DARTMOUTH-HITCHCOCK HEALTH AND SUBSIDIARIES (D/B/A DARTMOUTH HEALTH)

Cluster: Not applicable Sponsoring Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Award Numbers: Cheshire Medical Center 2019-BDAS-05-ACCES-04, 05-95-92-920510-7040-5007, RFP-2018-BDAS-05-INTEG Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2023-2024 Pass-through entity: New Hampshire Department of Health and Human Services Criteria 2 CFR 200.308 Revision of budget and program plans requires a recipient or subrecipient to request prior written approval from the Federal agency or pass-through entity for changes in key personnel (including employees and contractors) that are identified by name or position in the Federal award. Additionally, the terms of the Opioid STR award agreements at Cheshire Medical Center require changes in staffing, whether temporary or long term, to be provided to the New Hampshire Department of Health and Human Services (DHHS) for approval, 30 calendar days before making the change. Condition In testing conformity with the compliance requirements for key personnel, we selected 4 of the key personnel changes that occurred on the Cheshire Medical Center Opioid STR awards which included key personnel that changed roles or resigned from the System in fiscal year 2024. Management identified replacement key personnel to participate in the grant; however, management did not notify DHHS and did not obtain approval from DHHS regarding the changes. Cause Management did not have a control in place to notify DHHS and request approval for key personnel changes. Effect The granting agency was unaware of key changes made to personnel on the award and may have not concurred with the individual selected to fill the given role(s). Questioned Costs None noted. Recommendation We recommend that management communicate with their agency contacts regarding this matter and implement a control that monitors the key personnel assigned to the grant to ensure that they are notifying the agency of any changes in status and obtaining approval from the agency in a timely manner.

Management agrees with the finding related to Key Personnel Change Approval at our member, Cheshire Medical Center. The post-award management of this grant is currently handled outside of the Dartmouth Health Research Finance and Post-Award department. Management aims to centralize this function by December 31, 2025. In the interim, Dartmouth Health Management will provide training to award operational staff to implement policies that align with the centrally managed awards by June 30, 2025. Specifically, the Member will conduct a monthly review of key personnel efforts to identify any potential changes that require notification to the New Hampshire Department of Health and Human Services or any award sponsor in which the Key Personnel Change compliance requirement is required. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2023- 2024 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Dartmouth Health System did not have a process in place to ensure that all federally funded equipment included in the fixed asset register were included in its clinical engineering database where monitoring of federally funded equipment is tracked. As a result, while inspection was completed over 3 federal assets in FY2024, the Dartmouth Health System has not completed a physical inventory of all federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as the percentage of Federal participation in the project costs for the Federal award under which the property was acquired, asset location and the use and condition of the equipment. The full population of equipment funded with federal research and development dollars, as provided by the Dartmouth Health System, consisted of 15 items with a total historical cost of $122.6k. Cause In FY2024, the Dartmouth Health System was in progress implementing its corrective action plan with respect to the finding identified in FY2022, including creating a federal equipment tracking procedure, inspecting identified federal assets and updating property records to include details required by 2 CFR section 200.313. As the corrective action plan was not fully implemented by the end of FY2024, all compliance requirements with respect to federal equipment were not yet satisfied. Effect The Dartmouth Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Dartmouth Health System has not formally verified the existence, current utilization and continued need for all federally funded equipment through this physical inventory process. Questioned Costs None noted. Recommendation We recommend that the Dartmouth Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), updating its property records to include all details required by 2 CFR section 200.313(d)(1) and performing a reconciliation between the listing of federally purchased fixed assets and the full fixed asset register to ensure completeness.

Management agrees with the finding related to Equipment Management. Management conducted a biannual physical inventory count of specific federally purchased research equipment in Fiscal Year 2024. Management did not include all required fields within the clinical engineering database as required by 2 CFR section 200.313 (d) (1) such as the percentage of Federal participation in the project costs for the Federal award under which the property was acquired, asset location and the use and condition of the equipment. Management will update the clinical engineering database to include these fields within the details by June 30, 2025. Management did not verify the completeness of the listing against the entire federal equipment inventory. Management will establish a quarterly control in which Research Finance will reconcile federal equipment inventory within the clinical engineering database against the Corporate Finance federal equipment listing, starting with the quarter ending March 31, 2025. Leadership Responsible: John Muhlen, System Vice President of Corporate Finance Anticipated Completion Date: June 30, 2025

2022-001

Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Criteria According to 2 CFR section 200.313, procedures for managing equipment (including replacement equipment), whether acquired in whole or in part under a Federal award, until disposition takes place will, at a minimum, meet the following requirements: (1) Property records must be maintained that include a description of the property, a serial number or other identification number, the source of funding for the property (including the FAIN), who holds title, the acquisition date, and cost of the property, percentage of Federal participation in the project costs for the Federal award under which the property was acquired, the location, use and condition of the property, and any ultimate disposition data including the date of disposal and sale price of the property. (2) A physical inventory of the property must be taken and the results reconciled with the property records at least once every two years. (3) A control system must be developed to ensure adequate safeguards to prevent loss, damage, or theft of the property. Any loss, damage, or theft must be investigated. (4) Adequate maintenance procedures must be developed to keep the property in good condition. (5) If the non-Federal entity is authorized or required to sell the property, proper sales procedures must be established to ensure the highest possible return. Condition The Health System did not perform a physical inventory of federally purchased fixed assets at least once during the last two years. Additionally, the federal asset listing did not specify all of the details required by 2 CFR section 200.313 (d) (1) such as asset locations, tag numbers, use and condition. The full population of equipment funded with federal research and development dollars, as provided by the Health System, consisted of 9 items with a total historical cost of $105k. Cause The Health System lacks a process to ensure that policies and procedures related to identifying and managing its federally purchased fixed assets in accordance with 2 CFR section 200.313 are followed, including updating property records to include all required data elements and the performance of a physical inventory at least once every two years. Effect The Health System's accounting records for its federally purchased fixed assets could be inaccurate as the Health System has not formally verified the existence, current utilization and continued need for the equipment through this physical inventory process. Additionally, without maintaining tag numbers and records of asset locations, safeguarding of assets could be impacted. Questioned Costs None noted. Recommendation We recommend that the Health System implement a process to ensure its policies and procedures over equipment management are followed, including the performance of a physical inventory of federally purchased fixed assets at least once every two years in accordance with 2 CFR section 200.313(d)(2), and updating its property records to include all details required by 2 CFR section 200.313(d)(1). Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status.

Cluster: Research and Development Federal Agency: Various Award Names: Various Award Numbers: Various Assistance Listing Title: Various Assistance Listing Number: Various Award Year: 2021- 2022 Pass-through entity: Various Management agrees with the finding related to the federal equipment inventory and tracking. To address these deficiencies Research Operations will work closely with Corporate Finance, Facilities, and Purchasing to create a federal equipment tracking procedure that allows inventory to be identified and located in order to conduct an inventory at a minimum of every two years. Furthermore, the tracking system will include all of the detail surrounding the equipment needed to meet the requirements of 2 CFR section 200.313 (d) (1). Leadership Responsible: Barbara A. Vance, PhD, CRA, Vice President, Research Operations Anticipated Completion Date: 03/31/2024

Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Criteria 2 CFR 200.512 Report Submission requires the audit be completed and the data collection form and Uniform Guidance reporting package submitted within the earlier of 30 calendar days after receipt of the auditor's report(s), or nine months after the end of the audit period. Condition The Health System?s Uniform Guidance reporting package was due to be submitted to the Federal Audit Clearinghouse by March 31, 2023, however, since the report was not filed until June 2023, the report is considered late. Cause Our understanding is that management experienced turnover in their research operations department and as a result, audit preparation was delayed. As a result of the findings that were identified in our testing of the in-scope major programs, additional time was also needed to complete the audit procedures and for management to consider an appropriate corrective action plan. Effect Not receiving the Uniform Guidance reporting package in a timely manner could impact the oversight and monitoring procedures performed by the federal government and other constituents. Questioned Costs None noted. Recommendation We recommend management ensure controls are in place to allow for subsequent audits to be completed in a timely manner, consistent with previous years. Management?s Views and Corrective Action Plan Management?s Views and Corrective Action Plan is included at the end of this report after the summary schedule of prior audit findings and status

