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Program Integrity: FY22 Audit Results

Updated 3/20/24. 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 196 audits.
Entity 340B ID State Sort descending OPA Findings Sanction Corrective Action Status
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

CAP implemented

Audit closure date: April 28, 2023

Quality of Life Health Services, Inc.
Contact Information

President/Chief Executive Officer
1411 Piedmont Cutoff
Gadsden, Alabama 35903
wayne.rowe@qolhs.com
256-492-0131

CH044120 AL

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

Diversion - 340B drugs dispensed, not supported by a medical record; 340B drugs prescribed by ineligible providers.

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 15, 2024

HH Health System - Marshall, LLC DSH010005 AL

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for hospital control type, address, and shipping address; Failed to remove terminated contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: September 28, 2023

Banner Casa Grande Medical Center DSH030016 AZ

No adverse findings

None

N/A

Audit closure date: February 9, 2022

HonorHealth Scottsdale Osborn Med Ct RRC030038-00 AZ

No adverse findings

None

N/A

Audit closure date: March 23, 2022

Neighborhood Outreach Access to Health CHC26604-00 AZ

No adverse findings

None

N/A

Audit closure date: March 2, 2022

Mercy Gilbert Medical Center RRC030119-00 AZ

No adverse findings

None

N/A

Audit closure date: September 6, 2022

Conway Regional Medical Center, Inc.
Contact Information

Pharmacy Director
2303 College Ave Conway, AR 72034, jroberts@conwayregional.org
501-513-5703

DSH040029 AR

Diversion - 340B drug dispensed to inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: August 29, 2023

Mercy Hospital Fort Smith DSH040062 AR

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

None

CAP implemented

Audit closure date: July 17, 2023

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

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

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 implemented

Audit closure date: October 26, 2022

Palomar Medical Center Escondido (PMC Escondido)
Contact Information

District Director of Pharmacy
2185 Citracado Parkway
Escondido, CA 92029
Dondreia.Gelios@palomarhealth.org
442-281-1358

DSH050115 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 15, 2023

Gardner Family Health Network, Inc. CH090210 CA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

Korean Health, Education, Information and Research Center
Contact Information

Compliance Director 3727 West 6th Street, Suite 210 Los Angeles, CA 90020 compliance@lakheir.org (323) 863-6286

CHC26620-00 CA

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

Repayment to manufacturers

CAP implemented

Audit closure date: June 26, 2023

Northridge Hospital Medical Center DSH050116 CA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

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

CAP implemented

Audit closure date: October 3, 2022

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

No adverse findings

None

N/A

Audit closure date: July 29, 2022

Sutter Valley Hospitals dba Sutter Tracy Community Hospital DSH050313 CA

No adverse findings

None

N/A

Audit closure date: July 12, 2022

Alameda Health System DSH050320 CA

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

None

CAP implemented

Audit closure date: June 9, 2023

Children's Hospital and Research Center Oakland PED053301-00 CA

Incorrect 340B OPAIS record - Ineligible offsite outpatient facilities registered in 340B OPAIS.

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

CAP implemented

Audit closure date: March 10, 2023

Chinese Hospital DSH050407 CA

No adverse findings

None

N/A

Audit closure date: September 12, 2022

Marin City Health and Wellness Center
Contact Information

Chief Operating Officer
880 Las Gallinas Ave., Suite #2, San Rafael, CA 94903
415-328-3441
kwalker@marincityclinic.org

CHC22689-00 CA

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for sub-division name for grant associated site.

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

Repayment to manufacturers

CAP implemented

Audit closure date: February 16, 2024

Rideout Memorial Hospital DBA Adventist Health and Rideout DSH050133 CA

No adverse findings

None

N/A

Audit closure date: October 31, 2022

St. Joseph Health Northern California, LLC, dba Santa Rosa Memorial Hospital DSH050174 CA

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

None

CAP implemented

Audit closure date: December 7, 2022

Trinity Hospital
Contact Information

Senior Vice President, Compliance, Privacy, Technology & Regulatory Affairs
Authorizing Official
gewing@trilliumhealth.org
585-545-7218

CAH051315-00 CA

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.

Repayment to manufacturers

CAP implemented

Audit closure date: January 3, 2024

Centura Longmont United Hospital DSH060003 CO

No adverse findings

None

N/A

Audit closure date: September 27, 2022

Kit Carson County Memorial Hospital CAH061313-00 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: April 19, 2023

North Colorado Medical Center DSH060001 CO

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

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: September 15, 2023

Centura St. Thomas More Hospital
(formerly known as St. Thomas More Hospital)
Contact Information

340B Program Manager
9100 E. Mineral Circle
Centennial, CO 80112
303-673-7380
SamanthaMorgan@Centura.org

CAH061344-00 CO

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 HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP approved

Day Kimball Hospital DSH070003 CT

No adverse findings

None

N/A

Audit closure date: October 27, 2022

Lawrence & Memorial Hospital DSH070007 CT

Incorrect 340B OPAIS record - Ineligible offsite outpatient facility registered in 340B OPAIS; A shipping address was not listed in 340B OPAIS.

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

CAP implemented

Audit closure date: May 5, 2023

Staywell Health Care, Inc.
Contact Information

President/CEO
StayWell Health Care, Inc.
80 Phoenix Ave, Ste 201
Waterbury, CT 06702
203-756-8021 ext 3016
dthompson@staywellhealth.org

CH01241C CT

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Primary Contact email address; Failed to remove duplicate registrations of contract pharmacies from 340B OPAIS; Failed to remove contract pharmacies from 340B OPAIS that did not have a written contract in place.

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.

Repayment to manufacturers

Termination of ineligible offsite contract pharmacies from the 340B Program.*

CAP approved

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 outpatient facility 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

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

No adverse findings

None

N/A

Audit closure date: April 15, 2022

AdventHealth Tampa DSH100173 FL

No adverse findings

None

N/A

Audit closure date: July 13, 2022

Tallahassee Memorial Healthcare, Inc. DSH100135 FL

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: August 21, 2023

Memorial Hospital Pembroke DSH100230 FL

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: September 28, 2023

Nemours Childrens Hospital PED103304-00 FL

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 approved

Hendry County Hospital Authority
dba Hendry Regional Medical Center
Contact Information

Chief Financial Officer
524 W Sagamore Ave
Clewiston, FL 33440
863-902-3000
teller@hrmc.us

CAH101309-00 FL

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

Diversion - 340B drugs dispensed to inpatients

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

Repayment to manufacturers

CAP approved

Medical Center of Peach County CAH111310-00 GA

No adverse findings

None

N/A

Audit closure date: January 7, 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 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 31, 2023

Phoebe Worth Medical Center CAH111328-00 GA

No adverse findings

None

N/A

Audit closure date: July 29, 2022

WellStar Spalding Regional Hospital DSH110031 GA

No adverse findings

None

N/A

Audit closure date: July 13, 2022

Phoebe Sumter Medical Center
Contact Information

340B Pharmacy Analyst 2000 Palmyra Road Albany, Georgia 31702
229-312-2174
340BRxstaff@phoebehealth.com

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

CAP implemented

Audit closure date: September 8, 2023

Dodge County Hospital
Contact Information

Chief Financial Officer
901 Griffin Avenue
Eastman, GA 31023
478-448-4050
jhamrick@dodgehospital.onmicrosoft.com

DSH110092 GA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 3, 2023

Palmetto Health Council, Inc. CH045260 GA

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for subdivision name for parent and grant associated sites; Grant associated site was not listed in 340B OPAIS.

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

None

CAP approved

State Medicaid has since determined duplicate discounts did not occur.

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

No adverse findings

None

N/A

Audit closure date: July 14, 2022

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 implemented

Audit closure date: February 23, 2023

Alivio Medical Center, Inc.
Contact Information

Chief Executive Officer
2355 S Western Ave
Chicago, IL 60608-3837
312-829-6304
ecorpuz@aliviomedicalcenter.org

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

CAP implemented

Audit closure date: February 23, 2023

Franklin Hospital District CAH141321-00 IL

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

None

CAP implemented

Audit closure date: December 21, 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

CAP implemented

Audit closure date: January 19, 2023

Crawford Hospital District DBA Crawford Memorial Hospital CAH141343-00 IL

No adverse findings

None

N/A

Audit closure date: August 25, 2022

MacNeal Hospital DSH140054 IL

No adverse findings

None

N/A

Audit closure date: October 19, 2022

Ann and Robert H. Lurie Children's Hospital of Chicago
Contact Information

Jenny Elhadary
Vice President, Clinical Services
312-227-4161
pelhadary@luriechildrens.org

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

CAP implemented

Audit closure date: September 8, 2023

Humboldt Park Health
Contact Information

Authorizing Official
773-292-8208
khendren@hph.care

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 offsite outpatient facility registered in 340B OPAIS; Incorrect entry for Authorizing Official.

Diversion - 340B drugs prescribed by ineligible providers.

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

Repayment to manufacturers

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

CAP implemented

Audit closure date: October 13, 2023

Advocate Lutheran General Hospital RRC140223-00 IL

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: September 28, 2023

Decatur County Memorial Hospital CAH151332-00 IN

No adverse findings

None

N/A

Audit closure date: March 29, 2022

Palmer Lutheran Health Center CAH161316-00 IA

No adverse findings

None

N/A

Audit closure date: January 20, 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

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

CAP implemented

Audit closure date: September 23, 2022

Clarinda Regional Health Center CAH161352-00 IA

No adverse findings

None

N/A

Audit closure date:
July 12, 2022

Southeast Iowa Regional Medical Center RRC160057-00 IA

Incorrect 340B OPAIS record - Failed to remove duplicate registrations of contract pharmacies from 340B OPAIS.

None

CAP implemented

Audit closure date: March 14, 2023

Coffeyville Regional Medical Center, Inc. SCH170145-00 KS

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.; Incorrect entries in 340B OPAIS for Medicare Cost Report file date, cost reporting period, and disproportionate share percentage.

None

CAP implemented

Audit closure date: January 11, 2023

Hunter Health Clinic Inc., The CH070150 KS

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

None

CAP implemented

Audit closure date: October 12, 2022

UKHS Great Bend Campus SCH170191 KS

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; Incorrect entry for address for offsite outpatient facility.

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: August 25, 2023

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

CAP implemented

Audit closure date: May 18, 2023

St. Joe - Flaget DSH180025 KY

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

None

CAP implemented

Audit closure date: June 20, 2023

Hazard ARH Regional Medical Center DSH180029 KY

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: September 8, 2023

Tug Valley ARH Regional Medical Center DSH180069 KY

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

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: August 31, 2022

Kentucky Department for Public Health STD40621 KY

Incorrect 340B OPAIS record - Incorrect entry for Primary Contact; Healthcare delivery sites were not listed in 340B OPAIS.

None

Pending

Acadia General Hospital DSH190044 LA

No adverse findings

None

N/A

Audit closure date: September 12, 2022

Springhill Medical Center - Amended SCH190088-00 LA

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entries for Primary Contact telephone number for offsite outpatient facilities.

None

CAP implemented

Audit closure date: November 20, 2023

St. Thomas Community Health Center, Inc. CHC12863-00 LA

Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for name; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.

None

CAP approved

Lafayette General Medical Center
Contact Information

AVP of Pharmacy
1214 Coolidge Street
Lafayette, LA 70503
337-289-7888
rodney.good@ochsner.org

DSH190002 LA

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

Termination of ineligible contract pharmacy from the 340B Program*

CAP implemented

Audit closure date: December 12, 2023

University Hospital and Clinics
Contact Information

Director of Pharmacy - Ochsner University Hospital & Clinics
2390 W Congress St, Lafayette, LA 70506
337-261-6629
jeffery.bolotte@ochsner.org

DSH190006 LA

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and hospital control type; Failed to remove closed contract pharmacy from 340B OPAIS.

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

Repayment to manufacturers.

Termination of ineligible contract pharmacy from the 340B Program.*

CAP implemented

Audit closure date: September 28, 2023

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

CAP implemented

Audit closure date: October 27, 2022

Maryland General Hospital DSH210038 MD

No adverse findings

None

N/A

Audit closure date: July 14, 2022

Choptank Community Health System, Inc.
Contact Information

Chief Executive Officer
301 Randolph Street
Denton, MD 21629
410-479-4306
srich@choptankhealth.org

CH032750 MD

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: October 13, 2023

Meritus Medical Center DSH210001 MD

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 a duplicate registration of a contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: March 1, 2023

Union Memorial Hospital DSH210024 MD

No adverse findings

None

N/A

Audit closure date: December 15, 2022

Manet Community Health Center, Incorporated CH011640 MA

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

None

CAP implemented

Audit closure date: September 21, 2022

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 implemented

Audit closure date: October 26, 2022

Packard Health, Inc.
Contact Information

Chief Financial Officer
5200 Venture Dr 
Ann Arbor, MI 48108
734-971-1073 
Todd_montrief@packardhealth.org

CHC29011-00 MI

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

Repayment to manufacturers

CAP implemented

Audit closure date: December 13, 2022

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

CAP implemented

Audit closure date: December 13, 2022

Western Wayne Family Health Centers CH0530900 MI

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

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

Termination of ineligible contract pharmacy from the 340B Program.*

CAP implemented

Audit closure date: February 9, 2024

First Care Medical Services CAH241357-00 MN

No adverse findings

None

N/A

Audit closure date: March 15, 2022

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

CAP implemented

Audit closure date: September 23, 2022

RiverView Healthcare Association CAH241320-00 MN

No adverse findings

None

N/A

Audit closure date: March 24, 2022

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

Cambridge Medical Center DSH240020 MN

No adverse findings

None

N/A

Audit closure date: July 27, 2022

New ULM Medical Center CAH241378-00 MN

No adverse findings

None

N/A

Audit closure date: August 8, 2022

St. Josephs Medical Center SCH240075-00 MN

No adverse findings

None

N/A

Audit closure date: July 27, 2022

Allina Health Faribault Medical Center DSH240071 MN

No adverse findings

None

N/A

Audit closure date: December 19, 2022

Rice Memorial Hospital DSH240088 MN

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

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: January 24, 2024

Gillette Children's Specialty Healthcare PED243300-00 MN

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed in 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: January 4, 2024

Mercy Hospital DSH240115 MN

Incorrect 340B OPAIS record - Entity improperly registered offsite outpatient facilities as shipping addresses in 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: January 18, 2024

Baptist Memorial Hospital North Mississippi RRC250034-00 MS

No adverse findings

None

N/A

Audit closure date: November 1, 2022

Pontotoc Health Services CAH251308 MS

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

None

CAP approved

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

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

CAP implemented

Audit closure date: September 8, 2023

Freeman Neosho Hospital CAH261331-00 MO

No adverse findings

None

N/A

Audit closure date: October 25, 2022

Putnam County Memorial Hospital CAH261305-00 MO

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, Authorizing Official phone number and Primary Contact phone number; Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place.

None

CAP implemented

Audit closure date: February 21, 2023

Cox Barton County Hospital CAH261325-00 MO

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: December 12, 2023

Madison Medical Center
Contact Information

Chief Financial Officer
Madison Medical Center
611 W. Main St.
Fredericktown, MO 63645
asucharski@madisonmedicalcenter.net
573-783-1070

CAH261302-00 MO

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

Diversion - 340B drugs prescribed by ineligible provider.

Repayment to manufacturers

CAP implemented

Audit closure date: February 16, 2024

Southeast Health Center of Stoddard County
Contact Information

340B CoordinatorSoutheast Health of Stoddard County
1200 N. One Mile Road
Dexter, MO 63841
573-614-1957 wjuden@sehealth.org

DSH260160 MO

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 4, 2024

Cox Monett Hospital, Inc. CAH261329-00 MO

Incorrect 340B OPAIS record - Ineligible offsite outpatient facilities registered in 340B OPAIS.

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

Termination of ineligible offsite outpatient facilities*

CAP implemented

Audit closure date: June 7, 2023

Harrison County Community Hospital CAH261312-00 MO

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 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 27, 2023

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

Providence Saint Joseph Medical Center CAH271343-00 MT

No adverse findings

None

N/A

Audit closure date: March 31, 2022

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

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

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

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

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

CAP implemented

Audit closure date: January 11, 2023

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

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.

None

CAP implemented

Audit closure date: November 4, 2022

Sacred Heart Health Services dba Avera Creighton Hospital CAH281331-00 NE

No adverse findings

None

N/A

Audit closure date: May 25, 2022

Banner Churchill Community Hospital CAH291313-00 NV

No adverse findings

None

N/A

Audit closure date: March 17, 2022

Northern Nevada HIV Outpatient Program Education and Services
Contact Information

Pharmacy Director
580 W 5th St., Reno, NV 89503
775-348-1306 twatkins@nnhopes.org

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 HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: October 4, 2023

Kennedy Memorial Hospital-UMC
Contact Information

340B Manager
1101 Market St, 20th Floor, Philadelphia, PA 19107
215-955-6076
jmo011@jefferson.edu

DSH310086 NJ

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

Repayment to manufacturers

CAP approved

Saint Peter's University Hospital
Contact Information

Chief Financial Officer/Authorizing Official
Saint Peter's University Hospital
254 Easton Avenue
New Brunswick, NJ 08901
gstoldt@saintpetersuh.com

DSH310070 NJ

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 15, 2023

North Hudson Community Action Corporation
Contact Information

340B Coordinator800 31st Street
Union City, NJ 07087
amartinez@nhcac.org
201-494-3873

CH024490 NJ

Incorrect 340B OPAIS record - Contract pharmacy was not registered in 340B OPAIS.

Diversion - 340B drugs dispensed at a contract pharmacy, prescribed by ineligible provider.

Duplicate Discount - Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP approved

UH – University Hospital DSH310119 NJ

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: May 5, 2023

Sierra Vista Hospital CAH321300-00 NM

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entries for Authorizing Official name and phone number.

None

CAP implemented

Audit closure date: November 8, 2022

Gerald Champion Regional Medical Center DSH320004 NM

No adverse findings

None

N/A

Audit closure date: November 1, 2022

UNM Truman Health Services HV00130 NM

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

Termination of ineligible contract pharmacy from the 340B Program.*

CAP implemented

Audit closure date: April 28, 2023

Adirondack Medical Center SCH330079-00 NY

No adverse findings

None

N/A

Audit closure date: January 11, 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

Rochester General Hospital DSH330125 NY

No adverse findings

None

N/A

Audit closure date: January 7, 2022

Trillium Health, Inc.
Contact Information

Senior Vice President, Compliance, Privacy, Technology & Regulatory Affairs
Authorizing Official
gewing@trilliumhealth.org
585-545-7218

FQHCLA342 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 13, 2023

United Memorial Medical Center DSH330073 NY

No adverse findings

None

N/A

Audit closure date: January 11, 2022

Champlain Valley Physicians Hospital DSH330250 NY

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: January 27, 2023

Family Health Network of Central New York, Inc.
Contact Information

Chief Executive Officer 85 S West Street Homer, NY 13077 607-753-3797 kosborne@familyhealthnetwork.org

CH021240 NY

Incorrect 340B OPAIS record â Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place. Duplicate Discounts â Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File.

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

CAP implemented

Audit closure date: June 6, 2023

Coney Island Hospital (NYCHHC) DSH330196 NY

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

None

CAP implemented

Audit closure date: October 4, 2023

Medina Memorial Hospital CAH331319-00 NY

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Authorizing Official phone number; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period.

None

CAP implemented

Audit closure date: July 31, 2023

Nassau Health Care Corporation DSH330027 NY

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

Termination of ineligible contract pharmacy from the 340B Program*

CAP implemented

Audit closure date: February 7, 2024

UPMC Chautauqua at WCA
Contact Information

340B Director
3175 E. Carson St Pittsburgh, PA 15203
412-647-2940
lynchj8@upmc.edu

DSH330239 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: November 2, 2023

Jacobi Medical Center NYCHHC DSH330127 NY

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

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

None

CAP implemented

Audit closure date: January 24, 2024

Compassion Health Care, Inc. CH044920 NC

No adverse findings

None

N/A

Audit closure date: September 1, 2022

Greene County Health Care, Incorporated
Contact Information

Chief Executive Officer
Greene County Health Care, Inc.
7 Professional Drive
Snow Hill, NC 28580
252-747-8162 x2002
Mtorres@gchcinc.org

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

CAP implemented

Audit closure date: August 22, 2023

Granville Medical Center
Contact Information

Chief Financial Officer
1010 College Street
Oxford, NC 27565
919-690-3402

DSH340127 NC

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

Diversion - 340B drug dispensed to inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: October 13, 2023

Pitt County Memorial Hospital, Incorporated dba ECU Health Medical Center DSH340040 NC

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage; Incorrect entry in 340B OPAIS for shipping address; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: February 22, 2024

Grant Medical Center DSH360017 OH

No adverse findings

None

N/A

Audit closure date: May 13, 2022

Knox Community Hospital SCH360040-00 OH

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 HRSA Medicaid Exclusion File.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: February 22, 2024

Miami Valley Hospital DSH360051 OH

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: July 13, 2023

Health Partners of Western Ohio CH0516380 OH

No adverse findings

None

N/A

Audit closure date: March 1, 2023

Holzer Medical Center - Jackson CAH361320-00 OH

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.

None

CAP implemented

Audit closure date: February 15, 2024

Trinity Hospital Holding Company RRC360211-00, DSH360211 OH

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, and disproportionate share percentage; Offsite outpatient facilities were not listed in 340B OPAIS; Incorrect entry in 340B OPAIS for shipping address.

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

None

CAP implemented

Audit closure date: February 28, 2024

Children's Hospital Medical Center of Akron PED363303-00 OH

Incorrect 340B OPAIS record - Offsite outpatient facilities were not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for addresses for offsite outpatient facilities; Failed to remove duplicate registrations from 340B OPAIS for an offsite outpatient facility.

None

CAP implemented

Audit closure date: July 13, 2023

Pushmataha Family Medical Center, Inc. CHC06453-00 OK

No adverse findings

None

N/A

Audit closure date: July 29, 2022

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*

CAP implemented

Audit closure date: March 14, 2023

Northeastern Health System
Contact Information

Director of Pharmacy
1400 E Downing Tahlequah, OK 74464
918-453-2355
slarmon@nhs-ok.org

SCH370089-00 OK

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date; Failed to remove terminated contract pharmacies from 340B OPAIS.

Diversion - 340B drug dispensed to inpatient.

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

Repayment to manufacturers

CAP approved

Neighborhood Health Center CHC24160-00 OR

No adverse findings

None

N/A

Audit closure date: April 8, 2022

SHMC - Riverbend
Contact Information

System Director of Pharmacy Supply Chain & 340B Program
1115 SE 164th Ave.
Vancouver, WA 98683
360-729-2236
MLessard@peacehealth.org

DSH380102 OR

Duplicate Discounts - Entity's contract pharmacy was billing Medicaid without notification to HRSA.

Repayment to manufacturers

CAP implemented

Audit closure date: March 21, 2023

Portland Adventist Medical Center dba Adventist Health Portland
Contact Information

Director of Pharmacy
Adventist Health Portland
10123 SE Market St
Portland, OR 97216
503-251-6142
Declerkm@ah.org

DSH380060 OR

Diversion - 340B drug dispensed to inpatient.

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.

Repayment to manufacturers

CAP approved

B – K Health Center, Inc. CH03048E PA

No adverse findings

None

N/A

Audit closure date: January 7, 2022

Punxsutawney Area Hospital SCH390199-00 PA

No adverse findings

None

N/A

Audit closure date: February 2, 2022

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

Robert Packer Hospital
Contact Information

Chief Financial Officer Guthrie Hospitals
One Guthrie Square
Sayre, PA 188
570-887-5985
Fran.macafee@guthrie.org

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 HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: September 12, 2023

LCH Health and Community Services formerly La Comunidad Hispania, Inc
Contact Information

Chief Executive Officer
731 West Cypress Street, Kennett Square, PA 19348
610-444-7550 x 295
rgannon@lchservices.org

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

CAP implemented

Audit closure date: September 8, 2023

St. Luke’s Hospital RRC390049-00
DSH390049
PA

No adverse findings

None

N/A

Audit closure date: July 13, 2022

Reading Hospital DSH390044 PA

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

None

CAP implemented

Audit closure date: December 21, 2022

Welsh Mountain Health Centers CHC00495-00 PA

Incorrect 340B OPAIS record – Entity improperly registered an entity-owned pharmacy as a grant associated site in 340B OPAIS.

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

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

Termination of ineligible contract pharmacies from the 340B Program.*

CAP implemented

Audit closure date: December 21, 2022

State Medicaid has since determined duplicate discounts did not occur.

NEPA Community Healthcare, Hallstead FP Clinic FP188225 PA

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for grant number.

None

CAP implemented

Audit closure date: October 16, 2023

St. Luke's Quakertown Hospital DSH390035 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 HRSA Medicaid Exclusion File.

None

CAP implemented

Audit closure date: July 31, 2023

Thundermist Health Center CH011820 RI

Incorrect 340B OPAIS record - Ineligible offsite outpatient facility registered in 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.

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

CAP implemented

Audit closure date: January 18, 2022

Landmark Medical Center DSH410011 RI

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for disproportionate share percentage and for Primary Contact.

Entitys contract pharmacy was billing Medicaid without notification to HRSA. It was determined that duplicate discounts did not occur as a result of the finding.

None

CAP implemented

Audit closure date: January 3, 2024

Self Regional Healthcare DSH420071 SC

No adverse findings

None

N/A

Audit closure date: October 7, 2022

Rhea Medical Center CAH441310-00 TN

Incorrect 340B OPAIS record – Failed to remove closed offsite outpatient facility from 340B OPAIS. Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for address for offsite outpatient facility.

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

CAP implemented

Audit closure date: December 15, 2022

Memorial Hermann Sugar Land Hospital DSH450848 TX

No adverse findings

None

N/A

Audit closure date: May 12, 2022

Moore County Hospital District dba Memorial Hospital
Contact Information

Chief Compliance Officer
224 E. 2nd Street
Dumas, TX 79029
awiswell@mchd.net
806-934-7802

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 HRSA Medicaid Exclusion File.

Repayment to manufacturers

CAP implemented

Audit closure date: August 29, 2023

D.M. Cogdell Memorial Hospital
Contact Information

Chief Operating Officer
cmh.jeverett@cogdellhospital.com
325-574-7439

CAH451384-00 TX

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

Diversion â 340B drugs prescribed by ineligible providers.

Duplicate Discounts - Entityâs contract pharmacies billed Medicaid without notification to HRSA.

Repayment to manufacturers

CAP implemented

Audit closure date: June 20, 2023

Lamb County Hospital dba Lamb Healthcare Center
Contact Information

Chief Executive Officer
1500 S. Sunset
Littlefield, TX 79339
806-385-6444
cklein@lambhc.org

SCH450698-00 TX

Entity did not meet eligibility requirements as a DSH hospital for the time period April 29, 2022, through
September 7, 2022.

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 24, 2024

Yoakum County Hospital CAH451308-00 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 HRSA Medicaid Exclusion File.

None

CAP implemented

State Medicaid has since determined duplicate discounts did not occur.

Audit closure date: June 6, 2023

Asian American Health Coalition of the Greater Houston Area, Inc.
Contact Information

Chief Quality Officer
7001 Corporate Drive Suite 120
Houston, Texas 77036
kwgreen@hopechc.org
713-773-0803

CHC24153-00 TX

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

Repayment to manufacturers

CAP approved

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 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: April 28, 2023

Grimes St. Joseph Health Center CAH451322-00 TX

No adverse findings

None

N/A

Audit closure date: December 16, 2022

United Regional Health Care System SCH450010-00 TX

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

Termination of ineligible contract pharmacy from the 340B Program.*

CAP implemented

Audit closure date: June 26, 2023

Mother Frances Hospital-Winnsboro CAH451381-00 TX

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Failed to remove a duplicate registration of a contract pharmacy from 340B OPAIS; Failed to remove terminated contract pharmacy from 340B OPAIS.

None

CAP implemented

Audit closure date: May 15, 2023

Moab Valley Healthcare, Inc. CAH461302-00 UT

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 7, 2022

Northeast Washington County Community Health, Inc. CHC08230-00 VT

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for Authorizing Official.

None

CAP implemented

Audit closure date: February 2, 2023

St. Michael Medical Center RRC500039-00 WA

No adverse findings

None

N/A

Audit closure date: May 10, 2022

Valley Hospital and Medical Center DSH500119 WA

No adverse findings

None

N/A

Audit closure date:
October 21, 2022

Yakima Valley Memorial Hospital DSH500036 WA

No adverse findings

None

N/A

Audit closure date: November 2, 2022

Kittitas County Public Hospital District #1
Contact Information

Director of Pharmacy
Kittitas Valley Healthcare
603 S Chestnut Street
Ellensburg, WA 98926
509-925-8494
nbasmeh@kvhealthcare.org

CAH501333-00 WA

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

Diversion - 340B drug dispensed to inpatient.

Repayment to manufacturers

CAP implemented

Audit closure date: January 3, 2024

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

Hospital Development Corporation dba Roane General Hospital CAH511306-00 WV

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

None

CAP implemented

Audit closure date: September 15, 2023

Mercy Health System Corporation DSH520066 WI

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: May 18, 2023

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

Marshfield Medical Center Ladysmith
Contact Information

340B Program Manager
1000 North Oak Avenue Marshfield, WI 54449
715-858-4308
Neuendorf.kirstia@marshfieldclinic.org

CAH521328-00 WI

Incorrect 340B OPAIS record - Incorrect entry in 340B OPAIS for hospital classification.; 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

CAP implemented

Audit closure date: January 27, 2023

St. Clare Memorial Hospital, Inc. CAH521310-00 WI

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: January 27, 2023

Ascension Calumet Hospital, Inc. CAH521317-00 WI

No adverse findings

None

N/A

Audit closure date: November 15, 2022

Memorial Hospital of Carbon County
Contact Information

Chief Financial Officer
JFSMITH@IMHCC.COM
307-324-2221

CAH531316-00 WY

Incorrect 340B OPAIS record - Incorrect entries in 340B OPAIS for Medicare Cost Report filing date; Ineligible offsite outpatient facility registered in 340B OPAIS; Failed to remove duplicate registrations from 340B OPAIS for an offsite outpatient facility.

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

Termination of ineligible offsite outpatient facilities from the 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date: June 20, 2023

Washington Health Institute
Contact Information

Director of Operations
1140 Varnum Street NE, Suite 203
Washington, DC 20017
202-714-0066
bhaileab@dc-whi.org

STD20017 DC

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

Repayment to manufacturers

CAP implemented

Audit closure date: January 6, 2023

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

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

Date Last Reviewed: