Program Integrity: FY18 Audit Results

Updated 9/10/18. 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 (101) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
Abbeville General Hospital DSH190034 LA No adverse findings None

N/A

Audit closure date: August 14, 2018

 
Adventist Health Lodi Memorial DSH050336 CA Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Albert Einstein Medical Center DSH390142 PA No adverse findings None N/A

Audit closure date: July 31, 2018

 
Appalachian Regional Healthcare Inc. dba Summers County ARH Hospital CAH511310-00 WV No adverse findings None N/A

Audit closure date: May 3, 2018

 
ARH Mary Breckinridge Health Services, Inc. DBA Mary Breckinridge ARH Hospital CAH181316-00 KY Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.   Repayment to manufacturers Pending  
Ashtabula County Medical Center SCH360125-00 OH Incorrect 340B OPAIS record -  Failed to remove closed location registration;  Registered contract pharmacies without written contract in place. 

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program*
Repayment to manufacturers
Pending  
Avera Marshall DBA Avera Marshall Regional Medical Center CAH241359-00 MN No adverse findings None N/A

Audit closure date: January 16, 2018

 
Baylor Scott & White Medical Center - Irving DSH450079 TX Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.   Repayment to manufacturers Pending  
Belington Community Medical Services Association, Inc. CHC12878-00 WV No adverse findings None N/A

Audit closure date: May 18, 2018

 
Broaddus Hospital CAH511300-00 WV Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B database.

Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.

Incorrect or incomplete information in the Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of the finding.

Repayment to manufacturers Pending  
Bronson Lakeview Hospital CAH231332-00 MI No adverse findings None N/A

Audit closure date: March 23, 2018
 

 
Calhoun - Liberty Hospital CAH101304-00 FL No adverse findings None N/A

Audit closure date: June 22, 2018

 
Camden – Clark Memorial Hospital DSH510058 WV No adverse findings None N/A

Audit closure date: June 29, 2018

 
Carrington Health Center CAH351318-00 ND No adverse findings None N/A

Audit closure date: July 19, 2018

 
Community Health Care, Inc. CH021270 NJ Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to February 14, 2018; Failed to remove a duplicate registration of a contract pharmacy. None Pending  
CAN Community Health, Inc. RWII32117 FL No adverse findings None N/A

Audit closure date: March 28, 2018

 
CAN Community Health, Inc. STD336052 FL No adverse findings None N/A

Audit closure date: March 28, 2018

 
Children’s Mercy Hospital, The PED263302-00 MO Incorrect 340B OPAIS record - Entity-owned pharmacies were not listed as shipping addresses. None Pending  
Columbia Memorial Hospital RRC330094-00 NY Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility. None CAP implemented

Audit closure date: July 30, 2018

 
Columbia Lutheran Memorial Hospital DBA Columbia Memorial Hospital CAH381320-00 OR

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Entity-owned pharmacy was not listed as shipping address; Registered contract pharmacies without written contract in place.

Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites.

Incorrect or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP approved Director of Pharmacy & Cancer Center Services
Columbia Memorial Hospital
2111 Exchange Street
Astoria OR 97103
(503) 338-4665
Communicare Health Centers CHC08216-00 CA No adverse findings None

N/A

Audit closure date: August 23, 2018

 
Conejos County Hospital Corporation CAH061308-00 CO Entity did not provide contract pharmacy oversight.

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

Incorrect or incomplete information in the Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of the finding.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers.
 

CAP approved Director of Pharmacy
106 Blanca Ave.
Alamosa, Colorado 81101
719-587-1260
Lee.Hankins@slvrmc.org
Covington County Hospital CAH251325-00 MS Incorrect 340B OPAIS record – Failed to remove closed location registration; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. None CAP approved  
Cumberland County Hospital CAH181317-00 KY Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record.

Inaccurate or incomplete information in Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of this finding.

Repayment to manufacturers Pending  
Decatur Memorial Hospital RRC140135-00 IL No adverse findings None N/A

Audit closure date: April 11, 2018

 
Dell Seton Medical Center at The University of Texas DSH450124 TX Diversion - 340B drug dispensed to inpatients; 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site. Repayment to manufacturers Pending  
Door County Memorial Hospital CAH521358-00 WI Diversion - 340B drug dispensed at entity, not supported by a medical record. Repayment to manufacturer Pending  
Dundy County Hospital CAH281340-00 NE Diversion - 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies, not supported by a medical record. Repayment to manufacturers Pending  
East Alabama Health Services RWII36830 AL No adverse findings None N/A

Audit closure date: March 23, 2018
 

 
East Carolina Health d/b/a Vidant Roanoke-Chowan Hospital DSH340099 NC No adverse findings None N/A

Audit closure date: February 6, 2018
 

 
East Georgia Healthcare Center, Inc. CH049010 GA No adverse findings None N/A

Audit closure date: February 27, 2018
 

 
Fairview Hospital DBA Fairview Regional Medical Center CAH371329-00 OK No adverse findings None N/A

Audit closure date: June 7, 2018

 
Genesis Healthcare System DSH360039 OH Inaccurate or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of this finding. None Pending  
Grand River Hospital District CAH061317-00 CO Incorrect 340B OPAIS record - Offsite outpatient facility was not listed on the 340B database. None Pending  
Great Plains of Smith County DBA Smith County Memorial Hospital CAH171377-00 KS No adverse findings None N/A

Audit closure date: April 10, 2018

 
Gritman Medical Center CAH131327-00 ID Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to January 29, 2018.

