Program Integrity: FY18 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
Abbeville General Hospital	DSH190034	LA	No adverse findings	None	N/A Audit closure date: August 14, 2018
Abbott Northwestern Hospital Contact Information Pharmacy Services Portfolio Manager 2925 Chicago Avenue Mail Route 10807 Minneapolis, MN 55407 612-262-4785 Tony.collinskwong@allina.com	DSH240057	MN	Duplicate discounts - Incorrect 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: February 13, 2019
Adventist Health Lodi Memorial Contact Information Pharmacy Director 975 S Fairmont Ave Lodi, CA 95240 209-334-3411	DSH050336	CA	Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: July 25, 2019
AIDS Project of the East Bay	STD946121	CA	Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place; Incorrect entry for Primary Contact telephone number.	Termination of four contract pharmacies from 340B Program	CE self-terminated. In order to re-enroll in the 340B Program, CE must submit a corrective action plan (CAP) addressing each of the findings outlined in the Final Report. Audit closure date: January 23, 2019
Albert Einstein Medical Center	DSH390142	PA	No adverse findings	None	N/A Audit closure date: July 31, 2018
Alcona Citizens for Health, Inc. Contact Information Director of Pharmacy 1185 US Highway 23 North Alpena, MI 49707 989-358-3922	CH051980	MI	Incorrect 340B OPAIS record – Entity owned in-house pharmacies not listed as shipping addresses. Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: June 25, 2019
Ampla Health Contact Information President and CEO 935 Market Street Yuba City, CA 95991 530-751-3755	CH090850	CA	Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: June 25, 2019
Appalachian Regional Healthcare Inc. DBA McDowell ARH Hospital	CAH181331-00	KY	No adverse findings	None	N/A Audit closure date: February 28, 2019
Appalachian Regional Healthcare Inc. DBA Summers County ARH Hospital	CAH511310-00	WV	No adverse findings	None	N/A Audit closure date: May 3, 2018
ARH Mary Breckinridge Health Services, Inc. DBA Mary Breckinridge ARH Hospital Contact Information President and Chief Executive Officer Appalachian Regional Healthcare 130 Kate Ireland Drive Hyden, KY 41749 859-226-2450	CAH181316-00	KY	Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 17, 2019
Ashtabula County Medical Center	SCH360125-00	OH	Incorrect 340B OPAIS record - Failed to remove closed location registration; Registered contract pharmacies without written contract in place. Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: September 8, 2018
Asian Health Services Contact Information Controller 101 8th Street Oakland, CA 94607 510-735-3143	CH091030	CA	Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration; Registered contract pharmacy without written contract in place. Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers Termination of two contract pharmacies from 340B Program*	CAP implemented Audit closure date: May 3, 2019
Asian Human Services Family Health Center Contact Information Program Director 2424 W. Peterson Avenue Chicago, IL 60659 773-761-0300 x2453	CH051827A	IL	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 27, 2020
Aspirus Ironwood Hospital	CAH231333-00	MI	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to January 9, 2019.	None	CAP implemented Audit closure date: March 24, 2020
Avera Marshall DBA Avera Marshall Regional Medical Center	CAH241359-00	MN	No adverse findings	None	N/A Audit closure date: January 16, 2018
Baptist Hospitals of Southeast Texas dba Baptist Beaumont Hospital Contact Information Director of Revenue Cycle, Oncology 3555 Stagg Dr. Beaumont, TX 77701 409-212-5927	DSH450346	TX	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 31, 2019
Baylor Scott & White Medical Center - Irving Contact Information Pharmacy Director System 4004 Worth Street, Suite 200 Dallas, Texas 75246 214-820-6810	DSH450079	TX	Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 2, 2019
Baystate Franklin Medical Center Contact Information Chief Pharmacy Officer 280 Chestnut Street Springfield MA, 01199 413-794-3178 Gary.Kerr@BaystateHealth.org	DSH220016	MA	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: February 10, 2020
Belington Community Medical Services Association, Inc.	CHC12878-00	WV	No adverse findings	None	N/A Audit closure date: May 18, 2018
Billings Clinic Contact Information Director, Pharmacy Services 2800 Tenth Avenue North Billings, Montana 59101 406-657-4811	DSH270004	MT	Diversion – 340B drugs dispensed to inpatients.	Repayment to manufacturers	CAP implemented Audit closure date: November 19, 2019
Bradford Regional Medical Center Contact Information Richard Braun SVP Finance and CFO 130 South Union Street Suite 300 Olean, NY 14760 716-375-6190 rbraun@uahs.org	DSH390118	PA	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufactures	CAP implemented Audit closure date: October 8, 2019
Broaddus Hospital Contact Information Chief Executive Officer 1 Healthcare Drive Philippi, WV 26416 304-457-8155	CAH511300-00	WV	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B database. 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: June 19, 2019
Bronson Lakeview Hospital	CAH231332-00	MI	No adverse findings	None	N/A Audit closure date: March 23, 2018
