Program Integrity: Audit Results

updated 01/08/2014. The results chart includes audits where the entity has agreed to the HRSA Final Report. 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.

No.

Entity

340B ID

State

OPA Findings

Sanction

Corrective Action with Completion Date

1. Access Community Health Network

CH051750

 

IL

Diversion – 340B drug dispensed to non-patient at contract pharmacy. Repayment to manufacturers. Pending
2 Charlotte County Health Department

TB339507

FP339509

FP339524

FP342248

FL

  1. Incorrect 340B database record – Incorrect Authorizing Official;
  2. Duplicate discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File
To be determined. Pending
3. Children’s Healthcare of Atlanta at Egleston PED113300-00

GA

No adverse findings. None. N/A
4. CHC of Snohomish County

CH10228B

 

WA

  1. Incorrect 340B database record – Incorrect entries for primary office location and contact information.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.

To be determined.

 

Pending
5 Community Healthcare Network CH021630

NY

Diversion – 340B drug dispensed to non-patient at contract pharmacy. Repayment to manufacturers. Pending
6. Crouse Hospital DSH330203

NY

Diversion – 340B drug dispensed to inpatient; 340B drug dispensed to non-patient at contract pharmacy. Repayment to manufacturers. Pending
7. Denver Health Medical Center

DSH060011

 

CO

No adverse findings. None. N/A
8. El Centro Del Barrio, Inc. dba CentroMed CH063250

TX

Incorrect 340B database record – Closed outpatient facilities remained registered on the 340B database; incorrect name listed for an outpatient facility. None.

Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

 

Completion date:  August 2013.

9. Faulkner County Health Unit FP720337

AR

No adverse findings.

 

None. N/A
10. Fort Logan Hospital CAH181315-00

KY

No adverse findings. None. N/A
11. Freeman Health System DSH260137

MO

  1. Incorrect 340B database record – Pharmacy incorrectly registered as child site;
  2. Diversion – 340B drugs dispensed for prescriptions written at ineligible sites; 340B drugs dispensed to non-patients at contract pharmacies.
Repayment to manufacturers. Pending
12. Froedtert Memorial Lutheran Hospital

DSH520177

 

WI

No adverse findings. None. N/A
13. Good Shepherd Medical Center DSH450037

TX

No adverse findings.

 

None. N/A
14. Gordon County Health Department STD30701

GA

No adverse findings. None. N/A
15. Helen Keller Hospital DSH010019

AL

No adverse findings. None. N/A
16. Houston Medical Center DSH110069

GA

  1. Incorrect 340B database record – Incorrect entry for Authorizing Official listed for child sites.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.
To be determined. Pending
17. Immanuel Medical Center DSH280081

NE

  1. Diversion – 340B drug dispensed to non-patient at contract pharmacy.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File; Additionally, 340B drugs dispensed to Medicaid patients by contract pharmacy, absent arrangement to prevent duplicate discounts. 
Repayment to manufacturers. Pending
18. Jewish Hospital and St. Mary’s Healthcare (JHSMH) DSH180040

KY

  1. Incorrect 340B database record – Entity was shipping 340B drugs to a pharmacy not listed on the 340B database; an outpatient facility of the hospital was not listed on the 340B database.
  2. Duplicate discounts – Claims submitted without state required NPI numbers.
To be determined. Pending
19. Kingman Regional Medical Center DSH030055

AZ

  1. Diversion – 340B drug dispensed for prescription written at ineligible site by ineligible provider.
  2. Duplicate discounts – 340B drugs dispensed to Medicaid patients by contract pharmacy, absent arrangement to prevent duplicate discounts. 
Repayment to manufacturers. Pending
20. Lone Star Circle of Care (formerly Georgetown Community Clinic) CH0619490

TX

No adverse findings. None. N/A
21. Lucile Packard Children’s Hospital PED053305-00

CA

  1. Diversion – 340B drugs dispensed to ineligible individuals. 
  2. Duplicate discounts – Medicaid claims incorrectly coded when provided to the state.
Repayment to manufacturers. Pending
22. Magee-Womens Hospital of UPMC Health System DSH390114

PA

No adverse findings. None. N/A
23. McIntosh County Health Department TB31305

GA

No adverse findings. None. N/A
24 Mercy Hospital and Medical Center DSH140158

IL

Incorrect 340B database record – Closed outpatient facilities remained registered on the 340B database.

None.

 

Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.

 

Completion date:  June 2013.

25. Methodist Hospital of Southern California

DSH050238

     

CA

Duplicate discounts – Claims submitted without state required UD modifier.

 

To be determined.

 

Pending
26. Metropolitan Hospital DSH230236

MI

No adverse findings. None. N/A
27. Monroe County Medical Center DSH180105

KY

Diversion – 340B drug dispensed for prescription written by ineligible provider.

 

Repayment to manufacturers. Pending
28. New Hanover Regional Medical Center DSH340141

NC

Duplicate discounts - Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File. To be determined. Pending
29. Pecos County Memorial Hospital

DSH450178

 

TX

No adverse findings. None. N/A
30. Planned Parenthood of Northern New England STD05495

VT

No adverse findings.

 

None. N/A
31. Planned Parenthood of Western Pennsylvania, Inc. FP155015

PA

  1. Duplicate discounts – Medicaid Provider Numbers for two sites were incorrect on the Medicaid Exclusion File.
To be determined. Pending
32. Presbyterian Hospital DSH320021

NM

  1. Diversion –340B drug dispensed for prescription written at ineligible site; 340B drug dispensed not supported by a medical record; 340B drugs dispensed to non-patients at contract pharmacy for prescriptions written by ineligible providers;
  2. Duplicate discounts – Claims submitted without state required UD modifier.
Repayment to manufacturers. Pending
33. Primary Health Services Center CH068480

LA

  1. Incorrect 340B database record –Parent location listed on the 340B database was closed; incorrect address for a sub-grantee clinic site.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File
None.
  1. Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.
  2. Medicaid Exclusion File entry corrected; Internal audit conducted by the covered entity and communication with State Medicaid Agency concluded that duplicate discounts did not occur as a result of the finding; 340B Program policies and procedures revised to address routine review of Medicaid Exclusion File.

 

Completion date: August 2013.

34. Providence Health and Services – Washington Providence Centralia

DSH500019

     

WA

No adverse findings. None. N/A
35. Riverside Medical Center DSH140186

IL

No adverse findings. None. N/A
36. Robeson Health Care Corporation CH049000A

NC

  1. Incorrect 340B database record - Closed outpatient facilities remained registered on the 340B database;
  2. Diversion – 340B drug dispensed to non-patient at contract pharmacy;
  3. Duplicate discount – Entity billed Medicaid for a patient at a contract pharmacy contrary to information contained in the Medicaid
Repayment to manufacturers. Pending
37. Rutherford County Health Department

STD28160

FP281604

TB28160

 

NC

Incorrect 340B database record – Entity was using a contract pharmacy not listed on the 340B database even though there was a written contract in place. None.

Database entry corrected; 340B Program policies and procedures revised to address contract pharmacy registration and routine review of 340B Program database.

 

Completion Date: August 2013.

 

38. Scott and White Memorial Hospital DSH450054

TX

  1. Incorrect 340B database record - Site inappropriately listed on 340B database.
  2. Diversion – 340B drugs dispensed to inpatients.
  3. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.
Repayment to manufacturers. Pending
39. Shands Jacksonville Medical Center DSH100001

FL

No adverse findings. None. N/A
40. Spartanburg Regional Health Services District, Inc. HV00818

SC

Diversion – 340B drug dispensed for prescription written at ineligible site by ineligible provider. Repayment to manufacturers. Pending
41. St. Charles Health Council/Stone Mountain Health Services CH030740

VA

  1. Incorrect 340B database record – Closed sites inappropriately listed on 340B database; no written contract in place for contract pharmacy listed.
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File; Additionally, claims submitted without state required modifier.
To be determined. Pending
42. St. Luke’s Hospital of Kansas City

DSH260138

     

MO

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

 

None.

Contract executed; no 340B activity at contract pharmacies prior to execution of contract; 340B Program policies and procedures revised to address contract pharmacy registration.

 

Completion Date: September 2013.

43. St. Luke’s Regional Medical Center, Ltd. DSH130006

ID

Diversion – 340B drugs dispensed to inpatients. Repayment to manufacturers. Pending
44. St. Vincent Infirmary DSH040007

AR

Diversion – 340B drugs dispensed to ineligible individuals. Repayment to manufacturers. Pending
45. Swedish Covenant Hospital

DSH140114

 

IL

  1. Incorrect 340B database record –Contract pharmacies registered but entity has terminated its contract. 
  2. Diversion – 340B drugs dispensed to non-patients at contract pharmacy.
Repayment to manufacturers. Pending
46. Travis County Health Care District Central Texas Community Health Centers CHC11298-00

TX

Duplicate discounts – Offsite outpatient facilities incorrectly listed on Medicaid Exclusion File.   None.

Medicaid Exclusion File corrected; 340B Program policies and procedures revised to address routine review of 340B Program database.  It was determined that duplicate discounts did not occur as a result of the finding.

 

Completion date:  April 2013.

47. University of Louisville Hospital DSH180141

KY

No adverse findings. None. N/A
48. University of Miami Hospital and Clinics CAN100079-00

FL

Incorrect 340B database record – incorrect entry for primary contact. None.

Database entry corrected; 340B Program policies and procedures revised to address routine validation of 340B Program database.

 

Completion date:  February 7, 2013.

49. Wheaton Franciscan Healthcare – All Saints

DSH520096

 

WI

No adverse findings. None. N/A
50. White Memorial Medical Center DSH050103

CA

Duplicate discounts - Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File. To be determined. Pending
51. WomenCare, Inc. dba FamilyCare CH038440

WV

  1. Diversion – 340B drugs dispensed to non-patient at a contract pharmacy;
  2. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.
Repayment to manufacturers. Pending
Date Last Reviewed:  April 2017