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Program Integrity: FY15 Audit Results

Updated 5/1/17. The results chart includes audits where the findings have been finalized. Remaining audits are still under review. Information on Corrective Action Plans and Sanctions will be updated once approved by HRSA. HRSA recommends manufacturers do not contact audited entities regarding sanctions until a corrective action plan has been approved by HRSA and posted on this website.

Results posted for (200) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action with Audit Closure Date
Adventist Medical Center DSH050121 CA

Incorrect 340B database record – Incorrect entry for Primary Contact.

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

Duplicate Discounts – Medicaid billing numbers were incorrect on the Medicaid Exclusion File.

Repayment to manufacturers Public letter to manufacturers (PDF - 65 KB)
AIDS Healthcare Foundation RWI900481 CA

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

Repayment to manufacturers Public letter to manufacturers (PDF - 184 KB)
AIDS Resource Center Ohio HV43212, HV00531A, RWII45402, RWII432 OH Incorrect 340B database record – Incorrect Entries for Primary Contact, billing address and grant numbers. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: November 10, 2015

Alice Peck Day Memorial Hospital CAH301305-00 NH

Entity did not provide contract pharmacy oversight.

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

Entity had inaccurate information in the 340B Medicaid Exclusion File.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

Termination of contract pharmacies from 340B Program*

Public letter to manufacturers (PDF - 59 KB)

ARCARE CH060940 AR

Incorrect 340B database record – Incorrect entry for off-site outpatient facility’s address; Registered contract pharmacies without written contract in place.

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

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

Repayment to manufacturers

State Medicaid has since determined that duplicate discounts did not occur

Public letter to manufacturers (PDF - 17 KB)

Audit closure date: March 30, 2017

Atlanticare Regional Medical Center DSH310064 NJ

Incorrect 340B database record – Incorrect entries for offsite outpatient facilities addresses.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 11 KB)

Audit closure date: September 15, 2016

Aurora Health Care Central Inc. DBA Aurora Sheboygan Memorial Medical Center

DSH520035 WI Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites. Repayment to manufacturers

Public letter to manufacturers (PDF - 40 KB)

Audit closure date:  April 18, 2017

Avera Hand County Memorial Hospital CAH431337 SD No adverse findings None

N/A

Audit closure date:  July 1, 2015

AxessPointe Community Health Center CH057270 OH Diversion – 340B drugs dispensed for over-the counter medications, without a prescription. Repayment to manufacturers

Public letter to manufacturers (PDF - 67 KB)

Audit closure date: January 3, 2017.

Bakersfield Memorial Hospital DSH050036 CA Incorrect 340 database record – Incorrect DSH percentage entry. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: February 17, 2016

Banner - University Medical Center South DSH030111 AZ

Incorrect 340B database record – Registered a contract pharmacy without a contract in place.

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

Termination of contract pharmacy from 340B Program *

Repayment to manufacturers

Termination of contract pharmacy from 340B Program*

Public letter to manufacturers (PDF - 56 KB)

Banner - University Medical Center Tucson DSH030064 AZ Diversion – 340B drug dispensed for prescription originating from ineligible site. Repayment to manufacturers Public letter to manufacturers (PDF - 59 KB)
Baptist Medical Center South DSH010023 AL Diversion – 340B drugs dispensed at a contract pharmacy for prescriptions written at ineligible sites. Repayment to manufacturers

Public letter to manufacturers (PDF - 30 KB)

Audit closure date: April 6, 2016

Baystate Franklin Medical Center DSH220016 MA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to June 8, 2015.

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

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 93 KB)

Audit closure date: March 30, 2017

Bear Lake Community Health Center CH0811150 UT

Incorrect 340B database record – Incorrect billing address entries for off-site outpatient facilities.

Diversion – 340B drugs dispensed for prescriptions written by ineligible providers at ineligible sites.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File; NPI number was incorrect on the Medicaid Exclusion File for one offsite outpatient facility.

Repayment to manufacturers

Public letter to manufacturers (PDF - 39 KB)

Audit closure date: October 21, 2016

Belington Community Medical Services Association, Inc. CHC12878-00, FP262506 WV

Entity failed to maintain auditable medical records prior to June, 2015.

Incorrect 340B database record – Incorrect entries for addresses and site names.

Entity did not provide contract pharmacy oversight.

Repayment to manufacturers Public letter to manufacturers (PDF - 24 KB)
Beth Israel Medical Center DSH330169 NY No adverse finding None

N/A

Audit closure date:  March 9, 2015

 

Boston Medical Center DSH220031 MA

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

Repayment to manufacturer

Public letter to manufacturers (PDF - 33 KB)

Audit closure date: April 18, 2017

Bridgton Hospital CAH201310-00 ME No adverse findings None

N/A

Audit closure date:  October 13, 2015

Bronson Methodist Hospital DSH230017 MI

Incorrect 340B database record – Registered contract pharmacies without written contract in place; incorrect entry for contract pharmacy address.

Termination of contract pharmacies from 340B Program*

Database entry corrected

Termination of contract pharmacies from 340B Program*

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: July 21, 2015

BRFHH Shreveport LLC DSH190098 LA Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: September 15, 2016

Cambridge Public Health Commission DSH220011 MA

Incorrect 340B database record – Incorrect entries for shipping addresses for outpatient facilities.

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

None Audit closure date: March 30, 2016
Carle Foundation Hospital DSH140091 IL

Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 3, 2014.

Incorrect 340B database record – Ineligible Sites registered on 340B database.

Repayment to manufacturers

Public letter to manufacturers (PDF - 14 KB)

Audit closure date: June 17, 2016

Carson City Health and Human Services TB89410, STD89410, FP894234 NV No adverse findings None

N/A

Audit closure date:  May 11, 2015

Central Maine Medical Center DSH200024 ME No adverse findings None

N/A

Audit closure date:  October 13, 2015

Charles Cole Memorial Hospital CAH391313-00 PA

Incorrect 340B database record – Incorrect entry for Primary contact.

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

Public letter to manufacturers (PDF - 48 KB)

Audit closure date: September 2, 2016

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

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

Diversion – 340B drugs dispensed for prescriptions originating from an ineligible site; 340B drugs were not properly accumulated.

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

Repayment to manufacturers Public letter to manufacturers (PDF - 47 KB)
Children's Hospital of Wisconsin, Inc. PED523300-00 WI

Incorrect 340B database record – Registered a contract pharmacy without a written contract in place.

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

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

Public letter to manufacturers (PDF - 37 KB)

Audit closure date: September 15, 2016

Childress Regional Medical Center DSH450369 TX

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

Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed to inpatients.

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

Public letter to manufacturers (PDF - 68 KB)

Audit closure date: August 31, 2016

Christus Santa Rosa Health System DSH450237 TX

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacies without written contract in place.

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

Termination of contract pharmacies from 340B Program*

Repayment to manufacturers

Public letter to manufacturers (PDF - 17 KB)

Audit closure date: January 3, 2017.

Citrus Valley Medical Center DSH050369 CA

Covered outpatient drugs obtained through a Group Purchasing Organization.

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

Termination from the 340B Program*

Repayment to manufacturers

Public letter to manufacturers (PDF - 34.5 KB)
Clara Maass Medical Center DSH310009 NJ

Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 31, 2015.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

Public letter to manufacturers (PDF - 55 KB)

Audit closure date:  February 7, 2017

Clarendon Memorial Hospital DSH420069 SC

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 29, 2015.

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

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 51 KB)

Audit closure date:  February 10, 2017

Comanche County Memorial Hospital DSH370056 OK No adverse findings None

N/A

Audit closure date:  July 31, 2015

Community Hospitals of Indiana, Inc. DSH150074 IN Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers

Public letter to manufacturers (PDF - 16.9 KB)

County of Santa Clara, Valley Health Center – East Valley

CH091181A CA Duplicate Discounts – Incorrect or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers

Public letter to manufacturers (PDF - 28 KB)

Covenant Medical Center DSH160067 IA No adverse findings None

N/A

Audit closure date:  December 22, 2015

Custer Family Planning Center STD58504, FP585543 ND No adverse findings None

N/A

Audit closure date:  April 10, 2015

DeKalb Medical Center at Hillandale DSH110226 GA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to July 13, 2014.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 106 KB)

Audit closure date: June 21, 2016

Dr. Dan C. Trigg Memorial Hospital CAH321302-00 NM

Incorrect 340B database record – Registered contract pharmacy without written contract in place.

Violation of Orphan Drug Exclusion – ineligible 340B purchases for orphan drug designations.

Repayment to manufacturers

Public letter to manufacturers (PDF - 44 KB)

Audit closure date:  February 8, 2017

DuBois Regional Medical Center DSH390086 PA No adverse findings None

N/A

Audit closure date:  July 1, 2015

Dyer County Health Department STD380248, FP380247, TB38024 TN No adverse findings None

N/A

Audit closure date:  September 10, 2015

East Carolina University HM27834 NC No adverse findings None

N/A

Audit closure date:  August 18, 2015

Edward W Sparrow Hospital Association DSH230230 MI

Incorrect 340B database record – Incorrect Entries for addresses for offsite outpatient facility and contract pharmacies.

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

Repayment to manufactures

Public letter to manufacturers (PDF - 78 KB)

Audit closure date: March 30, 2017

Effort, Inc. CHC12872-00 CA

Incorrect 340B database record – Incorrect Entries for entity’s name; offsite outpatient facilities were not listed on the 340B database; registered contract pharmacy without written contract in place.

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

Public letter to manufacturers (PDF - 17 KB)
El Centro Regional Medical Center DSH050045 CA Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. 340B drugs were not properly accumulated. Repayment to manufacturers

Public letter to manufacturers (PDF - 125 KB)

Audit closure date: August 12, 2016

Elizabethtown Community Hospital CAH331302-00 NY

Violation of Orphan Drug Exclusion – Ineligible 340B purchases for orphan drug designations.

Duplicate Discounts – Entity had inaccurate information in the 340B Medicaid Exclusion File.

Repayment to manufacturers

Public letter to manufacturers (PDF - 114 KB)

Audit closure date: February 3, 2017

Emory Midtown Infectious Diseases Clinics

HV30308 GA Diversion – 340B drug dispensed at contract pharmacy for prescription written by ineligible provider at ineligible site. Repayment to manufacturers Public letter to manufacturers (PDF - 17 KB)
Erlanger Medical Center

DSH440104

CH041260

TN

Incorrect 340B database – Offsite outpatient facilities were not separately listed on the 340B database.

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

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

Repayment to manufacturers Public letter to manufacturers (PDF - 32 KB)
Espanola Hospital DSH320011 NM

Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 15, 2015.

Incorrect 340B database record – Registered contract pharmacy without written contract in place.

Diversion – 340B drugs dispensed at contract pharmacy for prescriptions written at an ineligible site.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 54 KB)

Audit closure date: March 30, 2017

Family Medical Center of Michigan Inc. CH052910 MI

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

Repayment to manufacturers Public letter to manufacturers (PDF - 80 KB)
Feather River Hospital DSH050225 CA

Incorrect 340B database record – Incorrect entry for shipping address.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 38 KB)

Audit closure date: February 3, 2017

Flagstaff Medical Center DSH030023 AZ Incorrect 340B database record – Incorrect entries for Authorizing Official’s contact information; Registered a contract pharmacy without a contract in place. Termination of contract pharmacy from 340B Program*

Database entry corrected

Termination of contract pharmacy from 340B Program*

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: November 20, 2015

Florida Hospital DSH100007 FL

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 1, 2015.

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

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

Repayment to manufacturers

State Medicaid has since determined that duplicate discounts did not occur

Public letter to manufacturers (PDF - 51 KB)

Floyd Medical Center DSH110054 GA Diversion – 340B drugs dispensed for prescriptions written at ineligible sites and by ineligible providers. Repayment to manufacturers

Public letter to manufacturers (PDF - 36 KB)

Audit closure date: September 15, 2016

Forsyth Memorial Hospital, Inc. dba Novant Health Forsyth Medical Center DSH340014 NC Diversion – 340B drugs dispensed to inpatients. Repayment to manufacturers Public letter to manufacturers (PDF - 103 KB)
Glencoe Regional Health Services CAH241355-00 MN Diversion - 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites. 340B drug dispensed to an inpatient; 340B drugs were not properly accumulated. Repayment to manufacturers

Public letter to manufacturers (PDF - 50 KB)

Audit closure date: February 3, 2017

Good Samaritan Hospital DSH330158 NY Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Public letter to manufacturers (PDF - 101 KB)
Good Samaritan Hospital of Cincinnati Ohio DSH360134 OH Inaccurate 340B database record – Registered a contract pharmacy without a contract prior to August 28, 2015. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: February 23, 2016

Graham County Health Department STD28771, FP287713, TB28771 NC

Incorrect 340B database record – Entity utilized contract pharmacy prior to its registration in the 340B database; Incorrect entry for Primary Contact.

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

Repayment to manufacturers

State Medicaid has since determined that duplicate discounts did not occur

Public letter to manufacturers (PDF - 63.2 KB)

Audit closer date: April 6, 2016

Gulf Coast Health Center, Inc. CH061730 TX Incorrect 340B database record – Registered a contract pharmacy without a contract in place. Termination of contract pharmacy from 340B Program*

Termination of contract pharmacy from 340B Program*

Audit closure date: August 6, 2015

Gulf Health Hospitals, Inc. DBA North Baldwin Infirmary DSH010129 AL Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites. Repayment to manufacturers

Public letter to manufacturers (PDF - 57 KB)

Audit closure date: September 27, 2016

Gundersen Lutheran Medical Center, Inc. DSH520087 WI

Diversion – 340B drug dispensed at contract pharmacy for a prescription originating from an ineligible site.

 

Repayment to manufacturers

Public letter to manufacturers (PDF - 56 KB)

Audit closure date: July 15, 2016

Highlands Hospital of Rochester DSH330164, FP14620 NY

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

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

Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

Pending

Public letter to manufacturers (PDF - 54 KB)

Holland Hospital DSH230072 MI

Incorrect 340B database record – Registered contract pharmacy without written contract in place.

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

Public letter to manufacturers (PDF - 93 KB)

Audit closure date: March 30, 2017

Hudson Headwaters Health Network CH021790 NY No adverse findings None

N/A

Audit closure date:  November 18, 2015

Huron Medical Center SCH230118-00 MI Incorrect 340B database record – Offsite outpatient facilities were not separately listed on the 340B database. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: February 23, 2016

Indiana University Health Inc. DSH150056 IN No adverse findings None

N/A

Audit closure date:  September 10, 2015

Integris Baptist Medical Center DSH370028 OK

Incorrect 340B database record – Incorrect entries for two offsite outpatient facilities; Offsite outpatient facilities were not listed on the 340B database; Registered contract pharmacies without a written contract in place.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 34 KB)

Audit closure date: March 30, 2017

Integris Canadian Valley Hospital DSH370211 NH

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

Repayment to manufacturers Public letter to manufacturers (PDF - 33.7 KB)
Integris South Oklahoma DSH370106 OK

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

Repayment to manufacturers Public letter to manufacturers (PDF - 35 KB)
Jackson Health System DSH100022 FL

Incorrect 340B database record – Closed Offsite outpatient facility listed on 340B database; One offsite outpatient facility listed twice on database; Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drug dispensed for a prescription originating from an ineligible site.

Repayment to manufacturers

Public letter to manufacturers (PDF - 71 KB)

Audit closure date:  February 7, 2017

Jewish Hospital and St. Mary’s Healthcare (JHSMH) DSH180040 KY Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date:  January 19, 2016

Johns Hopkins Bayview Medical Center DSH210029 MD

Incorrect 340B database record – Incorrect entries for addresses of off-site outpatient facilities.

Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

Public letter to manufacturers (PDF - 29 KB)

Audit closure date: January 3, 2017.

Kaleida Health DSH330005
FP14208
NY

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 64 KB)

Audit closure date: October 20, 2016

Kansas University Hospital DSH170040 KS No adverse findings None

N/A

Audit closure date:  March 9, 2015

Kings County Hospital Center (NYCHHC) DSH330202 NY Diversion – 340B drugs dispensed at contract pharmacy for prescription originating from ineligible site. Repayment to manufacturers

Public letter to manufacturers (PDF - 50KB)

Audit closure date: March 29, 2016

King’s Daughters Medical Center DSH180009 KY Diversion – 340B drugs dispensed at contract pharmacy for prescription originating from ineligible site. Repayment to manufacturers

Public letter to manufacturers (PDF - 57 KB)

Audit closure date: September 21, 2016

La Clinica de la Raza, Inc. CH091230 CA Diversion – 340B drug dispensed at contract pharmacy for prescription. Repayment to manufacturers

Public letter to manufacturers (PDF - 62 KB)

Audit closure date: September 21, 2016

Lafourche Hospital Service District #1 DBA Lady of the Sea General Hospital

CAH191325-00 LA Incorrect 340B database record – Ineligible site registered on 340B database. Termination of ineligible site from 340B Program*

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: September 1, 2015

Lake Charles Memorial DSH190060 LA No adverse findings None

N/A

Audit closure date:  July 29, 2015

Legacy Community Health Services, Inc. CHC07502-00 TX No adverse findings None

N/A

Audit closure date:  September 22, 2015

Lincoln County Public Hospital District No. 3 CAH501305-00 WA No adverse findings None

N/A

Audit closure date:  October 13, 2015

Madison PHU FP712823 LA

Incorrect 340B database record – Incorrect entries for Authorizing Official, Primary Contact, grant number and address.

None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: July 21, 2015

Marana Health Center, Inc. CH090080 AZ

Incorrect 340B database record – Incorrect entries for addresses.

Diversion – 340B drug dispensed at contract pharmacy for a prescription written by an ineligible provider.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 46 KB)

Audit closure date: October 11, 2016

Marillac CHC CHC24198-00 LA

Incorrect 340B database record – Incorrect entries for Primary Contact; Registered a contract pharmacy without a contract prior to March 24, 2015.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File and Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Repayment to manufacturers Public letter to manufacturers (PDF - 65 KB)
Massena Memorial Hospital DSH330223 NY

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

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site.

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

Repayment to manufacturers

Pending

Public letter to manufacturers (PDF - 65 KB)

McAlester Regional Health Center SCH370034-00 OK Entity had inaccurate information in 340B Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: March 17, 2016

McLaren Oakland DSH230207 MI

Incorrect 340B database record – Incorrect entries for Primary contact.

Diversion – 340B drug dispensed for prescriptions originating from ineligible sites.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 73 KB)

Audit closure date: September 15, 2016

McNairy County Health Department STD383758, FP383755, TB38375 TN No adverse findings None

N/A

Audit closure date:  September 10, 2015

Medical Center Bowling Green DSH180013 KY

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; ineligible site registered on the 340B database.

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

Repayment to manufacturers Public letter to manufacturers (PDF - 46 KB)
Medical Center, Inc. DSH110064 GA Duplicate Discount – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers

State Medicaid has since determined that duplicate discounts did not occur

Public letter to manufacturers (PDF - 62 KB)

Audit closure date: August 12, 2016

Memorial Health University Medical Center DSH110036 GA

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drugs dispensed to inpatients.

Repayment to manufacturers

Public letter to manufacturers (PDF - 269 KB)

Audit closure date: August 30, 2017

Memorial Hermann Hospital DSH450068 TX No adverse findings None

N/A

Audit closure date:  April 10, 2015

Memorial Hospital of South Bend DSH150058 IN

Incorrect 340B database record – Entity failed to remove a closed contract pharmacy from the 340B database.

Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites; 340B drug dispensed to an inpatient.

Repayment to manufacturers

Public letter to manufacturers (PDF - 22 KB)

Mercy General Hospital DSH050017 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to October 2014.

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database, contract pharmacies not terminated from the 340B database whose contracts were terminated, incorrect entries for shipping address and Primary Contact.

Diversion – 340B drugs dispensed at contract pharmacy for prescription originating from ineligible site.

Duplicate Discounts – Medicaid billing numbers were incorrect on the Medicaid Exclusion File.

Repayment to manufacturers

Public letter to manufactures (PDF - 47 KB)

Audit closure date:  February 7, 2017

Mercy Hospital of Valley City CAH351324-00 ND No adverse findings None

N/A

Audit closure date:  April 22, 2015

Mercy Hospital Tishomingo, Inc. CAH371304-00 OK No adverse findings None

N/A

Audit closure date:  June 30, 2015

Mercy Medical Center CAH351334-00 ND Incorrect 340B database record None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date:  February 23, 2016

Mercy Medical Center DSH220066 MA

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

Repayment to manufacturers Pending
Mercy St. Vincent Medical Center DSH360112 OH

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

Repayment to manufacturers Public letter to manufacturers (PDF - 59 KB)
Meriter Health Services DSH520089 WI

Incorrect 340B database record – Incorrect address and name entries for offsite outpatient facilities; one offsite outpatient facility was not separately listed on the 340B database.

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

Repayment to manufacturers Public letter to manufacturers (PDF - 43 KB)
Metropolitan Hospital Center (NYCHHC) DSH330199 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to November 2014.

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site.

Repayment to manufacturers

Public letter to manufacturers (PDF - 45 KB)

Audit closure date: November 8, 2016

Miami Valley Hospital DSH360051 OH

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

Diversion – 340B drugs were not properly accumulated; 340B drugs dispensed at the entity and contract pharmacies for prescriptions written by ineligible providers at ineligible sites.

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

Repayment to manufacturers Public letter to manufacturers (PDF - 87 KB)
Ministry Saint Mary's Hospital SCH520019-00 WI

Incorrect 340B database record – Incorrect authorizing official and primary contact information for offsite outpatient facilities; entity failed to remove a contract pharmacy from the 340B database whose contract was terminated.

Termination of contract pharmacies from 340B Program*

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Termination of contract pharmacies from 340B Program*

Audit closure date: June 17, 2016

Missouri Delta Medical Center DSH260113 MO

Diversion – 340B drugs dispensed to inpatients; 340B drugs dispensed for prescriptions originating from ineligible sites.

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

Repayment to manufacturers

Public letter to manufacturers (PDF 70 KB)

Mitchell County Hospital District CAH451342-00 TX No adverse findings None

N/A

Audit closure date:  January 4, 2016

Monadnock Community Hospital CAH301309-00 NH Violation of Orphan Drug Exclusion – ineligible 340B purchase for orphan drug designation. Repayment to manufacturers

Public letter to manufacturers (PDF - 14 KB)

Audit closure date: July 15, 2016

Monmouth Medical Center DSH310075 NJ

Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 26, 2015.

340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drugs were not properly accumulated.

Repayment to manufacturers Public letter to manufacturers (PDF - 44 KB)
Montefiore DSH330059 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to June 15, 2015.

Entity had inaccurate information in the 340B Medicaid Exclusion File.

Repayment to manufacturers Public letter to manufacturers (PDF - 12 KB)
Mosaic Medical CH105600 OR

Incorrect 340B database record – Incorrect entries for Authorizing Official and shipping address; Registered contract pharmacies without written contract in place.

Entity did not provide contract pharmacy oversight prior to November 11, 2015.

Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File and Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Pending; Repayment to manufacturer

Termination of contract pharmacies from 340B Program*

Public letter to manufacturers (PDF - 126 KB)

Audit closure date: September 15, 2016

Moses H. Cone Memorial Hospital Operating Corporation DSH340091 NC

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

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

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

Repayment to manufacturer

Public letter to manufacturers (PDF - 34 KB)

Audit closure date:  April 18, 2017

Mount Sinai Medical Center DSH100034 FL

Incorrect 340B database record – Incorrect entry for address.

Diversion – 340B drug dispensed to an inpatient.

Repayment to manufacturer Public letter to manufacturers (PDF - 189 KB)
Municipal Hospital Dr. Rafael Lopez Nussa DSH400015 PR

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

Diversion – 340B drugs dispensed for prescriptions written by ineligible providers at ineligible sites.

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

Repayment to manufacturers Public letter to manufacturers (PDF - 122 KB)
North County Health Project, Inc. CH090720 CA

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; incorrect entries for address and Primary Contact; terminated site registered on the 340B database; registered contract pharmacies without a written contract in place.

Duplicate Discounts – Medicaid billing numbers and NPI numbers were incorrect on the Medicaid Exclusion File.

Repayment to manufacturers

Public letter to manufacturers (PDF - 59 KB)

Audit closure date: August 31, 2016

Northeast Montana Health Services, Inc. DBA Poplar Community Hospital

CAH271300-00 MT Incorrect 340B database record – Registered contract pharmacies without a written contract in place. Termination of contract pharmacies from 340B Program*

Termination of contract pharmacies from 340B Program*

Audit closure date: January 20, 2016

NYU Lutheran Medical Center

DSH330306 NY Diversion – 340B drugs were not properly accumulated. Repayment to manufacturers Public letter to manufacturers (PDF - 118 KB)
Olive View – UCLA Medical Center DSH050040 CA Incorrect 340B database record –  Registered contract pharmacy without a written contract in place. Termination of contract pharmacies from 340B Program*

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Termination of contract pharmacies from 340B Program*

Audit closure date: June 17, 2016

Omni Family Health CH091600 CA

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; ineligible site registered on the 340B database.

Entity did not provide contract pharmacy oversight. Duplicate Discount – Inaccurate or incomplete information in the Medicaid Exclusion File.

Pending; Repayment to manufacturers

Public letter to manufacturers (PDF - 78 KB)

Audit closure date: March 30, 2016

Oregon Health Science Center DSH380009 OR No adverse findings None

N/A

Audit closure date:  March 30, 2015

Palmetto Richland DSH420018 SC

Incorrect 340B database record – Ineligible site registered on 340B database.

Termination of offsite outpatient facility from 340B Program Audit closure date:  April 18, 2017
Palomar Medical Center DSH050115 CA

Incorrect 340B database record – Registered contract pharmacy without a written contract in place; Offsite outpatient facilities were not listed on the 340B database.

Entity did not provide contract pharmacy oversight.

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drugs were not properly accumulated.

Pending; Repayment to manufacturers

Public letter to manufactures (PDF - 104 KB)

Audit closure date: April 14, 2016

Parkview Huntington Hospital DSH150091 IN

Incorrect 340B database record – Incorrect entry for billing address.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 42 KB)

Audit closure date: January 18, 2017.

Park Ridge Health DSH340023 NC No adverse findings None

N/A

Audit closure date:  November 20, 2015

Penn State – Milton S. Hershey Medical Center DSH390256 PA Incorrect 340B database record – incorrect entries for Primary Contact and Authorizing Official name, title and phone numbers. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: January 20, 2016

Plains Regional Medical Center - Clovis DSH320022 NM

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 1, 2015.

Incorrect 340B database – Offsite outpatient facilities were not listed on the 340B database; registered contract pharmacies without written contract in place; incorrect entry for off-site outpatient facility address.

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

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 57 KB)

Audit closure date: March 30, 2017

Planned Parenthood of Illinois FP606049, STD60610 IL

Incorrect 340B database record – Registered contract pharmacy without written contract in place.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 18 KB)

Audit closure date: February 3, 2017

Planned Parenthood of the Heartland STD50314C; STD50314K; FP52246 IA No adverse findings None

N/A

Audit closure date:  October 22, 2015

Planned Parenthood of Western PA FP155015 PA No adverse findings None

N/A

Audit closure date:  July 30, 2015

Platte County Memorial Hospital CAH531305-00 WY No adverse findings None

N/A

Audit closure date:  June 8, 2015

Porter Hospital CAH471307-00 VT No adverse findings None

N/A

Audit closure date:  August 18, 2015

Presence Saints Mary and Elizabeth Medical Center DSH140180 IL

Incorrect 340B database record – Registered contract pharmacies without written contract in place prior to March 27, 2015.

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

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

Repayment to manufacturers Public letter to manufacturers (PDF - 40 KB)
Richardson Medical Center DSH190151 LA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to March 26, 2015. 

Entity did not provide contract pharmacy oversight.

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

Repayment to manufacturers

Termination of contract pharmacies from 340B Program*

Public letter to manufacturers (PDF - 57 KB)

Audit closure date: March 15, 2017

Rosedale Infectious Diseases, PLLC RWI28078 NC No adverse findings None

N/A

Audit closure date:  December 21, 2015

Rural Health Services Consortium CH0412790 TN

Incorrect 340B database record – Registered contract pharmacies without written contract in place.

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

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

Termination of contract pharmacy from 340B Program *

Repayment to manufacturers

Public letter to manufacturers (PDF - 112 KB)

Audit closure date: September 15, 2016

Rutland Regional Medical Center SCH470005-00 VT

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 29 KB)

Audit closure date: August 31, 2016

Sacred Heart Health Services DBA Avera Sacred Heart Hospital SCH430012-00 SD Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Saint Joseph Health System DSH180011 KY No adverse findings None

N/A

Audit closure date:  November 15, 2015

San Francisco General Hospital DSH050228 CA

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

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

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

Repayment to manufacturers Public letter to manufacturers (PDF - 81 KB)
SC DHEC Midlands Region Lancaster Co FP FP297213 SC Incorrect 340B database record – Incorrect entry for grant number. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: June 17, 2016

Sentara Albemarle Regional Medical Center SCH340109-00 NC No adverse findings None

N/A

Audit closure date:  July 10, 2015

 

Shalom Health Care Center CH051741 IN Entity did not provide contract pharmacy oversight. None

340B Program policies and procedures revised to address contract pharmacy oversight

Audit closure date: March 2, 2016

Shands Teaching Hospital and Clinics, Inc. DSH100113 FL

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 56 KB)

Audit closure date: September 27, 2016

Shawnee Health Service and Development Corporation CH050040 IL

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; incorrect entry for name of one offsite outpatient facility; registered contract pharmacies without written contracts in place.

None Database entry corrected; 340B Program policies and procedures revised to address routine review of 340B Program database. Audit closure date: October 26, 2015.
Sierra View District Hospital DSH050261 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 15, 2015.

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

Diversion – 340B drugs dispensed for prescriptions written at an ineligible site; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 81 KB)

Audit closure date: September 27, 2016

Sioux Center Health CAH161346 IA Incorrect 340B database record – registered contract pharmacies without written contract in place prior to June, 2014. None

Contract executed

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date:  January 6, 2016

Sonora Community Hospital dba Sonora Regional Medical Center SCH050335-00 CA Diversion – 340B drug dispensed for prescription that was, not supported by a medical record. Repayment to manufacturer

Public letter to manufacturers (PDF - 90 KB)

Audit closure date: March 30, 2017

South Bay Family Health Care Center, Inc. CH0910260 CA Incorrect 340B database record – Registered contract pharmacies without written contract in place. Termination of contract pharmacies from 340B Program.*

Database entry corrected

Termination of contract pharmacies from 340B Program*

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: November 3, 2015

Speare Memorial CAH301311-00 NH No adverse findings None

N/A

Audit closure date:  October 16, 2015

Spectrum Health Hospitals DSH230038 MI

Incorrect 340B database record – Incorrect entry for Primary contact; duplicate entry for offsite outpatient facility.

Diversion – 340B drugs dispensed for prescriptions originating from ineligible sites.

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

Repayment to manufacturers

Public letter to manufacturers (PDF 32 KB)

Audit closure date:  February 14, 2017

SSM DePaul Health Center DSH260104 MO

Incorrect 340B database – Ineligible site registered on the 340B database.

Diversion – 340B drug dispensed at the entity and contract pharmacies for prescription originating from an ineligible site; 340B drug dispensed to inpatient; 340B drugs were not properly accumulated.

Repayment to manufacturers

Public letter to manufacturers (PDF - 60 KB)

Audit closure date: September 15, 2016

SSM St. Mary’s Health Center DSH260091, HM13100 MO

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; ineligible site registered on the 340B database.

Diversion – 340B drugs dispensed at the entity and contract pharmacy for prescriptions originating from ineligible sites.

Duplicate Discounts – Entity’s contract pharmacy was billing Medicaid without notification to HRSA.

Repayment to manufacturers

Public letter to manufacturers (PDF - 57.2 KB)

Audit closure date: September 15, 2016

St. Cloud Hospital SCH240036-00 MN Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers

Public letter to manufacturers (PDF - 39 KB)

Audit closure date: June 17, 2016

St. Croix Regional Medical Center CAH521337-00 WI

Incorrect 340B database record – Registered contract pharmacies without written contract in place; incorrect entries for addresses.

 

Termination of contract pharmacy from 340B Program

Termination of contract pharmacy from 340B Program

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: July 12, 2016

St. Elizabeth Hospital CAH501335-00 WA

No adverse findings

 

None

N/A

Audit closure date:  January 28, 2016

St. Elizabeth Hospital DSH520009 WI

Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site; 340B drug dispensed to an inpatient.

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

Repayment to manufacturers Public letter to manufacturers (PDF - 26 KB)
St. Francis Medical Center CAH241377-00 MN

Incorrect 340B database record – Ineligible site registered on 340B database.

Diversion – 340B drugs dispensed for prescriptions written at ineligible site.

 

Termination of ineligible site from 340B Program

Repayment to manufacturers

Public letter to manufacturers (PDF - 51 KB)
St. Helena Hospital Clearlake CAH051317-00 CA

Incorrect 340B database record – Incorrect entries for Authorizing Official contact information and billing addresses for offsite outpatient facilities.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 150 KB)

Audit closure date: March 15, 2017

St. Joseph’s Area Health Services CAH241380-00 MN

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

None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date:  February 23, 2016

St. Joseph Health System SCH230100-00 MI

Incorrect 340B database – incorrect entry for address for offsite outpatient facility; Registered contract pharmacy without written contract in place.

Inaccurate or incomplete information in the Medicaid Exclusion File.

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers.

State Medicaid has since determined that duplicate discounts did not occur

Public letter to manufacturers (PDF - 99 KB)
St. Luke’s Roosevelt Hospital Center DSH330046 NY

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; closed offsite outpatient facility listed on the database.

None

Pending

Audit closure date: October 12, 2016

St. Mary Medical Center DSH050191 CA

Covered outpatient drugs were obtained through a Group Purchasing Organization.

Incorrect 340B database record – Incorrect entries for addresses for offsite outpatient facilities.

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

Entity had inaccurate information in on the Medicaid Exclusion File.

Termination of covered entity from 340B Program*

Repayment to manufacturers.

Public letter to manufacturers (PDF - 59 KB)

Audit closure date: December 7, 2016

 

St. Mary's Medical Center DSH050457 CA

Incorrect 340B database record – Incorrect entries for Authorizing Official telephone number and Primary Contact; Offsite outpatient facilities were not listed on the 340B database.

Diversion – 340B drugs were not properly accumulated.

Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

Public letter to manufacturers (PDF - 138 KB)

Audit closure date: September 13, 2016

Stonewall Jackson Memorial Hospital DSH510038 WV

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; incorrect entry for address of one contract pharmacy.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 54 KB)

Audit closure date: June 21, 2016

Stony Brook University DSH330393 NY Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 26, 2015. Repayment to manufacturers

Public letter to manufacturers (PDF - 45 KB)

Audit closure date: August 12, 2016

Strong Memorial Hospital DSH330285 NY

Diversion – 340B drugs were not properly accumulated; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites.

Duplicate Discount – Inaccurate or incomplete information in theMedicaid Exclusion File.

Repayment to manufacturer Public letter to manufacturers (PDF - 30 KB)
Swedish American Hospital DSH140228 IL Diversion – 340B drug dispensed for prescription originating from ineligible site. Repayment to manufacturer

Public letter to manufacturers (PDF - 17 KB)

Audit closure date: August 31, 2016

Swedish Covenant Hospital DSH140114 IL

Incorrect 340B database record – Incorrect entries for off-site outpatient facility address.

Duplicate Discounts – Incorrect or incomplete in the Medicaid Exclusion File.

Repayment to manufacturers Public letter to manufacturers (PDF 22 KB)
Swedish Medical Center DSH500027 WA

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

None Pending
Triangle AIDS Network HV00684A TX

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

Repayment to manufacturers Public letter to manufacturers (PDF - 77 KB)
Tufts Medical Center DSH220116 MA Diversion – 340B drugs dispensed for prescription originating from ineligible site. Repayment to manufacturers

Public letter to manufacturers (PDF - 51 KB)

Audit closure date: September 15, 2016

UMASS Memorial Medical Center DSH220163 MA No adverse findings None

N/A

Audit closure date:  July 1, 2015

University Medical Center of Southern Nevada DSH290007 NV

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

Duplicate Discount – Incorrect or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

Public letter to manufacturers (PDF - 69 KB)

University of Arkansas Hospital DSH040016 AR No adverse findings None

N/A

Audit closure date:  May 19, 2015

University of Colorado Hospital DSH060024 CO Diversion – 340B drug dispensed for prescription originating from ineligible site. Repayment to manufacturers

Public letter to manufacturers (PDF - 56.6 KB)

Audit closure date: August 31, 2016

University of Connecticut Health Center DSH070036 CT Incorrect 340B database record – Incorrect entry for Authorizing Official. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: December 2, 2015

University of New Mexico Hospital DSH320001 NM

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

None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: December 2, 2015

University of South Alabama Medical Center DSH010087 AL Incorrect or incomplete billing information on the 340B Medicaid Exclusion File. None Audit closure date: September 13, 2016
University of Vermont Medical Center DSH470003 VT

Incorrect 340B database record – Incorrect entry for Authorizing Official.

Diversion – 340B drug dispensed for prescription originating from ineligible site.

Duplicate Discounts – Incorrect or incomplete in the Medicaid Exclusion File.

Repayment to manufacturers

Public letter to manufacturers (PDF - 30 KB)

Audit closure date: March 15, 2017

University of Virginia Medical Center DSH490009 VA No adverse findings None

N/A

Audit closure date:  March 25, 2015

Ventura County Medical Center DSH050159 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to December 4, 2015.

Incorrect 340B database record – Ineligible site registered on 340B database; entity failed to remove a closed facility from the 340B database.

Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites; 340B drugs were not properly accumulated.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 52 KB)

Vernon Memorial Hospital CAH521348-00 WI No adverse findings None

N/A

Audit closure date:  August 19, 2015

Via Christi Hospitals Wichita, Inc. DSH170122 KS No adverse findings None

N/A

Audit closure date:  September 14, 2015

Wake Forest University Health Sciences HM27157 NC No adverse findings None

N/A

Audit closure date:  August 7, 2015

Waupun Memorial Hospital CAH521327-00 WI

Incorrect 340B database record - Registered a contract pharmacy without a contract prior to August 6, 2015; incorrect entry for offsite outpatient facility address.

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

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

Repayment to manufacturers Public letter to manufacturers (PDF 56 KB)
Wayne County Hospital, Inc. CAH181321-00 KY No adverse findings None

N/A

Audit closure date:  January 19, 2016

Walker Baptist Medical Center DSH010089 AL

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 643 KB)

Audit closure date: March 28, 2017

Wayne County Hospital, Inc. CAH181321-00 KY No adverse findings None

N/A

Audit closure date:  January 19, 2016

West County Health Center CH09035A CA No adverse findings None

N/A

Audit closure date:  September 24, 2015

West River Health Services CAH351330-00 ND No adverse findings None

N/A

Audit closure date:  October 6, 2015

Western Wyoming Family Planning FP82930 WY

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; Incorrect entries for address, billing address, and shipping address for offsite outpatient facilities.
 

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

Repayment to manufacturers Public letter to manufacturers (PDF - 51 KB)
Westlake Regional Hospital DSH180149 KY

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

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

Repayment to manufacturers Public letter to manufacturers (PDF - 54 KB)
West Virginia University Hospitals, Inc. DSH510001 WV Incorrect 340B database record – Incorrect entries for Primary Contact phone numbers. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: September 1, 2015

Whatcom County STD982278; TB982275 WA

Incorrect 340B database record – Incorrect entries for billing and physical addresses; Registered a contract pharmacy without a contract in place.
 

Entity had inaccurate information in the 340B Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding.

None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: February 16, 2016.

Wheaton Franciscan Healthcare – St. Francis DSH520078 WI

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 51 KB)

Audit closure date:  February 7, 2017

Wheaton Franciscan, Inc. DSH520136 WI

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database. Contract pharmacy was not listed on 340B database prior to January 1, 2016.

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 49 KB)

Audit closure date: March 30, 2017

White County Health Department STD30528, TB30528 GA Inaccurate information in the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None

Database entry corrected

340B Program policies and procedures revised to address routine review of 340B Program database

Audit closure date: February 9, 2016

Windom Area Hospital CAH241332-00 MN No adverse findings None

N/A

Audit closure date:  September 9, 2015

Woodhull Medical & Mental Health Center (NYCHHC) DSH330396 NY

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; ineligible site registered on the 340B database.
 

Diversion – 340B drugs dispensed at contract pharmacy for prescription not supported by medical record.

Repayment to manufacturers

Public letter to manufacturers (PDF - 45 KB)

Audit closure date: April 14, 2016

Yakima Neighborhood Health Services, Inc. CH101340 WA

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

Repayment to manufacturers

Public letter to manufacturers (PDF - 97 KB)

Audit closure date:  February 23, 2017

Yakima Valley Farm Workers Clinic CH101030 WA No adverse findings None

N/A

Audit closure date:  June 8, 2015

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