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Program Integrity: FY18 Audit Results

Updated 12/3/20. 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
Abbeville General Hospital DSH190034 LA

No adverse findings

None

N/A

Audit closure date: August 14, 2018

Abbott Northwestern Hospital
Contact Information

Pharmacy Services Portfolio Manager
2925 Chicago Avenue
Mail Route 10807
Minneapolis, MN 55407
612-262-4785
Tony.collinskwong@allina.com

DSH240057 MN

Duplicate discounts - Incorrect 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: February 13, 2019

Adventist Health Lodi Memorial
Contact Information

Pharmacy Director
975 S Fairmont Ave
Lodi, CA 95240
209-334-3411

DSH050336 CA

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: July 25, 2019

AIDS Project of the East Bay STD946121 CA

Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place; Incorrect entry for Primary Contact telephone number.

Termination of four contract pharmacies from 340B Program

CE self-terminated. In order to re-enroll in the 340B Program, CE must submit a corrective action plan (CAP) addressing each of the findings outlined in the Final Report.

Audit closure date: January 23, 2019

Albert Einstein Medical Center DSH390142 PA

No adverse findings

None

N/A

Audit closure date: July 31, 2018

Alcona Citizens for Health, Inc.
Contact Information

Director of Pharmacy
1185 US Highway 23 North
Alpena, MI 49707
989-358-3922

CH051980 MI

Incorrect 340B OPAIS record – Entity owned in-house pharmacies not listed as shipping addresses.

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 25, 2019

Ampla Health
Contact Information

President and CEO
935 Market Street
Yuba City, CA 95991
530-751-3755

CH090850 CA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 25, 2019

Appalachian Regional Healthcare Inc. DBA McDowell ARH Hospital CAH181331-00 KY

No adverse findings

None

N/A

Audit closure date: February 28, 2019

Appalachian Regional Healthcare Inc. DBA Summers County ARH Hospital CAH511310-00 WV

No adverse findings

None

N/A

Audit closure date: May 3, 2018

ARH Mary Breckinridge Health Services, Inc. DBA Mary Breckinridge ARH Hospital
Contact Information

President and Chief Executive Officer
Appalachian Regional Healthcare
130 Kate Ireland Drive
Hyden, KY 41749
859-226-2450

CAH181316-00 KY

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: April 17, 2019

Ashtabula County Medical Center SCH360125-00 OH

Incorrect 340B OPAIS record - Failed to remove closed location registration; Registered contract pharmacies without written contract in place.

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program*
Repayment to manufacturers

Pending

Asian Health Services
Contact Information

Controller
101 8th Street
Oakland, CA 94607
510-735-3143

CH091030 CA

Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration; Registered contract pharmacy without written contract in place.

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

Termination of two contract pharmacies from 340B Program*

CAP implemented

Audit closure date: May 3, 2019

Asian Human Services Family Health Center
Contact Information

Program Director
2424 W. Peterson Avenue
Chicago, IL 60659
773-761-0300 x2453

CH051827A IL

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 27, 2020

Aspirus Ironwood Hospital CAH231333-00 MI

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to January 9, 2019.

None

CAP implemented

Audit closure date: March 24, 2020

Avera Marshall DBA Avera Marshall Regional Medical Center CAH241359-00 MN

No adverse findings

None

N/A

Audit closure date: January 16, 2018

Baptist Hospitals of Southeast Texas dba Baptist Beaumont Hospital
Contact Information

Director of Revenue Cycle, Oncology
3555 Stagg Dr.
Beaumont, TX 77701
409-212-5927

DSH450346 TX

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

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: October 31, 2019

Baylor Scott & White Medical Center - Irving
Contact Information

Pharmacy Director System
4004 Worth Street, Suite 200
Dallas, Texas 75246
214-820-6810

DSH450079 TX

Duplicate discounts - Incorrect or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: April 2, 2019

Baystate Franklin Medical Center
Contact Information

Chief Pharmacy Officer
280 Chestnut Street
Springfield MA, 01199
413-794-3178
Gary.Kerr@BaystateHealth.org

DSH220016 MA

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 10, 2020

Belington Community Medical Services Association, Inc. CHC12878-00 WV

No adverse findings

None

N/A

Audit closure date: May 18, 2018

Billings Clinic
Contact Information

Director, Pharmacy Services
2800 Tenth Avenue North
Billings, Montana 59101
406-657-4811

DSH270004 MT

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers

CAP implemented

Audit closure date: November 19, 2019

Bradford Regional Medical Center
Contact Information

Richard Braun
SVP Finance and CFO
130 South Union Street
Suite 300
Olean, NY 14760
716-375-6190
rbraun@uahs.org

DSH390118 PA

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

Repayment to manufactures

CAP implemented

Audit closure date: October 8, 2019

Broaddus Hospital
Contact Information

Chief Executive Officer
1 Healthcare Drive
Philippi, WV 26416
304-457-8155

CAH511300-00 WV

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

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: June 19, 2019

Bronson Lakeview Hospital CAH231332-00 MI

No adverse findings

None

N/A

Audit closure date: March 23, 2018

Broward Health Medical Center
Contact Information

Director of Pharmacy Services
1600 South Andrews Avenue
Fort Lauderdale, FL 33316
954-355-5559

DSH100039 FL

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

Diversion – 340B drug dispensed to inpatient.

Termination of contract pharmacy from 340B Program
Repayment to manufacturers.

CAP implemented

Audit closure date: March 27, 2020

Calhoun - Liberty Hospital CAH101304-00 FL

No adverse findings

None

N/A

Audit closure date: June 22, 2018

California Hospital Medical Center
Contact Information

Director of Pharmacy
1401 S. Grand Ave
Los Angeles, CA 90015
213-742-5483

DSH050149 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 1, 2018.

Incorrect 340B OPAIS record - Incorrect entry for Primary Contact telephone number.

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: September 16, 2019

Camden – Clark Memorial Hospital DSH510058 WV

No adverse findings

None

N/A

Audit closure date: June 29, 2018

CAN Community Health, Inc. RWII32117 FL

No adverse findings

None

N/A
Audit closure date: March 28, 2018

CAN Community Health, Inc. STD336052 FL

No adverse findings

None

N/A

Audit closure date: March 28, 2018

Cape Fear Valley Medical Center
Contact Information

Director of Hospital Pharmacy
1638 Owen Drive
Fayetteville, NC 28304
910-615-6839
tnicholson@capefearvalley.com

DSH340028 NC

Incorrect 340B OPAIS record - Ineligible site registered on 340B OPAIS.

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

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 26, 2019

Carrington Health Center CAH351318-00 ND

No adverse findings

None

N/A

Audit closure date: July 19, 2018

Cavalier County Memorial Hospital
Contact Information

Director of Pharmacy
909 2nd Street
Langdon, ND 58249
701-256-6100

CAH351323-00 ND

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 6, 2019

Centra Health, Inc. SCH490021-00 VA

No adverse findings

None

N/A

Audit closure date: September 10, 2018

Centracare Health – Paynesville Hospital
Contact Information

Todd Lemke
Pharmacist in Charge
200 First St W
Paynesville, MN 56362
320-243-7772

CAH241349-00 MN

Diversion - 340B drugs dispensed to inpatients.

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: September 12, 2019

Central Vermont Medical Center
Contact Information

Attention Department of Pharmacy
Director of Pharmacy
130 Fisher Road
Berlin, VT 05602
802-371-5938
Frank.Foti@CVMC.org

SCH470001-00 VT

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

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.

Repayment to manufacturers

CAP implemented

Audit closure date: October 4, 2019

Children’s Health Care DBA Children’s Minnesota PED243302-00 MN

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 8, 2019

Children’s Mercy Hospital, The PED263302-00 MO

Incorrect 340B OPAIS record - Entity-owned pharmacies were not listed as shipping addresses.

None

CAP implemented

Audit closure date: September 21, 2018

Choctaw General Hospital CAH011304-00 AL

No adverse findings

None

N/A

Audit closure date: September 10, 2018

Columbia Lutheran Memorial Hospital DBA Columbia Memorial Hospital
Contact Information

Director of Pharmacy & Cancer Center Services
Columbia Memorial Hospital
2111 Exchange Street
Astoria OR 97103
503-338-4665

CAH381320-00 OR

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Entity-owned pharmacy was not listed as shipping address; Registered contract pharmacies without written contract in place.

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

Columbia Memorial Hospital RRC330094-00 NY

Incorrect 340B OPAIS record - Incorrect entry for address for offsite outpatient facility.

None

CAP implemented

Audit closure date: July 30, 2018

Communicare Health Centers CHC08216-00 CA

No adverse findings

None

N/A

Audit closure date: August 23, 2018

Community Health Care, Inc. CH021270 NJ

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to February 14, 2018; Failed to remove a duplicate registration of a contract pharmacy.

None

CAP implemented
Audit closure date: September 20, 2018

Community Health Center, Incorporated CH012080 CT

Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS; Failed to remove duplicate registrations for offsite outpatient facilities; Registered contract pharmacies without written contract in place.

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 ineligible offsite outpatient facilities from the 340B Program*

Termination of two contract pharmacies from 340B Program*

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

CAP implemented

Audit closure date: October 1, 2019

Community Healthcare System, Inc.
Contact Information

Chief Financial Officer
120 West 8th Street
Onaga, KS 66521
785-889-5036

CAH171354-00 KS

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to August 14, 2018.

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 6, 2019

Conejos County Hospital Corporation
Contact Information

Director of Pharmacy
106 Blanca Ave.
Alamosa, Colorado 81101
719-587-1260
Lee.Hankins@slvrmc.org

CAH061308-00 CO

Entity did not provide contract pharmacy oversight.

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.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers.

CAP implemented

Audit closure date: April 5, 2019.

Connecticut, State of, Department of Health STD061345 CT

Entity failed to maintain auditable medical records prior to December 21, 2018.

Repayment to manufacturers

Covered entity terminated from 340B Program as of July 1, 2020.

Audit closure date: July 17, 2020

Covenant Hospital – Plainview
Contact Information

Executive Director of 340B Operations
2107 Oxford Ave
Lubbock, TX 79410
806-725-6654

SCH450539-00 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 31, 2019

Covington County Hospital CAH251325-00 MS

Incorrect 340B OPAIS record - Failed to remove closed location registration; Entity’s written contract pharmacy agreement listed information inconsistent with the 340B database record.

None

CAP implemented

Audit closure date: September 24, 2018

Cumberland County Hospital
Contact Information

Director of Support Services
Cumberland County Hospital
299 Glasgow Road
Burkesville, KY 42717
270-864-2511

CAH181317-00 KY

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 17, 2019

Decatur Memorial Hospital RRC140135-00 IL

No adverse findings

None

N/A

Audit closure date: April 11, 2018

Dell Seton Medical Center at The University of Texas
Contact Information

VP of Pharmacy
1500 Red River Street
Austin, TX 78701
512‐324‐7303

DSH450124 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 9, 2019

Door County Memorial Hospital
Contact Information

Chief Administrative Officer
323 South 18th Avenue
Sturgeon Bay, WI 54235
920-746-3737

CAH521358-00 WI

Diversion - 340B drug dispensed at entity, not supported by a medical record.

Repayment to manufacturer

CAP implemented

Audit closure date: May 3, 2019

Drew Memorial Hospital, Inc.
Contact Information

Director of Pharmacy Services
Drew Memorial Health System
778 Scogin Drive
Monticello, AR 71655
870-460-3523

DSH040051 AR

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place; Entity did not provide contract pharmacy oversight.

Diversion - 340B drugs dispensed at contract pharmacy for prescriptions written at ineligible sites; 340B drug dispensed to inpatient.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: September 16, 2019

Drexel University College of Medicine/Hahnemann
Contact Information

Associate Vice Provost, Drexel 340B POC
215-895-6080
kdw38@drexel.edu

Principal Investigator and Director of Women’s Care Center
215-762-1720
sandra.wolf@drexelmed.edu

FP191021 PA

Diversion - 340B drugs transferred to a separately registered covered entity.

Repayment to manufacturers

CAP implemented

Audit closure date: August 15, 2019

Dundy County Hospital
Contact Information

Chief Executive Officer
1313 North Cheyenne Street
Benkelman, NE 69021-3074
308-423-2204

CAH281340-00 NE

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 16, 2019

East Alabama Health Services RWII36830 AL

No adverse findings

None

N/A

Audit closure date: March 23, 2018

East Carolina Health d/b/a Vidant Roanoke-Chowan Hospital DSH340099 NC

No adverse findings

None

N/A

Audit closure date: February 6, 2018

East Georgia Healthcare Center, Inc. CH049010 GA

No adverse findings

None

N/A

Audit closure date: February 27, 2018

Fairview Hospital DBA Fairview Regional Medical Center CAH371329-00 OK

No adverse findings

None

N/A

Audit closure date: June 7, 2018

Fort Sanders Regional Medical Center
Contact Information

Director of Pharmacy
Fort Sanders Regional Medical Center
1901 Clinch Avenue
Knoxville, TN 37916
865-331-4930
Norris@covhith.com

RRC440125-00 TN

Incorrect 340B OPAIS record – Pharmacy incorrectly registered as child site.

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 27, 2020

Genesis Healthcare System DSH360039 OH

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

None

CAP implemented

Audit closure date: January 8, 2019

Georgetown Memorial Hospital DSH420020 SC

No adverse findings

None

N/A

Audit closure date: December 7, 2018

Grand River Hospital District CAH061317-00 CO

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

None

CAP implemented

Audit closure date: September 24, 2018

Great Plains of Smith County DBA Smith County Memorial Hospital CAH171377-00 KS

No adverse findings

None

N/A

Audit closure date: April 10, 2018

Gritman Medical Center
Contact Information

RPH Director of Pharmacy
Gritman Medical Center
700 South Main Street
Moscow, ID 83843
208-883-2236

CAH131327-00 ID

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to January 29, 2018.

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 28, 2018

H.C. Watkins Memorial Hospital CAH251316-00 MS

No adverse findings

None

N/A

Audit closure date: August 9, 2018

Health and Hospital Corporation of Marion County
Contact Information

Pharmacy Manager, Procurement
720 Eskenazi Avenue
Indianapolis, IN 46202
317-880-4450

DSH150024 IN

Diversion - 340B drugs dispensed at entity for prescriptions written at ineligible sites and without a documented provider to patient relationship.

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2019

Healthnet, Inc. CH053200 IN

No adverse findings

None

N/A

Audit closure date: November 29, 2017

Highlands Regional Medical Center DSH180005 KY

Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to April 23, 2018.

None

CAP implemented

Audit closure date: November 14, 2018

Holzer
Contact Information

340B Compliance Analyst
100 Jackson Pike
Gallipolis, Ohio 45631
740-446-5803
mclemente@holzer.org

DSH360054 OH

Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS.

Duplicate Discounts - Incorrect or incomplete information in the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.

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

Repayment to manufacturers

CAP implemented

Audit closure date October 23, 2019

Hospital District No. 5 of Harper County Kansas
Contact Information

Chief Financial Officer
700 W. 13th Street
Harper, KS 67058
620-896-7324

CAH171366-00 KS

Incorrect 340B OPAIS 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.

Repayment to manufacturers

CAP implemented

Audit closure date: April 10, 2019

Housing Works Health Services III, Inc. CHC26191-00 NY

No adverse findings

None

N/A

Audit closure date: October 5, 2018

Hyacinth Foundation
Contact Information

Senior Director of Program Development
317 George Street, Suite 203
New Brunswick, NJ 08901
732-246-0204
jriccardi@hyacinth.org

RWI07107 NJ

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 13, 2019

Inland Hospital DSH200041 ME

No adverse findings

None

N/A

Audit closure date: December 11, 2018

Jane Pauley Community Health Center, Inc. CHC26566-00 IN

No adverse findings

None

N/A

Audit closure date: January 11, 2018

Jessie Trice Community Health System, Inc.
Contact Information

340B Administrator
Jessie Trice Community Health Center, Inc.
5361 Northwest 22nd Avenue
Miami, FL 33142
HNCyrus@jtchc.org
(305) 805-1700

CH040330 FL

Entity did not provide contract pharmacy oversight prior to August 24, 2018.

Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facility names.

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 24, 2020

Johnson City Medical Center
Contact Information

Corporate Pharmacy Business
Director
2 Professional Park Drive
Suite 15
Johnson City, TN 37604
423-302-3535
cindy.tucker@balladhealth.org

DSH440063 TN

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 31, 2019

Kalispell Regional Medical Center
Contact Information

Pharmacy Analyst
310 Sunnyview Lane
Kalispell, MT 59901
406-751-6560

SCH270051-00 MT

Incorrect 340B OPAIS record - ineligible sites registered on 340B OPAIS.

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

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: July 9, 2019

Karmanos Cancer Center
Contact Information

Chief Pharmacy Officer
4100 John R
Detroit, Michigan 48201
313-576-8809

DSH230297 MI

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 19, 2019

Kootenai Hospital District
Contact Information

Business Manager
2003 Kootenai Health Way
Coeur d'Alene, ID 83814
208-625-5651
tchapman@kh.org

DSH130049 ID

Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to February 5, 2018.

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: June 25, 2019

Lake District Hospital
Contact Information

Director of Pharmacy
700 S. J St.
Lakeview, OR 97630
541-947-2114 ext. 281

CAH381309-00 OR

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 6, 2019

Lewis County General Hospital
Contact Information

Chief Financial Officer
7785 North State Street
Lowville, NY 13367
315-376-5597

CAH331317-00 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 29, 2019

Lincoln Community Health Center, Inc. CH040910 NC

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity did not have controls in place to prevent duplicate discounts.

None

Pending

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

Lincoln County Hospital
Contact Information

Chief Financial Officer
Lincoln County Hospital
624 N. 2nd
Lincoln, Kansas 67455
785-524-4030 ext. 212

CAH171360-00 KS

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2019

Lincoln Health (formerly St. Andrews Hospital) CAH201302-00 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: June 6, 2019

Little Falls Hospital
Contact Information

Chief Financial Officer
10300 Compton Ave.
Los Angeles, CA 90002
323-568-3093

CAH331311-00 NY

Diversion - 340B drugs dispensed to inpatients

Repayment to manufacturers

CAP implemented

Audit closure date: April 17, 2019

Livingston Hospital and Healthcare Services, Inc. CAH181320-00 KY

Incorrect 340B OPAIS Record – Incorrect entry for Primary Contact.

None

CAP implemented

Audit closure date: April 3, 2019

Loma Linda University Medical Center
Contact Information

Executive Director of Pharmacy
11234 Anderson Street
Loma Linda, CA 92354
909-558-4497
agobin@llu.edu

DSH050327 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: September 12, 2019

MaineGeneral Medical Center DSH200039 ME

No adverse findings

None

N/A

Audit closure date: December 7, 2018

Maricopa Medical Center
Contact Information

Director of Pharmacy
2601 E. Roosevelt Street
Phoenix, AZ 85008
Anna.Sogard@mihs.org
602-344-5253

DSH030022 AZ

Incorrect 340B OPAIS record - ineligible site registered on 340B OPAIS; Registered contract pharmacy without written contract in place.

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

Termination of one ineligible offsite outpatient facility from the 340B Program*

Termination of one contract pharmacy from 340B Program*

Repayment to manufacturers.

CAP implemented

Audit closure date: January 13, 2020

Marlborough Hospital DSH220049 MA

No adverse findings

None

N/A

Audit closure date: February 7, 2018

Mayo Clinic Health System – Albert Lea SCH240043-00 MN

Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address.

None

CAP implemented

Audit closure date: November 2, 2018

Mayview Community Health Center, Inc. FQHCLA263 CA

No adverse findings

None

N/A

Audit closure date: February 15, 2018

McCulloch County Hospital District DBA Heart of Texas Healthcare System CAH451348-00 TX

No adverse findings

None

N/A

Audit closure date: December 19, 2018

McKay-Dee Hospital Center DSH460004 UT

Duplicate Discounts - Inaccurate 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: June 12, 2018

Medical Center Hospital
Contact Information

340B Coordinator
500 West 4th Street
Odessa, TX 79761
432-640-2294

DSH450132 TX

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

Diversion –340B drug dispensed to an inpatient.

Termination of one contract pharmacy from 340B Program.

Repayment to manufacturer.

CAP implemented

Audit closure date: September 18, 2019

Medical Center of Central Georgia
Contact Information

Department of Pharmacy Services
MSC 113
Medical Center-Navicent Health
777 Hemlock Street
Macon, GA 31201
478-633-1429
478-796-4890

DSH110107 GA

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

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: October 8, 2019

Memorial Health Care Systems DBA Memorial Hospital CAH281339-00 NE

No adverse findings

None

N/A

Audit closure date: October 24, 2018

Memorial Hospital of Texas County Authority
Contact Information

Pharmacy Tech
520 Medical Drive
Guymon, OK 73942
580-338-3113 ext 2261

SCH370138-00 OK

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

Repayment to manufacturers

CAP approved

Covered entity, its outpatient facilities, and its contract pharmacies self-terminated from 340B Program as of April 1, 2018.

Settlement with affected manufacturers has not been finalized. CE will not be permitted to re-enroll in the 340B Program until such time: 1) CE has attested that it has finalized settlement with all affected manufacturers, including completion of any necessary repayment, for all findings listed in the Final Report; and 2) CE has attested that a HRSA-approved CAP has been fully implemented.

Audit closure date: July 10, 2019.

Methodist Charlton Medical Center
Contact Information

Director of Pharmacy Services
3500 W. Wheatland Rd.
Dallas, TX 75237
214-947-7581

DSH450723 TX

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: August 29, 2018

Mid-Valley Healthcare Inc. DBA Samaritan Lebanon Community Hospital CAH381323-00 OR

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

None

CAP implemented

Audit closure date: January 23, 2019

Mississippi State Dept of Health RWIID392133 MS

Incorrect 340B OPAIS record - Incorrect entry for grant number prior to January 29, 2018.

None

CAP implemented

Audit closure date: April 17, 2018

Monroe County Hospital CAH161342-00 IA

No adverse findings

None

N/A

Audit closure date: January 26, 2018

Morris Heights Health Center Inc.
Contact Information

Vice President Planning and Development
Morris Heights Health Center, Inc.
85 West Burnside Avenue
Bronx, New York 10453-4015
718-483-1270

CH021610 NY

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

Duplicate Discounts - Entity’s contract pharmacies were billing Medicaid without notification to HRSA.

Repayment to manufacturers

CAP implemented

Audit closure date: September 13, 2019

Morton Comprehensive Health CH063890 OK

Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address; Registered contract pharmacies without written contract in place.

Duplicate Discounts - Inaccurate or incomplete information 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: June 19, 2019

Mountainview Medical Center CAH271306-00 MT

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: May 24, 2019

Neighborhood Healthcare
Contact Information

Senior Financial Analyst
425 North Date Street
Escondido, CA 92025
760-737-6905

CH093540 CA

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, 2019

New Mexico Department of Health STD87502 NM

Incorrect 340B OPAIS record - Incorrect entry for address prior to December 4, 2018.

Entity did not have adequate controls in place to prevent duplicate discounts. However, since the time of audit, covered entity demonstrated that duplicate discounts did not occur as a result of the finding.

None

CAP implemented

Audit closure date: March 23, 2020

New York – Presbyterian / Queens DSH330055 NY

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

None

CAP implemented

Audit closure date: November 7, 2018

North Central Bronx Hospital Center (NYCHHC) DSH330385 NY

No adverse findings

None

N/A

Audit closure date: December 11, 2018

North Mississippi Primary Health Care, Inc.
Contact Information

Chief Quality Officer
PO Box 92
Ashland, MS 38603
662-502-3156

CH049100 MS

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

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 15, 2019

North Valley Hospital
Contact Information

Pharmacy Director
1600 Hospital Way
Whitefish, MT 59937-2990
406-863-3510

CAH271336-00 MT

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 17, 2019

Northeast Washington County Community Health, Inc.
Contact Information

Chief Operations Officer
PO Box 320
157 Towne Avenue
Plainfield, Vermont 05667
(802) 322-0711

CHC08230-00 VT

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Registered contract pharmacy without written contract in place prior to December 2018.

CE did not comply with HRSA’s conditions and requirements of the alternative methods demonstration project (AMDP).

Diversion –340B drugs dispensed at contract pharmacy to ineligible patients.

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File; Entity did not have adequate controls in place to prevent duplicate discounts.

Repayment to manufacturers

CAP implemented

Audit closure date: October 19, 2020

Northern Maine Medical Center
Contact Information

Chief Financial Officer
Northern Maine Medical Center
194 East Main Street
Fort Kent, ME 04743
207-834-1820

SCH200052-00 ME

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

Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at contract pharmacy for prescriptions written at an ineligible site.

Repayment to manufacturers

CAP implemented

Audit closure date: September 13, 2019

NYU Langone Hospitals
Contact Information

Director of Pharmacy, 340B Program
215 Lexington Avenue, 14th Floor
New York, NY 10016
646-754-9356

DSH330214 NY

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 25, 2019

OhioHealth Corporation DBA Doctors Hospital
Contact Information

Vice President of Finance
OhioHealth Doctors Hospital
5100 West Broad St
Columbus, OH 43228
614-544-2062

DSH360152 OH

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 27, 2020

Orange Coast Memorial Medical Center DSH050678 CA

No adverse findings

None

N/A

Audit closure date: March 7, 2018

Palmetto Health Baptist
Contact Information

System Director of Pharmacy
Dept of Pharmaceutical Services
5 Richland Medical Park Drive
Columbia SC 29203
803-434-3769

DSH420086 SC

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: September 18, 2019

Parkview Hospital
Contact Information

340B Program Supervisor
P.O. Box 5600
Fort Wayne, IN 46895
260-266-4408

DSH150021 IN

Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facilities.

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 17, 2019

Parkview Wabash Hospital, Inc. CAH151310-00 IN

Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to October 23, 2017.

None

CAP implemented

Audit closure date: March 14, 2018

Parmer County Community Hospital, Inc. CAH451300-00 TX

No adverse findings

None

N/A

Audit closure date: February 23, 2018.

Paulding County Hospital
Contact Information

VP Pharmacy/ Radiology
1035 West Wayne Street
Paulding, Ohio 45879
419-399-4080, Ext 320
bhoersten@pauldingcountyhospital.com

CAH361300-00 OH

Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: February 10, 2020

Peacehealth DBA St. Joseph Medical Center
Contact Information

Director of Pharmacy
PeaceHealth St Joseph Medical Center
2901 Squalicum Parkway
Bellingham, WA 98225
360-788-6022

SCH500030-00 WA

Incorrect 340B OPAIS record - Incorrect entry for address 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: March 7, 2019

Peak Vista Community Health Centers
Contact Information

Pharmacy Director
719-344-6269
preilly@peakvista.org

CH081460 CO

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 5, 2018

Penn Presbyterian Medical Center
Contact Information

Director of Pharmacy
Penn Presbyterian Medical Center
51 North 39th Street
Philadelphia PA 19104
215-662-8213

DSH390223 PA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 28, 2019

Pennsylvania Hospital, The
Contact Information

Suzanne Brown
Director of Pharmacy Services
Pennsylvania Hospital
800 Spruce St.
Philadelphia, PA 19107
215-829-5847

DSH390226 PA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 4, 2019

Phoebe Putney Memorial Hospital
Contact Information

Pharmacy Informatics & Technology Manager
417 Third Ave
Albany, GA 31701
229-312-0115

DSH110007 GA

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 26, 2019

Piedmont Mountainside Hospital, Inc. DSH110225 GA

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

None

CAP implemented

Audit closure date: December 31, 2018

Planned Parenthood Association of Utah – South Jordan
Contact Information

VP of Clinical Services
Planned Parenthood Association of Utah
654 South 900 East
Salt Lake City, UT 84102
801-532-1586
Penny.davies@ppau.org

FP84095 UT

Incorrect 340B OPAIS record - Utilized contract pharmacies that were not listed on OPAIS; Failed to remove two terminated contract pharmacies from OPAIS.

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: June 11, 2019

Planned Parenthood St. Louis Region and Southwest Missouri STD65807 MO

No adverse findings

None

N/A

Audit closure date: April 3, 2018

Pomona Valley Hospital Medical Center
Contact Information

Director of Pharmacy
Pomona Valley Hospital Medical Center
1798 Noth Garey Avenue
Pomona, CA 91767
909-865-9501

DSH050231 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 17, 2019

Positive Impact Health Centers, Inc.
Contact Information

Director of Pharmacy
523 Church Street
Decatur, GA 30030
404-977-5206

RWI30309 GA

Diversion – 340B drugs dispensed at entity and 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: January 27, 2020

Prairie Ridge Hospital and Health Services
Contact Information

Pharmacy Director and 340B Program Manager
Prairie Ridge Hospital & Health Services
1411 Hwy 79 E
Elbow Lake, MN 56531
218-685-7376
rlien@prairiehealth.org

CAH241379-00 MN

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 21, 2019

Presbyterian Hospital dba Novant Health Presbyterian Medical Center
Contact Information

340B Supervisor
3334 Healy Drive
Winston-Salem, NC 27103
336-277-0301
echansen@novanthealth.org

DSH340053 NC

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 10, 2019

Providence Hood River Memorial Hospital CAH381318-00 OR

No adverse findings

None

N/A

Audit closure date: December 27, 2018

Providence St. Joseph’s Hospital of Chewelah CAH501309-00 WA

No adverse findings

None

N/A

Audit closure date: September 19, 2018

Providence St. Vincent Medical Center DSH380004 OR

No adverse findings

None

N/A

Audit closure date: October 2, 2018

Public Hospital District No 1-A DBA Pullman Regional Hospital
Contact Information

Chief Financial Officer
835 SE Bishop Blvd
Pullman, WA 99163​
877-446-0473
steve.febus@pullmanregional.org

CAH501331-00 WA

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: October 1, 2019

Regional Health Sturgis Hospital CAH431321-00 SD

No adverse findings

None

N/A

Audit closure date: June 14, 2018

Rhode Island Hospital
Contact Information

Director of Pharmacy
593 Eddy St.
Providence, RI 02903
401-444-4434

DSH410007 RI

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 2, 2019

Richardson Medical Center
Contact Information

Director of Pharmacy
Richardson Medical Center
254 Hwy 3048
Rayville, LA 71269
318-728-8352
reneec@richardsonmed.org

DSH190151 LA

Diversion –340B drugs dispensed to inpatients; 340B drugs were not properly accumulated.

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: October 1, 2019

Riverside Regional Medical Center
Contact Information

Vice President/Chief Pharmacy Officer
856 J Clyde Morris Blvd, Suite C
Newport News, VA 23601
757-316-5707
cynthia.williams2@rivhs.com

DSH490052 VA

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 12, 2019

Ronald Reagan UCLA Medical Center
Contact Information

Director of Inpatient Pharmacy
Ronald Reagan UCLA Medical Center
757 Westwood Plaza Room B531
Los Angeles, CA 90095
310-267-8503

DSH050262 CA

Incorrect 340B OPAIS record - Incorrect entry for billing address.

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 2, 2019

Rumford Hospital CAH201306-00 ME

No adverse findings

None

N/A

Audit closure date: December 12, 2018

Rural Health Group, Inc.
Contact Information

Pharmacy Director
Rural Health Group, Inc.
252-536-5885
dawn.rush@rhgnc.org

CH046680 NC

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 21, 2018

Rush Memorial Hospital CAH151304-00 IN

No adverse findings

None

N/A

Audit closure date: November 16, 2017

Saint Francis Hospital DSH370091 OK

No adverse findings

None

N/A

Audit closure date: June 13, 2018

Saint Joseph – Martin CAH181305-00 KY

No adverse findings

None

N/A

Audit closure date: April 10, 2018

Salem Township Hospital
Contact Information

Chief Executive Officer
1201 Ricker Drive
Salem, IL 62881-4263
618-548-3194

CAH141345-00 IL

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

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 25, 2019

San Miguel County Department of Health and Environment
Contact Information

Director, San Miguel County Department of Health and Environment
PO Box 949
333 West Colorado Ave.
Telluride, CO 81435-00949
970-728-4289

FP814352 CO

Incorrect 340B OPAIS record - Incorrect entry for billing address; Incorrect entry for grant number.

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

Repayment to manufacturers

CAP implemented

Sanford Medical Center Luverne
Contact Information

340B Program Coordinator
1305 W. 18th St.
Sioux Falls, South Dakota 57117
605-333-4298

CAH241371-00 MN

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 26, 2019

Sanford Worthington Medical Center DSH240022 MN

No adverse findings

None

N/A

Audit closure date: January 23, 2018

SC DHEC Lowcountry Region Charleston County North Area FP FP294055 SC

No adverse finding

None

N/A

Audit closure date: November 15, 2018

Scott and White Memorial Hospital
Contact Information

Pharmacy Specialist, Scott & White Memorial Hospital
2401 S. 31st Street
Temple, TX 76502
254-724-3811

DSH450054 TX

Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 4, 2018.

Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; - Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to include entity owned pharmacies as shipping addresses.

Diversion –340B drug dispensed to an inpatient.

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

Repayment to manufacturers

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

CAP implemented

Audit closure date: March 23, 2020

Scott Regional Hospital
Contact Information

Compliance Officer
Scott Regional Hospital
317 Highway 13 South
Morton, MS 39117
601-703-4437

CAH251323-00 MS

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: December 20, 2018

SE Alabama Rural Health Associates (SARHA) CH048950 AL

Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to August 22, 2018.

None

CAP implemented

Audit closure date: August 20, 2019

Seattle Children’s Hospital PED503300-00 WA

Incorrect 340B OPAIS record - Incorrect entry for off-site outpatient facility billing address.

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: August 20, 2019

Shady Grove Adventist Hospital
Contact Information

Rockville Campus Director of Pharmacy
9901 Medical Center Drive
Rockville, MD 28050
240-826-6156

DSH210057 MD

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 29, 2019

Shelby Co Chris A Myrtue Memorial Hospital
Contact Information

340B Coordinator
1213 Garfield Avenue
Harlan, IA 51537
712-755-4411

CAH161374-00 IA

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 6, 2019

Shenandoah Medical Center CAH161366-00 IA

No adverse findings

None

N/A

Audit closure date: January 31, 2018

Skagit Valley Hospital
Contact Information

340B Coordinator
Skagit Valley Hospital
1415 East Kincaid Street
Mount Vernon, WA 98274

DSH500003 WA

Diversion - 340B drugs dispensed at entity 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: August 6, 2019

South Lincoln Hospital District
Contact Information

IT / Revenue Cycle Manager
711 Onyx Street
Kemmerer, WY 83101
307-877-5574

CAH531315-00 WY

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP implemented

Audit closure date: October 2, 2019

Southeast Community Health Systems
Contact Information

340B Coordinator
Skagit Valley Hospital
1415 East Kincaid Street
Mount Vernon, WA 98274

CH063710 LA

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 13, 2019

Southeast Health Medical Center
Contact Information

340B Program Coordinator
1108 Ross Clark Circle
Dothan, AL 36301
334-793-8113

DSH010001 AL

Incorrect 340B OPAIS record - Registered contract pharmacy without written contract in place prior to June 6, 2018.

Diversion - 340B drug dispensed to an inpatient; 340B drugs dispensed at entity for prescriptions written at ineligible sites.

Repayment to manufacturers

CAP implemented

Audit closure date: September 5, 2019

Spectrum Health Big Rapids Hospital SCH230093-00 MI

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place; Hospital classification on OPAIS was inconsistent with eligibility documents prior to September 7, 2018.

Termination of three contract pharmacies from 340B Program*

CAP implemented

Audit closure date: February 28, 2019

St. David’s Healthcare Partnership, L.P., LLP DBA St. David’s Medical Center
Contact Information

Chief Financial Officer
1025 E. 32nd Street
Austin, TX 78705
512-544-5030

DSH450431 TX

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 16, 2019

St. Francis Medical Center DSH310021 NJ

No adverse findings

None

N/A

Audit closure date: March 16, 2018

St. Francis Medical Center Inc.
Contact Information

Divisional Director
Clinical Ancillary Operations
309 Jackson St.
Monroe, LA 71201
318-966-4957

DSH190125 LA

Diversion - 340B drugs were not properly accumulated; 340B drugs dispensed at 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 6, 2019

St. Gabriel’s Hospital CAH241370-00 MN

No adverse findings

None

N/A

Audit closure date: May 29, 2018

St. Joseph’s Medical Center DSH240075
SCH240075-00
MN

No adverse findings

None

N/A

Audit closure date: August 8, 2018

St. Luke’s Hospital of Duluth
Contact Information

Vice President/CFO
915 East First Street
Duluth, MN 55805-2107
218-249-5475

DSH240047 MN

Incorrect 340B OPAIS record – Incorrect entries for offsite outpatient facilities’ addresses.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 29, 2019

St. Luke’s Wood River Medical Center CAH131323-00 ID

No adverse findings

None

N/A

Audit closure date: October 15, 2018

St. Mary’s Hospital and Medical Center, Inc. DSH060023 CO

No adverse findings

None

N/A

Audit closure date: May 23, 2018

St. Mary’s Regional Health Center DSH240101 MN

No adverse findings

None

N/A

Audit closure date: August 10, 2018

Stanford Health Care DSH050441 CA

No adverse findings

None

N/A

Audit closure date: February 1, 2018

Sterling Regional MedCenter RRC060076-00 CO

Incorrect 340B OPAIS record - Entity registered as an incorrect hospital type.

None

CAP implemented

Audit closure date: May 29, 2019

Sunset Park Health Council, Inc.
Contact Information

Compliance Officer
Callen-Lorde Community Health Center
356 West 18th Street
New York, NY 10011
212-271-7149
lmazzola@callen-lorde.org

CH0218870 NY

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 16, 2019

Sutter Bay Hospital DBA Alta Bates Summit Medical Center DSH050043 CA

Incorrect 340B OPAIS record - Ineligible site registered on 340B OPAIS; Incorrect entry for off-site outpatient facility address; Incorrect entry for billing address; Incorrect entry for authorizing official telephone number.

None

CAP implemented

Audit closure date: April 30, 2019

Swedish Medical Center DSH500027 WA

Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities.

None

CAP implemented

Audit closure date: July 23, 2019

Tarrant County Hospital District, John Peter Smith Hospital
Contact Information

Chief Pharmacy Officer
(817) 702-6718
1500 S. Main Street
Fort Worth, TX 76104

DSH450039 TX

Incorrect 340B OPAIS record - Incorrect entries for name and address of offsite outpatient location.

Diversion - 340B drug dispensed at contract pharmacy for a prescription written at an 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: January 27, 2020

Temple University Hospital
Contact Information

Chief Financial Officer
2450 West Hunting Park Avenue
Philadelphia, PA 19129
TUH340Program@tuhs.temple.edu

DSH390027 PA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 1, 2020

Three Rivers Medical Center
Contact Information

Chief Administrative and Financial Officer
Three Rivers Medical Center
500 SW Ramsey Avenue
Grants Pass, Oregon 97527
541-789- 4549

DSH380002 OR

Incorrect 340B OPAIS record - Failed to include entity owned pharmacy as a shipping address.

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 29, 2019

Trinity Hospital Twin City CAH361302-00 OH

No adverse findings

None

N/A

Audit closure date: February 8, 2018

Tyrone Hospital
Contact Information

Chief Executive Officer
Tyrone Hospital
187 Hospital Drive
Tyrone, PA 16686
814-684-1255, ext 2101

CAH391307-00 PA

Incorrect 340B OPAIS record - Failed to remove closed location’s registration; Incorrect entry for address.

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

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: April 12, 2019

UCSF - Medical Center
Contact Information

340B Manager
UCSF Medical Center
505 Parnassus Avenue
San Francisco, CA 94143
415-514-8398

DSH050454 CA

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place;

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

Termination of three contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: November 19, 2019

United Community Services, Inc. CHC29000-00 CT

No adverse findings

None

N/A

Audit closure date: January 24, 2018

United Regional Health Care System
Contact Information

Robert Pert,
Chief Financial Officer
1617 11th Street
Wichita Falls, TX 76301
940-764-3023

SCH450010-00 TX

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

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 duplicate discounts.

Repayment to manufacturers

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: October 3, 2019

University Hospitals Rainbow and Babies Children’s Hospital
Contact Information

Vice President & Corporate Controller
3605 Warrensville Center Rd.
Room: 1110 Mail Stop: MSC8100
Shaker Heights, OH 44122-5203
216-767-8729
Michael.Vehovec@UHhospitals.org

PED363302-00 OH

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 13, 2019

Urban Health Plan, Inc. CH023600 NY

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 17, 2019

USC Norris Cancer Hospital CAN050660-00 CA

Incorrect 340B OPAIS record - Incorrect entry for address

None

CAP implemented

Audit closure date: July 18, 2018

Valley AIDS Council RWII70 TX

Incorrect 340B OPAIS record –Incorrect grant number entry.

Entity did not provide contract pharmacy oversight.

Termination of contract pharmacies from 340B Program

CAP implemented

Audit closure date: November 20, 2019

Virginia Commonwealth University Health System DSH490032 VA

No adverse findings

None

N/A

Audit closure date: October 17, 2018

Waikiki Health CH092060 HI

Incorrect 340B OPAIS record – Incorrect entry for entity name; incorrect entry for primary contact information.

None

CAP implemented

Audit closure date: August 20, 2019

Wakemed
Contact Information

Executive Director of Clinical Services
919-350-8021
vbarlow@wakemed.org

DSH340069 NC

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 6, 2019

Watts Healthcare Corporation
Contact Information

Chief Financial Officer
10300 Compton Ave.
Los Angeles, CA 90002
323-568-3093

CHC00850-00 CA

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from 340B Program
Repayment to manufacturers

CAP implemented

Audit closure date: April 17, 2019

West Allis Memorial Hospital Inc. DBA Aurora West Allis Medical Center DSH520139 WI

Entity was billing Medicaid contrary to information included 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 10, 2019

Westchester Medical Center DSH330234 NY

Incorrect 340B OPAIS record - ineligible site registered on 340B OPAIS; Incorrect entry for offsite outpatient location zip code.

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

CAP implemented

Audit closure date: June 12, 2019

Whitesburg ARH Hospital DSH180002 KY

No adverse findings

None

N/A

Audit closure date: June 6, 2018

Whitley Memorial Hospital DSH150101 IN

No adverse findings

None

N/A

Audit closure date: December 12, 2017

Yuma Regional Medical Center
Contact Information

340B Program Manager
2400 S Avenue A
Yuma, AZ 85364
928-336-7721

DSH030013 AZ

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 23, 2019

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

Date Last Reviewed: