Program Integrity: FY19 Audit Results

Updated 8/30/24. The results chart includes audits where the findings have been finalized. Remaining audits are still under review. Information on Corrective Action Plans and Sanctions will be updated once approved by HRSA. HRSA recommends manufacturers do not contact audited entities regarding sanctions until a corrective action plan has been approved by HRSA and posted on this website.

Entity Sort descending	340B ID	State	OPA Findings	Sanction	Corrective Action Status
Abbeville County Memorial Hospital	CAH421301-00	SC	No adverse findings	None	N/A Audit closure date: October 4, 2019
Action for Boston Community Development	FP021118	MA	Incorrect 340B OPAIS record – Incorrect entries for grant number.	None	CAP implemented Audit closure date: April 6, 2021
Adams County Memorial Hospital dba Adams Memorial Hospital	CAH151330-00	IN	Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place prior to January 25, 2019.	None	CAP implemented Audit closure date: April 24, 2019
Adena Regional Medical Center Contact Information AHS Director of Pharmacy Services 272 Hospital Road Chillicothe OH 45601 fyingling@adena.org 740-779-7648	DSH360159	OH	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 4, 2021
Alamance Regional Medical Center	DSH340070	NC	No adverse findings	None	N/A Audit closure date: October 1, 2019
Albany Medical Center Hospital	DSH330013	NY	No adverse findings	None	N/A Audit closure date: December 20, 2019
Ammonoosuc Community Health Services Inc.	CH010980	NH	No adverse findings	None	N/A Audit closure date: March 7, 2019
Arkansas Department of Health	FP722051	AR	Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: September 17, 2020
Aroostook Medical Center, The	DSH200018	ME	No adverse findings	None	N/A Audit closure date: December 6, 2019
Athens-Limestone Contact Information Chief Financial Officer 700 West Market Street Athens, AL 35611 256-233-9172	DSH010079	AL	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 17, 2020
Avera St. Mary’s	DSH430015	SD	No adverse findings	None	N/A Audit closure date: January 27, 2020
Baptist Health Contact Information Corporate Director of Pharmacy 1000 W Moreno Street Pensacola, FL 32501 850-469-7567	DSH100093	FL	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.	Repayment to manufacturers	CAP implemented Audit closure date: September 23, 2020
Baptist Health Medical Center – LR	DSH040114	AR	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented Audit closure date: June 9, 2020 State Medicaid has since determined duplicate discounts did not occur.
Barnesville Hospital Association, Inc.	CAH361321-00	OH	No adverse findings	None	N/A Audit closure date: May 9, 2019
Baton Rouge General Medical Center Contact Information Compliance Officer 8490 Picardy Ave Suite 300 Baton Rouge, Louisiana 70809 ken.miller@brgeneral.org 225-237-1588	DSH190065	LA	Incorrect 340 OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS. Diversion – 340B drug dispensed to inpatient. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 18, 2021
Beaufort-Jasper-Hampton Comprehensive Health Services, Incorporated Contact Information 340B Program Coordinator 721 Okatie Highway Ridgeland, SC 29936 843-987-7545	CH041190	SC	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for address for offsite outpatient facility. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 3, 2020
Big Springs Medical Association, Inc. Contact Information CEO 110 South Second Street Ellington, MO 63638 573-663-2313 kwhite@mohigh.org	CH070430	MO	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 14, 2020
Brattleboro Memorial Hospital	DSH470011	VT	No adverse findings	None	N/A Audit closure date: July 9, 2019
Bridgeport Hospital	DSH070010	CT	No adverse findings	None	N/A Audit closure date: October 1, 2019
Brockton Hospital, Inc	DSH220052	MA	Inaccurate or incomplete information on 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: January 26, 2021
BronxCare Health System Fulton Division	DSH330009	NY	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove duplicate registration for offsite outpatient facility. Incorrect or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: February 5, 2020
Brooklyn Hospital Center, The Contact Information VP Revenue Enhancement 15 Metrotech 3rd Floor Brooklyn, N.Y. 11201 (O) 718-488-3775 (F) 718 488-3725	DSH330056	NY	Diversion – 340B drug dispensed at covered entity, not supported by a medical record. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 26, 2021
Cambridge Memorial Hospital, Inc. DBA Tri Valley Health System	CAH281348-00	NE	No adverse findings	None	N/A Audit closure date: August 27, 2019
CAN Community Health, Inc.	STD342372	FL	No adverse findings	None	N/A Audit closure date: January 7, 2020
Canton-Potsdam Hospital Contact Information Authorizing Official, Chief Financial Officer Canton-Potsdam Hospital 50 Leroy Street Potsdam, NY 13676 rjacobs@cphospital.org	DSH330197	NY	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 8, 2020
Caring Health Center, Inc.	CH01084B	MA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: June 4, 2020.
Carthage Area Hospital Inc.	CAH331318-00	NY	No adverse findings	None	N/A Audit closure date: December 6, 2019
Cass Regional Medical Center	CAH261324-00	MO	No adverse findings	None	N/A Audit closure date: May 29, 2019
Centro San Vicente Contact Information Chief Financial Officer 8061 Alameda Ave, El Paso, TX 79915 915-859-7545 ext. 1214	CH066580	TX	Diversion - 340B drug dispensed at contract pharmacy for prescription 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: May 18, 2020
Chambers Memorial Hospital Contact Information 340B Administrator, 479-495-6264 PO Box 639, Danville, AR 72833 jeffreywoods@chambershospital.com	SCH040011-00	AR	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 7, 2020
Charles A. Dean Memorial Hospital	CAH201301-00	ME	No adverse findings	None	N/A Audit closure date: June 23, 2020
Children’s National Medical Center Contact Information Chief of Pharmacy 111 Michigan Avenue, NW Washington, DC 20010 202-476-5553	PED093300-00	DC	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 14, 2020
Childress Regional Medical Center	DSH450369	TX	Incorrect 340B OPAIS record - Incorrect entry for disproportionate share percentage.	None	CAP implemented Audit closure date: February 7, 2020
Christus St. Michael Contact Information Michael French, J.D. Senior Consultant 19065 Hickory Creek Dr., Suite 115 Mokena, IL 60448 708-478-7030	DSH450801	TX	Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration. Diversion - 340B drugs dispensed at covered entity for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 19, 2020
Clara Maass Medical Center	DSH310009	NJ	No adverse findings	None	N/A Audit closure date: December 17, 2019
Clinch River Health Services, Incorporated	CH031230	VA	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entry for authorizing official.	None	CAP implemented Audit closure date: June 25, 2020
Community Health Center of Central Wyoming, Inc. Contact Information Director of Pharmacy jbeattie@chccw.org (307) 233-6050	CH086120	WY	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 31, 2019
Community Memorial Hospital, Inc.	CAH331316-00	NY	No adverse findings	None	N/A Audit closure date: December 10, 2019
Complete Care Community Health Center, Inc.	CHC28987-00	CA	No adverse findings	None	N/A Audit closure date: November 29, 2019
Coquille Indian Tribe Contact Information Pharmacy Manager 541-435-7039 carynmickelson@coquilletribe.org	FQHC638532	OR	Diversion - 340B drugs dispensed at covered entity and at contract pharmacy, not supported by a medical record. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 28, 2021
D. W. McMillan Memorial Hospital	DSH010099	AL	No adverse findings	None	N/A Audit closure date: January 17, 2019
Daviess Community Hospital	DSH150061	IN	Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Termination of ineligible offsite outpatient facilities from the 340B Program*	CAP implemented State Medicaid determined no duplicate discounts occurred. Audit closure date: May 7, 2020
Davis Street Community Center Inc.	CHC28979-00	CA	Incorrect 340B OPAIS record – Incorrect entry for primary contact.	None	N/A Audit closure date: May 20, 2020
Delaware Valley Hospital, Inc.	CAH331312-00	NY	No adverse findings	None	N/A Audit closure date: June 26, 2019
District of Columbia Department of Health HIV/AIDS, Hepatitis, STD & TB Administration	RWIID72	DC	No adverse findings	None	N/A Audit closure date: April 12, 2019
DOH Okaloosa	FP325481	FL	Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility.	None	CAP implemented Audit closure date: April 9, 2019
Duke University Hospital	DSH340030	NC	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.	None	CAP implemented Audit closure date: December 18, 2019
East Bay Community Action Program Contact Information Administrative Assistant Health Administration East Bay Community Action Program 100 Bullocks Point Avenue Riverside, RI 02915 401-437-1008	CH015160	RI	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 17, 2020
Ellis Hospital Contact Information 340B Manager Ellis Hospital 1101 Nott Street Schenectady, NY 12308 518-243-1824	DSH330153	NY	Diversion – 340B drug dispensed to inpatient	Repayment to manufacturers	CAP implemented Audit closure date: September 15, 2020
Ellsworth Municipal Hospital	CAH161380-00	IA	No adverse findings	None	N/A Audit closure date: July 9, 2019
Exempla Saint Joseph Hospital	DSH060028	CO	No adverse findings	None	N/A Audit closure date: May 3, 2019
Fairview Hospital	CAH221302-00	MA	No adverse findings	None	N/A Audit closure date: March 13, 2019
Faxton St. Luke’s Healthcare	DSH330044	NY	No adverse findings	None	N/A Audit closure date: June 17, 2019
Ferrell Hospital Community dba Ferrell Hospital Community Foundation Contact Information Director of Pharmacy/340B primary contact Ferrell Hospital 1201 Pine Street Eldorado, IL 62930 618-297-9627	CAH141324-00	IL	Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 10, 2020
Forrest General Hospital Contact Information Director of Pharmacy tmcdaniel@forrestgeneral.com 601-288-1485	DSH250078	MS	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 21, 2021
Franklin Medical Center Contact Information Director of Pharmacy/Compliance Officer 2106 Loop Road Winnsboro, LA 71295 ggough@fmc-cares.com 318-412-5340	DSH190140	LA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to May 29, 2020. Entity failed to maintain auditable medical records prior to May 29, 2020.	Repayment to manufacturers	CAP implemented Audit closure date: April 6, 2021
Freeman Regional Health Services	CAH431313-00	SD	No adverse findings	None	N/A Audit closure date: August 28, 2019
G.A. Carmichael Family Health Center, Inc. Contact Information Chief Financial Officer 1668 W. Peace Street Canton, MS 39046 270-245-7239	CH040760	MS	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove a duplicate registration of a contract pharmacy; Diversion - 340B drug dispensed at contract pharmacy, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: September 15, 2020
Galion Community Hospital	CAH361325-00	OH	Inaccurate or incomplete information on 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: September 15, 2020
Georgetown University Hospital Contact Information 340B Compliance Specialist MedStar Georgetown University Hospital 3800 Reservoir Road Washington DC 20007 thanhson.t.doan@gunet.georgetown.edu 202-444-0556	DSH090004	DC	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: May 12, 2020
Gerald Champion Regional Medical Center Contact Information 340B Coordinator 2669 Scenic Drive Alamogordo, NM 88310 575-443-7841	DSH320004	NM	Covered outpatient drugs obtained through a Group Purchasing Organization prior to July 1, 2019. Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. Diversion - 340B drug dispensed at contract pharmacy for prescriptions written at ineligible site. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	State Medicaid has since determined duplicate discounts did not occur. CAP implemented Audit closure date: January 5, 2021
GHS Laurens County Memorial Hospital	SCH420038	SC	No adverse findings	None	N/A Audit closure date: October 10, 2019
Golden Valley Health Centers Contact Information Accounting Manager, Primary Contact 1910 Customer Care Way Atwater, CA 95301 209-384-6524	CH090470	CA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 18, 2020
Gonzales Healthcare Systems Contact Information Compliance Officer GHS P.O. Box 587 Gonzales, Texas 78629 830-672-7581 ext 1011	DSH450235	TX	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts – Entity did not have adequate controls to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: May 20, 2020
Good Samaritan Regional Health Center Contact Information Finance Director 1195 Corporate Lake Drive St Louis, MO 63132 314-989-3532 jeff.peine@ssmhealth.com	RRC140046-00	IL	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: December 10, 2019
Graham Hospital Association	SCH140001-00	IL	Incorrect 340B OPAIS Record - Incorrect entry for Primary Contact. Duplicate Discounts - Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: June 9, 2020
Halifax Regional Medical Center Contact Information Patient Financial Services Manager 250 Smith Church Road Roanoke Rapids, NC 27870 252-535-8147 cferebee@halifaxmrc.org	DSH340151	NC	Duplicate Discounts – Entity did not have adequate controls to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: May 14, 2020
Harbor Beach Community Hospital, Inc. Contact Information Scott Rayl, Pharmacist 989-479-3201 x351, 210 S. First Street, Harbor Beach, MI 48441	CAH231313-00	MI	Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: June 9, 2020
Hartford Hospital	DSH070025	CT	No adverse findings	None	N/A Audit closure date: August 7, 2019
Healdsburg District Hospital Contact Information Chief Financial Officer 1375 University Ave. Healdsburg, CA 95448 707-385-2022 staj@nschd.org	CAH051321-00	CA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 26, 2020
Higgins General Hospital Contact Information Director of Pharmacy 705 Dixie Street Carrollton, GA 30117 770‐836‐9646	CAH111320-00	GA	Diversion – 340B drug dispensed to inpatient.	Repayment to manufacturers	CAP implemented Audit closure date: May 12, 2020
Highland Community Hospital	DSH250117	MS	No adverse findings	None	N/A Audit closure date: May 14, 2019
Highlands Hospital	DSH390184	PA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: May 12, 2020
Holdenville Hospital Authority Contact Information CEO/Administrator 100 McDougal Drive Holdenville, OK 74848 405-379-4287	CAH371321-00	OK	Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 8, 2020
Hospital Authority of Randolph County DBA Southwest Georgia Regional Medical Center Contact Information Chief Financial Officer 361 Randolph St. Cuthbert, GA 39840 229-777-4506	CAH111300-00	GA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 27, 2020
Hospital Service District 1A, Parish of Richland, State of Louisiana DBA Richland Parish Hospital	CAH191323-00	LA	No adverse findings	None	N/A Audit closure date: March 29, 2019
Huggins Hospital Contact Information Clinical Services Business Manager Huggins Hospital 240 South Main Street Wolfeboro, NH 03894 (603) 515 – 2065 atheberge@hugginshospital.org	CAH301312-00	NH	Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 3, 2020
Huron Memorial Hospital Contact Information Director of Finance 1100 S. Van Dyke Bad Axe, MI 48413 989-269-1510	DSH230118	MI	Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place; Diversion - 340B drugs dispensed to inpatients; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.	Termination of contract pharmacy from 340B Program	CAP implemented Audit closure date: June 19, 2020
Ida County Iowa Community Hospital dba Horn Memorial Hospital Contact Information Chief Financial Officer or CFO of Horn Memorial Hospital 701 E 2nd St Ida Grove, IA, 51445 712-364-3311	CAH161354-00	IA	Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites	Repayment to manufacturers	CAP implemented Audit closure date: April 8, 2020
IHC Health Services, Inc. dba Primary Children’s Hospital	PED463301-00	UT	No adverse findings	None	N/A Audit closure date: November 26, 2019
Inova Fairfax Hospital Contact Information 340B Compliance Pharmacist Inova Fairfax Medical Campus 3300 Gallows Road Falls Church, VA 22042 703-776-1114	DSH490063	VA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 12, 2020.	Repayment to manufacturers	CAP implemented Audit closure date: January 26, 2021
Interfaith Medical Center	DSH330397	NY	Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facility; Incorrect entry for offsite outpatient facility address.	None	CAP implemented Audit closure date: April 29, 2020
Iowa Lutheran Hospital	DSH160024	IA	No adverse findings	None	N/A Audit closure date: June 21, 2019
Jefferson Regional Medical Center Contact Information 340B Program Director 1600 West 40th Avenue Pine Bluff, AR 71603 hawkk@jrmc.org 870-541-3340	DSH040071	AR	Incorrect 340B OPAIS record - Ineligible offsite outpatient facility registered on 340B OPAIS; Offsite outpatient facility was not listed on 340B OPAIS. Diversion - 340B drugs dispensed at covered entity and at contract pharmacy, prescribed by ineligible provider. Duplicate Discounts - Inaccurate or incomplete information on the Medicaid Exclusion File.	Termination of ineligible offsite outpatient facility from the 340B Program. Repayment to affected manufacturers	CAP implemented Audit closure date: July 19, 2024
John C. Lincoln Medical Center	DSH030014	AZ	No adverse findings	None	N/A Audit closure date: May 17, 2019
Johnston Health Services Corporation	DSH340090	NC	No adverse findings	None	N/A Audit closure date: April 24, 2019
Kearney County Health Services	CAH281306-00	NE	No adverse findings	None	N/A Audit closure date: October 1, 2019
Keck Hospital of USC	DSH050696	CA	Inaccurate or incomplete information on 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 27, 2020
Kern Medical Center Contact Information Associate Director of Pharmacy Kern Medical Center 1700 Mount Vernon Avenue Bakersfield, CA 93306 (661) 326-2617	DSH050315	CA	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. Diversion - 340B drug dispensed at entity for a prescription written at an ineligible site. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 30, 2020
Kossuth Regional Health Center	CAH161353-00	IA	No adverse findings	None	N/A Audit closure date: June 19, 2019
Lake Regional Health System Contact Information Primary Contact 340B Program Lake Regional Health System 54 Hospital Drive Osage Beach, MO 65065 573-348-8190	SCH260186-00	MO	Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.	Repayment to manufacturers	CAP implemented Audit closure date: June 3, 2020
Lavaca Medical Center Contact Information Chief Financial Officer Lavaca Medical Center 1400 N. Texana Hallettsville, TX 77964 361-798-3671	CAH451376-00	TX	Duplicate Discounts – Entity did not have adequate controls in place to prevent duplicate discounts.	Repayment to manufacturers	CAP implemented Audit closure date: March 27, 2020
Legacy Mount Hood Medical Center	DSH380025	OR	No adverse findings	None	N/A Audit closure date: January 9, 2019
Lexington Memorial Hospital, Inc. Contact Information Pharmacy System Manager, 340B Medical Center Blvd Winston-Salem, NC 27157 336-713-3426	DSH340096	NC	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 26, 2020
Liberty Regional Medical Center	CAH111335-00	GA	No adverse findings	None	N/A Audit closure date: October 1, 2019
Lonesome Pine Hospital	DSH490114	VA	No adverse findings	None	N/A Audit closure date: March 8, 2019
Lost Rivers District Hospital	CAH131324-00	ID	No adverse findings	None	N/A Audit closure date: February 15, 2019
Lowell General Hospital, The	DSH220063	MA	No adverse findings	None	N/A Audit closure date: October 31, 2019
Lutheran Medical Center	DSH060009	CO	No adverse findings	None	N/A Audit closure date: October 7, 2019
Lynn County Hospital	CAH451351-00	TX	No adverse findings	None	N/A Audit closure date: May 14, 2019
Marietta Memorial Hospital	RRC360147-00	OH	Incorrect 340B OPAIS record – Ineligible sites registered on 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program*	CAP implemented Audit closure date: March 11, 2021
Marshall Hospital	DSH050254	CA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: November 20, 2019
Mary Bridge Children’s Hospital and Health Center Contact Information Pharmacy 340B Analyst MultiCare Health System PO Box 5299, 315-C2-RX 315 Martin Luther King Jr. Way Tacoma, WA 98415 jkim@multicare.org 253.403.5541	PED503301-00	WA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to September 26, 2019. Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facility addresses.	Repayment to manufacturers	CAP implemented Audit closure date: December 1, 2020
Mason General Hospital	CAH501336-00	WA	No adverse findings	None	N/A Audit closure date: June 6, 2019
Massac County Hospital District	CAH141323-00	IL	Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place.	Termination of contract pharmacy from 340B Program*	CAP implemented Audit closure date: October 31, 2019
McCloud Healthcare Clinic, Inc	CHC24112-00	CA	Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place.	Termination of contract pharmacies from 340B Program*	CAP implemented May 27, 2020
MedStar Southern Maryland Hospital Center Contact Information Corporate 340B Manager MedStar Health 7375 Washington Blvd, Suite 103 Elkridge, MD 21075 Anna.y.rosenfeld@medstar.net 410-540-4406	DSH210062	MD	Diversion – 340B drug dispensed to inpatient	Repayment to manufacturers	CAP implemented Audit closure date: March 10, 2021
MedStar Washington Hospital Center	DSH090011	DC	No adverse findings	None	N/A Audit closure date: October 24, 2019
Memorial Hospital dba Memorial Healthcare, The Contact Information 340B Manager 826 W. King Street Owosso, MI 48867 989-729-4793	DSH230121	MI	Incorrect 340B OPAIS record - Incorrect entry for address for an offsite outpatient facility; Failed to remove duplicate registration for contract pharmacy. 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 Audit closure date: June 24, 2020
Memorial Hospital of Boscobel Contact Information Pharmacy Director MHB 205 Parker Street Boscobel, WI 53805 608-375-6307	CAH521344-00	WI	Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: February 10, 2020
Mercy Catholic Medical Center	DSH390156	PA	Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facilities.	None	CAP implemented Audit closure date: May 13, 2020
Mercy Health Lourdes Hospital LLC	RRC180102-00	KY	No adverse findings	None	N/A Audit closure date: May 24, 2019
Mercy Medical Center – North Iowa	SCH160064-00	IA	No adverse findings	None	N/A Audit closure date: February 7, 2020
MetroHealth	HV01713	DC	No adverse findings	None	N/A Audit closure date: February 19, 2020
Metropolitan Charities, Inc.	STD33713	FL	No adverse findings	None	N/A Audit closure date: February 25, 2020
MGH Chelsea Student Health Center Contact Information Director, MGH Community Health Associates 300 Ocean Avenue 5th Floor Revere, MA 02151 781-485-6135 aduffy-keane@partners.org	FP021501	MA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 9, 2020
Minnie Hamilton Health Care Center, Inc.	CAH511303-00	WV	Incorrect 340B OPAIS record - Hospital classification on OPAIS was inconsistent with eligibility documents.	None	CAP implemented Audit closure date: October 8, 2020
Missouri Baptist Hospital of Sullivan dba Missouri Baptist Sullivan Hospital	CAH261337-00	MO	No adverse findings	None	N/A Audit closure date: June 27, 2019
Montefiore Medical Center Contact Information Vice President of Finance dmenashy@montefiore.org 917-280-2722	DSH330059	NY	Incorrect 340B OPAIS record – Offsite outpatient facilities and a shipping address were not listed on the 340B OPAIS. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 9, 2021
Montefiore Nyack Hospital	DSH330104	NY	No adverse findings	None	N/A Audit closure date: June 12, 2019
Mosaic Medical	CH105600	OR	Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facility names and addresses. 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: July 21, 2020
Mount St. Mary’s Hospital and Health Center	DSH330188	NY	Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy.	None	CAP implemented Audit closure date: April 14, 2020
Mountain Comprehensive Health Corp., Inc.	CH040600	KY	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: May 12, 2020
Munson Healthcare Charlevoix Hospital	CAH231322-00	MI	Incorrect 340B OPAIS record – Offsite outpatient facility was not listed on the 340B OPAIS.	None	CAP implemented Audit closure date: January 26, 2021
Nanticoke Memorial Hospital	DSH080006	DE	No adverse findings	None	N/A Audit closure date: June 12, 2019
Nationwide Children’s Hospital	PED363305-00	OH	No adverse findings	None	N/A Audit closure date: October 1, 2019
New Mexico Department of Health Title X Family Planning Program	FP875036	NM	No adverse findings	None	N/A Audit closure date: April 10, 2020
Northeast Georgia Medical Center Contact Information Director of Pharmacy 743 Spring St. NE Gainesville, GA 30501 770-219-7573	RRC110029-00	GA	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entries for addresses for offsite outpatient facilities. Diversion – 340B drugs dispensed to inpatients Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 25, 2021
Oakwood Healthcare Inc. dba Beaumont Hospital - Taylor	DSH230270	MI	No adverse findings	None	N/A Audit closure date: August 26, 2019
Ohio State University Hospital, The	DSH360085	OH	No adverse findings	None	N/A Audit closure date: June 6, 2019
Olean General Hospital	RRC330103-00	NY	Incorrect 340B OPAIS record – Ineligible sites registered on 340B OPAIS; Offsite outpatient facilities were not listed on the 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program*	CAP implemented Audit closure date: December 8, 2020
Olympic Medical Center Contact Information Director of Pharmacy Olympic Medical Center 939 Caroline Street Port Angeles, WA 98362 kbright@olympicmedical.org	RRC500072-00	WA	Diversion – 340B drugs dispensed to inpatients	Repayment to manufacturers	CAP implemented Audit closure date: November 3, 2020
Oneida Healthcare Center	DSH330115	NY	No adverse findings	None	N/A Audit closure date: November 1, 2019
Open Door Health Services, Inc. Contact Information Compliance Officer PO Box 1676 Muncie, IN 47308 765-747-2973	CH0510700	IN	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: June 26, 2020
Orlando Health	DSH100006	FL	Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities. Failed to include repackaging location as a shipping address.	None	CAP implemented Audit closure date: April 29, 2020
Ozarks Resource Group Contact Information Chief Executive Officer or Chief Financial Officer PO Box 125, Hermitage, MO 65668 417-745-0103	CHC24137-00	MO	Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File	Repayment to manufacturers	CAP implemented Audit closure date: December 10, 2019
Pediatric & Family Medical Center	CH0921340	CA	Inaccurate or incomplete information on 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: October 8, 2020
Pender Community Hospital	CAH281349-00	NE	No adverse findings	None	N/A Audit closure date: December 4, 2019
Peninsula Community Health Services	CH101540	WA	No adverse findings	None	N/A Audit closure date: October 1, 2019
Phelps Memorial Hospital Center	DSH330261	NY	No adverse findings	None	N/A Audit closure date: November 20, 2019
Piedmont Henry Hospital, Inc.	DSH110191	GA	No adverse findings	None	N/A Audit closure date: November 19, 2019
Piedmont Newnan Hospital, Inc.	DSH110229	GA	No adverse findings	None	N/A Audit closure date: February 4, 2019
Piggott Community Hospital	CAH041330-00	AR	No adverse findings	None	N/A Audit closure date: May 16, 2019
Pikeville Medical Center, Inc.	DSH180044	KY	No adverse findings	None	N/A Audit closure date: March 13, 2019
Planned Parenthood of the Rocky Mountains, Inc.	STD80203	CO	No adverse findings	None	N/A Audit closure date: December 17, 2019
Primary Health Network, Inc.	CH03406AE	OH	Incorrect 340B OPAIS record –Incorrect entry for site ID for offsite outpatient facility; Failed to remove a duplicate registration of a contract pharmacy.	None	CAP implemented Audit closure date: February 10, 2020
Providence Portland Medical Center	DSH380061	OR	No adverse findings	None	N/A Audit closure date: May 23, 2019
Rancho Los Amigos National Rehabilitation Center	DSH050717	CA	Duplicate Discounts - Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: September 18, 2019
Range Regional Health Services	DSH240040	MN	No adverse findings	None	N/A Audit closure date: October 8, 2019
Regional Health Care Affiliates, Inc. Contact Information CPO 121 E. Main St. Providence, KY 42450 270-667-7017	CHC17157-00	KY	Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: August 20, 2019
Regional Health Custer Hospital	CAH431323-00	SD	No adverse findings	None	N/A Audit closure date March 7, 2019
Renown Regional Medical Center	DSH290001	NV	No adverse findings	None	N/A Audit closure date: November 21, 2019
Sacred Heart Hospital	DSH390197	PA	No adverse findings	None	N/A Audit closure date: August 28, 2019
San Bernardino Mountains Community Hospital District	CAH051312-00	CA	No adverse findings	None	N/A Audit closure date: August 27, 2019
Sanford Bismarck	DSH350015	ND	No adverse findings	None	N/A Audit closure date: January 16, 2019
Sanford Health Westbrook Medical Center	CAH241302-00	MN	No adverse findings	None	N/A Audit closure date: January 25, 2019
Sierra View Medical Center	DSH050261	CA	Incorrect 340B OPAIS record - Incorrect entries for addresses for offsite outpatient facilities. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: March 26, 2020
Someone Cares, Inc. of Atlanta Early Detection Intervention Clinic Contact Information Chief Executive Officer 236 Forsyth Street, SW, Ste. 201 Atlanta, Georgia 30303-3700 678-921-2706 Ext: 3	STD303036	GA	Incorrect 340B OPAIS record – Registered contract pharmacy without written contract in place; Incorrect grant number entry. Diversion – 340B drugs dispensed at contract pharmacy for prescription written at ineligible sites.	Termination of contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: June 9, 2020
South Central Kansas Regional Medical Center	SCH170150-00	KS	No adverse findings	None	N/A Audit closure date: October 4, 2019
Southern Illinois University	CHC24098-00	IL	No adverse findings	None	N/A Audit closure date: February 12, 2020
Southern Ohio Medical Center	DSH360008	OH	Inaccurate or incomplete information on 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 8, 2020
Southwest Boulevard Family Health Care	HV00140	KS	No adverse findings	None	N/A Audit closure date: February 5, 2020
Southwest Health Center	CAH521354-00	WI	Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration; Registered contract pharmacy without written contract in place.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: June 25, 2019
Southwest Memorial Hospital	CAH061327-00	CO	No adverse findings	None	N/A Audit closure date: January 8, 2020
Sparrow Ionia Hospital Contact Information Chief Financial Officer of Community Hospitals 3565 S. State Road Ionia, MI 48846 616-523-4186	CAH231331-00	MI	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 6, 2020
SSM Health Saint Louis University Hospital	DSH260105	MO	Incorrect 340B OPAIS record – Offsite outpatient facility was not listed on the 340B OPAIS; Failed to include repackaging location as a shipping address.	None	CAP implemented Audit closure date: April 16, 2020
SSM St. Joseph Health Center	DSH260005	MO	Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; Failed to remove closed location registrations; Failed to remove duplicate registrations for offsite outpatient facilities.	Termination of ineligible offsite outpatient facility from the 340B Program	CAP implemented Audit closure date: February 7, 2020
St. Anthony Shawnee Hospital	DSH370149	OK	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined that duplicate discounts did not occur. Audit closure date: May 12, 2020
St. Charles Community Health Center, Inc.	CH061335A	LA	No adverse findings	None	N/A Audit closure date: June 6, 2019
St. Charles Health System, Inc. DBA St. Charles Bend	DSH380047	OR	No adverse findings	None	N/A Audit closure date: August 28, 2019
St. Francis Hospital Contact Information 340B Drug Program Manager 5901 West War Memorial Drive Peoria, IL 61615 309-308-0413	CAH231337-00	MI	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for address for an offsite outpatient facility. Diversion - 340B drugs were not properly accumulated.	Repayment to manufacturers	CAP implemented Audit closure date: May 12, 2020
St. Helena Hospital dba Adventist Health St. Helena Contact Information Director of Pharmacy 10 Woodland Road St. Helena, CA 94574 AhmadAU@ah.org 707-963-6584	DSH050013	CA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: November 13, 2020
St. Mary Medical Center Contact Information Director of Pharmacy St. Mary Medical Center 1050 Linden Avenue Long Beach, CA 90813-3393 562-491-9773	DSH050191	CA	Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented Audit closure date: September 29, 2020
St. Mary Medical Center	DSH050300	CA	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entries for shipping address for offsite outpatient facilities. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: October 24, 2019
St. Marys Healthcare Contact Information Chief Finance Officer St. Mary's Healthcare 427 Guy Park Ave Amsterdam, NY 12010 518-841-7435 Rick.Henze@ascension.org	DSH330047	NY	Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place. Duplicate Discounts – Inaccurate or incomplete information on 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*	CAP implemented Audit closure date: June 9, 2020
St. Vincent Healthcare	DSH270049	MT	No adverse findings	None	N/A Audit closure date: December 4, 2019
Ste. Genevieve County Memorial Hospital	CAH261330-00	MO	No adverse findings	None	N/A Audit closure date: October 1, 2019
Sturgis Hospital Contact Information VP Quality Management & Support Services 916 Myrtle Avenue Sturgis, MI 49091 269-659-4403	DSH230096	MI	Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 30, 2019. Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed at contract pharmacy for prescription written at ineligible sites. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Covered entity, its outpatient facilities, and its contract pharmacies terminated from 340B Program as of July 1, 2019. Settlement with affected manufacturers has not been finalized. SH will not be permitted to re-enroll in the 340B Program until such time: 1) SH has attested that it has contacted and offered settlement to all affected manufacturers, for all findings listed in the Final Report; and 2) SH has attested that a HRSA-approved CAP has been fully implemented. Audit closure date: June 16, 2020
Texas Children’s Hospital Contact Information Texas Children’s Hospital 6621 Fannin Street, Suite WB1-120 Houston, TX 77030 832-824-6091 jlwagner@texaschildrens.org	PED453304-00	TX	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 24, 2020
Trinity Hospitals	SCH350006-00	ND	Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: April 30, 2019
Unity Care Northwest	CHC08773-00	WA	No adverse findings	None	N/A Audit closure date: November 14, 2019
Unity Hospital of Rochester	DSH330226	NY	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: September 26, 2019
University Hospital of Brooklyn Contact Information Pharmacy 340B Manager 445 Lenox Road Attn: Pharmacy Box 36 Brooklyn, NY 11203 718-270-7648 Hossameldin.Ghanem@downstate.edu	DSH330350	NY	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Ineligible sites registered on 340B OPAIS prior to October 1, 2019; Incorrect entry for disproportionate share percentage. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: October 16, 2019
University of Alabama Hospital	DSH010033	AL	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: August 27, 2019
University of Missouri Health Care Contact Information Pharmacy Business Administrator – 340B Program 573-884-4614 simonsjp@health.missouri.edu	DSH260141	MO	Diversion - 340B drug dispensed at entity for a prescription written at an ineligible site.	Repayment to manufacturers	CAP implemented Audit closure date: May 27, 2020
University of South Carolina	RWII29203 RWII292030	SC	Incorrect 340B OPAIS record - Failed to remove duplicate registration for service location.	None	CAP implemented Audit closure date: May 19, 2020
UNM Sandoval Regional Medical Center	DSH320089	NM	No adverse findings	None	N/A Audit closure date: October 24, 2019
Washington County Hospital	CAH161344-00	IA	No adverse findings	None	N/A Audit closure date: February 5, 2019
Washington State Department of Health	STD98504	WA	Incorrect 340B database record – entity improperly registered a distribution site as a contract pharmacy. Registered contract pharmacies without written contract in place	Termination of contract pharmacies from 340B Program	CAP implemented Audit closure date: January 6, 2021
Wellstar Cobb Hospital	DSH110143	GA	No adverse findings	None	N/A Audit closure date: May 10, 2019
West Holt Memorial Hospital	CAH281343-00	NE	No adverse findings	None	N/A Audit closure date: December 31, 2019
West Oakland Health Council, Inc. Contact Information Director of Pharmacy Services 700 Adeline St Oakland, CA 94607 510-835-9610 x2076 jmccabe@wohc.org	CH090540	CA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 6, 2020
West Virginia Department of Health and Human Resources	FP253015	WV	Incorrect 340B OPAIS record – Incorrect entries for grant number.	None	CAP implemented Audit closure date: March 24, 2020
Western Missouri Medical Center	SCH260097-00	MO	No adverse findings	None	N/A Audit closure date: October 1, 2019
Whatley Health Services, Inc. Contact Information Chief Executive Officer 2731 Martin Luther King Jr Boulevard Tuscaloosa, AL 35401-5235 205-349-3250	CH042450	AL	Incorrect 340B OPAIS record - Failed to remove closed locations registration; Failed to remove duplicate registration for offsite outpatient facility; Incorrect entry for address for offsite outpatient facility; Registered contract pharmacies without written contract in place. Diversion – 340B drugs dispensed at contract pharmacies, not supported by medical records; 340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File; Inaccurate or incomplete information on the Medicaid Exclusion File.	Termination of contract pharmacies from 340B Program Repayment to manufacturers	CAP implemented Audit closure date: March 3, 2020
White County Medical Center	DSH040014	AR	Incorrect 340B OPAIS record - Failed to remove closed location registrations	None	CAP implemented Audit closure date: December 18, 2019
Will County Community Health Center Contact Information Chief Executive Officer Will County Community Health Center 1106 Neal Ave. Joliet, IL 60433 815-740-7635	CH057880	IL	Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 13, 2020
Willits Hospital Inc., dba Adventist Health Howard Memorial	CAH051310-00	CA	No adverse findings	None	N/A Audit closure date: May 14, 2019
Winslow Memorial Hospital dba Little Colorado Medical Center Contact Information Assistant Director of Pharmacy 1501 N. Williamson Ave. Winslow, AZ 86047 928-289-6325	CAH031311-00	AZ	Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to September 26, 2019. Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at entity for prescriptions written at ineligible sites. Duplicate discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: June 4, 2020
Witham Memorial Hospital	DSH150104	IN	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for disproportionate share percentage; Registered contract pharmacies without written contract in place.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: April 23, 2020

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

Date Last Reviewed:

August 2024

Parents: don’t struggle alone

Program Integrity: FY19 Audit Results