Program Integrity: FY16 Audit Results

Updated 12/1/23. 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
AHRC Health Care, Inc.	CHC10579-00	NY	No adverse findings	None	N/A Audit closure date: September 7, 2016
Alameda Health System Contact Information Rick Kibler VP Compliance and Internal Audit (510) 895-7271 rkibler@alamedahealthsystem.org	DSH050320	CA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drugs were not properly accumulated. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Duplicate Discounts – Entity did not have controls in place to prevent duplicated discounts.	Repayment to Manufacturers	CAP implemented Audit closure date: July 14, 2017
Alegent Health-Immanuel Medical Center d/b/a/ CHI Health Immanuel	DSH280081	NE	No adverse findings	None	N/A Audit closure date: September 7, 2016
Alexandria Neighborhood Health Service Inc. Contact Information Pharmacy Program Manager dhernandez@neighborhoodhealthva.org 703-535-5568 x2813	CH031060A	VA	Incorrect 340B database record – Incorrect entry for a shipping address. Diversion – 340B drug dispensed at contract pharmacy for a prescription written at ineligible site Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 18, 2018
Appling General Hospital Contact Information Director of Pharmacy Appling Healthcare System 163 East Tollison Street Baxley, GA 31515 912-367-9841 ext. 1230	SCH110071-00	GA	Diversion – 340B drug dispensed at entity for a prescription written at an ineligible site. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File	Repayment to manufacturer	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: July 18, 2018
Armstrong County Memorial Hospital Contact Information Manager of Budget and Reimbursement; (724) 543-8518 mcculloughi@acmh.org Or Budget and Reimbursement Analyst (724)543-8181 kingcm@acmh.org	RRC390163-00	PA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to Manufacturers	CAP approved Audit closure date: August 8, 2017
Baptist Memorial Hospital- Union County	DSH250006	MS	No adverse findings	None	N/A Audit closure date: December 7, 2016
Baylor Scott and White Hospital - Llano	SCH450219-00	TX	Incorrect 340B database record - ineligible site registered on 340B database. Entity did not provide contract pharmacy oversight prior to January 2016.	Termination of offsite outpatient facility from 340B Program	CAP implemented Audit closure date: October 10, 2016
Benefis Hospitals, Inc.	SCH270012-00	MT	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.	None	CAP implemented Audit closure date: January 3, 2017.
Blue Ridge HealthCare Hospitals, Inc. Contact Information System Director of Pharmacy Practice 828-580-5111 2201 South Sterling Street Morganton, NC 28655	DSH340075	NC	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
Boone County Hospital Contact Information Director of Pharmacy (515) 433-8271 sdonald@bchmail.org	CAH161372-00	IA	Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 19, 2018
Boone Memorial Hospital Contact Information Chief Financial Officer (304)-369-1230 or rfoxx@bmh.org.	CAH511313-00	WV	Diversion – 340B drug dispensed at the entity for prescription written by an ineligible provider; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 19, 2018
Bronson Battle Creek Hospital Contact Information 340B Pharmacy Specialist Bronson Healthcare Group 601 John Street Kalamazoo, MI, 49001 (269) 552-3076 potyrall@bronsonhg.org	DSH230075	MI	Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 15, 2017
Brooklyn Hospital Center Contact Information Senior Vice President & Chief Financial Officer The Brooklyn Hospital Center 15 Metrotech Center, 3rd Floor Brooklyn, NY 11201 (718)-488-3715 psemenza@tbh.org	DSH330056	NY	Covered outpatient drugs obtained through a Group Purchasing Organization from April 27, 2015 to January 4, 2016. Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File and Entity’s contract pharmacy was billing Medicaid without notification to HRSA.	Repayment to manufacturers	CAP implemented Audit closure date: May 19, 2017
Brookville Hospital	CAH391312-00	PA	No adverse findings	None	N/A Audit closure date: January 27, 2016
Brownsville Community Development Corporation Contact Information Controller Brownsville Multi-Service Family Health Center 408 Rockaway Avenue Brooklyn, New York 11212 (718) 345-6366 x6605 mwolf@bmsfhc.org	CH021960	NY	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts – Entity was billing at contract pharmacies and contrary to information included in the Medicaid Exclusion File.	Repayment to Manufacturers	CAP implemented Audit closure date: June 13, 2017
C.W. Williams Community Health Center, Inc. Contact Information Chief Executive Officer (704) 391-0819 dweeks@cwwilliams.org info@cwwilliams.org	CH047770	NC	Incorrect 340B database record - Closed offsite outpatient facility listed on the 340B database Entity did not provide contract pharmacy oversight. Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 10, 2017
Carilion Medical Center Contact Information Chief Compliance and Audit Officer 213 S. Jefferson Street Suite 1201 Roanoke, VA 24012 (540) 510-4573 compliance@carilionclinic.org	DSH490024	VA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; ineligible sites registered on the 340B database. Diversion – 340B drug dispensed to an inpatient; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 18, 2017
Cedars-Sinai Medical Center	DSH050625	CA	No adverse findings	None	N/A Audit closure date: February 14, 2017
Central Michigan Community Hospital dba McLaren Central Michigan Contact Information Director of Pharmacy McLaren Central Michigan 1221 South Drive Mt. Pleasant, MI 48858 James.baxter@mclaren.org	RRC230080-00	MI	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drugs were not properly accumulated. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: July 18, 2018
Central North Alabama Health Services, Inc. Contact Information Compliance Officer 256-534-8659 110 Walker Avenue Huntsville, AL 35801	CH048190	AL	Incorrect 340B database record – Incorrect entry for primary contact; Registered contract pharmacy without written contract in place. Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: May 16, 2018
Children's Hospital of Los Angeles Contact Information Pharmacy Director 4650 Sunset Blvd Los Angeles, California 90027 Mailstop #44 (323) 361-5988	PED053302-00	CA	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to Manufacturers	CAP implemented Audit closure date: May 19, 2017
Children's Hospital of Philadelphia, The Contact Information Director of Pharmacy The Children's Hospital of Philadelphia 3401 Civic Center Boulevard Philadelphia, Pennsylvania, 19104 (215) 590-1893	PED393303-00	PA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drug dispensed to an inpatient.	Repayment to Manufacturers	CAP implemented Audit closure date: January 29, 2018
Children’s Hospital	PED193300-00	LA	No adverse findings	None	N/A Audit closure date: January 27, 2016
Children’s Hospital Association, The	PED063301-00	CO	No adverse findings	None	N/A Audit closure date: November 22, 2016
Chippewa County Montevideo Hospital	CAH241325-00	MN	No adverse findings	None	N/A. Audit closure date: September 8, 2016
Chota Community Health Services	CH0442510	TN	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: June 21, 2017
Christus Spohn Hospital Beeville Contact Information Pharmacy Compliance Officer CHRISTUS Spohn Hospital Region 600 Elizabeth St. Corpus Christi, TX, 78404 361-881-3127 Elias.cavazos@christushealth.org	DSH450082	TX	Incorrect 340B database record - Incorrect entry for off-site outpatient facility address; registered contract pharmacies without written contract in place prior to February 9, 2016. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 24, 2017
Christus Spohn Hospital Corpus Christi Memorial Contact Information Pharmacy Compliance Officer CHRISTUS Spohn Hospital Region 600 Elizabeth St. Corpus Christi, TX 78404 361-881-3127 Elias.cavazos@christushealth.org	DSH450046	TX	Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to February 9, 2016. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: October 10, 2017
Citrus Health Network Inc.	CH0438180	FL	Incorrect 340B database - Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: June 13, 2017
Claxton Hepburn Medical Center Contact Information Chief Financial Officer (315)713-5350 214 King Street; Ogdensburg, New York 13669	SCH330211-00	NY	Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: May 3, 2018
Clinch River Health Services, Incorporated Contact Information Executive Director (276) 467-7000 17633 Veterans Memorial Hwy. Dungannon, VA 24245	CH031230	VA	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: May 4, 2018
Clinica Sierra Vista	CH090390 HV090390	CA	No adverse findings	None	N/A Audit closure date: January 13, 2016
Clinicas del Camino Real, Inc.	CH09365A	CA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Incorrect or incomplete information in the 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 4, 2017
Columbia St. Mary’s Hospital Milwaukee, Inc. Contact Information System Director of Pharmacy 414-585-1071 2323 N. Lake Drive Milwaukee, WI 53211	DSH520051	WI	Incorrect 340B database - Registered contract pharmacies without written contract in place. Diversion - 340B drug dispensed at entity for prescription written at an ineligible sites. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File	Termination of contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: November 14, 2017
Comanche County Medical Center Contact Information Director of Pharmacy SAbbey@comanchecmc.com (254) 879-4961	CAH451382-00	TX	Incorrect 340B database record – Incorrect entry for Primary contact. Diversion – 340B drugs dispensed to inpatients. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 30, 2017
Community Health Center of Snohomish County Contact Information Pharmacy Manager 425-551-6531 Pharmacy Lead 425-640-5491 8609 Evergreen Way Everett, WA 98208-2619	CH10228A	WA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drug dispensed at entity for a prescription written at an ineligible site. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufactures	CAP implemented Audit closure date: April 19, 2018
Community Hospital of LaGrange County	CAH151323-00	IN	No adverse findings	None	N/A Audit closure date: November 15, 2016
Community Memorial Healthcare, Inc.	CAH171363-00	KS	No adverse findings	None	N/A Audit closure date: June 1, 2016
Comprehensive Care Center, Inc.: DBA Community Aids Network	RWII342371	FL	No adverse findings	None	N/A Audit closure date: November 4, 2016
Conway Medical Center Contact Information Director of Pharmacy Conway Medical Center 300 Singleton Ridge Road Conway, SC 29526 (843) 347-8142	DSH420049	SC	Diversion – 340B drugs dispensed for prescriptions written at ineligible sites. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 23, 2018
Copley Memorial Hospital Contact Information Director of Pharmacy 2000 Ogden Avenue Aurora, IL 60504	DSH140029	IL	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 24, 2017
Cornell Scott-Hill Health Corporation	CH010070	CT	No adverse findings	None	N/A Audit closure date: March 9, 2016
Covenant Medical Center Contact Information Director of Pharmacy (989) 583-4075 1447 N Harrison Saginaw, Michigan 48602	DSH230070	MI	Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site.	Repayment to manufacturer	CAP implemented Audit closure date: November 14, 2017
Crete Area Medical Center Contact Information President and CEO Crete Area Medical Center 402.826.2102 or rebekah.mussman@bryanhealth.org	CAH281354-00	NE	Diversion - 340B drugs dispensed at contract pharmacy, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: May 12, 2017
Cumberland Family Medical Center, Inc.	CH0452070	KY	No adverse findings	None	N/A Audit closure date: November 8, 2016
Decatur Memorial Hospital Contact Information Tom West, Director Decision Supports 2300 N. Edwards Decatur, IL, 62526 (217) 876-2033 tomw@dmhhs.org	RRC140135-00	IL	Entity did not provide contract pharmacy oversight. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: February 8, 2017
Down East Community Hospital Contact Information Chief Operating Office at 207-255-0217 or slail@hech.org or Director of pharmacy services at 207-255-0422 or vamon@dech.org	CAH201311-00	ME	Incorrect 340B database record – Incorrect entry for offsite facility address. Diversion – 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site.	Repayment to manufacturer	CAP implemented Audit closure date: June 13, 2017
Earl and Lorraine Miller Children's Hospital of Long Beach Contact Information Executive Director, Pharmacy Services 2801 Atlantic Avenue, Long Beach, CA 90806 562-933-0282 jhodding@memorialcare.org	PED053309-00	CA	Duplicate Discounts - Entity was billing at contract pharmacies without notifying HRSA of an arrangement with contract pharmacy, the entity and the State Medicaid agency.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
East Texas Medical Center Quitman Contact Information Administrator (903) 763-6330 psswindle@etmc.org ETMC Quitman, 117 N. Winnsboro Street, Quitman, Texas 75783	CAH451380-00	TX	Diversion – 340B drug dispensed for prescription written at an ineligible site.	Repayment to manufacturer	CAP implemented Audit closure date: March 15, 2017
Eastern Maine Medical Center	DSH200033	ME	Incorrect or incomplete information in the 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 11, 2017
Elica Health Centers	CHC24113-00	CA	Incorrect 340B database record - Registered Contract Pharmacies without written contract in place. Entity did not provide contract pharmacy oversight.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: March 2, 2016
Elmhurst Hospital Center (NYCHHC) Contact Information Vice President, New York City Health and Hospitals (212) 748-2256 Paul.albertson@nychhc.org	DSH330128	NY	Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site, not supported by medical record; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.	Repayment to manufacturers	CAP implemented Audit closure date: February 8, 2017
Emory University Hospital Midtown Contact Information Chief Operating Officer Emory University Hospital Midtown 550 Peachtree Street NE Atlanta, GA, 30308 (404) 686-8903	DSH110078	GA	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 12, 2017
Escambia County Health Department	FP36502	AL	Incorrect 340B database record- Incorrect entry for Authorizing Official. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.		CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: June 13, 2017
Fenway Community Health Center, Inc.	CH010600	MA	No adverse findings	None	N/A Audit closure date: December 15, 2015
First Choice Community Healthcare Contact Information Chief Operating Officer 2001 N. Centro Familiar SW, Albuquerque, NM 87105-4592 Melissa_manlove@fcch.com (505) 873-7474	CH060240	NM	Incorrect 340B database record – Utilized contract pharmacies prior to registering on the 340B database. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to Manufacturers	CAP implemented Audit closure date: May 12, 2017
FirstHealth Moore Regional Hospital Contact Information Chief Operating Officer Administrative Director of Pharmacy (910) 715-1093 mcowell@firsthealth.org	RRC340115-00	NC	Diversion – 340B drugs were not properly accumulated. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to Manufacturers	CAP implemented Audit closure date: February 23, 2018
FoundCare, Inc.	CHC26626-00	FL	No adverse findings	None	N/A Audit closure date: April 27, 2016
Gaston Memorial Hospital Contact Information Director of Pharmacy mark.chaparro@caromonthealth.org 704-834-2239	DSH340032	NC	Incorrect 340B database record - Pharmacy incorrectly registered as child site. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 22, 2017
Geisinger Medical Center Contact Information Program Director 340B Program Geisinger Medical Center 100 N. Academy Avenue Danville, PA 17821-4201 (570) 214-0155	DSH390006	PA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites; 340B drug dispensed, not supported by medical record.	Repayment to manufacturers	CAP implemented Audit closure date: February 10, 2017
George County Hospital	SCH250036-00	MS	No adverse findings	None	N/A Audit closure date: September 7, 2016
Golden Valley Memorial Hospital District	RRC260175-00	MO	No adverse findings	None	N/A Audit closure date: September 26, 2016
Grossmont Hospital Contact Information Manager of Pharmacoeconomics 8695 Spectrum Center Blvd San Diego, CA 92130 858-499-4220	DSH050026	CA	Incorrect 340B database record – Incorrect entry for address of offsite outpatient facility. Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: May 19, 2017
Harborview Medical Center	DSH500064	WA	No adverse findings	None	N/A Audit closure date: April 14, 2016
Harlem Hospital (NYCHHC)	DSH330240	NY	No adverse findings	None	N/A Audit closure date: July 14, 2016
Harris County Hospital District dba Harris Health System Ben Taub Hospital	DSH450289	TX	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.	None	CAP implemented Audit closure date: November 22, 2016
Hawkins County Memorial Hospital	DSH440032	TN	No adverse findings	None	N/A Audit closure date: November 2, 2016
Healthreach Community Health Centers Contact Information Chief Executive Officer Healthreach Community Health Centers 237 Main Street Bingham, Maine 04920 (207) 872-5610 constance.coggins@healthreach.org	CH010460	ME	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 29, 2018
Ho Ola Lahui Hawaii	CH091290	HI	No adverse findings	None	N/A Audit closure date: June 7, 2016
Hospital of the University of Pennsylvania, The Contact Information Controller 215-349-8810 3400 Spruce Street Ground Rhoads, Philadelphia, PA 19104	DSH390111	PA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 21, 2016. Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate entry for offsite outpatient facility; Ineligible site registered on 340B database. Diversion - 340B drugs dispensed for prescriptions originating at ineligible sites; 340B drugs dispensed, not supported by medical records; 340B drugs were not properly accumulated. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 22, 2018
HSHS Holy Family Hospital, Inc. (formerly Greenville Regional Hospital, Inc.) Contact Information HSHS Holy Family Greenville Attn: Director of Pharmacy 200 Healthcare Drive Greenville, IL 62246 618-690-3427 Katlyn.obermark@hshs.org	DSH140137	IL	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 15, 2017
Ingalls Memorial Hospital	DSH140191	IL	No adverse findings	None	N/A Audit closure date: July 6, 2016
Institute for Family Health, The Contact Information Sr. Vice President of Regulatory Affairs and Human Resources The Institute for Family Health 2006 Madison Ave New York, NY 10035 Office: (212) 633-0815 x1241 Cell: (914) 497-8135 E-Fax: (212) 359-3270 Nnurse@institute.org	CH02371C	NY	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts – Entity was billing at contract pharmacies and contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: July 31, 2018
