Program Integrity: FY19 Audit Results

Updated 1/28/20. 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 157 audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
Abbeville County Memorial Hospital CAH421301-00 SC No adverse findings None N/A

Audit closure date: October 4, 2019

 
Adams County Memorial Hospital dba Adams Memorial Hospital CAH151330-00 IN Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place prior to January 25, 2019. None

CAP implemented

Audit closure date: April 24, 2019

 
Alamance Regional Medical Center DSH340070 NC No adverse findings None N/A

Audit closure date: October 1, 2019

 
Albany Medical Center Hospital DSH330013 NY No adverse findings None N/A

Audit closure date: December 20, 2019

 
Ammonoosuc Community Health Services Inc. CH010980 NH No adverse findings None

N/A

Audit closure date: March 7, 2019

 

Aroostook Medical Center, The DSH200018 ME No adverse findings None N/A

Audit closure date: December 6, 2019

 
Athens-Limestone DSH010079 AL Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

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

Repayment to manufacturers CAP approved Chief Financial Officer
700 West Market Street
Athens, AL 35611
256-233-9172
Baptist Health DSH100093 FL 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.

Repayment to manufacturers Pending  
Baptist Health Medical Center – LR DSH040114 AR Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP approved

State Medicaid has since determined duplicate discounts did not occur.

 
Barnesville Hospital Association, Inc. CAH361321-00 OH No adverse findings None N/A

Audit closure date: May 9, 2019

 
Beaufort-Jasper-Hampton Comprehensive Health Services, Incorporated CH041190 SC

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for address for offsite outpatient facility.

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

Repayment to manufacturers CAP approved 340B Program Coordinator
721 Okatie Highway
Ridgeland, SC 29936
843-987-7545
Big Springs Medical Association, Inc. CH070430 MO Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved CEO
110 South Second Street
Ellington, MO 63638
573-663-2313
kwhite@mohigh.org
Brattleboro Memorial Hospital DSH470011 VT No adverse findings None N/A

Audit closure date: July 9, 2019

 
Bridgeport Hospital DSH070010 CT No adverse findings None N/A

Audit closure date: October 1, 2019

 
BronxCare Health System Fulton Division DSH330009 NY Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS;  Failed to remove duplicate registration for offsite outpatient facility.

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  
Cambridge Memorial Hospital, Inc. DBA Tri Valley Health System CAH281348-00 NE No adverse findings None N/A

Audit closure date: August 27, 2019

 
CAN Community Health, Inc. STD342372 FL No adverse findings None N/A

Audit closure date: January 7, 2020

 
Caring Health Center, Inc. CH01084B MA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None

CAP approved

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

 
Carthage Area Hospital Inc. CAH331318-00 NY No adverse findings None N/A

Audit closure date: December 6, 2019

 
Cass Regional Medical Center CAH261324-00 MO No adverse findings None N/A

Audit closure date: May 29, 2019

 
Centro San Vicente CH066580 TX Diversion - 340B drug dispensed at contract pharmacy for prescription 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
8061 Alameda Ave, El Paso, TX 79915
915-859-7545 ext. 1214
Chambers Memorial Hospital SCH040011-00 AR Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved 340B Administrator, 479-495-6264
PO Box 639, Danville, AR 72833
jeffreywoods@chambershospital.com
Children’s National Medical Center PED093300-00 DC Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Chief of Pharmacy
111 Michigan Avenue, NW, Washington, DC 20010
202-476-5553
Christus St. Michael DSH450801 TX Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration.

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

Repayment to manufacturers CAP approved Michael French, J.D.
Senior Consultant
19065 Hickory Creek Dr., Suite 115
Mokena, IL 60448
708-478-7030
Clara Maass Medical Center DSH310009 NJ No adverse findings None N/A

Audit closure date: December 17, 2019

 
Community Health Center of Central Wyoming, Inc. CH086120 WY Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP implemented

Audit closure date: October 31, 2019

Director of Pharmacy
jbeattie@chccw.org
(307) 233-6050
Community Memorial Hospital, Inc. CAH331316-00 NY No adverse findings None N/A

Audit closure date: December 10, 2019

 
Complete Care Community Health Center, Inc. CHC28987-00 CA No adverse findings None N/A

Audit closure date: November 29, 2019

 
Coquille Indian Tribe FQHC638532 OR Diversion - 340B drugs dispensed at covered entity and at contract pharmacy, not supported by a medical record.

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

Repayment to manufacturers Pending  
Delaware Valley Hospital, Inc. CAH331312-00 NY No adverse findings None N/A

Audit closure date: June 26, 2019

 
D. W. McMillan Memorial Hospital DSH010099 AL No adverse findings None

N/A

Audit closure date: January 17, 2019

 
District of Columbia Department of Health HIV/AIDS, Hepatitis, STD & TB Administration RWIID72 DC No adverse findings None N/A

Audit closure date: April 12, 2019

 
Duke University Hospital DSH340030 NC Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS. None

CAP implemented

Audit closure date: December 18, 2019

 
East Bay Community Action Program CH015160 RI Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Administative Assistant Health Administration
East Bay Community Action Program, 100 Bullocks Point Avenue, Riverside, RI  02915
401-437-1008
Ellis Hospital DSH330153 NY Diversion – 340B drug dispensed to inpatient Repayment to manufacturers Pending  
Ellsworth Municipal Hospital CAH161380-00 IA No adverse findings None N/A

Audit closure date: July 9, 2019

 
Exempla Saint Joseph Hospital DSH060028 CO No adverse findings None N/A

Audit closure date: May 3, 2019

 
Fairview Hospital CAH221302-00 MA No adverse findings None N/A

Audit closure date: March 13, 2019

 
Faxton St. Luke’s Healthcare DSH330044 NY No adverse findings None N/A

Audit closure date: June 17, 2019

 
Ferrell Hospital Community dba Ferrell Hospital Community Foundation CAH141324-00 IL Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Director of Pharmacy/340B primary contact
Ferrell Hospital
1201 Pine Street
Eldorado, IL 62930
618-297-9627
Freeman Regional Health Services CAH431313-00 SD No adverse findings None N/A

Audit closure date: August 28, 2019

 
G.A. Carmichael Family Health Center, Inc. CH040760 MS Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove a duplicate registration of a contract pharmacy;

Diversion - 340B drug dispensed at contract pharmacy, not supported by a medical record.

Repayment to manufacturers CAP approved Chief Financial Officer, 1668 W. Peace Street, Canton, MS 39046
270-245-7239
Galion Community Hospital CAH361325-00 OH Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None Pending  
Georgetown University Hospital DSH090004 DC Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved 340B Compliance Specialist,
MedStar Georgetown University Hospital,
3800 Reservoir Road
Washington DC 20007
thanhson.t.doan@gunet.georgetown.edu 202-444-0556
Gerald Champion Regional Medical Center DSH320004 NM Covered outpatient drugs obtained through a Group Purchasing Organization prior to July 1, 2019.

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

Diversion - 340B drug dispensed at contract pharmacy for prescriptions written at ineligible site.

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

Repayment to manufacturers Pending  
GHS Laurens County Memorial Hospital SCH420038 SC No adverse findings None N/A

Audit closure date: October 10, 2019

 
Golden Valley Health Centers CH090470 CA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File Repayment to manufacturers CAP approved Accounting Manager, Primary Contact
1910 Customer Care Way, Atwater, CA 95301
209-384-6524
Gonzales Healthcare Systems DSH450235 TX Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Duplicate Discounts – Entity did not have adequate controls to prevent duplicate discounts.

Repayment to manufacturers CAP approved

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

Compliance Officer GHS, P.O. Box 587, Gonzales, Texas 78629
830-672-7581 ext 1011
Good Samaritan Regional Health Center RRC140046-00 IL

Incorrect 340B OPAIS Record – Incorrect entry for Primary Contact.

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

None

CAP approved

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

Finance Director
1195 Corporate Lake Drive
St Louis, MO 63132
314-989-3532
jeff.peine@ssmhealth.com
Graham Hospital Association SCH140001-00 IL Incorrect 340B OPAIS Record – Incorrect entry for Primary Contact.

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

None CAP approved

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

 
Halifax Regional Medical Center DSH340151 NC Duplicate Discounts – Entity did not have adequate controls to prevent duplicate discounts. Repayment to manufacturers CAP approved Patient Financial Services Manager
250 Smith Church Road
Roanoke Rapids, NC  27870
252-535-8147
cferebee@halifaxmrc.org
Harbor Beach Community Hospital, Inc. CAH231313-00 MI Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved

Scott Rayl, Pharmacist 989-479-3201 x351
210 S. First Street, Harbor Beach, MI 48441

Hartford Hospital DSH070025 CT No adverse findings None N/A

Audit closure date: August 7, 2019

 
Healdsburg District Hospital CAH051321-00 CA Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

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

Repayment to manufacturers CAP approved Chief Financial Officer
1375 University Ave. Healdsburg, CA 95448
707-385-2022
staj@nschd.org
Higgins General Hospital CAH111320-00 GA Diversion – 340B drug dispensed to inpatient. Repayment to manufacturers CAP approved Director of Pharmacy
705 Dixie Street
Carrollton, GA 30117
770‐836‐9646
Highland Community Hospital DSH250117 MS No adverse findings None N/A

Audit closure date: May 14, 2019

 
Highlands Hospital DSH390184 PA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP approved

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

 
Holdenville Hospital Authority CAH371321-00 OK Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File. Repayment to manufacturers CAP approved CEO/Administrator
100 McDougal Drive
Holdenville, OK 74848
405-379-4287
Hospital Authority of Randolph County DBA Southwest Georgia Regional Medical Center CAH111300-00 GA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Chief Financial Officer
361 Randolph St., Cuthbert, GA 39840
229-777-4506
Hospital Service District 1A, Parish of Richland, State of Louisiana DBA Richland Parish Hospital CAH191323-00 LA No adverse findings None N/A

Audit closure date: March 29, 2019

 
Huggins Hospital CAH301312-00 NH Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File. Repayment to manufacturers Pending  
Huron Memorial Hospital DSH230118 MI Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place;

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

Termination of contract pharmacy from 340B Program CAP approved Director of Finance
1100 S. Van Dyke, Bad Axe MI, 48413
989-269-1510
Ida County Iowa Community Hospital dba Horn Memorial Hospital CAH161354-00 IA Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites Repayment to manufacturers CAP approved Chief Financial Officer
701 E 2nd St, Ida Grove, IA, 51445 or CFO of Horn Memorial Hospital
712-364-3311
IHC Health Services, Inc. dba Primary Children’s Hospital PED463301-00 UT No adverse findings None N/A

Audit closure date: November 26, 2019

 
Iowa Lutheran Hospital DSH160024 IA No adverse findings None N/A

Audit closure date: June 21, 2019

 
John C. Lincoln Medical Center DSH030014 AZ No adverse findings None N/A

Audit closure date: May 17, 2019

 
Johnston Health Services Corporation DSH340090 NC No adverse findings None N/A

Audit closure date: April 24, 2019

 
Kearney County Health Services CAH281306-00 NE No adverse findings None N/A

Audit closure date: October 1, 2019

 
Keck Hospital of USC DSH050696 CA Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None CAP approved  
Kern Medical Center DSH050315 CA Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.
Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.
Repayment to manufacturers CAP approved Associate Director of Pharmacy
Kern Medical Center
1700 Mount Vernon Avenue
Bakersfield, CA 93306
(661) 326-2617
Kossuth Regional Health Center CAH161353-00 IA No adverse findings None N/A

Audit closure date: June 19, 2019

 
Lake Regional Health System SCH260186-00 MO Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Primary Contact 340B Program
Lake Regional Health System
54 Hospital Drive
Osage Beach, MO  65065
573-348-8190
Lavaca Medical Center CAH451376-00 TX Duplicate Discounts – Entity did not have adequate controls in place to prevent duplicate discounts. Repayment to manufacturers CAP approved Chief Financial Officer
Lavaca Medical Center 1400 N. Texana Hallettsville, TX 77964 361-798-3671
Legacy Mount Hood Medical Center DSH380025 OR No adverse findings None

N/A

Audit closure date: January 9, 2019

 
Lexington Memorial Hospital, Inc. DSH340096 NC Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Pharmacy System Manager, 340B
Medical Center Blvd
Winston-Salem, NC 27157
336-713-3426
Liberty Regional Medical Center CAH111335-00 GA No adverse findings None N/A

Audit closure date: October 1, 2019

 
Lonesome Pine Hospital DSH490114 VA No adverse findings None

N/A

Audit closure date: March 8, 2019

 
Lost Rivers District Hospital CAH131324-00 ID No adverse findings None

N/A

Audit closure date: February 15, 2019

 
Lowell General Hospital, The DSH220063 MA No adverse findings None N/A

Audit closure date: October 31, 2019

 
Lutheran Medical Center DSH060009 CO No adverse findings None N/A

Audit closure date: October 7, 2019

 
Lynn County Hospital CAH451351-00 TX No adverse findings None N/A

Audit closure date: May 14, 2019

 
Marshall Hospital DSH050254 CA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP implemented

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

Audit closure date: November 20, 2019

 
Mary Bridge Children’s Hospital and Health Center PED503301-00 WA Covered outpatient drugs obtained through a Group Purchasing Organization prior to September 26, 2019.

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

Repayment to manufacturers Pending  
Mason General Hospital CAH501336-00 WA No adverse findings None N/A

Audit closure date: June 6, 2019

 
Massac County Hospital District CAH141323-00 IL Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place. Termination of contract pharmacy from 340B Program* CAP implemented

Audit closure date: October 31, 2019

 
McCloud Healthcare Clinic, Inc CHC24112-00 CA Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place. Termination of contract pharmacies from 340B Program* CAP approved  
Memorial Hospital dba Memorial Healthcare, The DSH230121 MI Incorrect 340B OPAIS record - Incorrect entry for address for an offsite outpatient facility; Failed to remove duplicate registration for contract pharmacy.

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 340B Manager
826 W. King Street, Owosso, MI 48867
989-729-4793
MedStar Washington Hospital Center DSH090011 DC No adverse findings None N/A

Audit closure date: October 24, 2019

 
Memorial Hospital of Boscobel CAH521344-00 WI Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site. Repayment to manufacturers CAP approved Pharmacy Director MHB
205 Parker Street, Boscobel, WI 53805
608-375-6307
Missouri Baptist Hospital of Sullivan dba Missouri Baptist Sullivan Hospital CAH261337-00 MO No adverse findings None N/A

Audit closure date: June 27, 2019

 
Mercy Health Lourdes Hospital LLC RRC180102-00 KY No adverse findings None N/A

Audit closure date: May 24, 2019

 
MGH Chelsea Student Health Center FP021501 MA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Director, MGH Community Health Associates
300 Ocean Avenue 5th Floor, Revere, MA 02151
781-485-6135
aduffy-keane@partners.org
Montefiore Nyack Hospital DSH330104 NY No adverse findings None N/A

Audit closure date: June 12, 2019

 
Mosaic Medical CH105600 OR Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facility names and addresses.

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

Repayment to manufacturers Pending  
Nanticoke Memorial Hospital DSH080006 DE No adverse findings None N/A

Audit closure date: June 12, 2019

 
Nationwide Children’s Hospital PED363305-00 OH No adverse findings None N/A

Audit closure date: October 1, 2019

 
Oakwood Healthcare Inc. dba Beaumont Hospital - Taylor DSH230270 MI No adverse findings None N/A

Audit closure date: August 26, 2019

 
Ohio State University Hospital, The DSH360085 OH No adverse findings None N/A

Audit closure date: June 6, 2019

 
Oneida Healthcare Center DSH330115 NY No adverse findings None N/A

Audit closure date: November 1, 2019

 
Open Door Health Services, Inc. CH0510700 IN Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File Repayment to manufacturers CAP approved Compliance Officer
PO Box 1676 Muncie, IN 47308
765-747-2973
Ozarks Resource Group CHC24137-00 MO Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File Repayment to manufacturers

CAP implemented

Audit closure date: December 10, 2019

Chief Executive Officer or Chief Financial Officer
PO Box 125, Hermitage, MO 65668
417-745-0103
Pediatric & Family Medical Center CH0921340 CA Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding None Pending  
Pender Community Hospital CAH281349-00 NE No adverse findings None N/A

Audit closure date: December 4, 2019

 
Peninsula Community Health Services CH101540 WA No adverse findings None N/A

Audit closure date: October 1, 2019

 
Phelps Memorial Hospital Center DSH330261 NY No adverse findings None N/A

Audit closure date: November 20, 2019

 
Piedmont Henry Hospital, Inc. DSH110191 GA No adverse findings None N/A

Audit closure date: November 19, 2019

 
Piedmont Newnan Hospital, Inc. DSH110229 GA No adverse findings None

N/A

Audit closure date: February 4, 2019

 
Piggott Community Hospital CAH041330-00 AR No adverse findings None N/A

Audit closure date: May 16, 2019

 
Pikeville Medical Center, Inc. DSH180044 KY No adverse findings None N/A

Audit closure date: March 13, 2019

 
Planned Parenthood of the Rocky Mountains, Inc. STD80203 CO No adverse findings None N/A

Audit closure date: December 17, 2019

 
Providence Portland Medical Center DSH380061 OR No adverse findings None N/A

Audit closure date: May 23, 2019

 
Rancho Los Amigos National Rehabilitation Center DSH050717 CA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None

Pending

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

Audit closure date: September 18, 2019

 
Range Regional Health Services DSH240040 MN No adverse findings None N/A

Audit closure date: October 8, 2019

 
Regional Health Care Affiliates, Inc. CHC17157-00 KY Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site.

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: August 20, 2019

CPO
121 E. Main St. Providence, KY 42450
270-667-7017
Regional Health Custer Hospital CAH431323-00 SD No adverse findings None

N/A

Audit closure date March 7, 2019

 
Renown Regional Medical Center DSH290001 NV No adverse findings None N/A

Audit closure date: November 21, 2019

 
Sacred Heart Hospital DSH390197 PA No adverse findings None N/A

Audit closure date: August 28, 2019

 
San Bernardino Mountains Community Hospital District CAH051312-00 CA No adverse findings None N/A

Audit closure date: August 27, 2019

 
Sanford Bismarck DSH350015 ND No adverse findings None

N/A

Audit closure date: January 16, 2019

 
Sanford Health Westbrook Medical Center CAH241302-00 MN No adverse findings None

N/A

Audit closure date: January 25, 2019

 
Sierra View Medical Center DSH050261 CA Incorrect 340B OPAIS record - Incorrect entries for addresses for offsite outpatient facilities.

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

None CAP approved

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

 
Someone Cares, Inc. of Atlanta Early Detection Intervention Clinic STD303036 GA Incorrect 340B OPAIS record – Registered contract pharmacy without written contract in place; Incorrect grant number entry.

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP approved Chief Executive Officer
236 Forsyth Street, SW, Ste. 201
Atlanta, Georgia 30303-3700
678-921-2706 Ext: 3
South Central Kansas Regional Medical Center SCH170150-00 KS No adverse findings None N/A

Audit closeout date: October 4, 2019

 
Southwest Health Center CAH521354-00 WI Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration; Registered contract pharmacy without written contract in place. Termination of contract pharmacies from 340B Program* CAP implemented

Audit closure date: June 25, 2019

 
Southwest Memorial Hospital CAH061327-00 CO No adverse findings None N/A

Audit closeout date: January 8, 2020

 
Sparrow Ionia Hospital CAH231331-00 MI Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.

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

Repayment to manufacturers Pending  
SSM St. Joseph Health Center DSH260005 MO Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; Failed to remove closed location registrations; Failed to remove duplicate registrations for offsite outpatient facilities. Termination of ineligible offsite outpatient facility from the 340B Program Pending  
St. Anthony Shawnee Hospital DSH370149 OK Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP approved

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

 
St. Charles Community Health Center, Inc. CH061335A LA No adverse findings None N/A

Audit closure date: June 6, 2019

 
St. Charles Health System, Inc. DBA St. Charles Bend DSH380047 OR No adverse findings None N/A

Audit closure date: August 28, 2019

 
St. Francis Hospital CAH231337-00 MI Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for address for an offsite outpatient facility.

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers CAP approved 340B Drug Program Manager
5901 West War Memorial Drive, Peoria, IL 61615
309-308-0413
St. Helena Hospital dba Adventist Health St. Helena DSH050013 CA. Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File Repayment to manufacturers    
St. Mary Medical Center DSH050191 CA Inaccurate or incomplete information on the Medicaid Exclusion File. None Pending  
St. Marys Healthcare DSH330047 NY Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place.

Duplicate Discounts – Inaccurate or incomplete information on 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*

 

CAP approved  
St. Vincent Healthcare DSH270049 MT No adverse findings None N/A

Audit closure date: December 4, 2019

 
Ste. Genevieve County Memorial Hospital CAH261330-00 MO No adverse findings None N/A

Audit closure date: October 1, 2019

 
St. Mary Medical Center DSH050300 CA Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entries for shipping address for offsite outpatient facilities.

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

None CAP approved

State Medicaid has since determined duplicate discounts did not occur.

 
Sturgis Hospital DSH230096 MI Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 30, 2019.

Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed at contract pharmacy for prescription written at ineligible sites.

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

Repayment to manufacturers CAP approved VP Quality Management & Support Services
916 Myrtle Avenue, Sturgis, MI 49091
269-659-4403
Texas Children’s Hospital PED453304-00 TX Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS;

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

Repayment to manufacturers CAP approved Texas Children’s Hospital 6621 Fannin Street, Suite WB1-120, Houston, TX 77030
832-824-6091
jlwagner@texaschildrens.org
Trinity Hospitals SCH350006-00 ND Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS. Termination of ineligible offsite outpatient facilities from the 340B Program*
Repayment to manufacturers
CAP approved

Audit closure date: April 30, 2019

 
UNM Sandoval Regional Medical Center DSH320089 NM No adverse findings None N/A

Audit closure date: October 24, 2019

 
Unity Care Northwest CHC08773-00 WA No adverse findings None N/A

Audit closure date: November 14, 2019

 
Unity Hospital of Rochester DSH330226 NY Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: September 26, 2019

 
University of Alabama Hospital DSH010033 AL Duplicate Discounts – Inaccurate or incomplete information on 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: August 27, 2019

 
University of Missouri Health Care DSH260141 MO Diversion - 340B drug dispensed at entity for a prescription written at an ineligible site. Repayment to manufacturers CAP approved Pharmacy Business Administrator –
340B Program
573-884-4614
simonsjp@health.missouri.edu
University of South Carolina RWII29203; RWII292030 SC Incorrect 340B OPAIS record - Failed to remove duplicate registration for service location. None CAP approved  
Washington County Hospital CAH161344-00 IA No adverse findings None

N/A

Audit closure date: February 5, 2019

 
Wellstar Cobb Hospital DSH110143 GA No adverse findings None N/A

Audit closure date: May 10, 2019

 
West Oakland Health Council, Inc. CH090540 CA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers Pending  
West Virginia Department of Health and Human Resources FP253015 WV Incorrect 340B OPAIS record – Incorrect entries for grant number. None CAP approved  
Western Missouri Medical Center SCH260097-00 MO No adverse findings None N/A

Audit closure date: October 1, 2019

 
West Holt Memorial Hospital CAH281343-00 NE No adverse findings None N/A

Audit closure date: December 31, 2019

 
Whatley Health Services, Inc. CH042450 AL Incorrect 340B OPAIS record - Failed to remove closed locations registration; Failed to remove duplicate registration for offsite outpatient facility; Incorrect entry for address for offsite outpatient facility; Registered contract pharmacies without written contract in place.

Diversion – 340B drugs dispensed at contract pharmacies, not supported by medical records; 340B drugs dispensed at entity for prescriptions written at ineligible sites.

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP approved Chief Executive Officer
2731 Martin Luther King Jr Boulevard
Tuscaloosa, AL 35401-5235
205-349-3250
White County Medical Center DSH040014 AR Incorrect 340B OPAIS record - Failed to remove closed location registrations None

CAP implemented

Audit closure date: December 18, 2019

 
Will County Community Health Center CH057880 IL Duplicate Discounts – Entity was billing Medicaid contrary to information included on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Chief Executive Officer, Will County Community Health Center, 1106 Neal Ave., Joliet, IL 60433, 815-740-7635
Willits Hospital Inc., dba Adventist Health Howard Memorial CAH051310-00 CA No adverse findings None N/A

Audit closure date: May 14, 2019

 
Winslow Memorial Hospital dba Little Colorado Medical Center CAH031311-00 AZ Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to September 26, 2019.

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

Duplicate discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.

Repayment to manufacturers CAP approved Assistant Director of Pharmacy
1501 N. Williamson Ave.
Winslow, AZ 86047
928-289-6325

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

Date Last Reviewed:  January 2020