North Broward - November 2017

INDEPENDENT REVIEW ORGANIZATION

TABLE OF CONTENTS

I. INTRODUCTION .................................................................................................. 2 A. OVERVIEW OF NORTH BROWARD HOSPITAL DISTRICT .................... 2 B. OVERVIEW OF CHANGES AMONG BROWARD HEALTH'S SENIOR MANAGEMENT .......................................................................... 3 C. OVERVIEW OF INDEPENDENT REVIEW ORGANIZATION FINDINGS.................................................................................................. 4 D. OBJECTIVE............................................................................................... 7 E. SCOPE OF REVIEW ................................................................................. 7 F. DOCUMENTATION REVIEWED AND PERSONNEL INTERVIEWED.......................................................................................... 9 II. ARRANGEMENTS SYSTEMS REVIEW............................................................ 10 A. CENTRALIZED TRACKING SYSTEM..................................................... 10 B. TRACKING REMUNERATION TO AND FROM PARTIES TO FOCUS ARRANGEMENTS ............................................................... 2 0 C. TRACKING SERVICE AND ACTIVITY LOGS ......................................... 39 D. MONITORING LEASED SPACE & PATIENT CARE ITEMS ................... 46 E. PROCESS FOR INITIATING ARRANGEMENTS.................................... 50 F. INTERNAL REVIEW AND APPROVAL OF ARRANGEMENTS .............. 58 G. COMPLIANCE OFFICER'S ANNUAL REVIEW & REPORTING ............. 6 8 H. IMPLEMENTATION OF RESPONSES FOR SUSPECTED VIOLATIONS OF ANTI-KICKBACK LAW AND STARK LAW .................. 7 1 I. ENSURING COMPLIANCE WITH NEW FOCUS ARRANGEMENT REQUIREMENTS ....................................................... 8 1 III. SUPPLEMENTAL FOCUS ARRANGEMENT SYSTEMS REVIEW REPORTS OF MATTERS IMPLICATING THE CIA .......................................... 8 3

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