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

RPH Director of Pharmacy

208-883-2236

Gritman Medical Center, 700 South Main Street, Moscow, ID 83843

H.C. Watkins Memorial Hospital CAH251316-00 MS No adverse findings None

N/A

Audit closure date: August 9, 2018

 
Health and Hospital Corporation of Marion County DSH150024 IN Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites and without a documented provider to patient relationship. Repayment to manufacturers Pending  
Healthnet, Inc. CH053200 IN

No adverse findings

None

N/A

Audit closure date: November 29, 2017

 
Highlands Regional Medical Center DSH180005 KY Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to April 23, 2018. None Pending  
Hospital District No. 5 of Harper County Kansas CAH171366-00 KS Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site.

Repayment to manufacturers Pending

 

 
Hyacinth Foundation RWI07107 NJ Diversion – 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site. Repayment to manufacturers CAP approved Senior Director of Program Development
317 George Street, Suite 203
New Brunswick, New Jersey 08901
732-246-0204
jriccardi@hyacinth.org
Jane Pauley Community Health Center, Inc. CHC26566-00 IN No adverse findings None N/A

Audit closure date: January 11, 2018

 
Johnson City Medical Center DSH440063 TN Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Karmanos Cancer Center DSH230297 MI No adverse findings None N/A

Audit closure date: June 15, 2018

 
Kootenai Hospital District DSH130049 ID Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to February 5, 2018.

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers Pending  
Lewis County General Hospital CAH331317-00 NY Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Chief Financial Officer
(315) 376-5597
7785 North State Street
Lowville, NY 13367
Lincoln County Hospital CAH171360-00 KS Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers Pending  
Little Falls Hospital CAH331311-00 NY Diversion – 340B drugs dispensed to inpatients Repayment to manufacturers Pending  
Loma Linda University Medical Center DSH050327 CA Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Marlborough Hospital DSH220049 MA No adverse findings None N/A

Audit closure date: February 7, 2018
 

 
Mayo Clinic Health System – Albert Lea SCH240043-00 MN Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address. None Pending  
Mayview Community Health Center, Inc. FQHCLA263 CA No adverse findings None N/A

Audit closure date: February 15, 2018
 

 
McKay-Dee Hospital Center DSH460004 UT Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of the finding. None CAP implemented

Audit closure date: June 12, 2018

 
Memorial Hospital of Texas County Authority SCH370138-00 OK Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Methodist Charlton Medical Center DSH450723 TX Diversion - 340B drugs were not properly accumulated. Repayment to manufacturers

CAP implemented

Audit closure date: August 29, 2018

Director of Pharmacy Services
(214) 947-7581
3500 W. Wheatland Rd.
Dallas, TX 75237
Mississippi State Dept of Health RWIID392133 MS Incorrect 340B OPAIS record – Incorrect entry for grant number prior to January 29, 2018. None CAP implemented

Audit closure date: April 17, 2018

 
Monroe County Hospital CAH161342-00 IA No adverse findings None N/A

Audit closure date: January 26, 2018

 
Neighborhood Healthcare CH093540 CA Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Senior Financial Analyst
760-737-6905
425 North Date Street
Escondido, CA 92025
New York – Presbyterian / Queens DSH330055 NY Incorrect 340B database record – ineligible site registered on 340B database. None Pending  
North Mississippi Primary Health Care, Inc. CH049100 MS Diversion – 340B drug dispensed at a contract pharmacy, not supported by a medical record.

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

Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers Pending  
Orange Coast Memorial Medical Center DSH050678 CA No adverse findings None N/A

Audit closure date: March 7, 2018

 
Parkview Hospital DSH150021 IN Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities.

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

Repayment to manufacturers Pending  
Parkview Wabash Hospital, Inc. CAH151310-00 IN Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to October 23, 2017. None CAP implemented

Audit closure date: March 14, 2018

 
Parmer County Community Hospital, Inc. CAH451300-00 TX No adverse findings None N/A

Audit closure date: February 23, 2018.
 

 
Peacehealth dba St. Joseph Medical Center SCH500030-00 WA Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility.

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

Repayment to manufacturers CAP approved Director of Pharmacy
PeaceHealth St Joseph Medical Center
360-788-6022
2901 Squalicum Parkway
Bellingham, WA  98225
Peak Vista Community Health Centers CH081460 CO Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Penn Presbyterian Medical Center DSH390223 PA

Diversion – 340B drugs dispensed at entity for prescriptions written at ineligible site.

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers Pending  
Planned Parenthood Association of Utah – South Jordan FP84095 UT Incorrect 340B OPAIS record –Utilized contract pharmacies that were not listed on OPAIS; Failed to remove two terminated contract pharmacies from OPAIS.

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

Repayment to manufacturers Pending  
Planned Parenthood St. Louis Region and Southwest Missouri STD65807 MO No adverse findings None N/A

Audit closure date: April 3, 2018

 
Pomona Valley Hospital Medical Center DSH050231 CA Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts. Repayment to manufacturers Pending  
Regional Health Sturgis Hospital CAH431321-00 SD No adverse findings None N/A

Audit closure date: June 14, 2018

 
Ronald Reagan UCLA Medical Center DSH050262 CA Incorrect 340B OPAIS record – Incorrect entry for billing address.

Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers Pending  
Rural Health Group, Inc. CH046680 NC Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers Pending  
Rush Memorial Hospital CAH151304-00 IN No adverse findings None

N/A

Audit closure date: November 16, 2017
 

 
Saint Francis Hospital DSH370091 OK No adverse findings None N/A

Audit closure date: June 13, 2018

 
Saint Joseph – Martin CAH181305-00 KY No adverse findings None N/A

Audit closure date: April 10, 2018

 
Scott Regional Hospital CAH251323-00 MS Diversion - 340B drugs were not properly accumulated. Repayment to manufacturers CAP approved Compliance Officer
601-703-4437
Scott Regional Hospital
317 Highway 13 South
Morton, MS 39117
Shady Grove Adventist Hospital DSH210057 MD Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Shenandoah Medical Center CAH161366-00 IA No adverse findings None N/A

Audit closure date: January 31, 2018

 
South Lincoln Hospital District CAH531315-00 WY Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP approved IT / Revenue Cycle Manager
307-877-5574
711 Onyx Street
Kemmerer, WY 83101
SE Alabama Rural Health Associates (SARHA) CH048950 AL Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to August 22, 2018. None Pending  
St. David’s Healthcare Partnership, L.P., LLP dba St. David’s Medical Center DSH450431 TX

Diversion - 340B drugs were not properly accumulated.

Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers Pending  
St. Francis Medical Center DSH310021 NJ No adverse findings None N/A

Audit closure date: March 16, 2018

 
St. Francis Medical Center Inc. DSH190125 LA

Diversion - 340B drugs were not properly accumulated; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers Pending  
St. Gabriel’s Hospital CAH241370-00 MN No adverse findings None N/A

Audit closure date: May 29, 2018

 
St. Joseph’s Medical Center DSH240075;
SCH240075-00
MN No adverse findings None

N/A

Audit closure date: August 8, 2018

 
St. Mary’s Hospital and Medical Center, Inc. DSH060023 CO No adverse findings None N/A

Audit closure date: May 23, 2018

 
St. Mary’s Regional Health Center DSH240101 MN No adverse findings None

N/A

Audit closure date: August 10, 2018

 
Stanford Health Care DSH050441 CA No adverse findings None N/A

Audit closure date: February 1, 2018

 
Sterling Regional MedCenter RRC060076-00 CO Incorrect 340B OPAIS record – Entity registered as an incorrect hospital type. None Pending  
Three Rivers Medical Center DSH380002 OR Incorrect 340B OPAIS record – Failed to include entity owned pharmacy as a shipping address.

Diversion -340B drug dispensed at entity for a prescription written at an ineligible site.

Repayment to manufacturers Pending  
Trinity Hospital Twin City CAH361302-00 OH No adverse findings None N/A

Audit closure date: February 8, 2018

 
Tyrone Hospital CAH391307-00 PA Incorrect 340B OPAIS record - Failed to remove closed location’s registration; Incorrect entry for address.

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

Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers Pending  
United Community Services, Inc. CHC29000-00 CT No adverse findings None N/A

Audit closure date: January 24, 2018

 
United Regional Health Care System SCH450010-00 TX

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.

Diversion - 340B drugs were not properly accumulated.

Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.

Repayment to manufacturers Pending  
University Hospitals Rainbow and Babies Children’s Hospital PED363302-00 OH Diversion – 340B drugs dispensed at entity for prescriptions written at an ineligible site. Repayment to manufacturers CAP approved Vice President & Corporate Controller
3605 Warrensville Center Rd.
Room: 1110 Mail Stop: MSC8100
Shaker Hts., Ohio 44122-5203
Phone: (216) 767-8729
Email: Michael.Vehovec@UHhospitals.org
USC Norris Cancer Hospital CAN050660-00 CA Incorrect 340B OPAIS record – Incorrect entry for address None CAP implemented

Audit closure date: July 18, 2018

 
Watts Healthcare Corporation CHC00850-00 CA Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from 340B Program
Repayment to manufacturers
Pending  
Whitesburg ARH Hospital DSH180002 KY No adverse findings None N/A

Audit closure date: June 6, 2018

 
Whitley Memorial Hospital DSH150101 IN No adverse findings None N/A

Audit closure date: December 12, 2017
 

 

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

Date Last Reviewed:  September 2018