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Program Integrity: FY21 Audit Results

Updated 8/29/22. 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
AdventHealth Manchester DSH180043 KY

Incorrect 340B OPAIS record – Failed to remove a duplicate registration of a contract pharmacy from 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: May 4, 2021

Adventist Health Clearlake Hospital, Inc.
Contact Information

Director of Pharmacy
Adventist Health Clear Lake
15630 18th Ave
Clearlake, CA 95422
SheltoJ1@ah.org
707-994-6486

CAH051317-00 CA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 15, 2022

AIDS Action Coalition of Huntsville – Thrive Alabama HV358011A AL

No adverse findings

None

N/A

Audit closure date: March 17, 2021

AIDS Care Group HV190131 PA

No adverse findings

None

N/A

Audit closure date: April 27, 2021

Aitkin Community Hospital dba Riverwood Healthcare Center CAH241305-00 MN

Incorrect 340B OPAIS record - Incorrect Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: May 6, 2021

Alegent Health Bergan Mercy Health System dba CHI Health Creighton University Med Center-Bergan Mercy DSH280060 NE

No adverse findings

None

N/A

Audit closure date: March 5, 2021

Allen Parish Hospital DSH190133 LA

No adverse findings

None

N/A

Audit closure date: May 14, 2021

Altoona Regional Health System DSH390073 PA

Inaccurate or incomplete information in the HRSA 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 3, 2021

Altru Hospital SCH350019-00 ND

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

None

CAP implemented

Audit closure date: September 23, 2021

Ascension Seton d/b/a Ascension Seton Northwest DSH450867 TX

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

None

CAP implemented

Audit closure date: March 15, 2022

Auburn Community Hospital SCH330235 NY

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

None

CAP implemented

Audit closure date: July 14, 2021

Avera McKennan DBA Avera Flandreau Hospital CAH431310-00 SD

No adverse findings

None

N/A

Audit closure date: July 7, 2021

Banner Gateway Medical Center DSH030122 AZ

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

None

CAP implemented

Audit closure date: March 15, 2022

Banner Lassen Medical Center CAH051320-00 CA

No adverse findings

None

N/A

Audit closure date: April 9, 2021

Baptist Hospital of Miami, Inc. DSH100008 FL

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date.

None

CAP implemented

Audit closure date: February 15, 2022

Behavioral Health Services, Inc.
Contact Information

Chief Compliance Officer
15519 Crenshaw Blvd
Gardena, CA 90249
310-679-9126
mballue@bhs-inc.org

CHC29048-00 CA

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

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP approved

Benefis Hospitals, Inc. DSH270012 MT

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: January 4, 2022

Bennet County Hospital CAH431314-00 SD

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: June 16, 2021

Black River Health Services, Inc. FQHCLA364 NC

No adverse findings

None

N/A

Audit closure date: July 19, 2021

Bon Secours Community Hospital DSH330135 NY

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date.

None

CAP approved

Audit closure date: September 14, 2021

Boulder City Hospital
Contact Information

Chief Financial Officer
901 Adams Blvd
Boulder City, NV 89005
dlewis@bchnv.org
702-293-4111 x6509

CAH291309-00 NV

Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Authorizing Official phone number and Primary Contact phone number.

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

Repayment to manufacturers

CAP implemented March 8, 2022

Brevard Health Alliance Inc., The CH043823A FL

No adverse findings

None

N/A

Audit closure date: June 25, 2021

Brigham and Women’s Hospital RRC220110-00 MA

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

None

CAP implemented

Audit closure date: November 9, 2021

Brodstone Memorial Hospital CAH281315-00 NE

No adverse findings

None

N/A

Audit closure date: January 26, 2021

Butler County Health Department STD36037 AL

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for grant number and nature of support.

Entity billed Medicaid while not listed on the HRSA 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 7, 2021

California Hospital Medical Center DSH050149 CA

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

None

CAP implemented

Audit closure date: February 15, 2022

CAN Community Health Inc. STD333341 FL

No adverse findings

None

N/A

Audit closure date: December 2, 2020

Care for the Homeless CH020020 NY

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for grant associated site.

None

CAP implemented

Audit closure date: June 15, 2021

Carle Eureka Hospital CAH141309-00 IL

No adverse findings

None

N/A

Audit closure date: April 29, 2021

Carroll County Memorial Hospital
Contact Information

Chief Executive Officer khaverly@ccmhosp.com 502-732-3275

CAH181310-00 KY

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 13, 2022

Catholic Health Initiatives – Iowa, Corp. DSH160083 IA

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Ineligible sites registered on 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite outpatient facility; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

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

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

CAP approved

Central Florida Health Care, Inc. CH040210 FL

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

None

CAP implemented

Audit closure date: March 21, 2022

State Medicaid has since determined duplicate discounts did not occur.

Central Washington Health Services Association dba Central Washington Hospital DSH500016 WA

No adverse findings

None

N/A

Audit closure date: June 3, 2021

Cheyenne County Hospital Association, Inc. dba Sidney Regional Medical Center CAH281357-00 NE

No adverse findings

None

N/A Audit closure date: February 23, 2021

CHI St. Vincent Morrilton CAH041324-00 AR

Entity billed Medicaid while not listed in the HRSA 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 30, 2021

Children’s Hospital Medical Center PED363300-00 OH

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

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

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

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: May 12, 2022

Children’s Mercy Hospital Kansas, The PED173300-00 KS

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

None

CAP implemented

Audit closure date: November 9, 2021

Christus Hospital RRC450034-00 TX

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, disproportionate share percentage, and hospital control type.

None

CAP implemented

Audit closure date: June 23, 2021

Christus Santa Rosa Health System
Contact Information

Senior Consultant
7840 Graphics Drive, Suite 100
Tinley Park, IL 60477
708-478-7030

RRC450237-00 TX

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 15, 2022

Coastal Family Health Center Inc., The
Contact Information

Chief Executive Officer
1046 Division Street
Biloxi, MS 39530
angel_greer@coastalfamilyhealth.org
228-374-2494

CH042430 MS

Incorrect 340B OPAIS record – Entity improperly registered a distribution site in 340B OPAIS as a grant associated site; Incorrect entries in 340B OPAIS for name for grant associated sites.

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

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

Repayment to manufacturers

CAP implemented

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

Audit closure date: November 9, 2021

Coffey County Hospital
Contact Information

Chief Financial Officer
Senior Accountant
Coffey County Hospital
801 N. 4th
Burlington, KS 66839
620-364-2121

CAH171385-00 KS

Diversion – 340B drug dispensed to inpatient

Repayment to manufacturers

CAP implemented

Audit closure date: April 4, 2022

Columbia Lutheran Charities dba Columbia Memorial Hospital CAH381320-00 OR

No adverse findings

None

N/A

Audit closure date: February 12, 2021

Community Clinic, Inc. CHC10591-00 MD

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for site ID for grant associated site.

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

Pending

Community Health Care Systems Inc CH045180 GA

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

Entity and grant associated sites billed Medicaid while not listed on the HRSA 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 23, 2021

Community Medical Centers Inc. CH090780 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 29, 2022

Community Medical Wellness Centers USA CHC28986-00 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 27, 2021

Coon Memorial Hospital
Contact Information

Chief Executive Officer
1411 Denver Avenue
Dalhart, TX 79022
loreet@dhchd.org
806-244-9267

CAH451331-00 TX

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove registration in 340B OPAIS for closed offsite outpatient facility; Incorrect entries in 340B OPAIS for address for offsite outpatient facilities.

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

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: December 15, 2021

Cornerstone Family Healthcare
Contact Information

VP of Corporate Compliance and Risk Management
2570 US Route 9W
Suite 10
Cornwall, NY 12518
mcalero@cornerstonefh.org
845-220-3188

CH020620 NY

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

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 approved

Crisp Regional Hospital Inc. DSH110104 GA

No adverse findings

None

N/A

Audit closure date: December 2, 2020

Deaconess Medical Center DSH500044 WA

No adverse findings

None

N/A

Audit closure date: May 25, 2021

Desert AIDS Project CHC28988-00 CA

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that were registered in error.

None

CAP implemented

Audit closure date: June 8, 2021

Erlanger Medical Center DSH440104 TN

No adverse findings

None

N/A

Audit closure date: March 5, 2021

Falls Community Hospital and Clinic SCH450348-00 TX

No adverse findings

None

N/A

Audit closure date: March 3, 2021

Family Health Centers of San Diego, Inc. CH093120 CA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for subdivision names for offsite outpatient facilities; Incorrect entries in 340B OPAIS for Site ID and address for offsite outpatient facility; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: July 14, 2021

Family Health Services Corporation
Contact Information

Operations Manager
794 Eastland Dr.
Twin Falls, ID 83301
mavalos@fhsid.org
208-737-6707

CH101650 ID

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

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: January 27, 2022

Field Memorial Community Hospital CAH251309-00 MS

No adverse findings

None

N/A

Audit closure date: March 17, 2021

Flushing Hospital Medical Center DSH330193 NY

No adverse findings

None

N/A

Audit closure date: September 9, 2021

Fort Madison Community Hospital DSH160122 IA

Incorrect 340B OPAIS record – Failed to remove a closed contract pharmacy from 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date:
February 8, 2021

Franklin General Hospital CAH161308-00 IA

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: March 17, 2021

Franklin Memorial Hospital SCH200037-00 ME

No adverse findings

None

N/A

Audit closure date: March 16, 2021

Franklin Square Hospital DSH210015 MD

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: June 8, 2021

Friend Family Health Center Inc. CH059110 IL

Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that was registered in error.

None

CAP implemented

Audit closure date: February 2, 2022

Fulton County Medical Center CAH391303-00 PA

Incorrect 340B OPAIS record - Failed to remove a contract pharmacy from 340B OPAIS that was registered in error.

None

CAP implemented

Audit closure date:
June 29, 2021

Geisinger Wyoming Valley Medical Center DSH390270 PA

No adverse findings

None

N/A

Audit closure date: May 17, 2021

Glacial Ridge Health System CAH241376-00 MN

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for address for offsite outpatient facilities, Medicare Cost Report filing date, and cost reporting period.

None

CAP implemented

Audit closure date: April 28, 2021

Good Samaritan Hospital Corvallis RRC380014-00 OR

No adverse findings

None

N/A

Audit closure date: March 16, 2021

Grant County Public Hospital District No. 3
dba Columbia Basin Hospital
CAH501317-00 WA

No adverse findings

None

N/A

Audit closure date: May 5, 2021

Grayson County Hospital Foundation
dba Twin Lakes Regional Medical Center
DSH180070 KY

No adverse findings

None

N/A

Audit closure date: February 9, 2021

Greenwood Leflore Hospital
Contact Information

Director of Pharmacy
nmainelli@glh.org
662-459-2633

Chief Financial Officer
dholmes@glh.org
662-459-7119

DSH250099 MS

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 17, 2022

Guttenberg Municipal Hospital CAH161312-00 IA

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: April 20, 2021

Hampshire Memorial Hospital, Inc. CAH511311-00 WV

No adverse findings

None

N/A

Audit closure date: January 5, 2021

Harbor Health Services, Inc. CH010170 MA

No adverse findings

None

N/A

Audit closure date: July 15, 2021

Health and Life Organization Inc.
Contact Information

340B Compliance Specialist
3030 Explorer Drive
Sacramento, CA 95827
mbradford2@halocares.org

FQHCLA247 CA

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

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

Termination of contract pharmacies from 340B Program*

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: March 9, 2022

Healthsource of Ohio, Inc. CH050990 OH

No adverse findings

None

N/A

Audit closure date: June 16, 2021

Henry Ford Wyandotte Hospital RRC230146-00 MI

No adverse findings

None

N/A

Audit closure date: April 29, 2021

Hillsdale Community Health Center
Contact Information

Director of Pharmacy
Jkauffman@hillsdalehospital
517-437-5418

RRC230037-00 MI

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: December 16, 2021

Holston Valley Hospital and Medical Center RRC440017-00 TN

No adverse findings

None

N/A

Audit closure date: December 10, 2020

Holyoke Medical Center DSH220024 MA

No adverse findings

None

N/A

Audit closure date: July 15, 2021

Hope and Help Center of Central Florida, Inc. STD33150 FL

No adverse findings

None

N/A

Audit closure date: August 9, 2021

Hospital District No. 1 of Dickinson CAH171381-00 KS

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: November 16, 2021

IHC Health Services Inc. DBA Heber Valley Hospital CAH461307-00 UT

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

Repayment to manufacturers

Pending

IHC Health Services, Inc. DBA Utah Valley Hospital DSH460001 UT

No adverse findings

None

N/A

Audit closure date: July 15, 2021

Illini Community Hospital CAH141315-00 IL

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: February 22, 2021

Jacobson Memorial Hospital CAH351314-00 ND

Incorrect 340B OPAIS record - Entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: September 17, 2021

Jefferson Healthcare
Contact Information

Chief Ancillary and Support Services Office
834 Sheridan St.
Port Townsend, WA 98368
Jdavidson@jeffersonhealthcare.org
360-385-2200 x2039

CAH501323-00 WA

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

Repayment to manufacturers

CAP approved

JWCH Institute, Inc. CH0925360 CA

Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that were registered in error; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: April 20, 2021

Kalihi-Palama Health Center CH096010 HI

Incorrect 340B OPAIS record – Grant associated site was not listed on the 340B OPAIS.

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

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: July 30, 2021

Kent County Memorial Hospital DSH410009 RI

Incorrect 340B OPAIS record – A shipping address was not listed in 340B OPAIS.

None

Pending

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

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: June 17, 2021

Kiowa County Memorial Hospital CAH171332-00 KS

No adverse findings

None

N/A

Audit closure date: February 12, 2021

Klickitat County Public Hospital District No 1
dba Klickitat Valley Health
CAH501316-00 WA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: November 9, 2021

Lakeland Regional Health System, Lakeland Medical Center St. Joseph DSH230021 MI

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.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: January 28, 2022

Landmann-Jungman Memorial Hospital CAH431317-00 SD

No adverse findings

None

N/A

Audit closure date: July 15, 2021

Lawrence Memorial Health Foundation, Inc. CAH041309-00 AR

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

None

CAP implemented

Audit closure date: September 30, 2021

Legacy Good Samaritan Hospital DSH380017 OR

No adverse findings

None

N/A

Audit closure date: May 11, 2021

Lehigh Valley Hospital RRC390133-00 PA

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

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: February 17, 2022

Lenox Hill Hospital RRC330119-00 NY

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date. Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: July 27, 2022

Mackinac Straits Hospital and Health Center CAH231306-00 MI

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: March 15, 2022

Marshfield Medical Center
Contact Information

340B Program Manager
1000 North Oak Ave
Marshfield, WI 54446
neuendorf.kirstia@marshfieldclinic.org 715-858-4308

SCH520037-00 WI

Incorrect 340B OPAIS record – Failed to remove duplicate registrations of contract pharmacies in 340B OPAIS.

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

Repayment for manufacturer

CAP implemented

Audit closure date: March 7, 2022

Mary Hitchcock Memorial Hospital RRC300003-00 NH

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and disproportionate share percentage; Ineligible sites registered in 340B OPAIS.

