Program Integrity: FY17 Audit Results

Updated 11/28/23. 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
Access Community Health Network Contact Information Program Manager for 340B 600 W. Fulton, 2nd Floor, Chicago, IL 60661 (312) 526-2107	CH051750	IL	Incorrect 340B database record – Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. 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: April 5, 2018
Access Community Health Network	FP60101	IL	No adverse findings	None	N/A Audit closure date: October 23, 2017
Addabbo Joseph Family Health Center, The Contact Information Chief Financial Officer 6200 Beach Channel Drive Arverne, NY 11692 (718) 945-7150 x1311	CH022110	NY	Incorrect 340B database record – Incorrect entry for Primary Contact; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 13, 2018
Adelante Healthcare, Inc. Contact Information 340B Program Coordinator 9520 W Palm Ln, Ste. 200 Phoenix, AZ 85037 (623) 583-3001 x1312	CH093030	AZ	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate registrations of contract pharmacies on database; Registered contract pharmacy without written contract in place. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of contract pharmacy from the 340B Program Repayment to manufacturers	CAP implemented Audit closure date: November 8, 2018
Advocate Christ Medical Center	DSH140208	IL	No adverse findings	None	N/A Audit closure date: June 21, 2017
Advocate North Side Health Network	DSH140182	IL	No adverse findings	None	N/A Audit closure date: June 28, 2017
Allen County Hospital Contact Information Comptroller 3066 N Kentucky St Iola, KS 66749 (620) 365-1034	CAH171373-00	KS	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion - 340B drug dispensed at a contract pharmacy to a patient at entity without a documented provider to patient relationship.	Repayment to manufacturer	CAP implemented Audit closure date: November 7, 2018
Amery Regional Medical Center Contact Information Director of Pharmacy Amery Regional Medical Center 265 E. Griffin Street Amery, WI 54001 (715) 268-0670	CAH521308-00	WI	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 25, 2019
Appalachian Regional Healthcare dba Morgan County ARH Hospital	CAH181307-00	KY	No adverse findings	None	N/A Audit closure date: July 25, 2017
Aspirus Iron River Hospital and Clinics Contact Information Chief Financial Officer 340B Authorizing Official Aspirus Iron River Hospital and Clinics 1400 West Ice Lake Road Iron River, Michigan 49935 (906) 265-0436 Glenn.Dobson@Aspirus.org	CAH231318-00	MI	Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File	Repayment to manufactures	CAP implemented Audit closure date: November 15, 2018
Aspirus Medford Hospital and Clinics, Inc.	CAH521324-00	WI	No adverse findings	None	N/A Audit closure date: August 22, 2017
AU Medical Center, Inc. Contact Information 340B Program Manager AU Medical Center, Inc. 1120 15th Street, BI-2101 Augusta, GA 30912 (706) 721-0082	DSH110034	GA	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: December 18, 2018
Avera St. Benedict Health Center	CAH431330-00	SD	No adverse findings	None	N/A Audit closure date: September 7, 2017
Baptist Health Corbin Contact Information 340B Program Manager Baptist Health System Services 2701 Eastpoint Parkway Louisville, KY 40223 (502) 253-4746 quanika.penny@bhsi.com	DSH180080	KY	Diversion – 340B drug dispensed to a patient at entity for a prescription written at an ineligible site	Repayment to manufacturer	CAP implemented Audit closure date: December 4, 2018
Baptist Health Lagrange	DSH180138	KY	No adverse findings	None	N/A Audit closure date: October 19, 2017
Baptist Health Lexington Contact Information 340B Program Manager Baptist Health System Services 2600 Eastpoint Parkway, Suite 103 Louisville, KY 40223 (502) 253-4746	DSH180103	KY	Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed at entity for prescriptions written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: August 28, 2018
Baptist Health Medical Center - Arkadelphia Contact Information Senior Reimbursement Specialist Baptist Health - Little Rock, AR Attn: Accounting 9601 Baptist Health Drive Little Rock, AR 72205 (501) 202-1813 Office (501) 202-2385 Fax	CAH041321-00	AR	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 2, 2018
Baptist Hospital of Miami, Inc. Contact Information Director, Supply Chain Quality Assurance 9001 NW 33 Street Doral, FL 33172 786-595-9023 haleyf@baptisthealth.net	DSH100008	FL	Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 17, 2017 Diversion - 340B drugs dispensed at entity for prescriptions written at an 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: February 15, 2019
Bayhealth Medical Center Inc. Contact Information Pharmacy Business Manager Bayhealth Medical Center 640 S. State St. Dover, DE 19901 (302) 744-6753	DSH080004	DE	Incorrect 340B database record – ineligible site registered on 340B database. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at an ineligible sites.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: May 22, 2018
Baylor University Medical Center Contact Information Pharmacy Director BUMC 3500 Gaston Ave. Dallas, Texas 75246 (214) 820-6826	DSH450021	TX	Entity did not meet eligibility requirements as a DSH hospital as of November 29, 2016. Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; incorrect entry for Primary Contact. Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship.	Termination of covered entity from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: September 19, 2018
Belmond Community Hospital Contact Information Pharmacy Leader 1316 S. Main Street Clarion, IA 50525 (515) 532-9199	CAH161301-00	IA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at an ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: December 21, 2018
Berkshire Medical Center Contact Information 340B Coordinator 725 North Street Pittsfield, MA 01201 (413) 445-7079	DSH220046	MA	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: August 21, 2018
Bethesda Hospital Contact Information Director of Pharmacy 2815 South Seacrest Blvd. Boynton Beach, FL 33435 (561)737-7733 ext. 84584	DSH100002	FL	Diversion – 340B drug dispensed to a patient at entity for a prescription written at an ineligible site; 340B drug dispensed without a documented provider to patient relationship.	Repayment to manufacturer	CAP implemented Audit closure date: August 15, 2018
Blue Hill Memorial Hospital	CAH201300-00	ME	No adverse findings	None	N/A Audit closure date: August 29, 2017
Boa Vida Hospital of Aberdeen, MS, LLC D/B/A Monroe Regional Hospital formerly: Pioneer Health Services of Monroe County, Inc. dba Pioneer Community Hospital Contact Information Director of Pharmacy 400 Chestnut St. Aberdeen, MS 39730 (662) 369-2455	CAH251302-00	MS	Incorrect 340B database record – Failed to remove closed location registration; incorrect entry for primary contact information. Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drugs dispensed at contract pharmacy for prescriptions written by an ineligible provider.	Repayment to manufacturers	CAP implemented Audit closure date: April 10, 2019
Bon Secours Richmond Community Hospital Contact Information 340B Program Manager 1500 N. 28th Street Richmond, Virginia 23223 (804) 221-4837	DSH490094	VA	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drug dispensed at contract pharmacy for a prescription written at ineligible sites.	Repayment to manufacturer	CAP implemented Audit closure date: February 28, 2019
Boyle County Health Department	FP404228	KY	No adverse findings	None	N/A Audit closure date: April 20, 2017
BRFHH Monroe LLC d/b/a University Health Conway Contact Information Director of Pharmacy University Health Conway 4864 Jackson Street Monroe, LA 71202 (318) 330-7969	DSH190011	LA	Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: July 24, 2018
Care Resource Community Health Centers, Inc. (formerly Community AIDS Resource) Contact Information Director of Grants, Contract and Pharmacy Services 3510 Biscayne Blvd Miami, FL 33137 (305) 576-1234, Ext 230	CHC11399-00	FL	Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact; Incorrect entry for offsite outpatient facility address. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites	Repayment to manufacturers	CAP approved
Carolinas HealthCare System University	DSH340166	NC	No adverse findings	None	N/A Audit closure date: September 12, 2017
Carolinas Medical Center	DSH340113	NC	No adverse findings	None	N/A Audit closure date: September 11, 2017
Central Counties Health Centers, Inc. Contact Information Q2	CH059700	IL	No adverse findings	None	N/A Audit closure date: June 23, 2017
Central Mississippi Civic Improvement Association, Inc.	CH040750	MS	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 24, 2018
Chapa-De Indian Health Program Inc. Contact Information Primary Contact for 340B Chapa-De Indian Health Program 11670 Atwood Road Auburn, CA 95603 (530) 887-2800 rsingh@chapa-de.org	FQHC638002	CA	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: April 5, 2018
Charleston Area Medical Center	DSH510022	WV	No adverse findings	None	N/A Audit closure date: March 13, 2017
Children's Medical Center Dallas Contact Information Director Business Operations, Pharmacy Services 1935 Medical District Drive Dallas, Texas 75235 (214) 456-7437	PED453302-00	TX	Incorrect 340B database record – Incorrect entry for offsite facility address. 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: September 24, 2018
Children’s Hospital Boston Contact Information Chief Pharmacy Officer 300 Longwood Ave. Boston, MA 02115 (617) 355-6945	PED223302-00	MA	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 5, 2019
Children’s Hospital of San Antonio	PED453315-00	TX	No adverse findings	None	N/A Audit closure date: August 29, 2017
Children’s Hospital Orange County Contact Information 340B Compliance Analyst 1201 W. La Veta Ave Orange, CA 92868 (714) 509-8342	PED053304-00	CA	Diversion – 340B drugs dispensed at entity for prescriptions written at an ineligible site	Repayment to manufacturers	CAP implemented Audit closure date: August 7, 2018
Chinese Hospital Contact Information Director, Quality/Compliance Officer 845 Jackson St San Francisco, CA 94133 patriciac@chasf.org	DSH050407	CA	Incorrect 340B database record – Incorrect entries for off-site outpatient facility address, authorizing official and primary contact information. Diversion - 340B drugs dispensed at entity 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: March 29, 2019
Chippewa County War Memorial Hospital Contact Information Director of Pharmacy (906)635-4450 500 Osborn Boulevard Sault Sainte Marie, MI 49783	SCH230239-00	MI	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: September 12, 2018
Christus Spohn Hospital Alice Contact Information Pharmacy Director CHRISTUS Spohn Health System 600 Elizabeth Street Corpus Christi, TX 78404 361-881-6491 Deborah.allen3@christushealth.org	DSH450828	TX	Diversion- 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 9, 2018
Christus St. Frances Cabrini Hospital Contact Information Vice President – Advis Group 19065 Hickory Creek Drive, Suite 115 Mokena, IL 60448 708-478-7030 davants@theadvisgroup.com Director of Pharmacy 3330 Masonic Dr. Alexandria, LA 71301 318-348-1922	DSH190019	LA	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: September 24, 2018
Clara Barton Hospital Association	CAH171333-00	KS	No adverse findings	None	N/A Audit closure date: November 22, 2017
Community Clinic, Inc. Contact Information Associate Chief Medical Officer 8630 Fenton Street, Suite 1204 Silver Spring, MD 20910 Phone: 301-340-7525 Fax: 301-495-0318	CHC10591-00	MD	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for address for outpatient facilities; Registered two contract pharmacies without written contracts in place. Entity did not provide contract pharmacy oversight prior to November 2017. Diversion – 340B drug dispensed to patient at entity without a documented provider to patient relationship. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of contract pharmacy from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: June 27, 2019
Community Health Center of Lubbock, Inc.	CH062910	TX	No adverse findings	None	N/A Audit closure date: May 19, 2017
Community Health Centers of Pinellas, Inc.	CH049070	FL	Inaccurate or incomplete information in Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of this finding.	None	CAP implemented Audit closure date: January 2, 2018
Community Health Centers of the Central Coast, Inc. Contact Information Director of 340B Program Email: ayip@chccc.org 805-346-3987 150 Tejas Place, Nipomo, Ca 93444	CH090710	CA	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 19, 2018
Comprehensive Care Center, Inc. dba Community AIDS Network	RWII34287	FL	No adverse findings	None	N/A Audit closure date: June 29, 2017
County of Lake Contact Information Clinical Compliance Manager 847-377-8540 3010 Grand Avenue Waukegan, IL 60085	CH058870	IL	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: February 11, 2019
Crosbyton Clinic Hospital Contact Information Director 806-675-8700 Debbie.tue@crosbytonclinichospital.com	CAH451345-00	TX	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 25, 2018
Dallas County Medical Center	CAH041317-00	TX	No adverse findings	None	N/A Audit closure date: May 31, 2017
DCH Regional Medical Center Contact Information Corporate Director of Compliance and Internal Audit 205-759-7715 809 University Blvd. East Tuscaloosa, AL 35401	DSH010092	AL	Incorrect 340B database record - Incorrect entry for address for outpatient facilities. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Inaccurate or incorrect information on the 340B 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: February 11, 2019
Delano Regional Medical Center	DSH050608	CA	No adverse findings	None	N/A Audit closure date: May 3, 2017
Delta Regional Medical Center	DSH250082	MS	No adverse findings	None	N/A Audit closure date: May 10, 2017
Detroit Community Health Connection	CH052070	MI	No adverse findings	None	N/A Audit closure date: May 26, 2017
Dominican Hospital (formerly Dominican Santa Cruz Hospital)	DSH050242	CA	No adverse findings	None	N/A Audit closure date: August 8, 2017
East Alabama Medical Center Contact Information Manager of Purchasing & 340B Compliance East Alabama Medical Center 2000 Pepperell Parkway Opelika, AL 36801-5422 334-528-2565 Dana.jackson@eamc.org	DSH010029	AL	Diversion – 340B drugs dispensed at entity for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 2, 2019
East Liverpool City Hospital Contact Information System Director, 340B Program and Ambulatory Care 1000 Remington Clve, Suite 100 Bolingbrook, IL 60440 630-914-2872	DSH360096	OH	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written 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 16, 2019
Eau Claire Cooperative Health Center	CH043270	SC	No adverse findings	None	N/A Audit closure date: May 22, 2017
Ephraim McDowell Regional Medical Center, Inc. Contact Information Chief Financial Officer 217 S. Third Street Danville, KY 40422 859-239-2424	DSH180048	KY	Diversion - 340B drugs dispensed at entity and contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 26, 2019
Escambia Community Clinics, Inc. Contact Information Chief Administrative Officer 850-436-4630 14 West Jordan Pensacola, FL 32501	CH0452890	FL	Incorrect 340B database record – Registered contract pharmacies without written contracts in place. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of two contract pharmacies from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: July 31, 2018
Essentia Health St. Mary's Hospital-Superior	CAH521329-00	WI	No adverse findings	None	N/A Audit closure date: October 11, 2017
Family Christian Health Center	CH059300	IL	Incorrect 340B database record- Registered contract pharmacy without written contract in place	Termination of contract pharmacy from 340B Program	CAP implemented Audit closure date: August 7, 2018
Franciscan Health Hammond	DSH150004	IN	No adverse findings	None	N/A Audit closure date: July 25, 2017
Franklin Regional Hospital	CAH301306-00	NH	No adverse findings	None	N/A Audit closure date: August 30, 2017
Franklin Woods Community Hospital Contact Information Corporate Pharmacy Business Director (423) 302-3535 cindy.tucker@balladhealth.org	DSH440184	TN	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 12, 2019
Fresno Community Hospital & Medical Center dba Clovis Community Medical Center Contact Information Chief Audit, Ethics, and Compliance Officer 559-324-4830 789 N. Medical Center Drive East, Clovis, CA 93611	DSH050492	CA	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 25, 2018
Froedtert Memorial Lutheran Hospital Contact Information Froedtert Hospital 340B Manager Doreene.Brecheisen@froedtert.com 262-532-5160 Integrated Service Center N86W12999 Nightingale Way Memomonee Falls, WI 53051	DSH520177	WI	Diversion - 340B drug dispensed at entity for a prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: March 13, 2019
Grandview Hospital Contact Information Director of Pharmacy 405 West Grand Avenue Dayton OH 45405 937-723-5816 linda.mccall@ketteringhealth.org	DSH360133	OH	Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts – Inaccurate or incorrect information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: February 11, 2019
Granville Medical Center Contact Information Chief Financial Officer 1010 College Street Oxford, North Carolina 27565 919-690-3402	DSH340127	NC	Covered outpatient drugs obtained through a Group Purchasing Organization prior to September 29, 2017. Incorrect 340B database record – Duplicate registration off offsite outpatient facility on 340B database record; Ineligible sites registered on 340B database. Diversion – 340B drugs dispensed at entity and contract pharmacies for prescriptions written at ineligible sites.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: March 5, 2019
Halifax Health Medical Center Contact Information Halifax Health Pharmacy Dept Fountain Bldg, 3rd floor 303 N. Clyde Morris Blvd. Daytona Beach, FL 32114 (386) 425-4531	DSH100017	FL	Incorrect 340B database record - Ineligible site registered on 340B database prior to September 14, 2017 Diversion – 340B drug dispensed at contract pharmacy for a prescription written by an ineligible provider. Inaccurate or incorrect information on the 340B 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, 2019
Hamdard Center for Health and Human Services NFP	CHC26565-00	IL	Incorrect 340B database record - Registered contract pharmacies without written contract in place. Duplicate Discounts - Entity’s contract pharmacy was billing Medicaid without notification to HRSA.	Termination of two contract pharmacies from 340B Program.	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: February 2, 2018
Harrison Community Hospital	CAH361311-00	OH	No adverse findings	None	N/A Audit closure date: April 27, 2017
Heartland Community Health Clinic DBA: Heartland Health Services	CH051833A	IL	Incorrect 340B database record - Registered contract pharmacy without a contract in place. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program*	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: May 16, 2018
Hennepin County Medical Center	DSH240004	MN	No adverse findings	None	N/A Audit closure date: June 30, 2017
Hiawatha Community Hospital	CAH171341-00	KS	No adverse findings	None	N/A Audit closure date: June 9, 2017
Hospital District #1 of Crawford County Kansas Contact Information Chief Executive Officer 620-724-5152 Hospital District #1 of Crawford County dba Girard Medical Center 302 N Hospital Dr Girard, KS 66743-2000	CAH171376-00	KS	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record; 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: March 13, 2019
Hospital District #1 of Dickinson Contact Information Chief Financial Officer 785-263-6614 511 N.E. 10th Street Abilene, Kansas 67410	CAH171381-00	KS	Incorrect 340B database record – Ineligible sites registered on 340B database; Incorrect entry for offsite outpatient facility address. Diversion – 340B drugs dispensed at entity and contract pharmacies for prescriptions written 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.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: January 8, 2019
Hurley Medical Center	DSH230132	MI	No adverse findings	None	N/A Audit closure date: February 28, 2018
Independent Healthcare Management, Inc. dba SE Lackey Memorial Hospital Contact Information Pharmacy Director 330 North Broad Street Forest, MS 39074 (601) 469-4151	CAH251300-00	MS	Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturer	CAP implemented April 17, 2019
Integris Miami Hospital Contact Information System Administrative Director INTEGRIS Health, Inc. 3300 Northwest Expressway Oklahoma City, OK 73112	DSH370004	OK	Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: January 11, 2019
Iowa Specialty Hospital – Clarion Contact Information Pharmacy Leader 1316 S. Main Clarion, IA 50525 (515) 532-9199	CAH161302-00	IA	Diversion - 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: September 20, 2018
Iroquois Memorial Hospital and Resident Home Contact Information Chief Financial Officer (815) 432-7929 200 E. Fairman Ave Watseka, IL 60970-1644	SCH140167-00	IL	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written 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. Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: March 26, 2019
J Arthur Dosher Memorial Hospital Contact Information Pharmacy Director JA Dosher Memorial Hospital 924 N Howe St. Southport, NC 28461 (910) 457-3835	CAH341327-00	NC	Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: October 30, 2018
Jane Todd Crawford Memorial Hospital, Inc. dba Jane Todd Crawford Hospital	CAH181325-00	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: July 18, 2017
John H. Stroger, Jr. Hospital of Cook County Contact Information Senior Director of Pharmacy Cook County Health & Hospitals System 1901 West Harrison St, Suite LL134 Chicago, IL 60612 Cnorwood@cookcountyhhs.org	DSH140124	IL	Covered outpatient drugs obtained through a Group Purchasing Organization prior to August 23, 2016. Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File; Entity’s contract pharmacy was billing Medicaid without notification to HRSA.	Repayment to manufacturers.	CAP implemented Audit closure date: September 5, 2019
Jones Memorial Hospital Contact Information 340B Business Manager Pharmacy Department, University of Rochester Medical Center 120 Corporate Woods, Suite 350 Rochester, NY 14623 (505)-785-5154	SCH330096-00	NY	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: May 3, 2018
Keystone Rural Health Center	CH032700	PA	No adverse findings	None	N/A Audit closure date: March 23, 2017
Kiowa County Hospital District dba Weisbrod Memorial Hospital	CAH061300-00	CO	Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to August 11, 2017; Entity did not provide contract pharmacy oversight prior to onsite audit.	None	CAP implemented Audit closure date: January 2, 2018
Knox County Hospital District Contact Information CEO Knox County Hospital District 701 South 5th Street P.O. Box 608 Knox City, Texas 79529 940-657-3535	SCH450746-00	TX	Entity did not meet eligibility requirements as a DSH hospital as of March 10, 2017. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of covered entity from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: March 25, 2019
Lafayette General Medical Center Contact Information Director of Pharmacy 337-289-7888 1214 Coolidge Blvd Lafayette, LA 70503	DSH190002	LA	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; 340B drugs were not properly accumulated. Duplicate Discounts- Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: August 29, 2018
Laird Hospital, Inc.	CAH251322-00	MS	No adverse findings	None	N/A Audit closure date: May 5, 2017
Legacy Emanuel Hospital and Health Center	DSH380007	OR	No adverse findings	None	N/A Audit closure date: December 21, 2017
Los Angeles County Contact Information Pharmacy Service Chief LAC Pharmacy Affairs sdsouza@dhs.lacounty.gov 213-240-7717	DSH050376	CA	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufactures	CAP implemented Audit closure date: August 23, 2018
Lucile Salter Packard Children’s Hospital	HM6415	CA	No adverse findings	None	N/A Audit closure date: August 8, 2017
Lynn Community Health, Inc.	CH011430	MA	Incorrect 340B database record – Failed to remove shipping address of closed location; Registered contract pharmacy without a contract in place prior to November 3, 2017. 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: January 18, 2019
Manatee County Rural Health Services Inc.	CH044310	FL	Incorrect 340B database record - Registered contract pharmacies without written contract in place.	Termination of contract pharmacies from 340B Program	CAP implemented Audit closure date: May 23, 2018
Marengo Memorial Hospital Contact Information Authorizing Official, Marengo Memorial Hospital Chief Operating Officer 300 W May Street Marengo IA 52301 319-642-8013 mmurphy@marengohospital.org	CAH161317-00	IA	Diversion - 340B drugs were not properly accumulated;	Repayment to manufacturers	CAP implemented Audit closure date: April 19, 2018
Marion General Hospital, Inc.	DSH150011	IN	No adverse findings	None	N/A Audit closure date: September 1, 2017
Medical University Hospital Authority Contact Information Manager Pharmacy Supply Chain Medical University of South Carolina 150 Ashley Ave, MSC 584 Charleston, SC 29425 (843) 792-7354 millsja@musc.edu	DSH420004	SC	Diversion - 340B drug dispensed at entity for prescription written at an ineligible site; 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: September 5, 2019
Medina County Hospital District	CAH451330-00	TX	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 26, 2018
Memorial Hermann Sugar Land Hospital Contact Information System Director of Pharmacy Operations 902 Frostwood, Suite 190 Houston, TX 77024 713-242-2814	DSH450848	TX	Incorrect 340B database record – Incorrect entry for offsite facility address. Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drugs were not properly accumulated. Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers.	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: January 18, 2019
Memorial Medical Center Contact Information Chief Financial Officer Memorial Medical Center 815 N. Virginia Street Port Lavaca, Texas 77979 dmoore@mmcportlavaca.com 361-552-0224	CAH451356-00	TX	Incorrect 340B database record - Registered contract pharmacies without written contract in place. Diversion -340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: January 28, 2019
Memorial Medical Center, Inc.	CAH521359-00	WI	Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: April 17, 2018
Mercy Hospital Berryville	CAH041329-00	AR	No adverse findings	None	N/A Audit closure date: July 17, 2017
Mercy Hospital of Franciscan Sisters	CAH161338-00	IA	No adverse findings	None	N/A Audit closure date: June 27, 2017
Mercy Medical Center	CAH161377-00	IA	No adverse findings	None	N/A Audit closure date: August 29, 2017
Mercy Medical Center	DSH210008	MD	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure dated: September 12, 2018
Mercy San Juan Medical Center	DSH050516	CA	No adverse findings	None	N/A Audit closure date: June 29, 2017
Methodist Hospital of Sacramento Contact Information Director of Pharmacy 916-681-1665 6500 Hospital Drive Sacramento, CA 96823 Gurpreet.johal@dignityhealth.org	DSH050590	CA	Diversion – 340B drug dispensed for a prescription written for an inpatient. Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 21, 2018
Methodist Hospitals, The Contact Information Health System Director of Pharmacy 219-738-5807 600 Grant St. Gary, IN 46402	DSH150002	IN	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 11, 2018
Methodist Medical Center of Illinois Contact Information Regional Pharmacy IS Coordinator 221 NE Glen Oak Ave. Peoria, IL 61636 309-689-6029 Joseph.hersemann@unitypoint.org	DSH140209	IL	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 31, 2018
Mid-Columbia Medical Center Contact Information Pharmacy Director 541-296-7526 1700 E. 19th Street The Dalles, OR 97058	SCH380001-00	OR	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for Authorizing Official and Primary Contact; Registered contract pharmacies without written contract in place. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; A 340B drug was not properly accumulated. Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: July 24, 2018
Miller County Health Department	TB31737	GA	Incorrect 340B database record – Incorrect entry for grant number prior to April 29, 2017.	None	CAP implemented Audit closure date: August 17, 2017.
Mississippi County Health Unit	FP723708	MS	No adverse findings	None	N/A Audit closure date: August 9, 2017
Modoc Medical Center	CAH051330-00	CA	No adverse findings	None	N/A Audit closure date: August 9, 2017
Monroe County Hospital	DSH010120	AL	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.	None	CAP implemented Audit closure date: January 2, 2018
Montrose Memorial Hospital Contact Information Director of Pharmacy Services 800 S. 3rd St. Montrose CO 81401 (970) 249-2211	SCH060006-00	CO	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drug dispensed for a prescription written for an inpatient; 340B drugs dispensed at a contract pharmacy for a prescription written at an ineligible site. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 7, 2018
Moore County Hospital District dba Memorial Hospital Contact Information Chief Operating Officer 224 E. 2nd Dumas, Texas 79029 (806) 935-7171	DSH450221	TX	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Diversion - 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: October 30, 2018
Mount Sinai Hospital, The Contact Information Senior Director of Pharmacy, 340B Program 25-10 30th Avenue Astoria NY (718) 267-4295 Philip.manning@mountsinai.org	DSH330024	NY	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Ineligible sites registered on 340B database. Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites.	Termination of ineligible offsite outpatient facilities from the 340B Program Repayment to manufacturers	CAP implemented Audit closure date: September 7, 2018
Neshoba County General Hospital Contact Information Pharmacy Director Neshoba County General Hospital 1001 Holland Avenue, Philadelphia, MS 39250 (601) 781-2310 ricky@neshoba-hospital.com	SCH250043-00	MS	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 15, 2018
Newberry County Memorial Hospital Contact Information Director of Pharmacy Newberry County Memorial Hospital PO Box 497 2669 Kinard Street Newberry, SC 29108 (803) 405-7175	SCH420053-00	SC	Diversion – 340B drug dispensed to an inpatient; 340B drug dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: October 30, 2018
Niagara Falls Memorial Medical Center Contact Information 340B Program Coordinator 621 10th Street Niagara Falls, NY 14301 716-278-4537	DSH330065	NY	Covered outpatient drugs obtained through a Group Purchasing Organization prior to May 18, 2017. Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for offsite facility address; Registered contract pharmacies without written contract in place. Diversion – 340B drug dispensed at contract pharmacies without a documented provider to patient relationship; 340B drugs were not properly accumulated.	Termination of four contract pharmacies from the 340B Program. Repayment to manufacturers	CAP implemented Audit closure date: March 1, 2019
Northwest Medical Foundation of Tillamook DBA Tillamook Regional Medical Center Contact Information Pharmacy Director (503) 815-2260 1000 3rd Street Tillamook, OR 97141	CAH381317-00	OR	Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: November 15, 2018
Operation Samahan, Inc. Contact Information Director of Grants and Contracts 619.471.5433 1428 Highland Ave., National City, Ca 91950	CHC26623-00	CA	Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect entry for offsite facility address. Diversion – 340B drug dispensed at a 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.	Repayment to manufacturers	CAP implemented Audit closure date: January 25, 2019
Orchard Hospital	CAH051311-00	CA	No adverse findings	None	N/A Audit closure date: October 18, 2017
Palo Alto County Hospital	CAH161357-00	IA	No adverse findings	None	N/A Audit closure date: September 19, 2017
Pearl River County Hospital Contact Information Authorizing Official 601-795-4543, ext 2142 Gerald.vance@prc-med.com	CAH251333-00	MS	Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact; Registered contract pharmacies without written contract in place. Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship; 340B drug dispensed at entity, not supported by a medical record. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of two contract pharmacies from the 340B Program Repayment to manufacturers	CAP implemented Audit closure date: February 28, 2019
Perry County Memorial Hospital Contact Information Director of Pharmacy 8885 State Road 237 Tell City, IN 47586 (812) 847-0329	CAH151322-00	IN	Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact. Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: May 8, 2019
Perry County Memorial Hospital Contact Information CEO & Authorizing Official 434 N West St Perryville, MO 63775 (573) 547-2536, Ext. 3203 or 340B Program Manager 212 Hospital Ln, Ste 102 Perryville, MO 63775 (573) 547-2536, Ext. 3362	CAH261311-00	MO	Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect address listed for offsite outpatient facility. Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 15, 2018
Philadelphia Health & Education Corp. dba Drexel University College of Medicine	FP191045	PA	Incorrect 340B database record – Incorrect entry for address prior to April 11, 2017.	None	CAP implemented Audit closure date: August 7, 2018
Phoenix Children’s Hospital Contact Information Manager Pharmacy Business Services 1919 East Thomas Road Pharr Phoenix, AZ 85016 (602) 933-4033	PED033302-00	AZ	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drugs dispensed at the entity and at contract pharmacy for prescriptions originating from ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 25, 2017
Pipestone County Medical Center	CAH241374-00	MN	No adverse findings.	None	N/A Audit closure date: December 27, 2017
Presence Mercy Medical Center Contact Information System Director, 340B Program and Ambulatory Care 1000 Remington Clve, Suite 100 Bolingbrook, IL 60440 630-914-2872	DSH140174	IL	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: December 19, 2018
Presence Saint Francis Hospital Contact Information System Director, 340B Program and Ambulatory Care 630.914.2872 1000 Remington Blvd., Suite 100 Bolingbrook, IL 60440	DSH140080	IL	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 22, 2018
Providence Health and Services – Washington	DSH500054	WA	Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: July 19, 2018
Public Hospital District No. 1 of King County DBA Valley Medical Center Contact Information Director of Pharmacy Valley Medical Center 400 South 43rd St. Box 50010 Renton, WA 98055 (425) 228-3400, x5855	DSH500088	WA	Diversion – 340B drugs dispensed to patients at contract pharmacy without a documented provider to patient relationship.	Repayment to manufacturers	CAP implemented Audit closure date: May 29, 2019
Ripon Medical Center, Inc.	CAH521321-00	WI	No adverse findings	None	N/A Audit closure date: June 27, 2017
Rockford Memorial Hospital Contact Information Pharmacy Business Coordinator 2400 North Rockton Ave Rockford, IL 61103 (815) 971-2394	DSH140239	IL	Incorrect 340B database record – Utilized contract pharmacies prior to July 1, 2017 registration date; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: October 15, 2018
Rome Memorial Hospital, Inc.	DSH330215	NY	Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Listed duplicate record for an outpatient facility	None	CAP implemented Audit closure date: June 21, 2017
Rush University Medical Center Contact Information Director, Clinical Operations 1725 W Harrison St, Suite 418 Chicago, IL 60612 (312) 563-2326	DSH140119	IL	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drugs were not properly accumulated. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 26, 2019
Saint Anthony Hospital Contact Information Pharmacy Director Saint Anthony Hospital 2875 W 19th St Chicago, IL 60623 (773) 484-1317	DSH140095	IL	Diversion- 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: December 21, 2018
Saint Joseph East	DSH180143	KY	No adverse findings	None	N/A Audit closure date: March 16, 2017
Saint Mary’s Healthcare	DSH070016	CT	No adverse findings	None	N/A Audit closure date: November 16, 2017
Samaritan Hospital Contact Information Chief Financial Officer 801 E. Wheeler Road Moses Lake, WA 98837 (509) 793-9710	DSH500033	WA	Covered outpatient drugs obtained through a Group Purchasing Organization from October 3, 2016 to March 28, 2017. Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect entry for primary contact; Registered contract pharmacies without written contract in place. Diversion – 340B drugs dispensed at entity for inpatient; 340B drug dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufactures Termination of contract pharmacy from 340B Program*	CAP implemented Audit closure date: April 3, 2019
San Joaquin Community Hospital Contact Information Director of Pharmacy 661-869-6280 2615 Chester Ave. Bakersfield, Ca 93301	DSH050455	CA	Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: August 2, 2018
San Juan Basin Health Dept.	STD81303	CO	No adverse findings	None	N/A Audit closure date: April 13, 2017
San Mateo Medical Center Contact Information Director of Pharmacy 222 West 39th Ave San Mateo, CA 94403 (650) 573-2366	DSH050113	CA	Diversion – 340B drugs purchased for separately registered 340B covered entities with no reimbursable outpatient costs; 340B drugs were not properly accumulated at contract pharmacy. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 25, 2019
San Ysidro Health Center Contact Information Director of Contracts San Ysidro Health Center (619)662-4165	CH091080	CA	Incorrect 340B database record – Inaccurate entries for billing addresses. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 12, 2018
Sanford Health Network	CAH161321-00	IA	No adverse findings	None	N/A Audit closure date: August 9, 2017
Seton Health System	DSH330232	NY	No adverse findings	None	N/A Audit closure date: March 7, 2017
Shasta Community Health Center	CH092240	CA	No adverse findings	None	N/A Audit closure date: August 9, 2017
Skagit County Health Department	STD982738	WA	Incorrect 340B database record - entity improperly registered a repackager as a contract pharmacy.	None	CAP implemented Audit closure date: June 9, 2017
South Florida Baptist Hospital Contact Information Manager of Pharmacy Supply Chain BayCare Health System 7802 E. Telecom Parkway Temple Terrace, FL 33637 813-888-1920	DSH100132	FL	Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to August 25, 2017; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: January 11, 2019
Southcoast Hospitals Group Inc. Contact Information Sr Vice President & Chief Operating Officer 101 Page Street, New Bedford, MA 02740 508-973-5872	DSH220074	MA	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 29, 2018
Southern Monterey County Memorial Hospital DBA George L. Mee Memorial Hospital Contact Information Quality Assurance Director 300 Canal Street King City, CA 93930 831-386-7375	DSH050189	CA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 31, 2016. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: December 18, 2018
Southwest Memorial Hospital Contact Information Chief Financial Officer 1311 N. Mildred Road Cortez, CO 81321 akobel@swhealth.org 970-564-2153	CAH061327-00	CO	Entity did not provide contract pharmacy oversight. Diversion – 340B drugs dispensed at at entity and at contract pharmacies for prescriptions written 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.	Termination of contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: April 19, 2018
Spectrum Health United Hospital	DSH230035	MI	Incorrect 340B database record – Registered one contract pharmacy without written contract in place.	Termination of contract pharmacy from 340B Program	CAP implemented Audit closure date: June 14, 2018
SSM Cardinal Glennon Children’s Medical Center	HM13100	MO	No adverse findings	None	N/A Audit closure date: September 21, 2017
St. Barnabas Hospital	DSH330399	NY	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: January 11, 2019
St. Dominic - Jackson Memorial Hospital	DSH250048	MS	No adverse findings	None	N/A Audit closure date: March 30, 2017
St. Elizabeth’s Hospital of Wabasha, Inc.	CAH241335-00	MN	No adverse findings	None	N/A Audit closure date: July 18, 2017
St. Francis Memorial Hospital	DSH050152	CA	No adverse findings	None	N/A Audit closure date: April 24, 2017
St. Joseph’s Hospital Contact Information Manager of Pharmacy Supply Chain BayCare Health System 7802 E. Telecom Parkway Temple Terrace, FL 33637 813-888-1920	DSH100075	FL	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate registration of offsite outpatient facility on database; Registered contract pharmacies without written contract in place prior to June 29, 2017; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: January 11, 2019
St. Joseph’s Hospital and Medical Center Contact Information Director of Pharmacy St. Joseph’s Hospital and Medical Center 350 West Thomas Road Phoenix, AZ 85013 (602) 406-4744	DSH030024	AZ	Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: July 24, 2018
St. Joseph’s University Medical Center Contact Information Chief Financial Officer 703 Main Street Paterson, NJ 07503 (973) 754-2023	DSH310019	NJ	Incorrect 340B database record - Registered contract pharmacy without written contract in place. Diversion – 340B drug dispensed at the entity for prescriptions written at an ineligible sites; 340B drugs dispensed at entity for inpatients; 340B drugs were not properly accumulated.	Termination of one contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: June 19, 2019
St. Luke’s Magic Valley Regional Medical Center, LTD	SCH130002-00	ID	No adverse findings	None	N/A Audit closure date: June 1, 2017
St. Mary’s Hospital and Medical Center	HV00593	CO	No adverse findings	None	N/A Audit closure date: June 21, 2017
Tarzana Treatment Centers, Inc.	HV00791B	CA	Incorrect 340B database record – Registered contract pharmacy without written contract in place; Utilized contract pharmacies prior to registering on the 340B database.	Termination of five contract pharmacies from 340B Program	CAP implemented Audit closure date: July 12, 2017
Tennessee Department of Health	FPTN000	TN	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, 2018
Texas County Memorial Hospital Contact Information 340B Coordinator 417-967-1246 1333 S. Sam Houston Blvd, Houston. MO 65483	DSH260024	MO	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Diversion – 340B drug dispensed at the entity for a prescription written at an ineligible site; 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: April 20, 2018
ThedaCare Medical Center Berlin, Inc. Contact Information Pharmacy Director Robert.probasco@thedacare.org 715-584-8045	CAH521355-00	WI	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: November 15, 2018
Thomas Jefferson University Hospital	DSH390174	PA	No adverse findings	None	N/A Audit closure date: April 5, 2017
Thomas Memorial Hospital Contact Information 340B Coordinator 304-766-4320 4605 MacCorkle Ave., SW South Charleston, WV 25309	DSH510029	WV	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 24, 2018
Three Lower Counties Community Services, Inc.	CH03301H	MD	No adverse findings	None	N/A Audit closure date: September 14, 2017
Three Rivers Health Contact Information Interim Director of Pharmacy Three Rivers Health 701 S Health Pkwy Three Rivers, MI 49093 (269) 278-1145, x742	DSH230015	MI	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacy without written contract in place prior to December 27, 2017. Diversion – 340B drugs dispensed at entity for inpatient; 340B drug dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 8, 2019
Trinitas Regional Medical Center Contact Information Director of Pharmacy Trinitas Regional Medical Center 225 Williamson St. Elizabeth, NJ DSH310027 908-994-5238	DSH310027	NJ	Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 3, 2018. Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Ineligible sites registered on the 340B database; Entity did not provide contract pharmacy oversight prior to January 3, 2018. Diversion – 340B drugs dispensed at entity and contract pharmacies for prescriptions written at ineligible sites; Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers.	CAP implemented Audit closure date: May 3, 2019
Ukiah Valley Medical Center	DSH050301	CA	No adverse findings	None	N/A Audit closure date: November 2, 2017
UNC Hospitals	DSH340061	NC	No adverse findings	None	N/A Audit closure date: March 1, 2017
Union County Health Foundation Contact Information Chief Financial Officer or 340B Program Manager PO Box 99 109 N. Main Street Howard, SD 57349 (605) 772-4525	CH080890	SD	Diversion -340B drugs dispensed at contract pharmacies, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: August 28, 2018
United Health Services Hospitals, Inc.	DSH330394	NY	Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.	None	CAP implemented Audit closure date: May 22, 2018
Univ of Colorado Hemophilia Center School of Medicine	HM11980	CO	No adverse findings	None	N/A Audit closure date: October 23, 2017
University of Miami Hospital Contact Information Executive Pharmacy Director 1400 NW 12th Ave Miami, FL 33136 (305) 689-5630	DSH100009	FL	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entry for Authorizing Official. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: November 15, 2018.
University of Mississippi Medical Center Grenada	DSH250015	MS	No adverse findings	None	N/A Audit closure date: May 22, 2017
University of North Carolina – Chapel Hill	HM11947	NC	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.	None	CAP implemented Audit closure date: January 30, 2018
University of South Alabama Children’s and Women’s Hospital	PED013301-00	AL	No adverse findings	None	N/A Audit closure date: May 12, 2017
UPMC Mercy Contact Information Chief Finance Officer UPMC Mercy Department of Finance 1400 Locust Street Pittsburgh, PA 15219 Phone: 412‐647‐7713	DSH390028	PA	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity had a duplicate registration for an offsite outpatient facility. Diversion – 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: March 5, 2019
W.A. Foote Memorial Hospital DBA Henry Ford Allegiance Health Contact Information 340B Program Coordinator 205 N. East Ave. Jackson, MI 49201 (517) 205-7557	DSH230092	MI	Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; 340B drugs were not properly accumulated. Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: September 12, 2018
Wabash General Hospital District Contact Information Pharmacy Director Wabash General Hospital District 1418 College Drive Mt. Carmel, IL 62863 (618) 263-6316 mlockard@wabashgeneral.com	CAH141327-00	IL	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File; Entity did not have adequate controls to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: December 19, 2018
Wake Health Services, Inc.	CH041000	NC	No adverse findings	None	N/A Audit closure date: May 9, 2017
Waldo County General Hospital	CAH201312-00	ME	No adverse findings	None	N/A Audit closure date: August 29, 2017
War Memorial Hospital Inc.	CAH511309-00	WV	No adverse findings	None	N/A Audit closure date: June 9, 2017
Weatherford Hospital Authority Contact Information CEO (580) 772-5551 Ext: 750 dhowe@weatherfordhospital.com or Director of Pharmacy (580) 772-5551 Ext: 747 msauer@weatherfordhospital.com	CAH371323-00	OK	Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity did not provide contract pharmacy oversight. Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written 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.	Termination of contract pharmacies from the 340B Program Repayment to manufacturers	CAP implemented Audit closure date: February 8, 2019
Weeks Medical Center	CAH301303-00	NH	No adverse findings	None	N/A Audit closure date: January 9, 2018
Wheaton Franciscan Healthcare - All Saints Contact Information Regional Director, 340B Pharmacy (414) 874-6268 3801 Spring Street Racine WI 53405	DSH520096	WI	Incorrect 340B database record - ineligible site registered on 340B database; Entity failed to remove duplicate registration for off-site outpatient facility. Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: August 22, 2018
White Memorial Medical Center	DSH050103	CA	No adverse findings	None	N/A Audit closure date: February 28, 2017
William Newton Memorial Hospital Contact Information Director of Pharmacy (620) 222-6206 pharmacy@wnmh.org	CAH171383-00	KS	Diversion – 340B drugs dispensed at entity for inpatients; 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: February 26, 2019
Women and Infants Hospital of Rhode Island Contact Information 340B Program Manager 401-921-7525 CNE Pharmacy 626 Toll Gate Road Warwick, RI 02886	DSH410010	RI	Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: October 10, 2018

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

Date Last Reviewed:

November 2023

Parents: don’t struggle alone

Program Integrity: FY17 Audit Results