Program Integrity: FY18 Audit Results

Updated 6/7/18. 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 (60) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
Appalachian Regional Healthcare Inc. dba Summers County ARH Hospital CAH511310-00 WV No adverse findings None N/A

Audit closure date: May 3, 2018

 
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

 
Belington Community Medical Services Association, Inc. CHC12878-00 WV No adverse findings None N/A

Audit closure date: May 18, 2018

 
Bronson Lakeview Hospital CAH231332-00 MI No adverse findings None N/A

Audit closure date: March 23, 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

 
Columbia Memorial Hospital RRC330094-00 NY Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility. None Pending  
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.
 

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

Audit closure date: April 11, 2018

 
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
 

 
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 approved RPH Director of Pharmacy

208-883-2236

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

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 Pending  
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  
Lewis County General Hospital CAH331317-00 NY Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. 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
 

 
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. Repayment to manufacturers Pending  
Methodist Charlton Medical Center DSH450723 TX Diversion - 340B drugs were not properly accumulated. Repayment to manufacturers Pending  
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 Pending  
Orange Coast Memorial Medical Center DSH050678 CA No adverse findings None N/A

Audit closure date: March 7, 2018

 
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 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  
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 a contract pharmacies for a prescription written at an ineligible site. Repayment to manufacturers Pending  
Rush Memorial Hospital CAH151304-00 IN No adverse findings None

N/A

Audit closure date: November 16, 2017
 

 
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 Pending  
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

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

Audit closure date: March 16, 2018

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

Audit closure date: May 29, 2018

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

Audit closure date: May 23, 2018

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

Audit closure date: February 1, 2018

 
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

 
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 Pending  
USC Norris Cancer Hospital CAN050660-00 CA Incorrect 340B OPAIS record – Incorrect entry for address None Pending  
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  
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:  June 2018