Code of Conduct and Compliance Manual

UHS has developed written compliance policies and procedures that are designed to establish bright-line rules that help personnel carry out their job functions in compliance with federal healthcare program requirements, and to further the mission and objectives of UHS and its facilities. Copies of the UHS compliance policies and procedures are available on this website, or by contacting the applicable Facility Compliance Officer or the UHS Compliance Office. Below is a summary of UHS compliance policies.

1.0 – UHS Compliance Program
This policy outlines the Compliance Program components and describes the program's goal of assuring compliance with all laws, rules and regulations relating to federal and state healthcare programs. Read the complete policy.

2.0 – UHS Chief Compliance Officer
This policy describes the role and responsibilities of the UHS Chief Compliance Officer, who is charged with overseeing the Compliance Program and with assuring the effectiveness of healthcare compliance functions at every level of the organization. Read the complete policy.

3.0 – UHS Compliance Committee
This policy sets for the duties and responsibilities of the UHS Compliance Committee, which provides support for the UHS Chief Compliance Officer in overseeing the Compliance Program for UHS. Read the complete policy.

3.1 – Facility Compliance Committee
This policy establishes the duties and responsibilities of the Facility Compliance Committee, which provides support and oversight of the activities of the Facility Compliance Officers. Read the complete policy.

4.0 – Division Compliance Officers
This policy describes the role and responsibilities of the Acute and Behavioral Division Compliance Officers, who provide support and oversight of the activities of the Facility Compliance Officers in each division. Read the complete policy.

5.0 – Facility Compliance Officers
This policy provides a description of the role and responsibilities of the Facility Compliance Officers, who are tasked with assuring an effective compliance program at each of the facilities they serve. Read the complete policy.

6.0 – Education on Federal and State False Claims Laws
This policy sets forth the education requirements for the organization regarding federal and state false claims statutes, whistleblower protections and the role of such laws in preventing and detecting fraud, waste, and abuse in the federal healthcare programs, as required the Deficit Reduction Act of 2005 (DRA). Read the complete policy.

7.0 – Reporting Unethical or Illegal Conduct
This policy describes the mechanisms developed by UHS for personnel to report any known or suspected ethical violations or other activity that may be inconsistent with any provisions of the UHS Code of Conduct, Compliance Program, or UHS or facility policies, or that an individual believes may otherwise violate any law or regulation. These mechanisms provide for anonymous reporting. Read the complete policy.

8.0 – Process for Handling the UHS Compliance Hotline and Web Reporting Program
This policy establishes protocols for how the Compliance Hotline and internet-based reports are received, documented, investigated and ultimately resolved, including a process to allow for anonymous reporting, if that is requested by the caller. Read the complete policy.

9.0 – Conducting Internal Investigations
This policy discusses the procedures the organization uses for conducting internal investigations, which are overseen by the UHS Chief Compliance Officer, and sets forth the expectation that all UHS personnel are expected to cooperate in these investigations. Read the complete policy.

9.1 – Facility Surveillance Video Camera Recording
This policy provides direction for the retention of video surveillance recordings in the facility, as well as for the destruction of video surveillance recordings in the facility. Read the complete policy.

10.0 – Compliance Corrective Action
This policy describes the process for the development and imposition of Corrective Action Plans for compliance-related issues. Corrective Action Plans are intended to assist noncompliant individual(s) to understand specific issues and to reduce the likelihood of future noncompliance. They are developed to effectively address the particular instances or issues of noncompliance and are intended to reflect the severity of the noncompliance. Read the complete policy.

11.0 – Compliance Remedial Action
The Compliance Remedial Action policy outlines the procedure for developing and implementing remedial action, particularly when a gap has been identified in the Compliance Program or a compliance violation is detected. Remedial action is intended to be used to prevent recurrence of compliance violations in the organization and is a key factor in the success of the Compliance Program. Read the complete policy.

12.0 – Compliance Document Retention
The Compliance Document Retention policy sets forth the process and policy for Compliance Program-related document retention, destruction and privacy. Read the complete policy.

13.0 – Ineligible Persons
The Ineligible Persons policy requires that appropriate checks be performed for applicable individuals in accordance with state and federal laws relating to exclusion from government healthcare programs and licensure status. This policy is designed to assure that no government healthcare program payment is sought for any items or services directed or prescribed by a physician, practitioner or contractor who provides and/or orders services and who is an ineligible person. Read the complete policy.

14.0 – Response to Government Inquiries, Investigations or Audits
This policy establishes procedures for personnel regarding inquiries, investigations and audits from government officials, representatives, investigators or other individuals acting on behalf of the government, to assure that personnel act appropriately in cooperation with the investigation or audit, and to enable UHS to lawfully protect its interests. Read the complete policy.

15.0 – Billing and Claims Reimbursement
The Billing and Claims Reimbursement policy discusses the expectation that UHS personnel will comply with all federal and state healthcare program requirements and applicable facility policies for billing and claims reimbursement, including the preparation and submission of accurate claims consistent with such requirements. The policy also describes the procedures for overpayment refunds and reporting in the event a billing error is identified, and also discusses the privacy laws relating to patient billing information. Read the complete policy.

16.0 – Conflicts of Interest
The Conflicts of Interest policy sets forth the conflict of interest policy for facility personnel concerning the identification, disclosure, and management or elimination of potential and actual conflicts of interest. Read the complete policy.

17.0 – Policy on UHS Compliance Policies
This policy establishes the duties and responsibilities regarding the drafting, updating, approval and maintenance of all UHS compliance policies. Read the complete policy.

18.0 – Anti-Corruption and Anti-Bribery Policy
This policy applies to all directors, officers, employees, agents and shareholders of UHS of Delaware, Inc. (thereafter "UHS"), its subsidiaries and/or affiliates. Read the complete policy.

19.0 – CURES Act Information Blocking Policy
This policy helps ensure compliance with the requirements of the 21st Century Cures Act, which is intended to advance interoperability and to require the facilitation of access, exchange or use of electronic health information. Read the complete policy.