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Program Integrity: FY19 Audit Results

Updated 1/28/22. 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
Abbeville County Memorial Hospital CAH421301-00 SC

No adverse findings

None

N/A

Audit closure date: October 4, 2019

Action for Boston Community Development FP021118 MA

Incorrect 340B OPAIS record – Incorrect entries for grant number.

None

CAP implemented

Audit closure date: April 6, 2021

Adams County Memorial Hospital dba Adams Memorial Hospital CAH151330-00 IN

Incorrect 340B OPAIS record -Registered contract pharmacies without written contract in place prior to January 25, 2019.

None

CAP implemented

Audit closure date: April 24, 2019

Adena Regional Medical Center
Contact Information

AHS Director of Pharmacy Services
272 Hospital Road
Chillicothe OH 45601
fyingling@adena.org
740-779-7648

DSH360159 OH

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 4, 2021

Alamance Regional Medical Center DSH340070 NC

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Albany Medical Center Hospital DSH330013 NY

No adverse findings

None

N/A

Audit closure date: December 20, 2019

Ammonoosuc Community Health Services Inc. CH010980 NH

No adverse findings

None

N/A

Audit closure date: March 7, 2019

Arkansas Department of Health FP722051 AR

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

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

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: September 17, 2020

Aroostook Medical Center, The DSH200018 ME

No adverse findings

None

N/A

Audit closure date: December 6, 2019

Athens-Limestone
Contact Information

Chief Financial Officer
700 West Market Street
Athens, AL 35611
256-233-9172

DSH010079 AL

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 17, 2020

Avera St. Mary’s DSH430015 SD

No adverse findings

None

N/A

Audit closure date: January 27, 2020

Baptist Health
Contact Information

Corporate Director of Pharmacy
1000 W Moreno Street
Pensacola, FL 32501
850-469-7567

DSH100093 FL

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.

Repayment to manufacturers

CAP implemented

Audit closure date: September 23, 2020

Baptist Health Medical Center – LR DSH040114 AR

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

None

CAP implemented

Audit closure date: June 9, 2020

State Medicaid has since determined duplicate discounts did not occur.

Barnesville Hospital Association, Inc. CAH361321-00 OH

No adverse findings

None

N/A

Audit closure date: May 9, 2019

Baton Rouge General Medical Center
Contact Information

Compliance Officer
8490 Picardy Ave Suite 300
Baton Rouge, Louisiana 70809
ken.miller@brgeneral.org
225-237-1588

DSH190065 LA

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

Diversion – 340B drug dispensed to inpatient.

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 18, 2021

Beaufort-Jasper-Hampton Comprehensive Health Services, Incorporated
Contact Information

340B Program Coordinator
721 Okatie Highway
Ridgeland, SC 29936
843-987-7545

CH041190 SC

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for address for offsite outpatient facility.

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 3, 2020

Big Springs Medical Association, Inc.
Contact Information

CEO
110 South Second Street
Ellington, MO 63638
573-663-2313
kwhite@mohigh.org

CH070430 MO

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 14, 2020

Brattleboro Memorial Hospital DSH470011 VT

No adverse findings

None

N/A

Audit closure date: July 9, 2019

Bridgeport Hospital DSH070010 CT

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Brockton Hospital, Inc DSH220052 MA

Inaccurate or incomplete information on 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: January 26, 2021

BronxCare Health System Fulton Division DSH330009 NY

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove duplicate registration for offsite outpatient facility.

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

None

CAP implemented

Audit closure date: February 5, 2020

Brooklyn Hospital Center, The
Contact Information

VP Revenue Enhancement
15 Metrotech 3rd Floor
Brooklyn, N.Y. 11201
(O) 718-488-3775 (F) 718 488-3725

DSH330056 NY

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 26, 2021

Cambridge Memorial Hospital, Inc. DBA Tri Valley Health System CAH281348-00 NE

No adverse findings

None

N/A

Audit closure date: August 27, 2019

CAN Community Health, Inc. STD342372 FL

No adverse findings

None

N/A

Audit closure date: January 7, 2020

Canton-Potsdam Hospital
Contact Information

Authorizing Official, Chief Financial Officer
Canton-Potsdam Hospital
50 Leroy Street
Potsdam, NY 13676
rjacobs@cphospital.org

DSH330197 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 8, 2020

Caring Health Center, Inc. CH01084B MA

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

None

CAP implemented

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

Audit closure date: June 4, 2020.

Carthage Area Hospital Inc. CAH331318-00 NY

No adverse findings

None

N/A

Audit closure date: December 6, 2019

Cass Regional Medical Center CAH261324-00 MO

No adverse findings

None

N/A

Audit closure date: May 29, 2019

Centro San Vicente
Contact Information

Chief Financial Officer
8061 Alameda Ave, El Paso, TX 79915
915-859-7545 ext. 1214

CH066580 TX

Diversion - 340B drug dispensed at contract pharmacy for prescription 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: May 18, 2020

Chambers Memorial Hospital
Contact Information

340B Administrator, 479-495-6264
PO Box 639, Danville, AR 72833
jeffreywoods@chambershospital.com

SCH040011-00 AR

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 7, 2020

Charles A. Dean Memorial Hospital CAH201301-00 ME

No adverse findings

None

N/A

Audit closure date: June 23, 2020

Children’s National Medical Center
Contact Information

Chief of Pharmacy
111 Michigan Avenue, NW
Washington, DC 20010
202-476-5553

PED093300-00 DC

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 14, 2020

Childress Regional Medical Center DSH450369 TX

Incorrect 340B OPAIS record - Incorrect entry for disproportionate share percentage.

None

CAP implemented

Audit closure date: February 7, 2020

Christus St. Michael
Contact Information

Michael French, J.D.
Senior Consultant
19065 Hickory Creek Dr., Suite 115
Mokena, IL 60448
708-478-7030

DSH450801 TX

Incorrect 340B OPAIS record - Failed to remove closed contract pharmacy location registration.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 19, 2020

Clara Maass Medical Center DSH310009 NJ

No adverse findings

None

N/A

Audit closure date: December 17, 2019

Clinch River Health Services, Incorporated CH031230 VA

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B database; Incorrect entry for authorizing official.

None

CAP implemented

Audit closure date: June 25, 2020

Community Health Center of Central Wyoming, Inc.
Contact Information

Director of Pharmacy
jbeattie@chccw.org
(307) 233-6050

CH086120 WY

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 31, 2019

Community Memorial Hospital, Inc. CAH331316-00 NY

No adverse findings

None

N/A

Audit closure date: December 10, 2019

Complete Care Community Health Center, Inc. CHC28987-00 CA

No adverse findings

None

N/A

Audit closure date: November 29, 2019

Coquille Indian Tribe
Contact Information

Pharmacy Manager
541-435-7039 carynmickelson@coquilletribe.org

FQHC638532 OR

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 28, 2021

D. W. McMillan Memorial Hospital DSH010099 AL

No adverse findings

None

N/A

Audit closure date: January 17, 2019

Daviess Community Hospital DSH150061 IN

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

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

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

CAP implemented

State Medicaid determined no duplicate discounts occurred.

Audit closure date: May 7, 2020

Davis Street Community Center Inc. CHC28979-00 CA

Incorrect 340B OPAIS record – Incorrect entry for primary contact.

None

N/A

Audit closure date: May 20, 2020

Delaware Valley Hospital, Inc. CAH331312-00 NY

No adverse findings

None

N/A

Audit closure date: June 26, 2019

District of Columbia Department of Health HIV/AIDS, Hepatitis, STD & TB Administration RWIID72 DC

No adverse findings

None

N/A

Audit closure date: April 12, 2019

DOH Okaloosa FP325481 FL

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

None

CAP implemented

Audit closure date: April 9, 2019

Duke University Hospital DSH340030 NC

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

None

CAP implemented

Audit closure date: December 18, 2019

East Bay Community Action Program
Contact Information

Administrative Assistant Health Administration
East Bay Community Action Program
100 Bullocks Point Avenue
Riverside, RI 02915
401-437-1008

CH015160 RI

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 17, 2020

Ellis Hospital
Contact Information

340B Manager
Ellis Hospital
1101 Nott Street
Schenectady, NY 12308
518-243-1824

DSH330153 NY

Diversion – 340B drug dispensed to inpatient

Repayment to manufacturers

CAP implemented

Audit closure date: September 15, 2020

Ellsworth Municipal Hospital CAH161380-00 IA

No adverse findings

None

N/A

Audit closure date: July 9, 2019

Exempla Saint Joseph Hospital DSH060028 CO

No adverse findings

None

N/A

Audit closure date: May 3, 2019

Fairview Hospital CAH221302-00 MA

No adverse findings

None

N/A

Audit closure date: March 13, 2019

Faxton St. Luke’s Healthcare DSH330044 NY

No adverse findings

None

N/A

Audit closure date: June 17, 2019

Ferrell Hospital Community dba Ferrell Hospital Community Foundation
Contact Information

Director of Pharmacy/340B primary contact
Ferrell Hospital
1201 Pine Street
Eldorado, IL 62930
618-297-9627

CAH141324-00 IL

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 10, 2020

Forrest General Hospital
Contact Information

Director of Pharmacy tmcdaniel@forrestgeneral.com
601-288-1485

DSH250078 MS

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 21, 2021

Franklin Medical Center
Contact Information

Director of Pharmacy/Compliance Officer
2106 Loop Road
Winnsboro, LA 71295
ggough@fmc-cares.com
318-412-5340

DSH190140 LA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to May 29, 2020.

