PLEASANT VALLEY HOSPITAL, INC. SUBSIDIARY AND AFFILIATESNon-Profit

PLEASANT VALLEY HOSPITAL, INC. CORRECTIVE ACTION PLAN YEAR ENDED SEPTEMBER 30, 2021 October 18, 2022 Corrective Action Plan for Pleasant Valley Hospital, Inc. Subsidiary and Affiliates Combined Financial Statement and Compliance Report for the fiscal year ended September 30, 2021 as required by Uniform Administrative Requirements, Cost Principles, and Audit Requirements for Federal Awards at 2 CFR 200 (Uniform Guidance). Finding 2021-002: SECTION III - FEDERAL AWARD FINDINGS AND QUESTIONED COSTS 2021-002 ? Material Weakness in Internal Control - Reporting Federal Program: Provider Relief Fund and American Rescue Plan (ARP) Rural Distribution Program Assistance Listing Number: 93.498 Federal Agency: U.S. Department of Health and Human Services Award Number: N/A Award Year: 2020 Compliance Requirement: Reporting Questioned Costs: Not determinable Criteria: Non-federal entities in receipt of federal funds must comply with the requirements of 2 CFR 200.303(a), which require an entity to establish and maintain effective internal control over the Federal award to ensure compliance with Federal statutes, regulations, and the terms and conditions of the Federal award. Recipients of Provider Relief Fund (PRF) payments must also comply with the reporting requirements described in the PRF terms and conditions and specified in directions issued by the U.S. Department of Health and Human Services. Condition and Context: The Organization did not complete the PRF reporting in accordance with the U.S. Department of Health and Human Services guidance. The Organization inadvertently excluded from their reporting certain amounts attributable to implicit price concessions and miscalculated revenues generated as a result of participation in the 340B Drug Pricing Program. The adjustment needed within the PRF report to correct the exclusion of implicit price concessions and 340B increased year over year lost revenues from $25,931,689 to $26,413,110 on total distributions of PRF funding of $11,351,377. Effect: The amounts reported to the Health Resources & Services Administration (HRSA) were not in accordance with established U.S. Department of Health and Human Services reporting guidance. Cause: An oversight by management to include the implicit price concessions and a misinterpretation surrounding the 340B Drug Pricing Program revenues in the reporting of lost revenues based on the guidance in effect as of the date of the report. Recommendation: We recommend that management implement procedures to ensure that the most recent guidance is reviewed and understood and that information used in preparation of the reports is reviewed, with errors addressed, prior to reporting. View of Responsible Officials: Management agrees with the above noted finding and is currently working to address these issues. Corrective Action Plan: Pleasant Valley Hospital, Inc. Subsidiary and Affiliates agree with the finding and has begun the process of implementing controls sufficient to identify and correct errors prior to the completion of PRF reporting, which will include reviews of reconciliations to underlying accounting reports and records as well as a separate review and approval of the information begin reported by an individual with an appropriate amount of knowledge surrounding the Provider Relief Fund. Contact Person: Craig Gilliland, Chief Financial Officer, 2520 Valley Drive, Point Pleasant, WV 25550