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Program Integrity: FY16 Audit Results

Updated 2/20/19. 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 200 audits.
Entity Sort descending 340B ID State OPA Findings Sanction Corrective Action Status
AHRC Health Care, Inc. CHC10579-00 NY

No adverse findings

None

N/A

Audit closure date: September 7, 2016

Alameda Health System
Contact Information

Rick Kibler

VP Compliance and Internal Audit
(510) 895-7271
rkibler@alamedahealthsystem.org

DSH050320 CA

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

Diversion – 340B drugs were not properly accumulated.

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

Duplicate Discounts – Entity did not have controls in place to prevent duplicated discounts.

Repayment to Manufacturers

CAP implemented

Audit closure date: July 14, 2017

Alegent Health-Immanuel Medical Center d/b/a/ CHI Health Immanuel DSH280081 NE

No adverse findings

None

N/A

Audit closure date: September 7, 2016

Alexandria Neighborhood Health Service Inc.
Contact Information

Pharmacy Program Manager

dhernandez@neighborhoodhealthva.org

703-535-5568 x2813

CH031060A VA

Incorrect 340B database record – Incorrect entry for a shipping address.

Diversion – 340B drug dispensed at contract pharmacy for a prescription written at ineligible site

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 18, 2018

Appling General Hospital
Contact Information

Director of Pharmacy
Appling Healthcare System

163 East Tollison Street
Baxley, GA 31515

912-367-9841 ext. 1230

SCH110071-00 GA

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File

Repayment to manufacturer

CAP implemented

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

Audit closure date: July 18, 2018

Armstrong County Memorial Hospital
Contact Information

Manager of Budget and Reimbursement;
(724) 543-8518 mcculloughi@acmh.org
Or
Budget and
Reimbursement Analyst
(724)543-8181 kingcm@acmh.org

RRC390163-00 PA

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to Manufacturers

CAP approved

Audit closure date: August 8, 2017

Baptist Memorial Hospital- Union County DSH250006 MS

No adverse findings

None

N/A

Audit closure date: December 7, 2016

Baylor Scott and White Hospital - Llano SCH450219-00 TX

Incorrect 340B database record – Ineligible site registered on 340B database.

Entity did not provide contract pharmacy oversight prior to January 2016.

Termination of offsite outpatient facility from 340B Program

CAP implemented

Audit closure date: October 10, 2016

Benefis Hospitals, Inc. SCH270012-00 MT

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

None

CAP implemented

Audit closure date: January 3, 2017.

Blue Ridge HealthCare Hospitals, Inc.
Contact Information

System Director of Pharmacy Practice

2201 South Sterling Street
Morganton, NC, 28655
(828) 580-5111

DSH340075 NC

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

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to Manufacturers

CAP approved

Boone County Hospital
Contact Information

Director of Pharmacy
(515) 433-8271
sdonald@bchmail.org

CAH161372-00 IA

Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2018

Boone Memorial Hospital
Contact Information

Chief Financial Officer (304)-369-1230 or rfoxx@bmh.org.

CAH511313-00 WV

Diversion – 340B drug dispensed at the entity for prescription written by an ineligible provider; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2018

Bronson Battle Creek Hospital
Contact Information

340B Pharmacy Specialist

Bronson Healthcare Group
601 John Street
Kalamazoo, MI, 49001
(269) 552-3076
potyrall@bronsonhg.org

DSH230075 MI

Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: August 15, 2017

Brooklyn Hospital Center
Contact Information

Senior Vice President & Chief Financial Officer

The Brooklyn Hospital Center

15 Metrotech Center, 3rd Floor
Brooklyn, NY 11201
(718)-488-3715
psemenza@tbh.org

DSH330056 NY

Covered outpatient drugs obtained through a Group Purchasing Organization from April 27, 2015 to January 4, 2016.

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

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

Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File and Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Repayment to manufacturers

CAP implemented

Audit closure date: May 19, 2017

Brookville Hospital CAH391312-00 PA

No adverse findings

None

N/A

Audit closure date: January 27, 2016

Brownsville Community Development Corporation
Contact Information

Controller

Brownsville Multi-Service Family Health Center

408 Rockaway Avenue
Brooklyn, New York 11212
(718) 345-6366 x6605
mwolf@bmsfhc.org

CH021960 NY

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

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

Repayment to Manufacturers

CAP implemented

Audit closure date: June 13, 2017

C.W. Williams Community Health Center, Inc.
Contact Information

Chief Executive Officer

(704) 391-0819
dweeks@cwwilliams.org
info@cwwilliams.org

CH047770 NC

Incorrect 340B database record - closed offsite outpatient facility listed on the 340B database

Entity did not provide contract pharmacy oversight.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: October 10, 2017

Carilion Medical Center
Contact Information

Chief Compliance and Audit Officer

213 S. Jefferson Street Suite 1201
Roanoke, VA 24012
(540) 510-4573
compliance@carilionclinic.org

DSH490024 VA

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; ineligible sites registered on the 340B database.

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 18, 2017

Cedars-Sinai Medical Center DSH050625 CA

No adverse findings

None

N/A

Audit closure date: February 14, 2017

Central Michigan Community Hospital dba McLaren Central Michigan
Contact Information

Director of Pharmacy

McLaren Central Michigan
1221 South Drive
Mt. Pleasant, MI 48858

James.baxter@mclaren.org

RRC230080-00 MI

Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drugs were not properly accumulated.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 18, 2018

Central North Alabama Health Services, Inc.
Contact Information

Compliance Officer
256-534-8659
110 Walker Avenue, Huntsville, AL 35801

CH048190 AL

Incorrect 340B database record – incorrect entry for primary contact; Registered contract pharmacy without written contract in place.

