Trinity Health CorporationNon-Profit

Condition –During fiscal 2025, MCCN submitted inaccurate reporting of student enrollment information to NSLDS and in some cases such information was not submitted timely. Overall, the noncompliance exceptions are limited to timeliness and/or accuracy of enrollment details at campus-level and program-level including enrollment status. There were no questioned costs identified and no observations of unsupported enrollment status or incorrect financial aid amounts received by students. Cause – MCCN lacked a formally designed and implemented enrollment reporting control framework and also lacked an independent secondary review, to ensure NSLDS roster updates were accurate and submitted within required timelines. Effect – Untimely and/or inaccurate enrollment reporting may cause NSLDS to be inaccurate, resulting in U.S. Department of Education and loan servicers relying on incorrect or late information to administer Title IV loans. This potentially increases the risk of improper borrower status determinations and related servicing actions and heightens the risk of Title IV noncompliance. Questioned costs – None Context – Audit results showed 16 of 40 records tested had one or more noncompliance instances related to the timeliness and/or accuracy of campus-level and program-level enrollment information and enrollment status reporting. Specifically, there were 11 late reporting exceptions and 10 inaccurate-reporting exceptions. Repeat Finding from Prior Year – No Recommendation – MCCN should strengthen internal controls over NSLDS enrollment reporting by establishing a standardized process which includes a review of enrollment data to ensure both timely submission and accurate reporting of all required enrollment data elements.

Condition –During fiscal 2025, SJCON had several instances of noncompliance: (1) awarded and disbursed need-based Title IV funds in excess of calculated financial need; (2) failed to recalculate/adjust Title IV awards when student eligibility information changed; (3) did not review students’ federal loan history (e.g., Direct Loans, including PLUS) to ensure annual and aggregate limits were not exceeded; (4) lacked documentation supporting rationale basis for individual student COA adjustments in calculating Title IV awards; and (5) did not consistently assign and document SAP statuses (warning/probation) due to incomplete SAP tracking records. Cause – SJCON did not implement adequate procedures and protocols to identify, assess, and address Title IV noncompliance risks. In addition, duties were not appropriately segregated—one individual performed most key compliance activities without independent review. Further, personnel responsible for administering Title IV activities exhibited a knowledge gap (e.g. insufficient familiarity with applicable requirements), contributing to inconsistent execution of procedures and documentation. Effect – Questioned costs were identified due to the overaward and disbursement of Title IV aid to students. Ineffective SAP monitoring increases the risk that disbursements could continue for students who may not meet ongoing eligibility requirements. Collectively, these conditions may increase the likelihood of regulatory oversight and scrutiny. Questioned costs – $25,002 Context – Of 65 sampled students receiving Title IV aid, exceptions were noted across multiple types of financial aids and requirements: • Direct Subsidized Loans: 2/56 exceeded financial need. • Direct PLUS Loans: 2/9 exceeded PLUS program annual limit. • Federal Pell Grants: 2/31 exceeded eligible Pell maximum. • Aggregate Loan Limits: 1/65 exceeded the combined subsidized/unsubsidized aggregate limit. • SAP Monitoring: 6/6 SAP violations lacked evidence of warning/probation notification; 25/65 were improperly excluded from SAP tracking reports. • COA Adjustment: 58/65 records lacked documentation supporting individual student COA adjustments, including the rationale and basis for deviating from SJCON’s established standard COA. Repeat Finding from Prior Year – No Recommendation – SJCON should strengthen internal controls over Title IV federal student financial aid administration to ensure changes in student circumstances are promptly identified, evaluated and reflected in required award recalculations and updates. Additionally, SJCON should implement segregation of duties and independent supervisory review for key compliance activities and provide targeted training to personnel on applicable Title IV compliance requirements.

Condition –During fiscal 2025, SJCON reported Title IV aid disbursements to the COD system earlier than 7 days before the funds were disbursed. In addition, for all Title IV disbursement dates, SJCON inadvertently reported the payment period start date rather than the date the funds were actually credited to the student’s account. Cause – There was a lack of understanding of applicable COD reporting requirements. Additionally, SJCON did not implement standard processes to ensure disbursement records were submitted within the allowable reporting timeframe or independent review procedures to validate the accuracy of disbursement information submitted to COD. Effect – Untimely and/or inaccurate reporting of disbursement information may result in the U.S. Department of Education’s official records not accurately reflecting the actual timing of Title IV aid disbursed to students. In addition, such reporting issues may limit SJCON’s ability to demonstrate that Title IV draws were appropriately supported by eligible disbursements. Questioned costs – None Context – Audit results showed 40 out of 40 records tested did not report the actual date of disbursement correctly. Further, 9 out of 40 Title IV aid disbursement records tested were reported to COD earlier than 7 days prior to the actual disbursement date. Repeat Finding from Prior Year – No Recommendation – SJCON should strengthen internal controls over NSLDS enrollment reporting by establishing a standardized process which includes a review of enrollment data to ensure both timely submission and accurate reporting of all required enrollment data elements.

Condition –During fiscal 2025, SJCON submitted inaccurate reporting of student enrollment information to NSLDS and in some cases such information was not submitted timely. Overall, the noncompliance exceptions are limited to timeliness and/or accuracy of enrollment details at campus-level and program-level including enrollment status. There were no questioned costs identified and no observations of unsupported enrollment status or incorrect financial aid amounts received by students. Cause – SJCON lacked a formally designed and implemented enrollment reporting control framework and also lacked an independent secondary review, to ensure NSLDS roster updates were accurate and submitted within required timelines. Effect – Untimely and/or inaccurate enrollment reporting may cause NSLDS to be inaccurate, resulting in U.S. Department of Education and loan servicers relying on incorrect or late information to administer Title IV loans. This potentially increases the risk of improper borrower status determinations and related servicing actions and heightens the risk of Title IV noncompliance. Questioned costs – None Context – Audit results showed 25 of 40 records tested had one or more noncompliance instances related to the timeliness and/or accuracy of campus-level and program-level enrollment information and enrollment status reporting. Specifically, there were 25 late reporting exceptions and 18 inaccurate-reporting exceptions. Repeat Finding from Prior Year – No Recommendation – SJCON should strengthen internal controls over NSLDS enrollment reporting by establishing a standardized process which includes a review of enrollment data to ensure both timely submission and accurate reporting of all required enrollment data elements.

Condition – St. Peter's Health Partners ("SPHP") was unable to provide supporting documentation to evidence the occurrence of the rent reasonableness review was completed for three rental charges. SPHP received reimbursement for two damage payments that exceed the related tenants' one month's rent. Further, SPHP was reimbursed for three invoices related to repairs that were made during the normal course of the rental versus being identified during the exit process. Cause – SPHP does not have appropriate procedures in place to ensure sufficient documentation is retained. Additionally, SPHP did not design and implement controls to ensure damage payments made were in compliance with federal regulations. Effect – With the absence of underlying records, we were unable to verify compliance with the special test requirements for the three rent charges in pursuant to 24 CFR 578.51(g). Failure to establish effective internal controls (including review of documentation) over damage payments could potentially result in undetected noncompliance, exposing SPHP to consequences from regulatory agencies. Questioned Costs - $7,635 Context - Although there was no material noncompliance identified, 4 out of 5 damage payments (total population) were not in compliance as an adequate review was not performed. Repeat Finding – No. Recommendation – We recommend SPHP implement procedures to ensure documentation is appropriately maintained and available. We also recommend SPHP design and implement controls to ensure invoices related to damages that are submitted for reimbursement relate only to damages identified during the participant’s exit of the housing unit and do not exceed one month’s rent.

Condition – Pittsburgh Mercy Health System did not track or review individual matching expenditures to ensure that the sources were allowable. Additionally, there was a lack of documentation and a review of such documentation substantiating that the total dollar threshold for matching was satisfied. However, total matching expenditures for the program were subsequently analyzed and Pittsburgh Mercy Health System did expend sufficient allowable expenditures ($481,325) to fulfill the matching requirement. Cause – Pittsburgh Mercy Health System did not design and implement controls to ensure that there were sufficient expenditures to meet the matching requirement, and that such expenditures were allowable under the Continuum of Care Program. Effect –The lack of review and documentation of matching expenditures could have resulted in a breach of contractual obligations for the matching requirement. Questioned Costs – None. Context - Pittsburgh Mercy Health System failed to establish a system to regularly monitor matching activities and review the status of federal matching to ensure compliance. Lack of tracking and reviewing of matching requirements would potentially result in insufficient and inadequate match, and repayment of funds. Repeat Finding – No. Recommendation – We recommend Pittsburgh Mercy Health System establish internal control policies and procedures to ensure reviews are performed and documented for all expenditures related to the matching requirement.

Condition – The Corporation did not report $2,000,000 of CSLFRF grant expenditures received by Saint Agnes Medical Center Fresno (“Fresno”) in the consolidated SEFA for the year ended June 30, 2022. This resulted in an understatement of CSLFRF expenditures on the Corporation’s SEFA for the year ended June 30, 2022. This issue was discussed with the County of Fresno, the pass-through granting agency for this program, who requested the omitted CSLFRF expenditures be tested and included in the Corporation’s SEFA for the year ended June 30, 2023. Criteria – According to § 200.510(b) of the Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, “The auditee must also prepare a schedule of expenditures of Federal awards for the period covered by the auditee's financial statements which must include the total Federal awards expended as determined in accordance with § 200.502.” Cause – The Fresno accounting department reported the CSLFRF grant to the Trinity Health Financial Reporting team incorrectly which resulted in the Fresno CSLFRF grant not being included in ALN 21.027, which was a major program for the year ended June 30, 2022. Effect – The Corporation’s SEFA for the year ended June 30, 2022 was understated by $2,000,000. Consequences for failure to comply with grant conditions may include a reduction of overall award and/or a restriction or reduction in future awards. Questioned costs – None Context – The Corporation did not report $2,000,000 of CSLFRF funds on its prior year SEFA. Repeat Finding from Prior Year – No Recommendation – The Corporation should institute additional policies and procedures to ensure grant expenditures reported by all locations are appropriately and completely included in the consolidated SEFA.

Condition – During the fiscal year ended June 30, 2023, Saint Agnes Medical Center Fresno (“Fresno”) was granted multiple project fundings under the Federal Emergency Management Agency’s (FEMA) Public Assistance grant program in response to the COVID-19 public health emergency. A total of $7,336,096 of FEMA assistance payments were received from the pass-through entity, California Governor's Office of Emergency Services. The eligible expenses that were obligated and disbursed for FEMA funding were incurred between March 20, 2020 and July 31, 2022, during which some of the expenses were also eligible for and reimbursed by another federal source of funding (COVID-19 Provider Relief Fund and American Rescue Plan – “PRF”). It was discovered that a total of $670,625 COVID-19 eligible expenses (i.e., occupancy and supplies) that were reimbursed by PRF were duplicative of those reported as project obligations to FEMA. Criteria – According to § 200.403(f) of the Title 2 U.S. Code of Federal Regulations (CFR) Part 200, Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards, “allowable costs must not be included as a cost of any other federally financed program in either the current or a prior period”. Cause – Prior to submitting the project applications to FEMA, the Fresno accounting department aggregated the total amount of eligible expenses available to be used for both the FEMA and PRF programs and determined that there were more expenses than the total award amounts for both programs. However, they did not review expenses by category and did not identify that expenses reported in the PRF portal filings in the occupancy and expense categories when combined with occupancy and supplies expenses reported for FEMA resulted in duplicative submission of some expenses. Effect – Fresno included certain occupancy and supplies expenses in both the PRF portal filing and the FEMA project application. Questioned costs – $670,625* **The amount is a questioned cost because there is no mechanism to correct the PRF portal filing to change the categories of expenses to reduce the occupancy and supplies category and increase another category for allowable expenses that have not yet been applied to PRF or FEMA grants. While the amount reported in the PRF portal for the categories of occupancy and supplies expense was overstated because certain costs were applied to FEMA awards, the total amount of expenses reported in the PRF portal requires no revision. Context – The Corporation included $670,625 out of $7,336,096 of expenses that were previously included in a PRF portal filing under the occupancy and supplies category. Fresno has $2,035,190 of additional PRF eligible expenses in other categories that have not been reimbursed by any other grant programs. Repeat Finding from Prior Year – No Recommendation – The Corporation should not only look at total expenses that are allowable for use under multiple federal sources of funding, but should also review the expenses at a detailed level to ensure that individual expenses are not double counted.

Condition ? Direct Loan reconciliation is a mandatory monthly process, as required under 34 CFR 685.300(b)(5). A school should reconcile all cash (drawdowns and refunds of cash) and disbursement records (actual disbursements and adjustments) with information in the Common Origination and Disbursement (COD) System on an ongoing basis. There are two types of reconciliation that can be performed separately or simultaneously during the month: 1) Internal Reconciliation - the business and financial aid offices compare the monthly financial aid office roster for scheduled and actual disbursements in each office?s system to a monthly business office cash detail report that reflects funds drawn down and funds disbursed each month;2) External Reconciliation ? Institutions compare their reconciled internal records to the Department of Education?s records of funds received and returned, and loans originated and disbursed. Mount Carmel College of Nursing (?the College?) performed monthly a reconciliation process only for loan disbursement records between the student financial aid system at the financial aid office and the Department?s COD System. It appears that the College failed to complete reconciliation for disbursement records within the student financial aid system at the financial aid office and the accounting system at the business office. Additionally, there was no reconciliation procedure performed for cash activities among the College?s student financial aid system, accounting system, and Department of Education?s COD System. Criteria ? The Uniform Grant Guidance Compliance Supplement Direct Loan Reconciliation requirement states, ?Each month, COD provides institutions with a School Account Statement (SAS) data file which consists of a Cash Summary, Cash Detail, and (optional at the request of the institution) Loan Detail records. The institution is required to reconcile these files to the institution?s financial records.? Cause ? The College?s student financial aid administration lacks understanding about the Direct Loan reconciliation process and knowledge about SAS data files. Effect ? The College failed to complete the monthly Direct Loan reconciliation in conformity with regulatory requirements. This potentially leads to the College not being able to timely identify and resolve discrepancies that exist among financial aid, business office, and COD records. Questioned costs ? None Context ? The College did not complete this requirement for the entire fiscal year, resulting in 12 reconciliations that were not performed. Repeat Finding from Prior Year ? No Recommendation ? The College?s Student Financial Aid administration shall consult with Direct Loan reconciliation regulatory guidance as illustrated in Federal Student Aid Handbook Volume 4 Chapter 6 and develop the monthly Direct Loan reconciliation process that is compatible with the College?s Direct Loan program operations. Additionally, respective controls shall be placed surrounding these processes to ensure that all records are reconciled, and discrepancies are resolved in a timely manner.

Condition ? Mount Carmel College of Nursing (?the College?) administers HEERF Institutional Aid Portion under the reimbursement payment method. The reimbursement payment method requires that the College must disburse funds for HEERF program purposes before requesting payments from the federal awarding agency or pass-through entity. The College followed this reimbursing principle for the most part. However, it was discovered that there were 10 disbursements in March and April of 2022 didn?t occur until after the federal payment was received. Criteria ? The Uniform Grant Guidance Compliance Supplement Cash Management general requirement states, ?Under the reimbursement payment method, program costs must be paid by non-federal entity funds before submitting a payment request.? Cause ? The only personnel who was granted access to G5 for drawdown requests resigned in April of 2022. As a result, that personnel requested an advance payment for the remaining available funds prior to departure in anticipation that the funds would be disbursed in full. Effect ? Ten selections were disbursed after the drawdown date. The total questioned cost resulting from these 10 delayed disbursements is $390,053. Although none of the disbursements were deemed to be unreasonable for program purposes, these 10 transactions were identified to be in violation of the Cash Management requirement for reimbursement payment method. Questioned costs ? $390,053 Context ? Ten out of a total of 57 selected transactions were disbursed after the drawdown date. Repeat Finding from Prior Year ? No Recommendation ? The College?s business administration shall provide proper training and exercise oversight to employees who are involved with administering HEERF disbursements. Appropriate levels of review shall also be performed by personnel with knowledge and background of federal spending requirements and other statutory regulations outlined in the program agreement.

Condition ? St. Joseph?s Hospital College of Nursing (?the College?) administers HEERF Institutional Aid Portion under the reimbursement payment method. However, The College requested reimbursements based on the billing dates rather than actual payment dates. The reimbursement payment method requires that the College must disburse funds for HEERF program purposes before requesting payments from the federal awarding agency or passthrough entity. It was discovered that 6 invoices were not paid until after the federal payment was received. Criteria ? The Uniform Grant Guidance Compliance Supplement Cash Management general requirement states, ?Under the reimbursement payment method, program costs must be paid by non-federal entity funds before submitting a payment request.? Cause ? The College?s business administration drew down funding for costs eligible for reimbursement that were incurred and/or approved expenditures but not paid. Effect ? Six transactions had delayed disbursements, resulting in questioned costs of $158,701. Although none of the disbursements were deemed to be unreasonable for program purposes, these 6 transactions were identified to be in violation of the Cash Management requirement for reimbursement payment method. Questioned costs ? $158,701 Context ? Six out of 40 selected transactions were paid after the drawdown date. Repeat Finding from Prior Year ? No Recommendation ? The College?s business administration shall provide proper training and exercise oversight to employees who are involved with administering HEERF disbursements. Appropriate levels of review shall also be performed by personnel with knowledge and background of federal spending requirements and other statutory regulations outlined in the program agreement.

Condition ? As directed by the U.S. Department of Education for all HEERF funding, Mount Carmel College of Nursing (?the College?) is required to prepare quarterly reports for Institutional portions and conspicuously post them on the College?s website in a timely manner. During the audit it was determined that the College did not complete quarterly reports for Q3 and Q4 for fiscal year ending June 30, 2022, for HEERF Institutional portions of funding and hence no public postings were made available on the College?s website. Criteria ? The U.S. Department of Education, under sections 2 CFR 200.328 and 2 CFR 200.329, requires that each quarterly reporting form for both HEERF Institutional and Student Aid Portion must be completed and posted to the institution?s primary website no later than 10 days after the end of each calendar quarter. Cause ? The Senior Finance Director (report preparer) and Director of Financial Aid (report reviewer) for the College both resigned in March 2022 and April 2022, respectively. As a result, the quarterly reports were not prepared within the required timeframe. Effect ? Neither the Institutional nor Student Aid Portion quarterly reporting forms were prepared and posted for Q3 and Q4 of the current fiscal year. This results in noncompliance and could cause a negative impact on future fundings for the College. Questioned costs ? $0 Context ? Two out of four quarterly reports for the fiscal year ended June 30, 2022 were not completed. Repeat Finding from Prior Year ? No Recommendation ? The College?s business administration should have a plan in place to ensure that quarterly reports are prepared timely and have backup plans in place in the event that the preparer or reviewer are not available.

Condition ?The Corporation recorded fringe benefits for a grant employee at an incorrect amount. As a result, the Corporation understated expenditures on the SEFA by $200 for the year ended June 30, 2022. Criteria ? 2 CFR Part 200.1 states an improper payment means any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. Cause ? There was one fringe benefits expenditure selection that was recorded at the incorrect amount due to a manual error in the calculation of benefits allocated to the grant. In the identified instance of non-compliance, the fringe expense recorded was inconsistent with the amount of salary paid to the individual and the assigned fringe rate. The expenditure should not have been approved as entered after the review process. Effect ? Consequences for failure to comply with grant conditions may include a reduction of overall award and/or a restriction or reduction in future awards. Questioned costs ? None Context ? One out of forty expenditure selections was understated in the consolidated SEFA and the related payment by the granting agency was understated as well. Repeat Finding from Prior Year ? No Recommendation? Management should institute formal policies and procedures to ensure grant related expenditure support is reviewed in more detail and reported at the correct amount.

Condition ?The Corporation provided services funded by the Centers for Disease Control and Prevention (CDC) through the National Diabetes Prevention Program (NDPP) to individuals who did not qualify for the program. Criteria ? Per the CDC, in order to be eligible to participate in the NDPP, individuals must meet all of the following criteria: 18 years or older, Body Mass Index (BMI) over 25, not diagnosed with Type 1 or Type 2 Diabetes, and not currently pregnant. In addition, the individual must meet at least one of the following conditions: diagnosed with prediabetes, previously diagnosed with gestational diabetes, or achieve a high-risk result on prediabetes risk test. Cause ? There was one selected participant that did not meet the necessary requirements to be enrolled in the program and therefore was not an eligible participant. In the identified instance of non-compliance, the participant did not meet the BMI requirement to be enrolled in the program. The participant should have been removed from the program upon review of the eligibility criteria. Effect ? Consequences for failure to comply with grant conditions may include a reduction of overall award and/or a restriction or reduction in future awards. Questioned costs ? None Context ? One out of forty participants selected was not eligible for the program. After further review of data that included all program participants (1,606 participants), it was determined that a total of 15 individuals who participated in the program were not eligible under the requirements of the grant. Repeat Finding from Prior Year ? No Recommendation? Management should institute formal policies and procedures to ensure only eligible participants are participating in the program.

Condition ?The Corporation included expenses, at most totaling $21,338, that are not allowed under the criteria for Provider Relief Funds Skilled Nursing Facility Infection Control (?SNF?) funding, as dictated by the 2022 2 CFR Part 200 Compliance Supplement (?Compliance Supplement?). Criteria ? Per the Compliance Supplement, SNF funds may only be used to reimburse recipients for costs associated with administering COVID-19 testing, reporting COVID-19 tests results to local, state, and federal governments, hiring staff to provide patient care or administrative support, expenses incurred to improve infection control, or providing additional services to residents. Cause ? There were two expenditure selections that were recorded for the purchase of bulk food items that did not qualify as allowable activities under the grant. In the identified instances of noncompliance, these expenditures were recorded in the incorrect cost center and should not have been applied to the grants as SNF expenses eligible for reimbursement. Effect ? Consequences for failure to comply with grant conditions may include a reduction of overall award. Questioned costs ? None Context ? Two out of forty-two selections were improperly included as SNF expenditures. Repeat Finding from Prior Year ? No Recommendation? Management should institute formal policies and procedures to ensure grant related expenditure support is reviewed in more detail before including expenditures on in the HHS portal and on the consolidated SEFA.

Condition ? In order for a claim related to COVID-19 testing, testing-related items, or COVID-19 treatment to be eligible for reimbursement and inclusion on the Schedule of Expenditures of Federal Awards (?SEFA?), the individuals must not have any health care coverage at the time services were rendered. As part of the Add and Attest to Patient Roster Step within the claim submission process, providers must attest to the following: ?if you have direct contact with the patient, you should make best efforts to confirm that the patient was uninsured at the time the services were provided?? The Corporation made its best efforts and followed all its policies to determine that the patients did not have insurance. Two claim selections included in the SEFA were for services provided to individuals who had health care insurance at the time services were rendered. After it was identified the individuals had health care insurance, refunds to the Health Resources and Services Administration (?HRSA?) were delayed. Criteria ? The Uniform Grant Guidance Compliance Supplement Addendum states, ?Services must be for individuals who at the time services were provided were uninsured as described in the terms and conditions of the award.? Cause ? Two claims were improperly submitted for reimbursement under the program when the patients had active insurance at the time of service and such information was available to Trinity Health at the time of billing. Both instances were caused by failure to address double payments for the same expenses made by HRSA and subsequently by insurance providers in a timely manner. Effect ? Claims were submitted for reimbursement under the uninsured program that were subsequently determined to no longer be eligible for reimbursement. Refunds were not issued to HRSA on a timely basis and were only issued due to the two claims being selected for purposes of the single audit testing. Questioned costs ? None Context ? Two out of 60 claims in our sample included patients who had commercial insurance at the time of service. Refunds were not issued to HRSA on a timely basis. Repeat Finding from Prior Year ? Yes. In the prior year, there were three instances of refunds not being issued to HRSA on a timely basis. Recommendation ? The federal government ended the COVID Uninsured Testing grant program in 2022. However, for similar programs in the future, program administrators should review eligibility documentation for each claim prior to submitting claims for reimbursement. Program administrators should additionally review accounts that received HRSA reimbursements and check if refunds are needed. They should also review refunds needing to be made to ensure they are occurring in a timely manner.

Condition ? In order for a claim related to COVID-19 testing, testing-related items, or COVID-19 treatment to be eligible for reimbursement and inclusion on the Schedule of Expenditures of Federal Awards (?SEFA?), the individuals must not have any health care coverage at the time services were rendered. As part of the Add and Attest to Patient Roster Step within the claim submission process, providers must attest to the following: ?if you have direct contact with the patient, you should make best efforts to confirm that the patient was uninsured at the time the services were provided?? The Corporation made its best efforts and followed all of its policies to determine that the patients did not have insurance. Three claim selections included in the SEFA were for services provided to individuals who had health care insurance at the time services were rendered. After it was identified the individuals had health care insurance, refunds to the Health Resources and Services Administration (?HRSA?) were delayed. Criteria ? The Uniform Grant Guidance Compliance Supplement Addendum states, ?Services must be for individuals who at the time services were provided were uninsured as described in the terms and conditions of the award.? Cause ? Three claims were improperly submitted for reimbursement under the program when the patients had active insurance at the time of service and such information was available to Trinity Health at the time of billing. One instance was caused by conflicting billing information obtained at time of intake related to coverage that was not investigated timely. Two instances were caused by a clerical error whereby the insurance coverage was not documented properly. Upon discovery of the error, refunds were not issued to HRSA on a timely basis. Effect ? Claims were submitted for reimbursement under the uninsured program that were subsequently determined to no longer be eligible for reimbursement. Refunds were not issued to HRSA on a timely basis. Questioned costs ? None Context ? Three out of sixty claims in our sample included patients who had commercial insurance at the time of service. Refunds were not issued to HRSA on a timely basis. Repeat Finding from Prior Year ? No Recommendation ? The program administrators should review eligibility checks documentation for each claim prior to submitting claims to the HRSA for reimbursement. Program administrators should additionally review refunds needing to be made to ensure they are occurring in a timely manner.

Condition ?The Corporation submitted requests for grant expenditure reimbursements from the granting agency at incorrect amounts. As a result, the Corporation received improper payments in the amount of $181, and, prior to correction, overstated expenditures on the SEFA by $23 for the year ended June 30, 2021. Criteria ? 2 CFR Part 200.53 states an improper payment means any payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements. Cause ? There were seven selections that were reimbursed at incorrect amounts due to inaccurate procedure codes or hours billed for patient services billed under the grant. In the identified instances of non-compliance, the procedure codes and hours billed were inconsistent with medical records and should not have been approved at the incorrect amounts during the grant expenditure review process. Effect ? Consequences for failure to comply with grant conditions may include a reduction of overall award and/or a restriction or reduction in future awards. Questioned costs ? None Context ?Seven out of sixty selections were overstated in the SEFA and reimbursement was overstated as well. Repeat Finding from Prior Year ? No Recommendation? The Corporation should enforce formal policies and procedures to ensure grant related expenditures are reported at the correct amount. Management should perform more detailed reviews of grant expenditures to ensure that amounts requested from the granting agency for patient visits are correct and align with medical records and services provided.

FINDING 2020-01 Continuum of Care, CFDA No. 14.267 ? From U.S Department of Housing and Urban Development? Finding of Non-Compliance Condition ? In order to receive subsidized housing under the Continuum of Care grant the participant must meet certain eligibility criterion. One of these criteria includes signing a no income affidavit. There were two instances at Mercy Life Center Corporation, Pittsburgh, PA where there was no signature by the case manager on the no income affidavit. Criteria ? The Uniform Grant Compliance Supplement for CFDA 14.267 and 24 CFR section 578.49(b)(1) contains a ?special test? whereby ?when grants are used to pay for rent for all or part of a structure, the rent paid must be reasonable in relation to rents being charged in the area for comparable space. In addition, the rent may not exceed rents currently being charged by the same owner for comparable unassisted space.? Additionally, in order to qualify for receiving these reasonable rent funds, individuals participating in the program must qualify as ?individuals and/or families experiencing homelessness?, as certified by assigned case workers. Cause ? The income affidavits were filled out correctly, however, without a case manager's signature they should not have been approved. Effect ? Participants, whose no income affidavit forms are not signed by a case manager, should not be approved for the program which may result in the inappropriate use of grant funds. Questioned costs ? N/A Context ?Two out of the twenty-five selections lacked case manager signatures on the no income affidavit. Repeat Finding from Prior Year ? No Recommendation ?Reviewers of income eligibility forms should ensure that the forms contain the proper signatures to ensure that grant funds are properly provided to eligible participants. View of Responsible Officials ? Mercy Life Center Corporation will ensure that upon entrance to the program, all income affidavits are signed and completed by case managers and reviewed by the program?s senior manager and a fiscal department representative evidencing and verifying the participants income. Contact Person ? Eric Barley, Pittsburgh Mercy CFO, (412) 298-2455 Jerry Crockett, Pittsburgh Mercy Grants Administrator, (412) 323-4574

FINDING 2020-02 Health Center Cluster, CFDA No. 93.224 ?from Department of Health and Human Services ? Finding of Non-Compliance Condition ? Based on grant guidelines, annual reports for each grant should be submitted within one month of the grant period end date. For this grant at Mercy Health, Grand Rapids, MI the period end was June 30, 2020, therefore all reports should have been submitted to the government by July 31, 2020. However, the Annual Federal Financial Report (FFR) report was not submitted until August 2020. The grant administrator was unable to find evidence showing approval for the late submission. Criteria ? Per the Uniform Grant Guidance Compliance Supplement, ?Recipients use the FFR as a standardized format to report expenditures under federal awards, as well as, when applicable, cash status.? This report is required to be submitted ?no later than 30 days after the end of each report period.? Cause ? The final report was not submitted in a timely manner, per grant guidelines, due to turnover of colleagues within the grant accounting department. Effect ? The potential for reports to not be submitted in a timely manner, and thus not meet grant requirements for obtaining and using funds on an ongoing basis. Questioned costs ? None Context ? The FFR was submitted late. Repeat Finding from Prior Year ? No Recommendation ? The grant administrator should ensure that the FFR is submitted by the due date. View of Responsible Officials ? Due to colleague turnover, evidence of approval for the late submission of the FFR could not be located. The grant administrator is committed to ensuring that all future FFR submissions are timely and within grant guidelines. Contact Person ? Angie DeYoung, Mercy Health, Accounting Regional Manager, (616) 685-3730