Entity failed to maintain auditable medical records prior to May 29, 2020.

Repayment to manufacturers

CAP implemented

Audit closure date: April 4, 2021

Freeman Regional Health Services CAH431313-00 SD

No adverse findings

None

N/A

Audit closure date: August 28, 2019

G.A. Carmichael Family Health Center, Inc.
Contact Information

Chief Financial Officer
1668 W. Peace Street
Canton, MS 39046
270-245-7239

CH040760 MS

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove a duplicate registration of a contract pharmacy;

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 15, 2020

Galion Community Hospital CAH361325-00 OH

Inaccurate or incomplete information on 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: September 15, 2020

Georgetown University Hospital
Contact Information

340B Compliance Specialist
MedStar Georgetown University Hospital
3800 Reservoir Road
Washington DC 20007
thanhson.t.doan@gunet.georgetown.edu 202-444-0556

DSH090004 DC

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2020

Gerald Champion Regional Medical Center
Contact Information

340B Coordinator
2669 Scenic Drive
Alamogordo, NM 88310
575-443-7841

DSH320004 NM

Covered outpatient drugs obtained through a Group Purchasing Organization prior to July 1, 2019.

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

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

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

Repayment to manufacturers

State Medicaid has since determined duplicate discounts did not occur.

CAP implemented

Audit closure date: January 5, 2021

GHS Laurens County Memorial Hospital SCH420038 SC

No adverse findings

None

N/A

Audit closure date: October 10, 2019

Golden Valley Health Centers
Contact Information

Accounting Manager, Primary Contact
1910 Customer Care Way
Atwater, CA 95301
209-384-6524

CH090470 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 18, 2020

Gonzales Healthcare Systems
Contact Information

Compliance Officer
GHS
P.O. Box 587
Gonzales, Texas 78629
830-672-7581 ext 1011

DSH450235 TX

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

Duplicate Discounts – Entity did not have adequate controls to prevent duplicate discounts.

Repayment to manufacturers

CAP implemented

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

Audit closure date: May 20, 2020

Good Samaritan Regional Health Center
Contact Information

Finance Director
1195 Corporate Lake Drive
St Louis, MO 63132
314-989-3532
jeff.peine@ssmhealth.com

RRC140046-00 IL

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 10, 2019

Graham Hospital Association SCH140001-00 IL

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

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

None

CAP implemented

Audit closure date: June 9, 2020

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

Halifax Regional Medical Center
Contact Information

Patient Financial Services Manager
250 Smith Church Road
Roanoke Rapids, NC 27870
252-535-8147
cferebee@halifaxmrc.org

DSH340151 NC

Duplicate Discounts – Entity did not have adequate controls to prevent duplicate discounts.

Repayment to manufacturers

CAP implemented

Audit closure date: May 14, 2020

Harbor Beach Community Hospital, Inc.
Contact Information

Scott Rayl, Pharmacist
989-479-3201 x351
210 S. First Street
Harbor Beach, MI 48441

CAH231313-00 MI

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 9, 2020

Hartford Hospital DSH070025 CT

No adverse findings

None

N/A

Audit closure date: August 7, 2019

Healdsburg District Hospital
Contact Information

Chief Financial Officer
1375 University Ave.
Healdsburg, CA 95448
707-385-2022
staj@nschd.org

CAH051321-00 CA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 26, 2020

Higgins General Hospital
Contact Information

Director of Pharmacy
705 Dixie Street
Carrollton, GA 30117
770‐836‐9646

CAH111320-00 GA

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2020

Highland Community Hospital DSH250117 MS

No adverse findings

None

N/A

Audit closure date: May 14, 2019

Highlands Hospital DSH390184 PA

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

None

CAP implemented

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

Audit closure date: May 12, 2020

Holdenville Hospital Authority
Contact Information

CEO/Administrator
100 McDougal Drive
Holdenville, OK 74848
405-379-4287

CAH371321-00 OK

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 8, 2020

Hospital Authority of Randolph County DBA Southwest Georgia Regional Medical Center
Contact Information

Chief Financial Officer
361 Randolph St.
Cuthbert, GA 39840
229-777-4506

CAH111300-00 GA

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 27, 2020

Hospital Service District 1A, Parish of Richland, State of Louisiana DBA Richland Parish Hospital CAH191323-00 LA

No adverse findings

None

N/A

Audit closure date: March 29, 2019

Huggins Hospital
Contact Information

Clinical Services Business Manager
Huggins Hospital
240 South Main Street
Wolfeboro, NH 03894
(603) 515 – 2065
atheberge@hugginshospital.org

CAH301312-00 NH

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 3, 2020

Huron Memorial Hospital
Contact Information

Director of Finance
1100 S. Van Dyke
Bad Axe, MI 48413
989-269-1510

DSH230118 MI

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

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

Termination of contract pharmacy from 340B Program

CAP implemented

Audit closure date: June 19, 2020

Ida County Iowa Community Hospital dba Horn Memorial Hospital
Contact Information

Chief Financial Officer
or CFO of Horn Memorial Hospital
701 E 2nd St
Ida Grove, IA, 51445
712-364-3311

CAH161354-00 IA

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 8, 2020

IHC Health Services, Inc. dba Primary Children’s Hospital PED463301-00 UT

No adverse findings

None

N/A

Audit closure date: November 26, 2019

Inova Fairfax Hospital
Contact Information

340B Compliance Pharmacist
Inova Fairfax Medical Campus
3300 Gallows Road
Falls Church, VA 22042
703-776-1114

DSH490063 VA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 12, 2020.

Repayment to manufacturers

CAP implemented

Audit closure date: January 26, 2021

Interfaith Medical Center DSH330397 NY

Incorrect 340B OPAIS record - Failed to remove duplicate registrations for offsite outpatient facility; Incorrect entry for offsite outpatient facility address.

None

CAP implemented

Audit closure date: April 29, 2020

Iowa Lutheran Hospital DSH160024 IA

No adverse findings

None

N/A

Audit closure date: June 21, 2019

John C. Lincoln Medical Center DSH030014 AZ

No adverse findings

None

N/A

Audit closure date: May 17, 2019

Johnston Health Services Corporation DSH340090 NC

No adverse findings

None

N/A

Audit closure date: April 24, 2019

Kearney County Health Services CAH281306-00 NE

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Keck Hospital of USC DSH050696 CA

Inaccurate or incomplete information on 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 27, 2020

Kern Medical Center
Contact Information

Associate Director of Pharmacy
Kern Medical Center
1700 Mount Vernon Avenue
Bakersfield, CA 93306
(661) 326-2617

DSH050315 CA

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

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 30, 2020

Kossuth Regional Health Center CAH161353-00 IA

No adverse findings

None

N/A

Audit closure date: June 19, 2019

Lake Regional Health System
Contact Information

Primary Contact 340B Program
Lake Regional Health System
54 Hospital Drive
Osage Beach, MO 65065
573-348-8190

SCH260186-00 MO

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 3, 2020

Lavaca Medical Center
Contact Information

Chief Financial Officer
Lavaca Medical Center
1400 N. Texana
Hallettsville, TX 77964
361-798-3671

CAH451376-00 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 27, 2020

Legacy Mount Hood Medical Center DSH380025 OR

No adverse findings

None

N/A

Audit closure date: January 9, 2019

Lexington Memorial Hospital, Inc.
Contact Information

Pharmacy System Manager, 340B
Medical Center Blvd
Winston-Salem, NC 27157
336-713-3426

DSH340096 NC

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 26, 2020

Liberty Regional Medical Center CAH111335-00 GA

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Lonesome Pine Hospital DSH490114 VA

No adverse findings

None

N/A

Audit closure date: March 8, 2019

Lost Rivers District Hospital CAH131324-00 ID

No adverse findings

None

N/A

Audit closure date: February 15, 2019

Lowell General Hospital, The DSH220063 MA

No adverse findings

None

N/A

Audit closure date: October 31, 2019

Lutheran Medical Center DSH060009 CO

No adverse findings

None

N/A

Audit closure date: October 7, 2019

Lynn County Hospital CAH451351-00 TX

No adverse findings

None

N/A

Audit closure date: May 14, 2019

Marietta Memorial Hospital RRC360147-00 OH

Incorrect 340B OPAIS record – Ineligible sites registered on 340B OPAIS.

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

CAP implemented

Audit closure date: March 11, 2021

Marshall Hospital DSH050254 CA

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

None

CAP implemented

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

Audit closure date: November 20, 2019

Mary Bridge Children’s Hospital and Health Center
Contact Information

Pharmacy 340B Analyst
MultiCare Health System
PO Box 5299, 315-C2-RX
315 Martin Luther King Jr. Way
Tacoma, WA 98415
jkim@multicare.org
253.403.5541

PED503301-00 WA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to September 26, 2019.

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 1, 2020

Mason General Hospital CAH501336-00 WA

No adverse findings

None

N/A

Audit closure date: June 6, 2019

Massac County Hospital District CAH141323-00 IL

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

Termination of contract pharmacy from 340B Program*

CAP implemented

Audit closure date: October 31, 2019

McCloud Healthcare Clinic, Inc CHC24112-00 CA

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

Termination of contract pharmacies from 340B Program*

CAP implemented

May 27, 2020

MedStar Southern Maryland Hospital Center
Contact Information

Corporate 340B Manager
MedStar Health
7375 Washington Blvd, Suite 103
Elkridge, MD 21075
Anna.y.rosenfeld@medstar.net
410-540-4406

DSH210062 MD

Diversion – 340B drug dispensed to inpatient

Repayment to manufacturers

CAP implemented

Audit closure date: March 10, 2021

MedStar Washington Hospital Center DSH090011 DC

No adverse findings

None

N/A

Audit closure date: October 24, 2019

Memorial Hospital dba Memorial Healthcare, The
Contact Information

340B Manager
826 W. King Street
Owosso, MI 48867
989-729-4793

DSH230121 MI

Incorrect 340B OPAIS record - Incorrect entry for address for an offsite outpatient facility; Failed to remove duplicate registration for contract pharmacy.

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

Audit closure date: June 24, 2020

Memorial Hospital of Boscobel
Contact Information

Pharmacy Director MHB
205 Parker Street
Boscobel, WI 53805
608-375-6307

CAH521344-00 WI

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 10, 2020

Mercy Catholic Medical Center DSH390156 PA

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

None

CAP implemented

Audit closure date: May 13, 2020

Mercy Health Lourdes Hospital LLC RRC180102-00 KY

No adverse findings

None

N/A

Audit closure date: May 24, 2019

Mercy Medical Center – North Iowa SCH160064-00 IA

No adverse findings

None

N/A

Audit closure date: February 7, 2020

MetroHealth HV01713 DC

No adverse findings

None

N/A

Audit closure date: February 19, 2020

Metropolitan Charities, Inc. STD33713 FL

No adverse findings

None

Audit closure date: February 25, 2020

MGH Chelsea Student Health Center
Contact Information

Director, MGH Community Health Associates
300 Ocean Avenue 5th Floor
Revere, MA 02151
781-485-6135
aduffy-keane@partners.org

FP021501 MA

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 9, 2020

Minnie Hamilton Health Care Center, Inc. CAH511303-00 WV

Incorrect 340B OPAIS record - Hospital classification on OPAIS was inconsistent with eligibility documents.

None

CAP implemented

Audit closure date: October 8, 2020

Missouri Baptist Hospital of Sullivan dba Missouri Baptist Sullivan Hospital CAH261337-00 MO

No adverse findings

None

N/A

Audit closure date: June 27, 2019

Montefiore Medical Center
Contact Information

Vice President of Finance
dmenashy@montefiore.org
917-280-2722

DSH330059 NY

Incorrect 340B OPAIS record – Offsite outpatient facilities and a shipping address were not listed on the 340B OPAIS.

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 9, 2021

Montefiore Nyack Hospital DSH330104 NY

No adverse findings

None

N/A

Audit closure date: June 12, 2019

Mosaic Medical CH105600 OR

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

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: July 21, 2020

Mount St. Mary’s Hospital and Health Center DSH330188 NY

Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy.

None

CAP implemented

Audit closure date: April 14, 2020

Mountain Comprehensive Health Corp., Inc. CH040600 KY

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: May 12, 2020

Munson Healthcare Charlevoix Hospital CAH231322-00 MI

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

None

CAP implemented

Audit closure date: January 26, 2021

Nanticoke Memorial Hospital DSH080006 DE

No adverse findings

None

N/A

Audit closure date: June 12, 2019

Nationwide Children’s Hospital PED363305-00 OH

No adverse findings

None

N/A

Audit closure date: October 1, 2019

New Mexico Department of Health Title X Family Planning Program FP875036 NM

No adverse findings

None

N/A

Audit closure date: April 10, 2020

Northeast Georgia Medical Center
Contact Information

Director of Pharmacy
743 Spring St. NE
Gainesville, GA 30501
770-219-7573

RRC110029-00 GA

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entries for addresses for offsite outpatient facilities.

Diversion – 340B drugs dispensed to inpatients

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 25, 2021

Oakwood Healthcare Inc. dba Beaumont Hospital - Taylor DSH230270 MI

No adverse findings

None

N/A

Audit closure date: August 26, 2019

Ohio State University Hospital, The DSH360085 OH

No adverse findings

None

N/A

Audit closure date: June 6, 2019

Olean General Hospital RRC330103-00 NY

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

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

CAP implemented

Audit closure date: December 8, 2020

Olympic Medical Center
Contact Information

Director of Pharmacy
Olympic Medical Center
939 Caroline Street
Port Angeles, WA 98362
kbright@olympicmedical.org

RRC500072-00 WA

Diversion – 340B drugs dispensed to inpatients

Repayment to manufacturers

CAP implemented

Audit closure date: November 3, 2020

Oneida Healthcare Center DSH330115 NY

No adverse findings

None

N/A

Audit closure date: November 1, 2019

Open Door Health Services, Inc.
Contact Information

Compliance Officer
PO Box 1676
Muncie, IN 47308
765-747-2973

CH0510700 IN

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 26, 2020

Orlando Health DSH100006 FL

Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities. Failed to include repackaging location as a shipping address.

None

CAP implemented

Audit closure date: April 29, 2020

Ozarks Resource Group
Contact Information

Chief Executive Officer or Chief Financial Officer
PO Box 125
Hermitage, MO 65668
417-745-0103

CHC24137-00 MO

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 10, 2019

Pediatric & Family Medical Center CH0921340 CA

Inaccurate or incomplete information on 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: October 8, 2020

Pender Community Hospital CAH281349-00 NE

No adverse findings

None

N/A

Audit closure date: December 4, 2019

Peninsula Community Health Services CH101540 WA

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Phelps Memorial Hospital Center DSH330261 NY

No adverse findings

None

N/A

Audit closure date: November 20, 2019

Piedmont Henry Hospital, Inc. DSH110191 GA

No adverse findings

None

N/A

Audit closure date: November 19, 2019

Piedmont Newnan Hospital, Inc. DSH110229 GA

No adverse findings

None

N/A

Audit closure date: February 4, 2019

Piggott Community Hospital CAH041330-00 AR

No adverse findings

None

N/A

Audit closure date: May 16, 2019

Pikeville Medical Center, Inc. DSH180044 KY

No adverse findings

None

N/A

Audit closure date: March 13, 2019

Planned Parenthood of the Rocky Mountains, Inc. STD80203 CO

No adverse findings

None

N/A

Audit closure date: December 17, 2019

Primary Health Network, Inc. CH03406AE OH

Incorrect 340B OPAIS record –Incorrect entry for site ID for offsite outpatient facility; Failed to remove a duplicate registration of a contract pharmacy.

None

CAP implemented

Audit closure date: February 10, 2020

Providence Portland Medical Center DSH380061 OR

No adverse findings

None

N/A

Audit closure date: May 23, 2019

Rancho Los Amigos National Rehabilitation Center DSH050717 CA

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

None

Pending

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

Audit closure date: September 18, 2019

Range Regional Health Services DSH240040 MN

No adverse findings

None

N/A

Audit closure date: October 8, 2019

Regional Health Care Affiliates, Inc.
Contact Information

CPO
121 E. Main St.
Providence, KY 42450
270-667-7017

CHC17157-00 KY

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

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: August 20, 2019

Regional Health Custer Hospital CAH431323-00 SD

No adverse findings

None

N/A

Audit closure date March 7, 2019

Renown Regional Medical Center DSH290001 NV

No adverse findings

None

N/A

Audit closure date: November 21, 2019

Sacred Heart Hospital DSH390197 PA

No adverse findings

None

N/A

Audit closure date: August 28, 2019

San Bernardino Mountains Community Hospital District CAH051312-00 CA

No adverse findings

None

N/A

Audit closure date: August 27, 2019

Sanford Bismarck DSH350015 ND

No adverse findings

None

N/A

Audit closure date: January 16, 2019

Sanford Health Westbrook Medical Center CAH241302-00 MN

No adverse findings

None

N/A

Audit closure date: January 25, 2019

Sierra View Medical Center DSH050261 CA

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

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

None

CAP implemented

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

Audit closure date: March 26, 2020

Someone Cares, Inc. of Atlanta Early Detection Intervention Clinic
Contact Information

Chief Executive Officer
236 Forsyth Street, SW, Ste. 201
Atlanta, Georgia 30303-3700
678-921-2706 Ext: 3

STD303036 GA

Incorrect 340B OPAIS record – Registered contract pharmacy without written contract in place; Incorrect grant number entry.

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: June 9, 2020

South Central Kansas Regional Medical Center SCH170150-00 KS

No adverse findings

None

N/A

Audit closure date: October 4, 2019

Southern Illinois University CHC24098-00 IL

No adverse findings

None

N/A

Audit closure date: February 12, 2020

Southern Ohio Medical Center DSH360008 OH

Inaccurate or incomplete information on 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 8, 2020

Southwest Boulevard Family Health Care HV00140 KS

No adverse findings

None

N/A

Audit closure date: February 5, 2020

Southwest Health Center CAH521354-00 WI

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

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: June 25, 2019

Southwest Memorial Hospital CAH061327-00 CO

No adverse findings

None

N/A

Audit closure date: January 8, 2020

Sparrow Ionia Hospital
Contact Information

Chief Financial Officer of Community Hospitals
3565 S. State Road
Ionia, MI 48846
616-523-4186

CAH231331-00 MI

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 6, 2020

SSM Health Saint Louis University Hospital DSH260105 MO

Incorrect 340B OPAIS record – Offsite outpatient facility was not listed on the 340B OPAIS; Failed to include repackaging location as a shipping address.

None

CAP implemented

Audit closure date: April 16, 2020

SSM St. Joseph Health Center DSH260005 MO

Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; Failed to remove closed location registrations; Failed to remove duplicate registrations for offsite outpatient facilities.

Termination of ineligible offsite outpatient facility from the 340B Program

Pending

St. Anthony Shawnee Hospital DSH370149 OK

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

None

CAP implemented

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

Audit closure date: May 12, 2020

St. Charles Community Health Center, Inc. CH061335A LA

No adverse findings

None

N/A

Audit closure date: June 6, 2019

St. Charles Health System, Inc. DBA St. Charles Bend DSH380047 OR

No adverse findings

None

N/A

Audit closure date: August 28, 2019

St. Francis Hospital
Contact Information

340B Drug Program Manager
5901 West War Memorial Drive
Peoria, IL 61615
309-308-0413

CAH231337-00 MI

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for address for an offsite outpatient facility.

Diversion - 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2020

St. Helena Hospital dba Adventist Health St. Helena
Contact Information

Director of Pharmacy
10 Woodland Road
St. Helena, CA 94574
AhmadAU@ah.org
707-963-6584

DSH050013 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 13, 2020

St. Mary Medical Center DSH050300 CA

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entries for shipping address for offsite outpatient facilities.

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

None

CAP approved

State Medicaid has since determined duplicate discounts did not occur.

St. Mary Medical Center
Contact Information

Director of Pharmacy
St. Mary Medical Center
1050 Linden Avenue
Long Beach, CA 90813-3393
562-491-9773

DSH050191 CA

Inaccurate or incomplete information on the Medicaid Exclusion File.

None

CAP implemented

Audit closure date: September 29, 2020

St. Marys Healthcare
Contact Information

Chief Finance Officer
St. Mary's Healthcare
427 Guy Park Ave
Amsterdam, NY 12010
518-841-7435
Rick.Henze@ascension.org

DSH330047 NY

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

Duplicate Discounts – Inaccurate or incomplete information on 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*

CAP implemented

Audit closure date: June 9, 2020

St. Vincent Healthcare DSH270049 MT

No adverse findings

None

N/A

Audit closure date: December 4, 2019

Ste. Genevieve County Memorial Hospital CAH261330-00 MO

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Sturgis Hospital
Contact Information

VP Quality Management & Support Services
916 Myrtle Avenue
Sturgis, MI 49091
269-659-4403

DSH230096 MI

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 30, 2019.

Diversion – 340B drugs dispensed to inpatients; 340B drug dispensed at contract pharmacy for prescription written at ineligible sites.

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

Repayment to manufacturers

CAP implemented

Covered entity, its outpatient facilities, and its contract pharmacies terminated from 340B Program as of July 1, 2019. Settlement with affected manufacturers has not been finalized. SH will not be permitted to re-enroll in the 340B Program until such time: 1) SH has attested that it has contacted and offered settlement to all affected manufacturers, for all findings listed in the Final Report; and 2) SH has attested that a HRSA-approved CAP has been fully implemented.

Audit closure date: June 16, 2020

Texas Children’s Hospital
Contact Information

Texas Children’s Hospital
6621 Fannin Street, Suite WB1-120
Houston, TX 77030
832-824-6091
jlwagner@texaschildrens.org

PED453304-00 TX

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS;

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 24, 2020

Trinity Hospitals SCH350006-00 ND

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

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

CAP implemented

Audit closure date: April 30, 2019

Unity Care Northwest CHC08773-00 WA

No adverse findings

None

N/A

Audit closure date: November 14, 2019

Unity Hospital of Rochester DSH330226 NY

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

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: September 26, 2019

University Hospital of Brooklyn
Contact Information

Pharmacy 340B Manager
445 Lenox Road
Attn: Pharmacy Box 36
Brooklyn, NY 11203
718-270-7648
Hossameldin.Ghanem@downstate.edu

DSH330350 NY

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Ineligible sites registered on 340B OPAIS prior to October 1, 2019; Incorrect entry for disproportionate share percentage.

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 16, 2019

University of Alabama Hospital DSH010033 AL

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

None

CAP implemented

Audit closure date: August 27, 2019

University of Missouri Health Care
Contact Information

Pharmacy Business Administrator –
340B Program
573-884-4614
simonsjp@health.missouri.edu

DSH260141 MO

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 27, 2020

University of South Carolina RWII29203
RWII292030
SC

Incorrect 340B OPAIS record - Failed to remove duplicate registration for service location.

None

CAP implemented

Audit closure date: May 19, 2020

UNM Sandoval Regional Medical Center DSH320089 NM

No adverse findings

None

N/A

Audit closure date: October 24, 2019

Washington County Hospital CAH161344-00 IA

No adverse findings

None

N/A

Audit closure date: February 5, 2019

Washington State Department of Health STD98504 WA

Incorrect 340B database record – entity improperly registered a distribution site as a contract pharmacy. Registered contract pharmacies without written contract in place

Termination of contract pharmacies from 340B Program

CAP implemented

Audit closure date: January 6, 2021

Wellstar Cobb Hospital DSH110143 GA

No adverse findings

None

N/A

Audit closure date: May 10, 2019

West Holt Memorial Hospital CAH281343-00 NE

No adverse findings

None

N/A

Audit closure date: December 31, 2019

West Oakland Health Council, Inc.
Contact Information

Director of Pharmacy Services
700 Adeline St
Oakland, CA 94607
510-835-9610 x2076
jmccabe@wohc.org

CH090540 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 6, 2020

West Virginia Department of Health and Human Resources FP253015 WV

Incorrect 340B OPAIS record – Incorrect entries for grant number.

None

CAP implemented

Audit closure date: March 24, 2020

Western Missouri Medical Center SCH260097-00 MO

No adverse findings

None

N/A

Audit closure date: October 1, 2019

Whatley Health Services, Inc.
Contact Information

Chief Executive Officer
2731 Martin Luther King Jr Boulevard
Tuscaloosa, AL 35401-5235
205-349-3250

CH042450 AL

Incorrect 340B OPAIS record - Failed to remove closed locations registration; Failed to remove duplicate registration for offsite outpatient facility; Incorrect entry for address for offsite outpatient facility; Registered contract pharmacies without written contract in place.

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

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: March 3, 2020

White County Medical Center DSH040014 AR

Incorrect 340B OPAIS record - Failed to remove closed location registrations

None

CAP implemented

Audit closure date: December 18, 2019

Will County Community Health Center
Contact Information

Chief Executive Officer
Will County Community Health Center
1106 Neal Ave.
Joliet, IL 60433
815-740-7635

CH057880 IL

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 13, 2020

Willits Hospital Inc., dba Adventist Health Howard Memorial CAH051310-00 CA

No adverse findings

None

N/A

Audit closure date: May 14, 2019

Winslow Memorial Hospital dba Little Colorado Medical Center
Contact Information

Assistant Director of Pharmacy
1501 N. Williamson Ave.
Winslow, AZ 86047
928-289-6325

CAH031311-00 AZ

Incorrect 340B OPAIS record - Registered contract pharmacies without written contract in place prior to September 26, 2019.

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

Duplicate discounts – Inaccurate or incomplete information on the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: June 4, 2020

Witham Memorial Hospital DSH150104 IN

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Incorrect entry for disproportionate share percentage; Registered contract pharmacies without written contract in place.

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: April 23, 2020

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

Date Last Reviewed: