Program Integrity: FY17 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 (199) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
Access Community Health Network CH051750 IL

Incorrect 340B database record – Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP approved Program Manager for 340B
600 W. Fulton, 2nd Floor, Chicago, IL 60661
312-526-2107
Access Community Health Network FP60101 IL No adverse findings None

N/A

Audit closure date: October 23, 2017

 
Addabbo Joseph Family Health Center, The CH022110 NY

Incorrect 340B database record – Incorrect entry for Primary Contact; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP implemented

Audit closure date: April 13, 2018

Chief Financial Officer
718-945-7150 x1311
6200 Beach Channel Drive; Arverne, NY 11692
Adelante Healthcare, Inc. CH093030 AZ

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate registrations of contract pharmacies on database; Registered contract pharmacy without written contract in place.

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

Termination of contract pharmacy from the 340B Program

Repayment to manufacturers

CAP approved

340B Program Coordinator
9520 W Palm Ln, Ste. 200
Phoenix, AZ 85037
623-583-3001 EXT. 1312

Advocate Christ Medical Center DSH140208 IL No adverse findings None

N/A

Audit closure date: June 21, 2017

 
Advocate North Side Health Network DSH140182 IL No adverse findings None

N/A

Audit closure date: June 28, 2017

 
Allen County Hospital CAH171373-00 KS

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

Diversion - 340B drug dispensed at a contract pharmacy to a patient at entity without a documented provider to patient relationship.

Repayment to manufacturer CAP approved

Comptroller
620-365-1034
3066 N Kentucky St
Iola, KS 66749

Amery Regional Medical Center CAH521308-00 WI

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

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

Repayment to manufacturers CAP approved

Director of Pharmacy
Amery Regional Medical Center
265 E. Griffin Street
Amery, WI 54001
715-268-0670

Appalachian Regional Healthcare dba Morgan County ARH Hospital CAH181307-00 KY No adverse findings None

N/A

Audit closure date: July 25, 2017

 
Aspirus Iron River Hospital and Clinics CAH231318-00 MI Incorrect 340B database record - 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 manufactures CAP approved Chief Financial Officer
340B Authorizing Official
Aspirus Iron River Hospital and Clinics
1400 West Ice Lake Road
Iron River, Michigan 49935
Glenn.Dobson@Aspirus.org
(906) 265-0436
Aspirus Medford Hospital and Clinics, Inc. CAH521324-00 WI No adverse findings None

N/A

Audit closure date: August 22, 2017

 
AU Medical Center, Inc. DSH110034 GA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers CAP approved 340B Program Manager
AU Medical Center, Inc.
1120 15th Street, BI-2101
Augusta, GA 30912
(706)721-0082
Avera St. Benedict Health Center CAH431330-00 SD No adverse findings None

N/A

Audit closure date: September 7, 2017

 
Baptist Health Corbin DSH180080 KY Diversion – 340B drug dispensed to a patient at entity for a prescription written at an ineligible site Repayment to manufacturer CAP approved 340B Program Manager
Baptist Health System Services
2701 Eastpoint Parkway
Louisville, KY 40223
(502) 253-4746
quanika.penny@bhsi.com
Baptist Health Lagrange DSH180138 KY No adverse findings None N/A

Audit closure date: October 19, 2017

 
Baptist Health Lexington

DSH180103

KY

Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed at entity for prescriptions written at an ineligible site.

Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

340B Program Manager

Baptist Health System Services
2600 Eastpoint Parkway, Suite 103
Louisville, KY 40223

502-253-4746

quanika.penny@bhsi.com

Baptist Health Medical Center - Arkadelphia CAH041321-00 AR

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 2, 2018

Senior Reimbursement Specialist
Baptist Health - Little Rock, AR

Attn: Accounting

9601 Baptist Health Drive
Little Rock, AR 72205

501-202-1813 Office

501-202-2385 Fax

stefanie.jaeger@baptist-health.org

Baptist Hospital of Miami, Inc. DSH100008 FL

Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 17, 2017

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

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

Repayment to manufacturers CAP approved Director, Supply Chain Quality Assurance, 786-595-9023, 9001 NW 33 Street, Doral, FL 33172, haleyf@baptisthealth.net
Bayhealth Medical Center Inc. DSH080004 DE

Incorrect 340B database record – ineligible site registered on 340B database.

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2018

Pharmacy Business Manager
Bayhealth Medical Center
640 S. State St. Dover, DE 19901

302-744-6753

Tara_kompare@bayhealth.org

Baylor University Medical Center DSH450021 TX

Entity did not meet eligibility requirements as a DSH hospital as of November 29, 2016.

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; incorrect entry for Primary Contact.

Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient

relationship.

Termination of covered entity from the 340B Program*

Repayment to manufacturers

CAP approved

Pharmacy Director

BUMC 3500 Gaston Ave.,
Dallas, Texas 75246

214-820-6826

Belmond Community Hospital CAH161301-00 IA Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at an ineligible sites. Repayment to manufacturers CAP approved Pharmacy Leader
1316 S. Main Street
Clarion, IA 50525
515-532-9199
Berkshire Medical Center DSH220046 MA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 21, 2018

340B Coordinator

725 North Street
Pittsfield, MA 01201

413-445-7079

Bethesda Hospital

DSH100002

FL

Diversion – 340B drug dispensed to a patient at entity for a prescription written at an ineligible site; 340B drug dispensed without a documented provider to patient relationship.

