Program Integrity: FY22 Audit Results

Updated 10/28/24. The results chart includes audits where the findings have been finalized. 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.

Entity Sort descending	340B ID	State	OPA Findings	Sanction	Corrective Action Status
Acadia General Hospital	DSH190044	LA	No adverse findings	None	N/A Audit closure date: September 12, 2022
Adirondack Medical Center	SCH330079-00	NY	No adverse findings	None	N/A Audit closure date: January 11, 2022
AdventHealth Tampa	DSH100173	FL	No adverse findings	None	N/A Audit closure date: July 13, 2022
Advocate Lutheran General Hospital	RRC140223-00	IL	Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: September 28, 2023
Alameda Health System	DSH050320	CA	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for disproportionate share percentage.	None	CAP implemented Audit closure date: June 9, 2023
Alegent Creighton Health dba CHI Health Plainview	CAH281346-00	NE	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type.	None	CAP implemented Audit closure date: July 15, 2022
Alivio Medical Center, Inc. Contact Information Chief Executive Officer 2355 S Western Ave Chicago, IL 60608-3837 312-829-6304 ecorpuz@aliviomedicalcenter.org	CH056620	IL	Incorrect 340B OPAIS record - Grant associated sites were not listed in 340B OPAIS. Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 23, 2023
Allina Health Faribault Medical Center	DSH240071	MN	No adverse findings	None	N/A Audit closure date: December 19, 2022
Ann and Robert H. Lurie Children's Hospital of Chicago Contact Information Jenny Elhadary Vice President, Clinical Services 312-227-4161 pelhadary@luriechildrens.org	PED143300-00	IL	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for Medicare Cost Report file date, cost reporting period, and disproportionate share percentage. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 8, 2023
Antelope Memorial Hospital	CAH281326-00	NE	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report file date.	None	CAP implemented Audit closure date: July 12, 2022
ARH Mary Breckinridge Health Services, Inc.	CAH181328-00	KY	Incorrect 340B OPAIS record - Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS. Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: May 18, 2023
Arkansas Verdigris Valley Health Centers, Inc.	CHC12887-00	OK	Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: March 14, 2023
Ascension Calumet Hospital, Inc.	CAH521317-00	WI	No adverse findings	None	N/A Audit closure date: November 15, 2022
Asian American Health Coalition of the Greater Houston Area, Inc. Contact Information Chief Quality Officer 7001 Corporate Drive Suite 120 Houston, Texas 77036 kwgreen@hopechc.org 713-773-0803	CHC24153-00	TX	Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 19, 2024
B – K Health Center, Inc.	CH03048E	PA	No adverse findings	None	N/A Audit closure date: January 7, 2022
Banner Casa Grande Medical Center	DSH030016	AZ	No adverse findings	None	N/A Audit closure date: February 9, 2022
Banner Churchill Community Hospital	CAH291313-00	NV	No adverse findings	None	N/A Audit closure date: March 17, 2022
Baptist Memorial Hospital North Mississippi	RRC250034-00	MS	No adverse findings	None	N/A Audit closure date: November 1, 2022
Boone County Health Center	CAH281334-00	NE	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: May 17, 2022
Buena Vista Regional Medical Center	CAH161375-00	IA	Incorrect 340B OPAIS record – Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacy from 340B Program*	CAP implemented Audit closure date: May 25, 2022
Cambridge Medical Center	DSH240020	MN	No adverse findings	None	N/A Audit closure date: July 27, 2022
Centura Longmont United Hospital	DSH060003	CO	No adverse findings	None	N/A Audit closure date: September 27, 2022
Centura St. Thomas More Hospital (formerly known as St. Thomas More Hospital) Contact Information 340B Program Manager 9100 E. Mineral Circle Centennial, CO 80112 303-673-7380 SamanthaMorgan@Centura.org	CAH061344-00	CO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 24, 2024
Champlain Valley Physicians Hospital	DSH330250	NY	Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: January 27, 2023
Children's Hospital and Research Center Oakland	PED053301-00	CA	Incorrect 340B OPAIS record - Ineligible offsite outpatient facilities registered in 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program*	CAP implemented Audit closure date: March 10, 2023
Children's Hospital Medical Center of Akron	PED363303-00	OH	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for addresses for offsite outpatient facilities; Failed to remove duplicate registrations from 340B OPAIS for an offsite outpatient facility.	None	CAP implemented Audit closure date: July 13, 2023
Chinese Hospital	DSH050407	CA	No adverse findings	None	N/A Audit closure date: September 12, 2022
Choptank Community Health System, Inc. Contact Information Chief Executive Officer 301 Randolph Street Denton, MD 21629 410-479-4306 srich@choptankhealth.org	CH032750	MD	Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy from 340B OPAIS. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 13, 2023
Clarinda Regional Health Center	CAH161352-00	IA	No adverse findings	None	N/A Audit closure date: July 12, 2022
Coffeyville Regional Medical Center, Inc.	SCH170145-00	KS	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.; Incorrect entries in 340B OPAIS for Medicare Cost Report file date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: January 11, 2023
Community Hospital of Anaconda	CAH271335-00	MT	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report file date and cost reporting period; Entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite outpatient facility.	None	CAP implemented Audit closure date: August 25, 2022
Compassion Health Care, Inc.	CH044920	NC	No adverse findings	None	N/A Audit closure date: September 1, 2022
Coney Island Hospital (NYCHHC)	DSH330196	NY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report file date and cost reporting period.	None	CAP implemented Audit closure date: October 4, 2023
Conway Regional Medical Center, Inc. Contact Information Pharmacy Director 2303 College Ave Conway, AR 72034, jroberts@conwayregional.org 501-513-5703	DSH040029	AR	Diversion - 340B drug dispensed to inpatient.	Repayment to manufacturers	CAP implemented Audit closure date: August 29, 2023
Corry Memorial Hospital	CAH391308-00	PA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: May 13, 2022
Cox Barton County Hospital	CAH261325-00	MO	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: December 12, 2023
Cox Monett Hospital, Inc.	CAH261329-00	MO	Incorrect 340B OPAIS record - Ineligible offsite outpatient facilities registered in 340B OPAIS. Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	Termination of ineligible offsite outpatient facilities*	CAP implemented Audit closure date: June 7, 2023
Crawford Hospital District DBA Crawford Memorial Hospital	CAH141343-00	IL	No adverse findings	None	N/A Audit closure date: August 25, 2022
D.M. Cogdell Memorial Hospital Contact Information Chief Operating Officer cmh.jeverett@cogdellhospital.com 325-574-7439	CAH451384-00	TX	Incorrect 340B OPAIS record â Incorrect entry in 340B OPAIS for hospital control type. Diversion â 340B drugs prescribed by ineligible providers. Duplicate Discounts - Entityâs contract pharmacies billed Medicaid without notification to HRSA.	Repayment to manufacturers	CAP implemented Audit closure date: June 20, 2023
Day Kimball Hospital	DSH070003	CT	No adverse findings	None	N/A Audit closure date: October 27, 2022
Decatur County Memorial Hospital	CAH151332-00	IN	No adverse findings	None	N/A Audit closure date: March 29, 2022
Dodge County Hospital Contact Information Chief Financial Officer 901 Griffin Avenue Eastman, GA 31023 478-448-4050 jhamrick@dodgehospital.onmicrosoft.com	DSH110092	GA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Diversion - 340B drug dispensed to inpatient; 340B drugs dispensed at covered entity, and at contract pharmacies, not supported by a medical record. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 3, 2023
Ellett Memorial Hospital	CAH261301-00	MO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove offsite outpatient facility from 340B OPAIS that was not operational; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.	None	CAP implemented Audit closure date: September 8, 2023
Family Health Network of Central New York, Inc. Contact Information Chief Executive Officer 85 S West Street Homer, NY 13077 607-753-3797 kosborne@familyhealthnetwork.org	CH021240	NY	Incorrect 340B OPAIS record â Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place. Duplicate Discounts â Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers Termination of contract pharmacy from 340B Program*	CAP implemented Audit closure date: June 6, 2023
First Care Medical Services	CAH241357-00	MN	No adverse findings	None	N/A Audit closure date: March 15, 2022
Franklin Hospital District	CAH141321-00	IL	Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: December 21, 2022
Freeman Neosho Hospital	CAH261331-00	MO	No adverse findings	None	N/A Audit closure date: October 25, 2022
Gardner Family Health Network, Inc.	CH090210	CA	No adverse findings	None	N/A Audit closure date: July 29, 2022
Genoa Community Hospital	CAH281312-00	NE	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entries for Authorizing Official and Primary Contact.	None	CAP implemented Audit closure date: January 11, 2023
Gerald Champion Regional Medical Center	DSH320004	NM	No adverse findings	None	N/A Audit closure date: November 1, 2022
Gillette Children's Specialty Healthcare	PED243300-00	MN	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed in 340B OPAIS. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: January 4, 2024
Grafton City Hospital	CAH511307-00	WV	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: July 27, 2022
Grant Medical Center	DSH360017	OH	No adverse findings	None	N/A Audit closure date: May 13, 2022
Granville Medical Center Contact Information Chief Financial Officer 1010 College Street Oxford, NC 27565 919-690-3402	DSH340127	NC	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion - 340B drug dispensed to inpatient.	Repayment to manufacturers	CAP implemented Audit closure date: October 13, 2023
Greene County Health Care, Incorporated Contact Information Chief Executive Officer Greene County Health Care, Inc. 7 Professional Drive Snow Hill, NC 28580 252-747-8162 x2002 Mtorres@gchcinc.org	CH041020	NC	Incorrect 340B OPAIS record - Incorrect entries for Primary Contact; Incorrect entries in 340B OPAIS for site ID for grant associated sites. Diversion - 340B drugs prescribed by ineligible providers. Duplicate Discounts Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 22, 2023
Grimes St. Joseph Health Center	CAH451322-00	TX	No adverse findings	None	N/A Audit closure date: December 16, 2022
Harrison County Community Hospital	CAH261312-00	MO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: June 27, 2023
Hazard ARH Regional Medical Center	DSH180029	KY	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: September 8, 2023
Health Partners of Western Ohio	CH0516380	OH	No adverse findings	None	N/A Audit closure date: March 1, 2023
Hendry County Hospital Authoritydba Hendry Regional Medical Center Contact Information Chief Financial Officer 524 W Sagamore Ave Clewiston, FL 33440 863-902-3000 teller@hrmc.us	CAH101309-00	FL	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion - 340B drugs dispensed to inpatients Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding	Repayment to manufacturers	CAP implemented Audit closure date: September 16, 2024
HH Health System - Marshall, LLC	DSH010005	AL	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for hospital control type, address, and shipping address; Failed to remove terminated contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: September 28, 2023
Holy Rosary Healthcare	CAH271347-00	MT	Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: July 15, 2022
Holzer Medical Center - Jackson	CAH361320-00	OH	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.	None	CAP implemented Audit closure date: February 15, 2024
HonorHealth Scottsdale Osborn Med Ct	RRC030038-00	AZ	No adverse findings	None	N/A Audit closure date: March 23, 2022
Hospital Development Corporation dba Roane General Hospital	CAH511306-00	WV	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for Medicare Cost Report filing date.	None	CAP implemented Audit closure date: September 15, 2023
Hudson River Healthcare, Inc.	CH021510	NY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for grant associated site names and address; Failed to remove grant associated sites from 340B OPAIS that were not operational.	Termination of grant associated sites from the 340B Program*	CAP implemented Audit closure date: August 31, 2022
Humboldt Park Health Contact Information Authorizing Official 773-292-8208 khendren@hph.care	DSH140206	IL	Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 11, 2022. Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Ineligible offsite outpatient facility registered in 340B OPAIS; Incorrect entry for Authorizing Official. Diversion - 340B drugs prescribed by ineligible providers. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers Termination of ineligible offsite outpatient facility from the 340B Program*	CAP implemented Audit closure date: October 13, 2023
Hunter Health Clinic Inc., The	CH070150	KS	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for name for grant associated site.	None	CAP implemented Audit closure date: October 12, 2022
Jacobi Medical Center NYCHHC	DSH330127	NY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and disproportionate share percentage. Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed in 340B OPAIS.	None	CAP implemented Audit closure date: January 24, 2024
Jefferson Community Health Center DBA Jefferson Community Health & Life	CAH281319-00	NE	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.	None	CAP implemented Audit closure date: November 4, 2022
Johns Hopkins All Children’s Hospital, Inc.	PED103300-00	FL	No adverse findings	None	N/A Audit closure date: April 15, 2022
Kennedy Memorial Hospital-UMC Contact Information 340B Manager 1101 Market St, 20th Floor, Philadelphia, PA 19107 215-955-6076 jmo011@jefferson.edu	DSH310086	NJ	Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 2, 2024
Kentucky Department for Public Health	STD40621	KY	Incorrect 340B OPAIS record - Incorrect entry for Primary Contact; Healthcare delivery sites were not listed in 340B OPAIS.	None	Pending
Kit Carson County Memorial Hospital	CAH061313-00	CO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: April 19, 2023
Kittitas County Public Hospital District #1 Contact Information Director of Pharmacy Kittitas Valley Healthcare 603 S Chestnut Street Ellensburg, WA 98926 509-925-8494 nbasmeh@kvhealthcare.org	CAH501333-00	WA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion - 340B drug dispensed to inpatient.	Repayment to manufacturers	CAP implemented Audit closure date: January 3, 2024
Kittson Memorial Hospital	CAH241336-00	MN	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: September 23, 2022
Knox Community Hospital	SCH360040-00	OH	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: February 22, 2024
Korean Health, Education, Information and Research Center Contact Information Compliance Director 3727 West 6th Street, Suite 210 Los Angeles, CA 90020 compliance@lakheir.org (323) 863-6286	CHC26620-00	CA	Duplicate Discounts â Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 26, 2023
Lafayette General Medical Center Contact Information AVP of Pharmacy 1214 Coolidge Street Lafayette, LA 70503 337-289-7888 rodney.good@ochsner.org	DSH190002	LA	Incorrect 340B OPAIS record - Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS; Failed to remove closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Diversion - 340B drug dispensed to inpatient.	Repayment to manufacturers. Termination of ineligible contract pharmacy from the 340B Program*	CAP implemented Audit closure date: December 12, 2023
Lamb County Hospital dba Lamb Healthcare Center Contact Information Chief Executive Officer 1500 S. Sunset Littlefield, TX 79339 806-385-6444 cklein@lambhc.org	SCH450698-00	TX	Entity did not meet eligibility requirements as a DSH hospital for the time period April 29, 2022, through September 7, 2022. Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, disproportionate share percentage, and hospital control type. Diversion - 340B drugs dispensed at a contract pharmacy, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: January 24, 2024
Landmark Medical Center	DSH410011	RI	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for disproportionate share percentage and for Primary Contact. Entitys contract pharmacy was billing Medicaid without notification to HRSA. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: January 3, 2024
Lawrence & Memorial Hospital	DSH070007	CT	Incorrect 340B OPAIS record - Ineligible offsite outpatient facility registered in 340B OPAIS; A shipping address was not listed in 340B OPAIS.	Termination of ineligible offsite outpatient facility from the 340B Program*	CAP implemented Audit closure date: May 5, 2023
LCH Health and Community Services formerly La Comunidad Hispania, Inc Contact Information Chief Executive Officer 731 West Cypress Street, Kennett Square, PA 19348 610-444-7550 x 295 rgannon@lchservices.org	CHC24148-00	PA	Entity failed to maintain auditable records. Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Repayment to manufacturers	CAP implemented Audit closure date: September 8, 2023
MacNeal Hospital	DSH140054	IL	No adverse findings	None	N/A Audit closure date: October 19, 2022
Madelia Community Hospital and Clinic	CAH241323-00	MN	Incorrect 340B OPAIS record – Offsite outpatient facility was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entry for Authorizing Official.	None	CAP implemented Audit closure date: August 31, 2022
Madison Medical Center Contact Information Chief Financial Officer Madison Medical Center 611 W. Main St. Fredericktown, MO 63645 asucharski@madisonmedicalcenter.net 573-783-1070	CAH261302-00	MO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove closed contract pharmacy from 340B OPAIS. Diversion - 340B drugs prescribed by ineligible provider.	Repayment to manufacturers	CAP implemented Audit closure date: February 16, 2024
Maine Mobile Health Program, Inc.	CH01004M	ME	Incorrect 340B OPAIS record –Incorrect entries in 340B OPAIS for names and address for grant associated sites.	None	CAP implemented Audit closure date: October 27, 2022
Manet Community Health Center, Incorporated	CH011640	MA	Incorrect 340B OPAIS record – Grant associated site was not listed in 340B OPAIS.	None	CAP implemented Audit closure date: September 21, 2022
Marian Medical Center Contact Information Market Vice President Finance matt.richardson@commonspirit.org 805-739-3108	DSH050107	CA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Diversion - 340B drugs dispensed to inpatients.	Repayment to manufacturers	CAP approved
Marin City Health and Wellness Center Contact Information Chief Operating Officer 880 Las Gallinas Ave., Suite #2, San Rafael, CA 94903 415-328-3441 kwalker@marincityclinic.org	CHC22689-00	CA	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for sub-division name for grant associated site. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 16, 2024
Mark Twain Medical Center	CAH051332-00	CA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Offsite outpatient facilities were not listed in 340B OPAIS.	None	CAP implemented Audit closure date: August 30, 2022
Marshfield Medical Center Ladysmith Contact Information 340B Program Manager 1000 North Oak Avenue Marshfield, WI 54449 715-858-4308 Neuendorf.kirstia@marshfieldclinic.org	CAH521328-00	WI	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 27, 2023
Maryland General Hospital	DSH210038	MD	No adverse findings	None	N/A Audit closure date: July 14, 2022
McDonough District Hospital	SCH140089-00	IL	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period and disproportionate share percentage.	None	CAP implemented Audit closure date: January 19, 2023
Medical Center of Peach County	CAH111310-00	GA	No adverse findings	None	N/A Audit closure date: January 7, 2022
Medina Memorial Hospital	CAH331319-00	NY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Authorizing Official phone number; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: July 31, 2023
Memorial Hermann Sugar Land Hospital	DSH450848	TX	No adverse findings	None	N/A Audit closure date: May 12, 2022
Memorial Hospital of Carbon County Contact Information Chief Financial Officer JFSMITH@IMHCC.COM 307-324-2221	CAH531316-00	WY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date; Ineligible offsite outpatient facility registered in 340B OPAIS; Failed to remove duplicate registrations from 340B OPAIS for an offsite outpatient facility. Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record.	Termination of ineligible offsite outpatient facilities from the 340B Program Repayment to manufacturers	CAP implemented Audit closure date: June 20, 2023
Memorial Hospital Pembroke	DSH100230	FL	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: September 28, 2023
Mercy Gilbert Medical Center	RRC030119-00	AZ	No adverse findings	None	N/A Audit closure date: September 6, 2022
Mercy Health System Corporation	DSH520066	WI	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: May 18, 2023
Mercy Hospital	DSH240115	MN	Incorrect 340B OPAIS record - Entity improperly registered offsite outpatient facilities as shipping addresses in 340B OPAIS. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: January 18, 2024
Mercy Hospital Fort Smith	DSH040062	AR	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type.	None	CAP implemented Audit closure date: July 17, 2023
Meritus Medical Center	DSH210001	MD	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: March 1, 2023
Miami Valley Hospital	DSH360051	OH	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: July 13, 2023
Midland Memorial Hospital	RRC450133-00	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: April 28, 2023
MidMichigan Medical Center – Gratiot	DSH230030	MI	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: October 26, 2022
Migrant Health Center, Western Region, Inc.	CH021040	PR	Incorrect 340B OPAIS record – Entity improperly registered two pharmacies as grant associated sites in 340B OPAIS.	None	CAP implemented Audit closure date: August 27, 2022
Mitchell County Hospital	CAH111331-00	GA	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital control type; Incorrect entry in 340B OPAIS for address for offsite outpatient facility. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: July 31, 2023
Moab Valley Healthcare, Inc.	CAH461302-00	UT	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: November 7, 2022
Montgomery AIDS Outreach, Inc.	HV0413130	AL	Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.	Termination of ineligible contract pharmacies from the 340B Program	CAP implemented Audit closure date: April 28, 2023
Moore County Hospital District dba Memorial Hospital Contact Information Chief Compliance Officer 224 E. 2nd Street Dumas, TX 79029 awiswell@mchd.net 806-934-7802	CAH451386-00	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 29, 2023
Morrison Community Hospital	CAH141329-00	IL	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: February 23, 2023
Mother Frances Hospital-Winnsboro	CAH451381-00	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS; Failed to remove terminated contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: May 15, 2023
Nassau Health Care Corporation	DSH330027	NY	Incorrect 340B OPAIS record - Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.	Termination of ineligible contract pharmacy from the 340B Program*	CAP implemented Audit closure date: February 7, 2024
Neighborhood Health Center	CHC24160-00	OR	No adverse findings	None	N/A Audit closure date: April 8, 2022
Neighborhood Outreach Access to Health	CHC26604-00	AZ	No adverse findings	None	N/A Audit closure date: March 2, 2022
Nemours Childrens Hospital	PED103304-00	FL	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: May 20, 2024
NEPA Community Healthcare, Hallstead FP Clinic	FP188225	PA	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for grant number.	None	CAP implemented Audit closure date: October 16, 2023
New ULM Medical Center	CAH241378-00	MN	No adverse findings	None	N/A Audit closure date: August 8, 2022
North Colorado Medical Center	DSH060001	CO	Duplicate Discounts - Entity billed Medicaid while not listed in on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: September 15, 2023
North Hudson Community Action Corporation Contact Information 340B Coordinator800 31st Street Union City, NJ 07087 amartinez@nhcac.org 201-494-3873	CH024490	NJ	Incorrect 340B OPAIS record - Contract pharmacy was not registered in 340B OPAIS. Diversion - 340B drugs dispensed at a contract pharmacy, prescribed by ineligible provider. Duplicate Discount - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP approved
Northeast Washington County Community Health, Inc.	CHC08230-00	VT	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for Authorizing Official.	None	CAP implemented Audit closure date: February 2, 2023
Northeastern Health System (formerly Tahlequah City Hospital) Contact Information Director of Pharmacy 1400 E Downing Tahlequah, OK 74464 918-453-2355 slarmon@nhs-ok.org	SCH370089-00 (formerly DSH370089)	OK	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date; Failed to remove terminated contract pharmacies from 340B OPAIS. Diversion - 340B drug dispensed to inpatient. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: April 5, 2024
Northern Nevada HIV Outpatient Program Education and Services Contact Information Pharmacy Director 580 W 5th St., Reno, NV 89503 775-348-1306 twatkins@nnhopes.org	CHC26605-00	NV	Incorrect 340B OPAIS record - Grant associated site was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for site ID and name for grant associated site. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 4, 2023
Northridge Hospital Medical Center	DSH050116	CA	No adverse findings	None	N/A Audit closure date: July 29, 2022
Packard Health, Inc. Contact Information Chief Financial Officer 5200 Venture Dr Ann Arbor, MI 48108 734-971-1073 Todd_montrief@packardhealth.org	CHC29011-00	MI	Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 13, 2022
Palmer Lutheran Health Center	CAH161316-00	IA	No adverse findings	None	N/A Audit closure date: January 20, 2022
Palmetto Health Council, Inc.	CH045260	GA	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for subdivision name for parent and grant associated sites; Grant associated site was not listed in 340B OPAIS. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: March 27, 2024
Palomar Medical Center Escondido (PMC Escondido) Contact Information District Director of Pharmacy 2185 Citracado Parkway Escondido, CA 92029 Dondreia.Gelios@palomarhealth.org 442-281-1358	DSH050115	CA	Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 15, 2023
Pancare of Florida, Inc.	CH0442450	FL	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for subdivision name and address for grant associated sites; Ineligible outpatient facility registered on 340B OPAIS; Failed to remove a duplicate registration for a grant associated site from 340B OPAIS.	Termination of grant associated site from the 340B Program*	CAP implemented Audit closure date: August 24, 2022
Phoebe Sumter Medical Center Contact Information 340B Pharmacy Analyst 2000 Palmyra Road Albany, Georgia 31702 229-312-2174 340BRxstaff@phoebehealth.com	DSH110044	GA	Incorrect 340B OPAIS record - Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS. Diversion - 340B drugs dispensed to inpatients.	Repayment to manufacturers	CAP implemented Audit closure date: September 8, 2023
Phoebe Worth Medical Center	CAH111328-00	GA	No adverse findings	None	N/A Audit closure date: July 29, 2022
Pitt County Memorial Hospital, Incorporated dba ECU Health Medical Center	DSH340040	NC	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Incorrect entry in 340B OPAIS for shipping address; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: February 22, 2024
Pontotoc Health Services	CAH251308	MS	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date.	None	CAP implemented Audit closure date: March 27, 2024
Portland Adventist Medical Center dba Adventist Health Portland Contact Information Director of Pharmacy Adventist Health Portland 10123 SE Market St Portland, OR 97216 503-251-6142 Declerkm@ah.org	DSH380060	OR	Diversion - 340B drug dispensed to inpatient. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Repayment to manufacturers	CAP implemented Audit closure date: March 27, 2024
Providence Health System Southern California dba Providence Little Company of Mary Medical Center Torrance	DSH050353	CA	No adverse findings	None	N/A Audit closure date: March 4, 2022
Providence Little Company of Mary Medical Center San Pedro	DSH050078	CA	No adverse findings	None	N/A Audit closure date: January 19, 2022
Providence Saint Joseph Medical Center	CAH271343-00	MT	No adverse findings	None	N/A Audit closure date: March 31, 2022
Punxsutawney Area Hospital	SCH390199-00	PA	No adverse findings	None	N/A Audit closure date: February 2, 2022
Pushmataha Family Medical Center, Inc.	CHC06453-00	OK	No adverse findings	None	N/A Audit closure date: July 29, 2022
Putnam County Memorial Hospital	CAH261305-00	MO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, Authorizing Official phone number and Primary Contact phone number; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.	None	CAP implemented Audit closure date: February 21, 2023
Quality of Life Health Services, Inc. Contact Information President/Chief Executive Officer 1411 Piedmont Cutoff Gadsden, Alabama 35903 wayne.rowe@qolhs.com 256-492-0131	CH044120	AL	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for address for grant associated site. Diversion - 340B drugs dispensed, not supported by a medical record; 340B drugs prescribed by ineligible providers. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 15, 2024
Reading Hospital	DSH390044	PA	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for shipping address for offsite outpatient facility.	None	CAP implemented Audit closure date: December 21, 2022
Reedsburg Area Medical Center	CAH521351-00	WI	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed in 340B OPAIS.	None	CAP implemented Audit closure date: September 1, 2022
Rhea Medical Center	CAH441310-00	TN	Incorrect 340B OPAIS record – Failed to remove closed offsite outpatient facility from 340B OPAIS. Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for offsite outpatient facility.	Termination of offsite outpatient facilities from the 340B Program.*	CAP implemented Audit closure date: December 15, 2022
Rice Memorial Hospital	DSH240088	MN	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital control type. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: January 24, 2024
Rideout Memorial Hospital DBA Adventist Health and Rideout	DSH050133	CA	No adverse findings	None	N/A Audit closure date: October 31, 2022
