipt and is included on the Schedule.

Finding Details

Finding 2024-002

Federal Agency: United States Department of Health and Human Services (HHS) Program Name: Research and Development Cluster ALN Number: Various Federal Award Year: July 1, 2023 – June 30, 2024 Criteria In accordance with 2 CFR 200.332, a pass through entity (PTE) must: a. Ensure that every subaward is clearly identified to the subrecipient as a subaward and included the following information at the time of the subaward and if any of these data elements change, include the changes in subsequent subaward modification. When some of this information is not available, the pass through entity must provide the best information available to describe the Federal award and subaward. Required information includes: (xii) Assistance Listing number (ALN) and Title; the pass through entity must identify the dollar amount made available under each Federal award and the ALN at time of disbursement (2 CFR section 200.332xxi) b. Evaluate each subrecipient’s risk of noncompliance with Federal statutes, regulations, and the terms and conditions of the subaward for purposes of determining the appropriate subrecipient monitoring described in paragraphs (d) and (e) of this section, which may include consideration of such factors as: The subrecipient’s prior experience with the same or similar subawards; (1) The results of previous audits including whether or not the subrecipient receives a Single Audit in accordance with Subpart F of this part, and the extent to which the same or similar subaward has been audited as a major program; (2) Whether the subrecipient has new personnel or new substantially changed systems; and (3) The extent and results of Federal awarding agency monitoring (e.g., if the subrecipient also receives Federal awards directly from a Federal awarding agency). Additionally, 45 CRF section 75 303(a) states the non Federal entity must 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. Condition When subawards are made to subrecipients, the pass through entities are required to communicate the dollar amount made available under each Federal award and the Assistance Listings Number (ALN) at time of disbursement. The Health System does not have system in place to provide the ALN at the time of disbursement of funds. During the year ended September 30, 2024, the Health System passed through $15,600,763 of federal funding to subrecipients. In order to assess the subrecipient’s risk of non compliance, The Health System has subrecipient monitoring policies and procedures in place which include the use of a risk assessment questionnaire. The risk assessment questionnaire includes considerations consistent with 2 CFR 200.332(b), including the entity’s prior experience and results of Uniform Guidance Audits, in addition to other factors. As part of our testing related subrecipient monitoring, we identified that for each of the 10 subrecipients selected for testwork, the Health System did not perform a risk assessment of the entity for purposes of determining the appropriate subrecipient monitoring related to the subaward. However, for these subrecipients, The Health System did perform monitoring procedures, including review of invoices for reimbursement, review of Research Performance Progress Reports, and review of Uniform Guidance Audit reports. Cause The condition found was primarily due to the monitoring procedures implemented by the Health System do not include a review to ensure that a risk assessment is performed for each active subrecipient, and the Health System does not have a mechanism in place to provide the ALN at the time of disbursement of funds to the subrecipient. The Health System has put efforts into the design and implement a risk assessment control process which commenced late in fiscal year 2024 and the ongoing efforts were not complete as of September 30, 2024. Possible Asserted Effect Failure to perform an annual risk assessment to determine appropriate subrecipient monitoring procedures may result in insufficient monitoring procedures being performed to detect subrecipient noncompliance with Federal statutes, regulations, and the terms and conditions of the award. Failure to adequately communicate award identification information could result in the subrecipient not being able to adequately track and report the subawards received resulting in errors being reported on the schedule of expenditures of federal awards within a subrecipient’s annual single audit report and not being able to comply with required terms and conditions of the federal award. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend management continue to fully implement the designed policies, procedures, and internal controls to ensure subrecipient risk assessments are performed for each subrecipient to determine the appropriate subrecipient monitoring is performed in accordance with 45 CFR 75.352(d) and 45 CFR 75.352(e). Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.

Finding 2024-002

Finding 2024-003

Federal Agency: United States Department of Health and Human Services (HHS) Federal Program: Research & Development ALN Number: Various Federal Award Years: Various Criteria Internal Controls Title 2 U.S. Code of Federal Regulations Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements of Federal Awards, (2 CFR 200) section 200.303(a) states, the non federal entity must 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 statues, 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 or the “Internal Control Integrated Framework”, issued by the Committee of Sponsoring Organizations of the Treadway Commission (COSO). Condition The Health System utilizes Workday, a cloud based system, to provide human resources and payroll applications. The Health System’s management of Workday includes maintaining the application system layer of the information technology (IT) control environment. The Health System relies on the Workday vendor to support infrastructure layers through Service Organization Control (SOC) Type-1 reporting. Processes that support compliance and administration of the R&D program rely on Workday IT application controls. The Health System also utilizes Infor, a cloud based system, as the entity’s general ledger. The Health System's management of Infor includes maintaining the application system layer of the IT control environment and relies on the Infor vendor to support infrastructure layers through SOC 1 reporting. Processes that support compliance and administration of the R&D program rely on Infor IT application control. During our testing, we observed there were no inappropriate changes to the Workday and Infor application controls directly related to specific controls over compliance related to the R&D program, however we noted the following deficiencies in operating effectiveness of the Health System’s general IT controls environment: Workday 1) The Health System performed and documented a Workday change review during the fiscal year; however, the supporting document did not include sufficient appropriate evidence demonstrating such review. Specifically, management maintained an Excel spreadsheet that noted the changes to the business process definitions were appropriate; however, there were no screenshots to document the completeness and accuracy of the report from the system, or evidence of the sign off by the reviewer. Additionally, we noted appropriate evidence of testing and/or approval was not maintained for 4 of 25 sampled changes during the period. 2) The Health System performed a Workday User Access Review (UAR) during the fiscal year and maintained certain evidence demonstrating the UAR occurred, including required access updates; however, the Health System did not maintain specific evidence that all users were reviewed, approved and updated where necessary (i.e. evidence of the completeness & accuracy for pre and post user listing was not available). 3) With respect to our access removal testing, we noted that the Health System implemented automated controls to remove terminated user access in both Workday and Infor, following processing in Workday. We also tested a sample of 25 terminated users to determine whether their access was removed timely and noted that 9 of the sampled users were not removed timely prior processing in Workday. Cause The conditions above relate to the following, respectively: 1) The condition occurred because the Health System did not formally define the procedures to establish requirements for the change review, including retaining evidence of the completeness and accuracy of the review. Additionally, management does not have a centralized process for maintaining evidence of testing and approval for changes. 2) The condition occurred because the Health System did not formally define the procedures to document a complete and accurate UAR. 3) The exception occurred due to delays in supervisors’ timely reporting of terminations. Possible Asserted Effect Failure to have a reliable general IT control environment over logical access and change management may result in unauthorized changes being made to Workday, which may result in erroneous reliance on the operating effectiveness of automated IT controls, over allowability. Failure to have effective internal controls over allowability may result in federal awards being utilized for unallowable expenditures not in accordance with the federal statues, regulations, and terms and conditions of federal awards. Questioned Costs None. Statistical Sampling The sample was not intended to be, and was not, a statistically valid sample. Repeat Finding Yes. Recommendation We recommend that management review and emphasize the change management policies and procedures with key personnel to help ensure that the Workday change review is performed to address change management risks for the system. In addition, we recommend that evidence related to the review, as well as the testing and approval of changes is maintained. Additionally, we recommend that management maintain documentation of the completeness and accuracy of the user access review to ensure that all users are reviewed, approved, and corrective actions taken. Views of Responsible Officials Recommendation accepted. Please refer to corrective action plan.

Finding 2024-003

Finding 2024-002

Finding 2024-003