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Program Integrity: FY12 Audit Results

Updated 10/9/14. The results chart includes audits where the entity has agreed to the HRSA Final Report. 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.

 

No.

Entity

340B ID

State

OPA Findings

Sanction

Corrective Action with Audit Closure Date

1.

Access Community Health Network

CH051750

 

IL

Diversion – 340B drug dispensed to non-patient at contract pharmacy.

Repayment to manufacturers.

Public Letter to Manufacturers (PDF - 42 KB)

2

Charlotte County Health Department

TB339507

FP339509

FP339524

FP342248

FL

  1. Incorrect 340B database record – Incorrect Authorizing Official;
  2. Duplicate discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File

Repayment to manufacturers.

Pending

3.

Children’s Healthcare of Atlanta at Egleston

PED113300-00

GA

No adverse findings.

None.

N/A

4.

CHC of Snohomish County

CH10228B

 

WA

  1. Incorrect 340B database record – Incorrect entries for primary office location and contact information.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

Repayment to manufacturers.

 

  1. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public letter to manufacturers (PDF - 27 KB) Audit closure date: August 14, 2014

5

Community Healthcare Network

CH021630

NY

Diversion – 340B drug dispensed to non-patient at contract pharmacy.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 39 KB)

6.

Crouse Hospital

DSH330203

NY

Diversion – 340B drug dispensed to inpatient; 340B drug dispensed to non-patient at contract pharmacy.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 38 KB)

7.

Denver Health Medical Center

DSH060011

 

CO

No adverse findings.

None.

N/A

8.

El Centro Del Barrio, Inc. dba CentroMed

CH063250

TX

Incorrect 340B database record – Closed outpatient facilities remained registered on the 340B database; incorrect name listed for an outpatient facility.

None.

Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

 Audit closure date: December 26, 2013

9.

Faulkner County Health Unit

FP720337

AR

No adverse findings.

 

None.

N/A

10.

Fort Logan Hospital

CAH181315-00

KY

No adverse findings.

None.

N/A

11.

Freeman Health System

DSH260137

MO

  1. Incorrect 340B database record – Pharmacy incorrectly registered as child site;
  2. Diversion – 340B drugs dispensed for prescriptions written at ineligible sites; 340B drugs dispensed to non-patients at contract pharmacies.

Repayment to manufacturers.

  1. 1) Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public Letter to Manufacturers (PDF - 60 KB)

12.

Froedtert Memorial Lutheran Hospital

DSH520177

 

WI

No adverse findings.

None.

N/A

13.

Good Shepherd Medical Center

DSH450037

TX

No adverse findings.

 

None.

N/A

14.

Gordon County Health Department

STD30701

GA

No adverse findings.

None.

N/A

15.

Helen Keller Hospital

DSH010019

AL

No adverse findings.

None.

N/A

16.

Houston Medical Center

DSH110069

GA

  1. Incorrect 340B database record – Incorrect entry for Authorizing Official listed for child sites.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

Repayment to manufacturers.

  1. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public letter to manufacturers (PDF - 70 KB)

17.

Immanuel Medical Center

DSH280081

NE

  1. Diversion – 340B drug dispensed to non-patient at contract pharmacy.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File; Additionally, 340B drugs dispensed to Medicaid patients by contract pharmacy, absent arrangement to prevent duplicate discounts. 

Repayment to manufacturers.

Public Letter to Manufacturers (PDF - 16 KB)

18.

Jewish Hospital and St. Mary’s Healthcare (JHSMH)

DSH180040

KY

  1. Incorrect 340B database record – Entity was shipping 340B drugs to a pharmacy not listed on the 340B database; an outpatient facility of the hospital was not listed on the 340B database.
  2. Duplicate discounts – Claims submitted without state required NPI numbers.

Repayment to manufacturers.

  1. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public letter to manufacturers (PDF - 45 KB) Audit closure date: October 7, 2014

19.

Kingman Regional Medical Center

DSH030055

AZ

  1. Diversion – 340B drug dispensed for prescription written at ineligible site by ineligible provider.
  2. Duplicate discounts – 340B drugs dispensed to Medicaid patients by contract pharmacy, absent arrangement to prevent duplicate discounts. 

Repayment to manufacturers.

Public letter to manufacturers (PDF - 37 KB)

20.

Lone Star Circle of Care (formerly Georgetown Community Clinic)

CH0619490

TX

No adverse findings.

None.

N/A

21.

Lucile Packard Children’s Hospital

PED053305-00

CA

  1. Diversion – 340B drugs dispensed to ineligible individuals. 
  2. Duplicate discounts – Medicaid claims incorrectly coded when provided to the state.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 41 KB)

22.

Magee-Womens Hospital of UPMC Health System

DSH390114

PA

No adverse findings.

None.

N/A

23.

McIntosh County Health Department

TB31305

GA

No adverse findings.

None.

N/A

24

Mercy Hospital and Medical Center

DSH140158

IL

Incorrect 340B database record – Closed outpatient facilities remained registered on the 340B database.

None.

 

Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

Audit closure date: July 18, 2013

25.

Methodist Hospital of Southern California

DSH050238

     

CA

Duplicate discounts – Claims submitted without state required UD modifier.

 

Repayment to manufacturers.

Public letter to manufacturers (PDF - 10 KB)

26.

Metropolitan Hospital

DSH230236

MI

No adverse findings.

None.

N/A

27.

Monroe County Medical Center

DSH180105

KY

Diversion – 340B drug dispensed for prescription written by ineligible provider.

 

Repayment to manufacturers.

Public letter to manufacturers (PDF - 12 KB)

28.

New Hanover Regional Medical Center

DSH340141

NC

Duplicate discounts - Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

To be determined.

Public letter to manufacturers (PDF - 39 KB)

29.

Pecos County Memorial Hospital

DSH450178

 

TX

No adverse findings.

None.

N/A

30.

Planned Parenthood of Northern New England

STD05495

VT

No adverse findings.

 

None.

N/A

31.

Planned Parenthood of Western Pennsylvania, Inc.

FP155015

PA

  1. Duplicate discounts – Medicaid Provider Numbers for two sites were incorrect on the Medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 29 KB)

Audit closure date: September 5, 2014

32.

Presbyterian Hospital

DSH320021

NM

  1. Diversion –340B drug dispensed for prescription written at ineligible site; 340B drug dispensed not supported by a medical record; 340B drugs dispensed to non-patients at contract pharmacy for prescriptions written by ineligible providers;
  2. Duplicate discounts – Claims submitted without state required UD modifier.

Repayment to manufacturers.

Public Letter to Manufacturers (PDF - 45 KB)

33.

Primary Health Services Center

CH068480

LA

  1. Incorrect 340B database record –Parent location listed on the 340B database was closed; incorrect address for a sub-grantee clinic site.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File

None.

  1. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Medicaid Exclusion File entry corrected; Internal audit conducted by the covered entity and communication with State Medicaid Agency concluded that duplicate discounts did not occur as a result of the finding; 340B Program policies and procedures revised to address routine review of Medicaid Exclusion File.
  3. Public letter to manufacturers (PDF - 46 KB)

Audit closure date:
November 29, 2013

34.

Providence Health and Services – Washington Providence Centralia

DSH500019

     

WA

No adverse findings.

None.

N/A

35.

Riverside Medical Center

DSH140186

IL

No adverse findings.

None.

N/A

36.

Robeson Health Care Corporation

CH049000A

NC

  1. Incorrect 340B database record - Closed outpatient facilities remained registered on the 340B database;
  2. Diversion – 340B drug dispensed to non-patient at contract pharmacy;
  3. Duplicate discount – Entity billed Medicaid for a patient at a contract pharmacy contrary to information contained in the Medicaid

Repayment to manufacturers.

  1. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public letter to manufacturers (PDF - 13 KB)

37.

Rutherford County Health Department

STD28160

FP281604

TB28160

 

NC

Incorrect 340B database record – Entity was using a contract pharmacy not listed on the 340B database even though there was a written contract in place.

None.

Database entry corrected; 340B Program policies and procedures revised to address contract pharmacy registration and routine review of 340B Program database.

 

Audit closure date: November 29, 2013.

 

38.

Scott and White Memorial Hospital

DSH450054

TX

  1. Incorrect 340B database record - Site inappropriately listed on 340B database.
  2. Diversion – 340B drugs dispensed to inpatients.
  3. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

Repayment to manufacturers.

  1. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public letter to manufacturers (PDF - 64 KB)

39.

Shands Jacksonville Medical Center

DSH100001

FL

No adverse findings.

None.

N/A

40.

Spartanburg Regional Health Services District, Inc.

HV00818

SC

Diversion – 340B drug dispensed for prescription written at ineligible site by ineligible provider.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 68 KB)

Audit closure date: August 14, 2014

41.

St. Charles Health Council/Stone Mountain Health Services

CH030740

VA

  1. Incorrect 340B database record – Closed sites inappropriately listed on 340B database; no written contract in place for contract pharmacy listed.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File; Additionally, claims submitted without state required modifier.

To be determined.

  1. Database entries corrected; Contract pharmacy removed from database; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public Letter to Manufacturers (PDF - 21 KB)

42.

St. Luke’s Hospital of Kansas City

DSH260138

     

MO

Incorrect 340B database record – Registered contract pharmacies without written contract in place.

 

None.

Contract executed; no 340B activity at contract pharmacies prior to execution of contract; 340B Program policies and procedures revised to address contract pharmacy registration. 

Audit closure date: November 29, 2013

43.

St. Luke’s Regional Medical Center, Ltd.

DSH130006

ID

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 21 KB)

44.

St. Vincent Infirmary

DSH040007

AR

Diversion – 340B drugs dispensed to ineligible individuals.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 39 KB)

45.

Swedish Covenant Hospital

DSH140114

 

IL

  1. Incorrect 340B database record –Contract pharmacies registered but entity has terminated its contract. 
  2. Diversion – 340B drugs dispensed to non-patients at contract pharmacy.

Repayment to manufacturers.

  1. Contract pharmacies removed from database; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Public letter to manufacturers (PDF - 57 KB)

Audit closure date: September 5, 2014

46.

Travis County Health Care District Central Texas Community Health Centers

CHC11298-00

TX

Duplicate discounts – Offsite outpatient facilities incorrectly listed on Medicaid Exclusion File.  

None.

Medicaid Exclusion File corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.  It was determined that duplicate discounts did not occur as a result of the finding.

 

Audit closure date: June 26, 2013

47.

University of Louisville Hospital

DSH180141

KY

No adverse findings.

None.

N/A

48.

University of Miami Hospital and Clinics

CAN100079-00

FL

Incorrect 340B database record – incorrect entry for primary contact.

None.

Database entry corrected; 340B Program policies and procedures revised to address routine validation of 340B Program database.

 

Audit closure date: March 28, 2013

49.

Wheaton Franciscan Healthcare – All Saints

DSH520096

 

WI

No adverse findings.

None.

N/A

50.

White Memorial Medical Center

DSH050103

CA

Duplicate discounts - Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

 Repayment to manufacturers..

Public letter to manufacturers (PDF - 15 KB)

51.

WomenCare, Inc. dba FamilyCare

CH038440

WV

  1. Diversion – 340B drugs dispensed to non-patient at a contract pharmacy;
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 534 KB)