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Program Integrity: FY19 Audit Results

Updated 9/15/20. 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 199 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

 
Action for Boston Community Development FP021118 MA Incorrect 340B OPAIS record – Incorrect entries for grant number. None CAP approved  
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

 
Adena Regional Medical Center DSH360159 OH Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved

AHS Director of Pharmacy Services
272 Hospital Road
Chillicothe OH 45601
fyingling@adena.org
740-779-7648

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

 

Arkansas Department of Health FP722051 AR

Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility.

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

None

CAP approved

State Medicaid has since determined duplicate discounts did not occur.

 

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 implemented

Audit closure date: June 17, 2020

Chief Financial Officer
700 West Market Street
Athens, AL 35611
256-233-9172
Avera St. Mary’s DSH430015 SD No adverse findings None N/A

Audit closure date: January 27, 2020

 
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 CAP approved Corporate Director of Pharmacy
1000 W Moreno Street
Pensacola, FL 32501
850-469-7567
Baptist Health Medical Center – LR DSH040114 AR Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP implemented

Audit closure date: June 9, 2020

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

 
Baton Rouge General Medical Center DSH190065 LA

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

Diversion – 340B drug dispensed to inpatient.

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

Repayment to manufacturers CAP approved Compliance Officer
8490 Picardy Ave Suite 300
Baton Rouge, Louisiana 70809
ken.miller@brgeneral.org
225-237-1588
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 implemented

Audit closure date: March 3, 2020

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

 
Brockton Hospital, Inc DSH220052 MA 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  
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 CAP approved

Audit closure date: February 5, 2020

 
Brooklyn Hospital Center, The DSH330056 NY Diversion – 340B drug dispensed at covered entity, not supported by a medical record.

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

Repayment to manufacturers CAP approved

VP Revenue Enhancement
15 Metrotech 3rd Floor
Brooklyn, N.Y. 11201
(O) 718-488-3775 (F) 718 488-3725

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

 
Canton-Potsdam Hospital DSH330197 NY Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved

Authorizing Official, Chief Financial Officer
Canton-Potsdam Hospital
50 Leroy Street
Potsdam, NY 13676
rjacobs@cphospital.org

Caring Health Center, Inc. CH01084B MA 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: June 4, 2020.

 
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 implemented

Audit closure date: May 18, 2020

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 implemented

Audit closure date: August 7, 2020

340B Administrator, 479-495-6264
PO Box 639, Danville, AR 72833
jeffreywoods@chambershospital.com
Charles A. Dean Memorial Hospital CAH201301-00 ME No adverse findings None N/A

Audit closure date: June 23, 2020

 
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
Childress Regional Medical Center DSH450369 TX Incorrect 340B OPAIS record - Incorrect entry for disproportionate share percentage. None CAP implemented

Audit closure date: February 7, 2020

 
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 implemented

Audit closure date: May 19, 2020

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

 
Clinch River Health Services, Incorporated CH031230 VA Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entry for authorizing official. None CAP implemented

Audit closure date: June 25, 2020

 
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 CAP approved Pharmacy Manager
541-435-7039 carynmickelson@coquilletribe.org
Daviess Community Hospital DSH150061 IN Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS.

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

None CAP implemented

State Medicaid determined no duplicate discounts occurred.

Audit closure date: May 7, 2020

 
Davis Street Community Center Inc. CHC28979-00 CA Incorrect 340B OPAIS record – Incorrect entry for primary contact. None N/A

Audit closure date: May 20, 2020

 
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

 
DOH Okaloosa FP325481 FL Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility. None

CAP implemented

Audit closure date: April 9, 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 implemented

Audit closure date: June 17, 2020

Administrative 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 CAP approved 340B Manager
Ellis Hospital
1101 Nott Street
Schenectady, NY 12308
518-243-1824
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

 
Forrest General Hospital DSH250078 MS Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Director of Pharmacy tmcdaniel@forrestgeneral.com
601-288-1485
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 implemented

Audit closure date: February 10, 2020

Director of Pharmacy/340B primary contact
Ferrell Hospital
1201 Pine Street
Eldorado, IL 62930
618-297-9627
Franklin Medical Center DSH190140 LA Covered outpatient drugs obtained through a Group Purchasing Organization prior to May 29, 2020.

Entity failed to maintain auditable medical records prior to May 29, 2020.

Repayment to manufacturers CAP approved

Director of Pharmacy/Compliance Officer
2106 Loop Road
Winnsboro, LA 71295
ggough@fmc-cares.com
318-412-5340

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 CAP approved  
Georgetown University Hospital DSH090004 DC Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP implemented

Audit closure date: May 12, 2020

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 CAP approval 340B Coordinator
2669 Scenic Drive
Alamogordo, NM 88310
575-443-7841
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 implemented

Audit closure date: May 18, 2020

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 implemented

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

Audit closure date May 20, 2020

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

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

Repayment to manufacturers

CAP approved

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 implemented

Audit closure date: June 9, 2020

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 implemented

Audit closure date: May 14, 2020

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 implemented

Audit closure date: June 9, 2020

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 implemented

Audit closure date: March 26, 2020

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 implemented

Audit closure date: May 12, 2020

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 implemented

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

Audit closure date: May 12, 2020

 
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 implemented

Audit closure date: April 8, 2020

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 implemented

Audit closure date: March 27, 2020

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 CAP approved Clinical Services Business Manager
Huggins Hospital
240 South Main Street
Wolfeboro, NH 03894
(603) 515 – 2065
atheberge@hugginshospital.org
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 implemented

Audit closure date: June 19, 2020

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 implemented

Audit closure date: April 8, 2020

Chief Financial Officer
or CFO of Horn Memorial Hospital
701 E 2nd St
Ida Grove, IA, 51445
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

 
Inova Fairfax Hospital DSH490063 VA Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 12, 2020. Repayment to manufacturers CAP approved 340B Compliance Pharmacist
Inova Fairfax Medical Campus
3300 Gallows Road
Falls Church, VA 22042
703-776-1114
Interfaith Medical Center DSH330397 NY Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facility; Incorrect entry for offsite outpatient facility address. None CAP implemented

Audit closure date: April 29, 2020

 
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 implemented

Audit closure date: May 27, 2020

 
Kern Medical Center DSH050315 CA Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS.

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

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 implemented

Audit closure date: June 3, 2020

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 implemented

Audit closure date: March 27, 2020

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 implemented

Audit closure date: March 26, 2020

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

 
Marietta Memorial Hospital RRC360147-00 OH Incorrect 340B OPAIS record – Ineligible sites registered on 340B OPAIS. Termination of ineligible offsite outpatient facilities from the 340B Program* CAP approved  
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 CAP approved Pharmacy 340B Analyst
MultiCare Health System
PO Box 5299, 315-C2-RX
315 Martin Luther King Jr. Way
Tacoma, WA 98415
jkim@multicare.org
253.403.5541
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 implemented

May 27, 2020

 
MedStar Southern Maryland Hospital Center DSH210062 MD Diversion – 340B drug dispensed to inpatient Repayment to manufacturers CAP approved Corporate 340B Manager
MedStar Health
7375 Washington Blvd, Suite 103
Elkridge, MD 21075
Anna.y.rosenfeld@medstar.net
410-540-4406
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 implemented

Audit closure date: June 24, 2020

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 implemented

Audit closure date: February 10, 2020

Pharmacy Director MHB
205 Parker Street
Boscobel, WI 53805
608-375-6307
Mercy Catholic Medical Center DSH390156 PA Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facilities. None CAP implemented

Audit closure date: May 13, 2020

 
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

 
Mercy Medical Center – North Iowa SCH160064-00 IA No adverse findings None N/A

Audit closure date: February 7, 2020

 
MetroHealth HV01713 DC No adverse findings None N/A

Audit closure date: February 19, 2020

 
Metropolitan Charities, Inc. STD33713 FL No adverse findings None

Audit closure date: February 25, 2020

 
Minnie Hamilton Health Care Center, Inc. CAH511303-00 WV Incorrect 340B OPAIS record - Hospital classification on OPAIS was inconsistent with eligibility documents. None CAP approved  
MGH Chelsea Student Health Center FP021501 MA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP implemented

Audit closure date: June 9, 2020

Director, MGH Community Health Associates
300 Ocean Avenue 5th Floor
Revere, MA 02151
781-485-6135
aduffy-keane@partners.org
Montefiore Medical Center DSH330059 NY Incorrect 340B OPAIS record – Offsite outpatient facilities and a shipping address were not listed on the 340B OPAIS.

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

Repayment to manufacturers Pending  
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.

None CAP implemented

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

Audit closure date: July 21, 2020

 
Mountain Comprehensive Health Corp., Inc. CH040600 KY Duplicate Discounts - Inaccurate 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: May 12, 2020

 
Mount St. Mary’s Hospital and Health Center DSH330188 NY Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy. None CAP implemented

Audit closure date: April 14, 2020

 
Munson Healthcare Charlevoix Hospital CAH231322-00 MI Incorrect 340B OPAIS record – Offsite outpatient facility was not listed on the 340B OPAIS. None CAP approved  
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

 
New Mexico Department of Health Title X Family Planning Program FP875036 NM No adverse findings None N/A

Audit closure date: April 10, 2020

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

Audit closure date: August 26, 2019

 
Northeast Georgia Medical Center RRC110029-00 GA Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entries for addresses for offsite outpatient facilities.

Diversion – 340B drugs dispensed to inpatients

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

Repayment to manufacturers CAP approved Director of Pharmacy
743 Spring St. NE
Gainesville, GA 30501
770-219-7573
Ohio State University Hospital, The DSH360085 OH No adverse findings None N/A

Audit closure date: June 6, 2019

 
Olean General Hospital RRC330103-00 NY Incorrect 340B OPAIS record – Ineligible sites registered on 340B OPAIS; Offsite outpatient facilities were not listed on the 340B OPAIS. None CAP approved  
Olympic Medical Center RRC500072-00 WA Diversion – 340B drugs dispensed to inpatients Repayment to manufacturers CAP approved Director of Pharmacy
Olympic Medical Center
939 Caroline Street
Port Angeles, WA 98362
kbright@olympicmedical.org
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 implemented

Audit closure date: June 26, 2020

Compliance Officer
PO Box 1676
Muncie, IN 47308
765-747-2973
Orlando Health DSH100006 FL Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities. Failed to include repackaging location as a shipping address. None CAP implemented

Audit closure date: April 29, 2020

 
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 CAP approved  
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

 
Primary Health Network, Inc. CH03406AE OH Incorrect 340B OPAIS record –Incorrect entry for site ID for offsite outpatient facility; Failed to remove a duplicate registration of a contract pharmacy. None CAP implemented

Audit closure date: February 10, 2020

 
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 implemented

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

Audit closure date: March 26, 2020

 
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 implemented

Audit closure date: June 9, 2020

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 closure date: October 4, 2019

 
Southern Illinois University CHC24098-00 IL No adverse findings None N/A

Audit closure date: February 12, 2020

 
Southern Ohio Medical Center DSH360008 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 CAP implemented

Audit closure date: July 8, 2020

 
Southwest Boulevard Family Health Care HV00140 KS No adverse findings None N/A

Audit closure date: February 5, 2020

 
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 closure 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 CAP implemented

Audit closure date: May 6, 2020

Chief Financial Officer of Community Hospitals
3565 S. State Road
Ionia, MI 48846
616-523-4186
SSM Health Saint Louis University Hospital DSH260105 MO Incorrect 340B OPAIS record – Offsite outpatient facility was not listed on the 340B OPAIS; Failed to include repackaging location as a shipping address. None CAP implemented

Audit closure date: April 16, 2020

 
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 implemented

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

Audit closure date: May 12, 2020

 
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 implemented

Audit closure date: May 12, 2020

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 CAP approved Director of Pharmacy
10 Woodland Road
St. Helena, CA 94574
AhmadAU@ah.org
707-963-6584
St. Mary Medical Center DSH050191 CA Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP approved Director of Pharmacy
St. Mary Medical Center
1050 Linden Avenue
Long Beach, CA 90813-3393
562-491-9773
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 implemented

Audit closure date: June 9, 2020

Chief Finance Officer
St. Mary's Healthcare
427 Guy Park Ave
Amsterdam, NY 12010
518-841-7435
Rick.Henze@ascension.org
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

Covered entity, its outpatient facilities, and its contract pharmacies terminated from 340B Program as of July 1, 2019. Settlement with affected manufacturers has not been finalized. SH will not be permitted to re-enroll in the 340B Program until such time: 1) SH has attested that it has contacted and offered settlement to all affected manufacturers, for all findings listed in the Final Report; and 2) SH has attested that a HRSA-approved CAP has been fully implemented.

Audit closure date: June 16, 2020

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 implemented

Audit closure date: June 24, 2020

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

 
University Hospital of Brooklyn DSH330350 NY

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Ineligible sites registered on 340B OPAIS; Incorrect entry for disproportionate share percentage.

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

Repayment to manufacturers Pending  
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 implemented

Audit closure date: May 27, 2020

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 implemented

Audit closure date: May 19, 2020

 
Washington County Hospital CAH161344-00 IA No adverse findings None

N/A

Audit closure date: February 5, 2019

 
Washington State Department of Health STD98504 WA Incorrect 340B database record – entity improperly registered a distribution site as a contract pharmacy. Registered contract pharmacies without written contract in place Termination of contract pharmacies from 340B Program CAP approved  
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 CAP implemented

Audit closure date: May 6, 2020

Director of Pharmacy Services
700 Adeline St
Oakland, CA 94607
510-835-9610 x2076
jmccabe@wohc.org
West Virginia Department of Health and Human Resources FP253015 WV Incorrect 340B OPAIS record – Incorrect entries for grant number. None CAP implemented

Audit closure date: March 24, 2020

 
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 implemented

Audit closure date: March 3, 2020

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 implemented

Audit closure date: January 13, 2020

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 implemented

Audit closure date: June 4, 2020

Assistant Director of Pharmacy
1501 N. Williamson Ave.
Winslow, AZ 86047
928-289-6325
Witham Memorial Hospital DSH150104 IN Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for disproportionate share percentage; Registered contract pharmacies without written contract in place. Termination of contract pharmacies from 340B Program* CAP implemented

Audit closure date: April 23, 2020

 

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

Date Last Reviewed:  September 2020