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Program Integrity: FY20 Audit Results

Updated 3/18/22. 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 200 audits.
Entity Sort descending 340B ID State OPA Findings Sanction Corrective Action Status
AdventHealth Orlando DSH100007 FL

No adverse findings

None

N/A

Audit closure date: February 5, 2021

Adventist Medical Center – Reedley
Contact Information

Director of Pharmacy
Adventist Medical Center Reedley
372 W. Cypress Ave
Reedley, CA 93654
AbukhaAF@ah.org
559-537-2190

DSH050192 CA

Incorrect 340B OPAIS record – Ineligible sites registered on 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite facility; Failed to remove a duplicate registration a contract pharmacy from 340B OPAIS.

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

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 10, 2021

Alegent Health – Community Memorial Hospital DBA CHI Health Missouri Valley CAH161309-00 IA

No adverse findings

None

N/A

Audit closure date: June 19, 2020

Alice Hyde Medical Center
Contact Information

Director of Pharmacy
The University of Vermont Health Network
Alice Hyde Medical Center
133 Park Street
Malone, NY 12953-0729
mdufort@alicehyde.com
518-481-2404

DSH330084 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 13, 2021

Anthony L Jordan Health Corp
Contact Information

340B Analyst
82 Holland St
Rochester NY, 14605-2131
nadirahs@jordanhealth.org
585-423-5886

CH022070 NY

Incorrect 340B OPAIS record – Failed to terminate contract pharmacy carve-in arrangement from 340B OPAIS.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 29, 2021

Arnot Ogden Medical Center DSH330090 NY

Incorrect 340B OPAIS record – Failed to remove duplicate registrations for offsite outpatient facilities from 340B OPAIS; Failed to remove a duplicate registration for a contract pharmacy from 340B OPAIS; Incorrect entry in 340B OPAIS for Authorizing Official phone number; Incorrect Primary Contact listed in 340B OPAIS.

None

CAP implemented

Audit closure date: October 29, 2020

Ascension Seton DBA Ascension Seton Medical Center Austin DSH450056 TX

No adverse findings

None

N/A

Audit closure date: April 29, 2020

Atrium Health Lincoln DSH340145 NC

No adverse findings

None

N/A

Audit closure date: March 10, 2020

Atrium Health Union DSH340130 NC

No adverse findings

None

N/A

Audit closure date: June 23, 2020

Banner Fort Collins Medical Center DSH060126 CO

No adverse findings

None

N/A

Audit closure date: June 5, 2020

Baptist Memorial Hospital Memphis DSH440048 TN

No adverse findings

None

N/A

Audit closure date: August 26, 2020

Barrio Comprehensive Family Health Care Center, Inc.
Contact Information

President and CEO
3066 East Commerce Street
San Antonio, TX 78220
pnguyen@communicaresa.org
210-233-7070

CH062360 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 22, 2021

Beverly Hospital DSH220033 MA

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.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: March 10, 2021

Big Bend Cares STD323011 FL

No adverse findings

None

N/A

Audit closure date: June 4, 2020

Birmingham AIDS Outreach, Inc. STD35233 AL

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

None

CAP implemented

Audit closure date: June 18, 2020

Bliss Cares
Contact Information

Executive Director
2901 Curry Ford Road
Suite 106
Orlando, FL 32806
jrodriguez@blisscares.org
407-670-9557

STD328062 FL

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: April 9, 2021

Bon Secours Maryview Medical Center DSH490017 VA

No adverse findings

None

N/A

Audit closure date: May 28, 2020

Botsford General Hospital d/b/a Beaumont Hospital – Farmington Hills DSH230151 MI

No adverse findings

None

N/A

Audit closure date: March 25, 2020

Boys Town National Research Hospital PED283300-00 NE

No adverse findings

None

N/A

Audit closure date: June 24, 2020

Braxton County Memorial Hospital CAH511308-00 WV

No adverse findings

None

N/A

Audit closure date: June 19, 2020

Broaddus Hospital CAH511300-00 WV

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

None

CAP implemented

Audit closure date: December 14, 2020

Brockton Neighborhood Health Center, Inc. CH010700 MA

No adverse findings

None

N/A

Audit closure date: April 17, 2020

Brookdale Hospital Medical Center DSH330233 NY

No adverse findings

None

N/A

Audit closure date: May 15, 2020

Cabun Rural Health Services, Inc.
Contact Information

Chief Executive Officer
402 South Lee Street
Hampton, AR 71744
melanies@cabun.org?
870-798-4064