Broward Health Medical Center Contact Information Director of Pharmacy Services 1600 South Andrews Avenue Fort Lauderdale, FL 33316 954-355-5559	DSH100039	FL	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place. Diversion – 340B drug dispensed to inpatient.	Termination of contract pharmacy from 340B Program Repayment to manufacturers.	CAP implemented Audit closure date: March 27, 2020
Calhoun - Liberty Hospital	CAH101304-00	FL	No adverse findings	None	N/A Audit closure date: June 22, 2018
California Hospital Medical Center Contact Information Director of Pharmacy 1401 S. Grand Ave Los Angeles, CA 90015 213-742-5483	DSH050149	CA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 1, 2018. Incorrect 340B OPAIS record - Incorrect entry for Primary Contact telephone number. 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: September 16, 2019
Camden – Clark Memorial Hospital	DSH510058	WV	No adverse findings	None	N/A Audit closure date: June 29, 2018
CAN Community Health, Inc.	RWII32117	FL	No adverse findings	None	N/A Audit closure date: March 28, 2018
CAN Community Health, Inc.	STD336052	FL	No adverse findings	None	N/A Audit closure date: March 28, 2018
Cape Fear Valley Medical Center Contact Information Director of Hospital Pharmacy 1638 Owen Drive Fayetteville, NC 28304 910-615-6839 tnicholson@capefearvalley.com	DSH340028	NC	Incorrect 340B OPAIS record - Ineligible site registered on 340B OPAIS. Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Termination of ineligible offsite outpatient facility from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: August 26, 2019
Carrington Health Center	CAH351318-00	ND	No adverse findings	None	N/A Audit closure date: July 19, 2018
Cavalier County Memorial Hospital Contact Information Director of Pharmacy 909 2nd Street Langdon, ND 58249 701-256-6100	CAH351323-00	ND	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 6, 2019
Centra Health, Inc.	SCH490021-00	VA	No adverse findings	None	N/A Audit closure date: September 10, 2018
Centracare Health – Paynesville Hospital Contact Information Todd Lemke Pharmacist in Charge 200 First St W Paynesville, MN 56362 320-243-7772	CAH241349-00	MN	Diversion - 340B drugs dispensed to inpatients. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: September 12, 2019
Central Vermont Medical Center Contact Information Attention Department of Pharmacy Director of Pharmacy 130 Fisher Road Berlin, VT 05602 802-371-5938 Frank.Foti@CVMC.org	SCH470001-00	VT	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. 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.	Repayment to manufacturers	CAP implemented Audit closure date: October 4, 2019
Children’s Health Care DBA Children’s Minnesota	PED243302-00	MN	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 8, 2019
Children’s Mercy Hospital, The	PED263302-00	MO	Incorrect 340B OPAIS record - Entity-owned pharmacies were not listed as shipping addresses.	None	CAP implemented Audit closure date: September 21, 2018
Choctaw General Hospital	CAH011304-00	AL	No adverse findings	None	N/A Audit closure date: September 10, 2018
Columbia Lutheran Memorial Hospital DBA Columbia Memorial Hospital Contact Information Director of Pharmacy & Cancer Center Services Columbia Memorial Hospital 2111 Exchange Street Astoria OR 97103 503-338-4665	CAH381320-00	OR	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Entity-owned pharmacy was not listed as shipping address; Registered contract pharmacies without written contract in place. Diversion - 340B drugs dispensed at entity 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: March 29, 2019
Columbia Memorial Hospital	RRC330094-00	NY	Incorrect 340B OPAIS record - Incorrect entry for address for offsite outpatient facility.	None	CAP implemented Audit closure date: July 30, 2018
Communicare Health Centers	CHC08216-00	CA	No adverse findings	None	N/A Audit closure date: August 23, 2018
Community Health Care, Inc.	CH021270	NJ	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to February 14, 2018; Failed to remove a duplicate registration of a contract pharmacy.	None	CAP implemented Audit closure date: September 20, 2018
Community Health Center, Incorporated	CH012080	CT	Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS; Failed to remove duplicate registrations for offsite outpatient facilities; Registered contract pharmacies without written contract in place. 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 ineligible offsite outpatient facilities from the 340B Program* Termination of two contract pharmacies from 340B Program* State Medicaid has since determined that duplicate discounts did not occur.	CAP implemented Audit closure date: October 1, 2019
Community Healthcare System, Inc. Contact Information Chief Financial Officer 120 West 8th Street Onaga, KS 66521 785-889-5036	CAH171354-00	KS	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to August 14, 2018. Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: November 6, 2019
Conejos County Hospital Corporation Contact Information Director of Pharmacy 106 Blanca Ave. Alamosa, Colorado 81101 719-587-1260 Lee.Hankins@slvrmc.org	CAH061308-00	CO	Entity did not provide contract pharmacy oversight. 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.	Termination of contract pharmacies from 340B Program* Repayment to manufacturers.	CAP implemented Audit closure date: April 5, 2019.
Connecticut, State of, Department of Health	STD061345	CT	Entity failed to maintain auditable medical records prior to December 21, 2018.	Repayment to manufacturers	Covered entity terminated from 340B Program as of July 1, 2020. In order to re-enroll in the 340B Program, CE must submit a corrective action plan (CAP) addressing each of the findings outlined in the Final Report. Audit closure date: July 17, 2020
Covenant Hospital – Plainview Contact Information Executive Director of 340B Operations 2107 Oxford Ave Lubbock, TX 79410 806-725-6654	SCH450539-00	TX	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: October 31, 2019
Covington County Hospital	CAH251325-00	MS	Incorrect 340B OPAIS record - Failed to remove closed location registration; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.	None	CAP implemented Audit closure date: September 24, 2018
Cumberland County Hospital Contact Information Director of Support Services Cumberland County Hospital 299 Glasgow Road Burkesville, KY 42717 270-864-2511	CAH181317-00	KY	Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record. Inaccurate or incomplete information in Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of this finding.	Repayment to manufacturers	CAP implemented Audit closure date: April 17, 2019
Decatur Memorial Hospital	RRC140135-00	IL	No adverse findings	None	N/A Audit closure date: April 11, 2018
Dell Seton Medical Center at The University of Texas Contact Information VP of Pharmacy 1500 Red River Street Austin, TX 78701 512‐324‐7303	DSH450124	TX	Diversion - 340B drug dispensed to inpatients; 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: July 9, 2019
Door County Memorial Hospital Contact Information Chief Administrative Officer 323 South 18th Avenue Sturgeon Bay, WI 54235 920-746-3737	CAH521358-00	WI	Diversion - 340B drug dispensed at entity, not supported by a medical record.	Repayment to manufacturer	CAP implemented Audit closure date: May 3, 2019
Drew Memorial Hospital, Inc. Contact Information Director of Pharmacy Services Drew Memorial Health System 778 Scogin Drive Monticello, AR 71655 870-460-3523	DSH040051	AR	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place; Entity did not provide contract pharmacy oversight. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drug dispensed to inpatient.	Termination of contract pharmacies from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: September 16, 2019
Drexel University College of Medicine/Hahnemann Contact Information Associate Vice Provost, Drexel 340B POC 215-895-6080 kdw38@drexel.edu Principal Investigator and Director of Women’s Care Center 215-762-1720 sandra.wolf@drexelmed.edu	FP191021	PA	Diversion - 340B drugs transferred to a separately registered covered entity.	Repayment to manufacturers	CAP implemented Audit closure date: August 15, 2019
Dundy County Hospital Contact Information Chief Executive Officer 1313 North Cheyenne Street Benkelman, NE 69021-3074 308-423-2204	CAH281340-00	NE	Diversion - 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: September 16, 2019
East Alabama Health Services	RWII36830	AL	No adverse findings	None	N/A Audit closure date: March 23, 2018
East Carolina Health d/b/a Vidant Roanoke-Chowan Hospital	DSH340099	NC	No adverse findings	None	N/A Audit closure date: February 6, 2018
East Georgia Healthcare Center, Inc.	CH049010	GA	No adverse findings	None	N/A Audit closure date: February 27, 2018
Fairview Hospital DBA Fairview Regional Medical Center	CAH371329-00	OK	No adverse findings	None	N/A Audit closure date: June 7, 2018
Fort Sanders Regional Medical Center Contact Information Director of Pharmacy Fort Sanders Regional Medical Center 1901 Clinch Avenue Knoxville, TN 37916 865-331-4930 Norris@covhith.com	RRC440125-00	TN	Incorrect 340B OPAIS record – Pharmacy incorrectly registered as child site. Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 27, 2020
Genesis Healthcare System	DSH360039	OH	Inaccurate or incomplete information in the 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 8, 2019
Georgetown Memorial Hospital	DSH420020	SC	No adverse findings	None	N/A Audit closure date: December 7, 2018
Grand River Hospital District	CAH061317-00	CO	Incorrect 340B OPAIS record - Offsite outpatient facility was not listed on the 340B database.	None	CAP implemented Audit closure date: September 24, 2018
Great Plains of Smith County DBA Smith County Memorial Hospital	CAH171377-00	KS	No adverse findings	None	N/A Audit closure date: April 10, 2018
Gritman Medical Center Contact Information RPH Director of Pharmacy Gritman Medical Center 700 South Main Street Moscow, ID 83843 208-883-2236	CAH131327-00	ID	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to January 29, 2018. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: August 28, 2018
H.C. Watkins Memorial Hospital	CAH251316-00	MS	No adverse findings	None	N/A Audit closure date: August 9, 2018
Health and Hospital Corporation of Marion County Contact Information Pharmacy Manager, Procurement (317) 880-4450 720 Eskenazi Avenue Indianapolis, IN 46202	DSH150024	IN	Diversion - 340B drugs dispensed at entity for prescriptions written by an ineligible provider at an ineligible site not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: May 8, 2019
Healthnet, Inc.	CH053200	IN	No adverse findings	None	N/A Audit closure date: November 29, 2017
Highlands Regional Medical Center	DSH180005	KY	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to April 23, 2018.	None	CAP implemented Audit closure date: November 14, 2018
Holzer Contact Information 340B Compliance Analyst 100 Jackson Pike Gallipolis, Ohio 45631 740-446-5803 mclemente@holzer.org	DSH360054	OH	Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS. Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date October 23, 2019
Hospital District No. 5 of Harper County Kansas Contact Information Chief Financial Officer 700 W. 13th Street Harper, KS 67058 620-896-7324	CAH171366-00	KS	Incorrect 340B OPAIS 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.	Repayment to manufacturers	CAP implemented Audit closure date: April 10, 2019
Housing Works Health Services III, Inc.	CHC26191-00	NY	No adverse findings	None	N/A Audit closure date: October 5, 2018
Hyacinth Foundation Contact Information Senior Director of Program Development 317 George Street, Suite 203 New Brunswick, NJ 08901 732-246-0204 jriccardi@hyacinth.org	RWI07107	NJ	Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: March 13, 2019
Inland Hospital	DSH200041	ME	No adverse findings	None	N/A Audit closure date: December 11, 2018
Jane Pauley Community Health Center, Inc.	CHC26566-00	IN	No adverse findings	None	N/A Audit closure date: January 11, 2018
Jessie Trice Community Health System, Inc. Contact Information 340B Administrator Jessie Trice Community Health Center, Inc. 5361 Northwest 22nd Avenue Miami, FL 33142 HNCyrus@jtchc.org (305) 805-1700	CH040330	FL	Entity did not provide contract pharmacy oversight prior to August 24, 2018. Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facility names. Diversion –340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site. Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 24, 2020
Johnson City Medical Center Contact Information Corporate Pharmacy Business Director 2 Professional Park Drive Suite 15 Johnson City, TN 37604 423-302-3535 cindy.tucker@balladhealth.org	DSH440063	TN	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 31, 2019
Kalispell Regional Medical Center Contact Information Pharmacy Analyst (406) 751-6560 310 Sunnyview Lane Kalispell, MT 59901	SCH270051-00	MT	Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS. Diversion - 340B drug dispensed at a contract pharmacy for a prescription not supported by a medical record.	Termination of ineligible offsite outpatient facilities from the 340B Program Repayment to manufacturers	CAP implemented Audit closure date: July 9, 2019
Karmanos Cancer Center Contact Information Chief Pharmacy Officer 4100 John R Detroit, Michigan 48201 313-576-8809	DSH230297	MI	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 19, 2019
Kootenai Hospital District Contact Information Business Manager 2003 Kootenai Health Way Coeur d'Alene, ID 83814 208-625-5651 tchapman@kh.org	DSH130049	ID	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to February 5, 2018. Diversion - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: June 25, 2019
Lake District Hospital Contact Information Director of Pharmacy 700 S. J St. Lakeview, OR 97630 541-947-2114 ext. 281	CAH381309-00	OR	Diversion - 340B drug dispensed at contract pharmacy, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: November 6, 2019
Lewis County General Hospital Contact Information Chief Financial Officer 7785 North State Street Lowville, NY 13367 315-376-5597	CAH331317-00	NY	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 29, 2019
Lincoln Community Health Center, Inc.	CH040910	NC	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: December 21, 2018
Lincoln County Hospital Contact Information Chief Financial Officer Lincoln County Hospital 624 N. 2nd Lincoln, Kansas 67455 785-524-4030 ext. 212	CAH171360-00	KS	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 8, 2019
Lincoln Health (formerly St. Andrews Hospital)	CAH201302-00	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: June 6, 2019
Little Falls Hospital Contact Information Chief Financial Officer 10300 Compton Ave. Los Angeles, CA 90002 323-568-3093	CAH331311-00	NY	Diversion - 340B drugs dispensed to inpatients	Repayment to manufacturers	CAP implemented Audit closure date: April 17, 2019
Livingston Hospital and Healthcare Services, Inc.	CAH181320-00	KY	Incorrect 340B OPAIS Record – Incorrect entry for Primary Contact.	None	CAP implemented Audit closure date: April 3, 2019
Loma Linda University Medical Center Contact Information Executive Director of Pharmacy 11234 Anderson Street Loma Linda, CA 92354 909-558-4497 agobin@llu.edu	DSH050327	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: September 12, 2019
MaineGeneral Medical Center	DSH200039	ME	No adverse findings	None	N/A Audit closure date: December 7, 2018
Maricopa Medical Center Contact Information Director of Pharmacy 2601 E. Roosevelt Street Phoenix, AZ 85008 Anna.Sogard@mihs.org 602-344-5253	DSH030022	AZ	Incorrect 340B OPAIS record - ineligible site registered on 340B OPAIS; Registered contract pharmacy without written contract in place. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File; Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of one ineligible offsite outpatient facility from the 340B Program* Termination of one contract pharmacy from 340B Program* Repayment to manufacturers.	CAP implemented Audit closure date: January 13, 2020
Marlborough Hospital	DSH220049	MA	No adverse findings	None	N/A Audit closure date: February 7, 2018
Mayo Clinic Health System – Albert Lea	SCH240043-00	MN	Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address.	None	CAP implemented Audit closure date: November 2, 2018
Mayview Community Health Center, Inc.	FQHCLA263	CA	No adverse findings	None	N/A Audit closure date: February 15, 2018
McCulloch County Hospital District DBA Heart of Texas Healthcare System	CAH451348-00	TX	No adverse findings	None	N/A Audit closure date: December 19, 2018
McKay-Dee Hospital Center	DSH460004	UT	Duplicate Discounts - Inaccurate 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 12, 2018
Medical Center Hospital Contact Information 340B Coordinator 500 West 4th Street Odessa, TX 79761 432-640-2294	DSH450132	TX	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place. Diversion –340B drug dispensed to an inpatient.	Termination of one contract pharmacy from 340B Program. Repayment to manufacturer.	CAP implemented Audit closure date: September 18, 2019
Medical Center of Central Georgia Contact Information Department of Pharmacy Services MSC 113 Medical Center-Navicent Health 777 Hemlock Street Macon, GA 31201 478-633-1429 478-796-4890	DSH110107	GA	Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: October 8, 2019
Memorial Health Care Systems DBA Memorial Hospital	CAH281339-00	NE	No adverse findings	None	N/A Audit closure date: October 24, 2018
Memorial Hospital of Texas County Authority Contact Information Pharmacy Tech 520 Medical Drive Guymon, OK 73942 580-338-3113 ext 2261	SCH370138-00	OK	Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP approved Covered entity, its outpatient facilities, and its contract pharmacies self-terminated from 340B Program as of April 1, 2018. Settlement with affected manufacturers has not been finalized. CE will not be permitted to re-enroll in the 340B Program until such time: 1) CE has attested that it has finalized settlement with all affected manufacturers, including completion of any necessary repayment, for all findings listed in the Final Report; and 2) CE has attested that a HRSA-approved CAP has been fully implemented. Audit closure date: July 10, 2019.
Methodist Charlton Medical Center Contact Information Director of Pharmacy Services 3500 W. Wheatland Rd. Dallas, TX 75237 214-947-7581	DSH450723	TX	Diversion - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: August 29, 2018
Mid-Valley Healthcare Inc. DBA Samaritan Lebanon Community Hospital	CAH381323-00	OR	Inaccurate or incomplete information in the 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 23, 2019
Mississippi State Dept of Health	RWIID392133	MS	Incorrect 340B OPAIS record - Incorrect entry for grant number prior to January 29, 2018.	None	CAP implemented Audit closure date: April 17, 2018
Monroe County Hospital	CAH161342-00	IA	No adverse findings	None	N/A Audit closure date: January 26, 2018
Morris Heights Health Center Inc. Contact Information Vice President Planning and Development Morris Heights Health Center, Inc. 85 West Burnside Avenue Bronx, New York 10453-4015 718-483-1270	CH021610	NY	Incorrect 340B OPAIS record - Offsite outpatient facility was not listed on the 340B OPAIS. Duplicate Discounts - Entity’s contract pharmacies were billing Medicaid without notification to HRSA.	Repayment to manufacturers	CAP implemented Audit closure date: September 13, 2019
Morton Comprehensive Health	CH063890	OK	Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address; Registered contract pharmacies without written contract in place. Duplicate Discounts - Inaccurate or incomplete information 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: June 19, 2019
Mountainview Medical Center	CAH271306-00	MT	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: May 24, 2019
Neighborhood Healthcare Contact Information Senior Financial Analyst 425 North Date Street Escondido, CA 92025 760-737-6905	CH093540	CA	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, 2019
New Mexico Department of Health	STD87502	NM	Incorrect 340B OPAIS record - Incorrect entry for address prior to December 4, 2018. Entity did not have adequate controls in place to prevent duplicate discounts. However, since the time of audit, covered entity demonstrated that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: March 23, 2020
New York – Presbyterian / Queens	DSH330055	NY	Incorrect 340B database record - ineligible site registered on 340B database.	None	CAP implemented Audit closure date: November 7, 2018
North Central Bronx Hospital Center (NYCHHC)	DSH330385	NY	No adverse findings	None	N/A Audit closure date: December 11, 2018
North Mississippi Primary Health Care, Inc. Contact Information Chief Quality Officer PO Box 92 Ashland, MS 38603 662-502-3156	CH049100	MS	Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 15, 2019
North Valley Hospital Contact Information Pharmacy Director 1600 Hospital Way Whitefish, MT 59937-2990 406-863-3510	CAH271336-00	MT	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 17, 2019
Northeast Washington County Community Health, Inc. Contact Information Chief Operations Officer PO Box 320 157 Towne Avenue Plainfield, Vermont 05667 (802) 322-0711	CHC08230-00	VT	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Registered contract pharmacy without written contract in place prior to December 2018. CE did not comply with HRSA’s conditions and requirements of the alternative methods demonstration project (AMDP). Diversion –340B drugs dispensed at contract pharmacy to ineligible patients. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity did not have adequate controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: October 19, 2020
Northern Maine Medical Center Contact Information Chief Financial Officer Northern Maine Medical Center 194 East Main Street Fort Kent, ME 04743 207-834-1820	SCH200052-00	ME	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at contract pharmacy for prescriptions written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: September 13, 2019
NYU Langone Hospitals Contact Information Director of Pharmacy, 340B Program 215 Lexington Avenue, 14th Floor New York, NY 10016 646-754-9356	DSH330214	NY	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 25, 2019
OhioHealth Corporation DBA Doctors Hospital Contact Information Vice President of Finance OhioHealth Doctors Hospital 5100 West Broad St Columbus, OH 43228 614-544-2062	DSH360152	OH	Diversion – 340B drug dispensed at contract pharmacy for prescription written at ineligible site. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 27, 2020
Orange Coast Memorial Medical Center	DSH050678	CA	No adverse findings	None	N/A Audit closure date: March 7, 2018
Palmetto Health Baptist Contact Information System Director of Pharmacy Dept of Pharmaceutical Services 5 Richland Medical Park Drive Columbia SC 29203 803-434-3769	DSH420086	SC	Diversion - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: September 18, 2019
Parkview Hospital Contact Information 340B Program Supervisor P.O. Box 5600 Fort Wayne, IN 46895 260-266-4408	DSH150021	IN	Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facilities. Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 17, 2019
Parkview Wabash Hospital, Inc.	CAH151310-00	IN	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to October 23, 2017.	None	CAP implemented Audit closure date: March 14, 2018
Parmer County Community Hospital, Inc.	CAH451300-00	TX	No adverse findings	None	N/A Audit closure date: February 23, 2018.
Paulding County Hospital Contact Information VP Pharmacy/ Radiology 1035 West Wayne Street Paulding, Ohio 45879 419-399-4080, Ext 320 bhoersten@pauldingcountyhospital.com	CAH361300-00	OH	Diversion – 340B drugs dispensed to inpatients. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: February 10, 2020
Peacehealth DBA St. Joseph Medical Center Contact Information Director of Pharmacy PeaceHealth St Joseph Medical Center 2901 Squalicum Parkway Bellingham, WA 98225 360-788-6022	SCH500030-00	WA	Incorrect 340B OPAIS record - Incorrect entry for address 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: March 7, 2019
Peak Vista Community Health Centers Contact Information Pharmacy Director 719-344-6269 preilly@peakvista.org	CH081460	CO	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 5, 2018
Penn Presbyterian Medical Center Contact Information Director of Pharmacy Penn Presbyterian Medical Center 51 North 39th Street Philadelphia PA 19104 215-662-8213	DSH390223	PA	Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible site. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 28, 2019
Pennsylvania Hospital, The Contact Information Suzanne Brown Director of Pharmacy Services Pennsylvania Hospital 800 Spruce St. Philadelphia, PA 19107 215-829-5847	DSH390226	PA	Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible site. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 4, 2019
Phoebe Putney Memorial Hospital Contact Information Pharmacy Informatics & Technology Manager 417 Third Ave Albany, GA 31701 229-312-0115	DSH110007	GA	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 26, 2019
Piedmont Mountainside Hospital, Inc.	DSH110225	GA	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: December 31, 2018
Planned Parenthood Association of Utah – South Jordan Contact Information VP of Clinical Services Planned Parenthood Association of Utah 654 South 900 East Salt Lake City, UT 84102 801-532-1586 Penny.davies@ppau.org	FP84095	UT	Incorrect 340B OPAIS record - Utilized contract pharmacies that were not listed on OPAIS; Failed to remove two terminated contract pharmacies from OPAIS. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: June 11, 2019
Planned Parenthood St. Louis Region and Southwest Missouri	STD65807	MO	No adverse findings	None	N/A Audit closure date: April 3, 2018
Pomona Valley Hospital Medical Center Contact Information Director of Pharmacy Pomona Valley Hospital Medical Center 1798 Noth Garey Avenue Pomona, CA 91767 909-865-9501	DSH050231	CA	Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: June 17, 2019
Positive Impact Health Centers, Inc. Contact Information Director of Pharmacy 523 Church Street Decatur, GA 30030 404-977-5206	RWI30309	GA	Diversion – 340B drugs dispensed at entity and 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: January 27, 2020
Prairie Ridge Hospital and Health Services Contact Information Pharmacy Director and 340B Program Manager Prairie Ridge Hospital & Health Services 1411 Hwy 79 E Elbow Lake, MN 56531 218-685-7376 rlien@prairiehealth.org	CAH241379-00	MN	Diversion – 340B drug dispensed at contract pharmacy for prescription written at ineligible site; 340B drug dispensed at contract pharmacy, not supported by a medical record. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 21, 2019
Presbyterian Hospital dba Novant Health Presbyterian Medical Center Contact Information 340B Supervisor 3334 Healy Drive Winston-Salem, NC 27103 336-277-0301 echansen@novanthealth.org	DSH340053	NC	Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 10, 2019
Providence Hood River Memorial Hospital	CAH381318-00	OR	No adverse findings	None	N/A Audit closure date: December 27, 2018
Providence St. Joseph’s Hospital of Chewelah	CAH501309-00	WA	No adverse findings	None	N/A Audit closure date: September 19, 2018
Providence St. Vincent Medical Center	DSH380004	OR	No adverse findings	None	N/A Audit closure date: October 2, 2018
Public Hospital District No 1-A DBA Pullman Regional Hospital Contact Information Chief Financial Officer 835 SE Bishop Blvd Pullman, WA 99163 877-446-0473 steve.febus@pullmanregional.org	CAH501331-00	WA	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: October 1, 2019
Regional Health Sturgis Hospital	CAH431321-00	SD	No adverse findings	None	N/A Audit closure date: June 14, 2018
Rhode Island Hospital Contact Information Director of Pharmacy 593 Eddy St. Providence, RI 02903 401-444-4434	DSH410007	RI	Diversion - 340B drug dispensed at contract pharmacy for prescription written at ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: October 2, 2019
Richardson Medical Center Contact Information Director of Pharmacy Richardson Medical Center 254 Hwy 3048 Rayville, LA 71269 318-728-8352 reneec@richardsonmed.org	DSH190151	LA	Diversion –340B drugs dispensed to inpatients; 340B drugs were not properly accumulated. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: October 1, 2019
Riverside Regional Medical Center Contact Information Vice President/Chief Pharmacy Officer 856 J Clyde Morris Blvd, Suite C Newport News, VA 23601 757-316-5707 cynthia.williams2@rivhs.com	DSH490052	VA	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 12, 2019
Ronald Reagan UCLA Medical Center Contact Information Director of Inpatient Pharmacy Ronald Reagan UCLA Medical Center 757 Westwood Plaza Room B531 Los Angeles, CA 90095 310-267-8503	DSH050262	CA	Incorrect 340B OPAIS record - Incorrect entry for billing address. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 2, 2019
Rumford Hospital	CAH201306-00	ME	No adverse findings	None	N/A Audit closure date: December 12, 2018
Rural Health Group, Inc. Contact Information Pharmacy Director Rural Health Group, Inc. 252-536-5885 dawn.rush@rhgnc.org	CH046680	NC	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: December 21, 2018
Rush Memorial Hospital	CAH151304-00	IN	No adverse findings	None	N/A Audit closure date: November 16, 2017
Saint Francis Hospital	DSH370091	OK	No adverse findings	None	N/A Audit closure date: June 13, 2018
Saint Joseph – Martin	CAH181305-00	KY	No adverse findings	None	N/A Audit closure date: April 10, 2018
Salem Township Hospital Contact Information Chief Executive Officer 1201 Ricker Drive Salem, IL 62881-4263 618-548-3194	CAH141345-00	IL	Diversion - 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites. Inaccurate or incomplete information in Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of this finding. Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: July 25, 2019
San Miguel County Department of Health and Environment Contact Information Director, San Miguel County Department of Health and Environment PO Box 949, 333 West Colorado Ave. Telluride, CO 81435-00949 (970) 728-4289	FP814352	CO	Incorrect 340B OPAIS record - Incorrect entry for billing address; incorrect entry for grant number. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 21, 2019
Sanford Medical Center Luverne Contact Information 340B Program Coordinator 1305 W. 18th St. Sioux Falls, South Dakota 57117 605-333-4298	CAH241371-00	MN	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 26, 2019
Sanford Worthington Medical Center	DSH240022	MN	No adverse findings	None	N/A Audit closure date: January 23, 2018
SC DHEC Lowcountry Region Charleston County North Area FP	FP294055	SC	No adverse finding	None	N/A Audit closure date: November 15, 2018
Scott and White Memorial Hospital Contact Information Pharmacy Specialist, Scott & White Memorial Hospital 2401 S. 31st Street Temple, TX 76502 254-724-3811	DSH450054	TX	Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 4, 2018. Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; - Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to include entity owned pharmacies as shipping addresses. Diversion –340B drug dispensed to an inpatient. Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers Termination of ineligible offsite outpatient facility from the 340B Program*	CAP implemented Audit closure date: March 23, 2020
Scott Regional Hospital Contact Information Compliance Officer Scott Regional Hospital 317 Highway 13 South Morton, MS 39117 601-703-4437	CAH251323-00	MS	Diversion - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: December 20, 2018
SE Alabama Rural Health Associates (SARHA)	CH048950	AL	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to August 22, 2018.	None	CAP implemented Audit closure date: August 20, 2019
Seattle Children’s Hospital	PED503300-00	WA	Incorrect 340B OPAIS record - Incorrect entry for off-site outpatient facility billing address. 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: August 20, 2019
Shady Grove Adventist Hospital Contact Information Rockville Campus Director of Pharmacy 9901 Medical Center Drive Rockville, MD 28050 240-826-6156	DSH210057	MD	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 29, 2019
Shelby Co Chris A Myrtue Memorial Hospital Contact Information 340B Coordinator 1213 Garfield Avenue Harlan, IA 51537 712-755-4411	CAH161374-00	IA	Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: August 6, 2019
Shenandoah Medical Center	CAH161366-00	IA	No adverse findings	None	N/A Audit closure date: January 31, 2018
Skagit Valley Hospital Contact Information 340B Coordinator Skagit Valley Hospital 1415 East Kincaid Street Mount Vernon, WA 98274	DSH500003	WA	Diversion - 340B drugs dispensed at entity 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: August 6, 2019
South Lincoln Hospital District Contact Information IT / Revenue Cycle Manager 711 Onyx Street Kemmerer, WY 83101 307-877-5574	CAH531315-00	WY	Entity did not provide contract pharmacy oversight. Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible site.	Termination of contract pharmacies from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: October 2, 2019
Southeast Community Health Systems Contact Information 340B Coordinator Skagit Valley Hospital 1415 East Kincaid Street Mount Vernon, WA 98274	CH063710	LA	Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 13, 2019
Southeast Health Medical Center Contact Information 340B Program Coordinator 1108 Ross Clark Circle Dothan, AL 36301 334-793-8113	DSH010001	AL	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to June 6, 2018. Diversion - 340B drug dispensed to an inpatient; 340B drugs dispensed at entity for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: September 5, 2019
Spectrum Health Big Rapids Hospital	SCH230093-00	MI	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place; Hospital classification on OPAIS was inconsistent with eligibility documents prior to September 7, 2018.	Termination of three contract pharmacies from 340B Program*	CAP implemented Audit closure date: February 28, 2019
St. David’s Healthcare Partnership, L.P., LLP DBA St. David’s Medical Center Contact Information Chief Financial Officer 1025 E. 32nd Street Austin, TX 78705 512-544-5030	DSH450431	TX	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 16, 2019
St. Francis Medical Center	DSH310021	NJ	No adverse findings	None	N/A Audit closure date: March 16, 2018
St. Francis Medical Center Inc. Contact Information Divisional Director Clinical Ancillary Operations 309 Jackson St. Monroe, LA 71201 318-966-4957	DSH190125	LA	Diversion - 340B drugs were not properly accumulated; 340B drugs dispensed at 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 6, 2019
St. Gabriel’s Hospital	CAH241370-00	MN	No adverse findings	None	N/A Audit closure date: May 29, 2018
St. Joseph’s Medical Center	DSH240075 SCH240075-00	MN	No adverse findings	None	N/A Audit closure date: August 8, 2018
St. Luke’s Hospital of Duluth Contact Information Vice President/CFO 915 East First Street Duluth, MN 55805-2107 218-249-5475	DSH240047	MN	Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facilities’ addresses. Diversion - 340B drugs dispensed at entity and contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: July 29, 2019
St. Luke’s Wood River Medical Center	CAH131323-00	ID	No adverse findings	None	N/A Audit closure date: October 15, 2018
St. Mary’s Hospital and Medical Center, Inc.	DSH060023	CO	No adverse findings	None	N/A Audit closure date: May 23, 2018
St. Mary’s Regional Health Center	DSH240101	MN	No adverse findings	None	N/A Audit closure date: August 10, 2018
Stanford Health Care	DSH050441	CA	No adverse findings	None	N/A Audit closure date: February 1, 2018
Sterling Regional MedCenter	RRC060076-00	CO	Incorrect 340B OPAIS record - Entity registered as an incorrect hospital type.	None	CAP implemented Audit closure date: May 29, 2019
Sunset Park Health Council, Inc. Contact Information Compliance Officer Callen-Lorde Community Health Center 356 West 18th Street New York, NY 10011 212-271-7149 lmazzola@callen-lorde.org	CH0218870	NY	Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File. Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: October 16, 2019
Sutter Bay Hospital DBA Alta Bates Summit Medical Center	DSH050043	CA	Incorrect 340B OPAIS record - Ineligible site registered on 340B OPAIS; Incorrect entry for off-site outpatient facility address; Incorrect entry for billing address; Incorrect entry for authorizing official telephone number.	None	CAP implemented Audit closure date: April 30, 2019
Swedish Medical Center	DSH500027	WA	Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities.	None	CAP implemented Audit closure date: July 23, 2019
Tarrant County Hospital District, John Peter Smith Hospital Contact Information Chief Pharmacy Officer (817) 702-6718 1500 S. Main Street Fort Worth, TX 76104	DSH450039	TX	Incorrect 340B OPAIS record - Incorrect entries for name and address of offsite outpatient location. Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an 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: January 27, 2020
Temple University Hospital Contact Information Chief Financial Officer 2450 West Hunting Park Avenue Philadelphia, PA 19129 TUH340Program@tuhs.temple.edu	DSH390027	PA	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. Diversion - 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: April 1, 2020
Three Rivers Medical Center Contact Information Chief Administrative and Financial Officer Three Rivers Medical Center 500 SW Ramsey Avenue Grants Pass, Oregon 97527 541-789- 4549	DSH380002	OR	Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address. Diversion -340B drug dispensed at entity for a prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: March 29, 2019
Trinity Hospital Twin City	CAH361302-00	OH	No adverse findings	None	N/A Audit closure date: February 8, 2018
Tyrone Hospital Contact Information Chief Executive Officer Tyrone Hospital 187 Hospital Drive Tyrone, PA 16686 (814) 684-1255, ext 2101	CAH391307-00	PA	Incorrect 340B OPAIS record - Failed to remove closed locations registration; Incorrect entry for address. Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites not supported by a medical record. Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: April 12, 2019
UCSF - Medical Center Contact Information 340B Manager UCSF Medical Center 505 Parnassus Avenue San Francisco, CA 94143 415-514-8398	DSH050454	CA	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place; Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.	Termination of three contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: November 19, 2019
United Community Services, Inc.	CHC29000-00	CT	No adverse findings	None	N/A Audit closure date: January 24, 2018
United Regional Health Care System Contact Information Robert Pert, Chief Financial Officer 1617 11th Street Wichita Falls, TX 76301 940-764-3023	SCH450010-00	TX	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. 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 duplicate discounts.	Repayment to manufacturers	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: October 3, 2019
University Hospitals Rainbow and Babies Children’s Hospital Contact Information Vice President & Corporate Controller 3605 Warrensville Center Rd. Room: 1110 Mail Stop: MSC8100 Shaker Heights, OH 44122-5203 216-767-8729 Michael.Vehovec@UHhospitals.org	PED363302-00	OH	Diversion - 340B drugs dispensed at entity for prescriptions written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: March 13, 2019
Urban Health Plan, Inc.	CH023600	NY	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 17, 2019
USC Norris Cancer Hospital	CAN050660-00	CA	Incorrect 340B OPAIS record - Incorrect entry for address	None	CAP implemented Audit closure date: July 18, 2018
Valley AIDS Council	RWII70	TX	Incorrect 340B OPAIS record –Incorrect grant number entry. Entity did not provide contract pharmacy oversight.	Termination of contract pharmacies from 340B Program	CAP implemented Audit closure date: November 20, 2019
Virginia Commonwealth University Health System	DSH490032	VA	No adverse findings	None	N/A Audit closure date: October 17, 2018
Waikiki Health	CH092060	HI	Incorrect 340B OPAIS record – Incorrect entry for entity name; incorrect entry for primary contact information.	None	CAP implemented Audit closure date: August 20, 2019
Wakemed Contact Information Executive Director of Clinical Services 919-350-8021 vbarlow@wakemed.org	DSH340069	NC	Diversion - 340B drugs dispensed at entity for prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: August 6, 2019
Watts Healthcare Corporation Contact Information Chief Financial Officer 10300 Compton Ave. Los Angeles, CA 90002 323-568-3093	CHC00850-00	CA	Entity did not provide contract pharmacy oversight. Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Termination of contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: April 17, 2019
West Allis Memorial Hospital Inc. DBA Aurora West Allis Medical Center	DSH520139	WI	Entity was billing Medicaid contrary to information included 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 10, 2019
Westchester Medical Center	DSH330234	NY	Incorrect 340B OPAIS record - ineligible site registered on 340B OPAIS; Incorrect entry for offsite outpatient location zip code.	Termination of ineligible offsite outpatient facility from the 340B Program*	CAP implemented Audit closure date: June 12, 2019
Whitesburg ARH Hospital	DSH180002	KY	No adverse findings	None	N/A Audit closure date: June 6, 2018
Whitley Memorial Hospital	DSH150101	IN	No adverse findings	None	N/A Audit closure date: December 12, 2017
Yuma Regional Medical Center Contact Information 340B Program Manager 2400 S Avenue A Yuma, AZ 85364 928-336-7721	DSH030013	AZ	Diversion - 340B drugs dispensed at contract pharmacy for a prescriptions written at ineligible site. Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: October 23, 2019

*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: FY18 Audit Results