Jackson County Health Department Contact Information Director of Administration 4025 Bald Cypress Way, Bin A-20, Tallahassee, Florida 32399-1708 (850) 245-4444, ext. 2311	TB324469 STD32446 FP32446	FL	(FP324461) Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. (TB324469, STD32446) Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 21, 2018
Johns Hopkins Hospital Contact Information Assistant Director, Pharmacy 5901 Holabird Avenue, Suite A-2 Baltimore, Maryland 21224 (585) 770-0391	DSH210009	MD	Diversion – 340B drug dispensed at contract pharmacies for prescriptions originating from ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: February 22, 2017
Kadlec Regional Medical Center	DSH500058	WA	No adverse findings	None	N/A Audit closure date: November 23, 2016
Kaweah Delta Health Care District	DSH050057	CA	No adverse findings	None	N/A Audit closure date: September 15, 2016
Kennewick General Hospital Contact Information Pharmacy Director (509) 221-7351 900 S. Auburn Street Kennewick, WA 99336	DSH500053	WA	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: June 13, 2017
Kern Medical Center Contact Information Associate Director of Pharmacy Kern Medical Trailer #1 1700 Mt. Vernon Ave. Bakersfield, CA 93306 (661) 326-5682 / (661) 326-2617	DSH050315	CA	Entity did not provide contract pharmacy oversight. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: April 3, 2018
Klamath Health Partners Inc. Contact Information Klamath Health Partnership, Inc. 2074 S. 6th Street Klamath Falls, OR 97601 Contact: CFO 541-851-8110 x2022 sporter@kodfp.org	CH102910	OR	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 16, 2018
Labette County Medical Center D/B/A Labette Health Contact Information 340B Specialist Labette County Medical Center 1902 S HWY 59 Parsons, KS 67357 (620) 421-4881 tgilmore@LabetteHealth.com	SCH170120-00	KS	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: January 29, 2018
Legacy Salmon Creek Medical Center	DSH500150	WA	No adverse findings	None	N/A Audit closure date: December 13, 2016
Lester E Cox Medical Centers Contact Information CoxHealth 340B Coordinator Pharmacy Department 3801 South National Avenue Springfield, MO 65807 (417) 269-6231 Stacie.reed@coxhealth.com	DSH260040	MO	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 20, 2018
LifeLong Medical Care	CH092880	CA	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Ineligible site registered on 340B database; Incorrect entry for address of a contract pharmacy. Diversion - 340B drugs dispensed for prescriptions originating from ineligible sites. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 24, 2017
Lincoln County Medical Center	CAH321306-00	NM	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database.	None	CAP implemented Audit closure date: March 15, 2017
Long Beach Memorial Medical Center Contact Information Executive Director of Pharmacy (562)933-0282 2801 Atlantic Ave Long Beach, CA 90806	DSH050485	CA	Incorrect 340B database record – Incorrect entry for a shipping address. Diversion – 340B drugs purchased on entities account were dispensed to patients of a separate covered entity. Duplicate Discounts – Entity was billing at contract pharmacies without notifying HRSA of an arrangement with contract pharmacy, the entity and the State Medicaid agency; Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayments to manufacturers	CAP implemented Audit closed September 19, 2018
Lucile Packard Children’s Hospital Contact Information Pharmacy Compliance Analyst (650) 736-4075 4600 Bohannon Drive Suite 105 Menlo Park, CA 94025	PED053305-00	CA	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayments to manufacturers	CAP implemented Audit closure date: January 29, 2018
Madison Health Contact Information Director of Pharmacy Madison Health 210 N. Main Street, London, Ohio 43140 (740) 845-7352	DSH360189	OH	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to Manufacturers	CAP implemented Audit closure date: April 18, 2017
Maimonides Medical Center Contact Information Director of Pharmacy, V.P. Pharmaceutical Services Maimonides Medical Center 4802 Tenth Avenue Brooklyn, New York 11219 Phone: (718) 283-7205 Fax: (718) 283-8029 E-mail: fcassera@maimonidesmed.org	DSH330194	NY	Diversion – 340B drugs were not properly accumulated; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 22, 2018
Maricopa Integrated Health System Contact Information Director of Pharmacy Maricopa Integrated Health System 2601 East Roosevelt St. Phoenix, AZ 85008 (602) 739-2781	HCLA225A	AZ	Incorrect 340B database record – Incorrect entries for offsite outpatient facilities names. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 5, 2018
Marshall Medical Center	CAH441309-00	TN	No adverse findings	None	N/A Audit closure date: January 25, 2017
Marshall Medical Center South Contact Information 340B Coordinator 256-894-6733 Marshall Medical Centers, Finance Department, 227 Brittany Rd, Guntersville, AL 35976	DSH010005 (formerly RRC010005-00)	AL	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drug dispensed, not supported by medical record.	Repayment to manufacturers	CAP implemented Audit closure date: November 14, 2017
Mary Hitchcock Memorial Hospital Contact Information Director of System Pharmacy Operations One Medical Center Drive Lebanon, NH 03756 603-653-2381	RRC30003-00	NH	Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site, not supported by medical record.	Repayment to manufacturers	CAP implemented Audit closure date: May 5, 2017
Mayers Hospital Contact Information Chief Clinical Officer 530-336-5511 x1153 kearnest@mayersmemorial.com	CAH051305-00	CA	Incorrect 340B database record - Registered contract pharmacy without written contract in place. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions originating from ineligible sites. Incorrect or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Termination of contract pharmacies from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: July 19, 2017
Meade District Hospital	CAH171321-00	KS	No adverse findings	None	N/A Audit closure date: May 17, 2016
Memorial Hermann Northeast Hospital	DSH450684	TX	No adverse findings	None	N/A Audit closure date: July 18, 2016
Memorial Hospital at Gulfport Contact Information Manager, Outpatient Pharmacy Services 4500 13th Street PO Box 1810 Gulfport, MS, 39502-1810 (228) 867-4485	DSH250019	MS	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 27, 2016
Mercy Catholic Medical Center Contact Information 340B Program Manager 610-237-4062 Mercy Fitzgerald Hospital Pharmacy Department 1500 Lansdowne Avenue Darby, Pennsylvania 19023	DSH390156	PA	Entity did not provide contract pharmacy oversight. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions originating from ineligible sites.	Termination of contract pharmacies from 340B Program. Repayment to manufacturers.	CAP implemented Audit closure date: October 10, 2017
Mercy Medical Center Merced	DSH050444	CA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.	None	CAP implemented Audit closure date: March 8, 2017
Methodist Dallas Medical Center Contact Information Jon Albrecht jonalbrecht@mhd.com 214-947-2416	DSH450051	TX	Incorrect 340B database record - Incorrect entry for Primary contact. Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at the entity for a prescription written by an ineligible provider, not supported by a medical record.	Repayment to manufacturer	CAP implemented Audit closure date: May 8, 2017
Methodist Healthcare – Memphis Hospitals Contact Information 340B Program Manager Methodist Le Bonheur Healthcare 1350 Concourse Avenue Suite 668 Memphis, TN 38104 901-516-2440 Christopher.Bell@mlh.org	DSH440049	TN	Diversion –340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites	Repayment to manufacturers	CAP implemented Audit closure date: May 22, 2018
MetroHealth Medical Center Contact Information Mario Pisano, Pharm.D., 2500 MetroHealth Dr. Cleveland, OH, 44109 (216) 778-3362	DSH360059	OH	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturer	CAP implemented Audit closure date: February 14, 2017
Mission Hospitals Inc Contact Information 340B Program Pharmacy Specialist alan.knudsen@msj.org Mission Health System 509 Biltmore Avenue Asheville, North Carolina 28801	DSH340002	NC	Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 3, 2018
Nassau Health Care Corporation Contact Information Director of Pharmacy 2201 Hempstead Turnpike East Meadow, New York 11554 mknee@numc.edu (516) 572-4796	DSH330027	NY	Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 4, 2016. Incorrect 340B database – Offsite outpatient facility was not listed on 340B database. Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site. Inaccurate or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Repayment to manufacturer	CAP implemented Audit closure date: January 28, 2019
Natchitoches Regional Medical Center	SCH190007-00	LA	No adverse findings	None	N/A Audit closure date: July 18, 2016
National Jewish Medical and Research Center	DSH060107 BL80206X	CO	Incorrect 340B database record – Registered contract pharmacy without written contract in place.	Termination of contract pharmacy from the 340B Program*	CAP implemented Audit closure date: April 6, 2016
Nebraska Medical Center, The Contact Information Business Director, Pharmacy 988138 Nebraska Medical Center Omaha, NE, 68198-8138 (402) 559-9537	DSH280013	NE	Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 28, 2018
New York Methodist Hospital Contact Information Chief of Pharmacy Erb9001@nyp.org (718) 780-5575	DSH330236	NY	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drugs dispensed to inpatients.	Repayment to manufacturers	CAP implemented Audit closure date: May 22, 2017
Newark Community Health Centers, Inc.	CH020500	NJ	No adverse findings	None	N/A Audit closure date: June 7, 2016
North Carolina Baptist Hospital Contact Information Pharmacy Manager - Medication Control and Compliance Wake Forest Baptist Hospital Medical Center Blvd Winston Salem, NC 27157 Phone: 336-716-6456	DSH340047	NC	Diversion - 340B drug dispensed for prescription originating from ineligible site, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
North Shore Medical Center	DSH220035	MA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: March 8, 2017
Northbay Healthcare Group	DSH050367	CA	No adverse findings	None	N/A Audit closure date: April 21, 2016
Northeast Community Action Corp	FP63334	MO	No adverse findings	None	N/A Audit closure date: September 7, 2016
Northern Inyo Hospital Contact Information 340B Informatics Pharmacist 150 Pioneer Lane Bishop, California 93514 (760) 873-2111	CAH051324-00	CA	Diversion - 340B drugs dispensed at contract pharmacy, not supported by a medical record.	Repayment to Manufacturers	CAP implemented Audit closeout date: August 14, 2017
Northridge Hospital Medical Center Contact Information Director of Pharmacy (818) 885-8500 ext 2606	DSH050116	CA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 11, 2016. Diversion – 340B drug not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: February 23, 2018
Northside Hospital, Inc. Contact Information 340B Coordinator, Pharmacist, Pharmacy Systems Manager 1000 Johnson Ferry Road Atlanta, GA 30342 (404) 851-8528	DSH110161	GA	Diversion – 340B drug for a prescription written at an ineligible site. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturer	CAP implemented Audit closure date: February 22, 2017
Obleness Memorial Hospital	DSH360014	OH	No adverse findings	None	N/A Audit closure date: March 7, 2017
Ochsner Clinic Foundation	DSH190036	LA	No adverse findings	None	N/A Audit closure date: February 24, 2016
Olean General Hospital Contact Information Senior Vice President Finance and Chief Financial Officer (716) 375-6190 rbraun@uahs.org	RRC330103-00	NY	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 3, 2018
OneWorld Community Health Centers, Inc.	CH076290	NE	No adverse findings	None	N/A Audit closure date: May 13, 2016
OSF Holy Family Medical Center Contact Information 340B Drug Program Manager Josh.r.mccarroll@osfhealthcare.org (309) 308-3295	CAH141318-00	IL	Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: October 3, 2017
Ozarks Medical Center Contact Information Director of Pharmacy (417)257-5837 sherrie.lane@ozarksmedicalcenter.com	DSH260078	MO	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 9, 2018
PeaceHealth St. John Medical Center	DSH500041	WA	No adverse findings	None	N/A Audit closure date: October 20, 2016
Penobscot Bay Medical Center Contact Information Director of Operational Excellence 207-921-8210 mradloff@penbayhealthcare.org	DSH200063	ME	Diversion - 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites, not supported by a medical record; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
Planned Parenthood Mohawk Hudson	FP135021	NY	No adverse findings	None	N/A Audit closure date: December 7, 2015
Positive Impact Health Centers, Inc.	HV00799	GA	No adverse findings	None	N/A Audit closure date: December 15, 2015
Presbyterian Medical Services, Inc. Contact Information Director of Pharmacy and Laboratory Services 1422 Paseo de Peralta Sante Fe, New Mexico 87501 505-820-3491	CH063450	NM	Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: July 18, 2018
Princeton Community Hospital Contact Information Director of Pharmacy: sdrady@pchonline.org 304-487-7564	DSH510046	WV	Diversion – 340B drugs dispensed at contract pharmacy for prescriptions originating at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: January 3, 2017
Providence Health and Services - Washington Contact Information Regional 340B Program Manager 101 W. 8th Ave Attn: Pharmacy Spokane, WA 99204 (509) 474-3244	DSH500014	WA	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion - 340B drugs dispensed to inpatients; 340B drugs dispensed for prescriptions originating from ineligible sites. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to Manufacturers	CAP approved Audit closure date: August 8, 2017
River Valley Primary Care Services Contact Information 340B Coordinator/Admin Manager 9755 West State Highway 22 P.O. Box 130 Ratcliff, Arizona 72951 479-635-5300 x225	CH061202A	AR	Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to December 11, 2015. Diversion - 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site.	Repayment to manufacturer	CAP implemented Audit closure date: March 1, 2017
Riverside County Regional Medical Center Contact Information Director of Pharmacy Services Riverside University Health System 951-486-4529 G.Prouty@RUHealth.org.	DSH050292	CA	Incorrect 340B database record - Incorrect entry for off-site outpatient facilitys name. Diversions - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
Riverside Medical Center	CAH191313-00	LA	No adverse findings	None	N/A Audit closure date: January 21, 2016
Robeson Health Care Corp Contact Information Director of Pharmacy Services (910) 674-3174 402 N.Pine Street Lumberton, NC 28358	CH049000	NC	Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 30, 2018
Rush Foundation Hospital	DSH250069	MS	No adverse findings	None	N/A Audit closure date: November 1, 2016
Sacred Heart Health System	DSH100025	FL	No adverse findings	None	N/A Audit closure date: August 24, 2016
Saint Francis Hospital and Medical Center Contact Information Pharmacy Director 860-714-7983 Interim VP Integrity & Compliance 860-714-0437 Jamie.McKay@trinityhealth-ne.org	DSH070002	CT	Incorrect 340B database - Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur as a result of this finding. Audit closure date: April 3, 2018
Saint Francis Medical Center Contact Information Josh McCarroll 800 N. E. Glen Oak Avenue Peoria, IL, 61603 (309) 308-3295 josh.r.mccarroll@osfhealthcare.org	DSH140067	IL	Diversion – 340B drugs dispensed to inpatients, 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 30, 2017
Saint Mary's Health Care Contact Information Director of Pharmacy Services Mercy Health Saint Mary's 200 Jefferson Avenue SE Grand Rapids, Ml 49503 616-685-5000	DSH230059	MI	Diversion - 340B drug dispensed at contract pharmacy, not supported by a medical record. Diversion - Entity did not have adequate controls in place for proper accumulation and prevention of diversion.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
Saint Peter’s University Hospital Contact Information Chief Financial Officer 254 Easton Avenue New Brunswick, NJ 08901 (732) 745-6651 gstoldt@saintpetersuh.com	DSH310070	NJ	Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 23, 2016. Diversion – 340B drugs were not properly accumulated. Diversion – 340B drug dispensed to an inpatient; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 3, 2018
Samaritan Pacific Health Systems, Inc. DBA Samaritan Pacific Community Hospital	CAH381314-00	OR	No adverse findings	None	N/A Audit closure date: November 4, 2016
Sanford Bemidji Medical Center Contact Information Director of Pharmacy (218) 333-5543 karla.eischens@sanfordhealth.org 1300 Anne Street NW Bemidji, Minnesota 56601	DSH240100	MN	Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at contract pharmacy, not supported by medical record	Repayment to manufacturers	CAP implemented Audit closure date: April 18, 2017
Sanford Medical Center Fargo	RRC350011-00	ND	No adverse findings	None	N/A Audit closure date: September 7, 2016
Sanford USD Medical Center	DSH430027	SD	Incorrect 340B database record - Incorrect entry for grant number prior to December 21, 2015.	None	CAP implemented Audit closure date: April 6, 2016
Scripps Mercy Hospital Contact Information 340B Program Director (619) 260-7308 Todd.shohreh@scrippshealth.org	DSH050077	CA	Incorrect 340B database record ineligible sites registered on the 340B database prior to April 1, 2016. Diversion –340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: March 8, 2017
Seton Edgar. B. Davis Hospital	CAH451371-00	TX	Incorrect 340B database record - Closed offsite outpatient facility listed on the 340B database; Incomplete address listing for an offsite outpatient facility. Incorrect or incomplete information in the 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 19, 2017
Sharp County Health Unit	FP725131 STD722054 TB722057	AR	No adverse findings	None	N/A Audit closure date: January 6, 2016
Sharp Memorial Hospital Contact Information Manager of Pharmacoeconomics 8695 Spectrum Center Blvd San Diego, CA, 92130 (858) 499-4220	DSH050100	CA	Incorrect 340B database record Duplicate entry for offsite outpatient facility. Diversion 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 8, 2017
Sinai Hospital of Baltimore Contact Information Executive Director of Outpatient Pharmacy 5401 Old Court Rd. Randallstown, MD 21133 410-521-1772	DSH210012	MD	Diversion - 340B drug dispensed to an inpatient; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites. Incorrect or incomplete information in the 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: May 8, 2017
Singing River Health System Contact Information Administrator of Ancillary Services heath.thompson@mysrhs.com (228) 818-1191	DSH250040	MS	Diversion 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites; 340B drugs dispensed, not supported by medical records. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 10, 2017
Sisters of Charity Contact Information Sisters of Charity Hospital c/o Catholic Health System 340B Program Business Manager Administrative Regional Training Center- 4th Floor West 144 Genesee Street Buffalo, New York 14203 (716) 923-2920 dshuldman@chsbuffalo.org	DSH330078	NY	Covered outpatient drugs obtained through a Group Purchasing Organization prior to October 19, 2016. Diversion – 340B drugs dispensed to inpatients; 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites. Inaccurate or incomplete information in the 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: December 11, 2018
SMDC Medical Center	DSH240019	MN	No adverse findings	None	N/A Audit closure date: April 24, 2017
South Georgia Medical Center Contact Information Director of Pharmacy South GA Medical Center, 2501 N. Patterson Street, Valdosta, GA 31602 229-259-4870	DSH110122	GA	Diversion - 340B drugs were not properly accumulated	Repayment to manufacturers	CAP implemented Audit closure date: November 9, 2017
Southwest Georgia Health Care, Inc.	CH043340	GA	No adverse findings	None	N/A Audit closure date: October 4, 2016
Spartanburg Medical Center Contact Information Manager SRHS Pharmacy Business Operations Spartanburg Medical Center 101 East Wood Street Spartanburg, SC 864-560-6772 option #3, #3, #1	DSH420007	SC	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 11, 2018
SSM St. Anthony Hospital Contact Information System Vice President Finance – Oklahoma 1000 N. Lee Street PO Box205 Oklahoma City, OK 73101 405.272.7279	DSH370037	OK	Incorrect 340B database record – incorrect entry for shipping address. Diversion – 340B drugs dispensed to inpatients; 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to Manufacturers	CAP implemented Audit closure date: October 13, 2016
St. Bernardine Medical Center Contact Information Director of Pharmacy (909) 881-4473 kenneth.le@dignityhealth.org	DSH050129	CA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: October 10, 2017
St. Claire Medical Center, Inc.	DSH180018	KY	Incorrect or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: February 23, 2018
St. Francis Memorial Hospital	CAH281322-00	NE	Entity did not provide contract pharmacy oversight prior to November 2016.	None	CAP implemented Audit closure date: July 11, 2017
St. Johns Riverside Hospital Contact Information Janine O’Donnell 967 N. Broadway Yonkers, NY, 10701 (914) 964-4827	DSH330208	NY	Covered outpatient drugs obtained through a Group Purchasing Organization prior to November 16, 2015. Diversion – 340B drugs were not properly accumulated. Diversion – 340B drugs dispensed to inpatients.	Repayment to manufacturers	CAP implemented Audit closure date: February 22, 2017
St. Joseph’s Health Services, Inc. dba St. Joseph’s Health Services-Gundersen Lutheran	CAH521304-00	WI	No adverse findings	None	N/A Audit closure date: January 6, 2016
St. Joseph’s Medical Center	DSH050084	CA	Incorrect 340B database record – Registered contract pharmacies without written contracts in place.	Termination of contract pharmacies from the 340B Program*	CAP implemented Audit closure date: February 8, 2017
St. Vincent Charity Medical Center Contact Information Chief Financial Officer 2351 East 22nd Street Cleveland, Ohio, 44115	DSH360037	OH	Incorrect 340B database record - Registered Contract Pharmacies without written contract in place. Diversion 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites.	Termination of contract pharmacies from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: October 3, 2017
Sterling Area Health Center Contact Information Patient Assistant Coordinator 725 East State Street Sterling, MI 48659 (989) 654-2491 ext 3766	CH052250	MI	Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: November 2, 2017
Stillwater Medical Center Authority	SCH370049-00	OK	No adverse findings	None	N/A Audit closure date: April 20, 2016
Stormont-Vail Healthcare Inc.	DSH170086	KS	No adverse findings	None	N/A Audit closure date: January 24, 2017
Summersville Memorial Hospital	DSH510082	WV	Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 4, 2016. Offsite outpatient facility failed to maintain auditable records. Incorrect 340B database records - Offsite outpatient facilities were not listed on the 340B database; Incorrect listing for Authorizing Official Diversion - 340B drugs dispensed to inpatients; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of covered entity from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: January 3, 2018
Summit Healthcare Association DBA Summit Healthcare Regional Medical Center	DSH030062	AZ	No adverse findings	None	N/A Audit closure date: April 1, 2016
Sun Life Family Health Center, Inc. Contact Information Director of Pharmacy 520-350-7590 CEO 520-836-3446 865 N. Arizola Rd. Casa Grande, AZ 85122	CH090030	AZ	Incorrect 340B database record - Incorrect listing for shipping addresses; Inaccurate entries for names of offsite facilities. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: September 12, 2018
Sutter Medical Center Sacramento	DSH050108	CA	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Closed offsite outpatient facility listed on the 340B database; Pharmacy incorrectly registered as a child site.	None	CAP implemented Audit closure date: July 15, 2016
Sutton County Hospital District Contact Information Director of Pharmacy Services 325-387-1220 Pharmacy@sonora-hospital.com	CAH451324-00	TX	Diversion – 340B drugs dispensed at contract pharmacy for prescription originating from ineligible site. Incorrect or incomplete information in the 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: May 3, 2018
Tacoma General/ Allenmore Hospital Contact Information Pharmacy Purchasing Manager (253) 403-2082 vafa.aflatooni@multicare.org PO Box 5299, Mailstop 315-C2-RX, 315 Martin Luther King Jr Way, Tacoma, WA, 98415-0299	DSH500129	WA	Diversion – 340B drugs dispensed at the covered entity for prescriptions originating from ineligible sites	Repayment to manufacturers	CAP implemented Audit closure date: January 10, 2018
Thayer County Memorial Hospital dba Thayer County Health Services	CAH281304-00	NE	No adverse findings	None	N/A. Audit closure date: September 7, 2016
The Cooper Health System dba Cooper University Hospital	DSH310014	NJ	Incorrect 340B database record – Incorrect entry for DSH percentage	None	CAP implemented Audit closure date: April 19, 2018
Touro Infirmary Contact Information 340B Program Coordinator; Touro Infirmary 1401 Foucher St. New Orleans, LA, 70115 (504) 897-7515 daniel.henry@lcmchealth.org	DSH190046	LA	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 5, 2017
Tuality Healthcare Contact Information Director of Pharmacy 503-681-1041 Kevin.declercque@tuality.org	DSH380021	OR	Covered outpatient drugs obtained through a Group Purchasing Organization from August 7, 2013 to July 30, 2016. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 21, 2018
Uintah Basin Medical Center	SCH460019-00	UT	No adverse findings	None	N/A Audit closure date: June 14, 2016
Umpqua Community Health Center, Inc. Contact Information Chief Compliance Officer 150 Kenneth Ford Drive Roseburg, OR 97470 (541) 672-9596 x107 jpospisil@umpquach.org	CH103100	OR	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. State Medicaid has since determined that duplicate discounts did not occur as a result of this finding. Duplicate Discounts - Entity was billing at contract pharmacies and contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers.	CAP implemented Audit closure date: June 13, 2017
Unconditional Love, Inc.	HV32935	FL	No adverse findings	None	N/A Audit closure date: September 23, 2016
United Hospital Contact Information Pharmacy Portfolio Manager 2925 Chicago Avenue Mail Route 10807 Minneapolis, MN, 55407 (612) 262-4785 Tony.Collins-Kwong@allina.com	DSH240038	MN	Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 19, 2017
University Hospital Contact Information Director of Pharmacy University Hospital 1350 Walton Way Augusta, Georgia 30901 706-774-2718	DSH110028	GA	Diversion - 340B drugs dispensed at the entity for prescriptions originating at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: October 11, 2017
University Hospital	DSH330241	NY	Diversion – 340B drug dispensed to an inpatient.	Repayment to manufacturers	CAP implemented Audit closure date: February 23, 2018
University Hospitals and Clinics Contact Information Chief Integrity and Compliance Officer University of Mississippi Medical Center 2500 North State Street Jackson, MS, 39216	DSH250001	MS	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacy without written contract in place. Diversion – 340B drugs dispensed at the entity and at contract pharmacies for prescriptions originating from ineligible sites. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: November 2, 2017
University Medical Center Management Corporation d/b/a University Medical Center New Orleans Contact Information Pharmacy Director 2000 Canal Street New Orleans, Louisiana 70112 Anthony.Laurent@LCMCHealth.org (504) 702-3588	DSH190005	LA	Diversion – 340B drug dispensed to an inpatient.	Repayment to manufacturer	CAP implemented Audit closure date: May 18, 2017
University of Illinois Hospital	DSH140150	IL	No adverse findings	None	N/A Audit closure date: May 20, 2016
University of Iowa Hospitals & Clinics	DSH160058	IA	Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for grant number.	None	CAP implemented Audit closure date: September 27, 2016
University of Maryland Medical Center Contact Information Senior Director of Pharmacy 29 S. Greene St. Baltimore, Maryland, 21201 (410) 328-6746 jdicubellis@umm.edu	DSH210002	MD	Diversion – 340B drugs dispensed to inpatients.	Repayment to manufacturers	CAP implemented Audit closure date: September 15, 2016
University of Minnesota Medical Center	DSH240080	MN	Incorrect 340B database record - Incorrect entry for offsite facility address.	None	CAP implemented Audit closure date: February 22, 2017
University of Tennessee Medical Center Contact Information 340B Pharmacist (865) 305-8174 vshelton@utmck.edu	DSH440015	TN	Diversion – 340B drug dispensed to an inpatient; 340B drug dispensed at the entity for a prescription originating from ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: May 12, 2017
University of Utah Hospital	DSH460009	UT	No adverse findings	None	N/A Audit closure date: March 29, 2016
University of Washington Medical Center	DSH500008	WA	No adverse findings	None	N/A Audit closure date: September 27, 2016
Valley Health Systems Contact Information Associate CFP 3377 US Route 60, Huntington WV 25705 (304) 525-3334 (ext. 5110)	CH030880	WV	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites	Repayment to manufacturers	CAP implemented Audit closure date: August 14, 2018
VNA Health Care Contact Information Vice President of Specialty Care and Wellness Services 400 N. Highland Avenue, Aurora Illinois 60506 630-978-2532 Ext. 8116	CH0526100	IL	Incorrect 340B database record - Registered contract pharmacy without written contract in place. Diversion - 340B drug dispensed at the entity for a prescription originating from ineligible site. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of contract pharmacies from the 340B Program* Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: October 23, 2017
Webster County Health Department	FP397443	MS	No adverse findings.	None	N/A Audit closure date: November 15, 2016
West Penn Hospital Contact Information Director, Outpatient Pharmacy Services: 412-578-4050 or Jdavis@wpahs.org	DSH390090	PA	Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database. Diversion – 340B drug dispensed at a contract pharmacy for a prescription originating from ineligible site. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to Manufacturers	CAP approved Audit closure date: August 8, 2017
Westside Family Healthcare, Inc.	CH032960	DE	No adverse findings	None	N/A Audit closure date: October 4, 2016
Winter Haven Hospital Contact Information Manager of BayCare Pharmacy Supply Chain Winter Haven Hospital 200 Avenue F, NE Winter Haven, FL 33881 863-293-1121 x1432	DSH100052	FL	Incorrect 340B database record - Duplicate listing of a facility on the 340B database. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2017
WomenCare, Inc.	CH038440	WV	No adverse findings	None	N/A Audit closure date: November 8, 2016
Woodland Memorial Hospital Contact Information Director of Pharmacy 1325 Cottonwood St. Woodland, CA 95695 530-669-5506 Denise.foreman@dignityhealth.org	DSH050127	CA	Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufactures	CAP implemented Audit closure date: May 16, 2018
Yale New Haven Hospital	DSH070022	CT	No adverse findings	None	N/A Audit closure date: December 29, 2016

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

Date Last Reviewed:

December 2023

Parents: don’t struggle alone

Program Integrity: FY16 Audit Results