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  4. Program Integrity: FY22 Audit Results

Program Integrity: FY22 Audit Results

Updated 9/16/22. 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 99 audits.
Entity Sort descending 340B ID State OPA Findings Sanction Corrective Action Status
Adirondack Medical Center SCH330079-00 NY

No adverse findings

None

N/A

Audit closure date: January 11, 2022

AdventHealth Tampa DSH100173 FL

No adverse findings

None

N/A

Audit closure date: July 13, 2022

Alegent Creighton Health dba CHI Health Plainview CAH281346-00 NE

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

None

CAP implemented

Audit closure date: July 15, 2022

Alivio Medical Center, Inc. CH056620 IL

Incorrect 340B OPAIS record – Grant associated sites were not listed in 340B OPAIS.

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

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

Repayment to manufacturers

Pending

Ann and Robert H. Lurie Children's Hospital of Chicago PED143300-00 IL

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

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

Repayment to manufacturers

Pending

Antelope Memorial Hospital CAH281326-00 NE

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

None

CAP implemented

Audit closure date: July 12, 2022

ARH Mary Breckinridge Health Services, Inc. CAH181328-00 KY

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

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

Pending

Arkansas Verdigris Valley Health Centers, Inc. CHC12887-00 OK

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*

Pending

B – K Health Center, Inc. CH03048E PA

No adverse findings

None

N/A

Audit closure date: January 7, 2022

Banner Casa Grande Medical Center DSH030016 AZ

No adverse findings

None

N/A

Audit closure date: February 9, 2022

Banner Churchill Community Hospital CAH291313-00 NV

No adverse findings

None

N/A

Audit closure date: March 17, 2022

Boone County Health Center CAH281334-00 NE

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 17, 2022

Buena Vista Regional Medical Center CAH161375-00 IA

Incorrect 340B OPAIS record – 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 implemented

Audit closure date: May 25, 2022

Cambridge Medical Center DSH240020 MN

No adverse findings

None

N/A

Audit closure date: July 27, 2022

Champlain Valley Physicians Hospital DSH330250 NY

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

None

CAP approved

State Medicaid has since determined duplicate discounts did not occur.

Coffeyville Regional Medical Center, Inc. SCH170145-00 KS

Incorrect 340B OPAIS record – Hospital classification in 340B OPAIS was inconsistent with eligibility documents; Incorrect entries in 340B OPAIS for Medicare Cost Report file date, cost reporting period, and disproportionate share percentage.

None

Pending

Community Hospital of Anaconda CAH271335-00 MT

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report file date and cost reporting period; Entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite outpatient facility.

None

CAP implemented

Audit closure date: August 25, 2022

Compassion Health Care, Inc. CH044920 NC

No adverse findings

None

N/A

Audit closure date: September 1, 2022

Conway Regional Medical Center, Inc. DSH040029 AR

Diversion – 340B drug dispensed to inpatient.

Repayment to manufacturers

Pending

Corry Memorial Hospital CAH391308-00 PA

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 13, 2022

Crawford Hospital District DBA Crawford Memorial Hospital CAH141343-00 IL

No adverse findings

None

N/A

Audit closure date: August 25, 2022

D.M. Cogdell Memorial Hospital CAH451384-00 TX

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

Diversion – 340B drugs prescribed by ineligible providers.

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

Repayment to manufacturers

Pending

Decatur County Memorial Hospital CAH151332-00 IN

No adverse findings

None

N/A

Audit closure date: March 29, 2022

Ellett Memorial Hospital CAH261301-00 MO

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

None

Pending

Family Health Network of Central New York, Inc. CH021240 NY

Incorrect 340B OPAIS record – Failed to remove 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.

Repayment to manufacturers

Termination of contract pharmacies from 340B Program*

Pending

First Care Medical Services CAH241357-00 MN

No adverse findings

None

N/A

Audit closure date: March 15, 2022

Franklin Hospital District CAH141321-00 IL

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

None

Pending

Gardner Family Health Network, Inc. CH090210 CA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

Genoa Community Hospital CAH281312-00 NE

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entries for Authorizing Official and Primary Contact.

None

Pending

Grafton City Hospital CAH511307-00 WV

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 27, 2022

Grant Medical Center DSH360017 OH

No adverse findings

None

N/A

Audit closure date: May 13, 2022

Greene County Health Care, Incorporated CH041020 NC

Incorrect 340B OPAIS record – Incorrect entries for Primary Contact; Incorrect entries in 340B OPAIS for site ID for grant associated sites.

Diversion – 340B drugs prescribed by ineligible providers.

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

Repayment to manufacturers

Pending

Hazard ARH Regional Medical Center DSH180029 KY

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

Holy Rosary Healthcare CAH271347-00 MT

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: July 15, 2022

HonorHealth Scottsdale Osborn Med Ct RRC030038-00 AZ

No adverse findings

None

N/A

Audit closure date: March 23, 2022

Hudson River Healthcare, Inc. CH021510 NY

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for grant associated site names and address; Failed to remove grant associated sites from 340B OPAIS that were not operational.

Termination of grant associated sites from the 340B Program*

CAP implemented

Audit closure date: August 31, 2022

Humboldt Park Health DSH140206 IL

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 11, 2022.

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Ineligible site registered on 340B OPAIS; Incorrect entry for Authorizing Official.

Diversion – 340B drugs prescribed by ineligible providers.

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

Repayment to manufacturers

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

Pending

Hunter Health Clinic Inc., The CH070150 KS

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

None

Pending

Jefferson Community Health Center DBA Jefferson Community Health & Life CAH281319-00 NE

Incorrect 340B OPAIS record – Hospital classification in 340B OPAIS was inconsistent with eligibility documents.

None

Pending

Johns Hopkins All Children’s Hospital, Inc. PED103300-00 FL

No adverse findings

None

N/A

Audit closure date: April 15, 2022

Kennedy Memorial Hospital-UMC DSH310086 NJ

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

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

Repayment to manufacturers

Pending

Kittson Memorial Hospital CAH241336-00 MN

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

None

Pending

Korean Health, Education, Information and Research Center CHC26620-00 CA

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

Repayment to manufacturers

Pending

LCH Health and Community Services formerly La Comunidad Hispania, Inc CHC24148-00 PA

Entity failed to maintain auditable records.

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.

Repayment to manufacturers

Pending

Madelia Community Hospital and Clinic CAH241323-00 MN

Incorrect 340B OPAIS record – Offsite outpatient facility was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entry for Authorizing Official.

None

CAP implemented

Audit closure date: August 31, 2022

Maine Mobile Health Program, Inc. CH01004M ME

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

None

Pending

Manet Community Health Center, Incorporated CH011640 MA

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

None

Pending

Mark Twain Medical Center CAH051332-00 CA

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Offsite outpatient facilities were not listed in 340B OPAIS.

None

CAP implemented

Audit closure date: August 30, 2022

Marshfield Medical Center Ladysmith CAH521328-00 WI

Incorrect 340B OPAIS record – Hospital classification in 340B OPAIS was inconsistent with eligibility documentation; 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.

Repayment to manufacturers

Pending

Maryland General Hospital DSH210038 MD

No adverse findings

None

N/A

Audit closure date: July 14, 2022

McDonough District Hospital SCH140089-00 IL

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

None

Pending

Medical Center of Peach County CAH111310-00 GA

No adverse findings

None

N/A

Audit closure date: January 7, 2022

Memorial Hermann Sugar Land Hospital DSH450848 TX

No adverse findings

None

N/A

Audit closure date: May 12, 2022

Mercy Gilbert Medical Center RRC030119-00 AZ

No adverse findings

None

N/A

Audit closure date: September 6, 2022

Mercy Health System Corporation DSH520066 WI

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

Midland Memorial Hospital RRC450133-00 TX

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

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

Pending

MidMichigan Medical Center – Gratiot DSH230030 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 approved

Migrant Health Center, Western Region, Inc. CH021040 PR

Incorrect 340B OPAIS record – Entity improperly registered two pharmacies as grant associated sites in 340B OPAIS.

None

CAP implemented

Audit closure date: August 27, 2022

Mitchell County Hospital CAH111331-00 GA

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type; Incorrect entry in 340B OPAIS for address for offsite outpatient facility.

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

Pending

Montgomery AIDS Outreach, Inc. HV0413130 AL

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

Termination of ineligible contract pharmacies from the 340B Program

Pending

Moore County Hospital District dba Memorial Hospital CAH451386-00 TX

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

Pending

Morrison Community Hospital CAH141329-00 IL

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

None

CAP approved

Neighborhood Health Center CHC24160-00 OR

No adverse findings

None

N/A

Audit closure date: April 8, 2022

Neighborhood Outreach Access to Health CHC26604-00 AZ

No adverse findings

None

N/A

Audit closure date: March 2, 2022

New ULM Medical Center CAH241378-00 MN

No adverse findings

None

N/A

Audit closure date: August 8, 2022

Northern Nevada HIV Outpatient Program Education and Services CHC26605-00 NV

Incorrect 340B OPAIS record – Grant associated site was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for site ID and name for grant associated site.

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

Repayment to manufacturers

Pending

Northridge Hospital Medical Center DSH050116 CA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

Packard Health, Inc. CHC29011-00 MI

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

Repayment to manufacturers

CAP approved

Palmer Lutheran Health Center CAH161316-00 IA

No adverse findings

None

N/A

Audit closure date: January 20, 2022

Palomar Medical Center Escondido (PMC Escondido) DSH050115 CA

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

Repayment to manufacturers

Pending

Pancare of Florida, Inc. CH0442450 FL

Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for subdivision name and address for grant associated sites; Ineligible site registered on 340B OPAIS; Failed to remove a duplicate registration for a grant associated site from 340B OPAIS.

Termination of grant associated site from the 340B Program*

CAP implemented

Audit closure date: August 24, 2022

Phoebe Sumter Medical Center DSH110044 GA

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

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers

Pending

Phoebe Worth Medical Center CAH111328-00 GA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

Providence Health System Southern California dba Providence Little Company of Mary Medical Center Torrance DSH050353 CA

No adverse findings

None

N/A

Audit closure date: March 4, 2022

Providence Little Company of Mary Medical Center San Pedro DSH050078 CA

No adverse findings

None

N/A

Audit closure date: January 19, 2022

Providence Saint Joseph Medical Center CAH271343-00 MT

No adverse findings

None

N/A

Audit closure date: March 31, 2022

Punxsutawney Area Hospital SCH390199-00 PA

No adverse findings

None

N/A

Audit closure date: February 2, 2022

Pushmataha Family Medical Center, Inc. CHC06453-00 OK

No adverse findings

None

N/A

Audit closure date: July 29, 2022

Reedsburg Area Medical Center CAH521351-00 WI

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

None

CAP implemented

Audit closure date: September 1, 2022

RiverView Healthcare Association CAH241320-00 MN

No adverse findings

None

N/A

Audit closure date: March 24, 2022

Robert Packer Hospital RRC390079-00 PA

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

Pending

Rochester General Hospital DSH330125 NY

No adverse findings

None

N/A

Audit closure date: January 7, 2022

Saint Luke's Hospital of Chillicothe dba Hedrick Medical Center CAH261321-00 MO

No adverse findings

None

N/A

Audit closure date: February 25, 2022

San Antonio Regional Hospital DSH050099 CA

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

None

CAP approved

Santa Ynez Valley Cottage Hospital CAH051331-00 CA

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

None

Pending

Spectrum Health Gerber CAH231338-00 MI

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

None

Pending

St. Joe - Flaget DSH180025 KY

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

None

Pending

St. Joseph Health Northern California, LLC, dba St. Joseph Hospital DSH050006 CA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

St. Josephs Medical Center SCH240075-00 MN

No adverse findings

None

N/A

Audit closure date: July 27, 2022

St. Luke’s Elmore Medical Center CAH131311-00 ID

No adverse findings

None

N/A

Audit closure date: July 14, 2022

St. Luke’s Hospital RRC390049-00
DSH390049
PA

No adverse findings

None

N/A

Audit closure date: July 13, 2022

St. Michael Medical Center RRC500039-00 WA

No adverse findings

None

N/A

Audit closure date: May 10, 2022

Sutter Valley Hospitals dba Sutter Tracy Community Hospital DSH050313 CA

No adverse findings

None

N/A

Audit closure date: July 12, 2022

Trillium Health, Inc. FQHCLA342 NY

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

Repayment to manufacturers

Pending

Tug Valley ARH Regional Medical Center DSH180069 KY

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

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: August 31, 2022

United Memorial Medical Center DSH330073 NY

No adverse findings

None

N/A

Audit closure date: January 11, 2022

Washington Health Institute STD20017 DC

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

Repayment to manufacturers

Pending

Wayne County Hospital CAH161358-00 IA

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

None

Pending

WellStar Spalding Regional Hospital DSH110031 GA

No adverse findings

None

N/A

Audit closure date: July 13, 2022

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

Date Last Reviewed: