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Program Integrity: FY13 Audit Results

Updated 11/14/2014. The results chart includes audits where the entity has agreed to the HRSA Final Report.  Remaining audits are still under review. Information on Corrective Action Plans and Sanctions will be updated once approved by HRSA.  HRSA recommends manufacturers do not contact audited entities regarding sanctions until a corrective action plan has been approved by HRSA and posted on this website.

No.

Entity

340B ID

State

OPA Findings

Sanction

Corrective Action with Audit Closure Date

1Alder Health Services, Inc.RWII17101PANo adverse findings.None.N/A

2

Allegan General Hospital

CAH231328-00

MI

  1. Incorrect 340B database record - Registered contract pharmacies without written contract in place;
  2. Diversion – 340B drug dispensed to inpatient; 340B drug dispensed at contract pharmacy, not supported by a medical record.

Repayment to manufacturers.

Public letter to manufacturers - (PDF - 33 KB)

3Athens Regional Medical CenterDSH110074GA
  1. Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites and written by ineligible providers; 340B drugs were not properly accumulated;
  2. Duplicate Discounts – Medicaid billing numbers were incorrect on the Medicaid Exclusion File.
Repayment to manufacturers.Pending.
4Aurora Health Care Metro, Inc.DSH520138WI
  1. Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database;
  2. Diversion – 340B drugs dispensed at covered entity and at contract pharmacies for prescriptions written by ineligible providers.
Repayment to manufacturers.Pending.
5Avera McKennan Hospital and University Health CenterDSH430016SDNo adverse findings.None.N/A

6

Baptist Memorial Hospital – Desoto

DSH250141

MS

No adverse findings.

None.

N/A

7

BayState Medical Center

DSH220077

MA

Diversion – 340B drug dispensed for prescription written by ineligible provider.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 51 KB)

8

Beacon Christian Community Health Center

CHC12866-00

NY

Incorrect 340B database record - Registered contract pharmacies without written contract in place;None.

Contracts executed; 340B Program policies and procedures revised to address contract pharmacy registration.

Audit closure date: September 23, 2014.

9Boone County HospitalCAH161372-00IA
  1. Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database;
  2. Diversion – 340B drug dispensed to inpatient.
Repayment to manufacturers.Public letter to manufacturers (PDF - 46 KB)
10Borrego Community Health FoundationCH099010CA
  1. Diversion – 340B drugs dispensed at contract pharmacy, not supported by a medical record; 340B drugs dispensed for prescriptions written by ineligible providers;
  2. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.
Repayment to manufacturers.Public letter to manufacturers (PDF - 68 KB)
11Castle Medical CenterDSH120006HI
  1. Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for shipping address;
  2. Duplicate Discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.
Repayment to manufacturers.Pending.
12Children’s Hospital of Pittsburgh of University of Pittsburgh Medical CenterPED393302-00PA
  1. Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacies without written contract in place
  2. Duplicate Discounts – NPI and Medicaid billing numbers were incorrect on the Medicaid Exclusion File.
Repayment to manufacturers.Public letter to manufacturers (PDF - 36 KB)

13

Christ Community Health Services, Inc.

CH0417140

TN

No adverse findings.

None.

N/A

14

Citizen’s Baptist Medical Center

DSH010101

AL

Incorrect 340B database record – Incorrect Authorizing Official;

 

None.

Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

 

Audit closure date:  July 25, 2014

15

Citizens Memorial Hospital District

DSH260195

MO

  1. Incorrect 340B database record – Pharmacy incorrectly registered as child site;
  2. Diversion – 340B drugs dispensed to ineligible individual, not supported by a medical record.

Repayment to manufacturers.

Public Letter to Manufacturers (PDF - 17 KB)

16Clinch River Health Services, IncorporatedCH031230VA
  1. Incorrect 340B database record – Contract pharmacy with written contract in place was not listed on the 340B database;
  2. Entity did not provide contract pharmacy oversight
  3. Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written by ineligible providers, and to non-patients.
  4. Duplicate Discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.
Repayment to manufacturers.Pending.
17Community Regional Medical CenterDSH050060CA
  1. Incorrect 340B database record – Inpatient facility incorrectly registered as child site;
  2. Diversion – 340B drugs dispensed to ineligible individuals.
Repayment to manufacturers.Pending.
18Contra Costa Regional Medical CenterDSH050276CA
  1. Incorrect 340B database record - incorrect name listed for outpatient facility.
None

Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

Audit closure date: September 11, 2014.

19

Cook Children’s Medical Center

PED453300-00

TX

No adverse findings.

None.

N/A

20Crusader’s Central Clinic AssociationCH052760IL
  1. Incorrect 340B database record – An offsite outpatient facility was not listed on the 340B database.
  2. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.
Repayment to manufacturers.Public letter to manufacturers (PDF - 19 KB)

21

Dell Children’s Medical Center

PED453310-00

TX

No adverse findings.

None.

N/A

22East Central District Health DepartmentFP686011NEDuplicate Discounts - Medicaid billing number was incorrect on the Medicaid Exclusion File.Repayment to manufacturers.Pending.
23Eau Claire Cooperative Health Center, Inc.CH043270SC
  1. Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect names and addresses listed for outpatient facilities;
  2. Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites, written by ineligible providers, not supported by medical records;
  3. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.
Repayment to manufacturers.Pending.
24Family Health Centers of San DiegoCH093120
FP92102
CADiversion – 340B drugs dispensed, not supported by medical records.Repayment to manufacturers.Pending.

25

Family Health Services of Cranston

FP029107

RI

No adverse findings.

None.

N/A

26

Floyd Valley Hospital

CAH161368-00

IA

No adverse findings

None.

N/A

27Franciscan St. Anthony Health Michigan CityRRC150015-00INIncorrect 340B database record – An outpatient facility was not listed on the 340B database; Registered contract pharmacies without written contract in place.None.Pending.

28

Georgia Dept of Public Health

RWIID303031

GA

No adverse findings.

None.

N/A

29

Grady General Hospital

DSH110121

GA

  1. Diversion – 340B drugs dispensed for prescription written by ineligible provider; 340B drugs dispensed to non-patients.
  2. Duplicate Discounts – Medicaid Provider Number was incorrect on the Medicaid Exclusion File.

Repayment to manufacturers.

Public Letter to Manufacturers (PDF - 55 KB)

30

Hamblen County Health Department

STD378146

TN

  1. Incorrect 340B database record – Incorrect entries for authorizing official and shipping address;
  2. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

Pending

31

Holmes County General Health District

FP44654

OH

No adverse findings.

None.

N/A

32

Lawrence General Hospital

DSH220010

MA

Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed not supported by a medical record.

Repayment to manufacturers.

Public Letter to Manufacturers (PDF - 129 KB)

Audit closure date: November 3, 2014.  

33

Los Angeles County Department of Health Services – USC Medical Center

DSH050373

CA

No adverse findings.

None.

N/A

34Loyola University Medical CenterDSH140276ILIncorrect 340B database record – Contract pharmacy with a written contract in place was not listed on the 340B database.None.Pending

35

Madera Community Hospital

DSH050568

CA

Incorrect 340B database record – Outpatient facilities of the hospital were not listed on the 340B database

None.

Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

 

Audit closure date: July 25, 2014.

36Methodist Healthcare – Memphis HospitalsDSH440049TN
  1. Incorrect 340B database record – Outpatient facilities of the hospital were not listed on the 340B database; Contract pharmacy with written contract in place was not listed on the 340B database;
  2. Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites, written by ineligible providers;
  3. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.
Repayment to manufacturers.Pending.
37Muhlenberg Community Hospital, Inc.DSH180004KYDiversion – 340B drug dispensed for prescription written at ineligible site; 340B drugs dispensed to inpatients; 340B drugs were not properly accumulated.Repayment to manufacturers.Pending.

38

Northeast Alabama Regional Medical Center

DSH010078

AL

No adverse findings.

None.

N/A

39Oakland Mercy HospitalCAH281321-00NEDiversion – 340B drugs dispensed to inpatients.Repayment to manufacturersPending.

40

Ochsner Medical Center – Baton Rouge, LLC

DSH190202

LA

No adverse findings.

None.

N/A

41Orange County Health DepartmentFP229600VAIncorrect 340B database record – Incorrect entry for grant number.None.

Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

Audit closure date: September 23, 2014.

42Oroville HospitalDSH050030CAIncorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.None.Pending.
43Our Lady of the Lake Hospital, Inc.DSH190064LA
  1. Incorrect 340B database record - Pharmacy incorrectly registered as child site; Offsite outpatient facilities were not listed on the 340B database;
  2. Diversion – 340B drugs dispensed to inpatients.
Repayment to manufacturers.Pending.
44Pineville Community Hospital Assoc., Inc.DSH180021KY
  1. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites;
  2. Duplicate Discounts - NPI number was incorrect on the Medicaid Exclusion File.
Repayment to manufacturers.Public Letter to Manufacturers (PDF - 21 KB)
45Planned Parenthood Hudson Peconic, Inc.FP105322NY
  1. Incorrect 340B database record - Closed outpatient facility remained registered on the 340B database;
  2. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

 

Repayment to manufacturers.Pending.
46Pleasant Valley HospitalDSH510012WVIncorrect 340B database record –  Offsite outpatient facilities were not listed on the 340B databaseNone.

Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

Audit closure date: September 25, 2014.

47

Reeves County Hospital District

CAH451377-00

TX

No adverse findings.

None.

N/A

48Rush University Medical CenterDSH140119IL
  1. Diversion – 340B drugs dispensed to inpatients for prescriptions originating from an ineligible site;
  2. Duplicate Discounts – Contract pharmacy was using 340B drugs for Medicaid patients and did not notify HRSA of the arrangement.
Repayment to manufacturers.Pending.

49

Russell Medical Center

DSH010065

AL

No adverse findings.

None.

N/A

50

SeaMar Community Health Centers – Mount Vernon

STD982739

WA

No adverse findings.

None.

N/A

51

Sheltering Arms Hospital DBA O'Bleness Memorial Hospital

DSH360014

OH

No adverse findings.

None.

N/A

52St. John’s Regional Medical CenterDSH050082CANo adverse findings.None.N/A

53

St. Mary’s Hospital and Medical Center, Inc.

SCH060023-00

CO

  1. Incorrect 340B database record - Outpatient facilities of the hospital were incorrectly registered as a single entity; Incorrect billing address for outpatient facilities;
  2. Diversion – 340B drugs dispensed for prescriptions written by ineligible provider; lack of controls to prevent 340B drugs from being dispensed to inpatients.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 56 KB)

54

Stokes County Health Department

STD27016

NC

Incorrect 340B database record – Entity was using contract pharmacies not listed on the 340B database; Incorrect primary contact information.

None.

Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

Audit closure date: August 4, 2014.

55Taylor County Hospital DistrictDSH180087KY
  1. Incorrect 340B database record - Registered contract pharmacy without written contract in place;
  2. Diversion – 340B drugs dispensed at covered entity and at contract pharmacies for prescriptions originating from ineligible sites; 340B drugs dispensed, not supported by a medical record.

 

Repayment to manufacturers.Public letter to manufacturers (PDF - 18 KB)
56Trinitas Regional Medical CenterDSH310027NJ
  1. Incorrect 340B database record - Closed contract pharmacy remained registered on the 340B database;
  2. Diversion – 340B drugs dispensed to inpatients; 340B drugs dispensed for prescriptions originating from ineligible sites, not supported by responsibility of care; 340B drugs were not properly accumulated;
  3. Duplicate Discounts – Medicaid number was incorrect on the Medicaid Exclusion File.

 

Repayment to manufacturers.Pending.
57Uniontown HospitalDSH390041PANo adverse findings.None.N/A

58

University of Michigan Hospitals and Health Centers

DSH230046

MI

No adverse findings.

None.

N/A