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Program Integrity: FY17 Audit Results

Updated 1/15/21. 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 199 audits.
Entity Sort descending 340B ID State OPA Findings Sanction Corrective Action Status
Access Community Health Network
Contact Information

Program Manager for 340B
600 W. Fulton, 2nd Floor, Chicago, IL 60661
(312) 526-2107

CH051750 IL

Incorrect 340B database record – Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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: April 5, 2018

Access Community Health Network FP60101 IL

No adverse findings

None

N/A

Audit closure date: October 23, 2017

Addabbo Joseph Family Health Center, The
Contact Information

Chief Financial Officer
6200 Beach Channel Drive
Arverne, NY 11692
(718) 945-7150 x1311

CH022110 NY

Incorrect 340B database record – Incorrect entry for Primary Contact; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 13, 2018

Adelante Healthcare, Inc.
Contact Information

340B Program Coordinator
9520 W Palm Ln, Ste. 200
Phoenix, AZ 85037
(623) 583-3001 x1312

CH093030 AZ

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate registrations of contract pharmacies on database; Registered contract pharmacy without written contract in place.

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

Termination of contract pharmacy from the 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: November 8, 2018

Advocate Christ Medical Center DSH140208 IL

No adverse findings

None

N/A

Audit closure date: June 21, 2017

Advocate North Side Health Network DSH140182 IL

No adverse findings

None

N/A

Audit closure date: June 28, 2017

Allen County Hospital
Contact Information

Comptroller
3066 N Kentucky St
Iola, KS 66749
(620) 365-1034

CAH171373-00 KS

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

Diversion - 340B drug dispensed at a contract pharmacy to a patient at entity without a documented provider to patient relationship.

Repayment to manufacturer

CAP implemented

Audit closure date: November 7, 2018

Amery Regional Medical Center
Contact Information

Director of Pharmacy
Amery Regional Medical Center
265 E. Griffin Street
Amery, WI 54001
(715) 268-0670

CAH521308-00 WI

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 25, 2019

Appalachian Regional Healthcare dba Morgan County ARH Hospital CAH181307-00 KY

No adverse findings

None

N/A

Audit closure date: July 25, 2017

Aspirus Iron River Hospital and Clinics
Contact Information

Chief Financial Officer
340B Authorizing Official
Aspirus Iron River Hospital and Clinics
1400 West Ice Lake Road
Iron River, Michigan 49935
(906) 265-0436
Glenn.Dobson@Aspirus.org

CAH231318-00 MI

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

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

Repayment to manufactures

CAP implemented

Audit closure date: November 15, 2018

Aspirus Medford Hospital and Clinics, Inc. CAH521324-00 WI

No adverse findings

None

N/A

Audit closure date: August 22, 2017

AU Medical Center, Inc.
Contact Information

340B Program Manager
AU Medical Center, Inc.
1120 15th Street, BI-2101
Augusta, GA 30912
(706) 721-0082

DSH110034 GA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: December 18, 2018

Avera St. Benedict Health Center CAH431330-00 SD

No adverse findings

None

N/A

Audit closure date: September 7, 2017

Baptist Health Corbin
Contact Information

340B Program Manager
Baptist Health System Services
2701 Eastpoint Parkway
Louisville, KY 40223
(502) 253-4746
quanika.penny@bhsi.com

DSH180080 KY

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

Repayment to manufacturer

CAP implemented

Audit closure date: December 4, 2018

Baptist Health Lagrange DSH180138 KY

No adverse findings

None

N/A

Audit closure date: October 19, 2017

Baptist Health Lexington
Contact Information

340B Program Manager
Baptist Health System Services
2600 Eastpoint Parkway, Suite 103
Louisville, KY 40223
(502) 253-4746

DSH180103 KY

Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed at entity for prescriptions written at an ineligible site.

Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

Baptist Health Medical Center - Arkadelphia
Contact Information

Senior Reimbursement Specialist
Baptist Health - Little Rock, AR
Attn: Accounting
9601 Baptist Health Drive
Little Rock, AR 72205
(501) 202-1813 Office
(501) 202-2385 Fax

CAH041321-00 AR

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 2, 2018

Baptist Hospital of Miami, Inc.
Contact Information

Director, Supply Chain Quality Assurance
9001 NW 33 Street
Doral, FL 33172
786-595-9023
haleyf@baptisthealth.net

DSH100008 FL

Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 17, 2017

Diversion - 340B drugs dispensed at entity for prescriptions written at an 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: February 15, 2019

Bayhealth Medical Center Inc.
Contact Information

Pharmacy Business Manager
Bayhealth Medical Center
640 S. State St. Dover, DE 19901
(302) 744-6753

DSH080004 DE

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

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2018

Baylor University Medical Center
Contact Information

Pharmacy Director
BUMC 3500 Gaston Ave.
Dallas, Texas 75246
(214) 820-6826

DSH450021 TX

Entity did not meet eligibility requirements as a DSH hospital as of November 29, 2016.

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; incorrect entry for Primary Contact.

Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient

relationship.

Termination of covered entity from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: September 19, 2018

Belmond Community Hospital
Contact Information

Pharmacy Leader
1316 S. Main Street
Clarion, IA 50525
(515) 532-9199

CAH161301-00 IA

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 21, 2018

Berkshire Medical Center
Contact Information

340B Coordinator
725 North Street
Pittsfield, MA 01201
(413) 445-7079

DSH220046 MA

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: August 21, 2018

Bethesda Hospital
Contact Information

Director of Pharmacy
2815 South Seacrest Blvd.
Boynton Beach, FL 33435
(561)737-7733 ext. 84584

DSH100002 FL

Diversion – 340B drug dispensed to a patient at entity for a prescription written at an ineligible site; 340B drug dispensed without a documented provider to patient relationship.

Repayment to manufacturer

CAP implemented

Audit closure date: August 15, 2018

Blue Hill Memorial Hospital CAH201300-00 ME

No adverse findings

None

N/A

Audit closure date: August 29, 2017

Boa Vida Hospital of Aberdeen, MS, LLC D/B/A Monroe Regional Hospital formerly: Pioneer Health Services of Monroe County, Inc. dba Pioneer Community Hospital
Contact Information

Director of Pharmacy
400 Chestnut St.
Aberdeen, MS 39730
(662) 369-2455

CAH251302-00 MS

Incorrect 340B database record – Failed to remove closed location registration; incorrect entry for primary contact information.

Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drugs dispensed at contract pharmacy for prescriptions written by an ineligible provider.

Repayment to manufacturers

CAP implemented

Audit closure date: April 10, 2019

Bon Secours Richmond Community Hospital
Contact Information

340B Program Manager
1500 N. 28th Street
Richmond, Virginia 23223
(804) 221-4837

DSH490094 VA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturer

CAP implemented

Audit closure date: February 28, 2019

Boyle County Health Department FP404228 KY

No adverse findings

None

N/A

Audit closure date: April 20, 2017

BRFHH Monroe LLC d/b/a University Health Conway
Contact Information

Director of Pharmacy
University Health Conway
4864 Jackson Street
Monroe, LA 71202
(318) 330-7969

DSH190011 LA

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

Care Resource Community Health Centers, Inc. (formerly Community AIDS Resource)
Contact Information

Director of Grants, Contract and Pharmacy Services
3510 Biscayne Blvd
Miami, FL 33137
(305) 576-1234, Ext 230

CHC11399-00 FL

Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact; Incorrect entry for offsite outpatient facility address.

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

Repayment to manufacturers

CAP approved

Carolinas HealthCare System University DSH340166 NC

No adverse findings

None

N/A

Audit closure date: September 12, 2017

Carolinas Medical Center DSH340113 NC

No adverse findings

None

N/A

Audit closure date: September 11, 2017

Central Counties Health Centers, Inc.
Contact Information

Q2

CH059700 IL

No adverse findings

None

N/A

Audit closure date: June 23, 2017

Central Mississippi Civic Improvement Association, Inc. CH040750 MS

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 24, 2018

Chapa-De Indian Health Program Inc.
Contact Information

Primary Contact for 340B Chapa-De Indian Health Program
11670 Atwood Road
Auburn, CA 95603
(530) 887-2800
rsingh@chapa-de.org

FQHC638002 CA

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: April 5, 2018

Charleston Area Medical Center DSH510022 WV

No adverse findings

None

N/A

Audit closure date: March 13, 2017

Children's Medical Center Dallas
Contact Information

Director Business Operations, Pharmacy Services
1935 Medical District Drive
Dallas, Texas 75235
(214) 456-7437

PED453302-00 TX

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

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: September 24, 2018

Children’s Hospital Boston
Contact Information

Chief Pharmacy Officer
300 Longwood Ave.
Boston, MA 02115
(617) 355-6945

PED223302-00 MA

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 5, 2019

Children’s Hospital of San Antonio PED453315-00 TX

No adverse findings

None

N/A

Audit closure date: August 29, 2017

Children’s Hospital Orange County
Contact Information

340B Compliance Analyst
1201 W. La Veta Ave
Orange, CA 92868
(714) 509-8342

PED053304-00 CA

Diversion – 340B drugs dispensed at entity for prescriptions written at an ineligible site

Repayment to manufacturers

CAP implemented

Audit closure date: August 7, 2018

Chinese Hospital
Contact Information

Director, Quality/Compliance Officer

845 Jackson St
San Francisco, CA 94133

patriciac@chasf.org

DSH050407 CA

Incorrect 340B database record – Incorrect entries for off-site outpatient facility address, authorizing official and primary contact information.

Diversion - 340B drugs dispensed at entity 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: March 29, 2019

Chippewa County War Memorial Hospital
Contact Information

Director of Pharmacy

(906)635-4450

500 Osborn Boulevard
Sault Sainte Marie, MI 49783

SCH230239-00 MI

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 12, 2018

Christus Spohn Hospital Alice
Contact Information

Pharmacy Director

CHRISTUS Spohn
Health System

600 Elizabeth Street
Corpus Christi, TX 78404

361-881-6491

Deborah.allen3@christushealth.org

DSH450828 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 9, 2018

Christus St. Frances Cabrini Hospital
Contact Information

Vice President – Advis Group
19065 Hickory Creek Drive, Suite 115
Mokena, IL 60448
708-478-7030
davants@theadvisgroup.com

Director of Pharmacy
3330 Masonic Dr.
Alexandria, LA 71301
318-348-1922

DSH190019 LA

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 24, 2018

Clara Barton Hospital Association CAH171333-00 KS

No adverse findings

None

N/A

Audit closure date: November 22, 2017

Community Clinic, Inc.
Contact Information

Associate Chief Medical Officer
8630 Fenton Street, Suite 1204
Silver Spring, MD 20910
Phone: 301-340-7525
Fax: 301-495-0318

CHC10591-00 MD

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for address for outpatient facilities; Registered two contract pharmacies without written contracts in place.

Entity did not provide contract pharmacy oversight prior to November 2017.

Diversion – 340B drug dispensed to patient at entity without a documented provider to patient relationship.

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

Termination of contract pharmacy from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: June 27, 2019

Community Health Center of Lubbock, Inc. CH062910 TX

No adverse findings

None

N/A

Audit closure date: May 19, 2017

Community Health Centers of Pinellas, Inc. CH049070 FL

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

None

Pending

Community Health Centers of the Central Coast, Inc.
Contact Information

Director of 340B Program

Email: ayip@chccc.org

805-346-3987

150 Tejas Place,
Nipomo, Ca 93444

CH090710 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2018

Comprehensive Care Center, Inc. dba Community AIDS Network RWII34287 FL

No adverse findings

None

N/A

Audit closure date: June 29, 2017

County of Lake
Contact Information

Clinical Compliance Manager
847-377-8540
3010 Grand Avenue
Waukegan, IL 60085

CH058870 IL

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 11, 2019

Crosbyton Clinic Hospital
Contact Information

Director

806-675-8700

Debbie.tue@crosbytonclinichospital.com

CAH451345-00 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 25, 2018

Dallas County Medical Center CAH041317-00 TX

No adverse findings

None

N/A

Audit closure date: May 31, 2017

DCH Regional Medical Center
Contact Information

Corporate Director of Compliance and Internal Audit
205-759-7715
809 University Blvd. East
Tuscaloosa, AL 35401

DSH010092 AL

Incorrect 340B database record - Incorrect entry for address for outpatient facilities.

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

Inaccurate or incorrect information on the 340B 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: February 11, 2019

Delano Regional Medical Center DSH050608 CA

No adverse findings

None

N/A

Audit closure date: May 3, 2017

Delta Regional Medical Center DSH250082 MS

No adverse findings

None

N/A

Audit closure date: May 10, 2017

Detroit Community Health Connection CH052070 MI

No adverse findings

None

N/A

Audit closure date: May 26, 2017

Dominican Hospital (formerly Dominican Santa Cruz Hospital) DSH050242 CA

No adverse findings

None

N/A

Audit closure date: August 8, 2017

East Alabama Medical Center
Contact Information

Manager of Purchasing & 340B Compliance
East Alabama Medical Center
2000 Pepperell Parkway
Opelika, AL 36801-5422
334-528-2565
Dana.jackson@eamc.org

DSH010029 AL

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 2, 2019

East Liverpool City Hospital
Contact Information

System Director, 340B Program and Ambulatory Care
1000 Remington Clve, Suite 100
Bolingbrook, IL 60440
630-914-2872

DSH360096 OH

Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written 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 16, 2019

Eau Claire Cooperative Health Center CH043270 SC

No adverse findings

None

N/A

Audit closure date: May 22, 2017

Ephraim McDowell Regional Medical Center, Inc.
Contact Information

Chief Financial Officer
217 S. Third Street
Danville, KY 40422
859-239-2424

DSH180048 KY

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 26, 2019

Escambia Community Clinics, Inc.
Contact Information

Chief Administrative Officer
850-436-4630
14 West Jordan
Pensacola, FL 32501

CH0452890 FL

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

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

Termination of two contract pharmacies from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: July 31, 2018

Essentia Health St. Mary's Hospital-Superior CAH521329-00 WI

No adverse findings

None

N/A

Audit closure date: October 11, 2017

Family Christian Health Center CH059300 IL

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

Termination of contract pharmacy from 340B Program

CAP implemented

Audit closure date: August 7, 2018

Franciscan Health Hammond DSH150004 IN

No adverse findings

None

N/A

Audit closure date: July 25, 2017

Franklin Regional Hospital CAH301306-00 NH

No adverse findings

None

N/A

Audit closure date: August 30, 2017

Franklin Woods Community Hospital
Contact Information

Corporate Pharmacy Business Director
(423) 302-3535 cindy.tucker@balladhealth.org

DSH440184 TN

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 12, 2019

Fresno Community Hospital & Medical Center dba Clovis Community Medical Center
Contact Information

Chief Audit, Ethics, and Compliance Officer

559-324-4830

789 N. Medical Center Drive East, Clovis, CA 93611

DSH050492 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 25, 2018

Froedtert Memorial Lutheran Hospital
Contact Information

Froedtert Hospital 340B Manager
Doreene.Brecheisen@froedtert.com
262-532-5160

Integrated Service Center
N86W12999 Nightingale Way
Memomonee Falls, WI 53051

DSH520177 WI

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 13, 2019

Grandview Hospital
Contact Information

Director of Pharmacy

405 West Grand Avenue
Dayton OH 45405

937-723-5816

linda.mccall@ketteringhealth.org

DSH360133 OH

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

Duplicate Discounts – Inaccurate or incorrect information on the 340B Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

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

Audit closure date: February 11, 2019

Granville Medical Center
Contact Information

Chief Financial Officer

1010 College Street
Oxford, North Carolina 27565

919-690-3402

DSH340127 NC

Covered outpatient drugs obtained through a Group Purchasing Organization prior to September 29, 2017.

Incorrect 340B database record – Duplicate registration off offsite outpatient facility on 340B database record; Ineligible sites registered on 340B database.

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: March 5, 2019

Halifax Health Medical Center
Contact Information

Halifax Health Pharmacy Dept
Fountain Bldg, 3rd floor
303 N. Clyde Morris Blvd.
Daytona Beach, FL 32114
(386) 425-4531

DSH100017 FL

Incorrect 340B database record - Ineligible site registered on 340B database prior to September 14, 2017

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

Inaccurate or incorrect information on the 340B 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, 2019

Hamdard Center for Health and Human Services NFP CHC26565-00 IL

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

Duplicate Discounts - Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Termination of two contract pharmacies from 340B Program.

CAP implemented

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

Audit closure date: February 2, 2018

Harrison Community Hospital CAH361311-00 OH

No adverse findings

None

N/A

Audit closure date: April 27, 2017

Heartland Community Health Clinic DBA: Heartland Health Services CH051833A IL

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

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

Termination of contract pharmacy from 340B Program*

CAP implemented

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

Audit closure date: May 16, 2018

Hennepin County Medical Center DSH240004 MN

No adverse findings

None

N/A

Audit closure date: June 30, 2017

Hiawatha Community Hospital CAH171341-00 KS

No adverse findings

None

N/A

Audit closure date: June 9, 2017

Hospital District #1 of Crawford County Kansas
Contact Information

Chief Executive Officer
620-724-5152
Hospital District #1 of Crawford County dba Girard Medical Center
302 N Hospital Dr
Girard, KS 66743-2000

CAH171376-00 KS

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

Diversion - 340B drug dispensed at a contract pharmacy, not supported by a medical record; 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: March 13, 2019

Hospital District #1 of Dickinson
Contact Information

Chief Financial Officer

785-263-6614

511 N.E. 10th Street
Abilene, Kansas 67410

CAH171381-00 KS

Incorrect 340B database record – Ineligible sites registered on 340B database; Incorrect entry for offsite outpatient facility address.

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: January 8, 2019

Hurley Medical Center DSH230132 MI

No adverse findings

None

N/A

Audit closure date: February 28, 2018

Independent Healthcare Management, Inc. dba SE Lackey Memorial Hospital
Contact Information

Pharmacy Director
330 North Broad Street
Forest, MS 39074
(601) 469-4151

CAH251300-00 MS

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturer

CAP implemented

April 17, 2019

Integris Miami Hospital
Contact Information

System Administrative Director
INTEGRIS Health, Inc.
3300 Northwest Expressway
Oklahoma City, OK 73112

DSH370004 OK

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: January 11, 2019

Iowa Specialty Hospital – Clarion
Contact Information

Pharmacy Leader
1316 S. Main
Clarion, IA 50525
(515) 532-9199

CAH161302-00 IA

Diversion - 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: September 20, 2018

Iroquois Memorial Hospital and Resident Home
Contact Information

Chief Financial Officer
(815) 432-7929
200 E. Fairman Ave
Watseka, IL 60970-1644

SCH140167-00 IL

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

Duplicate Discounts - Entity did not have controls in place to prevent duplicate discounts.

Repayment to manufacturers

CAP implemented

Audit closure date: March 26, 2019

J Arthur Dosher Memorial Hospital
Contact Information

Pharmacy Director
JA Dosher Memorial Hospital
924 N Howe St.
Southport, NC 28461
(910) 457-3835

CAH341327-00 NC

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: October 30, 2018

Jane Todd Crawford Memorial Hospital, Inc. dba Jane Todd Crawford Hospital CAH181325-00 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: July 18, 2017

John H. Stroger, Jr. Hospital of Cook County
Contact Information

Senior Director of Pharmacy
Cook County Health & Hospitals System
1901 West Harrison St, Suite LL134
Chicago, IL 60612

Cnorwood@cookcountyhhs.org

DSH140124 IL

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

Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File; Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Repayment to manufacturers.

CAP implemented

Audit closure date: September 5, 2019

Jones Memorial Hospital
Contact Information

340B Business Manager

Pharmacy Department, University of Rochester Medical Center 120 Corporate Woods, Suite 350 Rochester, NY 14623

(505)-785-5154

SCH330096-00 NY

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: May 3, 2018

Keystone Rural Health Center CH032700 PA

No adverse findings

None

N/A

Audit closure date: March 23, 2017

Kiowa County Hospital District dba Weisbrod Memorial Hospital CAH061300-00 CO

Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to August 11, 2017; Entity did not provide contract pharmacy oversight prior to onsite audit.

None

CAP implemented

Audit closure date: January 2, 2018

Knox County Hospital District
Contact Information

CEO
Knox County Hospital District
701 South 5th Street
P.O. Box 608
Knox City, Texas 79529
940-657-3535

SCH450746-00 TX

Entity did not meet eligibility requirements as a DSH hospital as of March 10, 2017.

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

Termination of covered entity from the 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: March 25, 2019

Lafayette General Medical Center
Contact Information

Director of Pharmacy

337-289-7888

1214 Coolidge Blvd
Lafayette, LA 70503

DSH190002 LA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; 340B drugs were not properly accumulated.

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: August 29, 2018

Laird Hospital, Inc. CAH251322-00 MS

No adverse findings

None

N/A

Audit closure date: May 5, 2017

Legacy Emanuel Hospital and Health Center DSH380007 OR

No adverse findings

None

N/A

Audit closure date: December 21, 2017

Los Angeles County
Contact Information

Pharmacy Service Chief
LAC Pharmacy Affairs
sdsouza@dhs.lacounty.gov
213-240-7717

DSH050376 CA

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

Repayment to manufactures

CAP implemented

Audit closure date: August 23, 2018

Lucile Salter Packard Children’s Hospital HM6415 CA

No adverse findings

None

N/A

Audit closure date: August 8, 2017

Lynn Community Health, Inc. CH011430 MA

Incorrect 340B database record – Failed to remove shipping address of closed location; Registered contract pharmacy without a contract in place prior to November 3, 2017.

