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Program Integrity: FY21 Audit Results

Updated 10/18/21. 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 171 audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
AIDS Care Group HV190131 PA No adverse findings None N/A

Audit closure date: April 27, 2021

 
AdventHealth Manchester DSH180043 KY Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.

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: May 4, 2021
 
Adventist Health Clearlake Hospital, Inc. CAH051317-00 CA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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

Repayment to manufacturers CAP approved Director of Pharmacy
Adventist Health Clear Lake
15630 18th Ave
Clearlake, CA 95422
SheltoJ1@ah.org
707-994-6486
AIDS Action Coalition of Huntsville – Thrive Alabama HV358011A AL No adverse findings None N/A

Audit closure date: March 17, 2021

 
Aitkin Community Hospital dba Riverwood Healthcare Center CAH241305-00 MN Incorrect 340B OPAIS record - Incorrect Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: May 6, 2021

 
Alegent Health Bergan Mercy Health System dba CHI Health Creighton University Med Center-Bergan Mercy DSH280060 NE No adverse findings None N/A

Audit closure date: March 5, 2021

 
Allen Parish Hospital DSH190133 LA No adverse findings None N/A

Audit closure date: May 14, 2021

 
Altoona Regional Health System DSH390073 PA Inaccurate or incomplete information in the HRSA 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 3, 2021

 
Altru Hospital SCH350019-00 ND Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS. None CAP implemented

Audit closure date: September 23, 2021

 
Auburn Community Hospital SCH330235 NY Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. None Pending  
Avera McKennan DBA Avera Flandreau Hospital CAH431310-00 SD No adverse findings None N/A

Audit closure date:
July 7, 2021

 
Banner Gateway Medical Center DSH030122 AZ Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS None CAP approved  
Banner Lassen Medical Center CAH051320-00 CA No adverse findings None N/A

Audit closure date: April 9, 2021

 
Baptist Hospital of Miami, Inc. DSH100008 FL Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date. None CAP approved  
Behavioral Health Services, Inc. CHC29048-00 CA Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

Pending  
Bennet County Hospital CAH431314-00 SD Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: June 16, 2021

 
Black River Health Services, Inc. FQHCLA364 NC No adverse findings None N/A

Audit closure date: July 19, 2021

 
Bon Secours Community Hospital DSH330135 NY Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date. None CAP approved

Audit closure date: September 14, 2021

 
Boulder City Hospital CAH291309-00 NV Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Authorizing Official phone number and Primary Contact phone number.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers CAP approved Chief Financial Officer
901 Adams Blvd
Boulder City, NV 89005
dlewis@bchnv.org
702-293-4111 x6509
Brevard Health Alliance Inc., The CH043823A FL No adverse findings None N/A

Audit closure date: June 25, 2021

 
Brodstone Memorial Hospital CAH281315-00 NE No adverse findings None N/A

Audit closure date: January 26, 2021

 
Butler County Health Department STD36037 AL Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for grant number and nature of support.

Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

None CAP approved  
California Hospital Medical Center DSH050149 CA Incorrect 340B OPAIS record –Incorrect entry in 340B OPAIS for disproportionate share percentage. None CAP approved  
Care for the Homeless CH020020 NY Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for grant associated site. None CAP implemented

Audit closure date: June 15, 2021

 
CAN Community Health Inc. STD333341 FL No adverse findings None N/A

Audit closure date: December 2, 2020

 
Carle Eureka Hospital CAH141309-00 IL No adverse findings None N/A

Audit closure date: April 29, 2021

 
Carroll County Memorial Hospital CAH181310-00 KY Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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

Repayment to manufacturers CAP approved Chief Executive Officer
khaverly@ccmhosp.com
502-732-3275
Catholic Health Initiatives – Iowa, Corp. DSH160083 IA Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Ineligible sites registered on 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite outpatient facility; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

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

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

Pending  
Central Washington Health Services Association dba Central Washington Hospital DSH500016 WA No adverse findings None N/A

Audit closure date: June 3, 2021

 
Cheyenne County Hospital Association, Inc.
dba Sidney Regional Medical Center
CAH281357-00 NE No adverse findings None N/A

Audit closure date: February 23, 2021

 
Christus Hospital RRC450034-00 TX Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, disproportionate share percentage, and hospital control type. None Pending  
Christus Santa Rosa Health System RRC450237-00 TX Diversion – 340B drug dispensed at a contract pharmacy, not supported by a medical record. Repayment to manufacturers CAP approved Senior Consultant
7840 Graphics Drive, Suite 100
Tinley Park, IL 60477
708-478-7030
Coastal Family Health Center Inc., The CH042430 MS Incorrect 340B OPAIS record – Entity improperly registered a distribution site in 340B OPAIS as a grant associated site; Incorrect entries in 340B OPAIS for name for grant associated sites.

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

Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.
Repayment to manufacturers Pending  
Coffey County Hospital CAH171385-00 KS Diversion – 340B drug dispensed to inpatient Repayment to manufacturers CAP approved Chief Financial Officer
Senior Accountant
Coffey County Hospital
801 N. 4th
Burlington, KS 66839
620-364-2121
Columbia Lutheran Charities dba Columbia Memorial Hospital CAH381320-00 OR No adverse findings None N/A

Audit closure date: February 12, 2021

 
Community Health Care Systems Inc CH045180 GA Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

Entity and grant associated sites billed Medicaid while not listed on the HRSA 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 23, 2021

 
Community Medical Centers Inc. CH090780 CA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved  
Coon Memorial Hospital CAH451331-00 TX Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove registration in 340B OPAIS for closed offsite outpatient facility; Incorrect entries in 340B OPAIS for address for offsite outpatient facilities.

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

Inaccurate or incomplete information on 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
1411 Denver Avenue
Dalhart, TX 79022
loreet@dhchd.org
806-244-9267
Community Medical Wellness Centers USA CHC28986-00 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: July 27, 2021

 
Crisp Regional Hospital Inc. DSH110104 GA No adverse findings None N/A

Audit closure date: December 2, 2020

 
Deaconess Medical Center DSH500044 WA No adverse findings None N/A

Audit closure date: May 25, 2021

 
Desert AIDS Project CHC28988-00 CA Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that were registered in error. None CAP implemented

Audit closure date: June 8, 2021

 
Erlanger Medical Center DSH440104 TN No adverse findings None N/A

Audit closure date: March 5, 2021

 
Falls Community Hospital and Clinic SCH450348-00 TX No adverse findings None N/A

Audit closure date: March 3, 2021

 
Family Health Centers of San Diego, Inc. CH093120 CA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for subdivision names for offsite outpatient facilities; Incorrect entries in 340B OPAIS for Site ID and address for offsite outpatient facility; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place. Termination of contract pharmacies from 340B Program* CAP implemented

Audit closure date: July 14, 2021

 
Family Health Services Corporation CH101650 ID Diversion – 340B drug dispensed, not supported by a medical record.

Duplicate Discounts – Entity and grant associated sites billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers CAP approved Operations Manager
794 Eastland Dr.
Twin Falls, ID 83301
mavalos@fhsid.org
208-737-6707
Field Memorial Community Hospital CAH251309-00 MS No adverse findings None N/A

Audit closure date: March 17, 2021

 
Flushing Hospital Medical Center DSH330193 NY No adverse findings None N/A

Audit closure date: September 9, 2021

 
Fort Madison Community Hospital DSH160122 IA Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date:
February 8, 2021

 
Franklin General Hospital CAH161308-00 IA Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: March 17, 2021

 
Franklin Memorial Hospital SCH200037-00 ME No adverse findings None N/A

Audit closure date: March 16, 2021

 
Franklin Square Hospital DSH210015 MD Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: June 8, 2021

 
Friend Family Health Center Inc. CH059110 IL Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that was registered in error. None CAP approved  
Fulton County Medical Center CAH391303-00 PA Incorrect 340B OPAIS record - Failed to remove a contract pharmacy from 340B OPAIS that was registered in error. None CAP implemented

Audit closure date:
June 29, 2021

 
Good Samaritan Hospital Corvallis RRC380014-00 OR No adverse findings None N/A

Audit closure date: March 16, 2021

 
Grant County Public Hospital District No. 3
dba Columbia Basin Hospital
CAH501317-00 WA No adverse findings None N/A

Audit closure date: May 5, 2021

 
Geisinger Wyoming Valley Medical Center DSH390270 PA No adverse findings None N/A

Audit closure date: May 17, 2021

 
Glacial Ridge Health System CAH241376-00 MN Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for address for offsite outpatient facilities, Medicare Cost Report filing date, and cost reporting period. None CAP implemented

Audit closure date: April 28, 2021

 
Grayson County Hospital Foundation
dba Twin Lakes Regional Medical Center
DSH180070 KY No adverse findings None N/A

Audit closure date: February 9, 2021

 
Greenwood Leflore Hospital DSH250099 MS Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Director of Pharmacy
nmainelli@glh.org
662-459-2633

Chief Financial Officer
dholmes@glh.org
662-459-7119

Guttenberg Municipal Hospital CAH161312-00 IA Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: April 20, 2021

 
Hampshire Memorial Hospital, Inc. CAH511311-00 WV No adverse findings None N/A

Audit closure date: January 5, 2021

 
Harbor Health Services, Inc. CH010170 MA No adverse findings None N/A

Audit closure date: July 15, 2021

 
Health and Life Organization Inc. FQHCLA247 CA Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP approved 340B Compliance Specialist
3030 Explorer Drive
Sacramento, CA 95827
mbradford2@halocares.org
Healthsource of Ohio, Inc. CH050990 OH No adverse findings None N/A

Audit closure date: June 16, 2021

 
Henry Ford Wyandotte Hospital RRC230146-00 MI No adverse findings None N/A

Audit closure date: April 29, 2021

 
Hillsdale Community Health Center RRC230037-00 MI Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers Pending  
Holston Valley Hospital and Medical Center RRC440017-00 TN No adverse findings None N/A

Audit closure date: December 10, 2020

 
Holyoke Medical Center DSH220024 MA No adverse findings None N/A

Audit closure date: July 15, 2021

 
Hope and Help Center of Central Florida, Inc. STD33150 FL No adverse findings None N/A

Audit closure date: August 9, 2021

 
Hospital District No. 1 of Dickinson CAH171381-00 KS Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP approved  
IHC Health Services, Inc. DBA Utah Valley Hospital DSH460001 UT No adverse findings None N/A

Audit closure date: July 15, 2021

 
Illini Community Hospital CAH141315-00 IL 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: February 22, 2021
 
Jacobson Memorial Hospital CAH351314-00 ND Incorrect 340B OPAIS record - Entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS. None

CAP implemented

Audit closure date: September 17, 2021

 
Jefferson Healthcare CAH501323-00 WA Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. Repayment to manufacturers CAP approved Chief Ancillary and Support Services Office
834 Sheridan St.
Port Townsend, WA 98368
Jdavidson@jeffersonhealthcare.org
360-385-2200 x2039
JWCH Institute, Inc. CH0925360 CA Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that were registered in error; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS. None CAP implemented

Audit closure date: April 20, 2021

 
Kalihi-Palama Health Center CH096010 HI Incorrect 340B OPAIS record – Grant associated site was not listed on the 340B OPAIS.

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

None CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: July 30, 2021
 
Kiowa County Hospital District
dba Weisbrod Memorial Hospital
CAH061300-00 CO Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: June 17, 2021

 
Kiowa County Memorial Hospital CAH171332-00 KS No adverse findings None N/A

Audit closure date: February 12, 2021

 
Klickitat County Public Hospital District No 1
dba Klickitat Valley Health
CAH501316-00 WA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP approved  
Lakeland Regional Health System, Lakeland Medical Center St. Joseph DSH230021 MI

Incorrect 340B OPAIS record – Failed to remove a duplicate registration for an offsite outpatient facility from 340B OPAIS.

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

None CAP approved

State Medicaid has since determined duplicate discounts did not occur.

 
Landmann-Jungman Memorial Hospital CAH431317-00 SD No adverse findings None N/A

Audit closure date: July 15, 2021

 
Lawrence Memorial Health Foundation, Inc. CAH041309-00 AR Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type. None CAP implemented

Audit closure date: September 30, 2021

 
Legacy Good Samaritan Hospital DSH380017 OR No adverse findings None N/A

Audit closure date: May 11, 2021

 
Mackinac Straits Hospital and Health Center CAH231306-00 MI Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP approved  
Marshfield Medical Center SCH520037-00 WI Incorrect 340B OPAIS record – Failed to remove duplicate registrations of contract pharmacies in 340B OPAIS.

Diversion – 340B drug dispensed to inpatient; 340B drug dispensed at a contract pharmacy, not supported by a medical record.

Repayment for manufacturer CAP approved 340B Program Manager
1000 North Oak Ave
Marshfield, WI 54446
neuendorf.kirstia@marshfieldclinic.org 715-858-4308
Maury Regional Hospital RRC440073-00 TN Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

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

Repayment to manufacturers Pending  
Meharry Community Wellness Center HV01706 TN Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for name and address; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place; Failed to remove a closed contract pharmacy from 340B OPAIS. Termination of contract pharmacies from 340B Program* CAP approved  
Memorial Hospital, The CAH301307-00 NH Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for offsite outpatient facility. None N/A

Audit closure date: March 11, 2021

 
Memorial Hospital West DSH100281 FL No adverse findings None N/A

Audit closure date: August 5, 2021

 
Memorial Regional Hospital DSH100038 FL Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for offsite outpatient facility. None CAP implemented

Audit closure date: April 30, 2021

 
Mena Regional Health System DSH040015 AR Diversion – 340B drug dispensed to inpatient.

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

Repayment to manufacturers CAP approved

Director of Pharmacy
311 North Morrow St.
Mena, AR 71953
Angiea@menaregional.com
479-243-2225

Mendota Community Hospital
DBA OSF Saint Paul Medical Center
CAH141310-00 IL Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for hospital control type and Medicare Cost Report filing date.

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

None CAP approved  
Mercy Hospital Springfield DSH260065 MO No adverse findings None N/A

Audit closure date: March 5, 2021

 
Metro Community Provider Network, Inc. CH080730 CO No adverse findings None N/A

Audit closure date: July 14, 2021

 
Mid-Columbia Medical Center SCH380001-00 OR Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None CAP approved  
Milwaukee Health Services, Inc. CH052090 WI Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy location from 340B OPAIS.

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

None Pending  
Minidoka Memorial Hospital CAH131319-00 ID No adverse findings None N/A

Audit closure date: June 25, 2021

 
Mitchell County Regional Health Center CAH161323-00 IA No adverse findings None N/A

Audit closure date: January 7, 2021

 
Montgomery General Hospital, Inc. CAH511318-00 WV

Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

Diversion – 340B drugs dispensed to inpatients; and 340B drugs prescribed by an ineligible provider.

Termination of contract pharmacies from 340B Program CAP approved  
Mosaic Medical Center Maryville SCH260050-00 MO Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that were registered in error.

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

Repayment to manufacturers CAP approved 340B Primary Contact
Mosaic Health System
5325 Faraon Street
St. Joseph, MO 64506
Craig.gordon@mymlc.com
816-271-6069
Murray County Memorial Hospital CAH241319-00 MN Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: June 8, 2021

 
Nevada City Hospital DSH260061 MO Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 7, 2021.

Inaccurate or incomplete information on 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
800 S. Ash Street
Nevada, MO 64772
jmashek@nrmchealth.com
417-448-3649
New York City Health and Hospitals CHC29018-00 NY Incorrect 340B OPAIS record – Failed to remove a duplicate registration for a grant associated site from 340B OPAIS; Grant associated site was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for name and address for grant associated sites; Ineligible site registered on 340B OPAIS.

Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File at entity and grant associated sites.

None Pending  
North County Health Project, Inc. CH090720 CA Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File. Repayment to manufacturers Pending  
North Mississippi Medical Center DSH250004 MS 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: June 24, 2021

 
Northeastern Vermont Regional Hospital CAH471303-00 VT No adverse findings None N/A

Audit closure date: June 9, 2021

 
Northern Pines Medical Center CAH241340-00 MN No adverse findings None N/A

Audit closure date: May 17, 2021

 
Northeast Florida Health Services, Inc. CH0423770 FL Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP implemented

Audit closure date: August 12, 2021

Chief Executive Officer
lasbury@familyhealthsource.org
386-202-6025

Pharmacy Director
mmoll@familyhealthsource.org
386-327-6049

Northern Valley Indian Health FQHC638012 CA 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: March 10, 2021
 
Northwest Hospital Center, Inc. DSH210040 MD No adverse findings None N/A

Audit closure date: May 5, 2021

 
NY Community Hospital of Brooklyn DSH330019 NY No adverse findings None N/A

Audit closure date: August 17, 2021

 
Oak Valley District Hospital DSH050067 CA No adverse findings None N/A

Audit closure date: March 16, 2021

 
Oaklawn Hospital DSH230217 MI No adverse findings None N/A

Audit closure date: February 9, 2021

 
Oakwood Healthcare, Inc.
dba Beaumont Hospital – Wayne
DSH230142 MI Incorrect 340B OPAIS record – A shipping address was not listed in 340B OPAIS. None

CAP implemented

Audit closure date: October 4, 2021

 
OSF Little Company of Mary Medical Center RRC140179-00 IL

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

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

Repayment to manufacturers CAP approved 340B Drug Program Manager
5901 West War Memorial Drive
Peoria, IL 61615
309-308-0413
OU Medical Center DSH370093 OK No adverse findings None N/A

Audit closure date: April 1, 2021

 
Palo Pinto General Hospital DSH450565 TX Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers CAP approved

State Medicaid has since determined duplicate discounts did not occur.

Chief Pharmacy Technician
TCROSS@ppgh.com
940-328-6375
Paul Oliver Memorial Hospital CAH231300-00 MI No adverse findings None N/A

Audit closure date: April 28, 2021

 
Pella Regional Health Center CAH161367-00 IA Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place. Termination of contract pharmacy from 340B Program* CAP implemented

Audit closure date: June 8, 2021

 
Pemiscot County Memorial Hospital DSH260070 MO Diversion – 340B drug dispensed to inpatient Repayment to manufacturers CAP approved Director of Pharmacy Services
946 E Reed Street
Hayti, MO 63581
dketchum@pemiscot.org
573-359-1372
Peninsula Regional Medical Center DSH210019 MD No adverse findings None N/A

Audit closure date: April 9, 2021

 
Pinckneyville Community Hospital District CAH141307-00 IL No adverse findings None N/A

Audit closure date: December 18, 2020

 
Pioneers Medical Center CAH061325-00 CO Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: October 4, 2021

 
Platte Valley Medical Center DSH060004 CO No adverse findings None N/A

Audit closure date: January 29, 2021

 
Portsmouth Community Health Center, Inc.
DBA Hampton Roads Community Health Center
CH034100 VA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for shipping addresses and names for grant associated sites.

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

Termination of contract pharmacy from 340B Program CAP implemented

Audit closure date: August 5, 2021

 
Positively Living, Inc. RWII37917 TN Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that were registered in error.

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

Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.
Repayment to manufacturers Pending  
Prairie Ridge Health, Inc. CAH521338-00 WI No adverse findings None N/A

Audit closure date: April 29, 2021

 
Presence St. Mary’s Hospital DSH140155 IL No adverse findings None N/A

Audit closure date: April 6, 2021

 
Pueblo Community Health Center, Inc. CH080170A CO 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 3, 2021

 
Raritan Bay Medical Center / HMH Hospitals Corporation DSH310039 NJ Incorrect 340B OPAIS record – Ineligible site registered on 340B OPAIS; Offsite outpatient facilities were not listed in 340B OPAIS. Termination of ineligible offsite outpatient facility from the 340B Program CAP approved  
Richland, Parish of CHC24167-00 LA No adverse findings None N/A Audit closure date: July 14, 2021  
Rural Medical Services, Inc. CH046810 TN Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy in 340B OPAIS. None CAP implemented

Audit closure date: June 11, 2021

 
Rutland Regional Medical Center DSH470005 VT Entity billed Medicaid while not listed on the HRSA 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 25, 2021

 
Saint Mary’s Hospital dba CHI Health St. Mary’s CAH281342-00 NE Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

None CAP implemented

State Medicaid agencies have since determined duplicate discounts did not occur.

Audit closure date: August 31, 2021
Pharmacy Supervisor
Apekny@stez.org
402-873-8938
Salem Township Hospital CAH141345-00 IL Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP approved

Audit closure date: May 13, 2021

 
Sanford Bagley Medical Center CAH241328-00 MN Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP approved  
Schneck Medical Center DSH150065 IN No adverse findings None N/A

Audit closure date: June 24, 2021

 
Scotland County Hospital CAH261310-00 MO Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: May 25, 2021

 
Sheridan Community Hospital CAH231312-00 MI Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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  
South Miami Hospital DSH100154 FL No adverse findings None N/A

Audit closure date: May 11, 2021

 
South Sunflower County Hospital SCH250095-00 MS Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date None CAP approved  
South Texas Rural Health Services, Inc. CH062120 TX No adverse findings None N/A

Audit closure date: February 22, 2021

 
Sparta Community Hospital District CAH141349-00 IL No adverse findings None N/A

Audit closure date: December 11, 2020

 
St. Agnes Hospital DSH210011 MD Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for disproportionate share percentage, Medicare Cost Report filing date, and cost reporting period.

Diversion – 340B drugs dispensed at contract pharmacies and at covered entity, not supported by a medical record.

Repayment to manufacturers

CAP approved 340B Program Manager
900 Canton Avenue
Baltimore, MD 21229
Kelsey.Fiser@ascension.org
615-222-5190
St. Mary’s Medical Center, Inc. DSH510007 WV No adverse findings None N/A

Audit closure date: February 11, 2021

 
St. Mary’s Regional Medical Center DSH200034 ME No adverse findings None N/A

Audit closure date: March 30, 2021

 
St. Tammany Parish Hospital DSH190045 LA Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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 30, 2021

 
St. Joseph Health Center DSH360161 OH No adverse findings None N/A

Audit closure date: January 21, 2021

 
St. Joseph Regional Health Center RRC450011-00 TX No adverse findings None N/A

Audit closure date: April 30, 2021

 
St. Luke's Jones Regional Medical Center CAH161306-00 IA No adverse findings None N/A

Audit closure date: December 10, 2020

 
St. Vincent Salem Hospital, Inc.
Dba Ascension St. Vincent Salem
CAH151314-00 IN Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type. None CAP implemented

Audit closure date: March 23, 2021

 
Stephens Memorial Hospital CAH201315-00 ME No adverse findings None N/A

Audit closure date: April 14, 2021

 
Sullivan County Memorial Hospital CAH261306-00 MO Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Ineligible sites registered on 340B OPAIS. Termination of ineligible offsite outpatient facilities from the 340B Program CAP implemented

Audit closure date: May 4, 2021

 
Sutter Bay Hospitals, dba Sutter Lakeside Hospital CAH051329-00 CA No adverse findings None N/A

Audit closure date: August 4, 2021

 
Sweeny Hospital District CAH451311-00 TX Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date.

Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacy, not supported by a medical record.

Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.
Repayment to manufacturers Pending  
Tahoe Forest Hospital CAH051328-00 CA Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers CAP approved Director of Pharmacy
Tahoe Forest Hospital District
PO Box 759
Truckee, CA 96160
tmather@tfhd.com
530-582-6465
Thomas H Boyd Critical ACC Hospital CAH141300-00 IL 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  
Tri-County Hospital CAH241354 MN No adverse findings None N/A

Audit closure date: May 14, 2021

 
Tucson Medical Center DSH030006 AZ Incorrect 340B OPAIS record – Ineligible sites registered in 340B OPAIS.

Diversion – 340B drug dispensed to inpatient.

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

Pending  
University Hospitals of Cleveland DSH360137 OH Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 22, 2021.

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

Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.
None CAP approved

State Medicaid has since determined duplicate discounts did not occur.

 
University Medical Center of El Paso DSH450024 TX Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for disproportionate share percentage None CAP implemented

Audit closure date: February 9, 2021

 
Van Buren County Hospital CAH161337-00 IA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: February 22, 2021

 
Virginia Gay Hospital CAH161349-00 IA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP implemented

Audit closure date: March 26, 2021

 
Virtua Our Lady of Lourdes Hospital DSH310029 NJ Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None Cap implemented

Audit closure date:
July 1, 2021

 
Watts Healthcare Corporation CHC00850-00 CA Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Incorrect entry in 340B OPAIS for Authorizing Official.

Duplicate Discounts – Grant associated site billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers CAP approved Chief Medical Officer
10300 Compton Ave
Los Angeles, CA 90002
oliver.brooks@wattshealth.org
323-564-4331 x3141
West Alabama AIDS Outreach RWII354011 AL No adverse findings None N/A

Audit closure date:
July 9, 2021

 
West Calcasieu-Cameron Hospital DSH190013 LA Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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

Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.
Repayment to manufacturers CAP approved Director of Pharmacy
701 Cypress Street
Sulphur, LA 70663 gforeman@wcch.com
337-527-4290
White River Medical Center DSH040119 AR Inaccurate or incomplete information on the Medicaid Exclusion File. None CAP implemented

Audit closure date: May 25, 2021

 
William W. Backus Hospital, The RRC070024-00 CT No adverse findings None N/A

Audit closure date: April 29, 2021

 
William Beaumont Hospital DBA Beaumont Hospital – Royal Oak RRC230130-00 MI Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. None Pending  

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

Date Last Reviewed:  October 2021