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Program Integrity: FY16 Audit Results

Updated 6/1/17. 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 (198) audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
AHRC Health Care, Inc. CHC10579-00 NY

No adverse findings

None

N/A

Audit closure date: September 7, 2016

 
Alameda Health System DSH050320 CA

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

Diversion – 340B drugs were not properly accumulated.

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

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

Repayment to Manufacturers

CAP approved

Rick Kibler

VP Compliance and Internal Audit
(510) 895-7271
rkibler@alamedahealthsystem.org

Alegent Health-Immanuel Medical Center d/b/a/ CHI Health Immanuel DSH280081 NE

No adverse findings

None

N/A

Audit closure date: September 7, 2016

 
Alexandria Neighborhood Health Service Inc. CH031060A VA

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

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

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

Repayment to manufacturers Pending  
Appling General Hospital SCH110071-00 GA

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

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File

Repayment to manufacturer Pending  
Armstrong County Memorial Hospital RRC390163-00 PA

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

Repayment to Manufacturers

CAP approved

Manager of Budget and Reimbursement;
(724) 543-8518  mcculloughi@acmh.org
Or
Budget and
Reimbursement Analyst
(724)543-8181  kingcm@acmh.org
Baptist Memorial Hospital- Union County DSH250006 MS No adverse findings None

N/A

Audit closure date: December 7, 2016

 

 
Baylor Scott and White Hospital - Llano SCH450219-00 TX

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

Entity did not provide contract pharmacy oversight prior to January 2016.

Termination of offsite outpatient facility from 340B Program

CAP implemented

Audit closure date: October 10, 2016

 

 

Benefis Hospitals, Inc. SCH270012-00 MT

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

None

CAP implemented

Audit closure date: January 3, 2017.

 
Blue Ridge HealthCare Hospitals, Inc. DSH340075 NC

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

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

Repayment to Manufacturers

CAP approved

System Director of Pharmacy Practice

2201 South Sterling Street
Morganton, NC, 28655
(828) 580-5111

Boone County Hospital CAH161372-00 IA Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Director of Pharmacy
(515) 433-8271
sdonald@bchmail.org
Boone Memorial Hospital CAH511313-00 WV Diversion – 340B drug dispensed at the entity for prescription written by an ineligible provider; 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Chief Financial Officer (304)-369-1230 or rfoxx@bmh.org.
Bronson Battle Creek Hospital DSH230075 MI

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

Repayment to manufacturers Pending

340B Pharmacy Specialist

Bronson Healthcare Group
601 John Street
Kalamazoo, MI, 49001
(269) 552-3076
potyrall@bronsonhg.org

Brooklyn Hospital Center DSH330056 NY

Covered outpatient drugs obtained through a Group Purchasing Organization from April 27, 2015 to January 4, 2016.

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

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

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

CAP implemented

Audit closure date: May 19, 2017

Senior Vice President & Chief Financial Officer

The Brooklyn Hospital Center

15 Metrotech Center, 3rd Floor
Brooklyn, NY 11201
(718)-488-3715
psemenza@tbh.org

 

Brookville Hospital CAH391312-00 PA

No adverse findings

None

N/A

Audit closure date: January 27, 2016

 

Brownsville Community Development Corporation CH021960 NY

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

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

Repayment to Manufacturers

CAP approved

Controller

Brownsville Multi-Service Family Health Center

408 Rockaway Avenue
Brooklyn, New York  11212
(718) 345-6366 x6605
mwolf@bmsfhc.org

 

C.W. Williams Community Health Center, The Inc. CH047770 NC

Incorrect 340B database record - closed offsite outpatient facility listed on the 340B database.

Entity did not provide contract pharmacy oversight.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of contract pharmacies from 340B Program.

Repayment to manufacturers.

Pending  
Carilion Medical Center DSH490024 VA

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 18, 2017

Chief Compliance and Audit Officer

213 S. Jefferson Street Suite 1201
Roanoke, VA 24012
(540) 510-4573
compliance@carilionclinic.org

 

 

Cedars-Sinai Medical Center DSH050625 CA No adverse findings None

N/A

Audit closure date: February 14, 2017

 
Central Michigan Community Hospital dba McLaren Central Michigan RRC230080-00 MI

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

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

Repayment to manufacturers Pending  
Central North Alabama Health Services, Inc. CH048190 AL

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

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

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

Pending  
Children’s Hospital PED193300-00 LA

No adverse findings

None

N/A

Audit closure date: January 27, 2016

 

Children’s Hospital Association, The PED063301-00 CO No adverse findings None

N/A

Audit closure date:
November 22, 2016

 

Children's Hospital of Los Angeles PED053302-00 CA

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

Repayment to Manufacturers

CAP implemented

Audit closure date: May 19, 2017

Pharmacy Director

4650 Sunset Blvd
Los Angeles,
California  90027
Mailstop #44
(323) 361-5988

Children's Hospital of Philadelphia, The PED393303-00 PA

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

Diversion – 340B drug dispensed to an inpatient.

Repayment to Manufacturers

CAP approved

Director of Pharmacy

The Children's Hospital of Philadelphia
3401 Civic Center Boulevard
Philadelphia, Pennsylvania, 19104
(215) 590-1893

Chippewa County Montevideo Hospital CAH241325-00 MN

No adverse findings

None

N/A.

Audit closure date: September 8, 2016

 
Chota Community Health Services CH0442510 TN Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File Repayment to manufacturers Pending  
Christus Spohn Hospital Beeville DSH450082 TX

Incorrect 340B database record – Incorrect entry for off-site outpatient facility address; registered contract pharmacies without written contract in place prior to February 9, 2016.

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

Repayment to manufacturers CAP approved

Pharmacy Compliance Officer

CHRISTUS Spohn Hospital Region
600 Elizabeth St.
Corpus Christi, TX, 78404
(361) 881-3127
Elias.cavazos@christushealth.org

Christus Spohn Hospital Corpus Christi Memorial DSH450046 TX

Incorrect 340B database record – Registered Contract Pharmacies without written contract in place prior to February 9, 2016.

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

Repayment to manufacturers CAP approved

Pharmacy Compliance Officer

CHRISTUS Spohn Hospital Region
600 Elizabeth St.
Corpus Christi, TX, 78404
(361) 881-3127
Elias.cavazos@christushealth.org

Citrus Health Network Inc. CH0438180 FL

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

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

Repayment to manufacturers Pending  
Claxton Hepburn Medical Center SCH330211-00 NY

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 manufacturers Pending  
Clinch River Health Services, Incorporated CH031230 VA Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File Repayment to manufacturers CAP approved Executive Director
(276) 467-7000
17633 Veterans Memorial Hwy.
Dungannon, VA 24245
Clinica Sierra Vista CH090390
HV090390
CA No adverse findings None

N/A

Audit closure date: January 13, 2016

 

Clinicas del Camino Real, Inc. CH09365A CA

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

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

None

CAP implemented

Audit closure date: April 4, 2017

 
Columbia St. Mary’s Hospital Milwaukee, Inc. DSH520051 WI

Incorrect 340B database - registered contract pharmacies without written contract in place.

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

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP approved

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

System Director of Pharmacy
414-585-1071, 2323
N. Lake Drive,
Milwaukee, WI 53211
Community Health Center of Snohomish County CH10228A WA

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

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

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

Repayment to manufactures Pending  
Community Hospital of LaGrange County CAH151323-00 IN No adverse findings None

N/A

Audit closure date: November 15, 2016

 

 
Comanche County Medical Center CAH451382-00 TX

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

Diversion – 340B drugs dispensed to inpatients.

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 30, 2017

Director of Pharmacy

SAbbey@comanchecmc.com
(254) 879-4961

Community Memorial Healthcare, Inc. CAH171363-00 KS No adverse findings None

N/A

Audit closure date: June 1, 2016

 
Comprehensive Care Center, Inc.: DBA Community Aids Network RWII342371 FL No adverse findings None

N/A

Audit closure date: November 4, 2016

 

 
Conway Medical Center DSH420049 SC

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

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

Repayment to manufacturers Pending  
Copley Memorial Hospital DSH140029 IL

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: April 24, 2017

Director of Pharmacy

2000 Ogden Avenue
Aurora, IL 60504

Cornell Scott-Hill Health Corporation CH010070 CT

No adverse findings

None

N/A
Audit closure date: March 9, 2016

 

Covenant Medical Center DSH230070 MI Diversion – 340B drug dispensed at a contract pharmacy for a prescription written at an ineligible site. Repayment to manufacturer CAP approved Director of Pharmacy
(989) 583-4075
1447 N Harrison
Saginaw, Michigan 48602
Crete Area Medical Center CAH281354-00 NE Diversion - 340B drugs dispensed , not supported by a medical record. Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2017

President and CEO

Crete Area Medical Center
402.826.2102 or 
rebekah.mussman@bryanhealth.org

 

Cumberland Family Medical Center, Inc. CH0452070 KY No adverse findings None

N/A

Audit closure date: November 8, 2016

 

 
C.W. Williams Community Health Center, Inc. CH047770 NC

Incorrect 340B database record - closed offsite outpatient facility listed on the 340B database

Entity did not provide contract pharmacy oversight.

Duplicate Discounts – Incorrect or incomplete billing information on the 340B Medicaid Exclusion File.

Termination of contract pharmacies from 340B Program.

Repayment to manufacturers

Pending  
Decatur Memorial Hospital RRC140135-00 IL

Entity did not provide contract pharmacy oversight.

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

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

Termination of contract pharmacies from 340B Program

Repayment to manufacturers

CAP implemented

Audit closure date:  February 8, 2017

Tom West, Director Decision Supports

2300 N. Edwards
Decatur, IL, 62526
(217) 876-2033
tomw@dmhhs.org

Down East Community Hospital CAH201311-00 ME

Incorrect 340B database record – Incorrect entry for offsite facility address.

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

 

Repayment to manufacturer CAP approved Chief Operating Office at 207-255-0217 or slail@hech.org or
Director of pharmacy services at 207-255-0422 or vamon@dech.org
Earl and Lorraine Miller Children’s Hospital of Long Beach PED053309-00 CA

Duplicate Discounts – Entity was billing at contract pharmacies without notifying HRSA of an arrangement with contract pharmacy, the entity and the State Medicaid agency.

Repayment to manufacturers

CAP approved

Executive Director, Pharmacy Services

2801 Atlantic Avenue
Long Beach, CA, 90806
(562) 933-0282
jhodding@memorialcare.org    

Eastern Maine Medical Center DSH200033 ME 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 Pending  
East Texas Medical Center Quitman CAH451380-00 TX

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

Repayment to manufacturer

CAP implemented

Audit closure date: March 15, 2017

Administrator
(903) 763-6330
psswindle@etmc.org
ETMC Quitman,
117 N. Winnsboro Street,
Quitman, Texas 75783
Elica Health Centers CHC24113-00 CA

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

Entity did not provide contract pharmacy oversight.

Termination of contract pharmacies from 340B Program*

CAP implemented

Audit closure date: March 2, 2016

 

Elmhurst Hospital Center (NYCHHC) DSH330128 NY

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site, not supported by medical record; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

CAP implemented

Audit closure date: February 8, 2017

Vice President, New York City Health and Hospitals
(212) 748-2256
Paul.albertson@nychhc.org

Emory University Hospital Midtown DSH110078 GA

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 12, 2017

Chief Operating Officer

Emory University Hospital Midtown
550 Peachtree Street NE
Atlanta, GA, 30308
(404) 686-8903

Escambia County Health Department FP36502 AL

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

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

Repayment to manufacturers

CAP approved

Assistant Area Administrator

Hwy 31 North Suite 17
Atmore, AL, 36502
(251) 368-9188/8600

Fenway Community Health Center, Inc. CH010600 MA No adverse findings None

N/A

Audit closure date: December 15, 2015

 

First Choice Community Healthcare CH060240 NM

Incorrect 340B database record – Utilized contract pharmacies prior to registering on the 340B database.

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

Repayment to Manufacturers

CAP implemented

Audit closure date: May 12, 2017

Chief Operating Officer

2001 N. Centro Familiar SW, Albuquerque, NM  87105-4592
Melissa_manlove@fcch.com
(505) 873-7474

 

FirstHealth Moore Regional Hospital RRC340115-00 NC

Diversion – 340B drugs were not properly accumulated.

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

Repayment to Manufacturers CAP Approved

Chief Operating Officer

Administrative Director of Pharmacy
(910) 715-1093
mcowell@firsthealth.org

FoundCare, Inc. CHC26626-00 FL No adverse findings None

N/A

Audit closure date: April 27, 2016

 

Harborview Medical Center

DSH500064

WA

No adverse findings

None

N/A

Audit closure date: April 14, 2016

 

Gaston Memorial Hospital DSH340032 NC

Incorrect 340B database record Pharmacy incorrectly registered as child site.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2017

Director of Pharmacy

mark.chaparro@caromonthealth.org
(704) 8342239

Geisinger Medical Center DSH390006 PA Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites; 340B drug dispensed, not supported by medical record. Repayment to manufacturers

CAP implemented

Audit closure date: February 10, 2017

 

Program Director 340B Program

Geisinger Medical Center
100 N. Academy Avenue
Danville, PA 17821-4201
(570) 214-0155

 

George County Hospital SCH250036-00 MS

No adverse findings

None

N/A

Audit closure date: September 7, 2016

 
Golden Valley Memorial Hospital District RRC260175-00 MO No adverse findings None

N/A

Audit closure date: September 26, 2016

 
Grossmont Hospital DSH050026

CA

 

Incorrect 340B database record – Incorrect entry for address of offsite outpatient facility.

Diversion  – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: May 19, 2017

Manager of Pharmacoeconomics

8695 Spectrum Center Blvd
San Diego, CA 92130
858-499-4220

 

Harlem Hospital (NYCHHC)

DSH330240

NY

No adverse findings

None

N/A

Audit closure date: July 14, 2016

 
Harris County Hospital District dba Harris Health System Ben Taub Hospital DSH450289 TX

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

None

CAP implemented

Audit closure date: November 22, 2016

 
Hawkins County Memorial Hospital DSH440032 TN No adverse findings None

N/A

Audit closure date: November 2, 2016

 
Healthreach Community Health Centers CH010460 ME Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File. Repayment to manufacturers CAP approved

Chief Executive Officer

Healthreach Community Health Centers
237 Main Street
Bingham, Maine 04920
(207) 872-5610
constance.coggins@healthreach.org

Ho Ola Lahui Hawaii

CH091290

HI

No adverse findings

None

N/A

Audit closure date: June 7, 2016

 
Hospital of the University of Pennsylvania, The DSH390111 PA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 21, 2016.

Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database; duplicate entry for offsite outpatient facility; Ineligible site registered on 340B database.

Diversion – 340B drugs dispensed for prescriptions originating at ineligible sites; 340B drugs dispensed, not supported by medical records; 340B drugs were not properly accumulated.

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

Repayment to manufacturers Pending  
HSHS Holy Family Hospital, Inc. (formerly Greenville Regional Hospital, Inc.) DSH140137 IL Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating at ineligible sites. Repayment to manufacturers Pending  

Ingalls Memorial Hospital

DSH140191

IL

No adverse findings

None

N/A

Audit closure date: July 6, 2016

 

 

Institute for Family Health, The

CH02371C

NY

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

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

Repayment to manufacturers

CAP approved

 

Sr. Vice President of Regulatory
Affairs and Human Resources

The Institute for Family Health

2006 Madison Ave
New York, NY 10035
Office: (212) 633-0815 x1241
Cell: (914) 497-8135
E-Fax: (212) 359-3270
Nnurse@institute.org

 

Jackson County Health Department

TB324469
STD32446
FP32446

FL

(FP324461) Duplicate Discounts – Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File.

(TB324469, STD32446) Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayment to manufacturers

CAP approved

Director of Administration

4025 Bald Cypress Way, Bin A-20, 
Tallahassee, Florida 32399-1708
(850) 245-4444, ext. 2311

 

Johns Hopkins Hospital

DSH210009

MD

Diversion – 340B drug dispensed at contract pharmacies for prescriptions originating from ineligible site.

Repayment to manufacturers

CAP implemented

Audit closure date: February 22, 2017

Assistant Director, Pharmacy

5901 Holabird Avenue, Suite A-2
Baltimore, Maryland 21224
(585) 770-0391

Kadlec Regional Medical Center DSH500058 WA No adverse findings None

N/A

Audit closure date: November 23, 2016

 
Kaweah Delta Health Care District DSH050057 CA

No adverse findings

None

N/A

Audit closure date: September 15, 2016

 
Kennewick General Hospital DSH500053 WA

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.

Repayment to manufacturers CAP approved

Pharmacy Director
(509) 221-7351
900 S. Auburn Street
Kennewick, WA 99336

Kern Medical Center DSH050315 CA

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

Pending  
Klamath Health Partners Inc. CH102910 OR Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites. Repayment to manufacturers CAP approved Klamath Health Partnership, Inc.
2074 S. 6th Street
Klamath Falls, OR  97601
Contact:  CFO
541-851-8110 x2022
sporter@kodfp.org
Labette County Medical Center D/B/A Labette Health

SCH170120-00

KS Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites. Repayment to manufacturers CAP approved 340B Specialist
Labette County Medical Center
1902 S HWY 59
Parsons, KS 67357
(620) 421-4881
tgilmore@LabetteHealth.com
Legacy Salmon Creek Medical Center DSH500150

WA

No adverse findings None

N/A

Audit closure date: December 13, 2016

 
Lester E Cox Medical Centers DSH260040

MO

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

LifeLong Medical Care

CH092880

CA

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

Ineligible site registered on 340B database; Incorrect entry for address of a contract pharmacy.

Diversion – 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

Pending

 
Lincoln County Medical Center CAH321306-00 NM Incorrect 340B database record - Offsite outpatient facilities were not listed on the 340B database. None

CAP implemented

Audit closure date: March 15, 2017

 
Long Beach Memorial Medical Center DSH050485 CA

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

Diversion – 340B drugs purchased on entities account were dispensed to patients of a separate covered entity.

Duplicate Discounts – Entity was billing at contract pharmacies without notifying HRSA of an arrangement with contract pharmacy, the entity and the State Medicaid agency; Inaccurate or incomplete information in the Medicaid Exclusion File.

Repayments to manufacturers Pending  
Lucile Packard Children’s Hospital PED053305-00 CA Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayments to manufacturers

CAP implemented

Audit closure date: May 16, 2017

Pharmacy Compliance Analyst
(650) 736-4075
4600 Bohannon Drive
Suite 105
Menlo Park, CA 94025

Madison Health DSH360189 OH

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

Repayment to Manufacturers

CAP implemented

Audit closure date:  April 18, 2017

Director of Pharmacy

Madison Health
210 N. Main Street,
London, Ohio  43140
(740) 845-7352

Maimonides Medical Center DSH330194 NY

Diversion – 340B drugs were not properly accumulated; 340B drugs dispensed at 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 Pending  

Maricopa Integrated Health System

FQHCLA225A

AZ

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

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

Repayment to manufacturers

Pending

 
Marshall Medical Center CAH441309-00 TN No adverse findings None

N/A

Audit closure date: January 25, 2017

 
Marshall Medical Center South DSH010005
(formerly RRC010005-00)
AL

Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites; 340B drug dispensed, not supported by medical record.

Repayment to manufacturers CAP approved 340B Coordinator
256-894-6733
Marshall Medical Centers, Finance Department,
227 Brittany Rd,
Guntersville, AL 35976

Mary Hitchcock Memorial Hospital

RRC30003-00

NH

Diversion – 340B drug dispensed at contract pharmacy for prescription originating from ineligible site, not supported by medical record.

Repayment to manufacturers

CAP implemented

Audit closure date: May 5, 2017

Director of System Pharmacy Operations

One Medical Center Drive
Lebanon, NH 03756
603-653-2381

Mayers Hospital CAH051305-00 CA

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

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

Termination of contract pharmacies from the 340B Program*

Repayment to manufacturers

Pending Chief Clinical Officer
(530) 336-5511 x1153
kearnest@mayersmemorial.com

Meade District Hospital

CAH171321-00

KS

No adverse findings

None

N/A

Audit closure date: May 17, 2016

 
Memorial Hermann Northeast Hospital DSH450684 TX No adverse findings None

N/A

Audit closure date: July 18, 2016

 

Memorial Hospital at Gulfport

DSH250019

MS

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

Repayment to manufacturers

CAP implemented

Audit closure date: September 27, 2016

Manager, Outpatient Pharmacy Services

4500 13th Street
PO Box 1810
Gulfport, MS, 39502-1810
(228) 867-4485

Mercy Catholic Medical Center DSH390156 PA

Entity did not provide contract pharmacy oversight.

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

Termination of contract pharmacies from 340B Program.

Repayment to manufacturers.

Pending 340B Program Manager
(610) 237-4062
Mercy Fitzgerald Hospital
Pharmacy Department
1500 Lansdowne Avenue
Darby, Pennsylvania 19023

Mercy Medical Center Merced

DSH050444

CA

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

None

CAP implemented

Audit closure date: March 8, 2017

 
Methodist Dallas Medical Center DSH450051 TX

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2017

Jon Albrecht

jonalbrecht@mhd.com  
(214) 947-2416

MetroHealth Medical Center DSH360059 OH

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

Repayment to manufacturer

CAP implemented

Audit closure date: February 14, 2017

Mario Pisano, Pharm.D.,

2500 MetroHealth Dr.
Cleveland, OH, 44109
(216) 778-3362

Mission Hospitals Inc DSH340002 NC Diversion – 340B drugs dispensed at the entity and contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved 340B Program Pharmacy Specialist
alan.knudsen@msj.org
Mission Health System
509 Biltmore Avenue
Asheville, North Carolina 28801
Nassau Health Care Corporation DSH330027 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to January 4, 2016.

Incorrect 340B database – Offsite outpatient facility was not listed on 340B database.

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

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

Repayment to manufacturer

CAP approved

Director of Pharmacy

2201 Hempstead Turnpike
East Meadow, New York  11554
mknee@numc.edu
(516) 572-4796
 

 

Natchitoches Regional Medical Center SCH190007-00 LA No adverse findings None

N/A

Audit closure date: July 18, 2016

 
National Jewish Medical and Research Center DSH060107
BL80206X
CO

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

Termination of contract pharmacy from the 340B Program*

CAP implemented

Audit closure date: April 6, 2016

 
Nebraska Medical Center, The DSH280013 NE

Covered outpatient drugs obtained through a Group Purchasing Organization prior to November 21, 2015.

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

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

Repayment to manufacturers

CAP approved

Business Director, Pharmacy 

988138 Nebraska Medical Center 
Omaha, NE, 68198-8138
(402) 559-9537

New York Methodist Hospital DSH330236 NY

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 22, 2017

Chief of Pharmacy
Erb9001@nyp.org
(718) 780-5575

Newark Community Health Centers, Inc. CH020500 NJ No adverse findings None

N/A

Audit closure date: June 7, 2016

 
Northeast Community Action Corp FP63334 MO

No adverse findings

None

N/A

Audit closure date: September 7, 2016

 
North Carolina Baptist Hospital DSH340047 NC

Diversion – 340B drug dispensed for prescription originating from ineligible site, not supported by a medical record.

Repayment to manufacturers

CAP approved

Pharmacy Manager – Medication Control and Compliance

Wake Forest Baptist Hospital
Medical Center Blvd
Winston Salem, NC, 27157
(336) 716-6456

North Shore Medical Center DSH220035 MA

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

Repayment to manufacturers

CAP implemented

Audit closure date: March 8, 2017

 
Northern Inyo Hospital CAH051324-00 CA

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

Repayment to Manufacturers

CAP approved

340B Informatics Pharmacist

150 Pioneer Lane
Bishop, California  93514
(760) 873-2111

Northbay Healthcare Group DSH050367 CA No adverse findings None N/A  
Northside Hospital, Inc. DSH110161 GA

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

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

Repayment to manufacturer

CAP implemented

Audit closure date: February 22, 2017

340B Coordinator, Pharmacist, Pharmacy Systems Manager

1000 Johnson Ferry Road
Atlanta, GA 30342
(404) 851-8528  

Northridge Hospital Medical Center DSH050116 CA

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 11, 2016.

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

 

Repayment to manufacturers CAP approved Director of Pharmacy
(818) 885-8500 ext 2606
Obleness Memorial Hospital DSH360014 OH No adverse findings None

N/A

Audit closure date: March 7, 2017

 
Ochsner Clinic Foundation DSH190036 LA No adverse findings None

N/A

Audit closure date:
February 24, 2016

 
Olean General Hospital RRC330103-00 NY Diversion – 340B drugs dispensed at contract pharmacies for prescriptions written at ineligible sites. Repayment to manufacturers CAP approved Senior Vice President Finance and Chief Financial Officer
(716) 375-6190
rbraun@uahs.org
OneWorld Community Health Centers, Inc. CH076290 NE No adverse findings None

N/A

Audit closure date: May 13, 2016

 
OSF Holy Family Medical Center CAH141318-00 IL Diversion – 340B drugs were not properly accumulated. Repayment to manufacturers CAP approved 340B Drug Program Manager
Josh.r.mccarroll@osfhealthcare.org
(309) 308-3295
Ozarks Medical Center DSH260078 MO Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers CAP approved Director of Pharmacy
(417)257-5837
sherrie.lane@ozarksmedicalcenter.com
PeaceHealth St. John Medical Center DSH500041 WA No adverse findings None

N/A

Audit closure date: October 20, 2016

 
Penobscot Bay Medical Center DSH200063 ME

Diversion – 340B drug dispensed to inpatient; 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites, not supported by a medical record; Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

CAP approved

Director of Operational Excellence
207-921-8210
mradloff@penbayhealthcare.org

Planned Parenthood Mohawk Hudson FP135021 NY No adverse findings None

N/A

Audit closure date:  December 7, 2015

 
Positive Impact Health Centers, Inc. HV00799 GA No adverse findings None

N/A

Audit closure date:  December 15, 2015

 
Presbyterian Medical Services, Inc. CH063450 NM

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

Repayment to manufacturers    
Princeton Community Hospital DSH510046 WV Diversion – 340B drugs dispensed at contract pharmacy for prescriptions originating at ineligible sites. Repayment to manufacturers

CAP implemented

Audit closure date:  January 3, 2017

Director of Pharmacy:

sdrady@pchonline.org
304-487-7564

Providence Health and Services - Washington DSH500014 WA

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

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

Repayment to Manufacturers

CAP approved

Regional 340B Program Manager

101 W. 8th Ave
Attn: Pharmacy
Spokane, WA 99204
(509) 474-3244

Riverside County Regional Medical Center DSH050292 CA

Incorrect 340B database record – Incorrect entry for off-site outpatient facility’s name.

Diversions – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP approved

Director of Pharmacy Services

Riverside University Health System
(951) 486-4529
G.Prouty@RUHealth.org

River Valley Primary Care Services CH061202A AR

Incorrect 340B database record – Registered Contract Pharmacies without written contract in place prior to December 11, 2015.

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

Repayment to manufacturer

CAP implemented

Audit closure date: March 1, 2017

340B Coordinator/Admin Manager

9755 West State Highway 22
P.O. Box 130
Ratcliff, Arizona 72951
(479) 635-5300 x225

Riverside Medical Center CAH191313-00 LA No adverse findings None

N/A

Audit closure date:January 21, 2016

 
Robeson Health Care Corp CH049000 NC

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

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

Repayment to manufacturers Pending  
Rush Foundation Hospital DSH250069 MS No adverse findings None

N/A

Audit closure date: November 1, 2016

 
Sacred Heart Health System DSH100025 FL No adverse findings None

N/A

Audit closure date: August 24, 2016

 
Saint Mary's Health Care DSH230059 MI

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

Diversion – Entity did not have adequate controls in place for proper accumulation and prevention of diversion.

Repayment to manufacturers

CAP approved

Director of Pharmacy Services

Mercy Health Saint Mary's
200 Jefferson Avenue SE
Grand Rapids, Ml 49503
(616) 685-5000

Saint Francis Hospital and Medical Center DSH070002 CT

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

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

Repayment to manufacturers CAP approved

Pharmacy Director
860-714-7983

Interim VP Integrity & Compliance
860-714-0437
Jamie.McKay@trinityhealth-ne.org

Saint Francis Medical Center DSH140067 IL

Diversion – 340B drugs dispensed to inpatients, 340B drugs dispensed at 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

CAP implemented

Audit closure date: March 30, 2017

Josh McCarroll

800 N. E. Glen Oak Avenue
Peoria, IL, 61603
(309) 308-3295
josh.r.mccarroll@osfhealthcare.org

Saint Peter’s University Hospital DSH310070 NJ

Covered outpatient drugs obtained through a Group Purchasing Organization prior to February 23, 2016.

Diversion – 340B drugs were not properly accumulated.

Diversion – 340B drug dispensed to an inpatient; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.

Repayment to manufacturers

CAP approved

Chief Financial Officer

254 Easton Avenue
New Brunswick, NJ 08901
(732) 745-6651
gstoldt@saintpetersuh.com

Samaritan Pacific Health Systems, Inc. DBA Samaritan Pacific Community Hospital CAH381314-00 OR No adverse findings None

N/A

Audit closure date: November 4, 2016

 
Sanford Bemidji Medical Center DSH240100 MN Diversion - 340B drug dispensed to an inpatient; 340B drug dispensed at contract pharmacy, not supported by medical record Repayment to manufacturers

CAP implemented

Audit closure date: April 18, 2017

Director of Pharmacy
(218) 333-5543
karla.eischens@sanfordhealth.org
1300 Anne Street NW
Bemidji, Minnesota 56601
Sanford Medical Center Fargo RRC350011-00 ND

No adverse findings

None

N/A

Audit closure date: September 7, 2016

 
Sanford USD Medical Center DSH430027 SD

Incorrect 340B database record – Incorrect entry for grant number prior to December 21, 2015.

None

CAP implemented

Audit closure date: April 6, 2016

 
Scripps Mercy Hospital DSH050077 CA

Incorrect 340B database record ineligible sites registered on the 340B database prior to April 1, 2016.

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

Diversion – 340B drugs were not properly accumulated.

Repayment to manufacturers

CAP implemented

Audit closure date: March 8, 2017

340B Program Director
(619) 260-7308
Todd.shohreh@scrippshealth.org

Seton Edgar. B. Davis Hospital CAH451371-00 TX

Incorrect 340B database record – closed offsite outpatient facility listed on the 340B database; incomplete address listing for an offsite outpatient facility.

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 Pending  
Sharp County Health Unit FP725131
STD722054
TB722057
AR No adverse findings None

N/A

Audit closure date: January 6, 2016

 
Sharp Memorial Hospital DSH050100 CA

Incorrect 340B database record Duplicate entry for offsite outpatient facility.

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 8, 2017

Manager of Pharmacoeconomics

8695 Spectrum Center Blvd
San Diego, CA, 92130
(858) 499-4220

Sinai Hospital of Baltimore DSH210012 MD

340B drug dispensed to an inpatient; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at 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

CAP implemented

Audit closure date: May 8, 2017

Executive Director of Outpatient Pharmacy

5401 Old Court Rd.
Randallstown, MD 21133
(410) 521-1772

Singing River Health System DSH250040 MS

Diversion 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating at ineligible sites; 340B drugs dispensed, not supported by medical records.

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

Repayment to manufacturers CAP implemented

Administrator of Ancillary Services
heath.thompson@mysrhs.com
(228) 818-1191

SMDC Medical Center DSH240019 MN No adverse findings None

N/A

Audit closure date: April 24, 2017

 
South Georgia Medical Center DSH110122 GA Diversion – 340B drugs were not properly accumulated. Repayment to manufacturers CAP approved

Director of Pharmacy

South GA Medical Center
2501 N. Patterson Street
Valdosta, GA 31602
(229) 259-4870

Southwest Georgia Health Care, Inc. CH043340 GA No adverse findings None

N/A

Audit closure date: October 4, 2016

 
Spartanburg Medical Center DSH420007 SC Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers Pending  
SSM St. Anthony Hospital DSH370037 OK

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

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

Repayment to Manufacturers

Pending

 
Sterling Area Health Center CH052250 MI Duplicate Discounts - Entity was billing Medicaid contrary to information included in the Medicaid Exclusion File Repayment to manufacturers CAP approved

Patient Assistant Coordinator

725 East State Street
Sterling, MI 48659
(989) 654-2491 ext 3766

Stillwater Medical Center Authority

SCH370049-00

OK

No adverse findings

None

N/A

Audit closure date:  April 20, 2016

 
Stormont-Vail Healthcare Inc. DSH170086 KS No adverse findings None

N/A

Audit closure date:
January 24, 2017

 
St. Bernardine Medical Center DSH050129 CA Diversion – 340B drugs dispensed at contract pharmacies for prescriptions originating from ineligible sites. Repayment to manufacturers CAP approved

Director of Pharmacy

(909) 881-4473

kenneth.le@dignityhealth.org

St. Claire Medical Center, Inc. DSH180018 KY Incorrect or incomplete information in the Medicaid Exclusion File.  It was determined that duplicate discounts did not occur as a result of the finding. None CAP approved  
St. Francis Memorial Hospital CAH281322-00 NE Entity did not provide contract pharmacy oversight prior to November 2016. None Pending  
St. Johns Riverside Hospital DSH330208 NY

Covered outpatient drugs obtained through a Group Purchasing Organization prior to November 16, 2015.

Diversion – 340B drugs were not properly accumulated.

Diversion – 340B drugs dispensed to inpatients.

Repayment to manufacturers

CAP implemented

Audit closure date: February 22, 2017

Janine O’Donnell

67 N. Broadway
Yonkers, NY, 10701 
(914) 964-4827

St. Joseph’s Health Services, Inc. dba St. Joseph’s Health Services-Gundersen Lutheran CAH521304-00 WI No adverse findings None

N/A

Audit closure date: January 6, 2016

 
St. Joseph’s Medical Center DSH050084 CA

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

Termination of contract pharmacies from the 340B Program*

CAP implemented

Audit closure date: February 8, 2017

 
St. Vincent Charity Medical Center DSH360037 OH

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

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

Termination of contract pharmacies from the 340B Program*

Repayment to manufacturers

CAP approved

Chief Financial Officer

2351 East 22nd Street
Cleveland, Ohio, 44115

Summersville Memorial Hospital DSH510082 WV

Covered outpatient drugs obtained through a Group Purchasing Organization prior to April 4, 2016.

Offsite outpatient facility failed to maintain auditable records.

Incorrect 340B database records –  Offsite outpatient facilities were not listed on the 340B database; incorrect listing for Authorizing Official

Diversion- 340B drugs dispensed to inpatients; 340B drugs dispensed at the entity and contract pharmacies for prescriptions originating from ineligible sites.

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

Termination of offsite outpatient facility from the 340B Program*

Repayment to manufacturers

CAP approved  

Summit Healthcare Association DBA Summit Healthcare Regional Medical Center

DSH030062

AZ

No adverse findings

None

N/A

Audit closure date: April 1, 2016

 
Sun Life Family Health Center, Inc. CH090030 AZ

Incorrect 340B database record – Incorrect listing for shipping addresses; and inaccurate entries for names of offsite facilities.

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File

Repayment to manufacturers Pending  
Sutter Medical Center Sacramento DSH050108 CA

Incorrect 340B database record – Offsite outpatient facilities were not listed on the 340B database; closed offsite outpatient facility listed on the 340B database; pharmacy incorrectly registered as a child site.

None

CAP implemented

Audit closure date: July 15, 2016

 
Sutton County Hospital District CAH451324-00 TX

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

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 Pending  
Tacoma General/ Allenmore Hospital DSH500129 WA Diversion – 340B drugs dispensed at the covered entity for prescriptions originating from ineligible sites Repayment to manufacturers CAP approved Pharmacy Purchasing Manager
(253) 403-2082
vafa.aflatooni@multicare.org
PO Box 5299, Mailstop 315-C2-RX,
315 Martin Luther King Jr Way,
Tacoma, WA, 98415-0299
Thayer County Memorial Hospital dba Thayer County Health Services CAH281304-00 NE

No adverse findings

None

N/A.

Audit closure date: September 7, 2016

 
The Cooper Health System dba Cooper University Hospital DSH310014 NJ Incorrect 340B database record – Incorrect entry for DSH percentage None CAP approved  
Touro Infirmary DSH190046 LA Duplicate Discounts – Inaccurate or incomplete information in the Medicaid Exclusion File. Repayment to manufacturers

CAP implemented

Audit closure date: May 5, 2017

340B Program Coordinator; Touro Infirmary

1401 Foucher St.
New Orleans, LA, 70115
(504) 897-7515
daniel.henry@lcmchealth.org

Tuality Healthcare DSH380021 OR

Covered outpatient drugs obtained through a Group Purchasing Organization from August 7, 2013 to July 30, 2016.

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

Repayment to manufacturers Pending  
Unconditional Love, Inc. HV32935 FL

No adverse findings

None

N/A

Audit closure date: September 23, 2016

 

United Hospital DSH240038 MN

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

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

Repayment to manufacturers

CAP implemented

Audit closure date: May 19, 2017

Pharmacy Portfolio Manager

2925 Chicago Avenue
Mail Route 10807
Minneapolis, MN, 55407
(612) 262-4785
Tony.Collins-Kwong@allina.com

Uintah Basin Medical Center SCH460019-00 UT No adverse findings None

N/A

Audit closure date: June 14, 2016

 
Umpqua Community Health Center, Inc. CH103100 OR

Duplicate Discounts - Inaccurate or incomplete information in the Medicaid Exclusion File.  State Medicaid has since determined that duplicate discounts did not occur as a result of this finding.

Duplicate Discounts - Entity was billing at contract pharmacies and contrary to information included in the Medicaid Exclusion File.

Repayment to manufacturers. CAP approved

Chief Compliance Officer

150 Kenneth Ford Drive
Roseburg, OR 97470
(541) 672-9596 x107
jpospisil@umpquach.org

University Hospital DSH110028 GA Diversion -  340B drugs dispensed at the entity for prescriptions originating at ineligible sites. Repayment to manufacturers CAP approved

Director of Pharmacy

University Hospital
1350 Walton Way
Augusta, Georgia  30901

(706) 774-2718

University Hospital DSH330241 NY Diversion – 340B drug dispensed to an inpatient. Repayment to manufacturers CAP approved 340B Program Coordinator
(315) 464-4212
750 E. Adams St.
Pharmacy Department, 3rd Floor
Syracuse, NY 13114
University Hospitals and Clinics DSH250001 MS

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

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

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

Termination of contract pharmacy from 340B Program*

Repayment to manufacturers

CAP approved

Chief Integrity and Compliance Officer

University of Mississippi Medical Center
2500 North State Street
Jackson, MS, 39216

University Medical Center Management Corporation d/b/a University Medical Center New Orleans DSH190005 LA Diversion – 340B drug dispensed to an inpatient. Repayment to manufacturer CAP implemented

Audit closure date: May 18, 2017

Pharmacy Director

2000 Canal Street
New Orleans, Louisiana 70112
Anthony.Laurent@LCMCHealth.org
(504) 702-3588

University of Illinois Hospital DSH140150 IL No adverse findings None

N/A

Audit closure date: May 20, 2016

 
University of Iowa Hospitals & Clinics DSH160058 IA

Incorrect 340B database record – Offsite outpatient facility was not listed on the 340B database; Incorrect entry for grant number.

None

CAP implemented

Audit closure date: September 27, 2016

 
University of Maryland Medical Center DSH210002 MD Diversion – 340B drugs dispensed to inpatients. Repayment to manufacturers

CAP implemented

Audit closure date: September 15, 2016

Senior Director of Pharmacy

29 S. Greene St. 
Baltimore, Maryland, 21201
(410) 328-6746
jdicubellis@umm.edu

University of Minnesota Medical Center DSH240080 MN

Incorrect 340B database record – Incorrect entry for offsite facility address.

None

CAP implemented

Audit closure date: February 22, 2017

 
University of Tennessee Medical Center DSH440015 TN Diversion – 340B drug dispensed to an inpatient; 340B drug dispensed at the entity for a prescription originating from ineligible site. Repayment to manufacturers CAP implemented

Audit closure date: May 12, 2017
340B Pharmacist
(865) 305-8174
vshelton@utmck.edu

University of Utah Hospital

DSH460009

UT

No adverse findings

None

N/A

Audit closure date: March 29, 2016

 
University of Washington Medical Center DSH500008 WA No adverse findings None

N/A

Audit closure date: September 27, 2016

 
Valley Health Systems CH030880 WV

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

Repayment to manufacturers Pending  
VNA Health Care CH0526100 IL

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

Diversion – 340B drug dispensed at the entity for a prescription originating from ineligible site.

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

Termination of contract pharmacies from the 340B Program*

Repayment to manufacturers

CAP approved

State Medicaid has since determined that duplicate discounts did not occur

Vice President of Specialty Care and Wellness Services

400 N. Highland Avenue
Aurora Illinois 60506
(630) 978-2532 Ext.8116

Webster County Health Department FP397443 MS No adverse findings. None

N/A

Audit closure date: November 15, 2016

 
WomenCare, Inc. CH038440 WV No adverse findings None

N/A

Audit closure date: November 8, 2016

 
West Penn Hospital DSH390090 PA

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database.

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

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

Repayment to Manufacturers

CAP approved

Director, Outpatient Pharmacy Services:

Jdavis@wpahs.org or
412-578-4050

Westside Family Healthcare, Inc. CH032960 DE No adverse findings None

N/A

Audit closure date: October 4, 2016

 

Winter Haven Hospital

DSH100052

FL

Incorrect 340B database record – Duplicate listing of a facility on the 340B database.

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

Repayment to manufacturers

CAP approved

Manager of BayCare Pharmacy Supply Chain

Winter Haven Hospital
200 Avenue F, NE
Winter Haven, FL, 33881
(863) 293-1121 x1432

Woodland Memorial Hospital DSH050127 CA

Incorrect 340B database record - Offsite outpatient facility was not listed on the 340B database.

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

Repayment to manufactures Pending  
Yale New Haven Hospital DSH070022 CT No adverse findings None

N/A

Audit closure date:
December 29, 2016

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