FINDING 2020-06 COVID-19 Testing For The Uninsured Grant, CFDA No. 93.461 ? Trinity Health Corporation ? Finding of Non-Compliance Condition ? In order for COVID-19 testing, testing-related items or COVID-19 treatment to be eligible for reimbursement, submitted as a valid claim for reimbursement and for inclusion on the SEFA, the individuals must not have any health care coverage at the time services were rendered. As part of the Add and Attest to Patient Roster Step within the claim submission process, providers must attest to the following: ?if you have direct contact with the patient, you should make best efforts to confirm that the patient was uninsured at the time the services were provided?? Two claim selections included in the SEFA were for services provided to individuals who had health care insurance at the time services were rendered. Criteria ? The Uniform Grant Guidance Compliance Supplement Addendum states, ?Services must be for individuals who at the time of service were provided were uninsured as described in the terms and conditions of the award.? Cause ? Two claims were improperly submitted for reimbursement under the program when the patients had active insurance at the time of service and such information was available to Trinity Health at the time of billing. One instance was caused by conflicting information obtained at time of intake related to coverage that was not investigated timely prior to billing. The second instance was caused by an error on the part of the third-party eligibility vendor who added a note indicating coverage but did not complete the process of adding the payor to the claim. Effect ? Claims were submitted for reimbursement under the uninsured program that were not eligible for reimbursement. Questioned costs ? None Context ? Two out of one hundred seventy-seven claims in our sample were submitted for reimbursement when the patient had active insurance. Repeat Finding from Prior Year ? No Recommendation ? The program administrators should review eligibility checks documentation for each claim prior to submitting claims to the Health Resources and Services Administration (HRSA) for reimbursement. View of Responsible Officials ? Trinity Health Leadership is in agreement with the indicated finding. To ensure appropriate compliance with the HRSA COVID-19 Uninsured Grant, Trinity Health will review eligibility checks documentation for each claim prior to submitting claims to HRSA for reimbursement. Utilizing the weekly reporting process used to capture patients eligible for the HRSA grant, each Program Administrator will be required to review each account on the file and confirm the patient?s eligibility for HRSA funding. This verification will include a thorough check within the patient?s medical record, validation of eligible diagnosis codes, and confirmation that the patient is truly uninsured. Once confirmation is complete, the Program Administrator will document this review within both the HIS system and data file that the patient is eligible for HRSA funding. The Program Administrator will also be required to save the data file with their notes confirming the patient eligibility, to ensure that an appropriate audit trail is maintained. In addition, Trinity Health leadership will regularly audit this process to ensure team members are actively reviewing all eligible accounts and documenting appropriately. Contact Person ? Ian Sullivan, Enterprise Director of Hospital Revenue Cycle Operations, 203-219-6833 Sabrina Mapes, Enterprise Vice President of Hospital Revenue Cycle Operations, 734-343-2358

FINDING 2019-001 Student Financial Aid Cluster, CFDA No. 84.268 (the ?SFA Cluster?) ? from U.S Department of Education ? Finding of Non-Compliance Condition ? In the Fall of 2018, a transfer-student at Mt. Carmel School of Nursing (MCCN) applied for subsidized and unsubsidized loans for the 2018-2019 school year, and incorrectly represented herself as a third-year student. MCCN reviewed the loan-package application and correctly identified the student as a first-year student in accordance with their program standards and transfer credits, but incorrectly disbursed to the student a third-year level package. During the Fall of 2019, the MCCN Director of Financial Aid adjusted the 2018-2019 package to a first-year level and returned the excess funds to the federal government. Criteria ? The 2018-2019 Federal Student Aid Handbook, released by the U.S. Department of Education (DOE), states, ?If your school has conflicting information for a student or you have any reason to believe his application is incorrect, you must resolve such dis?crepancies before disbursing FSA funds. If you discover a discrepancy after disbursing FSA funds, you must reconcile the conflicting information and require the student to repay any aid for which he wasn?t eligible, unless he is no longer enrolled for the award year and will not re-enroll.? (34 CFR 668.16(f)) Cause ? While MCCN appropriately identified the conflicting information (the student mis-representing herself as a third-year), MCCN failed to interpret the above requirements correctly and did not resolve the discrepancy prior to disbursing the funds. Effect ? Providing awards to ineligible students may result in a reduction of overall grants awarded or a reduction in future awards. Questioned costs ? The student received $7,422 in Direct Loans, or $1,922 in excess of the maximum loan amounts for dependent first-year students ($5,500) (34 CFR 685.203). Context ? This instance of non-compliance does not appear to be pervasive to other areas. The student identified above was the only instance of a student receiving funds at a level which differed from their enrollment status from our sample of 40 students. MCCN performed an additional analysis over all 2018-2019 loan packages, and determined there were no other instances of conflicting information. Further, MCCN has taken steps to refund the excess award to the DOE, in accordance with the guidance above. Repeat Finding from Prior Year ? No Recommendation ? MCCN should institute formal policies and procedures to ensure the consistency of any data related to a student?s application or eligibility for Federal Student Aid regardless of the source of that data. Action Plan ? The Financial Aid Department (FAD) department has implemented a process to cross check the subsidized loan amount and the grade level to make sure a student has not been over awarded. Selections sets in POWERFaids allow for a quick check. This process will be run on a continuous basis, so no loans will be disbursed at the wrong amount. View of Responsible Officials ? MCCN agrees with the above finding. FAD reversed the funds in the student's account to the Department of Education and notified the student, by both verbal and email communication, that the applicant was not eligible for the entire previously awarded loan package. This was a unique situation and not common in practice. Going forward, the FAD will attempt to resolve all conflicting information prior to disbursing a loan, in accordance with 34 CFR 668.16(f). For any loans refused or reduced, the reason for that action will be documented and provided to the borrower in writing by the FAD. Contact Person ? Todd Everett, Associate Dean, Student Services, (614) 234-5169 Kathy Smith, Director, Business Affairs, (614) 234-2230

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