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	Incorrect 340B database record – Incorrect Authorizing Official; 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	Incorrect 340B database record – Incorrect entries for primary office location and contact information. 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	Incorrect 340B database record – Pharmacy incorrectly registered as child site; 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	Incorrect 340B database record – Incorrect entry for Authorizing Official listed for child sites. 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	Diversion – 340B drug dispensed to non-patient at contract pharmacy. 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	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. Duplicate discounts – Claims submitted without state required NPI numbers.	To be determined.	Pending
19.	Kingman Regional Medical Center	DSH030055	AZ	Diversion – 340B drug dispensed for prescription written at ineligible site by ineligible provider. 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	Diversion – 340B drugs dispensed to ineligible individuals. 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	Duplicate discounts – Medicaid Provider Numbers for two sites were incorrect on the Medicaid Exclusion File.	To be determined.	Pending
32.	Presbyterian Hospital	DSH320021	NM	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; Duplicate discounts – Claims submitted without state required UD modifier.	Repayment to manufacturers.	Pending
33.	Primary Health Services Center	CH068480	LA	Incorrect 340B database record –Parent location listed on the 340B database was closed; incorrect address for a sub-grantee clinic site. Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File	None.	Database entries corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. 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	Incorrect 340B database record - Closed outpatient facilities remained registered on the 340B database; Diversion – 340B drug dispensed to non-patient at contract pharmacy; 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	Incorrect 340B database record - Site inappropriately listed on 340B database. Diversion – 340B drugs dispensed to inpatients. 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	Incorrect 340B database record – Closed sites inappropriately listed on 340B database; no written contract in place for contract pharmacy listed. 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	Incorrect 340B database record –Contract pharmacies registered but entity has terminated its contract. 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	Diversion – 340B drugs dispensed to non-patient at a contract pharmacy; Duplicate discounts – Entity was billing Medicaid contrary to information contained in the Medicaid Exclusion File.	Repayment to manufacturers.	Pending

Date Last Reviewed: April 2017

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Program Integrity: Audit Results

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