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: January 18, 2019

Manatee County Rural Health Services Inc. CH044310 FL

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

Termination of contract pharmacies from 340B Program

CAP implemented

Audit closure date: May 23, 2018

Marengo Memorial Hospital
Contact Information

Authorizing Official, Marengo Memorial Hospital
Chief Operating Officer

300 W May Street
Marengo IA 52301

319-642-8013

mmurphy@marengohospital.org

CAH161317-00 IA

Diversion - 340B drugs were not properly accumulated;

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2018

Marion General Hospital, Inc. DSH150011 IN

No adverse findings

None

N/A

Audit closure date: September 1, 2017

Medical University Hospital Authority
Contact Information

Manager Pharmacy Supply Chain
Medical University of South Carolina
150 Ashley Ave, MSC 584
Charleston, SC 29425
(843) 792-7354
millsja@musc.edu

DSH420004 SC

Diversion - 340B drug dispensed at entity for prescription written at an ineligible site; 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: September 5, 2019

Medina County Hospital District CAH451330-00 TX

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 26, 2018

Memorial Hermann Sugar Land Hospital
Contact Information

System Director of Pharmacy Operations

902 Frostwood, Suite 190
Houston, TX 77024

713-242-2814

DSH450848 TX

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

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

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

Repayment to manufacturers.

CAP implemented

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

Audit closure date: January 18, 2019

Memorial Medical Center
Contact Information

Chief Financial Officer
Memorial Medical Center
815 N. Virginia Street
Port Lavaca, Texas 77979
dmoore@mmcportlavaca.com
361-552-0224

CAH451356-00 TX

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

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

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

Termination of contract pharmacy from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: January 28, 2019

Memorial Medical Center, Inc. CAH521359-00 WI

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

None

CAP implemented

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

Audit closure date: April 17, 2018

Mercy Hospital Berryville CAH041329-00 AR

No adverse findings

None

N/A

Audit closure date: July 17, 2017

Mercy Hospital of Franciscan Sisters CAH161338-00 IA

No adverse findings

None

N/A

Audit closure date: June 27, 2017

Mercy Medical Center DSH210008 MD

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

Repayment to manufacturers

CAP implemented

Audit closure dated: September 12, 2018

Mercy Medical Center CAH161377-00 IA

No adverse findings

None

N/A

Audit closure date: August 29, 2017

Mercy San Juan Medical Center DSH050516 CA

No adverse findings

None

N/A

Audit closure date: June 29, 2017

Methodist Hospital of Sacramento
Contact Information

Director of Pharmacy
916-681-1665
6500 Hospital Drive
Sacramento, CA 96823
Gurpreet.johal@dignityhealth.org

DSH050590 CA

Diversion – 340B drug dispensed for a prescription written for an inpatient.

Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: December 21, 2018

Methodist Hospitals, The
Contact Information

Health System Director of Pharmacy
219-738-5807
600 Grant St.
Gary, IN 46402

DSH150002 IN

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 11, 2018

Methodist Medical Center of Illinois
Contact Information

Regional Pharmacy IS Coordinator

221 NE Glen Oak Ave.
Peoria, IL 61636

309-689-6029

Joseph.hersemann@unitypoint.org

DSH140209 IL

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 31, 2018

Mid-Columbia Medical Center
Contact Information

Pharmacy Director

541-296-7526

1700 E. 19th Street
The Dalles, OR 97058

SCH380001-00 OR

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for Authorizing Official and Primary Contact; Registered contract pharmacies without written contract in place.

Diversion - 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; A 340B drug was not properly accumulated.
Duplicate Discounts - Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

Miller County Health Department TB31737 GA

Incorrect 340B database record – Incorrect entry for grant number prior to April 29, 2017.

None

CAP implemented

Audit closure date: August 17, 2017.

Mississippi County Health Unit FP723708 MS

No adverse findings

None

N/A

Audit closure date: August 9, 2017

Modoc Medical Center CAH051330-00 CA

No adverse findings

None

N/A

Audit closure date: August 9, 2017

Monroe County Hospital DSH010120 AL

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

None

CAP implemented

Audit closure date:
January 2, 2018

Montrose Memorial Hospital
Contact Information

Director of Pharmacy Services
800 S. 3rd St.
Montrose CO 81401
(970) 249-2211

SCH060006-00 CO

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

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 7, 2018

Moore County Hospital District dba Memorial Hospital
Contact Information

Chief Operating Officer
224 E. 2nd
Dumas, Texas 79029
(806) 935-7171

DSH450221 TX

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

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

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: October 30, 2018

Mount Sinai Hospital, The
Contact Information

Senior Director of Pharmacy, 340B Program
25-10 30th Avenue
Astoria NY
(718) 267-4295
Philip.manning@mountsinai.org

DSH330024 NY

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

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

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: September 7, 2018

Neshoba County General Hospital
Contact Information

Pharmacy Director
Neshoba County General Hospital
1001 Holland Avenue, Philadelphia, MS 39250
(601) 781-2310
ricky@neshoba-hospital.com

SCH250043-00 MS

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 15, 2018

Newberry County Memorial Hospital
Contact Information

Director of Pharmacy
Newberry County Memorial Hospital
PO Box 497
2669 Kinard Street
Newberry, SC 29108
(803) 405-7175

SCH420053-00 SC

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 30, 2018

Niagara Falls Memorial Medical Center
Contact Information

340B Program Coordinator

621 10th Street
Niagara Falls, NY 14301

716-278-4537

DSH330065 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to May 18, 2017.

Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for offsite facility address; Registered contract pharmacies without written contract in place.

Diversion – 340B drug dispensed at contract pharmacies without a documented provider to patient relationship; 340B drugs were not properly accumulated.

Termination of four contract pharmacies from the 340B Program.

Repayment to manufacturers

CAP implemented

Audit closure date: March 1, 2019

Northwest Medical Foundation of Tillamook DBA Tillamook Regional Medical Center
Contact Information

Pharmacy Director
(503) 815-2260
1000 3rd Street
Tillamook, OR 97141

CAH381317-00 OR

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: November 15, 2018

Operation Samahan, Inc.
Contact Information

Director of Grants and Contracts

619.471.5433

1428 Highland Ave., National City, Ca 91950

CHC26623-00 CA

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect entry for offsite facility address.

Diversion – 340B drug dispensed at a 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.

Repayment to manufacturers

CAP implemented

Audit closure date: January 25, 2019

Orchard Hospital CAH051311-00 CA

No adverse findings

None

N/A

Audit closure date: October 18, 2017

Palo Alto County Hospital CAH161357-00 IA

No adverse findings

None

N/A

Audit closure date: September 19, 2017

Pearl River County Hospital
Contact Information

Authorizing Official
601-795-4543, ext 2142
Gerald.vance@prc-med.com

CAH251333-00 MS

Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact; Registered contract pharmacies without written contract in place.

Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship; 340B drug dispensed at entity, not supported by a medical record.

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

Termination of two contract pharmacies from the 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: February 28, 2019

Perry County Memorial Hospital
Contact Information

Director of Pharmacy
8885 State Road 237
Tell City, IN 47586
(812) 847-0329

CAH151322-00 IN

Incorrect 340B database record – Incorrect entries for Authorizing Official and Primary Contact.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2019

Perry County Memorial Hospital
Contact Information

CEO & Authorizing Official
434 N West St
Perryville, MO 63775
(573) 547-2536, Ext. 3203

or

340B Program Manager
212 Hospital Ln, Ste 102
Perryville, MO 63775
(573) 547-2536, Ext. 3362

CAH261311-00 MO

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect address listed for offsite outpatient facility.

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 15, 2018

Philadelphia Health & Education Corp. dba Drexel University College of Medicine FP191045 PA

Incorrect 340B database record – Incorrect entry for address prior to April 11, 2017.

None

CAP implemented

Audit closure date: August 7, 2018

Phoenix Children’s Hospital
Contact Information

Manager Pharmacy Business Services

1919 East Thomas Road
Pharr
Phoenix, AZ 85016

(602) 933-4033

PED033302-00 AZ

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 25, 2017

Pipestone County Medical Center CAH241374-00 MN

No adverse findings.

None

N/A

Audit closure date: December 27, 2017

Presence Mercy Medical Center
Contact Information

System Director, 340B Program and Ambulatory Care
1000 Remington Clve, Suite 100
Bolingbrook, IL 60440
630-914-2872

DSH140174 IL

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 19, 2018

Presence Saint Francis Hospital
Contact Information

System Director, 340B Program and Ambulatory Care

630.914.2872

1000 Remington Blvd., Suite 100
Bolingbrook, IL 60440

DSH140080 IL

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.
Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2018

Providence Health and Services – Washington DSH500054 WA

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

None

CAP implemented

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

Audit closure date: July 19, 2018

Public Hospital District No. 1 of King County DBA Valley Medical Center
Contact Information

Director of Pharmacy
Valley Medical Center
400 South 43rd St. Box 50010
Renton, WA 98055
(425) 228-3400, x5855

DSH500088 WA

Diversion – 340B drugs dispensed to patients at contract pharmacy without a documented provider to patient relationship.

Repayment to manufacturers

CAP implemented

Audit closure date: May 29, 2019

Ripon Medical Center, Inc. CAH521321-00 WI

No adverse findings

None

N/A

Audit closure date: June 27, 2017

Rockford Memorial Hospital
Contact Information

Pharmacy Business Coordinator
2400 North Rockton Ave
Rockford, IL 61103
(815) 971-2394

DSH140239 IL

Incorrect 340B database record – Utilized contract pharmacies prior to July 1, 2017 registration date; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 15, 2018

Rome Memorial Hospital, Inc. DSH330215 NY

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Listed duplicate record for an outpatient facility

None

CAP implemented

Audit closure date: June 21, 2017

Rush University Medical Center
Contact Information

Director, Clinical Operations
1725 W Harrison St, Suite 418
Chicago, IL 60612
(312) 563-2326

DSH140119 IL

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: August 26, 2019

Saint Anthony Hospital
Contact Information

Pharmacy Director
Saint Anthony Hospital
2875 W 19th St
Chicago, IL 60623
(773) 484-1317

DSH140095 IL

Diversion- 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: December 21, 2018

Saint Joseph East DSH180143 KY

No adverse findings

None

N/A

Audit closure date: March 16, 2017

Saint Mary’s Healthcare DSH070016 CT

No adverse findings

None

N/A

Audit closure date:
November 16, 2017

Samaritan Hospital
Contact Information

Chief Financial Officer
801 E. Wheeler Road
Moses Lake, WA 98837
(509) 793-9710

DSH500033 WA

Covered outpatient drugs obtained through a Group Purchasing Organization from October 3, 2016 to March 28, 2017.

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database; Incorrect entry for primary contact; Registered contract pharmacies without written contract in place.

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

Repayment to manufactures

Termination of contract pharmacy from 340B Program*

CAP implemented

Audit closure date: April 3, 2019

San Joaquin Community Hospital
Contact Information

Director of Pharmacy

661-869-6280

2615 Chester Ave.
Bakersfield, Ca 93301

DSH050455 CA

Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: August 2, 2018

San Juan Basin Health Dept. STD81303 CO

No adverse findings

None

N/A

Audit closure date: April 13, 2017

San Mateo Medical Center
Contact Information

Director of Pharmacy
222 West 39th Ave
San Mateo, CA 94403
(650) 573-2366

DSH050113 CA

Diversion – 340B drugs purchased for separately registered 340B covered entities with no reimbursable outpatient costs; 340B drugs were not properly accumulated at contract pharmacy.

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 25, 2019

San Ysidro Health Center
Contact Information

Director of Contracts
San Ysidro Health Center
(619)662-4165

CH091080 CA

Incorrect 340B database record – Inaccurate entries for billing addresses.

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 12, 2018

Sanford Health Network CAH161321-00 IA

No adverse findings

None

N/A

Audit closure date: August 9, 2017

Seton Health System DSH330232 NY

No adverse findings

None

N/A

Audit closure date: March 7, 2017

Shasta Community Health Center CH092240 CA

No adverse findings

None

N/A

Audit closure date: August 9, 2017

Skagit County Health Department STD982738 WA

Incorrect 340B database record – entity improperly registered a repackager as a contract pharmacy.

None

Pending

South Florida Baptist Hospital
Contact Information

Manager of Pharmacy Supply Chain

BayCare Health System
7802 E. Telecom Parkway
Temple Terrace, FL 33637

813-888-1920

DSH100132 FL

Incorrect 340B database record - Registered contract pharmacies without written contract in place prior to August 25, 2017; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 11, 2019

Southcoast Hospitals Group Inc.
Contact Information

Sr Vice President & Chief Operating Officer

101 Page Street, New Bedford, MA 02740

508-973-5872

DSH220074 MA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 29, 2018

Southern Monterey County Memorial Hospital DBA George L. Mee Memorial Hospital
Contact Information

Quality Assurance Director
300 Canal Street
King City, CA 93930
831-386-7375

DSH050189 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 31, 2016.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.

Repayment to manufacturers

CAP implemented

Audit closure date: December 18, 2018

Southwest Memorial Hospital
Contact Information

Chief Financial Officer

1311 N. Mildred Road
Cortez, CO 81321

akobel@swhealth.org

970-564-2153

CAH061327-00 CO

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2018

Spectrum Health United Hospital DSH230035 MI

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

Termination of contract pharmacy from 340B Program

CAP implemented

Audit closure date: June 14, 2018

SSM Cardinal Glennon Children’s Medical Center HM13100 MO

No adverse findings

None

N/A

Audit closure date: September 21, 2017

St. Barnabas Hospital DSH330399 NY

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

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

None

CAP implemented

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

Audit closure date: January 11, 2019

St. Dominic - Jackson Memorial Hospital DSH250048 MS

No adverse findings

None

N/A

Audit closure date: March 30, 2017

St. Elizabeth’s Hospital of Wabasha, Inc. CAH241335-00 MN

No adverse findings

None

N/A

Audit closure date: July 18, 2017

St. Francis Memorial Hospital DSH050152 CA

No adverse findings

None

N/A

Audit closure date: April 24, 2017

St. Joseph’s Hospital
Contact Information

Manager of Pharmacy Supply Chain

BayCare Health System
7802 E. Telecom Parkway
Temple Terrace, FL 33637

813-888-1920

DSH100075 FL

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Duplicate registration of offsite outpatient facility on database; Registered contract pharmacies without written contract in place prior to June 29, 2017; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 11, 2019

St. Joseph’s Hospital and Medical Center
Contact Information

Director of Pharmacy

St. Joseph’s Hospital and Medical Center
350 West Thomas Road
Phoenix, AZ 85013

(602) 406-4744

DSH030024 AZ

Diversion – 340B drugs dispensed to patients at entity without a documented provider to patient relationship.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

St. Joseph’s University Medical Center
Contact Information

Chief Financial Officer
703 Main Street
Paterson, NJ 07503
(973) 754-2023

DSH310019 NJ

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

Diversion – 340B drug dispensed at the entity for prescriptions written at an ineligible sites; 340B drugs dispensed at entity for inpatients; 340B drugs were not properly accumulated.

Termination of one contract pharmacy from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: June 19, 2019

St. Luke’s Magic Valley Regional Medical Center, LTD SCH130002-00 ID

No adverse findings

None

N/A

Audit closure date: June 1, 2017

St. Mary’s Hospital and Medical Center HV00593 CO

No adverse findings

None

N/A

Audit closure date: June 21, 2017

Tarzana Treatment Centers, Inc. HV00791B CA

Incorrect 340B database record – Registered contract pharmacy without written contract in place; Utilized contract pharmacies prior to registering on the 340B database.

Termination of five contract pharmacies from 340B Program

CAP implemented

Audit closure date: July 12, 2017

Tennessee Department of Health FPTN000 TN

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

None

CAP implemented

Audit closure date: June 13, 2018

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

Texas County Memorial Hospital
Contact Information

340B Coordinator

417-967-1246

1333 S. Sam Houston Blvd, Houston. MO 65483

DSH260024 MO

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

Diversion – 340B drug dispensed at the entity for a prescription written at an ineligible site; 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: April 20, 2018

ThedaCare Medical Center Berlin, Inc.
Contact Information

Pharmacy Director
Robert.probasco@thedacare.org
715-584-8045

CAH521355-00 WI

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 15, 2018

Thomas Jefferson University Hospital DSH390174 PA

No adverse findings

None

N/A

Audit closure date: April 5, 2017

Thomas Memorial Hospital
Contact Information

340B Coordinator

304-766-4320

4605 MacCorkle Ave., SW
South Charleston, WV 25309

DSH510029 WV

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 24, 2018

Three Lower Counties Community Services, Inc. CH03301H MD

No adverse findings

None

N/A

Audit closure date: September 14, 2017

Three Rivers Health
Contact Information

Interim Director of Pharmacy
Three Rivers Health
701 S Health Pkwy
Three Rivers, MI 49093
(269) 278-1145, x742

DSH230015 MI

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacy without written contract in place prior to December 27, 2017.

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 8, 2019

Trinitas Regional Medical Center
Contact Information

Director of Pharmacy
Trinitas Regional Medical Center
225 Williamson St.
Elizabeth, NJ DSH310027
908-994-5238

DSH310027 NJ

Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 3, 2018.

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Ineligible sites registered on the 340B database;

Entity did not provide contract pharmacy oversight prior to January 3, 2018.

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

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers.

CAP implemented

Audit closure date: May 3, 2019

Ukiah Valley Medical Center DSH050301 CA

No adverse findings

None

N/A

Audit closure date: November 2, 2017

UNC Hospitals DSH340061 NC

No adverse findings

None

N/A

Audit closure date: March 1, 2017

Union County Health Foundation
Contact Information

Chief Financial Officer or 340B Program Manager

PO Box 99 109 N. Main Street Howard, SD 57349

(605) 772-4525

CH080890 SD

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

United Health Services Hospitals, Inc. DSH330394 NY

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

None

CAP implemented

Audit closure date: May 22, 2018

Univ of Colorado Hemophilia Center School of Medicine HM11980 CO

No adverse findings

None

N/A

Audit closure date: October 23, 2017

University of Miami Hospital
Contact Information

Executive Pharmacy Director
1400 NW 12th Ave
Miami, FL 33136
(305) 689-5630

DSH100009 FL

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entry for Authorizing Official.

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 15, 2018.

University of Mississippi Medical Center Grenada DSH250015 MS

No adverse findings

None

N/A

Audit closure date: May 22, 2017

University of North Carolina – Chapel Hill HM11947 NC

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

None

CAP implemented

Audit closure date: January 30, 2018

University of South Alabama Children’s and Women’s Hospital PED013301-00 AL

No adverse findings

None

N/A

Audit closure date: May 12, 2017

UPMC Mercy
Contact Information

Chief Finance Officer
UPMC Mercy Department of Finance
1400 Locust Street
Pittsburgh, PA 15219
Phone: 412‐647‐7713

DSH390028 PA

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity had a duplicate registration for an offsite outpatient facility.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: March 5, 2019

W.A. Foote Memorial Hospital DBA Henry Ford Allegiance Health
Contact Information

340B Program Coordinator
205 N. East Ave.
Jackson, MI 49201
(517) 205-7557

DSH230092 MI

Diversion – 340B drugs dispensed at entity and at contract pharmacies for prescriptions written at ineligible sites; 340B drug dispensed at entity to a patient without a documented provider to patient relationship; 340B drugs were not properly accumulated.

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 12, 2018

Wabash General Hospital District
Contact Information

Pharmacy Director
Wabash General Hospital District
1418 College Drive
Mt. Carmel, IL 62863
(618) 263-6316
mlockard@wabashgeneral.com

CAH141327-00 IL

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

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File; Entity did not have adequate controls to prevent duplicate discounts.

Repayment to manufacturers

CAP implemented

Audit closure date: December 19, 2018

Wake Health Services, Inc. CH041000 NC

No adverse findings

None

N/A

Audit closure date: May 9, 2017

Waldo County General Hospital CAH201312-00 ME

No adverse findings

None

N/A

Audit closure date: August 29, 2017

War Memorial Hospital Inc. CAH511309-00 WV

No adverse findings

None

N/A

Audit closure date: June 9, 2017

Weatherford Hospital Authority
Contact Information

CEO
(580) 772-5551 Ext: 750
dhowe@weatherfordhospital.com
or
Director of Pharmacy
(580) 772-5551 Ext: 747
msauer@weatherfordhospital.com

CAH371323-00 OK

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from the 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: February 8, 2019

Weeks Medical Center CAH301303-00 NH

No adverse findings

None

N/A

Audit closure date: January 9, 2018

Wheaton Franciscan Healthcare – All Saints
Contact Information

Regional Director, 340B Pharmacy
3801 Spring Street
Racine WI 53405
(414) 874-6268

DSH520096 WI

Incorrect 340B database record – ineligible site registered on 340B database; Entity failed to remove duplicate registration for off-site outpatient facility.

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

Termination of ineligible offsite outpatient facilities from the 340B Program*

Repayment to manufacturers

CAP approved

White Memorial Medical Center DSH050103 CA

No adverse findings

None

N/A

Audit closure date: February 28, 2017

William Newton Memorial Hospital
Contact Information

Director of Pharmacy
(620) 222-6206
pharmacy@wnmh.org

CAH171383-00 KS

Diversion – 340B drugs dispensed at entity for inpatients; 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: February 26, 2019

Women and Infants Hospital of Rhode Island
Contact Information

340B Program Manager
CNE Pharmacy
626 Toll Gate Road
Warwick, RI 02886
(401) 921-7525

DSH410010 RI

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

None

CAP implemented

Audit closure date: October 10, 2018

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

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

Date Last Reviewed: