Detected Offenses and Developing Corrective Action Initiatives

  1. Prevention and Detection

    Broward Health is committed to advancing the prevention of fraud, waste, and abuse at Broward Health, while at the same time furthering the fundamental mission of providing enhanced patient care to our patients for the betterment of the community.  One of the Compliance Department’s functions is reviewing and proposing strategies to promote compliance and detection of potential violations within Broward Health.
  1. Investigations and Reporting

    Reports or reasonable indications of fraud, waste or abuse, violations of Broward Health’s compliance program, violations of Broward Health’s Code of Conduct, or violations of applicable laws and regulations are promptly investigated. The purpose of the investigation shall be to identify those situations involving fraud, waste, abuse, relevant violations and unacceptable conduct; also, to identify individuals who may have knowingly or inadvertently caused or participated in such instances. The results of an investigation may identify the need for further training and education; to facilitate corrective action; and to implement procedures necessary to ensure future compliance. 

    Because of the many situations or problems which are possible, the process or method of investigation is at the discretion of the Compliance Officer and will be determined on a case-by-case basis, with consultation from the Office of General Counsel, and in coordination with the President/CEO of Broward Health as appropriate.

    The Chief Compliance Officer will identify, summarize, and present to the Board of Commissioners any external investigations initiated and paid for by Broward Health. The Chief Compliance Officer will report on all investigations to the CEO, General Counsel, and the Chairman of the Board of Commissioners on a monthly basis. 

    When there is information of potential compliance violations or misconduct, the Chief Compliance Officer has the responsibility of conducting an investigation.  An internal investigation may include interviews and a review of medical records, billing, and other relevant documents.

    Link to Hotline and provide phone number to report
  1. Plans of Correction

    A plan of correction will be taken promptly following completion of an audit or investigation.  If an audit or investigation reveals a material violation of Broward Health policies or procedures and/or Medicare or Medicaid regulations and guidelines, the Internal Stakeholder will draft a plan of correction.  The Internal Stakeholder will establish deadlines by which the plan of correction must be completed.  Compliance staff will assist Internal Stakeholders throughout the plan of correction process.  Examples include, but not limited to, refunds of any overpayment received, employee disciplinary action up to and including termination, and reporting to federal or state authorities. All plans of correction will be documented and include progress reports with respect to each error identified and maintained in the Corporate Compliance Department database and may be reported to the ECG’s Auditing and Monitoring Subcommittee.

    This is not an exhaustive list Corrective actions may include:
    • Policy/Procedure Revision
    • Training/Education
    • Disciplinary action
  2. Overpayments

    Once an overpayment has been quantified, a prompt refund will be made to Federal Health Care Program (i.e. Medicare, Medicaid, etc.). Any required disclosures will be made by the Chief Compliance Officer, in collaboration with others as needed.

    If another department identifies other significant incorrect receipt of revenue, the Corporate Compliance Department will be notified and will receive a copy of the accounting documentation supporting the repayment. The Chief Compliance Officer will determine if further review is needed.

    Link to Overpayments policy
    Link to Compliance with Federal Anti-Kickback Statute and Stark Law policy
    • Written Policies and Procedures
      • Code of Conduct
      • Policies and Procedures
    • 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
    • Auditing and Monitoring      
      • Compliance Auditing
      • Monitoring
    • Responding to Detected Offenses and Developing Corrective Action Initiatives
      • Prevention and Detection
      • Investigations and Reporting
      • Corrective Actions
      • Overpayments



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.

Link to statement of independence (LANGUAGE BELOW)


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.