CHC00342-00 AR

Incorrect entries in 340B OPAIS for address, site ID, and name for offsite outpatient facilities.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: December 15, 2020

Cahaba Medical Care Foundation
Contact Information

CCO
405 Belcher St.
Centreville, AL 35042
kay.cox@cahabamedicalcare.com
205-277-2384

CHC24177-00 AL

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

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File; Inaccurate or incomplete information on the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: May 5, 2021

Calais Regional Hospital - Amended
Contact Information

VP HR/Quality, Compliance Officer
24 Hospital Lane
Calais, ME 04619
mary.barnett@calaishospital.org
207-454-9228

CAH201305-00 ME

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: May 27, 2021

CAN Community Health, Inc. – Daytona STD32114 FL

No adverse findings

None

N/A

Audit closure date: May 19, 2020

Capital Health Med Center – Hopewell DSH310044 NJ

No adverse findings

None

N/A

Audit closure date: July 16, 2020

Carle Hoopeston Regional Health Center CAH141316-00 IL

No adverse findings

None

N/A

Audit closure date: March 24, 2020

Central Maine Medical Center RRC200024-00 ME

Incorrect 340B OPAIS record – Ineligible site registered on 340B OPAIS; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.

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

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: December 14, 2020

Central Mississippi Health Services, Inc. CH046080 MS

No adverse findings

None

N/A

Audit closure date: June 3, 2020

Children’s Medical Center Plano PED453316-00 TX

No adverse findings

None

N/A

Audit closure date: June 5, 2020

Choctaw Regional Medical Center CAH251334-00 MS

No adverse findings

None

N/A

Audit closure date: April 30, 2020

Christ Community Health Services Augusta Inc. CHC24172-00 GA

No adverse findings

None

N/A

Audit closure date: July 16, 2020

Clackamas, County of CH101310 OR

No adverse findings

None

N/A

Audit closure date: August 7, 2020

Community Health Service Agency, Inc. of Hunt County, The
Contact Information

Chief Executive Officer
4500 Wesley Street
Greenville, TX 75401
mcarter@carevide.org
903-455-5986

CH060820 TX

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: September 20, 2021

Community Hospital Anderson DSH150113 IN

No adverse findings

None

N/A

Audit closure date: August 6, 2020

Community Hospital of Indiana, Inc. DSH150169 IN

No adverse findings

None

N/A

Audit closure date: July 14, 2020

Community Howard Regional Health DSH150007 IN

No adverse findings

None

N/A

Audit closure date: July 8, 2020

County of Lane
Contact Information

Program Services Coordinator
151 West 7th Ave #520
Eugene, OR 97401
Juan.Rivera@lanecountyor.gov
541-731-4439

CH107920 OR

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 28, 2020

Deer Valley Medical Center RRC030092-00 AZ

No adverse findings

None

N/A

Audit closure date: April 29, 2020

Dickinson County Healthcare System SCH230055-00 MI

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

None

CAP implemented

Audit closure date: June 23, 2020

Driscoll Children’s Hospital
Contact Information

Pharmacy Department
3533 S. Alameda Street
Corpus Christi, TX 78411
Jessy.thomas@dchstx.org

PED453301-00 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: April 1, 2021

Eastern Iowa Health Center CH0718570 IA

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: December 14, 2020

Effingham Health System CAH111306-00 GA

No adverse findings

None

N/A

Audit closure date: June 9, 2020

Einstein Medical Center Montgomery DSH390329 PA

No adverse findings

None

N/A

Audit closure date: April 7, 2020

Episcopal Health Services, Inc.
Contact Information

Director of Pharmacy
327 Beach 19th Street
Far Rockaway, NY 11691
kmuir@ehs.org
718-869-7180

DSH330395 NY

Diversion – 340B drugs dispensed at contract pharmacies, not supported by medical records.