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

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: May 16, 2018

Children's Hospital of Los Angeles
Contact Information

Pharmacy Director

4650 Sunset Blvd
Los Angeles,
California 90027
Mailstop #44
(323) 361-5988

PED053302-00 CA

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

Repayment to Manufacturers

CAP implemented

Audit closure date: May 19, 2017

Children's Hospital of Philadelphia, The
Contact Information

Director of Pharmacy

The Children's Hospital of Philadelphia
3401 Civic Center Boulevard
Philadelphia, Pennsylvania, 19104
(215) 590-1893

PED393303-00 PA

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

Diversion – 340B drug dispensed to an inpatient.

Repayment to Manufacturers

CAP implemented

Audit closure date: January 29, 2018

Children’s Hospital PED193300-00 LA

No adverse findings

None

N/A

Audit closure date: January 27, 2016

Children’s Hospital Association, The PED063301-00 CO

No adverse findings

None

N/A

Audit closure date:
November 22, 2016

Chippewa County Montevideo Hospital CAH241325-00 MN

No adverse findings

None

N/A.

Audit closure date: September 8, 2016

Chota Community Health Services CH0442510 TN

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

None

CAP implemented

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

Audit closure date: June 21, 2017

Christus Spohn Hospital Beeville
Contact Information

Pharmacy Compliance Officer

CHRISTUS Spohn Hospital Region
600 Elizabeth St.
Corpus Christi, TX, 78404
(361) 881-3127
Elias.cavazos@christushealth.org

DSH450082 TX

Incorrect 340B database record – Incorrect entry for off-site outpatient facility address; registered contract pharmacies without written contract in place prior to February 9, 2016.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2017

Christus Spohn Hospital Corpus Christi Memorial
Contact Information

Pharmacy Compliance Officer

CHRISTUS Spohn Hospital Region
600 Elizabeth St.
Corpus Christi, TX, 78404
(361) 881-3127
Elias.cavazos@christushealth.org

DSH450046 TX

Incorrect 340B database record – Registered Contract Pharmacies without written contract in place prior to February 9, 2016.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP approved

Citrus Health Network Inc. CH0438180 FL

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

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: June 13, 2017

Claxton Hepburn Medical Center
Contact Information

Chief Financial Officer

(315)713-5350

214 King Street; Ogdensburg, New York 13669

SCH330211-00 NY

Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 3, 2018

Clinch River Health Services, Incorporated
Contact Information

Executive Director
(276) 467-7000
17633 Veterans Memorial Hwy.
Dungannon, VA 24245

CH031230 VA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 4, 2018

Clinica Sierra Vista CH090390
HV090390
CA

No adverse findings

None

N/A

Audit closure date: January 13, 2016

Clinicas del Camino Real, Inc. CH09365A CA

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

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 implemented

Audit closure date: April 4, 2017

Columbia St. Mary’s Hospital Milwaukee, Inc.
Contact Information

System Director of Pharmacy
414-585-1071, 2323
N. Lake Drive,
Milwaukee, WI 53211

DSH520051 WI

Incorrect 340B database - registered contract pharmacies without written contract in place.

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

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP implemented

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

Audit closure date: November 14, 2017

Comanche County Medical Center
Contact Information

Director of Pharmacy

SAbbey@comanchecmc.com
(254) 879-4961

CAH451382-00 TX

Incorrect 340B database record – Incorrect entry for Primary contact.

Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 30, 2017

Community Health Center of Snohomish County
Contact Information

Pharmacy Manager
425-551-6531

Pharmacy Lead 425-640-5491

8609 Evergreen Way Everett, WA 98208-2619

CH10228A WA

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

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

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

Repayment to manufactures

CAP implemented

Audit closure date: April 19, 2018

Community Hospital of LaGrange County CAH151323-00 IN

No adverse findings

None

N/A

Audit closure date: November 15, 2016

Community Memorial Healthcare, Inc. CAH171363-00 KS

No adverse findings

None

N/A

Audit closure date: June 1, 2016

Comprehensive Care Center, Inc.: DBA Community Aids Network RWII342371 FL

No adverse findings

None

N/A

Audit closure date: November 4, 2016

Conway Medical Center
Contact Information

Director of Pharmacy
Conway Medical Center
300 Singleton Ridge Road
Conway, SC 29526

(843) 347-8142

DSH420049 SC

Diversion – 340B drugs dispensed for prescriptions written at ineligible sites.

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 23, 2018

Copley Memorial Hospital
Contact Information

Director of Pharmacy

2000 Ogden Avenue
Aurora, IL 60504

DSH140029 IL

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

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: April 24, 2017

Cornell Scott-Hill Health Corporation CH010070 CT

No adverse findings

None

N/A
Audit closure date: March 9, 2016

Covenant Medical Center
Contact Information

Director of Pharmacy
(989) 583-4075
1447 N Harrison
Saginaw, Michigan 48602

DSH230070 MI

Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site.

Repayment to manufacturer

CAP implemented

Audit closure date: November 14, 2017

Crete Area Medical Center
Contact Information

President and CEO

Crete Area Medical Center
402.826.2102 or
rebekah.mussman@bryanhealth.org

CAH281354-00 NE

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2017

Cumberland Family Medical Center, Inc. CH0452070 KY

No adverse findings

None

N/A

Audit closure date: November 8, 2016

Decatur Memorial Hospital
Contact Information

Tom West, Director Decision Supports

2300 N. Edwards
Decatur, IL, 62526
(217) 876-2033
tomw@dmhhs.org

RRC140135-00 IL

Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: February 8, 2017

Down East Community Hospital
Contact Information

Chief Operating Office at 207-255-0217 or slail@hech.org or
Director of pharmacy services at 207-255-0422 or vamon@dech.org

CAH201311-00 ME

Incorrect 340B database record – Incorrect entry for offsite facility address.

Diversion – 340B drug dispensed at contract pharmacy for a prescription written at an ineligible site.

Repayment to manufacturer

CAP implemented

Audit closure date: June 13, 2017

Earl and Lorraine Miller Children’s Hospital of Long Beach
Contact Information

Executive Director, Pharmacy Services

2801 Atlantic Avenue
Long Beach, CA, 90806
(562) 933-0282
jhodding@memorialcare.org

PED053309-00 CA

Duplicate Discounts – Entity was billing at contract pharmacies without notifying HRSA of an arrangement with contract pharmacy, the entity and the State Medicaid agency.

Repayment to manufacturers

CAP approved

East Texas Medical Center Quitman
Contact Information

Administrator
(903) 763-6330
psswindle@etmc.org
ETMC Quitman,
117 N. Winnsboro Street,
Quitman, Texas 75783

CAH451380-00 TX

Diversion – 340B drug dispensed for prescription written at an ineligible site.

Repayment to manufacturer

CAP implemented

Audit closure date: March 15, 2017

Eastern Maine Medical Center DSH200033 ME

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 implemented

Audit closure date: August 11, 2017

Elica Health Centers CHC24113-00 CA

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

Entity did not provide contract pharmacy oversight.

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: March 2, 2016

Elmhurst Hospital Center (NYCHHC)
Contact Information

Vice President, New York City Health and Hospitals
(212) 748-2256
Paul.albertson@nychhc.org

DSH330128 NY

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site, not supported by medical record; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

CAP implemented

Audit closure date: February 8, 2017

Emory University Hospital Midtown
Contact Information

Chief Operating Officer

Emory University Hospital Midtown
550 Peachtree Street NE
Atlanta, GA, 30308
(404) 686-8903

DSH110078 GA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2017

Escambia County Health Department FP36502 AL

Incorrect 340B database record- Incorrect entry for Authorizing Official.

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

CAP implemented

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

Audit closure date: June 13, 2017

Fenway Community Health Center, Inc. CH010600 MA

No adverse findings

None

N/A

Audit closure date: December 15, 2015

First Choice Community Healthcare
Contact Information

Chief Operating Officer

2001 N. Centro Familiar SW, Albuquerque, NM 87105-4592
Melissa_manlove@fcch.com
(505) 873-7474

CH060240 NM

Incorrect 340B database record – Utilized contract pharmacies prior to registering on the 340B database.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to Manufacturers

CAP implemented

Audit closure date: May 12, 2017

FirstHealth Moore Regional Hospital
Contact Information

Chief Operating Officer

Administrative Director of Pharmacy
(910) 715-1093
mcowell@firsthealth.org

RRC340115-00 NC

Diversion – 340B drugs were not properly accumulated.

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

Repayment to Manufacturers

CAP implemented

Audit closure date: February 23, 2018

FoundCare, Inc. CHC26626-00 FL

No adverse findings

None

N/A

Audit closure date: April 27, 2016

Gaston Memorial Hospital
Contact Information

Director of Pharmacy

mark.chaparro@caromonthealth.org
(704) 8342239

DSH340032 NC

Incorrect 340B database record Pharmacy incorrectly registered as child site.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2017

Geisinger Medical Center
Contact Information

Program Director 340B Program

Geisinger Medical Center
100 N. Academy Avenue
Danville, PA 17821-4201
(570) 214-0155

DSH390006 PA

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites; 340B drug dispensed, not supported by medical record.

Repayment to manufacturers

CAP implemented

Audit closure date: February 10, 2017

George County Hospital SCH250036-00 MS

No adverse findings

None

N/A

Audit closure date: September 7, 2016

Golden Valley Memorial Hospital District RRC260175-00 MO

No adverse findings

None

N/A

Audit closure date: September 26, 2016

Grossmont Hospital
Contact Information

Manager of Pharmacoeconomics

8695 Spectrum Center Blvd
San Diego, CA 92130
858-499-4220

DSH050026 CA

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

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: May 19, 2017

Harborview Medical Center DSH500064 WA

No adverse findings

None

N/A

Audit closure date: April 14, 2016

Harlem Hospital (NYCHHC) DSH330240 NY

No adverse findings

None

N/A

Audit closure date: July 14, 2016

Harris County Hospital District dba Harris Health System Ben Taub Hospital DSH450289 TX

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

None

CAP implemented

Audit closure date: November 22, 2016

Hawkins County Memorial Hospital DSH440032 TN

No adverse findings

None

N/A

Audit closure date: November 2, 2016

Healthreach Community Health Centers
Contact Information

Chief Executive Officer

Healthreach Community Health Centers
237 Main Street
Bingham, Maine 04920
(207) 872-5610
constance.coggins@healthreach.org

CH010460 ME

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 29, 2018

Ho Ola Lahui Hawaii CH091290 HI

No adverse findings

None

N/A

Audit closure date: June 7, 2016

Hospital of the University of Pennsylvania, The
Contact Information

Controller

(215) 349-8810
3400 Spruce Street
Ground Rhoads,
Philadelphia, PA 19104

DSH390111 PA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 21, 2016.

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; duplicate entry for offsite outpatient facility; Ineligible site registered on 340B database.

Diversion – 340B drugs dispensed for prescriptions originating at ineligible sites; 340B drugs dispensed, not supported by medical records; 340B drugs were not properly accumulated.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2018

HSHS Holy Family Hospital, Inc. (formerly Greenville Regional Hospital, Inc.)
Contact Information

HSHS Holy Family Greenville
Attn: Director of Pharmacy
200 Healthcare Drive
Greenville, IL 62246
618-690-3427
Katlyn.obermark@hshs.org

DSH140137 IL

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites.

Repayment to manufacturers

CAP approved

Ingalls Memorial Hospital DSH140191 IL

No adverse findings

None

N/A

Audit closure date: July 6, 2016

Institute for Family Health, The
Contact Information

Sr. Vice President of Regulatory
Affairs and Human Resources

The Institute for Family Health

2006 Madison Ave
New York, NY 10035
Office: (212) 633-0815 x1241
Cell: (914) 497-8135
E-Fax: (212) 359-3270
Nnurse@institute.org

CH02371C NY

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 31, 2018

Jackson County Health Department
Contact Information

Director of Administration

4025 Bald Cypress Way, Bin A-20,
Tallahassee, Florida 32399-1708
(850) 245-4444, ext. 2311

TB324469
STD32446
FP32446
FL

(FP324461) Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

(TB324469, STD32446) Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: August 21, 2018

Johns Hopkins Hospital
Contact Information

Assistant Director, Pharmacy

5901 Holabird Avenue, Suite A-2
Baltimore, Maryland 21224
(585) 770-0391

DSH210009 MD

Diversion – 340B drug dispensed at contract pharmacies for prescriptions originating from ineligible site.

Repayment to manufacturers

CAP implemented

Audit closure date: February 22, 2017

Kadlec Regional Medical Center DSH500058 WA

No adverse findings

None

N/A

Audit closure date: November 23, 2016

Kaweah Delta Health Care District DSH050057 CA

No adverse findings

None

N/A

Audit closure date: September 15, 2016

Kennewick General Hospital
Contact Information

Pharmacy Director

(509) 221-7351

900 S. Auburn Street
Kennewick, WA 99336

DSH500053 WA

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

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: June 13, 2017

Kern Medical Center
Contact Information

Associate Director of Pharmacy

Kern Medical
Trailer #1
1700 Mt. Vernon Ave.
Bakersfield, CA 93306

(661) 326-5682 / (661) 326-2617

DSH050315 CA

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: April 3, 2018

Klamath Health Partners Inc.
Contact Information

Klamath Health Partnership, Inc.
2074 S. 6th Street
Klamath Falls, OR 97601
Contact: CFO
541-851-8110 x2022
sporter@kodfp.org

CH102910 OR

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: May 16, 2018

Labette County Medical Center D/B/A Labette Health
Contact Information

340B Specialist
Labette County Medical Center
1902 S HWY 59
Parsons, KS 67357
(620) 421-4881
tgilmore@LabetteHealth.com

SCH170120-00 KS

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: January 29, 2018

Legacy Salmon Creek Medical Center DSH500150 WA

No adverse findings

None

N/A

Audit closure date: December 13, 2016

Lester E Cox Medical Centers
Contact Information

CoxHealth 340B Coordinator

Pharmacy Department
3801 South National Avenue
Springfield, MO 65807

(417) 269-6231

Stacie.reed@coxhealth.com

DSH260040 MO

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: July 20, 2018

LifeLong Medical Care CH092880 CA

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

Ineligible site registered on 340B database; Incorrect entry for address of a contract pharmacy.

Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites.

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

Repayment to manufacturers

Pending

Lincoln County Medical Center CAH321306-00 NM

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

None

CAP implemented

Audit closure date: March 15, 2017

Long Beach Memorial Medical Center
Contact Information

Executive Director of Pharmacy

(562)933-0282

2801 Atlantic Ave
Long Beach, CA 90806

DSH050485 CA

Incorrect 340B database record – Incorrect entry for a shipping address.

Diversion – 340B drugs purchased on entities account were dispensed to patients of a separate covered entity.

Duplicate Discounts – Entity was billing at contract pharmacies without notifying HRSA of an arrangement with contract pharmacy, the entity and the State Medicaid agency; Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayments to manufacturers

CAP implemented

Audit closed September 19, 2018

Lucile Packard Children’s Hospital
Contact Information

Pharmacy Compliance Analyst
(650) 736-4075
4600 Bohannon Drive
Suite 105
Menlo Park, CA 94025

PED053305-00 CA

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

Repayments to manufacturers

CAP implemented

Audit closure date: January 29, 2018

Madison Health
Contact Information

Director of Pharmacy

Madison Health
210 N. Main Street,
London, Ohio 43140
(740) 845-7352

DSH360189 OH

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to Manufacturers

CAP implemented

Audit closure date: April 18, 2017

Maimonides Medical Center
Contact Information

Director of Pharmacy, V.P. Pharmaceutical Services

Maimonides Medical Center
4802 Tenth Avenue
Brooklyn, New York 11219

Phone: (718) 283-7205
Fax: (718) 283-8029

E-mail: fcassera@maimonidesmed.org

DSH330194 NY

Diversion – 340B drugs were not properly accumulated; 340B drugs dispensed at contract pharmacies for prescriptions 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: June 22, 2018

Maricopa Integrated Health System
Contact Information

Director of Pharmacy

Maricopa Integrated Health System
2601 East Roosevelt St.
Phoenix, AZ 85008

(602) 739-2781

HCLA225A AZ

Incorrect 340B database record – Incorrect entries for offsite outpatient facilities names.

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 5, 2018

Marshall Medical Center CAH441309-00 TN

No adverse findings

None

N/A

Audit closure date: January 25, 2017

Marshall Medical Center South
Contact Information

340B Coordinator
256-894-6733
Marshall Medical Centers, Finance Department,
227 Brittany Rd,
Guntersville, AL 35976

DSH010005
(formerly RRC010005-00)
AL

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drug dispensed, not supported by medical record.

Repayment to manufacturers

CAP implemented

Audit closure date: November 14, 2017

Mary Hitchcock Memorial Hospital
Contact Information

Director of System Pharmacy Operations

One Medical Center Drive
Lebanon, NH 03756
603-653-2381

RRC30003-00 NH

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site, not supported by medical record.

Repayment to manufacturers

CAP implemented

Audit closure date: May 5, 2017

Mayers Hospital
Contact Information

Chief Clinical Officer
(530) 336-5511 x1153
kearnest@mayersmemorial.com

CAH051305-00 CA

Incorrect 340B database record - Registered contract pharmacy without written contract in place.

Diversion-340B drugs dispensed at contract pharmacy for prescriptions originating from ineligible sites.

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

Termination of contract pharmacies from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: July 19, 2017

Meade District Hospital CAH171321-00 KS

No adverse findings

None

N/A

Audit closure date: May 17, 2016

Memorial Hermann Northeast Hospital DSH450684 TX

No adverse findings

None

N/A

Audit closure date: July 18, 2016

Memorial Hospital at Gulfport
Contact Information

Manager, Outpatient Pharmacy Services

4500 13th Street
PO Box 1810
Gulfport, MS, 39502-1810
(228) 867-4485

DSH250019 MS

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 27, 2016

Mercy Catholic Medical Center
Contact Information

340B Program Manager
(610) 237-4062
Mercy Fitzgerald Hospital
Pharmacy Department
1500 Lansdowne Avenue
Darby, Pennsylvania 19023

DSH390156 PA

Entity did not provide contract pharmacy oversight.

Diversion-340B drugs dispensed at contract pharmacy for prescriptions originating from ineligible sites.

Termination of contract pharmacies from 340B Program.

Repayment to manufacturers.

CAP implemented

Audit closure date: October 10, 2017

Mercy Medical Center Merced DSH050444 CA

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

None

CAP implemented

Audit closure date: March 8, 2017

Methodist Dallas Medical Center
Contact Information

Jon Albrecht

jonalbrecht@mhd.com
(214) 947-2416

DSH450051 TX

Incorrect 340B database record – Incorrect entry for Primary contact.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2017

Methodist Healthcare – Memphis Hospitals
Contact Information

340B Program Manager

Methodist Le Bonheur Healthcare
1350 Concourse Avenue Suite 668
Memphis, TN 38104

901-516-2440

Christopher.Bell@mlh.org

DSH440049 TN

Diversion –340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2018

MetroHealth Medical Center
Contact Information

Mario Pisano, Pharm.D.,

2500 MetroHealth Dr.
Cleveland, OH, 44109
(216) 778-3362

DSH360059 OH

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

Repayment to manufacturer

CAP implemented

Audit closure date: February 14, 2017

Mission Hospitals Inc
Contact Information

340B Program Pharmacy Specialist
alan.knudsen@msj.org
Mission Health System
509 Biltmore Avenue
Asheville, North Carolina 28801

DSH340002 NC

Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: April 3, 2018

Nassau Health Care Corporation
Contact Information

Director of Pharmacy

2201 Hempstead Turnpike
East Meadow, New York 11554
mknee@numc.edu
(516) 572-4796

DSH330027 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 4, 2016.

Incorrect 340B database – Offsite outpatient facility was not listed on 340B database.

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site.

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

Repayment to manufacturer

CAP implemented

Audit closure date: January 28, 2019

Natchitoches Regional Medical Center SCH190007-00 LA

No adverse findings

None

N/A

Audit closure date: July 18, 2016

National Jewish Medical and Research Center DSH060107
BL80206X
CO

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

Termination of contract pharmacy from the 340B Program*

CAP implemented

Audit closure date: April 6, 2016

Nebraska Medical Center, The
Contact Information

Business Director, Pharmacy

988138 Nebraska Medical Center
Omaha, NE, 68198-8138
(402) 559-9537

DSH280013 NE

Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

New York Methodist Hospital
Contact Information

Chief of Pharmacy
Erb9001@nyp.org
(718) 780-5575

DSH330236 NY

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drugs dispensed to inpatients.

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2017

Newark Community Health Centers, Inc. CH020500 NJ

No adverse findings

None

N/A

Audit closure date: June 7, 2016

North Carolina Baptist Hospital
Contact Information

Pharmacy Manager – Medication Control and Compliance

Wake Forest Baptist Hospital
Medical Center Blvd
Winston Salem, NC, 27157
(336) 716-6456

DSH340047 NC

Diversion – 340B drug dispensed for prescription originating from ineligible site, not supported by a medical record.

Repayment to manufacturers

CAP approved

North Shore Medical Center DSH220035 MA

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: March 8, 2017

Northbay Healthcare Group DSH050367 CA

No adverse findings

None

N/A

Audit closure date: April 21, 2016

Northeast Community Action Corp FP63334 MO

No adverse findings

None

N/A

Audit closure date: September 7, 2016

Northern Inyo Hospital
Contact Information

340B Informatics Pharmacist

150 Pioneer Lane
Bishop, California 93514
(760) 873-2111

CAH051324-00 CA

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

Repayment to Manufacturers

CAP implemented

Audit closeout date: August 14, 2017

Northridge Hospital Medical Center
Contact Information

Director of Pharmacy
(818) 885-8500 ext 2606

DSH050116 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 11, 2016.

Diversion – 340B drug not supported by a medical record.

Repayment to manufacturers

CAP implemented

Audit closure date: February 23, 2018

Northside Hospital, Inc.
Contact Information

340B Coordinator, Pharmacist, Pharmacy Systems Manager

1000 Johnson Ferry Road
Atlanta, GA 30342
(404) 851-8528

DSH110161 GA

Diversion – 340B drug for a prescription written at an ineligible site.

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

Repayment to manufacturer

CAP implemented

Audit closure date: February 22, 2017

Obleness Memorial Hospital DSH360014 OH

No adverse findings

None

N/A

Audit closure date: March 7, 2017

Ochsner Clinic Foundation DSH190036 LA

No adverse findings

None

N/A

Audit closure date:
February 24, 2016

Olean General Hospital
Contact Information

Senior Vice President Finance and Chief Financial Officer
(716) 375-6190
rbraun@uahs.org

RRC330103-00 NY

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: April 3, 2018

OneWorld Community Health Centers, Inc. CH076290 NE

No adverse findings

None

N/A

Audit closure date: May 13, 2016

OSF Holy Family Medical Center
Contact Information

340B Drug Program Manager
Josh.r.mccarroll@osfhealthcare.org
(309) 308-3295

CAH141318-00 IL

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: October 3, 2017

Ozarks Medical Center
Contact Information

Director of Pharmacy
(417)257-5837
sherrie.lane@ozarksmedicalcenter.com

DSH260078 MO

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 9, 2018

PeaceHealth St. John Medical Center DSH500041 WA

No adverse findings

None

N/A

Audit closure date: October 20, 2016

Penobscot Bay Medical Center
Contact Information

Director of Operational Excellence
207-921-8210
mradloff@penbayhealthcare.org

DSH200063 ME

Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites, not supported by a medical record; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

CAP approved

Planned Parenthood Mohawk Hudson FP135021 NY

No adverse findings

None

N/A

Audit closure date: December 7, 2015

Positive Impact Health Centers, Inc. HV00799 GA

No adverse findings

None

N/A

Audit closure date: December 15, 2015

Presbyterian Medical Services, Inc.
Contact Information

Director of Pharmacy and Laboratory Services

1422 Paseo de Peralta
Sante Fe, New Mexico 87501

505-820-3491

CH063450 NM

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 18, 2018

Princeton Community Hospital
Contact Information

Director of Pharmacy:

sdrady@pchonline.org
304-487-7564

DSH510046 WV

Diversion – 340B drugs dispensed at contract pharmacy for prescriptions originating at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: January 3, 2017

Providence Health and Services - Washington
Contact Information

Regional 340B Program Manager

101 W. 8th Ave
Attn: Pharmacy
Spokane, WA 99204
(509) 474-3244

DSH500014 WA

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

Diversion - 340B drugs dispensed to inpatients; 340B drugs dispensed for prescriptions originating from ineligible sites.

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

Repayment to Manufacturers

CAP approved

Audit closure date: August 8, 2017

River Valley Primary Care Services
Contact Information

340B Coordinator/Admin Manager

9755 West State Highway 22
P.O. Box 130
Ratcliff, Arizona 72951
(479) 635-5300 x225

CH061202A AR

Incorrect 340B database record – Registered Contract Pharmacies without written contract in place prior to December 11, 2015.

Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site.

Repayment to manufacturer

CAP implemented

Audit closure date: March 1, 2017

Riverside County Regional Medical Center
Contact Information

Director of Pharmacy Services

Riverside University Health System
(951) 486-4529
G.Prouty@RUHealth.org

DSH050292 CA

Incorrect 340B database record – Incorrect entry for off-site outpatient facility’s name.

Diversions – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP approved

Riverside Medical Center CAH191313-00 LA

No adverse findings

None

N/A

Audit closure date:January 21, 2016

Robeson Health Care Corp
Contact Information

Director of Pharmacy Services

(910) 674-3174

402 N.Pine Street
Lumberton, NC 28358

CH049000 NC

Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site.

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 30, 2018

Rush Foundation Hospital DSH250069 MS

No adverse findings

None

N/A

Audit closure date: November 1, 2016

Sacred Heart Health System DSH100025 FL

No adverse findings

None

N/A

Audit closure date: August 24, 2016

Saint Francis Hospital and Medical Center
Contact Information

Pharmacy Director
860-714-7983

Interim VP Integrity & Compliance
860-714-0437
Jamie.McKay@trinityhealth-ne.org

DSH070002 CT

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

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 as a result of this finding.

Audit closure date: April 3, 2018

Saint Francis Medical Center
Contact Information

Josh McCarroll

800 N. E. Glen Oak Avenue
Peoria, IL, 61603
(309) 308-3295
josh.r.mccarroll@osfhealthcare.org

DSH140067 IL

Diversion – 340B drugs dispensed to inpatients, 340B drugs dispensed at contract pharmacies for prescriptions 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: March 30, 2017

Saint Mary's Health Care
Contact Information

Director of Pharmacy Services

Mercy Health Saint Mary's
200 Jefferson Avenue SE
Grand Rapids, Ml 49503
(616) 685-5000

DSH230059 MI

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

Diversion – Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

CAP approved

Saint Peter’s University Hospital
Contact Information

Chief Financial Officer

254 Easton Avenue
New Brunswick, NJ 08901
(732) 745-6651
gstoldt@saintpetersuh.com

DSH310070 NJ

Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 23, 2016.

Diversion – 340B drugs were not properly accumulated.

Diversion – 340B drug dispensed to an inpatient; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: April 3, 2018

Samaritan Pacific Health Systems, Inc. DBA Samaritan Pacific Community Hospital CAH381314-00 OR

No adverse findings

None

N/A

Audit closure date: November 4, 2016

Sanford Bemidji Medical Center
Contact Information

Director of Pharmacy
(218) 333-5543
karla.eischens@sanfordhealth.org
1300 Anne Street NW
Bemidji, Minnesota 56601

DSH240100 MN

Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at contract pharmacy, not supported by medical record

Repayment to manufacturers

CAP implemented

Audit closure date: April 18, 2017

Sanford Medical Center Fargo RRC350011-00 ND

No adverse findings

None

N/A

Audit closure date: September 7, 2016

Sanford USD Medical Center DSH430027 SD

Incorrect 340B database record – Incorrect entry for grant number prior to December 21, 2015.

None

CAP implemented

Audit closure date: April 6, 2016

Scripps Mercy Hospital
Contact Information

340B Program Director
(619) 260-7308
Todd.shohreh@scrippshealth.org

DSH050077 CA

Incorrect 340B database record ineligible sites registered on the 340B database prior to April 1, 2016.

Diversion –340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites;

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: March 8, 2017

Seton Edgar. B. Davis Hospital CAH451371-00 TX

Incorrect 340B database record – closed offsite outpatient facility listed on the 340B database; incomplete address listing for an offsite outpatient facility.

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

None

Pending

Sharp County Health Unit FP725131
STD722054
TB722057
AR

No adverse findings

None

N/A

Audit closure date: January 6, 2016

Sharp Memorial Hospital
Contact Information

Manager of Pharmacoeconomics

8695 Spectrum Center Blvd
San Diego, CA, 92130
(858) 499-4220

DSH050100 CA

Incorrect 340B database record Duplicate entry for offsite outpatient facility.

Diversion 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2017

Sinai Hospital of Baltimore
Contact Information

Executive Director of Outpatient Pharmacy

5401 Old Court Rd.
Randallstown, MD 21133
(410) 521-1772

DSH210012 MD

Diversion - 340B drug dispensed to an inpatient; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites. Incorrect or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2017

Singing River Health System
Contact Information

Administrator of Ancillary Services
heath.thompson@mysrhs.com
(228) 818-1191

DSH250040 MS

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 10, 2017

Sisters of Charity
Contact Information

Sisters of Charity Hospital c/o Catholic Health System

340B Program Business Manager

Administrative Regional Training Center- 4th Floor West
144 Genesee Street
Buffalo, New York 14203

(716) 923-2920
dshuldman@chsbuffalo.org

DSH330078 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to October 19, 2016.

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 11, 2018

SMDC Medical Center DSH240019 MN

No adverse findings

None

N/A

Audit closure date: April 24, 2017

South Georgia Medical Center
Contact Information

Director of Pharmacy

South GA Medical Center
2501 N. Patterson Street
Valdosta, GA 31602
(229) 259-4870

DSH110122 GA

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP approved

Southwest Georgia Health Care, Inc. CH043340 GA

No adverse findings

None

N/A

Audit closure date: October 4, 2016

Spartanburg Medical Center
Contact Information

Manager SRHS Pharmacy Business Operations

Spartanburg Medical Center
101 East Wood Street
Spartanburg, SC

864-560-6772 option #3, #3, #1

DSH420007 SC

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 11, 2018

SSM St. Anthony Hospital
Contact Information

System Vice President Finance – Oklahoma
1000 N. Lee Street
PO Box205
Oklahoma City, OK 73101
405.272.7279

DSH370037 OK

Incorrect 340B database record – incorrect entry for shipping address.

Diversion – 340B drugs dispensed to inpatients; 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to Manufacturers

CAP implemented

Audit closure date: October 13, 2016

St. Bernardine Medical Center
Contact Information

Director of Pharmacy

(909) 881-4473

kenneth.le@dignityhealth.org

DSH050129 CA

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: October 10, 2017

St. Claire Medical Center, Inc. DSH180018 KY

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 implemented

Audit closure date: February 23, 2018

St. Francis Memorial Hospital CAH281322-00 NE

Entity did not provide contract pharmacy oversight prior to November 2016.

None

Pending

St. Johns Riverside Hospital
Contact Information

Janine O’Donnell

967 N. Broadway
Yonkers, NY, 10701
(914) 964-4827

DSH330208 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to November 16, 2015.

Diversion – 340B drugs were not properly accumulated.

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers

CAP implemented

Audit closure date: February 22, 2017

St. Joseph’s Health Services, Inc. dba St. Joseph’s Health Services-Gundersen Lutheran CAH521304-00 WI

No adverse findings

None

N/A

Audit closure date: January 6, 2016

St. Joseph’s Medical Center DSH050084 CA

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

Termination of contract pharmacies from the 340B Program*

CAP implemented

Audit closure date: February 8, 2017

St. Vincent Charity Medical Center
Contact Information

Chief Financial Officer

2351 East 22nd Street
Cleveland, Ohio, 44115

DSH360037 OH

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

Diversion 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites.

Termination of contract pharmacies from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: October 3, 2017

Sterling Area Health Center
Contact Information

Patient Assistant Coordinator

725 East State Street
Sterling, MI 48659
(989) 654-2491 ext 3766

CH052250 MI

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 2, 2017

Stillwater Medical Center Authority SCH370049-00 OK

No adverse findings

None

N/A

Audit closure date: April 20, 2016

Stormont-Vail Healthcare Inc. DSH170086 KS

No adverse findings

None

N/A

Audit closure date:
January 24, 2017

Summersville Memorial Hospital DSH510082 WV

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 4, 2016.

Offsite outpatient facility failed to maintain auditable records.

Incorrect 340B database records – Offsite outpatient facilities were not listed on the 340B database; incorrect listing for Authorizing Official

Diversion- 340B drugs dispensed to inpatients; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.

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

Termination of covered entity from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: January 3, 2018

Summit Healthcare Association DBA Summit Healthcare Regional Medical Center DSH030062 AZ

No adverse findings

None

N/A

Audit closure date: April 1, 2016

Sun Life Family Health Center, Inc.
Contact Information

Director of Pharmacy
520-350-7590

CEO
520-836-3446

865 N. Arizola Rd.
Casa Grande, AZ 85122

CH090030 AZ

Incorrect 340B database record – Incorrect listing for shipping addresses; and inaccurate entries for names of offsite facilities.

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 12, 2018

Sutter Medical Center Sacramento DSH050108 CA

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; closed offsite outpatient facility listed on the 340B database; pharmacy incorrectly registered as a child site.

None

CAP implemented

Audit closure date: July 15, 2016

Sutton County Hospital District
Contact Information

Director of Pharmacy Services

325-387-1220

Pharmacy@sonora-hospital.com

CAH451324-00 TX

Diversion – 340B drugs dispensed at contract pharmacy for prescription originating from ineligible site.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 3, 2018

Tacoma General/ Allenmore Hospital
Contact Information

Pharmacy Purchasing Manager
(253) 403-2082
vafa.aflatooni@multicare.org
PO Box 5299, Mailstop 315-C2-RX,
315 Martin Luther King Jr Way,
Tacoma, WA, 98415-0299

DSH500129 WA

Diversion – 340B drugs dispensed at the covered entity for prescriptions originating from ineligible sites

Repayment to manufacturers

CAP implemented

Audit closure date: January 10, 2018

Thayer County Memorial Hospital dba Thayer County Health Services CAH281304-00 NE

No adverse findings

None

N/A.

Audit closure date: September 7, 2016

The Cooper Health System dba Cooper University Hospital DSH310014 NJ

Incorrect 340B database record – Incorrect entry for DSH percentage

None

CAP implemented

Audit closure date: April 19, 2018

Touro Infirmary
Contact Information

340B Program Coordinator; Touro Infirmary

1401 Foucher St.
New Orleans, LA, 70115
(504) 897-7515
daniel.henry@lcmchealth.org

DSH190046 LA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 5, 2017

Tuality Healthcare
Contact Information

Director of Pharmacy
503-681-1041
Kevin.declercque@tuality.org

DSH380021 OR

Covered outpatient drugs obtained through a Group Purchasing Organization from August 7, 2013 to July 30, 2016.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: August 21, 2018

Uintah Basin Medical Center SCH460019-00 UT

No adverse findings

None

N/A

Audit closure date: June 14, 2016

Umpqua Community Health Center, Inc.
Contact Information

Chief Compliance Officer

150 Kenneth Ford Drive
Roseburg, OR 97470
(541) 672-9596 x107
jpospisil@umpquach.org

CH103100 OR

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. State Medicaid has since determined that duplicate discounts did not occur as a result of this finding.

Duplicate Discounts - Entity was billing at contract pharmacies and contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers.

CAP implemented

Audit closure date: June 13, 2017

Unconditional Love, Inc. HV32935 FL

No adverse findings

None

N/A

Audit closure date: September 23, 2016

United Hospital
Contact Information

Pharmacy Portfolio Manager

2925 Chicago Avenue
Mail Route 10807
Minneapolis, MN, 55407
(612) 262-4785
Tony.Collins-Kwong@allina.com

DSH240038 MN

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 19, 2017

University Hospital
Contact Information

Director of Pharmacy

University Hospital
1350 Walton Way
Augusta, Georgia 30901

(706) 774-2718

DSH110028 GA

Diversion - 340B drugs dispensed at the entity for prescriptions originating at ineligible sites.

Repayment to manufacturers

CAP approved

University Hospital DSH330241 NY

Diversion – 340B drug dispensed to an inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: February 23, 2018

University Hospitals and Clinics
Contact Information

Chief Integrity and Compliance Officer

University of Mississippi Medical Center
2500 North State Street
Jackson, MS, 39216

DSH250001 MS

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacy without written contract in place.

Diversion – 340B drugs dispensed at the entity and at contract pharmacies for prescriptions originating from ineligible sites.

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: November 2, 2017

University Medical Center Management Corporation d/b/a University Medical Center New Orleans
Contact Information

Pharmacy Director

2000 Canal Street
New Orleans, Louisiana 70112
Anthony.Laurent@LCMCHealth.org
(504) 702-3588

DSH190005 LA

Diversion – 340B drug dispensed to an inpatient.

Repayment to manufacturer

CAP implemented

Audit closure date: May 18, 2017

University of Illinois Hospital DSH140150 IL

No adverse findings

None

N/A

Audit closure date: May 20, 2016

University of Iowa Hospitals & Clinics DSH160058 IA

Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for grant number.

None

CAP implemented

Audit closure date: September 27, 2016

University of Maryland Medical Center
Contact Information

Senior Director of Pharmacy

29 S. Greene St.
Baltimore, Maryland, 21201
(410) 328-6746
jdicubellis@umm.edu

DSH210002 MD

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers

CAP implemented

Audit closure date: September 15, 2016

University of Minnesota Medical Center DSH240080 MN

Incorrect 340B database record – Incorrect entry for offsite facility address.

None

CAP implemented

Audit closure date: February 22, 2017

University of Tennessee Medical Center
Contact Information

340B Pharmacist
(865) 305-8174
vshelton@utmck.edu

DSH440015 TN

Diversion – 340B drug dispensed to an inpatient; 340B drug dispensed at the entity for a prescription originating from ineligible site.

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2017

University of Utah Hospital DSH460009 UT

No adverse findings

None

N/A

Audit closure date: March 29, 2016

University of Washington Medical Center DSH500008 WA

No adverse findings

None

N/A

Audit closure date: September 27, 2016

Valley Health Systems
Contact Information

Associate CFP
3377 US Route 60, Huntington WV 25705

(304) 525-3334 (ext. 5110)

CH030880 WV

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites

Repayment to manufacturers

CAP implemented

Audit closure date: August 14, 2018

VNA Health Care
Contact Information

Vice President of Specialty Care and Wellness Services

400 N. Highland Avenue
Aurora Illinois 60506
(630) 978-2532 Ext.8116

CH0526100 IL

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

Diversion – 340B drug dispensed at the entity for a prescription originating from ineligible site.

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

Termination of contract pharmacies from the 340B Program*

Repayment to manufacturers

CAP approved

State Medicaid has since determined that duplicate discounts did not occur

Webster County Health Department FP397443 MS

No adverse findings.

None

N/A

Audit closure date: November 15, 2016

West Penn Hospital
Contact Information

Director, Outpatient Pharmacy Services:

412-578-4050 or Jdavis@wpahs.org

DSH390090 PA

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database.

Diversion – 340B drug dispensed at a contract pharmacy for a prescription originating from ineligible site.

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

Repayment to Manufacturers

CAP approved

Audit closure date: August 8, 2017

Westside Family Healthcare, Inc. CH032960 DE

No adverse findings

None

N/A

Audit closure date: October 4, 2016

Winter Haven Hospital
Contact Information

Manager of BayCare Pharmacy Supply Chain

Winter Haven Hospital
200 Avenue F, NE
Winter Haven, FL, 33881
(863) 293-1121 x1432

DSH100052 FL

Incorrect 340B database record – Duplicate listing of a facility on the 340B database.

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

Repayment to manufacturers

CAP approved

WomenCare, Inc. CH038440 WV

No adverse findings

None

N/A

Audit closure date: November 8, 2016

Woodland Memorial Hospital
Contact Information

Director of Pharmacy

1325 Cottonwood St. Woodland, CA 95695

530-669-5506

Denise.foreman@dignityhealth.org

DSH050127 CA

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database.

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

Repayment to manufactures

CAP implemented

Audit closure date: May 16, 2018

Yale New Haven Hospital DSH070022 CT

No adverse findings

None

N/A

Audit closure date:
December 29, 2016

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

Date Last Reviewed: