Board Compliance & Audit Committee AgendaDate: November 15, 2021 Time: 12:00 PMPublic may follow the meeting via the following link call1-877-853-5247 and enter webinar ID 928 6745 6249Mission StatementBartlett Regional Hospital provides its community with quality, patient-centered care in a sustainable manner.CALL TO ORDERAPPROVAL OF AGENDAAPPROVAL OF THE MINUTES – August 5th BOD Compliance & Audit Committee MeetingINFORMATIONAL – October 26th draft meeting minutes and agenda from Hospital Compliance CommitteeTRAINING340B for the C-Suite(Apexus 340B University online training module)TRAINING DISCUSSION340B Contract Pharmacy Q&A15 minutesNathan Overson, CO10 minutesCommittee DiscussionOLD BUSINESSA. 340B Contract Pharmacy - Eide Bailly audit recommendationsB. Compliance Program Evaluation – 3rd Party Review & Risk Assessmenta. Full Reportb. Risk Assessment Recommendationsc. Program Recommendations20 minutesCommittee DiscussionNEW BUSINESSA. Compliance Officer Report10 minutes1. Current and new Compliance Program initiatives/involvementCommittee Discussiona. Creation of new service line policy and Committeeb. Contracts process work-flow – with Beth Mow and Barbra Naultc. Creation of 340B Oversite Committee – Kevin Benson, CFO as Committee Chair2. Requesting input from the Committee for dashboard reporting elementsand other priorities moving forward (PYA report gives a sample dashboard template in Appendix E)3. Annual Board Compliance Training for 2021EXECUTIVE SESSIONA. None plannedFUTURE AGENDA ITEMSA. Next Committee Education and TrainingCOMMITTEE MEMBER COMMENTSADJOURN - Next scheduled meeting: February5 minutesBartlett Regional Hospital — A City and Borough of Juneau Enterprise Fund1/83

3260 Hospital Drive, Juneau, Alaska 99801 907.796.8900 www.bartletthospital.orgBoard Compliance & Audit Committee MeetingDraft MinutesAugust 05, 2021Called to order at 12:05 PM., by Board Compliance Committee Chair, Iola YoungCOMPLIANCE COMMITTEE AND BOARD MEMBERS:Board Members: *Iola Young, Committee Chair; *Deborah Johnston; Rosemary Hagevig;Absent: *Hal GeigerStaff/Other: Nathan Overson, Compliance Officer; Rose Lawhorne, CEO; Bradley Grigg,CBHO; Vlad Toca, COO; Kim McDowell, CNO; Kevin Benson, CFOPREVIOUS BOARD COMPLIANCE MEETING MINUTES APPROVAL:Ms. Johnston made a motion to approve the May 18th 2021 Board Compliance and AuditCommittee Meeting minutes as submitted. Ms. Young seconded the motion, and hearing noobjection, Ms. Young approved the meeting minutes without change.INFORMATIONAL:Mr. Overson gave a verbal update from the last Hospital Compliance Meeting, which was thatthe Hospital Compliance Committee discussed the PYA Compliance Program Review & RiskAssessment report; including future prioritization of recommendations, and possible strategiesfor completing the action items that come from the priority list.EXECUTIVE SESSION:A motion was made by Ms. Johnston, to recess into executive session to discuss matters:Those which by law, municipal charter, or ordinance are required to be confidential or involveconsideration of records that are not subject to public disclosure, specifically the ComplianceProgram Review & Risk Assessment Report and corresponding program recommendationsand risk assessment recommendations.The committee went into executive session at 12:10 PM and returned at 12:45 PMPOST EXECUTIVE SESSION:A motion was made by Ms. Johnston to forward the PYA Compliance Program Review & RiskAssessment report to the full Board for its acceptance. Ms. Young seconded the motion, andhearing no objection, Ms. Young approved the motion.COMMITTEE MEMBER COMMENTS:Ms. Young asked for input from the meeting attendees for possible meeting times, and possibletraining topics for the next Compliance & Audit Committee meeting.Meeting Adjourned: 12:50 PMNext Meeting: Tentatively scheduled for November 4th at 12:00 PM2/83

3260 Hospital Drive, Juneau, Alaska 99801 907.796.8900 www.bartletthospital.orgHospital Compliance Committee MeetingDraft MinutesOctober 26, 2021Called to order at 2:01 PM., by Compliance Committee Chair, Nathan Overson, COHospital Compliance Committee Members in attendance: Nathan Overson, Beth Mow, ScottChille, Rachael Stark, Angelita Rivera, Jeanette Lacey, Jerel Humphrey, Karen Forrest, VladToca, Gail Moorehead, Debbie Kesselring, Dallas Hargrave, Kevin Benson, Sara DoddCompliance Committee Recent Activities:Mr. Overson provided the Hospital Compliance Committee (HCC) with an update on the recentactivities regarding a compliance workgroup that met on 9-27-2021. The workgroup met toreview and discuss the Eide Bailly 340B Contract Pharmacy Report received on 9-24-2021. Theoutcome of the meeting was that the workgroup unanimously agreed to recommend that the HCCadopt all of the recommendations of the Eide Bailly report. Mr. Overson also provided an updateregarding an ad hoc HCC meeting that met on 9-28-2021. The outcome of this meeting was thatthe HCC would follow the recommendation of the compliance workgroup by adopting all of therecommendations of the Eide Bailly report into the hospital’s Compliance Work Plan.Education and Training:Mr. Overson provided the HCC an overview of BRH’s 340B program including the addedcomponent of the contract pharmacy rules as they relate to 340B.Compliance Work Plan Review:The committee discussed the PYA report after having a chance to review it since the lastregularly scheduled meeting on July 29th; when the report was introduced to the HCC for the firsttime. Ms. Lacy commented on the benefits of having departmental compliance plans hospitalwide, especially if included in the education process of onboarding new managers. Mr.Humphrey stated that we couldn’t assume that all directors know, and completely understandtheir role in compliance. Mr. Humphrey, Ms. Lawson-Churchill, and Mr. Benson agreed that thecompliance risk would be reduced, and awareness would increase by having departmentalcompliance plans hospital wide. It was suggested that the information from the different plans behoused in a centralized document, or location for all of the department directors to view, andupdate. They could also see what other departments are doing as part of their plans. Ms. Lacyasked for the committee’s support in several topics of risk that affects some of her areasregarding physician queries and documentation. Ms. Stark also noted that she, and Mr. Bensonwere engaging an outside auditor to perform regular coding audits, including use of modifiers, toaddress documentation and coding risks identified in the PYA risk assessment. Mr. Benson notedthat he, and Ms. Dodd was doing something similar.Compliance Officer Report:Mr. Overson gave updates on the PYA program recommendations, and possible strategies forimplementation of some. The committee also heard a verbal update from the HIPAA PrivacyOfficer, Ms. Stark, and a verbal update from Mr. Chille the HIPAA Security Officer.Executive Session: The meeting did not go into executive session.Meeting Adjourned: 3:03 PMNext Meeting Scheduled: January 19th at 2:00 PM3/83

Hospital Compliance Committee AgendaDate: October 26, 2021Time: 2:00 PMMission StatementBartlett Regional Hospital provides its community with quality, patient-centered care in a sustainable manner.CALL TO ORDERAPPROVAL OF AGENDAAPPROVAL OF THE MINUTES -- July 29th Hospital Compliance Committee MeetingOLD BUSINESSA. PYA Compliance Program Review and Risk AssessmentB. A 340B Contract Pharmacy Compliance workgroup met on 9-27-2021 (under ACP) to review the EideBailly 340B Contract Pharmacy Compliance Audit Report received by BRH on 9-24-2021 (Report alsounder ACP).C. Ad hoc Compliance Committee Meeting met on 9-28-2021 and adopted all of the compliance workgrouprecommendations, which were to adopt all recommendations from the Eide Bailly report based on howBRH’s 340B program would move forward.NEW BUSINESSA. Committee Education and Training1) BRH 340B Program overview10 minutesNathan Overson, COB. Review of the dynamic Compliance Work Plan1) Ongoing risk assessment feedback and prioritization from the committeea. PYA Risk Assessment integration into the Work Plan20 minutesCommittee DiscussionC. Program Updates1) 340B Oversite Committee – 340B Eide Bailly recommendations2) PYA Compliance Program recommendations3) HIPAA Privacy Officer update4) HIPAA Security Officer update20 minutesCommittee DiscussionFUTURE AGENDA ITEMS &COMMITTEE MEMBER COMMENTSADJOURN5 minutes- Next meeting: January 19th 2:00 PMBartlett Regional Hospital — A City and Borough of Juneau Enterprise Fund4/83

sulaJordanKevin340B Program Recommendations Assignment Summary 09-27-20211) Management Recommendation: We recommend the Hospital establish a 340B OversightCommittee.We would also recommend that one or two people become experts at the Verity products used forb. the in-house pharmacy as well as the contract pharmacies.2) Enrollment Recommendation: Management should continue to monitor the disproportionateshare percentage on the cost report each year to ensure it is at least 11.75%.3) Policy and Procedures Manual Recommendation: We recommend the policies and proceduremanual be updated.4) Human Resources Recommendation: We recommend the development of appropriate jobdescriptions as necessary for those individuals who work with the 340B Program.5)Audits Recommendation: The Contract Pharmacy program needs to be evaluated to determinewhether these findings meets the Hospital’s definition of a material 11)b.RachaelUrsulaJordanScottc.12)We recommend that the internal audit process documentation be revised to ensure that theresolution of the prescriptions identified as either Risk of Diversion or Diversion is evident.We also recommend that for those prescriptions where the Patient Status and Patient Location areInpatient, the audit documentation needs to be expanded to explain why these are considered 340Beligible and how that eligibility was determined.Contracts Recommendation: We recommend adding the specific store number, and address tothe Fred Meyer contract pharmacy information on the 340 OPAIS database.If it is decided to discontinue the contract pharmacy program, the contracts will need to be termedappropriately.Orientation and Training Recommendation: We recommend that a 340B Orientation andTraining Program be developedWe recommend that the 340B specific training be included in the orientation process along withannual training/updates.In addition, management may want to consider more formalized training for the 340B OversightCommittee, or those individuals more heavily involved with the 340B Program, on a periodic basis.Inventory Recommendation: NonePatient Eligibility Recommendation: We recommend that the 340B Oversight Committee reviewthese reports and become familiar with the reports and the processes for transferring the informationto Verity.Providers Recommendation: We recommend that the Hospital implement policies andprocedures around the tracking of eligible providers and providing timely updates to Verity.Compliance Recommendation: We would recommend that the Compliance Officer obtain allaudits being completed over in-house and contract pharmacies and review them as they are beingcompleted.Contract pharmacy agreements should also be reviewed on an annual basis to ensure that thecontract is beneficial for the Hospital as the primary purpose of the 340B Program is to stretch scarcefederal dollars.We would suggest that the self-reporting policy be included in the 340B Policies and Procedures forthe material breach to ensure that the appropriate steps are taken if a material breach were to occur.340B Transaction Review Recommendation: We recommend ensuring that all 12 elementsrequired by HRSA can be easily obtained from the Transaction Reports.b.We also recommend that the Hospital review the 365-lookback period for claims to ensure that scriptswritten from the Hospital are appropriately matching with eligible visit dates from Bartlett.5/83

Compliance Program and Risk AssessmentExecutive Summary Report and Detailed FindingsPrepared for Bartlett Regional HospitalJune 3, 20216/83

June 3, 2021Mr. Nathan OversonCompliance and Risk Management DirectorBartlett Regional Hospital3260 Hospital Dr.Juneau, AK 99801Dear Mr. Overson:PYA, P.C. (PYA) is pleased to submit this report to Bartlett Regional Hospital (Bartlett) which detailsour methodology, findings, and recommendations from conducting a compliance program and riskassessment of Bartlett’s compliance program.We appreciate the opportunity to assist Bartlett with its compliance initiatives, and to serving Bartlettin the future. We look forward to speaking with you soon.Respectfully,PYA, P.C.Via Email Only: [email protected]/83

COMPLIANCE PROGRAM AND RISK ASSESSMENTEXECUTIVE SUMMARY REPORT AND DETAILED FINDINGSTABLE OF CONTENTSCompliance Program and Risk Assessment Executive Summary . 1Project Background and Engagement Approach . 2Compliance Program Key Observations . 4Appendix A: Compliance Program Assessment Summary and Detailed Findings . A-1Appendix B: Compliance Risk Assessment Summary and Detailed Findings. B-1Appendix C: Compliance Program and Risk Assessment Interview List . C-1Appendix D: Request for Information . D-2Appendix E: Sample Compliance Dashboard Template . E-1Appendix F: Sample Departmental Work Plan Template . F-1Prepared for Bartlett Regional HospitalJune 3, 20218/83


COMPLIANCE PROGRAM AND RISK ASSESSMENT EXECUTIVE SUMMARYPROJECT BACKGROUND AND ENGAGEMENT APPROACHBACKGROUNDBartlett Regional Hospital (Bartlett) is a not-for-profit community hospital serving a 15,000-square-mile region in Southeast Alaska. Bartlett is ownedby the City and Borough of Juneau and is the only hospital and emergency department in the Juneau community. Bartlett is Joint CommissionAccredited and includes 57 inpatient beds, and 16 residential substance abuse treatment facility beds.PYA, P.C. (PYA) was engaged by Bartlett, to perform an independent, third-party assessment of the effectiveness of Bartlett’s compliance program(Program). In addition to the assessment of Program infrastructure (Program Assessment), Bartlett also requested an assessment of key compliancerisk areas (Risk Assessment), which will enable Bartlett to continue to develop and execute a comprehensive compliance work plan.TIMELINE AND APPROACHA kick-off conference call was held on January 29, 2021 to discuss the project scope, goals, interviewees, remote interview scheduling, and PYA’sRequest for Information (RFI) with Bartlett’s Compliance and Risk Management Director (CRMD) and Interim Chief Executive Officer (CEO). PYAconducted remote video interviews in March 2021. Interviews encompassed 16 sessions with over 30 key members of Bartlett’s staff, management,and leadership. The list of interviewed Bartlett key personnel is located in Appendix C.Additionally, risk assessment questionnaires were distributed to selected members of leadership, as identified by the CRMD. A total of 17questionnaires from various departments were completed and returned by leadership for use in this evaluation. Additional information related to eachrisk area was obtained during interviews and through document review.ASSESSMENT METHODOLOGYPYA utilized the Department of Health and Human Services’ (HHS) Office of Inspector General (OIG) Compliance Program Guidance, the FederalSentencing Guidelines, the OIG’s Current Work Plan, the U.S. Department of Justice’s (DOJ) “Evaluation of Corporate Compliance Programs,” andthe Health Care Compliance Association’s (HCCA) and OIG’s “HCCA-OIG Compliance Effectiveness Roundtable’s Measuring Compliance ProgramEffectiveness: A Resource Guide”1 (collectively referred to as “Guidance”) as the foundation for PYA’s review.1HCCA‐OIG Compliance Effectiveness Roundtable. Measuring Compliance Program Effectiveness: A Resource Guide. Roundtable Meeting: January 17, 2017, Washington DC.Retrieved from -portal/files/HCCA-OIG-Resource-Guide.pdfPrepared for Bartlett Regional HospitalJune 3, 2021Page 210/83

COMPLIANCE PROGRAM AND RISK ASSESSMENT EXECUTIVE SUMMARYAdditionally, PYA’s experience in regulatory compliance matters, along with serving as an Independent Review Organization (IRO) for entities undera Corporate Integrity Agreement (CIA), facilitates our understanding of key compliance risk areas. A comprehensive compliance program incorporatesthe following seven elements as recommended by the Guidance: (1) high-level oversight; (2) integration of compliance into standards, policies andprocedures (P&Ps); (3) consistent enforcement; (4) training and education; (5) open lines of communication; (6) response to detected deficiencies; and(7) monitoring and auditing.ENGAGEMENT SCOPEThe scope of PYA’s Program and Risk Assessment included an evaluation of the structure of Bartlett’s Program as it relates to the Guidance, interviewswith key Bartlett personnel, a review of compliance documents provided2, and risk assessment questionnaire responses received. This multi-levelevaluation of the Program specifically assessed the Program’s design, implementation progress, and the organizational impact as it relates to theGuidance’s seven elements. The information provided from interviews, document reviews and risk assessment questionnaires were aggregated andanalyzed using PYA’s proprietary risk ranking methodology.As with the Program Assessment, PYA’s risk methodology also utilizes the Guidance to identify potential compliance risks which may impact Bartlettand provides the basic framework for the compliance work plan with the identification and prioritization of risk. Using a formal risk assessmentmethodology assures Bartlett’s executive leadership team and the Board that thorough consideration has been given to the organization’s risks, andthat the resulting compliance work plan will be relevant and valuable to Bartlett’s operational strategy.The information received as a result of the Bartlett interviews, document reviews and the questionnaire respondents has been aggregated and reportedin this assessment as it was communicated to PYA by key Bartlett leadership and personnel. The information itself was not validated or tested foraccuracy. The scope of the assessment also did not include a financial analysis or an effectiveness review of Bartlett’s financial reporting process. PYAdid not conduct testing that would provide assurance of effective controls to mitigate risk areas identified.2In response to PYA’s request for copies of compliance program P&Ps, PYA was provided with a table of the Program’s P&Ps, but did not receive copies of the P&Ps referencedwithin the table. As such, many of PYA’s findings reflect the fact that a detailed review of the context of these P&Ps was not performed. Bartlett should ensure that its ProgramP&Ps address control requirements and the findings and recommendations provided within this report.Prepared for Bartlett Regional HospitalJune 3, 2021Page 311/83

COMPLIANCE PROGRAM AND RISK ASSESSMENT EXECUTIVE SUMMARYCOMPLIANCE PROGRAM KEY OBSERVATIONSTONE AT THE TOPThe success of an effective compliance program is highly dependent upon the support provided by the organization’s governance and management (theTone at the Top). The Tone at the Top is the foundation of an effective compliance program and begins with the Board of Directors’ (Board) oversightresponsibility3, followed by the CEO’s commendation of the program, support by a senior leadership team, and a Chief Compliance Officer (CCO)that facilitates organization-wide accountability for compliance issues. Furthermore, “The Individual Accountability for Corporate Wrongdoing”guidance issued September 9, 2015, informally known as the Yates Memo 4, has increased emphasis on individual accountability regarding ethics andcompliance issues.Bartlett’s executive leadership team and the Board have verbalized their commitment to, and support of, the compliance function; however, theorganization is undergoing a leadership change, with the current CEO’s retirement, leading to the hiring of a new CEO. While executive leadershipand the Board recognize the importance of a culture of compliance and of modeling those expectations across the entire organization, it is imperativethat Bartlett continues to build the current Program’s infrastructure in order for the Program to continue to grow. Implementing an optimized complianceprogram conveys the importance of compliance publicly and demonstrates to the staff that Bartlett is committed to making the right decisions.COMPLIANCE FUNCTIONCompliance is complex, and successfully managing compliance is a challenge in the best of circumstances. Expectations of compliance, encompassingboth external regulatory requirements and internal policies, must be clearly communicated to the workforce in order to assign responsibility and createaccountability. It is the responsibility of the CCO and other senior leaders to establish ethical values, solidify company policies, and communicateclearly with the workforce by relaying information updates, reminders, and feedback. Additionally, the compliance officer must cultivate anenvironment that rewards the workforce for communicating openly about violations they have witnessed or concerns they have. In accordance with theOIG’s Compliance Program Guidance for Hospitals, “Every hospital should designate a compliance officer to serve as the focal point for complianceactivities.” 5 Therefore, PYA recommends that the CRMD position be modified to recognize the distinct responsibilities of the organization’s CCO.Further, the inclusion of additional compliance activities, including implementation of a formal, documented organizational risk assessment process,345OIG, Association of Healthcare Internal Auditors, American Health Lawyers Association, et al. (OIG, et al.). Practical Guidance for Health Care Governing Boards on ComplianceOversight. April 20, 2015. Retrieved from Compliance-Oversight.pdf[hereinafter, Practical Guidance]Memorandum from Sally Quillian Yates, Deputy Attorney General, U.S. Department of Justice to All U.S. Attorneys et al., Individual Accountability for Corporate Wrongdoing.Sept. 9, 2015. Retrieved from partment of Health and Human Services. Office of Inspector General. Publication of the OIG Compliance Program Guidance for Hospitals. Federal Register. Vol. 63. Number35. Monday, February 23, 1998.Prepared for Bartlett Regional HospitalJune 3, 2021Page 412/83

COMPLIANCE PROGRAM AND RISK ASSESSMENT EXECUTIVE SUMMARYsystematic auditing and monitoring, and innovative training with measurable outcomes would serve to further strengthen Bartlett’s compliance function.In addition, it best serves an organization to include the compliance officer as a key stakeholder in due diligence activities and strategic initiatives.Compliance-Related FunctionsThe Compliance, Quality, and Risk Management functions and the associated interrelationships should be defined within Bartlett’s organizationalstructure. Pursuant to the Practical Guidance for Healthcare Governing Boards on Compliance Oversight6, the purpose, reporting relationships, andinteraction of correlated functions should be integrated in the organizational structure as roles and responsibilities are defined. Additionally, by definingthese interrelationships, reasonable expectations are clarified. The Practical Guidance for Healthcare Governing Boards on Compliance Oversightdefines the compliance and quality functions as follows:“The compliance function promotes the prevention, detection, and resolution of actions that do not conform to legal, policy, or businessstandards. This responsibility includes the obligation to develop policies and procedures that provide employees guidance, the creation ofincentives to promote employee compliance, the development of plans to improve or sustain compliance, the development of metrics to measureexecution (particularly by management) of the program and implementation of corrective actions, and the development of reports anddashboards that help management and the Board evaluate the effectiveness of the Program.The quality improvement function promotes consistent, safe, and high-quality practices within health care organizations. This functionimproves efficiency and health outcomes by measuring and reporting on quality outcomes and recommends necessary changes to clinicalprocesses to management and the Board. Quality improvement is critical to maintaining patient-centered care and helping the organizationminimize the risk of patient harm.”Currently the CRMD is responsible for both the compliance and risk management functions. The compliance function guides the organization inmeeting regulatory and policy requirements, while the risk management function is the set of processes by which adverse operational risks are analyzed,managed, and resolved effectively. As such, risk management is considered to be a distinct competence function that protects the organization fromrisk; correspondingly, compliance is achieved by leadership’s ethical commitment to do the right thing. Therefore, it is important to note that, whilethe risk management and compliance functions must collaborate with one another to prevent, detect and mitigate organizational compliance risks,organizational separation of these functions as distinct, but collaborative roles would allow the autonomy necessary for effective compliance and riskmanagement throughout the Care-Boards-on-Compliance-Oversight.pdfPrepared for Bartlett Regional HospitalJune 3, 2021Page 513/83

COMPLIANCE PROGRAM AND RISK ASSESSMENT EXECUTIVE SUMMARYDEDICATED COMPLIANCE RESOURCESCompliance Management includes development and implementation of the seven elements of an effective compliance program as described by theHHS-OIG7. Specifically, Compliance Management activity may include, but is not limited to, conducting a compliance risk assessment and developinga corresponding work plan, reporting auditing and monitoring results to the Board, performing investigations, and managing an organization’scompliance P&P repository.Bartlett employs approximately 600 individuals. The CRMD is currently responsible for all compliance program and risk management activities. Theability to achieve Bartlett’s goals of a high-performing compliance team and Program is currently limited by Program staffing constraints. Notably,under the direction of the CRMD, interviews revealed that Bartlett has continued to strengthen the Program’s infrastructure through development ofP&Ps and compliance-related training. Additionally, in response to the identification of the need for reporting metrics and information to theCompliance and Audit Committee of the Board (CAC), the CRMD is supported by both a Hospital Compliance Committee (HCC) and a RevenueCycle Committee (RCC), which have served to further strengthen the Program’s foundation. The CRMD plans to utilize the results of this assessmentreport to continue to build upon the foundation for Bartlett’s 2021/2022 compliance work plan.For healthcare organizations comparable to Bartlett, PYA recommends the compliance function be supported by two full-time equivalent employees(FTEs)8, including a dedicated FTE CCO, to support the operational structure and maintain the continuous process of abiding by legal, ethical, andprofessional healthcare standards. Given Bartlett’s growth, PYA also recommends re-evaluating compliance staffing needs on an annual basis, atminimum, with immediate re-evaluation for significant compliance needs that may arise throughout the year.Recommended Corporate Compliance StaffPYA recommends the following staffing structure for Bartlett’s compliance department:78 1.0 FTE CCO with responsibilities for oversight of the organizational Bartlett compliance function 1.0 FTE, Compliance Specialist, dedicated to compliance P&Ps and addressing regulatory compliance issues such as exclusion screening,vendor management, conflicts of interest, etc.Health Care Fraud Prevention and Enforcem

Nov 15, 2021 · 340B for the C-Suite 15 minutes (Apexus 340B University online training module) Nathan Overson, CO TRAINING DISCUSSION 340B Contract Pharmacy Q&A 10 minutes Committee Discussion OLD BUSINESS A. 340B Contract Pharmacy - Eide Bailly audit recomm