Compliance

Compliance Program Effectiveness

This Compliance Plan is intended to be flexible and readily adaptable to changes in regulatory requirements and in the healthcare system as a whole. This plan shall be reviewed annually and modified, as necessary.

The Chief Compliance Officer shall monitor the ongoing activities of this Compliance Plan through effective training regarding compliance issues, investigation and enforcement of compliance reports and complaints as well as periodic audits. The Chief Compliance Officer will provide updates on the monitoring results to the ECG as well as the Compliance Committee of the NBHD Board of Commissioners.

Independence

To permit the rendering of impartial and unbiased judgment essential to the proper conduct of Broward Health’s Corporate Compliance and Ethics Program, the Chief Compliance Officer and staff will be independent of the activities they review. In performing the Compliance function, the Corporate Compliance and Ethics Department cannot have any direct responsibility for or authority over, any of the activities reviewed.

Auditing and Monitoring

Auditing and monitoring may be both routine or as requested. Auditing will be calibrated based on the enterprise-wide risk assessment, previous audit and monitoring activities, and compliance investigations.

Broward Health conducts compliance audits to detect deficiencies and irregularities. Due to the complex nature of the various provisions that generate compliance issues, the areas to be audited will likely change over time in response to revisions on statutes, regulations, program bulletin and other relevant resources.

The Corporate Compliance and Ethics Program auditing and monitoring process does not in any way relieve other persons in the organization of their compliance responsibility.

The Corporate Compliance Department, Internal Audit and leaders across the organization will be responsible for conducting an enterprise-wide risk assessment on a bi-annual basis.

The Process Includes the Following Steps:

Corporate services is responsible for assisting the executive compliance group's ("ECG") auditing & monitoring subcommittee in identifying risks to develop the risk assessment.
Corporate services is responsible for assisting the ECG’s auditing & monitoring subcommittee in assessing the risks.
The management teams across the regions are responsible for prioritizing risks. The management teams across the regions are responsible for developing responses to those risks.
The management teams across the regions are responsible for implementing control activities.
Corporate services and the management teams across the regions are responsible for reporting results of assessment and corresponding responses.
The ECG’s auditing & monitoring subcommittee and the management teams across the regions are responsible for monitoring the effectiveness of the control activities.

Additional Links:

Compliance Program Elements

Written Policies and Procedures

Code of Conduct
Policies and Procedures

Auditing and Monitoring

Compliance Auditing
Monitoring

Designation of a Compliance Officer and Executive Compliance Group

Chief Compliance Officer
Executive Compliance Group

Conducting Effective Training and Education

Initial Compliance Training
Annual Compliance Training
Chief Compliance Officer and Corporate Compliance Staff

Developing Effective Lines of Communication

Access to the Chief Compliance Officer
Methods of Reporting

Enforcing Standards through Well-Publicized Guidelines

Non-Retaliation
Progressive Discipline
District Performance Management Policy

Responding to Detected Offenses and Developing Corrective Action Initiatives

Prevention and Detection
Investigations and Reporting
Corrective Actions
Overpayments