Repayment to manufacturer

CAP implemented

Audit closure date: August 15, 2018

Director of Pharmacy

(561)737-7733 ext. 84584

2815 South Seacrest Blvd.,
Boynton Beach, FL 33435

Blue Hill Memorial Hospital

CAH201300-00

ME

No adverse findings

None

N/A

Audit closure date: August 29, 2017

 
Boa Vida Hospital of Aberdeen, MS, LLC D/B/A Monroe Regional Hospital formerly: Pioneer Health Services of Monroe County, Inc. dba Pioneer Community Hospital CAH251302-00 MS

Incorrect 340B database record – Failed to remove closed location registration; incorrect entry for primary contact information.

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

Repayment to manufacturers CAP approved Director of Pharmacy
400 Chestnut St.
Aberdeen, MS 39730
662-369-2455
Bon Secours Richmond Community Hospital DSH490094 VA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion - 340B drug dispensed at contract pharmacy for a prescription written at ineligible sites.

Repayment to manufacturer CAP approved 340B Program Manager
1500 N. 28th Street
Richmond, Virginia 23223
804-221-4837
Boyle County Health Department

FP404228

KY

No adverse findings

None

N/A

Audit closure date: April 20, 2017

 
BRFHH Monroe LLC d/b/a University Health Conway DSH190011 LA

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

Director of Pharmacy

University Health Conway
4864 Jackson Street
Monroe, LA 71202

318-330-7969

Care Resource Community Health Centers, Inc. (formerly Community AIDS Resource) CHC11399-00 FL

Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact; Incorrect entry for offsite outpatient facility address.

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

Repayment to manufacturers CAP approved

Director of Grants, Contract and Pharmacy Services

3510 Biscayne Blvd
Miami, FL 33137

305-576-1234, Ext 230

Carolinas HealthCare System University DSH340166 NC No adverse findings None N/A

Audit closure date: September 12, 2017

 
Carolinas Medical Center DSH340113 NC No adverse findings None N/A

Audit closure date: September 11, 2017

 
Central Counties Health Centers, Inc. CH059700 IL No adverse findings None N/A

Audit closure date: June 23, 2017

Q2
Central Mississippi Civic Improvement Association, Inc. CH040750 MS Incorrect 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: April 24, 2018

 
Chapa-De Indian Health Program Inc. FQHC638002 CA Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Primary Contact for 340B Chapa-De Indian Health Program
11670 Atwood Road, Auburn, CA 95603
(530) 887-2800
rsingh@chapa-de.org
Charleston Area Medical Center

DSH510022

WV

No adverse findings

None

N/A

Audit closure date: March 13, 2017

 
Children’s Hospital Boston PED223302-00 MA Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers

CAP approved

Chief Pharmacy Officer
617-355-6945
300 Longwood Ave.
Boston, MA 02115

Children’s Hospital of San Antonio

PED453315-00

TX

No adverse findings

None

N/A

Audit closure date: August 29, 2017

 
Children’s Hospital Orange County

PED053304-00

CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 7, 2018

340B
Compliance Analyst

714-509-8342

1201 W. La Veta Ave
Orange, CA 92868

Children's Medical Center Dallas PED453302-00 TX Incorrect 340B database record – Incorrect entry for offsite facility address.

Diversion – 340B drugs were not properly accumulated

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

Repayment to manufacturers CAP approved Director Business Operations, Pharmacy Services
1935 Medical District Drive
Dallas, Texas 75235
214-456-7437
Chinese Hospital DSH050407 CA

Incorrect 340B database record – Incorrect entries for off-site outpatient facility address, authorizing official and primary contact information.

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

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

Repayment to manufacturers CAP approved Director, Quality/Compliance Officer

845 Jackson St
San Francisco, CA 94133

patriciac@chasf.org

Chippewa County War Memorial Hospital SCH230239-00 MI Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity, not supported by a medical record. Repayment to manufacturers CAP approved

Director of Pharmacy

(906)635-4450

500 Osborn Boulevard
Sault Sainte Marie, MI 49783

Christus Spohn Hospital Alice DSH450828 TX Diversion- 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers

CAP implemented

Audit closure date: August 9, 2018

Pharmacy Director

CHRISTUS Spohn
Health System

600 Elizabeth Street
Corpus Christi, TX 78404

361-881-6491

Deborah.allen3@christushealth.org

Christus St. Frances Cabrini Hospital DSH190019 LA Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved

Vice President – Advis Group
19065 Hickory Creek Drive, Suite 115
Mokena, IL 60448
708-478-7030
davants@theadvisgroup.com

Director of Pharmacy
3330 Masonic Dr.
Alexandria, LA 71301
318-348-1922
Spencer.gauthreaux@christushealth.org

Clara Barton Hospital Association CAH171333-00 KS No adverse findings None N/A

Audit closure date: November 22, 2017
 

 
Community Clinic, Inc.

CHC10591-00

MD

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for address for outpatient facilities; Registered two contract pharmacies without written contracts in place.

Entity did not provide contract pharmacy oversight prior to November 2017.

Diversion – 340B drug dispensed to patient at entity without a documented provider to patient relationship.

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

Termination of contract pharmacy from the 340B Program*

Repayment to manufacturers

CAP approved

Associate Chief Medical Officer
8630 Fenton Street, Suite 1204
Silver Spring, MD 20910
Phone: 301-340-7525
Fax: 301-495-0318
Community Health Center of Lubbock, Inc. CH062910 TX No adverse findings None N/A

Audit closure date: May 19, 2017

 
Community Health Centers of Pinellas, Inc.

CH049070

FL

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

None

Pending

 
Community Health Centers of the Central Coast, Inc.

CH090710

CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2018

Director of 340B Program

Email: ayip@chccc.org

805-346-3987

150 Tejas Place,
Nipomo, Ca 93444

Comprehensive Care Center, Inc. dba Community AIDS Network RWII34287 FL No adverse findings None

N/A

Audit closure date: June 29, 2017

 
County of Lake CH058870 IL Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Clinical Compliance Manager
847-377-8540
3010 Grand Avenue
Waukegan, IL 60085
Crosbyton Clinic Hospital CAH451345-00 TX Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers

CAP implemented

Audit closure date: July 25, 2018

Director

806-675-8700

Debbie.tue@crosbytonclinichospital.com

Dallas County Medical Center CAH041317-00 TX No adverse findings None

N/A

Audit closure date: May 31, 2017

 
Delano Regional Medical Center

DSH050608

CA

No adverse findings

None

N/A

Audit closure date: May 3, 2017

 
DCH Regional Medical Center DSH010092 AL Incorrect 340B database record - Incorrect entry for address for outpatient facilities.

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

Inaccurate or incorrect information on the 340B Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

Repayment to manufacturers CAP approved Corporate Director of Compliance and Internal Audit
205-759-7715
809 University Blvd. East
Tuscaloosa, AL 35401
Delta Regional Medical Center

DSH250082

MS

No adverse findings

None

N/A

Audit closure date: May 10, 2017

 
Detroit Community Health Connection CH052070 MI No adverse findings None

N/A

Audit closure date: May 26, 2017

 
Dominican Hospital (formerly Dominican Santa Cruz Hospital) DSH050242 CA No adverse findings None

N/A

Audit closure date: August 8, 2017

 
East Alabama Medical Center DSH010029 AL Diversion – 340B drugs dispensed at entity for prescriptions written at ineligible sites. Repayment to manufacturers Pending  
East Liverpool City Hospital DSH360096 OH

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

CAP approved

System Director, 340B Program and Ambulatory Care
1000 Remington Clve, Suite 100
Bolingbrook, IL 60440
630-914-2872

Eau Claire Cooperative Health Center

CH043270

SC

No adverse findings

None

N/A

Audit closure date: May 22, 2017

 
Ephraim McDowell Regional Medical Center, Inc. DSH180048 KY Diversion - 340B drugs dispensed at entity and contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Chief Financial Officer
217 S. Third Street
Danville, KY 40422
859-239-2424
Escambia Community Clinics, Inc. CH0452890 FL

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

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

Termination of two contract pharmacies from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: July 31, 2018

Chief Administrative Officer
850-436-4630
14 West Jordan
Pensacola, FL 32501

Essentia Health St. Mary's Hospital-Superior CAH521329-00 WI No adverse findings None N/A

Audit closure date: October 11, 2017
 

 
Family Christian Health Center CH059300 IL Incorrect 340B database record- Registered contract pharmacy without written contract in place Termination of contract pharmacy from 340B Program

CAP implemented

Audit closure date: August 7, 2018

 
Franciscan Health Hammond DSH150004 IN No adverse findings None

N/A

Audit closure date: July 25, 2017

 
Franklin Regional Hospital CAH301306-00 NH No adverse findings None

N/A

Audit closure date: August 30, 2017

 
Franklin Woods Community Hospital DSH440184 TN

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers Pending  
Fresno Community Hospital & Medical Center dba Clovis Community Medical Center DSH050492 CA Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers CAP implemented

Audit closure date: April 25, 2018

Chief Audit, Ethics, and Compliance Officer

559-324-4830

789 N. Medical Center Drive East, Clovis, CA 93611

Froedtert Memorial Lutheran Hospital DSH520177 WI Diversion - 340B drug dispensed at entity for a prescription written at an ineligible site. Repayment to manufacturers CAP approved

Froedtert Hospital 340B Manager
Doreene.Brecheisen@froedtert.com
262-532-5160

Integrated Service Center
N86W12999 Nightingale Way
Memomonee Falls, WI 53051

Grandview Hospital DSH360133 OH Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites.

Duplicate Discounts – Inaccurate or incorrect information on the 340B Medicaid Exclusion File.

Repayment to manufacturers CAP approved

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

Director of Pharmacy

405 West Grand Avenue
Dayton OH 45405

937-723-5816

linda.mccall@ketteringhealth.org

Granville Medical Center DSH340127 NC

Covered outpatient drugs obtained through a Group Purchasing Organization prior to September 29, 2017.

Incorrect 340B database record – Duplicate registration off offsite outpatient facility on 340B database record; Ineligible sites registered on 340B database.

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP approved Chief Financial Officer

1010 College Street
Oxford, North Carolina 27565

919-690-3402

Halifax Health Medical Center DSH100017 FL Incorrect 340B database record - Ineligible site registered on 340B database prior to September 14, 2017

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

Inaccurate or incorrect information on the 340B Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of the finding.

Repayment to manufacturers Pending  
Hamdard Center for Health and Human Services NFP

CHC26565-00

IL

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

Duplicate Discounts - Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Termination of two contract pharmacies from 340B Program.

Repayment to manufacturers

CAP implemented

 

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

Audit closure date: February 2, 2018

 
Harrison Community Hospital

CAH361311-00

OH

No adverse findings

None

N/A

Audit closure date: April 27, 2017

 
Hennepin County Medical Center DSH240004 MN No adverse findings None

N/A

Audit closure date: June 30, 2017

 
Heartland Community Health Clinic DBA: Heartland Health Services CH051833A IL

Incorrect 340B database record - Registered contract pharmacy without a contract in place.

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

Termination of contract pharmacy from 340B Program*

CAP implemented

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

Audit closure date: May 16, 2018

 
Hospital District #1 of Crawford County Kansas CAH171376-00 KS

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

Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record; 340B drugs were not properly accumulated.

Repayment to manufacturers CAP approved Chief Executive Officer
620-724-5152
Hospital District #1 of Crawford County dba Girard Medical Center
302 N Hospital Dr
Girard, KS 66743-2000
Hospital District #1 of Dickinson CAH171381-00 KS Incorrect 340B database record – Ineligible sites registered on 340B database; Incorrect entry for offsite outpatient facility address.

Diversion – 340B drugs dispensed at entity and 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 ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP approved

Chief Financial Officer

785-263-6614

511 N.E. 10th Street
Abilene, Kansas 67410

Hiawatha Community Hospital CAH171341-00 KS No adverse findings None

N/A

Audit closure date: June 9, 2017

 
Hurley Medical Center DSH230132 MI No adverse findings None

N/A

Audit closure date: February 28, 2018

 
Independent Healthcare Management, Inc. dba SE Lackey Memorial Hospital CAH251300-00 MS Diversion – 340B drugs were not properly accumulated. Repayment to manufacturer Pending  
Integris Miami Hospital DSH370004 OK Diversion – 340B drugs were not properly accumulated. Repayment to manufacturers CAP approved

System Administrative Director
INTEGRIS Health, Inc.
3300 Northwest Expressway
Oklahoma City, OK 73112

Iowa Specialty Hospital – Clarion CAH161302-00 IA Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

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

Repayment to manufacturers CAP approved

Pharmacy Leader
1316 S. Main
Clarion, IA 50525
515-532-9199

Iroquois Memorial Hospital and Resident Home SCH140167-00 IL

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.

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

Repayment to manufacturers CAP approved Chief Financial Officer
(815) 432-7929
200 E. Fairman Ave
Watseka, IL 60970-1644
J Arthur Dosher Memorial Hospital CAH341327-00 NC Diversion – 340B drugs were not properly accumulated. Repayment to manufacturers

CAP approved

Pharmacy Director

910-457-3835

JA Dosher Memorial Hospital
924 N Howe St.
Southport, NC 28461

Jane Todd Crawford Memorial Hospital, Inc. dba Jane Todd Crawford Hospital CAH181325-00 KY Incorrect 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: July 18, 2017

 
John H. Stroger, Jr. Hospital of Cook County DSH140124 IL

Covered outpatient drugs obtained through a Group Purchasing Organization prior to August 23, 2016.

Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File; Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Repayment to manufacturers. CAP approved

Senior Director of Pharmacy
Cook County Health & Hospitals System
1901 West Harrison St, Suite LL134
Chicago, IL 60612

Cnorwood@cookcountyhhs.org

Jones Memorial Hospital

SCH330096-00

NY

Incorrect 340B database record – 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

CAP implemented

Audit closure date: May 3, 2018

340B Business Manager

Pharmacy Department, University of Rochester Medical Center 120 Corporate Woods, Suite 350 Rochester, NY 14623

(505)-785-5154

Keystone Rural Health Center

CH032700

PA

No adverse findings

None

N/A

Audit closure date: March 23, 2017

 
Kiowa County Hospital District dba Weisbrod Memorial Hospital

CAH061300-00

CO

Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to August 11, 2017; Entity did not provide contract pharmacy oversight prior to onsite audit.

None

Pending

 
Knox County Hospital District SCH450746-00 TX Entity did not meet eligibility requirements as a DSH hospital as of March 10, 2017.

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

Termination of covered entity from the 340B Program*

Repayment to manufacturers
 

CAP approved CEO
Knox County Hospital District
701 South 5th Street
P.O. Box 608
Knox City, Texas 79529
940-657-3535
Lafayette General Medical Center

DSH190002

LA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; 340B drugs were not properly accumulated.

Duplicate Discounts- Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

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

Audit closure date: August 29, 2018

Director of Pharmacy

337-289-7888

1214 Coolidge Blvd
Lafayette, LA 70503

Laird Hospital, Inc.

CAH251322-00

MS

No adverse findings

None

N/A

Audit closure date: May 5, 2017

 
Legacy Emanuel Hospital and Health Center DSH380007 OR No adverse findings None N/A

Audit closure date: December 21, 2017

 
Los Angeles County

DSH050376

CA

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

Repayment to manufactures

CAP implemented

Audit closure date: August 23, 2018

Pharmacy Service Chief
LAC Pharmacy Affairs
sdsouza@dhs.lacounty.gov
213-240-7717

Lucile Salter Packard Children’s Hospital HM6415 CA No adverse findings None

N/A

Audit closure date: August 8, 2017

 
Lynn Community Health, Inc. CH011430 MA Incorrect 340B database record – Failed to remove shipping address of closed location; Registered contract pharmacy without a contract in place prior to November 3, 2017.

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

Repayment to manufacturers. CAP approved

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

 
Manatee County Rural Health Services Inc. CH044310 FL Incorrect 340B database record - Registered contract pharmacies without written contract in place. Termination of contract pharmacies from 340B Program CAP implemented

Audit closure date: May 23, 2018

 
Marengo Memorial Hospital CAH161317-00 IA Diversion - 340B drugs were not properly accumulated; Repayment to manufacturers CAP implemented

Audit closure date: April 19, 2018

Authorizing Official, Marengo Memorial Hospital
Chief Operating Officer

300 W May Street
Marengo IA 52301

319-642-8013

mmurphy@marengohospital.org

Marion General Hospital, Inc. DSH150011 IN No adverse findings None

N/A

Audit closure date: September 1, 2017

 
Medical University Hospital Authority DSH420004 SC Diversion - 340B drug dispensed at entity for prescription written at an ineligible site; 340B drugs were not properly accumulated. Repayment to manufacturers Pending  
Medina County Hospital District CAH451330-00 TX Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.   CAP implemented

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

Audit closure date: June 26, 2018

 
Memorial Hermann Sugar Land Hospital DSH450848 TX Incorrect 340B database record – Incorrect entry for offsite facility address.

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

Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers. CAP approved

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

System Director of Pharmacy Operations

902 Frostwood, Suite 190
Houston, TX 77024

713-242-2814

Memorial Medical Center CAH451356-00 TX Incorrect 340B database record - Registered contract pharmacies without written contract in place.

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

Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program

Repayment to manufacturers
 

CAP approved Chief Financial Officer
Memorial Medical Center
815 N. Virginia Street
Port Lavaca, Texas 77979
dmoore@mmcportlavaca.com
361-552-0224
Memorial Medical Center, Inc. CAH521359-00 WI Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File. Repayment to manufacturers CAP implemented

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

Audit closure date: April 17, 2018

 
Mercy Hospital Berryville CAH041329-00 AR No adverse findings None

N/A

Audit closure date: July 17, 2017

 
Mercy Medical Center CAH161377-00 IA No adverse findings None

N/A

Audit closure date: August 29, 2017

 
Mercy Medical Center DSH210008 MD Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved

Vice President/Chief Pharmacy Officer
301 St. Paul St.
Baltimore, MD 21202

410-332-9627

Gsmith10@mdmercy.com

Mercy Hospital of Franciscan Sisters CAH161338-00 IA No adverse findings None

N/A

Audit closure date: June 27, 2017

 
Mercy San Juan Medical Center DSH050516 CA No adverse findings None

N/A

Audit closure date: June 29, 2017

 
Methodist Hospital of Sacramento DSH050590 CA

Diversion – 340B drug dispensed for a prescription written for an inpatient.

Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers CAP approved Director of Pharmacy
916-681-1665
6500 Hospital Drive
Sacramento, CA 96823
Gurpreet.johal@dignityhealth.org
Methodist Hospitals, The DSH150002 IN

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP implemented

Audit closure date: July 11, 2018

Health System Director of Pharmacy
219-738-5807
600 Grant St.
Gary, IN 46402
Methodist Medical Center of Illinois DSH140209 IL Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers

CAP implemented

Audit closure date: July 31, 2018

Regional Pharmacy IS Coordinator

221 NE Glen Oak Ave.
Peoria, IL 61636

309-689-6029

Joseph.hersemann@unitypoint.org

Mid-Columbia Medical Center SCH380001-00 OR Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for Authorizing Official and Primary Contact; Registered contract pharmacies without written contract in place.

Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; A 340B drug was not properly accumulated.
Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program

Repayment to manufacturers
 

CAP implemented

Audit closure date: July 24, 2018

Pharmacy Director

541-296-7526

1700 E. 19th Street
The Dalles, OR 97058

 

Miller County Health Department TB31737 GA Incorrect 340B database record – Incorrect entry for grant number prior to April 29, 2017. None

CAP implemented

Audit closure date: August 17, 2017.

 
Mississippi County Health Unit FP723708 MS No adverse findings None

N/A

Audit closure date: August 9, 2017

 
Modoc Medical Center CAH051330-00 CA No adverse findings None N/A

Audit closure date: August 9, 2017
 

 
Monroe County Hospital DSH010120 AL Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. None CAP implemented

Audit closure date:
January 2, 2018
 

 
Montrose Memorial Hospital SCH060006-00 CO Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers CAP approved Director of Pharmacy Services
970-249-2211
800 S. 3rd St., Montrose CO 81401
Moore County Hospital District dba Memorial Hospital DSH450221 TX Incorrect 340B database 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.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers CAP approved

Chief Operating Officer
224 E. 2nd
Dumas, Texas 79029
806-935-7171

Mount Sinai Hospital, The DSH330024 NY

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Ineligible sites registered on 340B database.

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

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

CAP approved

Senior Director of Pharmacy, 340B Program
25-10 30th Avenue
Astoria NY
718-267-4295
Philip.manning@mountsinai.org

Neshoba County General Hospital SCH250043-00 MS Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Pharmacy Director
Neshoba County General Hospital
1001 Holland Avenue, Philadelphia, MS 39250
(601) 781-2310
ricky@neshoba-hospital.com
Newberry County Memorial Hospital SCH420053-00 SC Diversion – 340B drug dispensed to an inpatient; 340B drug dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved

Director of Pharmacy

Newberry County Memorial Hospital
PO Box 497
2669 Kinard Street
Newberry, SC 29108

(803) 405-7175

Valerie.leaphart@newberryhospital.net

Niagara Falls Memorial Medical Center DSH330065 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to May 18, 2017.

Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for offsite facility address; Registered contract pharmacies without written contract in place.

Diversion – 340B drug dispensed at contract pharmacies without a documented provider to patient relationship; 340B drugs were not properly accumulated.

Termination of four contract pharmacies from the 340B Program.

Repayment to manufacturers
 

CAP approved 340B Program Coordinator

621 10th Street
Niagara Falls, NY 14301

716-278-4537

Northwest Medical Foundation of Tillamook DBA Tillamook Regional Medical Center CAH381317-00 OR Diversion – 340B drugs were not properly accumulated. Repayment to manufacturers CAP approved

Pharmacy Director
(503) 815-2260
1000 3rd Street
Tillamook, OR 97141

Operation Samahan, Inc. CHC26623-00 CA Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect entry for offsite facility address.

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

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

Repayment to manufacturers CAP approved Director of Grants and Contracts

619.471.5433

1428 Highland Ave., National City, Ca 91950

Orchard Hospital CAH051311-00 CA No adverse findings None N/A

Audit closure date: October 18, 2017

 
Palo Alto County Hospital CAH161357-00 IA No adverse findings None

N/A

Audit closure date: September 19, 2017

 
Pearl River County Hospital CAH251333-00 MS

Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact; Registered contract pharmacies without written contract in place.

Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship; 340B drug dispensed at entity, not supported by a medical record.

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

Termination of two contract pharmacies from the 340B Program

Repayment to manufacturers

CAP approved Authorizing Official
601-795-4543, ext 2142
Gerald.vance@prc-med.com
Perry County Memorial Hospital CAH151322-00 IN Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers Pending  
Perry County Memorial Hospital CAH261311-00 MO

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect address listed for offsite outpatient facility.

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 15, 2018

CEO & Authorizing Official

434 N West St
Perryville, MO 63775

573-547-2536, Ext. 3203

or

340B Program Manager

212 Hospital Ln, Ste 102
Perryville, MO 63775

573-547-2536, Ext. 3362

Philadelphia Health & Education Corp. dba Drexel University College of Medicine FP191045 PA Incorrect 340B database record – Incorrect entry for address prior to April 11, 2017. None

CAP implemented

Audit closure date: August 7, 2018

 
Phoenix Children’s Hospital PED033302-00 AZ

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

Diversion – 340B drugs dispensed at the entity and at contract pharmacy for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: July 25, 2017

Manager Pharmacy Business Services

1919 East Thomas Road
Pharr
Phoenix, AZ 85016

(602) 933-4033

Pipestone County Medical Center CAH241374-00 MN No adverse findings. None N/A

Audit closure date: December 27, 2017

 
Presence Mercy Medical Center DSH140174 IL

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP approved

System Director, 340B Program and Ambulatory Care
1000 Remington Clve, Suite 100
Bolingbrook, IL 60440
630-914-2872

Presence Saint Francis Hospital DSH140080 IL Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.
Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.
Repayment to manufacturers CAP implemented

Audit closure date: May 22, 2018

System Director, 340B Program and Ambulatory Care

630.914.2872

1000 Remington Blvd., Suite 100
Bolingbrook, IL 60440

Providence Health and Services – Washington DSH500054 WA Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.  

CAP implemented

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

Audit closure date: July 19, 2018

 
Public Hospital District No. 1 of King County DBA Valley Medical Center DSH500088 WA Diversion – 340B drugs dispensed to patients at contract pharmacy without a documented provider to patient relationship.

CAP implemented

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

Audit closure date: July 19, 2018

Pending  
Ripon Medical Center, Inc. CAH521321-00 WI No adverse findings None

N/A

Audit closure date: June 27, 2017

 
Rockford Memorial Hospital DSH140239 IL Incorrect 340B database record – Utilized contract pharmacies prior to July 1, 2017 registration date; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP approved Pharmacy Business Coordinator

815-971-2394

2400 North Rockton Ave
Rockford, IL 61103

Rome Memorial Hospital, Inc. DSH330215 NY Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Listed duplicate record for an outpatient facility None

CAP implemented

Audit closure date: June 21, 2017

 
Rush University Medical Center DSH140119 IL Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drugs were not properly accumulated.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers CAP approved Director, Clinical Operations
1725 W Harrison St, Suite 418
Chicago, IL 60612
(312) 563-2326
Saint Joseph East

DSH180143

KY

No adverse findings

None

N/A

Audit closure date: March 16, 2017

 
Saint Anthony Hospital DSH140095 IL Diversion- 340B drugs were not properly accumulated. Repayment to manufacturers CAP approved Pharmacy Director
(773) 484-1317
Saint Anthony Hospital
2875 W 19th St
Chicago, IL 60623
Saint Mary’s Healthcare DSH070016 CT No adverse findings None N/A

Audit closure date:
November 16, 2017
 

 
Samaritan Hospital DSH500033 WA Covered outpatient drugs obtained through a Group Purchasing Organization from October 3, 2016 to March 28, 2017. 

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect entry for primary contact; Registered contract pharmacies without written contract in place.

Diversion – 340B drugs dispensed at entity for inpatient; 340B drug dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufactures

Termination of contract pharmacy from 340B Program*

Pending  
San Juan Basin Health Dept.

STD81303

CO

No adverse findings

None

N/A

Audit closure date:  April 13, 2017

 
San Joaquin Community Hospital DSH050455 CA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: August 2, 2018

Director of Pharmacy

661-869-6280

2615 Chester Ave.
Bakersfield, Ca 93301

Sanford Health Network CAH161321-00 IA No adverse findings None

N/A

Audit closure date: August 9, 2017

 
San Mateo Medical Center DSH050113 CA

Diversion – 340B drugs purchased for separately registered 340B covered entities with no reimbursable outpatient costs; 340B drugs were not properly accumulated at contract pharmacy.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers CAP approved

Director of Pharmacy
(650) 573-2366
222 West 39th Ave
San Mateo, CA 94403

San Ysidro Health Center CH091080 CA

Incorrect 340B database record – Inaccurate entries for billing addresses.

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers CAP approved

Director of Contracts
San Ysidro Health Center

(619)662-4165

Disrael@syhc.org

Seton Health System

DSH330232

NY

No adverse findings

None

N/A

Audit closure date: March 7, 2017

 
Shasta Community Health Center CH092240 CA No adverse findings None

N/A

Audit closure date: August 9, 2017

 
Skagit County Health Department

STD982738

WA

Incorrect 340B database record – entity improperly registered a repackager as a contract pharmacy.

None

Pending

 
South Florida Baptist Hospital DSH100132 FL Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to August 25, 2017; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP approved

Manager of Pharmacy Supply Chain

BayCare Health System
7802 E. Telecom Parkway
Temple Terrace, FL 33637

813-888-1920

Southcoast Hospitals Group Inc. DSH220074 MA

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: August 29, 2018

Sr Vice President & Chief Operating Officer

101 Page Street, New Bedford, MA 02740

508-973-5872

Southern Monterey County Memorial Hospital DBA George L. Mee Memorial Hospital DSH050189 CA Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 31, 2016. 

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.
 

Repayment to manufacturers CAP approved Quality Assurance Director
300 Canal Street
King City, CA 93930
831-386-7375
Southwest Memorial Hospital CAH061327-00 CO

Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed at at entity and 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 implemented

Audit closure date: April 19, 2018

Chief Financial Officer

1311 N. Mildred Road
Cortez, CO 81321

akobel@swhealth.org

970-564-2153

Spectrum Health United Hospital DSH230035 MI Incorrect 340B database record – Registered one contract pharmacy without written contract in place. Termination of contract pharmacy from 340B Program CAP implemented

Audit closure date: June 14, 2018

 
SSM Cardinal Glennon Children’s Medical Center HM13100 MO No adverse findings None

N/A

Audit closure date: September 21, 2017

 
St. Barnabas Hospital DSH330399 NY

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers

CAP approved

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

 
St Dominic - Jackson Memorial Hospital

DSH250048

MS

No adverse findings

None

N/A

Audit closure date: March 30, 2017

 
St. Elizabeth’s Hospital of Wabasha, Inc. CAH241335-00 MN No adverse findings None

N/A

Audit closure date: July 18, 2017

 
St. Francis Memorial Hospital

DSH050152

CA

No adverse findings

None

N/A

Audit closure date: April 24, 2017

 
St. Joseph’s Hospital DSH100075 FL Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate registration of offsite outpatient facility on database; Registered contract pharmacies without written contract in place prior to June 29, 2017; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers CAP approved

Manager of Pharmacy Supply Chain

BayCare Health System
7802 E. Telecom Parkway
Temple Terrace, FL 33637

813-888-1920

St. Joseph’s Hospital and Medical Center DSH030024 AZ

Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

Director of Pharmacy

St. Joseph’s Hospital and Medical Center
350 West Thomas Road
Phoenix, AZ 85013

(602) 406-4744

St. Joseph’s University Medical Center DSH310019 NJ

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

Diversion – 340B drug dispensed at the entity for prescriptions written at an ineligible sites; 340B drugs dispensed at entity for inpatients; 340B drugs were not properly accumulated.

Termination of one contract pharmacy from 340B Program*

Repayment to manufacturers

Pending  
St. Luke’s Magic Valley Regional Medical Center, LTD SCH130002-00 ID No adverse findings None

N/A

Audit closure date: June 1, 2017

 
St. Mary’s Hospital and Medical Center HV00593 CO No adverse findings None

N/A

Audit closure date: June 21, 2017

 
Tarzana Treatment Centers, Inc.

HV00791B

CA

Incorrect 340B database record – Registered contract pharmacy without written contract in place; Utilized contract pharmacies prior to registering on the 340B database.

Termination of five contract pharmacies from 340B Program

 

CAP implemented

Audit closure date: July 12, 2017

 
Tennessee Department of Health FPTN000 TN Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.   CAP implemented

Audit closure date: June 13, 2018

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

 
Texas County Memorial Hospital DSH260024 MO Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drug dispensed at the entity for a prescription written at an ineligible site; 340B drugs were not properly accumulated.

Repayment to manufacturers CAP implemented

Audit closure date: April 20, 2018

340B Coordinator

417-967-1246

1333 S. Sam Houston Blvd, Houston. MO 65483

ThedaCare Medical Center Berlin, Inc. CAH521355-00 WI Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Pharmacy Director
Robert.probasco@thedacare.org
715-584-8045
Thomas Jefferson University Hospital DSH390174 PA No adverse findings None

N/A

Audit closure date: April 5, 2017

 
Thomas Memorial Hospital DSH510029 WV Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

340B Coordinator

304-766-4320

4605 MacCorkle Ave., SW
South Charleston, WV 25309

Three Lower Counties Community Services, Inc. CH03301H MD No adverse findings None

N/A

Audit closure date: September 14, 2017

 
Three Rivers Health DSH230015 MI

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacy without written contract in place prior to December 27, 2017.

Diversion – 340B drugs dispensed at entity for inpatient; 340B drug dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers Pending  
Trinitas Regional Medical Center DSH310027 NJ

Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 3, 2018.

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Ineligible sites registered on the 340B database;

Entity did not provide contract pharmacy oversight prior to January 3, 2018.

Diversion – 340B drugs dispensed at entity and contract pharmacies for prescriptions written at ineligible sites;

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers.

CAP approved

Director of Pharmacy
Trinitas Regional Medical Center
225 Williamson St.
Elizabeth, NJ DSH310027
908-994-5238

Ukiah Valley Medical Center DSH050301 CA No adverse findings None N/A

Audit closure date: November 2, 2017

 
UNC Hospitals

DSH340061

NC

No adverse findings

None

N/A

Audit closure date: March 1, 2017

 
Union County Health Foundation CH080890 SD Diversion -340B drugs dispensed at contract pharmacies, not supported by a medical record. Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

Chief Financial Officer or 340B Program Manager

PO Box 99 109 N. Main Street Howard, SD 57349

(605) 772-4525

 

United Health Services Hospitals, Inc.

DSH330394

NY

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database.

None

CAP implemented

Audit closure date: May 22, 2018

 
Univ of Colorado Hemophilia Center School of Medicine HM11980 CO No adverse findings None N/A

Audit closure date: October 23, 2017

 
University of Miami Hospital DSH100009 FL

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entry for Authorizing Official.

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

Repayment to manufacturers Pending  
University of Mississippi Medical Center Grenada

DSH250015

MS

No adverse findings

None

N/A

Audit closure date: May 22, 2017

 
University of North Carolina – Chapel Hill HM11947 NC Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record. None

CAP implemented

Audit closure date: January 30, 2018

 
University of South Alabama Children’s and Women’s Hospital

PED013301-00

AL

No adverse findings

None

N/A

Audit closure date: May 12, 2017

 
UPMC Mercy DSH390028 PA

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity had a duplicate registration for an offsite outpatient facility.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers CAP approved

Chief Finance Officer
UPMC Mercy Department of Finance
1400 Locust Street
Pittsburgh, PA 15219
Phone: 412‐647‐7713

W.A. Foote Memorial Hospital DBA Henry Ford Allegiance Health

DSH230092

MI

Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; 340B drugs were not properly accumulated.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File

Repayment to manufacturers

CAP approved

340B Program Coordinator

(517) 205-7557

205 N. East Ave. Jackson, MI 49201

Wabash General Hospital District CAH141327-00 IL

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

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File; Entity did not have adequate controls to prevent duplicate discounts.

Repayment to manufacturers CAP approved Pharmacy Director
Wabash General Hospital District
1418 College Drive
Mt. Carmel, IL 62863
(618) 263-6316
mlockard@wabashgeneral.com
Wake Health Services, Inc.

CH041000

NC

No adverse findings

None

N/A

Audit closure date: May 9, 2017

 
Waldo County General Hospital

CAH201312-00

ME

No adverse findings

None

N/A

Audit closure date: August 29, 2017

 
War Memorial Hospital Inc.

CAH511309-00

WV

No adverse findings

None

N/A

Audit closure date: June 9, 2017

 
Weatherford Hospital Authority CAH371323-00 OK

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed at entity and 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 the 340B Program

Repayment to manufacturers

CAP approved CEO
(580) 772-5551 Ext: 750
dhowe@weatherfordhospital.com
or
Director of Pharmacy
(580) 772-5551 Ext: 747
msauer@weatherfordhospital.com
Weeks Medical Center CAH301303-00 NH No adverse findings None

N/A

Audit closure date: January 9, 2018

 
Wheaton Franciscan Healthcare – All Saints DSH520096 WI

 

Incorrect 340B database record – ineligible site registered on 340B database; Entity failed to remove duplicate registration for off-site outpatient facility.

 

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP approved Regional Director, 340B Pharmacy
(414) 874-6268
3801 Spring Street
Racine WI 53405
White Memorial Medical Center

DSH050103

CA

No adverse findings

None

N/A

Audit closure date: February 28, 2017

 
William Newton Memorial Hospital CAH171383-00 KS Diversion – 340B drugs dispensed at entity for inpatients; 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Director of Pharmacy
pharmacy@wnmh.org
620-222-6206
Women and Infants Hospital of Rhode Island

DSH410010

RI

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File

Repayment to manufacturers

CAP approved

340B Program Manager

401-921-7525

CNE Pharmacy

626 Toll Gate Road

Warwick, RI 02886

 

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

Date Last Reviewed:  September 2018