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 1, 2021

Espanola Hospital DSH320011 NM

No adverse findings

None

N/A

Audit closure date: August 4, 2020

Faith Community Hospital SCH450241-00 TX

No adverse findings

None

N/A

Audit closure date: June 1, 2020

Finger Lakes Migrant Health Care Project, Inc.
Contact Information

Chief Financial Officer
Finger Lakes Migrant Health Care Project, Inc
14 Maiden Lane
PO Box 423
Penn Yan, NY 14527
annes@flchealth.org
315-531-9102

CH028210 NY

Incorrect 340B OPAIS record - Failed to remove a closed contract pharmacy from 340B OPAIS.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: August 12, 2021

Firelands Regional Medical Center
Contact Information

Pharmacy Services Director
1111 Hayes Avenue
Sandusky, OH 44870
WallerD@Firelands.com

DSH360025 OH

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 6, 2021

Florida Department of Health
Contact Information

Bureau Chief of Public Health Pharmacy
4042 Bald Cypress Way Tallahassee, Florida 32399
niaz.siddiqui@flhealth.gov
850-922-9036

FP323993 FL

Incorrect 340B OPAIS record – Incorrect entry for address; Shipping addresses were not listed on the 340B OPAIS; Incorrect entries for grant number for grant associated sites.

Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File at grant associated sites; Grant associated sites billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: December 9, 2021

Gibson General Hospital CAH151319-00 IN

No adverse findings

None

N/A

Audit closure date: July 24, 2020

Glendale Adventist Medical Center DSH050239 CA

No adverse findings

None

N/A

Audit closure date: March 19, 2020

GraceMed Health Clinic, Inc. CHC08772-00 KS

Incorrect 340B OPAIS record – Incorrect entry for address for offsite outpatient facility; Incorrect entries for authorizing official and primary contact; Failed to remove closed contract pharmacies from 340B OPAIS.

None

CAP implemented

Audit closure date: December 18, 2020

Grande Ronde Hospital, Inc. CAH381321-00 OR

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

None

CAP implemented

Audit closure date: July 9, 2020

Greene County General Hospital CAH151317-00 IN

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: October 27, 2020

Hardin Memorial Hospital DSH180012 KY

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for disproportionate share percentage.

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: February 17, 2021

Harrisburg Medical Center, Inc.
Contact Information

Cody Sandusky, PharmD, Primary Contact
100 Dr. Warren Tuttle Dr.
Harrisburg, IL 62946
csandusky@harrisburgmc.com
618-253-0263

SCH140210-00 IL

Duplicate Discounts – Offsite outpatient facilities billed Medicaid while not listed on the HRSA Medicaid Exclusion File; Inaccurate or incomplete information on the Medicaid Exclusion File at offsite outpatient facilities.

Repayment to manufacturers

CAP implemented

Audit closure date: July 21, 2021

Health Access Network CH015110 ME

No adverse findings

None

N/A

Audit closure date: June 24, 2020

HealthAlliance Hospital Marys Avenue Campus DSH330224 NY

No adverse findings

None

N/A

Audit closure date: February 19, 2020

Heart of America Medical Center CAH351332-00 ND

No adverse findings

None

N/A

Audit closure date: July 2, 2020

Henry District Hospital CAH141319-00 IL

No adverse findings

None

N/A

Audit closure date: February 19, 2020

Highland Hospital of Rochester RRC330164-00 NY

Inacurate 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 11, 2021

Horizon Health Care, Inc.
Contact Information

Chief Financial Officer
P.O. Box 99
Howard, SD 57349
werickson@horizonhealthcare.org
www.horizonhealthcare.org
605-772-4525

CH081030 SD

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

Duplicate Discounts – Entity and grant associated sites were billing Medicaid contrary to information included on the Medicaid Exclusion File.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: June 10, 2021

Hospital & Medical Foundation of Paris, Inc. CAH141320-00 IL

No adverse findings

None

N/A

Audit closure date: July 2, 2020

Hospital Authority of Miller County DBA Miller County Hospital CAH111305-00 GA

No adverse findings

None

N/A

Audit closure date: June 16, 2020

Hospital of Central Connecticut, The DSH070035 CT

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: October 14, 2020

Hospital of the University of Pennsylvania, The DSH390111 PA

Incorrect 340B OPAIS record - Ineligible sites registered on 340B OPAIS; Failed to remove registrations for closed offsite outpatient facilities from 340B OPAIS; Failed to remove a duplicate registration for an offsite outpatient facility from 340B OPAIS; Offsite outpatient facilities were not listed on 340B OPAIS; Incorrect address listed for offsite outpatient facility.

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

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

CAP implemented

Audit closure date:
December 14, 2021

Indiana University Health Ball Memorial Hospital, Inc.
Contact Information

Director - 340B Program
950 N. Meridian St., Ste 1200
Indianapolis, IN 46204
Lstewar1@iuhealth.org
317-962-3540

DSH150089 IN

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: June 10, 2021

Inova Health Care Services dba Inova Juniper Program HV220311 VA

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 18, 2020

Iowa Methodist Medical Center DSH160082 IA

No adverse findings

None

N/A

Audit closure date: July 30, 2020

IU Health Bloomington Hospital DSH150051 IN

No adverse findings

None

N/A

Audit closure date: July 24, 2020

Jackson County Memorial Hospital SCH370022-00 OK

No adverse findings

None

N/A

Audit closure date: May 29, 2020

Jackson Hospital and Clinic Inc. RRC010024-00 AL

No adverse findings

None

N/A

Audit closure date: April 7, 2020

Jefferson Community Health Care Centers, Inc.
Contact Information

Chief Operating Officer
4028 US Hwy. 90
Avondale, LA 70072
wrose@inclusivcare.com
504-206-7738

CH0623760 LA

Duplicate Discounts – Entity and grant associated sites billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: June 17, 2021

Jefferson County Department of Health
Contact Information

Pharmacy Manager
Jefferson County Department of Health
1400 6th Ave. S
Birmingham, AL 35233
Pharmacy.jcdh@jcdh.org
205-930-1987

FP352129 AL

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 20, 2021

Jerold Phelps Community Hospital CAH051309-00 CA

No adverse findings

None

N/A

Audit closure date: February 28, 2020

Jersey City Medical Center DSH310074 NJ

No adverse findings

None

N/A

Audit closure date: April 9, 2020

Kemper CAH, Inc. d/b/a John C. Stennis Memorial Hospital CAH251335-00 MS

No adverse findings

None

N/A

Audit closure date: May 29, 2020

Kiamichi Family Medical Center CH0611930 OK

Duplicate Discounts – Entity and grant associated sites billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: October 15, 2020

Klickitat County Public Hospital District #2 dba Skyline Hospital CAH501315-00 WA

No adverse findings

None

N/A

Audit closure date: July 16, 2020

Lallie Kemp Regional Medical Center
Contact Information

Chief Financial Officer
52579 Highway 51 South
Independence, LA 70443
Cthom5@lsuhsc.edu
985-878-1350

CAH191321-00 LA

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 15, 2020

Langlade Hospital Hotel Dieu of St. Joseph, of Antigo, WI CAH521350-00 WI

No adverse findings

None

N/A

Audit closure date: August 10, 2020

Lee Memorial Health System dba Lee Memorial Hospital
Contact Information

Pharmacy & 340B Compliance Officer
4211 Metro Parkway, 1st Floor
Fort Myers, FL 33916
Joseph.bitner@leememorial.org
239-343-8602

DSH100012 FL

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

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File

Repayment to manufacturers

CAP implemented

Audit closure date: April 19, 2021

Lexington Regional Health Center CAH281361-00 NE

No adverse findings

None

N/A

Audit closure date: August 21, 2020

Lincoln Medical Center DSH440102 TN

No adverse findings

None

N/A

Audit closure date: March 9, 2020

Loma Linda University Children's Hospital DSH050778 CA

No adverse findings

None

N/A

Audit closure date: March 18, 2020

Mahaska County Hospital CAH161379-00 IA

No adverse findings

None

N/A

Audit closure date: June 30, 2020

Marin Community Clinic CH095380 CA

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

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: March 22, 2021

Marin General Hospital DSH050360 CA

No adverse findings

None

N/A

Audit closure date: May 15, 2020

Mary Imogene Bassett Hospital SCH330136-00 NY

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

None

CAP implemented

Audit closure date: October 15, 2020

Massachusetts General Hospital DSH220071 MA

No adverse findings

None

N/A

Audit closure date: April 22, 2020

Massena Hospital
Contact Information

Director of Pharmacy
1 Hospital Drive
Massena, NY 13662
emiller@massenahospital.org
315-769-4216

SCH330223-00 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 20, 2021

McKee Medical Center DSH060030 CO

No adverse findings

None

N/A

Audit closure date: June 4, 2020

McLaren Greater Lansing DSH230167 MI

No adverse findings

None

N/A

Audit closure date: July 10, 200

Meadville Medical Center DSH390113 PA

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: January 15, 2021

Memorial Hospital of South Bend, Inc. DSH150058 IN

No adverse findings

None

N/A

Audit closure date: July 23, 2020

Memorial Medical Center CAH521323-00 WI

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

None

CAP implemented

Audit closure date: October 30, 2020

Mercy General Hospital DSH050017 CA

No adverse findings

None

N/A

Audit closure date: July 16, 2020

Mercy Health Hackley Campus DSH230066 MI

Incorrect 340B OPAIS record – Ineligible sites registered in 340B OPAIS; Failed to remove a duplicate registration for an offsite outpatient facility from 340B OPAIS.

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

CAP implemented

Audit closure date: April 8, 2021

Mercy Hospital Lebanon DSH260059 MO

No adverse findings

None

N/A

Audit closure date: June 26, 2020

Mercy Hospital – St. Louis DSH260020 MO

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 18, 2020

Middlesboro ARH Hospital
Contact Information

System Director of Pharmacy
100 Airport Gardens Road
Hazard, KY 41701
jakers@arh.org
606-437-1320

DSH180020 KY

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 21, 2021

MidMichigan Medical Center SCH230222-00 MI

No adverse findings

None

N/A

Audit closure date: February 19, 2020

Midwest Medical Center CAH141302-00 IL

No adverse findings

None

N/A

Audit closure date: April 3, 2020

Monmouth Medical Center Southern Campus DSH310084 NJ

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

None

CAP implemented

Audit closure date: July 13, 2020

Morton Plant North Bay Hospital DSH100063 FL

No adverse findings

None

N/A

Audit closure date: May 20, 2020

Mount Carmel Health DSH360035 OH

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: January 21, 2021

Mountainlands Community Health Center, Inc
Contact Information

340B Coordinator
mleavitt1@mchc.org
801-429-2000

CH083950 UT

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

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closeout date: November 5, 2020

MRH Corp. DBA Northern Light Mayo Hospital CAH201309-00 ME

No adverse findings

None

N/A

Audit closure date: August 6, 2020

Munson Healthcare Cadillac Hospital SCH230081-00 MI

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

None

CAP implemented

Audit closure date: July 29, 2020

Munson Healthcare Manistee Hospital SCH230303-00 MI

No adverse findings

None

N/A

Audit closure date: June 5, 2020

Munson Medical Center SCH230097-00 MI

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

None

CAP implemented

Audit closure date: January 21, 2021

MyCareHealth Center CHC26572-00 MI

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

None

CAP implemented

Audit closure date: August 20, 2020

Neighborhood Improvement Project, Inc. CH0438590 GA

No adverse findings

None

N/A

Audit closure date:
September 8, 2020

Nemaha County Hospital CAH281324-00 NE

No adverse findings

None

N/A

Audit closure date: June 18, 2020

Niagara Falls Memorial Medical Center
Contact Information

340B Program Coordinator
621 10th St
Niagara Falls, NY 14301
716-278-4537

DSH330065 NY

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Primary Contact.

Diversion – 340B drug dispensed to inpatients

Repayment to manufacturers

CAP implemented

Audit closure date: September 14, 2021

Nicholas H. Noyes Memorial Hospital DSH330238 NY

No adverse findings

None

N/A

Audit closure date: April 3, 2020

North Caddo Medical Center CAH191304-00 LA

No adverse findings

None

N/A

Audit closure date: June 12, 2020

North Country Family Health Center, Inc. CHC24165-00 NY

No adverse findings

None

N/A

Audit closure date: February 25, 2020

North Country Health System CAH471304-00 VT

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

None

CAP implemented

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

Audit closure date: May 27, 2021

North Oaks Medical Center LLC DSH190015 LA

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

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: December 1, 2020

Northern Montana Hospital
Contact Information

Vice President Regulatory & Community Services
Northern Montana Hospital Compliance Office
30 W 13th St
Havre, MT 59501
obrechrm@nmhcare.org
406-262-1420

DSH270032 MT

Incorrect 340B OPAIS record - entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS.

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: November 10, 2021

Northside Hospital Gwinnett DSH110087 GA

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for authorizing official.

None

CAP implemented

Audit closure date: September 10, 2020

Oakbend Medical Center DSH450330 TX

Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date:
February 8, 2021

Oakwood Healthcare, Inc. dba Beaumont Hospital - Dearborn DSH230020 MI

No adverse findings

None

N/A

Audit closure date: October 5, 2020

Ochsner Bayou LLC CAH191324-00 LA

No adverse findings

None

N/A

Audit closure date: April 2, 2020

Onslow Memorial Hospital SCH340042-00 NC

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type.

None

CAP implemented

Audit closure date: July 29, 2020

Opelousas General Hospital DSH190017 LA

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type; Offsite outpatient facilities were not listed on the 340B OPAIS.

None

CAP implemented

Audit closure date: April 2, 2021

Osborne County Memorial Hospital CAH171364-00 KS

No adverse findings

None

N/A

Audit closure date: April 15, 2020

Our Lady of Lourdes Memorial Hosp RRC330011-00 NY

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

None

CAP implemented

Audit closure date: October 30, 2020

Pana Community Hospital CAH141341-00 IL

No adverse findings

None

N/A

Audit closure date: July 16, 2020

PeaceHealth dba Peace Harbor Medical Center CAH381316-00 OR

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

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

CAP implemented

Audit closure date: August 12, 2020

Peoples Community Health Clinic, Inc. CH071410 IA

No adverse findings

None

N/A

Audit closure date: September 15, 2020

Perkins County Health Services CAH281356-00 NE

No adverse findings

None

N/A

Audit closure date: July 23, 2020

Philadelphia Fight CHC26634-00 PA

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

None

CAP implemented

Audit closure date: September 10, 2020

Piedmont Newton Hospital, Inc. DSH110018 GA

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: September 30, 2020

Plains Regional Medical Center – Clovis DSH320022 NM

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

None

CAP implemented

Audit closure date:
February 2, 2021

Planned Parenthood Association of Utah
Contact Information

Chief Financial Officer
654 South 900 East
Salt Lake City, UT 84102
Lesley.bailey@ppau.org
801-532-1586

STD841021 UT

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: March 17, 2021

Power County Hospital District CAH131304-00 ID

No adverse findings

None

N/A

Audit closure date: March 5, 2020

Premier Community Healthcare Group, Inc.
Contact Information

Chief Executive Officer
PO Box 232
Dade City, FL 33526
jresnick@hcnetwork.org
352-518-2000

CH045500 FL

Incorrect 340B OPAIS record – Failed to remove a duplicate registration for an offsite outpatient facility from 340B OPAIS.

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 1, 2020

Preston Memorial Hospital CAH511312-00 WV

No adverse findings

None

N/A

Audit closure date: June 15, 2020

Project Vida Health Center CH067960 TX

Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: October 30, 2020

Providence Health DBA Providence Seaside Hospital CAH381303-00 OR

No adverse findings

None

N/A

Audit closure date: May 13, 2020

Providence Medford Medical Center DSH380075 OR

Incorrect 340B OPAIS record – Offsite outpatient facility was not listed on the 340B OPAIS; Incorrect entry in 340B OPAIS for an offsite outpatient facility address.

None

CAP implemented

Audit closure date: October 21, 2020

Regional Health Rapid City Hospital DSH430077 SD

No adverse findings

None

N/A

Audit closure date: May 15, 2020

Regional Health Services of Howard County CAH161328-00 IA

No adverse findings

None

N/A

Audit closure date: June 23, 2020

Richmond University Medical Center
Contact Information

340B Manager
355 Bard Avenue
Inpatient Pharmacy Department
Staten Island, NY 10310
zparnas@rumcsi.org
718-818-3272

DSH330028 NY

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

Repayment to manufacturer

CAP implemented

Audit closure date: April 8, 2021

Riverside Shore Memorial Hospital DSH490037 VA

No adverse findings

None

N/A

Audit closure date: April 21, 2020

Rowan Regional Hospital RRC340015-00 NC

No adverse findings

None

N/A

Audit closure date:
March 3, 2020

Saint Alphonsus Medical Center Nampa DSH130013 ID

No adverse findings

None

N/A

Audit closure date: September 8, 2020

Saint Alphonsus Regional Medical Center DSH130007 ID

No adverse findings

None

N/A

Audit closure date: June 12, 2020

San Francisco AIDS Foundation STD94114 CA

No adverse findings

None

N/A

Audit closure date: April 17, 2020

Sanford Thief River Falls CAH241381-00 MN

No adverse findings

None

N/A

Audit closure date: March 3, 2020

Santa Monica UCLAMC and Orthopaedic Hospital
Contact Information

Director of Pharmacy
757 Westwood Plaza B531
Los Angeles, CA 90095
kmenmuir@mednet.ucla.edu
310-267-8500

DSH050112 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 17, 2021

Scotland Memorial Hospital DSH340008 NC

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 13, 2020

Seton Medical Center DSH050289 CA

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for disproportionate share percentage.

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: June 26, 2020

Sharp Chula Vista Medical Center DSH050222 CA

No adverse findings

None

N/A

Audit closure date: April 28, 2020

Sheridan County Hospital CAH171347-00 KS

No adverse findings

None

N/A

Audit closure date: March 17, 2020

Sioux Valley Memorial Hospital Association dba Cherokee Regional Medical Center CAH161362-00 IA

No adverse findings

None

N/A

Audit closure date: June 24, 2020

Sisters of Charity Hospital
Contact Information

340B Program Business Manager
144 Genesee St
ARTC - 6th Floor West
Buffalo, NY 14203
tgreer@chsbuffalo.org
716-923-2920

DSH330078 NY

Diversion – 340B drugs dispensed to inpatients.

Inaccurate or incomplete information on 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: February 9, 2022

Sonora Community Hospital dba Adventist Health Sonora DSH050335 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: July 28, 2020

Southeast Mississippi Rural Health Initiative, Inc.
Contact Information

340B Coordinator
64 Old Airport Road
Hattiesburg, MS 39401
lellis@semrhi.com
601-544-4163 x3908

CH045770 MS

Duplicate Discounts – Grant associated sites were billing Medicaid contrary to information included on the Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: May 14, 2021

Southeast Missouri Health Network CH071370 MO

Incorrect 340B OPAIS record - Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS; Incorrect entry in 340B OPAIS for address for grant associated site.

Termination of ineligible contract pharmacy from the 340B Program*

CAP implemented

Audit closure date: January 8, 2021

Southwest Mississippi Regional Medical Center DSH250097 MS

No adverse findings

None

N/A

Audit closure date: June 11, 2020

Southwestern Vermont Medical Center RRC470012-00 VT

No adverse findings

None

N/A

Audit closure date: August 6, 2020

Sparrow Clinton Hospital CAH231326-00 MI

No adverse findings

None

N/A

Audit closure date: July 14, 2020

St. Anthony Regional Hospital SCH160005-00 IA

No adverse findings

None

N/A

Audit closure date: June 17, 2020

St. Catherine Hospital SCH170023-00 KS

No adverse findings

None

N/A

Audit closure date: July 23, 2020

St. Cloud Hospital DSH240036 MN

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 4, 2020

St. Jude Medical Center Fullerton DSH050168 CA

No adverse findings

None

N/A

Audit closure date: March 5, 2020

St. Louis Children’s
Contact Information

Director of Pharmacy
St. Louis Children’s Hospital
11E36 One Children’s Place
St. Louis, MO 63110
melissa.heigham@bjc.org
314-497-9450

PED263301-00 MO

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: September 8, 2021

St. Luke’s Methodist Hospital
Contact Information

Director Pharmacy
St. Luke's Methodist Hospital
1026 A Avenue NE
Cedar Rapids, IA 52402
Patrick.Thies@UnityPoint.org
319-368-5861

DSH160045 IA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 6, 2021

St. Mary’s Hospital, Centralia, Illinois RRC140034-00 IL

No adverse findings

None

N/A

Audit closure date: June 11, 2020

Stacy McKay Health and Education Center
Contact Information

Pharmacy Director
6050 Sterling Creek Rd.
Portage, IN 46368
mwichlinski@northshorehealth.org
219-763-8112

CH0518280 IN

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

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: July 27, 2021

Stamford Hospital, The
Contact Information

Pharmacy Business Manager
One Hospital Plaza
Stamford, CT 06902
PManirakiza@stamhealth.org
203-276-4232

DSH070006 CT

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 18, 2021

Stokes Family Health Center FP270168 NC

No adverse findings

None

N/A

Audit closure date: July 9, 2020

Tallahatchie General Hospital CAH251304-00 MS

No adverse findings

None

N/A

Audit closure date: May 29, 2020

Trigg County Hospital Inc. CAH181304-00 KY

No adverse findings

None

N/A

Audit closure date: April 14, 2020

Trinitas Regional Medical Center DSH310027 NJ

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 14, 2020

Trinity Regional Medical Center SCH160016-00 IA

No adverse findings

None

N/A

Audit closure date: June 11, 2020

University of Cincinnati Medical Center LLC DSH360003 OH

No adverse findings

None

N/A

Audit closure date: July 23, 2020

UPMC Horizon Hospital DSH390178 PA

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: November 10, 2020

UPMC McKeesport DSH390002 PA

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 27, 2021

Upson County Hospital, Inc. SCH110002-00 GA

No adverse findings

None

N/A

Audit closure date: May 12, 2020

Val Verde Regional Medical Center DSH450154 TX

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

None

CAP implemented

Audit closure date: April 2, 2021

Ventura County Medical Center DSH050159 CA

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

None

CAP implemented

Audit closure date: November 19, 2020

Verde Valley Medical Center SCH030007-00 AZ

Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: December 11, 2020

Walter Knox Memorial Hospital CAH131318-00 ID

No adverse findings

None

N/A

Audit closure date: July 23, 2020

Weatherford Hospital Authority CAH371323-00 OK

No adverse findings

None

N/A

Audit closure date: July 23, 2020

Weiser Valley Hospital District, dba Weiser Memorial Hospital CAH131307-00 ID

No adverse findings

None

N/A

Audit closure date: August 4, 2020

Welia Health
Contact Information

340B Coordinator
ckordiak@welia.org
320-225-3999

CAH241367-00 MN

Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: January 15, 2021

WellStar Atlanta Medical Center DSH110115 GA

No adverse findings

None

N/A

Audit closure date: August 4, 2020

Western Sierra Medical Clinic
Contact Information

Senior Director of Operations
844 Old Tunnel Road
Grass Valley, CA 95945
francine@wsmcmed.org
530-273-4984 x102

CH0921760 CA

Incorrect 340B OPAIS record – Incorrect Authorizing Official listed; Incorrect Primary Contact listed; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.

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

Repayment to manufacturers

CAP implemented

Audit closure date: July 20, 2021

Wickenburg Community Hospital Association Inc.
Contact Information

Director of Pharmacy Services and 340B Program
520 Rose Lane
Wickenburg, AZ 85390
928-684-4380

CAH031300-00 AZ

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

Diversion – 340B drugs dispensed to inpatients

Repayment to manufacturers

CAP implemented

Audit closure date: April 13, 2021

William Beaumont Hospital DBA Beaumont Hospital - Grosse Pointe DSH230089 MI

No adverse findings

None

N/A

Audit closure date: August 21, 2020

Willis Knighton Medical Center, Inc. DSH190111 LA

No adverse findings

None

N/A

Audit closure date: June 11, 2020

Windsor Hospital Corporation
dba Mt. Ascutney Hospital and Health Center
Contact Information

Chief Financial Officer
Windsor Hospital Corporation d/b/a Mt. Ascutney Hospital and Health Center
289 County Road
Windsor, VT 05089
david.sanville@mahhc.org
802-674-7240

CAH471302-00 VT

Incorrect 340B OPAIS record – Incorrect Primary Contact listed.

Diversion – 340B drugs dispensed at contract pharmacy, not supported by medical records.

Repayment to manufacturers

CAP implemented

Audit closure date: November 4, 2021

Wyckoff Heights Medical Center
Contact Information

Director of Pharmacy
Wyckoff Heights Medical Center
374 Stockholm Street
Brooklyn, NY 11237
jrumore@wyckoffhospital.org
718-963-7141

DSH330221 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to October 2019.

Diversion – 340B drugs dispensed at contract pharmacy, not supported by medical records.

Repayment to manufacturers

CAP implemented

Audit closure date: March 17, 2021

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

Date Last Reviewed: