Program Integrity: FY22 Audit Results

Updated 6/16/22. The results chart includes audits where the findings have been finalized. Remaining audits are still under review. Information on Corrective Action Plans and Sanctions will be updated once approved by HRSA. HRSA recommends manufacturers do not contact audited entities regarding sanctions until a corrective action plan has been approved by HRSA and posted on this website.

Results posted for 54 audits.

Entity 340B ID State OPA Findings Sanction Corrective Action Status Entity Contact Information
Adirondack Medical Center SCH330079-00 NY No adverse findings None N/A

Audit closure date: January 11, 2022

 
Alegent Creighton Health dba CHI Health Plainview CAH281346-00 NE Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for hospital control type. None Pending  
Alivio Medical Center, Inc. CH056620 IL

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

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

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

Repayment to manufacturers Pending  
Antelope Memorial Hospital CAH281326-00 NE Incorrect 340B OPAIS record – Incorrect entry in 340B OPAIS for Medicare Cost Report file date. None Pending  
B – K Health Center, Inc. CH03048E PA No adverse findings None N/A

Audit closure date: January 7, 2022

 
Banner Casa Grande Medical Center DSH030016 AZ No adverse findings None N/A

Audit closure date: February 9, 2022

 
Banner Churchill Community Hospital CAH291313-00 NV No adverse findings None N/A

Audit closure date: March 17, 2022

 
Boone County Health Center CAH281334-00 NE Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, and cost reporting period. None

CAP implemented

Audit closure date: May 17, 2022

 
Buena Vista Regional Medical Center CAH161375-00 IA Incorrect 340B OPAIS record – Failed to remove contract pharmacy from 340B OPAIS that did not have a written contract in place. Termination of contract pharmacy from 340B Program*

CAP implemented

Audit closure date:
May 25, 2022

 
Champlain Valley Physicians Hospital DSH330250 NY Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. None

CAP approved

State Medicaid has since determined duplicate discounts did not occur.

 
Coffeyville Regional Medical Center, Inc. SCH170145-00 KS Incorrect 340B OPAIS record – Hospital classification in 340B OPAIS was inconsistent with eligibility documents; Incorrect entries in 340B OPAIS for Medicare Cost Report file date, cost reporting period, and disproportionate share percentage. None Pending  
Community Hospital of Anaconda CAH271335-00 MT Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report file date and cost reporting period; Entity improperly registered a distribution site as a contract pharmacy in 340B OPAIS; Incorrect entry in 340B OPAIS for address for offsite outpatient facility. None Pending  
Corry Memorial Hospital CAH391308-00 PA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None

CAP implemented

Audit closure date: May 13, 2022

 
Decatur County Memorial Hospital CAH151332-00 IN No adverse findings None N/A

Audit closure date: March 29, 2022

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

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

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

Repayment to manufacturers

Termination of contract pharmacies from 340B Program*

Pending  
First Care Medical Services CAH241357-00 MN No adverse findings None N/A

Audit closure date: March 15, 2022

Grafton City Hospital CAH511307-00 WV Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None Pending
Grant Medical Center DSH360017 OH No adverse findings None

N/A

Audit closure date: May 13, 2022

Holy Rosary Healthcare CAH271347-00 MT Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None Pending
HonorHealth Scottsdale Osborn Med Ct RRC030038-00 AZ No adverse findings None N/A

Audit closure date: March 23, 2022

Hudson River Healthcare, Inc. CH021510 NY Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for grant associated site names and address; Failed to remove grant associated sites from 340B OPAIS that were not operational. Termination of grant associated sites from the 340B Program* Pending
Johns Hopkins All Children’s Hospital, Inc. PED103300-00 FL No adverse findings None

N/A

Audit closure date: April 15, 2022

 
Kittson Memorial Hospital CAH241336-00 MN Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None Pending
Madelia Community Hospital and Clinic CAH241323-00 MN Incorrect 340B OPAIS record – Offsite outpatient facility was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Incorrect entry for Authorizing Official. None Pending
Mark Twain Medical Center CAH051332-00 CA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period; Offsite outpatient facilities were not listed in 340B OPAIS. None Pending
Medical Center of Peach County CAH111310-00 GA No adverse findings None N/A

Audit closure date: January 7, 2022

 
Memorial Hermann Sugar Land Hospital DSH450848 TX No adverse findings None N/A

Audit closure date: May 12, 2022

 
Mercy Health System Corporation DSH520066 WI Inaccurate or incomplete information on the Medicaid Exclusion File. It was determined that duplicate discounts did not occur as a result of the finding. None Pending  
MidMichigan Medical Center – Gratiot DSH230030 MI Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. None CAP approved  
Migrant Health Center, Western Region, Inc. CH021040 PR Incorrect 340B OPAIS record – Entity improperly registered two pharmacies as grant associated sites in 340B OPAIS. None Pending  
Mitchell County Hospital CAH111331-00 GA

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

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

None Pending  
Moore County Hospital District dba Memorial Hospital CAH451386-00 TX

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

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

Repayment to manufacturers Pending  
Morrison Community Hospital CAH141329-00 IL Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None CAP approved  
Neighborhood Health Center CHC24160-00 OR No adverse findings None

N/A

Audit closure date: April 8, 2022

 
Neighborhood Outreach Access to Health CHC26604-00 NV

No adverse findings

None

N/A

Audit closure date: March 2, 2022

 
Northern Nevada HIV Outpatient Program Education and Services CHC26605-00 NV Incorrect 340B OPAIS record – Grant associated site was not listed in 340B OPAIS; Incorrect entries in 340B OPAIS for site ID and name for grant associated site.

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

Repayment to manufacturers

Pending

 
Packard Health, Inc. CHC29011-00 MI Duplicate Discounts – Entity billed Medicaid while not listed on the HRSA Medicaid Exclusion File. Repayment to manufacturers Pending  
Palmer Lutheran Health Center CAH161316-00 IA No adverse findings None N/A

Audit closure date: January 20, 2022

 
Pancare of Florida, Inc. CH0442450 FL Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for subdivision name and address for grant associated sites; Ineligible site registered on 340B OPAIS; Failed to remove a duplicate registration for a grant associated site from 340B OPAIS. Termination of grant associated site from the 340B Program* Pending  
Providence Health System Southern California dba Providence Little Company of Mary Medical Center Torrance DSH050353 CA No adverse findings None N/A

Audit closure date: March 4, 2022

 
Providence Little Company of Mary Medical Center San Pedro DSH050078 CA No adverse findings None N/A

Audit closure date: January 19, 2022

 
Providence Saint Joseph Medical Center CAH271343-00 MT No adverse findings None N/A

Audit closure date: March 31, 2022

 
Punxsutawney Area Hospital SCH390199-00 PA No adverse findings None N/A

Audit closure date: February 2, 2022

 
Reedsburg Area Medical Center CAH521351-00 WI Incorrect 340B OPAIS record – Offsite outpatient facilities were not listed in 340B OPAIS. None Pending  
RiverView Healthcare Association CAH241320-00 MN No adverse findings None N/A

Audit closure date: March 24, 2022

 
Robert Packer Hospital RRC390079-00 PA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage.

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

Repayment to manufacturers Pending  
Rochester General Hospital DSH330125 NY No adverse findings None N/A

Audit closure date: January 7, 2022

 
Saint Luke’s Hospital of Chillicothe dba Hedrick Medical Center CAH261321-00 MO No adverse findings None N/A

Audit closure date: February 25, 2022

 
San Antonio Regional Hospital DSH050099 CA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date, cost reporting period, and disproportionate share percentage. None CAP approved  
Spectrum Health Gerber CAH231338-00 MI Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None Pending  
St. Michael Medical Center RRC500039-00 WA No adverse findings None

N/A

Audit closure date: May 10, 2022

 
Trillium Health, Inc. FQHCLA342 NY Duplicate Discounts – Inaccurate or incomplete information on the Medicaid Exclusion File. Repayment to manufacturers Pending  
United Memorial Medical Center DSH330073 NY No adverse findings None N/A

Audit closure date: January 11, 2022

 
Wayne County Hospital CAH161358-00 IA Incorrect 340B OPAIS record – Incorrect entries in 340B OPAIS for Medicare Cost Report filing date and cost reporting period. None Pending  

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

Date Last Reviewed:  June 2022