Program Integrity: FY21 Audit Results

Updated 10/28/24. The results chart includes audits where the findings have been finalized. Remaining audits are still under review. Information on Corrective Action Plans and Sanctions will be updated once approved by HRSA. HRSA recommends manufacturers do not contact audited entities regarding sanctions until a corrective action plan has been approved by HRSA and posted on this website.

Entity Sort descending	340B ID	State	OPA Findings	Sanction	Corrective Action Status
AdventHealth Manchester	DSH180043	KY	Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS. 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: May 4, 2021
Adventist Health Clearlake Hospital, Inc. Contact Information Director of Pharmacy Adventist Health Clear Lake 15630 18th Ave Clearlake, CA 95422 SheltoJ1@ah.org 707-994-6486	CAH051317-00	CA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 15, 2022
AIDS Action Coalition of Huntsville - Thrive Alabama	HV358011A	AL	No adverse findings	None	N/A Audit closure date: March 17, 2021
AIDS Care Group	HV190131	PA	No adverse findings	None	N/A Audit closure date: April 27, 2021
Aitkin Community Hospital dba Riverwood Healthcare Center	CAH241305-00	MN	Incorrect 340B OPAIS record - Incorrect Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: May 6, 2021
Alegent Health Bergan Mercy Health System dba CHI Health Creighton University Med Center-Bergan Mercy	DSH280060	NE	No adverse findings	None	N/A Audit closure date: March 5, 2021
Allen Parish Hospital	DSH190133	LA	No adverse findings	None	N/A Audit closure date: May 14, 2021
Altoona Regional Health System	DSH390073	PA	Inaccurate or incomplete information in the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: August 3, 2021
Altru Hospital	SCH350019-00	ND	Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: September 23, 2021
Ascension Seton d/b/a Ascension Seton Northwest	DSH450867	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: March 15, 2022
Auburn Community Hospital	SCH330235	NY	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: July 14, 2021
Avera McKennan DBA Avera Flandreau Hospital	CAH431310-00	SD	No adverse findings	None	N/A Audit closure date: July 7, 2021
Banner Gateway Medical Center	DSH030122	AZ	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.	None	CAP implemented Audit closure date: March 15, 2022
Banner Lassen Medical Center	CAH051320-00	CA	No adverse findings	None	N/A Audit closure date: April 9, 2021
Baptist Hospital of Miami, Inc.	DSH100008	FL	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date.	None	CAP implemented Audit closure date: February 15, 2022
Behavioral Health Services, Inc. Contact Information Chief Compliance Officer 15519 Crenshaw Blvd Gardena, CA 90249 310-679-9126 mballue@bhs-inc.org	CHC29048-00	CA	Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place. Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Termination of contract pharmacy from 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: September 15, 2022
Benefis Hospitals, Inc.	DSH270012	MT	Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: January 4, 2022
Bennet County Hospital	CAH431314-00	SD	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: June 16, 2021
Black River Health Services, Inc.	FQHCLA364	NC	No adverse findings	None	N/A Audit closure date: July 19, 2021
Bon Secours Community Hospital	DSH330135	NY	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date.	None	CAP implemented Audit closure date: September 14, 2021
Boulder City Hospital Contact Information Chief Financial Officer 901 Adams Blvd Boulder City, NV 89005 dlewis@bchnv.org 702-293-4111 x6509	CAH291309-00	NV	Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Authorizing Official phone number and Primary Contact phone number. Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 8, 2022
Brevard Health Alliance Inc., The	CH043823A	FL	No adverse findings	None	N/A Audit closure date: June 25, 2021
Brigham and Women's Hospital	RRC220110-00	MA	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for disproportionate share percentage.	None	CAP implemented Audit closure date: November 9, 2021
Brodstone Memorial Hospital	CAH281315-00	NE	No adverse findings	None	N/A Audit closure date: January 26, 2021
Butler County Health Department	STD36037	AL	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for grant number and nature of support. Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: December 7, 2021
California Hospital Medical Center	DSH050149	CA	Incorrect 340B OPAIS record –Incorrect entry in 340B OPAIS for disproportionate share percentage.	None	CAP implemented Audit closure date: February 15, 2022
CAN Community Health Inc.	STD333341	FL	No adverse findings	None	N/A Audit closure date: December 2, 2020
Care for the Homeless	CH020020	NY	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for grant associated site.	None	CAP implemented Audit closure date: June 15, 2021
Carle Eureka Hospital	CAH141309-00	IL	No adverse findings	None	N/A Audit closure date: April 29, 2021
Carroll County Memorial Hospital Contact Information Chief Executive Officer khaverly@ccmhosp.com 502-732-3275	CAH181310-00	KY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion – 340B drug dispensed at a contract pharmacy, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: June 13, 2022
Catholic Health Initiatives - Iowa, Corp.	DSH160083	IA	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Ineligible sites registered on 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite outpatient facility; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place. Duplicate Discounts - Inaccurate or incomplete information on the Medicaid Exclusion File.	Termination of contract pharmacies from 340B Program*	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: November 15, 2022
Central Florida Health Care, Inc.	CH040210	FL	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: March 21, 2022
Central Washington Health Services Association dba Central Washington Hospital	DSH500016	WA	No adverse findings	None	N/A Audit closure date: June 3, 2021
Cheyenne County Hospital Association, Inc. dba Sidney Regional Medical Center	CAH281357-00	NE	No adverse findings	None	N/A Audit closure date: February 23, 2021
CHI St. Vincent Morrilton	CAH041324-00	AR	Entity billed Medicaid while not listed in the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: November 30, 2021
Children's Hospital Medical Center	PED363300-00	OH	Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed in 340B OPAIS; Ineligible sites registered in 340B OPAIS. Duplicate Discounts - Inaccurate or incomplete information on the Medicaid Exclusion File.	Termination of ineligible offsite outpatient facility from the 340B Program*	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: May 12, 2022
Children's Mercy Hospital Kansas, The	PED173300-00	KS	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: November 9, 2021
Christus Hospital	RRC450034-00	TX	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, disproportionate share percentage, and hospital control type.	None	CAP implemented Audit closure date: June 23, 2021
Christus Santa Rosa Health System Contact Information Senior Consultant 7840 Graphics Drive, Suite 100 Tinley Park, IL 60477 708-478-7030	RRC450237-00	TX	Diversion – 340B drug dispensed at a contract pharmacy, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: February 15, 2022
Coastal Family Health Center Inc., The Contact Information Chief Executive Officer 1046 Division Street Biloxi, MS 39530 angel_greer@coastalfamilyhealth.org 228-374-2494	CH042430	MS	Incorrect 340B OPAIS record – Entity improperly registered a distribution site in 340B OPAIS as a grant associated site; Incorrect entries in 340B OPAIS for name for grant associated sites. Diversion – 340B drugs dispensed at contract pharmacies, not supported by a medical record. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid agency has since determined duplicate discounts did not occur. Audit closure date: November 9, 2021
Coffey County Hospital Contact Information Chief Financial Officer Senior Accountant Coffey County Hospital 801 N. 4th Burlington, KS 66839 620-364-2121	CAH171385-00	KS	Diversion – 340B drug dispensed to inpatient	Repayment to manufacturers	CAP implemented Audit closure date: April 4, 2022
Columbia Lutheran Charities dba Columbia Memorial Hospital	CAH381320-00	OR	No adverse findings	None	N/A Audit closure date: February 12, 2021
Community Clinic, Inc.	CHC10591-00	MD	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for site ID for grant associated site. 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: April 10, 2023
Community Health Care Systems Inc	CH045180	GA	Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. Entity and grant associated sites billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: August 23, 2021
Community Medical Centers Inc.	CH090780	CA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 29, 2022
Community Medical Wellness Centers USA	CHC28986-00	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: July 27, 2021
Coon Memorial Hospital Contact Information Chief Executive Officer 1411 Denver Avenue Dalhart, TX 79022 loreet@dhchd.org 806-244-9267	CAH451331-00	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove registration in 340B OPAIS for closed offsite outpatient facility; Incorrect entries in 340B OPAIS for address for offsite outpatient facilities. Diversion – 340B drug dispensed at a contract pharmacy, not supported by a medical record. Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	Repayment to manufacturers	CAP implemented Audit closure date: December 15, 2021
Cornerstone Family Healthcare Contact Information VP of Corporate Compliance and Risk Management 2570 US Route 9W Suite 10 Cornwall, NY 12518 mcalero@cornerstonefh.org 845-220-3188	CH020620	NY	Diversion – 340B drug dispensed at a contract pharmacy, not supported by a medical record. Inaccurate or incomplete information on 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: November 9, 2022
Crisp Regional Hospital Inc.	DSH110104	GA	No adverse findings	None	N/A Audit closure date: December 2, 2020
Deaconess Medical Center	DSH500044	WA	No adverse findings	None	N/A Audit closure date: May 25, 2021
Desert AIDS Project	CHC28988-00	CA	Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that were registered in error.	None	CAP implemented Audit closure date: June 8, 2021
Erlanger Medical Center	DSH440104	TN	No adverse findings	None	N/A Audit closure date: March 5, 2021
Falls Community Hospital and Clinic	SCH450348-00	TX	No adverse findings	None	N/A Audit closure date: March 3, 2021
Family Health Centers of San Diego, Inc.	CH093120	CA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for subdivision names for offsite outpatient facilities; Incorrect entries in 340B OPAIS for Site ID and address for offsite outpatient facility; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: July 14, 2021
Family Health Services Corporation Contact Information Operations Manager 794 Eastland Dr. Twin Falls, ID 83301 mavalos@fhsid.org 208-737-6707	CH101650	ID	Diversion – 340B drug dispensed, not supported by a medical record. Duplicate Discounts – Entity and grant associated sites billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 27, 2022
Field Memorial Community Hospital	CAH251309-00	MS	No adverse findings	None	N/A Audit closure date: March 17, 2021
Flushing Hospital Medical Center	DSH330193	NY	No adverse findings	None	N/A Audit closure date: September 9, 2021
Fort Madison Community Hospital	DSH160122	IA	Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: February 8, 2021
Franklin General Hospital	CAH161308-00	IA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: March 17, 2021
Franklin Memorial Hospital	SCH200037-00	ME	No adverse findings	None	N/A Audit closure date: March 16, 2021
Franklin Square Hospital	DSH210015	MD	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: June 8, 2021
Friend Family Health Center Inc.	CH059110	IL	Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that was registered in error.	None	CAP implemented Audit closure date: February 2, 2022
Fulton County Medical Center	CAH391303-00	PA	Incorrect 340B OPAIS record - Failed to remove a contract pharmacy from 340B OPAIS that was registered in error.	None	CAP implemented Audit closure date: June 29, 2021
Geisinger Wyoming Valley Medical Center	DSH390270	PA	No adverse findings	None	N/A Audit closure date: May 17, 2021
Glacial Ridge Health System	CAH241376-00	MN	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for address for offsite outpatient facilities, Medicare Cost Report filing date, and cost reporting period.	None	CAP implemented Audit closure date: April 28, 2021
Good Samaritan Hospital Corvallis	RRC380014-00	OR	No adverse findings	None	N/A Audit closure date: March 16, 2021
Grant County Public Hospital District No. 3 dba Columbia Basin Hospital	CAH501317-00	WA	No adverse findings	None	N/A Audit closure date: May 5, 2021
Grayson County Hospital Foundation dba Twin Lakes Regional Medical Center	DSH180070	KY	No adverse findings	None	N/A Audit closure date: February 9, 2021
Greenwood Leflore Hospital Contact Information Director of Pharmacy nmainelli@glh.org 662-459-2633 Chief Financial Officer dholmes@glh.org 662-459-7119	DSH250099	MS	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 17, 2022
Guttenberg Municipal Hospital	CAH161312-00	IA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: April 20, 2021
Hampshire Memorial Hospital, Inc.	CAH511311-00	WV	No adverse findings	None	N/A Audit closure date: January 5, 2021
Harbor Health Services, Inc.	CH010170	MA	No adverse findings	None	N/A Audit closure date: July 15, 2021
Health and Life Organization Inc. Contact Information 340B Compliance Specialist 3030 Explorer Drive Sacramento, CA 95827 mbradford2@halocares.org	FQHCLA247	CA	Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place. Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Termination of contract pharmacies from 340B Program*	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: March 9, 2022
Healthsource of Ohio, Inc.	CH050990	OH	No adverse findings	None	N/A Audit closure date: June 16, 2021
Henry Ford Wyandotte Hospital	RRC230146-00	MI	No adverse findings	None	N/A Audit closure date: April 29, 2021
Hillsdale Community Health Center Contact Information Director of Pharmacy Jkauffman@hillsdalehospital 517-437-5418	RRC230037-00	MI	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Diversion – 340B drug dispensed to inpatient.	Repayment to manufacturers	CAP implemented Audit closure date: December 16, 2021
Holston Valley Hospital and Medical Center	RRC440017-00	TN	No adverse findings	None	N/A Audit closure date: December 10, 2020
Holyoke Medical Center	DSH220024	MA	No adverse findings	None	N/A Audit closure date: July 15, 2021
Hope and Help Center of Central Florida, Inc.	STD33150	FL	No adverse findings	None	N/A Audit closure date: August 9, 2021
Hospital District No. 1 of Dickinson	CAH171381-00	KS	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: November 16, 2021
IHC Health Services Inc. DBA Heber Valley Hospital Contact Information 340B Program Director Intermountain Healthcare 340B@imail.org 385-429-2887	CAH461307-00	UT	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 2, 2023
IHC Health Services, Inc. DBA Utah Valley Hospital	DSH460001	UT	No adverse findings	None	N/A Audit closure date: July 15, 2021
Illini Community Hospital	CAH141315-00	IL	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: February 22, 2021
Jacobson Memorial Hospital	CAH351314-00	ND	Incorrect 340B OPAIS record - Entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: September 17, 2021
Jefferson Healthcare Contact Information Chief Ancillary and Support Services Office 834 Sheridan St. Port Townsend, WA 98368 Jdavidson@jeffersonhealthcare.org 360-385-2200 x2039	CAH501323-00	WA	Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: September 15, 2022
JWCH Institute, Inc.	CH0925360	CA	Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that were registered in error; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.	None	CAP implemented Audit closure date: April 20, 2021
Kalihi-Palama Health Center	CH096010	HI	Incorrect 340B OPAIS record – Grant associated site was not listed on the 340B OPAIS. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: July 30, 2021
Kent County Memorial Hospital	DSH410009	RI	Incorrect 340B OPAIS record – A shipping address was not listed in 340B OPAIS.	None	CAP implemented Audit closure date: September 21, 2022
Kiowa County Hospital District dba Weisbrod Memorial Hospital	CAH061300-00	CO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: June 17, 2021
Kiowa County Memorial Hospital	CAH171332-00	KS	No adverse findings	None	N/A Audit closure date: February 12, 2021
Klickitat County Public Hospital District No 1 dba Klickitat Valley Health	CAH501316-00	WA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: November 9, 2021
Lakeland Regional Health System, Lakeland Medical Center St. Joseph	DSH230021	MI	Incorrect 340B OPAIS record – Failed to remove a duplicate registration for an offsite outpatient facility from 340B OPAIS. 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: January 28, 2022
Landmann-Jungman Memorial Hospital	CAH431317-00	SD	No adverse findings	None	N/A Audit closure date: July 15, 2021
Lawrence Memorial Health Foundation, Inc.	CAH041309-00	AR	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type.	None	CAP implemented Audit closure date: September 30, 2021
Legacy Good Samaritan Hospital	DSH380017	OR	No adverse findings	None	N/A Audit closure date: May 11, 2021
Lehigh Valley Hospital	RRC390133-00	PA	Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: February 17, 2022
Lenox Hill Hospital	RRC330119-00	NY	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: July 27, 2022
Mackinac Straits Hospital and Health Center	CAH231306-00	MI	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: March 15, 2022
Marshfield Medical Center Contact Information 340B Program Manager 1000 North Oak Ave Marshfield, WI 54446 neuendorf.kirstia@marshfieldclinic.org 715-858-4308	SCH520037-00	WI	Incorrect 340B OPAIS record – Failed to remove duplicate registrations of contract pharmacies in 340B OPAIS. Diversion – 340B drug dispensed to inpatient; 340B drug dispensed at a contract pharmacy, not supported by a medical record.	Repayment for manufacturer	CAP implemented Audit closure date: March 7, 2022
Mary Hitchcock Memorial Hospital	RRC300003-00	NH	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and disproportionate share percentage; Ineligible sites registered in 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program.*	CAP implemented Audit closure date: September 19, 2022
Maury Regional Hospital	RRC440073-00	TN	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	None	CAP implemented State Medicaid agency has since determined duplicate discounts did not occur. Audit closure date: February 4, 2022
Meharry Community Wellness Center	HV01706	TN	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for name and address; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place; Failed to remove a closed contract pharmacy from 340B OPAIS.	Termination of contract pharmacies from 340B Program*	CAP implemented Audit closure date: February 15, 2022
Memorial Hospital West	DSH100281	FL	No adverse findings	None	N/A Audit closure date: August 5, 2021
Memorial Hospital, The	CAH301307-00	NH	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for offsite outpatient facility.	None	N/A Audit closure date: March 11, 2021
Memorial Regional Hospital	DSH100038	FL	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for offsite outpatient facility.	None	CAP implemented Audit closure date: April 30, 2021
Mena Regional Health System Contact Information Director of Pharmacy 311 North Morrow St. Mena, AR 71953 Angiea@menaregional.com 479-243-2225	DSH040015	AR	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: March 8, 2022
Mendota Community Hospital DBA OSF Saint Paul Medical Center	CAH141310-00	IL	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for hospital control type and Medicare Cost Report filing date. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: March 9, 2022
Mercy Hospital Springfield	DSH260065	MO	No adverse findings	None	N/A Audit closure date: March 5, 2021
Metro Community Provider Network, Inc.	CH080730	CO	No adverse findings	None	N/A Audit closure date: July 14, 2021
Mid-Columbia Medical Center	SCH380001-00	OR	Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: June 15, 2022
Milwaukee Health Services, Inc.	CH052090	WI	Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy location from 340B OPAIS. Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: November 16, 2021
Minidoka Memorial Hospital	CAH131319-00	ID	No adverse findings	None	N/A Audit closure date: June 25, 2021
Mitchell County Regional Health Center	CAH161323-00	IA	No adverse findings	None	N/A Audit closure date: January 7, 2021
Montgomery General Hospital, Inc.	CAH511318-00	WV	Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion – 340B drugs dispensed to inpatients; and 340B drugs prescribed by an ineligible provider.	Repayment to manufacturers Termination of contract pharmacies from 340B Program	CAP implemented Audit closure date: April 12, 2022
Mosaic Medical Center Maryville Contact Information 340B Primary Contact Mosaic Health System 5325 Faraon Street St. Joseph, MO 64506 Craig.gordon@mymlc.com 816-271-6069	SCH260050-00	MO	Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that were registered in error. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: March 9, 2022
Multicare Auburn Medical Center	DSH500015	WA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacy from 340B Program*	CAP implemented Audit closure date: October 7, 2022
Murray County Memorial Hospital	CAH241319-00	MN	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: June 8, 2021
Nevada City Hospital Contact Information Director of Pharmacy 800 S. Ash Street Nevada, MO 64772 jmashek@nrmchealth.com 417-448-3649	DSH260061	MO	Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 7, 2021. Inaccurate or incomplete information on 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: March 15, 2022
New York City Health and Hospitals	CHC29018-00	NY	Incorrect 340B OPAIS record – Failed to remove a duplicate registration for a grant associated site from 340B OPAIS; Grant associated site was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for name and address for grant associated sites; Ineligible site registered on 340B OPAIS. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File at entity and grant associated sites.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: December 3, 2021
North County Health Project, Inc. Contact Information Senior Director of Operations 150 Valpreda Road San Marcos, CA 92069 irene.torres@truecare.org 760-566-1722	CH090720	CA	Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: April 10, 2023
North Mississippi Medical Center	DSH250004	MS	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: June 24, 2021
Northeast Florida Health Services, Inc. Contact Information Chief Executive Officer lasbury@familyhealthsource.org 386-202-6025 Pharmacy Director mmoll@familyhealthsource.org 386-327-6049	CH0423770	FL	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: August 12, 2021
Northeastern Vermont Regional Hospital	CAH471303-00	VT	No adverse findings	None	N/A Audit closure date: June 9, 2021
Northern Pines Medical Center	CAH241340-00	MN	No adverse findings	None	N/A Audit closure date: May 17, 2021
Northern Valley Indian Health	FQHC638012	CA	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: March 10, 2021
Northwest Health Services, Inc. Contact Information Director of Pharmacy Northwest Health Services 2303 Village Drive St Joseph, MO 64506 816-385-5997 mirandaphillips@nwhealth-services.org	CH072130	MO	Incorrect 340B OPAIS record – Ineligible site registered on 340B OPAIS; Incorrect entry in 340B OPAIS for grant associated site name. Diversion – 340B drugs dispensed at a contract pharmacy, not supported by a medical record.	Repayment to manufacturers Termination of ineligible offsite outpatient facility from the 340B Program*	CAP implemented Audit closure date: February 23, 2023
Northwest Hospital Center, Inc.	DSH210040	MD	No adverse findings	None	N/A Audit closure date: May 5, 2021
NY Community Hospital of Brooklyn	DSH330019	NY	No adverse findings	None	N/A Audit closure date: August 17, 2021
Oak Valley District Hospital	DSH050067	CA	No adverse findings	None	N/A Audit closure date: March 16, 2021
Oaklawn Hospital	DSH230217	MI	No adverse findings	None	N/A Audit closure date: February 9, 2021
Oakwood Healthcare, Inc. dba Beaumont Hospital - Wayne	DSH230142	MI	Incorrect 340B OPAIS record - A shipping address was not listed in 340B OPAIS.	None	CAP implemented Audit closure date: October 4, 2021
Ocean Beach Hospital	CAH501314-00	WA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and Primary Contact email address. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 13, 2022
Okanogan County Public Hospital District No. 3 DBA Mid-Valley Hospital	CAH501328-00	WA	No adverse findings	None	N/A Audit closure date: January 24, 2022
OSF Little Company of Mary Medical Center Contact Information 340B Drug Program Manager 5901 West War Memorial Drive Peoria, IL 61615 309-308-0413	RRC140179-00	IL	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: December 7, 2021
OU Medical Center	DSH370093	OK	No adverse findings	None	N/A Audit closure date: April 1, 2021
Palo Pinto General Hospital Contact Information Chief Pharmacy Technician TCROSS@ppgh.com 940-328-6375	DSH450565	TX	Diversion – 340B drugs dispensed to inpatients. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: December 9, 2021
Paul Oliver Memorial Hospital	CAH231300-00	MI	No adverse findings	None	N/A Audit closure date: April 28, 2021
Pella Regional Health Center	CAH161367-00	IA	Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacy from 340B Program*	CAP implemented Audit closure date: June 8, 2021
Pemiscot County Memorial Hospital Contact Information Director of Pharmacy Services 946 E Reed Street Hayti, MO 63581 dketchum@pemiscot.org 573-359-1372	DSH260070	MO	Diversion – 340B drug dispensed to inpatient. Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: January 7, 2022
Peninsula Regional Medical Center	DSH210019	MD	No adverse findings	None	N/A Audit closure date: April 9, 2021
Pinckneyville Community Hospital District	CAH141307-00	IL	No adverse findings	None	N/A Audit closure date: December 18, 2020
Pioneers Medical Center	CAH061325-00	CO	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: October 4, 2021
Platte Valley Medical Center	DSH060004	CO	No adverse findings	None	N/A Audit closure date: January 29, 2021
Portsmouth Community Health Center, Inc. DBA Hampton Roads Community Health Center	CH034100	VA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for shipping addresses and names for grant associated sites. Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.	Termination of contract pharmacy from 340B Program	CAP implemented Audit closure date: August 5, 2021
Positively Living, Inc. Contact Information Client Services Director 290 E Hill Ave, Ste. 290 Knoxville, TN 37915 865-525-1540 x201	RWII37917	TN	Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that were registered in error. Diversion – 340B drugs dispensed at contract pharmacies, not supported by a medical record. Inaccurate or incomplete information on 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: November 5, 2021
Prairie Ridge Health, Inc.	CAH521338-00	WI	No adverse findings	None	N/A Audit closure date: April 29, 2021
Presence St. Mary's Hospital	DSH140155	IL	No adverse findings	None	N/A Audit closure date: April 6, 2021
Providence Willamette Falls Medical Center	DSH380038	OR	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type.	None	CAP implemented Audit closure date: December 7, 2021
Pueblo Community Health Center, Inc.	CH080170A	CO	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 3, 2021
Raritan Bay Medical Center / HMH Hospitals Corporation	DSH310039	NJ	Incorrect 340B OPAIS record – Ineligible site registered on 340B OPAIS; Offsite outpatient facilities were not listed in 340B OPAIS.	Termination of ineligible offsite outpatient facility from the 340B Program	CAP implemented Audit closure date: March 29, 2022
Richland, Parish of	CHC24167-00	LA	No adverse findings	None	N/A Audit closure date: July 14, 2021
Rural Medical Services, Inc.	CH046810	TN	Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy in 340B OPAIS.	None	CAP implemented Audit closure date: June 11, 2021
Rutland Regional Medical Center	DSH470005	VT	Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: May 25, 2021
Saint Mary’s Hospital dba CHI Health St. Mary’s Contact Information Pharmacy Supervisor Apekny@stez.org 402-873-8938	CAH281342-00	NE	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid agencies have since determined duplicate discounts did not occur. Audit closure date: August 31, 2021
Salem Township Hospital	CAH141345-00	IL	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: May 13, 2021
Sanford Bagley Medical Center	CAH241328-00	MN	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: March 29, 2022
Sanford Medical Center Fargo	DSH350011	ND	Incorrect 340B OPAIS record – Entity improperly listed retail pharmacies as shipping addresses in 340B OPAIS; Incorrect address entry in 340B OPAIS for offsite outpatient facility; Ineligible offsite outpatient facilities registered on 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program.	CAP approved
Schneck Medical Center	DSH150065	IN	No adverse findings	None	N/A Audit closure date: June 24, 2021
Scotland County Hospital	CAH261310-00	MO	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: May 25, 2021
Shenandoah Memorial Hospital	CAH491305-00	VA	No adverse findings	None	N/A Audit closure date: February 2, 2022
Sheridan Community Hospital	CAH231312-00	MI	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.	None	CAP implemented Audit closure date: November 16, 2021
Slidell Memorial Hospital	DSH190040	LA	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date.	None	CAP implemented Audit closure date: October 17, 2022
South Miami Hospital	DSH100154	FL	No adverse findings	None	N/A Audit closure date: May 11, 2021
South Sunflower County Hospital	SCH250095-00	MS	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date	None	CAP implemented Audit closure date: November 16, 2021
South Texas Rural Health Services, Inc.	CH062120	TX	No adverse findings	None	N/A Audit closure date: February 22, 2021
Sparta Community Hospital District	CAH141349-00	IL	No adverse findings	None	N/A Audit closure date: December 11, 2020
St. Agnes Hospital Contact Information 340B Program Manager 900 Canton Avenue Baltimore, MD 21229 Kelsey.Fiser@ascension.org 615-222-5190	DSH210011	MD	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for disproportionate share percentage, Medicare Cost Report filing date, and cost reporting period. Diversion – 340B drugs dispensed at contract pharmacies and at covered entity, not supported by a medical record.	Repayment to manufacturers	CAP implemented Audit closure date: June 13, 2022
St. Elizabeth Healthcare Contact Information Director of Reimbursement 1 Medical Village Drive Attn: Reimbursement/Dolwick Edgewood, KY 41017 joe.thamann@stelizabeth.com 859-655-1889	DSH180035	KY	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date; Ineligible site registered on 340B OPAIS. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Termination of ineligible offsite outpatient facility from the 340B Program* Repayment to manufacturers.	CAP implemented Audit closure date: October 31, 2020
St. Joseph Health Center	DSH360161	OH	No adverse findings	None	N/A Audit closure date: January 21, 2021
St. Joseph Regional Health Center	RRC450011-00	TX	No adverse findings	None	N/A Audit closure date: April 30, 2021
St. Luke's Jones Regional Medical Center	CAH161306-00	IA	No adverse findings	None	N/A Audit closure date: December 10, 2020
St. Mary's Health Care System Inc.	RRC110006-00	GA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for primary contact. Duplicate Discounts - Entity billed Medicaid while not listed in the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: May 16, 2023
St. Mary's Medical Center, Inc.	DSH510007	WV	No adverse findings	None	N/A Audit closure date: February 11, 2021
St. Mary's Regional Medical Center	DSH200034	ME	No adverse findings	None	N/A Audit closure date: March 30, 2021
St. Peter's Hospital	SCH270003-00	MT	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: February 10, 2022
St. Tammany Parish Hospital	DSH190045	LA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Inaccurate or incomplete information on the 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 30, 2021
St. Vincent Salem Hospital, Inc. Dba Ascension St. Vincent Salem	CAH151314-00	IN	Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital control type.	None	CAP implemented Audit closure date: March 23, 2021
Stephens Memorial Hospital	CAH201315-00	ME	No adverse findings	None	N/A Audit closure date: April 14, 2021
Sullivan County Memorial Hospital	CAH261306-00	MO	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Ineligible sites registered on 340B OPAIS.	Termination of ineligible offsite outpatient facilities from the 340B Program	CAP implemented Audit closure date: May 4, 2021
Sutter Bay Hospitals, dba Alta Bates Summit Medical Center	DSH050305	CA	Covered outpatient drugs obtained through a Group Purchasing Organization prior to July 21, 2021.	Repayment to manufacturers	CAP implemented Audit closure date: November 9, 2022
Sutter Bay Hospitals, dba Sutter Lakeside Hospital	CAH051329-00	CA	No adverse findings	None	N/A Audit closure date: August 4, 2021
Sweeny Hospital District Contact Information Chief Pharmacy Technician msaha@sweenyhospital.org 979-548-1818	CAH451311-00	TX	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date. Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacy, not supported by a medical record. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented State Medicaid determined duplicate discounts did not occur. Audit closure date: October 7, 2022
Tahoe Forest Hospital Contact Information Director of Pharmacy Tahoe Forest Hospital District PO Box 759 Truckee, CA 96160 tmather@tfhd.com 530-582-6465	CAH051328-00	CA	Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 17, 2022
Thomas H Boyd Critical ACC Hospital	CAH141300-00	IL	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: February 17, 2022
Toledo Hospital, The	DSH360068	OH	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place. 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 pharmacy from 340B Program*	CAP implemented Audit closure date: June 22, 2023
Tri-County Hospital	CAH241354	MN	No adverse findings	None	N/A Audit closure date: May 14, 2021
Tucson Medical Center	DSH030006	AZ	Incorrect 340B OPAIS record – Ineligible sites registered in 340B OPAIS. Diversion – 340B drug dispensed to inpatient.	Termination of ineligible offsite outpatient facilities from the 340B Program* Repayment to manufacturers	CAP implemented Audit closure date: October 12, 2022
University Hospitals of Cleveland	DSH360137	OH	Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 22, 2021. Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.	None	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: March 15, 2022
University Medical Center of El Paso	DSH450024	TX	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for disproportionate share percentage.	None	CAP implemented Audit closure date: February 9, 2021
University of Toledo Medical Center	DSH360048	OH	Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove registration in 340B OPAIS for closed offsite outpatient facility; Incorrect entry in 340B OPAIS for shipping address.	None	CAP implemented Audit closure date: April 5, 2022
Urban Health Solutions Inc.	RWI19146 and FP19146	PA	Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for grant number. 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: June 9, 2022
Van Buren County Hospital	CAH161337-00	IA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: February 22, 2021
Virginia Gay Hospital	CAH161349-00	IA	Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: March 26, 2021
Virtua Our Lady of Lourdes Hospital	DSH310029	NJ	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.	None	CAP implemented Audit closure date: July 1, 2021
Watts Healthcare Corporation Contact Information Chief Medical Officer 10300 Compton Ave Los Angeles, CA 90002 oliver.brooks@wattshealth.org 323-564-4331 x3141	CHC00850-00	CA	Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Incorrect entry in 340B OPAIS for Authorizing Official. Duplicate Discounts – Grant associated site billed Medicaid while not listed on the HRSA Medicaid Exclusion File.	Termination of ineligible contract pharmacy from the 340B Program*	CAP implemented State Medicaid has since determined duplicate discounts did not occur. Audit closure date: May 25, 2022
West Alabama AIDS Outreach	RWII354011	AL	No adverse findings	None	N/A Audit closure date: July 9, 2021
West Calcasieu-Cameron Hospital Contact Information Director of Pharmacy 701 Cypress Street Sulphur, LA 70663 gforeman@wcch.com 337-527-4290	DSH190013	LA	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. Diversion – 340B drugs dispensed at contract pharmacies, not supported by a medical record. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.	Repayment to manufacturers	CAP implemented Audit closure date: February 17, 2022
White River Medical Center	DSH040119	AR	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 25, 2021
William Beaumont Hospital DBA Beaumont Hospital - Royal Oak	RRC230130-00	MI	Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.	None	CAP implemented Audit closure date: January 27, 2022
William W. Backus Hospital, The	RRC070024-00	CT	No adverse findings	None	N/A Audit closure date: April 29, 2021

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

Date Last Reviewed:

October 2024

Parents: don’t struggle alone

Program Integrity: FY21 Audit Results