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Program Integrity: FY12 Audit Results

Updated 2/5/16. 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.

Results posted for (51) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action with Audit Closure Date
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). Audit closure date: May 7, 2015
Charlotte County Health Department TB339507, FP339509, FP339524, FP342248 FL Incorrect 340B database record - Incorrect Authorizing Official.

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

Repayment to manufacturers. Public letter to manufacturers (PDF - 42 KB). Audit closure date: October 15, 2015
Children's Healthcare of Atlanta at Egleston. PED113300-00 GA No adverse findings. None.

N/A;

Audit closure date:  August 21, 2012.

CHC of Snohomish County CH10228B WA Incorrect 340B database record – Incorrect entries for primary office location and contact information.

Duplicate discounts – Entity was billing Medicaid contrary to information contain in the Medicaid Exclusion File.

Repayment to manufacturers. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 27 KB). Audit closure date: August 14, 2014.
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). Audit closure date: April 28, 2015
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 - 38KB)

Audit closure date: January 13, 2016

Denver Health Medical Center DSH060011 CO No adverse findings. None. N/A
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
Faulkner County Health Unit FP720337 AR No adverse findings. None.

N/A;

Audit closure date:  January 9, 2012.

Fort Logan Hospital CAH181315-00 KY No adverse findings. None.

N/A;

Audit closure date:  August 21, 2012.

Freeman Health System DSH260137 MO Incorrect 340B database record – Pharmacy incorrectly registered as child site.

Diversion – 340B drugs dispensed for prescriptions written at ineligible sites; 340B drugs dispensed to non-patients at contract pharmacies.

Repayment to manufacturers. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 60 KB). Audit closure date: November 10, 2015
Froedtert Memorial Lutheran Hospital DSH520177 WI No adverse findings. None.

N/A;

Audit closure date:  December 11, 2012.

Good Shepherd Medical Center DSH450037 TX No adverse findings. None.

N/A;

Audit closure date:  November 2, 2012.

Gordon County Health Department STD30701 GA No adverse findings. None.

N/A;

Audit closure date:  December 21, 2012.

Helen Keller Hospital DSH010019 AL No adverse findings. None.

N/A;

Audit closure date:  February 8, 2013.

Houston Medical Center DSH110069 GA

Incorrect 340B database record – Incorrect entry for Authorizing Official listed for child sites.

Duplicate discounts – entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

Repayment to manufacturers. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 70 KB). Audit closure date: May 11, 2015
Immanuel Medical Center DSH280081 NE Diversion – 340B drug dispensed to non-patient at contract pharmacy.

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). Audit closure date: May 7, 2015
Jewish Hospital and St. Mary's Healthcare (JHSMH) DSH180040 KY 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.

Duplicate discounts – Claims submitted without state-required NPI numbers.

Repayment to manufacturers. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 45 KB). Audit closure date: October 7, 2014
Kingman Regional Medical Center DSH030055 AZ Diversion – 340B drug dispensed for prescription written at ineligible site by ineligible provider.

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). Audit closure date: May 7, 2015
Lone Star circle of Care (formerly Georgetown Community Clinic) CH0619490 TX No adverse findings. None.

N/A;

Audit closure date:  August 15, 2012.

Lucile Packard Children's Hospital PED053305-00 CA Diversion – 340B drugs dispensed to ineligible individuals.

Duplicate discounts – Medicaid claims incorrectly coded when provided to the state.

Repayment to manufacturers.. Public letter to manufacturers (PDF - 41 KB). Audit closure date: December 9, 2015
Magee-Womens Hospital of UPMC Health System DSH390114 PA No adverse findings. None.

N/A;

Audit closure date:  May 6, 2013.

McIntosh County Health Department TB31305 GA No adverse findings. None.

N/A;

Audit closure date:  September 25, 2012.

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
Methodist Hospital of Southern California DSH050238 CA Duplicate discounts – Claims submitted without state-required UD modifier. Repayment to manufacturers. Public letter to manufacturers (PDF - 10KB). Audit closure date: December 7, 2015
Metropolitan Hospital DSH230236 MI No adverse findings. None.

N/A;

Audit closure date:  February 8, 2013.

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). Audit closure date: June 10, 2015
New Hanover Regional Medical Center DSH340141 NC Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File. Repayment to manufacturers. Public letter to manufacturers (PDF - 39 KB). Audit closure date: May 7, 2015
Pecos County Memorial Hospital DSH450178 TX No adverse findings. None.

N/A;

Audit closure date:  February 8, 2013.

Planned Parenthood of Northern New England STD05495 VT No adverse findings. None.

N/A;

Audit closure date:  January 7, 2013.

Planned Parenthood of Western Pennsylvania, Inc. FP155015 PA 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
Presbyterian Hospital DSH320021 NM 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.

Duplicate discounts – Claims submitted without state-required UD modified.

Repayment to manufacturers. Public letter to manufacturers (PDF - 45 KB)
Primary Health Services Center CH068480 LA Incorrect 340B database record – Parent location listed on the 340B database was closed; incorrect address for a sub-grantee clinic site.

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

None.

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

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.

Public letter to manufacturers (PDF - 46 KB). Audit closure date: November 29, 2013

Providence Health and Services – Washington Providence Centralia DSH500019 WA No adverse findings. None.

N/A;

Audit closure date:  February 5, 2013.

Riverside Medical Center DSH140186 IL No adverse findings. None.

N/A;

Audit closure date:  December 11, 2013.

Robeson Health Care Corporation CH04900A NC Incorrect 340B database record – Closed outpatient facilities remained registered on the 340B database.

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

Duplicate discount – Entity billed Medicaid for a patient at a contract pharmacy contrary to information contained in the Medicaid Exclusion File.

Repayment to manufacturers. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 13 KB). Audit closure date: December 9, 2015
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
Scott and White Memorial Hospital DSH450054 TX Incorrect 340B database record – Site inappropriately listed on 340B database.

Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 64)
Shands Jacksonville Medical Center DSH100001 FL No adverse findings. None.

N/A;

Audit closure date:  February 8, 2013.

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
St Charles Health Council/Stone Mountain Health Services CH030740 VA Incorrect 340B database record – Closed sites inappropriately listed on 340B database; no written contract in place for contract pharmacy listed.

Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File; Additionally, claims submitted without state-required modifier.

Repayment to manufacturers. Database entries corrected; Contract pharmacy removed from database; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 21 KB. Audit closure date: April 27, 2015
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
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). Audit closure date: October 15, 2015
St. Vincent Infirmary DSH040007 AR Diversion – 340B drugs dispensed to inpatients. Repayment to manufacturers. Public letter to manufacturers (PDF - 39 KB)
Swedish Covenant Hospital DSH140114 IL Incorrect 340B database record – Contract pharmacies registered but entity has terminated its contract.

Diversion --340B drugs dispensed to non-patients at contract pharmacy.

Repayment to manufacturers. Contract pharmacies removed from database; 340B Program policies and procedures revised to address routine review of 340B Program database. Public letter to manufacturers (PDF - 57 KB). Audit closure date: September 5, 2014
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
University of Louisville Hospital DSH180141 KY No adverse findings. None.

N/A;

Audit closure date:  May 15, 2013.

University of Miami Hospital and Clinics CAN100079-00 FL Incorrect 340B database record; incorrect entry for primary contact. None. Database entry corrected; 240B Program policies and procedures revised to address routine validation of 340B Program database. Audit closure date: March 28, 2013
Wheaton Franciscan Healthcare – All Saints DSH520096 WI No adverse findings. None.

N/A;

Audit closure date:  February 5, 2013.

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). Audit closure date: May 11, 2015
WomenCare, Inc. dba FamilyCare CH038440 WV Diversion -- 340B drugs dispensed to non-patient at a contract pharmacy.

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

Repayment to manufacturers. Public letter to manufacturers (PDF - 45 KB). Audit closure date: November 10, 2015