Cluster: All represented on the Schedule of Expenditures of Federal Awards (?SEFA?) Sponsoring Agency: All federal agencies represented on the SEFA Award Names: All awards on the SEFA Award Numbers: All awards on the SEFA Assistance Listing Title: All awards on the SEFA Assistance Listing Number: All awards on the SEFA Award Year: All awards on the SEFA Pass-through entity: All identified on the SEFA Management agrees with this finding related to the late submission of the UG Audit Report. The current year audit process was not indicative of the typical audit process for D-HH. Management has subsequently hired additional staff and will file the audit timely moving forward. Leadership Responsible: Barbara A. Vance, PhD, CRA, Vice President, Research Operations Anticipated Completion Date: 3/31/2024

Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH Dept of Health and Human Services Criteria To be eligible under the Substance Use Disorder Treatment and Recovery Support Services award, a patient must 1) have income below 400% of the federal poverty level, 2) be a resident of New Hampshire or experiencing homelessness in New Hampshire, and 3) be determined positive for substance use disorder. Additionally, patient income information for all eligible patients receiving services must be updated at a minimum interval of once every four weeks. Condition Cheshire Medical Center operates The Doorway program in Keene, NH. The Doorway connects patients positive for substance use disorder with support services and treatment, and receives a portion of its funding from the Substance Use Disorder Treatment and Recovery Support Services federal award. Through our testing of eligibility requirements for 25 patients, we noted the following: ? For all selections, no formal documentation was maintained regarding patient income levels. ? For all selections, income reassessments were not completed and documented at least once every four weeks. ? One selected patient was neither a resident of New Hampshire, nor experiencing homelessness in New Hampshire. While The Doorway provides services to patients beyond those defined as eligible under the Substance Use Disorder Treatment and Recovery Support Services award, there is no differentiation between patients that are eligible or ineligible under the federal program. As a result of patients not being differentiated, time and effort incurred by personnel on the award is commingled with non-award activity. For example, a clinician?s salary is funded under the award, but she is not seeing only eligible patients. As such, any time she spent treating a patient who is not eligible would be a questioned cost under the grant. Cause The nature and purpose of the federal program is very similar and consistent with the mission and operations of The Doorway. Management did not understand the need to differentiate the services performed and patients served in order to demonstrate compliance with award terms and conditions. Effect The commingling of activities between federal and non-federal programs does not allow for compliance with award specific terms and conditions and with eligibility requirements to be effectively managed. Questioned Costs We were unable to verify eligibility requirements were met for the program which had total expenditures of $838,932. Recommendation We recommend that internal controls and policies be implemented to manage the eligibility requirements of the federal awards and ensure that documentation to support eligibility determinations is maintained. Further, procedures to differentiate patients eligible under the award from those determined to beineligible, along with a mechanism to track the time and expenses associated with eligible patients should be put in place. Management?s View and Corrective Action Plan Management's views and corrective action plan is included at the end of this report after the summary schedule of prior audit findings and status.

Cluster: Not applicable Federal Agency: Department of Health and Human Services Award Names: Substance Use Disorder Treatment and Recovery Support Services Award Numbers: T1081685 Assistance Listing Title: Opioid STR Assistance Listing Number: 93.788 Award Year: 2021 - 2022 Pass-through entity: NH Dept of Health and Human Services Management understands and agrees that there was a failure to follow the documentation requirements of the Opioid STR award during the majority of the time period covered by the audit. In June 2022 the Doorway began implementing a screening tool used at the time of patient intake to determine which patients are eligible under the grant. Additionally, a process will be implemented to perform the required income reassessments every 4 weeks and to track time and differentiate costs between eligible and non-eligible patients. Any patient deemed ineligible in the initial screening or subsequent four week reassessments will continue to be treated, but the associated cost will not be charged to the grant. This documentation will be reviewed a minimum of two times per year by Cheshire?s Compliance Manager, and more frequently if errors are found. Results will be reported to the Chief Operating Officer and the Chief Financial Officer Cheshire has implemented a separation of duties where the clinic administrator will ensure and maintain appropriate documentation, while a senior finance analyst will review and verify appropriateness prior to invoicing the grant. This process will add an additional check to be certain only eligible patients are charged to the grant. Leadership Responsible: Daniel Gross, Chief Financial Officer ? Cheshire Medical Center Anticipated Completion Date: 9/30/2023