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Program Integrity: FY13 Audit Results

Updated 4/27/16. 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 (94) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action with Audit Closure Date
Alder Health Services, Inc. RWII17101 PA No adverse findings. None.

N/A;

Audit closure date:  August 14, 2014.

Allegan General Hospital CAH231328-00 MI Incorrect 340B database record - Registered contract pharmacies without written contract in place.

Diversion – 340B drug dispensed to inpatient at contract pharmacy; not supported by a medical record.

Repayment to manufacturers. Public letter to manufacturers (PDF - 33 KB)
Aspirus Medofrd Hospital and Clinics, Inc. (formerly Memorial Health Center) CAH521324-00 WI Incorrect 340B database record - Offsite outpatient facilities were not listed on the 240B database.

Diversion – 340B drug dispensed to inpatients; 340B drugs dispensed for prescriptions written by ineligible providers.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 75 KB)

Audit closure date: March 30, 2016.

Athens Regional Medical Center DSH110074 GA Diversion – 340B drugs dispensed for prescriptions written at ineligible sites by ineligible providers; 340B drugs were not properly accumulated.

Duplicate Discounts – Medicaid billing numbers were incorrect on the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 123 KB)
Aurora Health Care Metro, Inc. DSH520138 WI Incorrect 340B database record - Offsite outpatient facilities were not listed on the 240B database.

Diversion – 340B drug dispensed at covered entity and at contract pharmacies for prescriptions written by ineligible providers..
Repayment to manufacturers. Public letter to manufacturers (PDF - 118 KB). Audit closure date: May 15, 2015
Avera McKennan Hospital and University Health Center DSH430016 SD No adverse findings. None.

N/A;

Audit closure date:  September 8, 2014.

Baptist Hospitals of Southeast Texas DBA Memorial Hermann Baptist Orange Hospital DSH450005 TX Diversion – 340B drug dispensed at contract pharmacies for prescriptions originating at ineligible sites. Repayment to manufacturers. Public letter to manufacturers (PDF - 97 KB). Audit closure date: October 13, 2015
Baptist Medical Center DSH100088 FL Incorrect 340B database record - Registered contract pharmacies without written contract in place. None. Contract executed; 340B Program policies and procedures revised to address contract pharmacy registration. Audit closure date: June 16, 2015
Baptist Memorial Hospital – Desoto DSH250141 MS No adverse findings. None.

N/A;

Audit closure date:  February 14, 2014.

BayState Medical Center DSH220077 MA Diversion – 340B drug dispensed for prescription written by ineligible provider. Repayment to manufacturers. Public letter to manufacturers (PDF - 51 KB). Audit closure date: January 22, 2015
Beacon Christian Community Health Center CHC12866-00 NY Incorrect 340B database record - Registered contract pharmacies without written contract in place. None. Contracts executed; 340B Program policies and procedures revised to address contract pharmacy registration. Audit closure date: September 23, 2014
Boone County Hospital CAH161372-00 IA Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers. Public letter to manufacturers (PDF - 46 KB) Audit closure date: December 31, 2014
Borrego Community Health Foundation CH099010 CA Diversion – 340B drug dispensed at contract pharmacy, not supported by a medical record; 340B drugs dispensed for prescriptions written by ineligible providers.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 68 KB)

Audit closure date: March 18, 2016

Calhoun-Liberty Hospital CAH101304-00 FL Entity failed to maintain auditable medical records prior to December 1, 2014.

Diversion – Entity did not have a mechanism in place to prevent diversion.

Repayment to manufacturers. Public letter to manufacturers (PDF - 98 KB)
Capital Health System - Hopewell DSH310044 NJ Entity does not meet 340B eligibility requirements (DSH %).

Diversion – 340B drug dispensed for prescriptions originating at ineligible sites, not supported by responsibility of care.

Diversion – 340B drugs were not properly accumulated.

Covered entity removed from 340B Program; Repayment to manufacturers. Public letter to manufacturers (PDF - 74 KB)
Castle Medical Center DSH120006 HI

Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for shipping address.

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

Repayment to manufacturers. State Medicaid has since determined that duplicate discounts did not occur.
Public letter to manufacturers (PDF - 270 KB). Audit closure date: March 31, 2015.
Chadron Community Hospital - Western Community Health Resources FP693011 NE Incorrect 230B database record – incorrect address listed for offsite outpatient facility.

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

Repayment to manufacturers. Public letter to manufacturers (PDF - 208 KB). Audit closure date: December 2, 2015
Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center PED393302-00 PA Incorrect 340B database record – Offsite outpatient facilities were not listed in the 340B database; Registered contract pharmacies without written contract in place.

Duplicate discounts – NPI and Medicaid billing numbers were incorrect in the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 36 KB). Audit closure date: October 15, 2015
Christ Community Health Services, Inc. CH0417140 TN No adverse findings. None.

N/A;

Audit closure date:  December 12, 2013.

Christus Health Shreveport-Bossier (formerly Christus Schumpert Health System) DSH190041 LA Entity did not provide contract pharmacy oversight;

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites..

Repayment to manufacturers. Public letter to manufacturers (PDF - 80 KB). Audit closure date: December 9, 2015
Citizen's Baptist Medical Center DSH010101 AL Incorrect 340B database record – Incorrect Authorizing Official. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: July 25, 2014
Citizens Memorial Hospital District DSH260195 MO Incorrect 340B database record – Pharmacy incorrectly registered as child site.

Diversion – 340B drug dispensed to ineligible individual, not supported by a medical record.

Repayment to manufacturers. Public letter to manufacturers (PDF - 17 KB). Audit closure date: May 7, 2015
Clinch River Health Services, Incorporated CH031230 VA Incorrect 340B database record – Contract pharmacy with written contract in place was not listed on the 340B database.

Entity did not provide contract pharmacy oversight.

Diversion – 340B drug dispensed at contract pharmacy for prescriptions written by ineligible providers, and to non-patients.

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

Repayment to manufacturers. Public letter to manufacturers (PDF - 23 KB). Audit closure date: December 9, 2015
Community Medical Center, Inc. DSH270023 MT Incorrect 340B database record – incorrect names and addresses for offsite outpatient facilities listed.

Diversion – 340B drug dispensed for prescription written at an ineligible site, not supported by responsibility of care.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 17 KB)

Audit closure date:  February 19, 2016.

Community Regional Medical Center DSH050060 CA Incorrect 340B database record – Inpatient facility incorrectly registered as child site.

Diversion – 340B drug dispensed to ineligible individuals.

Repayment to manufacturers. Public letter to manufacturers (PDF - 70 KB). Audit closure date: December 2, 2015
Contra Costa Regional Medical Center DSH050276 CA Incorrect 340B database record – Incorrect name listed for outpatient facility. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: September 11, 2014
Cook Children's Medical Center PED453300-00 TX No adverse findings. None.

N/A;

Audit closure date:  June 10, 2014.

Crusader's Central Clinic Association CH052760 IL Incorrect 340B database record – An offsite outpatient facility was not listed on the 340B database.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 19 KB). Audit closure date: March 9, 2015
Cuyuna Regional Medical Center CAH241353-00 MN No adverse findings. None.

N/A;

Audit closure date:  November 6, 2014.

Dallas County Hospital District Parkland Health and Hospital System DSH450015 TX Diversion – 340B drug dispensed at contract pharmacies for prescriptions written by ineligible providers at ineligible sites. Repayment to manufacturers. Public letter to manufacturers (PDF - 17 KB)
Dell Children's Medical Center PED453310-00 TX No adverse findings. None.

N/A;

Audit closure date:  February 28, 2014.

East Central District Health Department FP686011 NE Duplicate Discounts – Medicaid billing number was incorrect on the Medicaid Exclusion File. Repayment to manufacturers. Public letter to manufacturers (PDF - 27 KB). Audit closure date: December 2, 2015
East Orange General Hospital DSH310083 NJ Covered outpatient drugs obtained through a Group Purchasing Organization prior to August 30, 2013.

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

Diversion – 340B drug dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drugs were not properly accumulated.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 26 KB)

Audit closure date: March 29, 2016.

Eau Claire Cooperative Health Center, Inc. CH043270 SC Incorrect 340B database record – Offsite outpatient facilities were not listed on the 240B database; Incorrect names and addresses listed for outpatient facilities.

Diversion – 340B drug dispensed for prescriptions originating from ineligible sites, written by ineligible providers, not supported by medical records.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 81 KB)
Ephraim McDowell Regional Medical Center, Inc DSH180048 KY Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites, written by ineligible providers; 340B drugs were not properly accumulated. Repayment to manufacturers.

Public letter to manufacturers (PDF - 37 KB)

Audit closure date: March 17, 2016

Family Health Centers of San Diego CH093120 FP92102 CA Diversion – 340B drugs dispensed, not supported by medical records. Repayment to manufacturers.

Public letter to manufacturers (PDF - 40 KB)

Audit closure date: August 14, 2014

Family Health Services of Cranston FP029107 RI No adverse findings. None.

N/A;

Audit closure date:  December 24, 2013.

Floyd Valley Hospital CAH161368-00 IA No adverse findings. None.

N/A;

Audit closure date:  June 5, 2014.

Franciscan St. Anthony Health Michigan City RRC150015-00 IN Incorrect 340B database record – An outpatient facility was not listed on the 340B database; Registered contract pharmacies without written contract in place. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Contracts executed. Audit closure date: December 22, 2014.
Georgia Dept. of Public Health RWIID303031 GA No adverse findings. None.

N/A;

Audit closure date:  December 26, 2013.

Grady General Hospital DSH110121 GA Diversion – 340B drugs dispensed for prescription written by ineligible provider; 340B drugs dispensed to non-patients.

Duplicate discounts – Medicaid Provider Number was incorrect on the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 55 KB)
Audit closure date: May 11, 2015
Hamblen County Health Department STD378146 TN Incorrect 340B database record – Incorrect entries for authorizing official and shipping address.

Duplicate Discounts – Entity was billing medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 38 KB). Audit closure date: October 15, 2015
Henry Ford Hospital DSH230053 MI Diversion – Entity did not have adequate controls in place for proper accumulation and prevention of diversion. Repayment to manufacturers. Public letter to manufacturers (PDF - 34 KB)
Holmes County General Health District FP44654 OH No adverse findings. None.

N/A;

Audit closure date:  June 13, 2014.

Holy Cross Hospital DSH141033 IL Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 88 KB)

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

Audit closure date: January 19, 2016.

Iraan General Hospital District CAH451307-00 TX Non-reimbursable facilities incorrectly registered as child site.

Incorrect 340B database record – incorrect entries for Primary Contact and Authorizing Official.

Diversion – 340 drugs dispensed for prescriptions written at ineligible sites.

Termination of ineligible sites from 240B Program; Repayment to manufacturers. Covered entity, its outpatient facilities, and its contract pharmacies terminated from 240B Program as of August 11, 2015 for failure to submit Corrective Action Plan.
Lawrence General Hospital DSH220010 MA Diversion – 340B drugs dispensed to inpatients; 340 drug dispensed not supported by a medical record. Repayment to manufacturers. Public letter to manufacturers (PDF - 129 KB). Audit closure date: November 3, 2014
Legacy Emanuel Medical Center DSH380007 OR Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

State Medicaid has since determined that duplicate discounts did not occur.

Public letter to manufacturers (PDF - 39 KB)

Audit closure date: March 17, 2016

Los Angeles County Department of Health Services – USC Medical Center DSH050373 CA No adverse findings. None.

N/A;

Audit closure date:  January 10, 2014.

Loyola University Medical Center DSH140276 IL Incorrect 240B database record – Contract pharmacy with a written contract in place was not listed in the 340B database. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: November 18, 2014
Madera Community Hospital DSH050568 CA Incorrect 340B database record – Outpatient facilities of the hospital were not listed on the 340B database. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: July 25, 2014
Mary Rutan Hospital DSCH360197-00 OH Incorrect 340B database record – Non-reimbursable facilities incorrectly registered as child site.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites, written by ineligible providers at ineligible sites; 340B drugs dispensed at non-reimbursable facilities, for prescriptions originating from non-reimbursable sites.

Ineligible sites removed from 340B Program; Repayment to manufacturers. Public letter to manufacturers (PDF - 21 KB)
Matagorda Regional Medical Center DSH220010 TX Diversion – 340B drug dispensed, not supported by a medical record. Repayment to manufacturers. Public letter to manufacturers (PDF - 13 KB)
Medical Center Hospital DSH450132 TX Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed at contract pharmacy for prescriptions originating from ineligible site.

Repayment to manufacturers. Public letter to manufacturers (PDF - 72 KB)
Memorial Health System DSH060022 CO Incorrect 340B database record – Closed offsite outpatient facility listed on database.

Diversion – 340B drugs dispensed for prescriptions written by ineligible providers an/or at ineligible sites; 340B drugs dispensed to employees for prescriptions written by ineligible providers and/or at ineligible sites.

Repayment to manufacturers. Public letter to manufacturers (PDF - 70 KB)
Methodist Healthcare – Memphis Hospitals (TN) DSH440049 TN

Incorrect 340B database record – Outpatient facilities of the hospital were not listed on the 340B database; Contract pharmacy with written contract in place was not listed on the 340B database.

Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites, written by ineligible providers.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File..

Repayment to manufacturers. Public letter to manufacturers (PDF - 171 KB). Audit closure date: October 13, 2015.
Mt. Sinai School of Medicine HM7439 NY Duplicate Discounts – Medicaid billing number was missing on the Medicaid Exclusion File. Repayment to manufacturers. Pending.
Muhlenberg Community Hospital, Inc. DSH180004 KY Diversion – 340B drug dispensed for prescription written at ineligible site; 340B drugs dispensed to inpatients; 240B drugs were not properly accumulated. Repayment to manufacturers. Public letter to manufacturers (PDF - 98 KB). Audit closure date: December 9, 2015
Nemours/Alfred I. Dupont Hospital for Children PED083300-00 DE Incorrect 340B database record – Registered contract pharmacies without written contract in place.

Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites; 340B drugs dispensed at contract pharmacy for prescription written by ineligible provider..

Repayment to manufacturers. Public letter to manufacturers (PDF - 46 KB)
Niagara Falls Memorial Medical Center DSH330065 NY Incorrect 340B database record – Contract pharmacies registered but entity has terminated its contract.

Diversion – 340B drugs dispensed to inpatients; 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drugs were not properly accumulated.

Duplicate Discounts – Entity was billing medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers. Pending
Northeast Alabama Regional Medical Center DSH010078 AL No adverse findings. None

N/A;

Audit closure date:  August 1, 2013.

Oakland Mercy Hospital CAH281321-00 NE Diversion – 340B drugs dispensed to inpatients. Repayment to manufacturers. Public letter to manufacturers (PDF - 67 KB). Audit closure date: October 15, 2015
Ochsner Medical Center – Baton Rouge, LLC DSH190202 LA No adverse findings. None.

N/A;

Audit closure date:  June 2, 2014.

Orange County Health Department FP229600 VA Incorrect 340B database record – Incorrect entry for grant number. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: September 23, 2014
Oroville Hospital DSH050030 CA Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: December 22, 2014
Our Lady of the Lake Hospital, Inc. DSH190064 LA Incorrect 340B database record – Pharmacy incorrectly registered as child site; Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers. Public letter to manufacturers (PDF - 108 KB). Audit closure date: November 13, 2015
Outer Cape Health Services, Inc. CH011190 MA Diversion – 340B drug dispensed for prescription written by an ineligible provider at an ineligible site.

Diversion – 340B drugs dispensed to ineligible individuals due to reverse replenishment.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF- 40 KB)
PeaceHealth Southwest Medical Center DSH500050 WA Incorrect 340B database record – Pharmacies incorrectly registered as child sites.

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers. Public letter to manufacturers (PDF - 6 KB). Audit closure date: December 9, 2015
Pineville Community Hospital Association, Inc. DSH180021 KY Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Duplicate Discounts – NPI number was incorrect on the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 21 KB)
Planned Parenthood Hudson Peconic, Inc. FP105322 NY Incorrect 340B database record – Closed outpatient facility remained registered on the 340B database.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 39 KB)

Audit closure date:  February 2, 2016.

Pleasant Valley Hospital DSH510012 MA Incorrect 340B database record – Offsite outpatient facilities were not listed 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: September 25, 2014
Reeves County Hospital District CAH451377-00 TX No adverse findings. None.

N/A;

Audit closure date:  January 2, 2014.

Regional Medical Center at Memphis DSH440152 TN Incorrect 340B database record – Registered contract pharmacy without written contract in place.

Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites.

Duplicate Discounts – medicaid number was incorrect on the Medicaid Exclusion File.

Repayment to manufacturers. Public letter to manufacturers (PDF - 42 KB)
Rochester Primary Care Network, Inc. CH020560 NY Incorrect 340B database record – Ineligible sites registered on 340B database. None. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: September 1, 2015
Rush University Medical Center DSH140119 IL Diversion – 340B drugs dispensed to inpatients for prescriptions originating from an ineligible site.

Duplicate Discounts – Entity was billing Medicaid at contract pharmacies and did not notify HRSA of the arrangement.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 147 KB)

Audit closure date: February 1, 2016.

Russell Medical Center DSH010065 AL No adverse findings. None.

N/A;

Audit closure date:  August 6, 2013.

Samaritan North Lincoln Hospital CAH381302-00 OR Diversion – 340B drugs dispensed for prescription originating from ineligible site. Repayment to manufacturers. Public letter to manufacturers (PDF - 90 KB)
SeaMar Community Health centers – Mount Vernon STD982739 WA No adverse findings. None.

N/A;

Audit closure date:  December 12, 2013.

Sheltering Arms Hospital DBA O'Bleness Memorial Hospital DSH360014 OH No adverse findings. None.

N/A;

Audit closure date:  June 4, 2014.

Siskiyou Community Health Center, Inc. CH100150 OR Duplicate Discounts - NPI number not listed on the Medicaid Exclusion File.

Repayment to manufacturers.

State Medicaid has since determined that duplicate discounts did not occur.

Public letter to manufacturers (PDF - 246 KB). 

Audit closure date: December 15, 2015.

St. Bernard's Hospital Inc. DBA St. Bernard's Medical Center DSH040020 AR Diversion – 340B drugs dispensed at contract pharmacy for prescriptions originating from ineligible sites. Repayment to manufacturers. Public letter to manufacturers (PDF - 227 KB)
St. Clare Hospital DSH500021 WA Incorrect 340B database record – Incorrect contact information for Authorizing Official.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites, and written by ineligible providers.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 112 KB)

Audit closure date: March 30, 2016.

St. John's Regional Medical Center DSH050082 CA No adverse findings. None.

N/A;

Audit closure date:  October 28, 2014.

St. Joseph Medical Center DSH500801 WA Incorrect 340B database record – incorrect contact information for Authorizing Official; Registered contract pharmacies without written contract in place.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites written by ineligible providers.

Duplicate Discounts – NPI number was incorrect in the Medicaid Exclusion File..

Repayment to manufacturers.

Public letter to manufacturers (PDF - 117 KB)

Audit closure date: March 30, 2016.

St. Mary's Hospital and Medical Center, Inc. SCH060023-00 CO Incorrect 340B database record – Outpatient facilities of the hospital were incorrectly registered as a single entity; Incorrect billing address for outpatient facilities.

Diversion – 340B drugs dispensed for prescriptions written by ineligible provider; lack of controls to prevent 340B drugs from being dispensed to inpatients.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 56 KB)

Audit closure date: March 2, 2016.

St. Vincent Hospital DSH320002 NM Incorrect 340B database record – Ineligible sites registered on 340B database; Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers. Public letter to manufacturers (PDF - 16 KB)
Stokes County Health Department STD27016 NC Incorrect 340B database record – Entity was using contract pharmacies not listed on the 340B database; Incorrect primary contact information. None. Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: August 4, 2014
Sutter Lakeside Hospital CAH051329-00 CA Incorrect 340B database record – offsite outpatient facilities were not accurately listed, incorrect entries for Authorizing Official information.

Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites, not supported by responsibility of care; Entity did not have a mechanism in place to prevent diversion.

Entity was billing Medicaid contrary to information in the medicaid Exclusion File..

Repayment to manufacturers.Removal of contract pharmacies. Public letter to manufacturers (PDF - 115 KB)
Taylor County Hospital District DSH180087 KY Incorrect 340B database record – Registered contract pharmacy without written contract in place.

Diversion – 340B drugs dispensed at covered entity and at contract pharmacies for prescriptions originating from ineligible sites; 240B drugs dispensed, not supported by a medical record..

Repayment to manufacturers.

Public letter to manufacturers (PDF - 18 KB)

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

Audit closure date: January 19, 2016.

Trinitas Regional Medical Center DSH310027 NJ Incorrect 340B database record – Closed contract pharmacy remained registered on the 240B database.

Diversion – 340B drugs dispensed to inpatients; 240B drugs dispensed for prescriptions originating from ineligible sites, not supported by responsibility of care; 240B drugs were not properly accumulated.

Duplicate Discounts – Medicaid number was incorrect on the medicaid Exclusion File.

Repayment to manufacturers.

Public letter to manufacturers (PDF - 42 KB)

Audit closure date:  February 3, 2016.

Truman Medical center Hospital Hill; Truman Medical Center Lakewood DSH2600048 DSH260102 MO Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written by ineligible providers; 240B drugs dispensed for prescriptions written at ineligible sites. Repayment to manufacturers. Public letter to manufacturers (PDF - 12 KB)
Uniontown Hospital DSH390041 PA No adverse findings. None.

N/A;

Audit closure date:  September 10, 2014.

United Hospital Center SCH51500066-00 (formerly DSH510006) WV Incorrect 340B database record – offsite outpatient facilities were not listed on the 240B database.

Diversion – 340B drug dispensed to an inpatient, 340B drugs dispensed for prescriptions written at ineligible sites, not supported by responsibility of care.

Repayment to manufacturers. Pending.
University of Michigan Hospital and Health Centers DSH230046 MI No adverse findings. None.

N/A;

Audit closure date:  June 18, 2014.