RiverView Healthcare Association	CAH241320-00	MN	No adverse findings	None	N/A Audit closure date: March 24, 2022
Robert Packer Hospital Contact Information Chief Financial Officer Guthrie Hospitals One Guthrie Square Sayre, PA 188 570-887-5985 Fran.macafee@guthrie.org	RRC390079-00	PA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 12, 2023
Rochester General Hospital	DSH330125	NY	No adverse findings	None	N/A Audit closure date: January 7, 2022
Sacred Heart Health Services dba Avera Creighton Hospital	CAH281331-00	NE	No adverse findings	None	N/A Audit closure date: May 25, 2022
Saint Luke's Hospital of Chillicothe dba Hedrick Medical Center	CAH261321-00	MO	No adverse findings	None	N/A Audit closure date: February 25, 2022
Saint Peter's University Hospital Contact Information Chief Financial Officer/Authorizing Official Saint Peter's University Hospital 254 Easton Avenue New Brunswick, NJ 08901 gstoldt@saintpetersuh.com	DSH310070	NJ	Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 15, 2023
San Antonio Regional Hospital	DSH050099	CA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: October 26, 2022
Santa Ynez Valley Cottage Hospital	CAH051331-00	CA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: October 3, 2022
Self Regional Healthcare	DSH420071	SC	No adverse findings	None	N/A Audit closure date: October 7, 2022
SHMC - Riverbend Contact Information System Director of Pharmacy Supply Chain & 340B Program 1115 SE 164th Ave. Vancouver, WA 98683 360-729-2236 MLessard@peacehealth.org	DSH380102	OR	Duplicate Discounts - Entity's contract pharmacy was billing Medicaid without notification to HRSA.	Repayment to manufacturers	CAP implemented Audit closure date: March 21, 2023
Sierra Vista Hospital	CAH321300-00	NM	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entries for Authorizing Official name and phone number.	None	CAP implemented Audit closure date: November 8, 2022
Southeast Health Center of Stoddard County Contact Information 340B CoordinatorSoutheast Health of Stoddard County 1200 N. One Mile Road Dexter, MO 63841 573-614-1957 wjuden@sehealth.org	DSH260160	MO	Duplicate Discounts - Entity billed Medicaid while not listed in on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 4, 2024
Southeast Iowa Regional Medical Center	RRC160057-00	IA	Incorrect 340B OPAIS record - Failed to remove duplicate registrations of contract pharmacies from 340B OPAIS.	None	CAP implemented Audit closure date: March 14, 2023
Spectrum Health Gerber	CAH231338-00	MI	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: December 13, 2022
Springhill Medical Center - Amended	SCH190088-00	LA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entries for Primary Contact telephone number for offsite outpatient facilities.	None	CAP implemented Audit closure date: November 20, 2023
St. Clare Memorial Hospital, Inc.	CAH521310-00	WI	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: January 27, 2023
St. Joe - Flaget	DSH180025	KY	Incorrect 340B OPAIS record â Incorrect entry in 340B OPAIS for hospital control type.	None	CAP implemented Audit closure date: June 20, 2023
St. Joseph Health Northern California, LLC, dba Santa Rosa Memorial Hospital	DSH050174	CA	Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: December 7, 2022
St. Joseph Health Northern California, LLC, dba St. Joseph Hospital	DSH050006	CA	No adverse findings	None	N/A Audit closure date: July 29, 2022
St. Josephs Medical Center	SCH240075-00	MN	No adverse findings	None	N/A Audit closure date: July 27, 2022
St. Luke's Quakertown Hospital	DSH390035	PA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented Audit closure date: July 31, 2023
St. Luke’s Elmore Medical Center	CAH131311-00	ID	No adverse findings	None	N/A Audit closure date: July 14, 2022
St. Luke’s Hospital	RRC390049-00 DSH390049	PA	No adverse findings	None	N/A Audit closure date: July 13, 2022
St. Michael Medical Center	RRC500039-00	WA	No adverse findings	None	N/A Audit closure date: May 10, 2022
St. Thomas Community Health Center, Inc.	CHC12863-00	LA	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for name; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP approved
Staywell Health Care, Inc. Contact Information President/CEO StayWell Health Care, Inc. 80 Phoenix Ave, Ste 201 Waterbury, CT 06702 203-756-8021 ext 3016 dthompson@staywellhealth.org	CH01241C	CT	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Primary Contact email address; Failed to remove duplicate registrations of contract pharmacies from 340B OPAIS; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place. Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers Termination of ineligible offsite contract pharmacies from the 340B Program.*	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: May 29, 2024
Sutter Valley Hospitals dba Sutter Tracy Community Hospital	DSH050313	CA	No adverse findings	None	N/A Audit closure date: July 12, 2022
Tallahassee Memorial Healthcare, Inc.	DSH100135	FL	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: August 21, 2023
Tampa General Hospital	DSH100128	FL	Diversion – 340B drugs prescribed by ineligible provider, not supported by a medical record. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Repayment to manufacturers	Pending
Thundermist Health Center	CH011820	RI	Incorrect 340B OPAIS record - Ineligible offsite outpatient facility registered in 340B OPAIS. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Termination of ineligible offsite outpatient facilities from the 340B Program.*	CAP implemented Audit closure date: January 18, 2022
Trillium Health, Inc. Contact Information Senior Vice President, Compliance, Privacy, Technology & Regulatory Affairs Authorizing Official gewing@trilliumhealth.org 585-545-7218	FQHCLA342	NY	Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 13, 2023
Trinity Hospital Contact Information Senior Vice President, Compliance, Privacy, Technology & Regulatory Affairs Authorizing Official gewing@trilliumhealth.org 585-545-7218	CAH051315-00	CA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: January 3, 2024
Trinity Hospital Holding Company	RRC360211-00, DSH360211	OH	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, and disproportionate share percentage; Offsite outpatient facilities were not listed in 340B OPAIS; Incorrect entry in 340B OPAIS for shipping address. Duplicate Discounts - Entity billed Medicaid while not listed in on the HRSA Medicaid Exclusion File.	None	CAP implemented Audit closure date: February 28, 2024
Tug Valley ARH Regional Medical Center	DSH180069	KY	Incorrect 340B OPAIS record - Incorrect entries for Authorizing Official and Primary Contact. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: August 31, 2022
UH – University Hospital	DSH310119	NJ	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: May 5, 2023
UKHS Great Bend Campus	SCH170191	KS	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, disproportionate share percentage, and hospital control type; Incorrect entry for address for offsite outpatient facility. Duplicate Discounts Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: August 25, 2023
Union Memorial Hospital	DSH210024	MD	No adverse findings	None	N/A Audit closure date: December 15, 2022
United Memorial Medical Center	DSH330073	NY	No adverse findings	None	N/A Audit closure date: January 11, 2022
United Regional Health Care System	SCH450010-00	TX	Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy from 340B OPAIS.	Termination of ineligible contract pharmacy from the 340B Program.*	CAP implemented Audit closure date: June 26, 2023
University Hospital and Clinics Contact Information Director of Pharmacy - Ochsner University Hospital & Clinics 2390 W Congress St, Lafayette, LA 70506 337-261-6629 jeffery.bolotte@ochsner.org	DSH190006	LA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and hospital control type; Failed to remove closed contract pharmacy from 340B OPAIS. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers. Termination of ineligible contract pharmacy from the 340B Program.*	CAP implemented Audit closure date: September 28, 2023
UNM Truman Health Services	HV00130	NM	Incorrect 340B OPAIS record - Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place.	Termination of ineligible contract pharmacy from the 340B Program.*	CAP implemented Audit closure date: April 28, 2023
UPMC Chautauqua at WCA Contact Information 340B Director 3175 E. Carson St Pittsburgh, PA 15203 412-647-2940 lynchj8@upmc.edu	DSH330239	NY	Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 2, 2023
Valley Hospital and Medical Center	DSH500119	WA	No adverse findings	None	N/A Audit closure date: October 21, 2022
Washington Health Institute Contact Information Director of Operations 1140 Varnum Street NE, Suite 203 Washington, DC 20017 202-714-0066 bhaileab@dc-whi.org	STD20017	DC	Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 6, 2023
Wayne County Hospital	CAH161358-00	IA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: September 23, 2022
WellStar Spalding Regional Hospital	DSH110031	GA	No adverse findings	None	N/A Audit closure date: July 13, 2022
Welsh Mountain Health Centers	CHC00495-00	PA	Incorrect 340B OPAIS record - Entity improperly registered an entity-owned pharmacy as a grant associated site in 340B OPAIS. Incorrect 340B OPAIS record - Failed to remove contract pharmacies that did not have written contracts in place. Duplicate Discounts - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Termination of ineligible contract pharmacies from the 340B Program.*	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: December 21, 2022
Western Wayne Family Health Centers	CH0530900	MI	Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy from 340B OPAIS. Diversion - 340B drugs dispensed at a contract pharmacy, not supported by a medical record.	Termination of ineligible contract pharmacy from the 340B Program.*	CAP implemented Audit closure date: February 9, 2024
Yakima Valley Memorial Hospital	DSH500036	WA	No adverse findings	None	N/A Audit closure date: November 2, 2022
Yoakum County Hospital	CAH451308-00	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Duplicate Discounts - Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: June 6, 2023

*Note: Covered entity self-terminated cited facilities prior to termination of facilities by OPA.

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October 2024

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Program Integrity: FY22 Audit Results