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

CAP approved

Maury Regional Hospital RRC440073-00 TN

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

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

None

CAP implemented

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

Audit closure date: February 4, 2022

Meharry Community Wellness Center HV01706 TN

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for name and address; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place; Failed to remove a closed contract pharmacy from 340B OPAIS.

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: February 15, 2022

Memorial Hospital West DSH100281 FL

No adverse findings

None

N/A

Audit closure date: August 5, 2021

Memorial Hospital, The CAH301307-00 NH

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

None

N/A

Audit closure date: March 11, 2021

Memorial Regional Hospital DSH100038 FL

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

None

CAP implemented

Audit closure date: April 30, 2021

Mena Regional Health System
Contact Information

Director of Pharmacy
311 North Morrow St.
Mena, AR 71953
Angiea@menaregional.com
479-243-2225

DSH040015 AR

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: March 8, 2022

Mendota Community Hospital
DBA OSF Saint Paul Medical Center
CAH141310-00 IL

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for hospital control type and Medicare Cost Report filing date.

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

None

CAP implemented

Audit closure date: March 9, 2022

Mercy Hospital Springfield DSH260065 MO

No adverse findings

None

N/A

Audit closure date: March 5, 2021

Metro Community Provider Network, Inc. CH080730 CO

No adverse findings

None

N/A

Audit closure date: July 14, 2021

Mid-Columbia Medical Center SCH380001-00 OR

Inaccurate or incomplete information on the HRSA 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 15, 2022

Milwaukee Health Services, Inc. CH052090 WI

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

Inaccurate or incomplete information on the HRSA 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 16, 2021

Minidoka Memorial Hospital CAH131319-00 ID

No adverse findings

None

N/A

Audit closure date: June 25, 2021

Mitchell County Regional Health Center CAH161323-00 IA

No adverse findings

None

N/A

Audit closure date: January 7, 2021

Montgomery General Hospital, Inc. CAH511318-00 WV

Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

Diversion – 340B drugs dispensed to inpatients; and 340B drugs prescribed by an ineligible provider.

Repayment to manufacturers

Termination of contract pharmacies from 340B Program

CAP implemented

Audit closure date: April 12, 2022

Mosaic Medical Center Maryville
Contact Information

340B Primary Contact
Mosaic Health System
5325 Faraon Street
St. Joseph, MO 64506
Craig.gordon@mymlc.com
816-271-6069

SCH260050-00 MO

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that were registered in error.

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 9, 2022

Multicare Auburn Medical Center DSH500015 WA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.

Termination of contract pharmacy from 340B Program*

CAP approved

Murray County Memorial Hospital CAH241319-00 MN

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: June 8, 2021

Nevada City Hospital
Contact Information

Director of Pharmacy
800 S. Ash Street
Nevada, MO 64772
jmashek@nrmchealth.com
417-448-3649

DSH260061 MO

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 7, 2021.

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: March 15, 2022

New York City Health and Hospitals CHC29018-00 NY

Incorrect 340B OPAIS record – Failed to remove a duplicate registration for a grant associated site from 340B OPAIS; Grant associated site was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for name and address for grant associated sites; Ineligible site registered on 340B OPAIS.

Duplicate Discounts – Inaccurate or incomplete information on the HRSA Medicaid Exclusion File at entity and grant associated sites.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: December 3, 2021

North County Health Project, Inc.
Contact Information

Senior Director of Operations
150 Valpreda Road
San Marcos, CA 92069
irene.torres@truecare.org
760-566-1722

CH090720 CA

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

Repayment to manufacturers

CAP approved

North Mississippi Medical Center DSH250004 MS

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 24, 2021

Northeast Florida Health Services, Inc.
Contact Information

Chief Executive Officer
lasbury@familyhealthsource.org
386-202-6025

Pharmacy Director
mmoll@familyhealthsource.org
386-327-6049

CH0423770 FL

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

Repayment to manufacturers

CAP implemented

Audit closure date: August 12, 2021

Northeastern Vermont Regional Hospital CAH471303-00 VT

No adverse findings

None

N/A

Audit closure date: June 9, 2021

Northern Pines Medical Center CAH241340-00 MN

No adverse findings

None

N/A

Audit closure date: May 17, 2021

Northern Valley Indian Health FQHC638012 CA

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

Northwest Health Services, Inc. CH072130 MO

Incorrect 340B OPAIS record – Ineligible site registered on 340B OPAIS; Incorrect entry in 340B OPAIS for grant associated site name. Diversion – 340B drugs dispensed at a contract pharmacy, not supported by a medical record.

Repayment to manufacturers

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

CAP approved

Northwest Hospital Center, Inc. DSH210040 MD

No adverse findings

None

N/A

Audit closure date: May 5, 2021

NY Community Hospital of Brooklyn DSH330019 NY

No adverse findings

None

N/A

Audit closure date: August 17, 2021

Oak Valley District Hospital DSH050067 CA

No adverse findings

None

N/A

Audit closure date: March 16, 2021

Oaklawn Hospital DSH230217 MI

No adverse findings

None

N/A

Audit closure date: February 9, 2021

Oakwood Healthcare, Inc.
dba Beaumont Hospital – Wayne
DSH230142 MI

Incorrect 340B OPAIS record – A shipping address was not listed in 340B OPAIS.

None

CAP implemented

Audit closure date: October 4, 2021

Ocean Beach Hospital CAH501314-00 WA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and Primary Contact email address.

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

Repayment to manufacturers

CAP approved

Okanogan County Public Hospital District No. 3 DBA Mid-Valley Hospital CAH501328-00 WA

No adverse findings

None

N/A

Audit closure date: January 24, 2022

OSF Little Company of Mary Medical Center
Contact Information

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

RRC140179-00 IL

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 7, 2021

OU Medical Center DSH370093 OK

No adverse findings

None

N/A

Audit closure date: April 1, 2021

Palo Pinto General Hospital
Contact Information

Chief Pharmacy Technician
TCROSS@ppgh.com
940-328-6375

DSH450565 TX

Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: December 9, 2021

Paul Oliver Memorial Hospital CAH231300-00 MI

No adverse findings

None

N/A

Audit closure date: April 28, 2021

Pella Regional Health Center CAH161367-00 IA

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

Termination of contract pharmacy from 340B Program*

CAP implemented

Audit closure date: June 8, 2021

Pemiscot County Memorial Hospital
Contact Information

Director of Pharmacy Services 946 E Reed Street Hayti, MO 63581 dketchum@pemiscot.org 573-359-1372

DSH260070 MO

Diversion – 340B drug dispensed to inpatient.

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

Repayment to manufacturers

CAP implemented Audit closure date: January 7, 2022

Peninsula Regional Medical Center DSH210019 MD

No adverse findings

None

N/A

Audit closure date: April 9, 2021

Pinckneyville Community Hospital District CAH141307-00 IL

No adverse findings

None

N/A

Audit closure date: December 18, 2020

Pioneers Medical Center CAH061325-00 CO

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: October 4, 2021

Platte Valley Medical Center DSH060004 CO

No adverse findings

None

N/A

Audit closure date: January 29, 2021

Portsmouth Community Health Center, Inc.
DBA Hampton Roads Community Health Center
CH034100 VA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for shipping addresses and names for grant associated sites.

Incorrect 340B OPAIS record – Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

Termination of contract pharmacy from 340B Program

CAP implemented

Audit closure date: August 5, 2021

Positively Living, Inc.
Contact Information

Client Services Director
290 E Hill Ave, Ste. 290
Knoxville, TN 37915
865-525-1540 x201

RWII37917 TN

Incorrect 340B OPAIS record - Failed to remove contract pharmacies from 340B OPAIS that were registered in error.

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

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: November 5, 2021

Prairie Ridge Health, Inc. CAH521338-00 WI

No adverse findings

None

N/A

Audit closure date: April 29, 2021

Presence St. Mary’s Hospital DSH140155 IL

No adverse findings

None

N/A

Audit closure date: April 6, 2021

Providence Willamette Falls Medical Center DSH380038 OR

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

None

CAP implemented

Audit closure date: December 7, 2021

Pueblo Community Health Center, Inc. CH080170A CO

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 3, 2021

Raritan Bay Medical Center / HMH Hospitals Corporation DSH310039 NJ

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

Termination of ineligible offsite outpatient facility from the 340B Program

CAP implemented

Audit closure date: March 29, 2022

Richland, Parish of CHC24167-00 LA

No adverse findings

None

N/A Audit closure date: July 14, 2021

Rural Medical Services, Inc. CH046810 TN

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

None

CAP implemented

Audit closure date: June 11, 2021

Rutland Regional Medical Center DSH470005 VT

Entity billed Medicaid while not listed on the HRSA 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 25, 2021

Saint Mary’s Hospital dba CHI Health St. Mary’s
Contact Information

Pharmacy Supervisor
Apekny@stez.org
402-873-8938

CAH281342-00 NE

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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

None

CAP implemented

State Medicaid agencies have since determined duplicate discounts did not occur.

Audit closure date: August 31, 2021

Salem Township Hospital CAH141345-00 IL

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP approved

Audit closure date: May 13, 2021

Sanford Bagley Medical Center CAH241328-00 MN

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: March 29, 2022

Schneck Medical Center DSH150065 IN

No adverse findings

None

N/A

Audit closure date: June 24, 2021

Scotland County Hospital CAH261310-00 MO

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: May 25, 2021

Shenandoah Memorial Hospital CAH491305-00 VA

No adverse findings

None

N/A

Audit closure date: February 2, 2021

Sheridan Community Hospital CAH231312-00 MI

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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 16, 2021

Slidell Memorial Hospital DSH190040 LA

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date.

None

CAP approved

South Miami Hospital DSH100154 FL

No adverse findings

None

N/A

Audit closure date: May 11, 2021

South Sunflower County Hospital SCH250095-00 MS

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report filing date

None

CAP implemented

Audit closure date: November 16, 2021

South Texas Rural Health Services, Inc. CH062120 TX

No adverse findings

None

N/A

Audit closure date: February 22, 2021

Sparta Community Hospital District CAH141349-00 IL

No adverse findings

None

N/A

Audit closure date: December 11, 2020

St. Agnes Hospital
Contact Information

340B Program Manager 900 Canton Avenue Baltimore, MD 21229 Kelsey.Fiser@ascension.org 615-222-5190

DSH210011 MD

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for disproportionate share percentage, Medicare Cost Report filing date, and cost reporting period.

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 13, 2022

St. Elizabeth Healthcare DSH180035 KY

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date; Ineligible site registered on 340B OPAIS.

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

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

Repayment to manufacturers.

CAP approved

St. Joseph Health Center DSH360161 OH

No adverse findings

None

N/A

Audit closure date: January 21, 2021

St. Joseph Regional Health Center RRC450011-00 TX

No adverse findings

None

N/A

Audit closure date: April 30, 2021

St. Luke's Jones Regional Medical Center CAH161306-00 IA

No adverse findings

None

N/A

Audit closure date: December 10, 2020

St. Mary’s Health Care System Inc. RRC110006-00 GA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for primary contact.

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

Repayment to manufacturers

Pending

St. Mary’s Medical Center, Inc. DSH510007 WV

No adverse findings

None

N/A

Audit closure date: February 11, 2021

St. Mary’s Regional Medical Center DSH200034 ME

No adverse findings

None

N/A

Audit closure date: March 30, 2021

St. Peter's Hospital SCH270003-00 MT

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

None

Pending

St. Tammany Parish Hospital DSH190045 LA

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

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 30, 2021

St. Vincent Salem Hospital, Inc.
Dba Ascension St. Vincent Salem
CAH151314-00 IN

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

None

CAP implemented

Audit closure date: March 23, 2021

Stephens Memorial Hospital CAH201315-00 ME

No adverse findings

None

N/A

Audit closure date: April 14, 2021

Sullivan County Memorial Hospital CAH261306-00 MO

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Ineligible sites registered on 340B OPAIS.

Termination of ineligible offsite outpatient facilities from the 340B Program

CAP implemented

Audit closure date: May 4, 2021

Sutter Bay Hospitals, dba Alta Bates Summit Medical Center DSH050305 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to July 21, 2021.

Repayment to manufacturers

CAP approved

Sutter Bay Hospitals, dba Sutter Lakeside Hospital CAH051329-00 CA

No adverse findings

None

N/A

Audit closure date: August 4, 2021

Sweeny Hospital District CAH451311-00 TX

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date.

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

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

Repayment to manufacturers

Pending

State Medicaid determined duplicate discounts did not occur.

Tahoe Forest Hospital
Contact Information

Director of Pharmacy
Tahoe Forest Hospital District
PO Box 759
Truckee, CA 96160
tmather@tfhd.com
530-582-6465

CAH051328-00 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 17, 2022

Thomas H Boyd Critical ACC Hospital CAH141300-00 IL

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, 2022

Toledo Hospital, The DSH360068 OH

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.

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 pharmacy from 340B Program*

Pending

Tri-County Hospital CAH241354 MN

No adverse findings

None

N/A

Audit closure date: May 14, 2021

Tucson Medical Center DSH030006 AZ

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

Diversion – 340B drug dispensed to inpatient.

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

CAP approved

University Hospitals of Cleveland DSH360137 OH

Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 22, 2021.

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

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

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: March 15, 2022

University Medical Center of El Paso DSH450024 TX

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

None

CAP implemented

Audit closure date: February 9, 2021

University of Toledo Medical Center DSH360048 OH

Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed on the 340B OPAIS; Failed to remove registration in 340B OPAIS for closed offsite outpatient facility; Incorrect entry in 340B OPAIS for shipping address.

None

CAP implemented

Audit closure date: April 5, 2022

Urban Health Solutions Inc. RWI19146 and FP19146 PA

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for grant number. Inaccurate or incomplete information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

None

CAP implemented

Audit closure date: June 9, 2022

Van Buren County Hospital CAH161337-00 IA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: February 22, 2021

Virginia Gay Hospital CAH161349-00 IA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: March 26, 2021

Virtua Our Lady of Lourdes Hospital DSH310029 NJ

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date:
July 1, 2021

Watts Healthcare Corporation
Contact Information

Chief Medical Officer
10300 Compton Ave
Los Angeles, CA 90002
oliver.brooks@wattshealth.org
323-564-4331 x3141

CHC00850-00 CA

Incorrect 340B OPAIS record – Failed to remove a contract pharmacy from 340B OPAIS that did not have a written contract in place; Incorrect entry in 340B OPAIS for Authorizing Official.

Duplicate Discounts – Grant associated site billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Termination of ineligible contract pharmacy from the 340B Program*

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: May 25, 2022

West Alabama AIDS Outreach RWII354011 AL

No adverse findings

None

N/A

Audit closure date:
July 9, 2021

West Calcasieu-Cameron Hospital
Contact Information

Director of Pharmacy
701 Cypress Street
Sulphur, LA 70663 gforeman@wcch.com
337-527-4290

DSH190013 LA

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

Diversion – 340B drugs dispensed at contract pharmacies, 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: February 17, 2022

White River Medical Center DSH040119 AR

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 25, 2021

William Beaumont Hospital DBA Beaumont Hospital – Royal Oak RRC230130-00 MI

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

None

CAP implemented

Audit closure date: January 27, 2022

William W. Backus Hospital, The RRC070024-00 CT

No adverse findings

None

N/A

Audit closure date: April 29, 2021

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

Date Last Reviewed: