Program Integrity: FY18 Audit Results

Updated 4/10/19. 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 196 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

 
Abbott Northwestern Hospital DSH240057 MN Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File. None

CAP implemented

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

Audit closure date: February 13, 2019

Pharmacy Services Portfolio Manager
2925 Chicago Avenue
Mail Route 10807
Minneapolis, MN 55407
612-262-4785
Tony.collinskwong@allina.com
Adventist Health Lodi Memorial DSH050336 CA Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Pharmacy Director
975 S Fairmont Ave
Lodi, CA 95240
209-334-3411
AIDS Project of the East Bay STD946121 CA Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place; Incorrect entry for Primary Contact telephone number. Termination of four contract pharmacies from 340B Program CE self-terminated.  In order to re-enroll in the 340B Program, CE must submit a corrective action plan (CAP) addressing each of the findings outlined in the Final Report.

Audit closure date: January 23, 2019

 
Albert Einstein Medical Center DSH390142 PA No adverse findings None N/A

Audit closure date: July 31, 2018

 
Alcona Citizens for Health, Inc. CH051980 MI Incorrect 340B OPAIS record – Entity owned in-house pharmacies not listed as shipping addresses.

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

Repayment to manufacturers Pending  
Ampla Health CH090850 CA

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

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

Repayment to manufacturers CAP approved President and CEO
935 Market Street
Yuba City, CA 95991
530-751-3755
Appalachian Regional Healthcare Inc. DBA McDowell ARH Hospital CAH181331-00 KY No adverse findings None

N/A

Audit closure date: February 28, 2019

 
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 CAP approved President and Chief Executive Officer
Appalachian Regional Healthcare
130 Kate Ireland Drive
Hyden, KY 41749
859-226-2450
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  
Asian Health Services CH091030 CA Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration; Registered contract pharmacy without written contract in place.

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

Repayment to manufacturers

Termination of two contract pharmacies from 340B Program*

Pending  
Asian Human Services Family Health Center CH051827A IL Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Aspirus Ironwood Hospital CAH231333-00 MI Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to January 9, 2019. None Pending  
Avera Marshall DBA Avera Marshall Regional Medical Center CAH241359-00 MN No adverse findings None N/A

Audit closure date: January 16, 2018

 
Baptist Hospitals of Southeast Texas dba Baptist Beaumont Hospital DSH450346 TX Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

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

Repayment to manufacturers Pending  
Baylor Scott & White Medical Center - Irving DSH450079 TX Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.   Repayment to manufacturers CAP implemented

Audit closure date: April 2, 2019

Pharmacy Director System
4004 Worth Street, Suite 200
Dallas, Texas 75246
214-820-6810
Baystate Franklin Medical Center DSH220016 MA Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. 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

 
Billings Clinic DSH270004 MT Diversion – 340B drugs dispensed to inpatients. Repayment to manufacturers Pending  
Bradford Regional Medical Center DSH390118 PA Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufactures CAP approved Richard Braun
SVP Finance and CFO
130 South Union Street
Suite 300
Olean, NY 14760
716-375-6190
rbraun@uahs.org
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 CAP approved Chief Executive Officer
1 Healthcare Drive
Philippi, WV 26416
304-457-8155
Bronson Lakeview Hospital CAH231332-00 MI No adverse findings None N/A

Audit closure date: March 23, 2018
 

 
Broward Health Medical Center DSH100039 FL No adverse findings None N/A

Audit closure date: January 25, 2019

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

Audit closure date: June 22, 2018

 
California Hospital Medical Center DSH050149 CA Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 1, 2018.

Incorrect 340B OPAIS record - Incorrect entry for Primary Contact telephone number.

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 Director of Pharmacy
1401 S. Grand Ave
Los Angeles, CA 90015
213-742-5483
Camden – Clark Memorial Hospital DSH510058 WV No adverse findings None N/A

Audit closure date: June 29, 2018

 
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
 
Cape Fear Valley Medical Center DSH340028 NC

Incorrect 340B OPAIS record - Ineligible site registered on 340B OPAIS.

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

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

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

Repayment to manufacturers

CAP approved Director of Hospital Pharmacy
1638 Owen Drive
Fayetteville, NC 28304
910-615-6839
tnicholson@capefearvalley.com
Carrington Health Center CAH351318-00 ND No adverse findings None N/A

Audit closure date: July 19, 2018

 
Cavalier County Memorial Hospital CAH351323-00 ND Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.

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

Repayment to manufacturers CAP approved Director of Pharmacy
909 2nd Street
Langdon, ND 58249
701-256-6100
Centra Health, Inc. SCH490021-00 VA No adverse findings None

N/A

Audit closure date: September 10, 2018

 
Centracare Health – Paynesville Hospital CAH241349-00 MN Diversion - 340B drugs dispensed to inpatients.

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

Repayment to manufacturers CAP approved Todd Lemke
Pharmacist in Charge
200 First St W
Paynesville, MN 56362
320-243-7772
Central Vermont Medical Center SCH470001-00 VT Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.

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.

Repayment to manufacturers CAP approved Attention Department of Pharmacy
Director of Pharmacy
130 Fisher Road
Berlin, VT 05602
802-371-5938
Frank.Foti@CVMC.org
Children’s Health Care DBA Children’s Minnesota PED243302-00 MN Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP implemented

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

Audit closure date: January 8, 2019

 
Choctaw General Hospital CAH011304-00 AL No adverse findings None N/A

Audit closure date: September 10, 2018

 
Children’s Mercy Hospital, The PED263302-00 MO Incorrect 340B OPAIS record - Entity-owned pharmacies were not listed as shipping addresses. None CAP implemented

Audit closure date: September 21, 2018

 
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 implemented

Audit closure date: March 29, 2019

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

 
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  CAP implemented
Audit closure date: September 20, 2018
 
Community Health Center, Incorporated CH012080 CT Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS; Failed to remove duplicate registrations for offsite outpatient facilities; Registered contract pharmacies without written contract in place.

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 ineligible offsite outpatient facilities from the 340B Program*

Termination of two contract pharmacies from 340B Program*

Repayment to manufacturers

Pending  
Community Healthcare System, Inc. CAH171354-00 KS

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to August 14, 2018.

Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record.

Repayment to manufacturers 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.
 

CAP approved Director of Pharmacy
106 Blanca Ave.
Alamosa, Colorado 81101
719-587-1260
Lee.Hankins@slvrmc.org
Covenant Hospital – Plainview SCH450539-00 TX Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. 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 CAP implemented

Audit closure date: September 24, 2018

 
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 CAP approved Director of Support Services
Cumberland County Hospital
299 Glasgow Road
Burkesville, KY  42717
270-864-2511
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 CAP approved Chief Administrative Officer
323 South 18th Avenue
Sturgeon Bay, WI 54235
920-746-3737
Drew Memorial Hospital, Inc. DSH040051 AR Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place;   Entity did not provide contract pharmacy oversight.

Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drug dispensed to inpatient.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP approved Director of Pharmacy Services
Drew Memorial Health System
778 Scogin Drive
Monticello, AR 71655
870-460-3523
Drexel University College of Medicine/Hahnemann FP191021 PA Diversion - 340B drugs transferred to a separately registered covered entity. Repayment to manufacturers CAP approved Associate Vice Provost, Drexel 340B POC
215-895-6080
kdw38@drexel.edu

Principal Investigator and Director of Women’s Care Center
215-762-1720
sandra.wolf@drexelmed.edu

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 CAP approved Chief Executive Officer
1313 North Cheyenne Street
Benkelman, NE  69021-3074
308-423-2204
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

 
Fort Sanders Regional Medical Center RRC440125-00 TN

Incorrect 340B OPAIS record – Pharmacy incorrectly registered as child site.

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

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

Repayment to manufacturers Pending  
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 CAP implemented

Audit closure date: January 8, 2019

 
Georgetown Memorial Hospital DSH420020 SC No adverse findings None N/A

Audit closure date: December 7, 2018

 
Grand River Hospital District CAH061317-00 CO Incorrect 340B OPAIS record - Offsite outpatient facility was not listed on the 340B database. None CAP implemented

Audit closure date: September 24, 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 implemented

Audit closure date: August 28, 2018

RPH Director of Pharmacy
Gritman Medical Center, 700 South Main Street, Moscow, ID 83843
208-883-2236
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 CAP approved Pharmacy Manager, Procurement
720 Eskenazi Avenue
Indianapolis, IN 46202
317-880-4450
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 CAP implemented

Audit closure date: November 14, 2018

 
Holzer DSH360054 OH Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS.

Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.

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

Repayment to manufacturers

CAP approved

340B Compliance Analyst
100 Jackson Pike
Gallipolis, Ohio  45631
740-446-5803
mclemente@holzer.org

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

 

 
Housing Works Health Services III, Inc. CHC26191-00 NY No adverse findings None N/A

Audit closure date: October 5, 2018

 
Hyacinth Foundation RWI07107 NJ Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site. Repayment to manufacturers CAP implemented

Audit closure date: March 13, 2019

Senior Director of Program Development
317 George Street, Suite 203
New Brunswick, New Jersey 08901
732-246-0204
jriccardi@hyacinth.org
Inland Hospital DSH200041 ME No adverse findings None N/A

Audit closure date: December 11, 2018

 
Jane Pauley Community Health Center, Inc. CHC26566-00 IN No adverse findings None N/A

Audit closure date: January 11, 2018

 
Jessie Trice Community Health System, Inc. CH040330 FL Entity did not provide contract pharmacy oversight prior to August 24, 2018.

Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facility names.

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

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

Repayment to manufacturers Pending  
Johnson City Medical Center DSH440063 TN Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Corporate Pharmacy Business
Director
2 Professional Park Drive
Suite 15
Johnson City, TN 37604
423-302-3535
cindy.tucker@balladhealth.org
Kalispell Regional Medical Center SCH270051-00 MT Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS.

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

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

CAP approved Pharmacy Analyst
310 Sunnyview Lane
Kalispell, MT 59901
406-751-6560
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 CAP approved Business Manager
2003 Kootenai Health Way
Coeur d'Alene, ID 83814
208-625-5651
tchapman@kh.org
Lake District Hospital CAH381309-00 OR Diversion - 340B drug dispensed at contract pharmacy, not supported by a medical record. 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 implemented

Audit closure date: March 29, 2019

Chief Financial Officer
7785 North State Street
Lowville, NY 13367
315-376-5597
Lincoln Community Health Center, Inc. CH040910 NC Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts. None

Pending

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

 
Lincoln County Hospital CAH171360-00 KS Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Chief Financial Officer
Lincoln County Hospital, 624 N. 2nd, Lincoln, Kansas 67455
785-524-4030 ext. 212
Lincoln Health (formerly St. Andrews Hospital) CAH201302-00 ME 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 Pending  
Little Falls Hospital CAH331311-00 NY Diversion - 340B drugs dispensed to inpatients Repayment to manufacturers Pending  
Livingston Hospital and Healthcare Services, Inc. CAH181320-00 KY Incorrect 340B OPAIS Record – Incorrect entry for Primary Contact. None CAP implemented

Audit closure date: April 3, 2019

 
Loma Linda University Medical Center DSH050327 CA Duplicate Discounts -Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP implemented Executive Director of Pharmacy
11234 Anderson Street
Loma Linda, CA 92354
909-558-4497
agobin@llu.edu
MaineGeneral Medical Center DSH200039 ME No adverse findings None N/A

Audit closure date: December 7, 2018

 
Maricopa Medical Center DSH030022 AZ Incorrect 340B OPAIS record - ineligible site registered on 340B OPAIS; Registered contract pharmacy without written contract in place.

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

Termination of one ineligible offsite outpatient facility from the 340B Program*

Termination of one contract pharmacy from 340B Program*

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

CAP implemented

Audit closure date: November 2, 2018

 
Mayview Community Health Center, Inc. FQHCLA263 CA No adverse findings None N/A

Audit closure date: February 15, 2018
 

 
McCulloch County Hospital District DBA Heart of Texas Healthcare System CAH451348-00 TX No adverse findings None N/A

Audit closure date: December 19, 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

 
Medical Center Hospital DSH450132 TX

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

Diversion –340B drug dispensed to an inpatient.

Termination of one contract pharmacy from 340B Program.

Repayment to manufacturer.

CAP approved 340B Coordinator
500 West 4th Street
Odessa, TX 79761
432-640-2294
Medical Center of Central Georgia DSH110107 GA Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites.

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

Repayment to manufacturers CAP approved Department of Pharmacy Services-MSC 113
Medical Center-Navicent Health
777 Hemlock Street
Macon, GA 31201
478-633-1429
478-796-4890
Memorial Health Care Systems DBA Memorial Hospital CAH281339-00 NE No adverse findings None N/A

Audit closure date: October 24, 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 CAP approved Pharmacy Tech
520 Medical Drive
Guymon, OK 73942
580-338-3113 ext 2261
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
3500 W. Wheatland Rd.
Dallas, TX 75237
214-947-7581
Mid-Valley Healthcare Inc. DBA Samaritan Lebanon Community Hospital CAH381323-00 OR 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

CAP implemented

Audit closure date: January 23, 2019

 
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

 
Morris Heights Health Center Inc. CH021610 NY Incorrect 340B OPAIS record - Offsite outpatient facility was not listed on the 340B OPAIS.

Duplicate Discounts - Entity’s contract pharmacies were billing Medicaid without notification to HRSA.

Repayment to manufacturers CAP approved Vice President Planning and Development
Morris Heights Health Center, Inc.
85 West Burnside Avenue
Bronx, New York  10453-4015
Morton Comprehensive Health CH063890 OK Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address; Registered contract pharmacies without written contract in place.

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

Termination of contract pharmacy from 340B Program. CAP approved

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

 
Mountainview Medical Center CAH271306-00 MT 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 Pending  
Neighborhood Healthcare CH093540 CA Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP implemented

Audit closure date: January 29, 2019

Senior Financial Analyst
425 North Date Street
Escondido, CA 92025
760-737-6905
New York – Presbyterian / Queens DSH330055 NY Incorrect 340B database record - ineligible site registered on 340B database. None CAP implemented

Audit closure date: November 7, 2018

 
North Central Bronx Hospital Center (NYCHHC) DSH330385 NY No adverse findings None N/A

Audit closure date: December 11, 2018

 
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 CAP approved Chief Quality Officer
PO Box 92
Ashland, MS 38603
662-502-3156
North Valley Hospital CAH271336-00 MT

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 Director
1600 Hospital Way
Whitefish, MT  59937-2990
406-863-3510
Northern Maine Medical Center SCH200052-00 ME Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.

Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at contract pharmacy for prescriptions written at an ineligible site.

Repayment to manufacturers CAP approved Chief Financial Officer
Northern Maine Medical Center
194 East Main Street
Fort Kent, ME  04743
207-834-1820
NYU Langone Hospitals DSH330214 NY Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
OhioHealth Corporation DBA Doctors Hospital DSH360152 OH Diversion – 340B drug dispensed at contract pharmacy for prescription written at ineligible site.

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

 
Palmetto Health Baptist DSH420086 SC Diversion - 340B drugs were not properly accumulated. Repayment to manufacturers Pending  
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 CAP approved 340B Program Supervisor
P.O. Box 5600
Fort Wayne, IN 46895
260-266-4408
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.
 

 
Paulding County Hospital CAH361300-00 OH

Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers Pending  
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 implemented

Audit closure date: March 7, 2019

Director of Pharmacy
PeaceHealth St Joseph Medical Center
2901 Squalicum Parkway
Bellingham, WA  98225
360-788-6022

Peak Vista Community Health Centers CH081460 CO Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP implemented

Audit closure date: October 5, 2018

Pharmacy Director
719-344-6269
preilly@peakvista.org
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 CAP approved Director of Pharmacy
Penn Presbyterian Medical Center
51 North 39th Street
Philadelphia PA 19104
215-662-8213
Pennsylvania Hospital, The DSH390226 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 CAP approved Suzanne Brown
Director of Pharmacy Services
Pennsylvania Hospital
800 Spruce St.
Philadelphia, PA 19107
215-829-5847
Phoebe Putney Memorial Hospital DSH110007 GA Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Piedmont Mountainside Hospital, Inc. DSH110225 GA Inaccurate or incomplete information in Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of this finding. None CAP implemented

Audit closure date: December 31, 2018

 
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.

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP approved VP of Clinical Services
Planned Parenthood Association of Utah
654 South 900 East
Salt Lake City, UT 84102
801-532-1586
Penny.davies@ppau.org
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 CAP approved Director of Pharmacy
Pomona Valley Hospital Medical Center
1798 Noth Garey Avenue
Pomona, CA 91767
909-865-9501
Positive Impact Health Centers, Inc. RWI30309 GA Diversion – 340B drugs dispensed at entity and 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 Pending  
Prairie Ridge Hospital and Health Services CAH241379-00 MN

Diversion – 340B drug dispensed at contract pharmacy for prescription written at ineligible site; 340B drug dispensed at contract pharmacy, not supported by a medical record.

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

Repayment to manufacturers Pending  
Presbyterian Hospital dba Novant Health Presbyterian Medical Center DSH340053 NC Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved 340B Supervisor
3334 Healy Drive
Winston-Salem, NC 27103
336-277-0301
echansen@novanthealth.org
Providence Hood River Memorial Hospital CAH381318-00 OR No adverse findings None N/A

Audit closure date: December 27, 2018

 
Providence St. Joseph’s Hospital of Chewelah CAH501309-00 WA No adverse findings None

N/A

Audit closure date: September 19, 2018

 
Providence St. Vincent Medical Center DSH380004 OR No adverse findings None N/A

Audit closure date: October 2, 2018

 
Public Hospital District No 1-A DBA Pullman Regional Hospital CAH501331-00 WA 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 Chief Financial Officer
835 SE Bishop Blvd
Pullman, WA 99163​
877-446-0473
steve.febus@pullmanregional.org
Regional Health Sturgis Hospital CAH431321-00 SD No adverse findings None N/A

Audit closure date: June 14, 2018

 
Rhode Island Hospital DSH410007 RI Diversion - 340B drug dispensed at contract pharmacy for prescription written at ineligible site. Repayment to manufacturers Pending  
Richardson Medical Center DSH190151 LA Diversion –340B drugs dispensed to inpatients; 340B drugs were not properly accumulated.

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

Repayment to manufacturers CAP approved Director of Pharmacy
Richardson Medical Center
254 Hwy 3048
Rayville, LA 71269
318-728-8352
reneec@richardsonmed.org
Riverside Regional Medical Center DSH490052 VA Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. 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 CAP implemented

Audit closure date: April 2, 2019

Director of Inpatient Pharmacy
Ronald Reagan UCLA Medical Center
757 Westwood Plaza Room B531
Los Angeles, CA 90095
310-267-8503
Rumford Hospital CAH201306-00 ME No adverse findings None N/A

Audit closure date: December 12, 2018

 
Rural Health Group, Inc. CH046680 NC Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP implemented

Audit closure date: December 21, 2018

Pharmacy Director
Rural Health Group, Inc.
252-536-5885
dawn.rush@rhgnc.org
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

 
Salem Township Hospital CAH141345-00 IL Diversion - 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.

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

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

Repayment to manufacturers CAP approved Chief Executive Officer 
1201 Ricker Drive
Salem, IL 62881-4263
618-548-3194
San Miguel County Department of Health and Environment FP814352 CO Incorrect 340B OPAIS record - Incorrect entry for billing address; Incorrect entry for grant number.

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

Repayment to manufacturers CAP implemented Director, San Miguel County Department of Health and Environment
PO Box 949, 333 West Colorado Ave.
Telluride, CO  81435-00949
970-728-4289
Sanford Medical Center Luverne CAH241371-00 MN Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers Pending  
Sanford Worthington Medical Center DSH240022 MN No adverse findings None N/A

Audit closure date: January 23, 2018

 
SC DHEC Lowcountry Region Charleston County North Area FP FP294055 SC No adverse finding None N/A

Audit closure date: November 15, 2018

 
Scott and White Memorial Hospital DSH450054 TX Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 4, 2018.

Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; - Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to include entity owned pharmacies as shipping addresses.

Diversion –340B drug dispensed to an inpatient.

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

Repayment to manufacturers

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

Pending  
Scott Regional Hospital CAH251323-00 MS Diversion - 340B drugs were not properly accumulated. Repayment to manufacturers

CAP implemented

Audit closure date: December 20, 2018

Compliance Officer
Scott Regional Hospital
317 Highway 13 South
Morton, MS 39117
601-703-4437
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 CAP approved  
Seattle Children’s Hospital PED503300-00 WA Incorrect 340B OPAIS record - Incorrect entry for off-site outpatient facility billing address.

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

Repayment to manufacturers CAP approved Director, Pharmacy Operations
Mail: M/S MB. 420
PO Box 5371
Seattle, WA 98145
506-978-6170
Shady Grove Adventist Hospital DSH210057 MD Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Rockville Campus Director of Pharmacy
9901 Medical Center Drive
Rockville, MD  28050
240-826-6156
Shelby Co Chris A Myrtue Memorial Hospital CAH161374-00 IA Diversion - 340B drugs dispensed at contract pharmacies, not supported by a medical record. Repayment to manufacturers CAP approved 340B Coordinator
1213 Garfield Avenue
Harlan, IA 51537
712-755-4411
Shenandoah Medical Center CAH161366-00 IA No adverse findings None N/A

Audit closure date: January 31, 2018

 
Skagit Valley Hospital DSH500003 WA Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites.

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

Repayment to manufacturers CAP approved 340B Coordinator
Skagit Valley Hospital
1415 East Kincaid Street
Mount Vernon, WA 98274
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
711 Onyx Street
Kemmerer, WY 83101
307-877-5574
Southeast Health Medical Center DSH010001 AL Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to June 6, 2018.

Diversion - 340B drug dispensed to an inpatient; 340B drugs dispensed at entity for prescriptions written at ineligible sites.

Repayment to manufacturers CAP approved 340B Program Coordinator
1108 Ross Clark Circle
Dothan, AL 36301
334-793-8113
Southeast Community Health Systems CH063710 LA Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved 340B Coordinator
Skagit Valley Hospital
1415 East Kincaid Street
Mount Vernon, WA 98274
Spectrum Health Big Rapids Hospital SCH230093-00 MI Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place; Hospital classification on OPAIS was inconsistent with eligibility documents prior to September 7, 2018. Termination of three contract pharmacies from 340B Program* CAP implemented

Audit closure date: February 28, 2019

 
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 CAP approved Chief Financial Officer
1025 E. 32nd Street
Austin, TX 78705
512-544-5030
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 CAP approved Divisional Director
Clinical Ancillary Operations
309 Jackson St.
Monroe, LA 71201
318-966-4957
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. Luke’s Hospital of Duluth DSH240047 MN Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facilities’ addresses.

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

Repayment to manufacturers CAP approved Vice President/CFO
915 East First Street
Duluth, MN  55805-2107
218-249-5475
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 CAP approved  
St. Luke’s Wood River Medical Center CAH131323-00 ID No adverse findings None N/A

Audit closure date: October 15, 2018

 
Sunset Park Health Council, Inc. CH0218870 NY Duplicate Discounts - Incorrect 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  
Sutter Bay Hospital DBA Alta Bates Summit Medical Center DSH050043 CA Incorrect 340B OPAIS record -  Ineligible site registered on 340B OPAIS; Incorrect entry for off-site outpatient facility address; Incorrect entry for billing address; Incorrect entry for authorizing official telephone number. None Pending  
Swedish Medical Center DSH500027 WA Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities. None Pending  
Tarrant County Hospital District, John Peter Smith Hospital DSH450039 TX Incorrect 340B OPAIS record - Incorrect entries for name and address of offsite outpatient location.

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

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  
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 CAP implemented

Audit closure date: March 29, 2019

Chief Administrative and Financial Officer
Three Rivers Medical Center
500 SW Ramsey Avenue
Grants Pass, Oregon 97527
541-789- 4549
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 CAP approved Chief Executive Officer
Tyrone Hospital
187 Hospital Drive
Tyrone, PA 16686
814-684-1255, ext 2101
UCSF - Medical Center DSH050454 CA Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place;

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

Termination of three contract pharmacies from 340B Program

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 CAP approved Robert Pert,
Chief Financial Officer
1617 11th Street
Wichita Falls, TX 76301
940-764-3023
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 implemented

Audit closure date: March 13, 2019

Vice President & Corporate Controller
3605 Warrensville Center Rd.
Room: 1110 Mail Stop: MSC8100
Shaker Heights, OH 44122-5203
216-767-8729
Michael.Vehovec@UHhospitals.org
Urban Health Plan, Inc. CH023600 NY Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File Repayment to manufacturers Pending  
USC Norris Cancer Hospital CAN050660-00 CA Incorrect 340B OPAIS record - Incorrect entry for address None CAP implemented

Audit closure date: July 18, 2018

 
Virginia Commonwealth University Health System DSH490032 VA No adverse findings None

 N/A

Audit closure date: October 17, 2018

 
Waikiki Health CH092060 HI Incorrect 340B OPAIS record – Incorrect entry for entity name; incorrect entry for primary contact information. None CAP approved  
Wakemed DSH340069 NC Diversion - 340B drugs dispensed at entity for prescription written at an ineligible site. Repayment to manufacturers CAP approved Executive Director of Clinical Services
919-350-8021
vbarlow@wakemed.org
West Allis Memorial Hospital Inc. DBA Aurora West Allis Medical Center DSH520139 WI Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. 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
CAP approved Chief Financial Officer
10300 Compton Ave.
Los Angeles, CA 90002
323-568-3093
Westchester Medical Center DSH330234 NY Incorrect 340B OPAIS record - ineligible site registered on 340B OPAIS; Incorrect entry for offsite outpatient location zip code. Termination of ineligible offsite outpatient facility from the 340B Program* 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
 

 
Yuma Regional Medical Center DSH030013 AZ Diversion - 340B drugs dispensed at contract pharmacy for a prescriptions written at ineligible site.

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

Repayment to manufacturers CAP approved 340B Program Manager
2400 S Avenue A
Yuma, AZ 85364
928-336-7721

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

Date Last Reviewed:  April 2019