The UHS Compliance Program includes appropriate policies and procedures consistent with all applicable legal and regulatory requirements, compliance education and its audit and monitoring and disclosure programs.

Our Chief Compliance and Privacy Officer oversees the UHS Compliance Program and reports on the Company’s compliance program operations to the Quality and Compliance Committee of the Board of Directors on a quarterly basis.

Fast Facts:

  • UHS is committed to fostering a culture of accountability at all levels and encourage employees to report anything they believe could be noncompliant with our values.
  • Our commitment to fairness and integrity extends to everyone with whom we interact and do business.
  • Our Code of Conduct is intended to promote honest and ethical conduct, deter wrongdoing, promote compliance with all applicable governmental laws, rules and regulations and prompt internal reporting of violations and compliance concerns.
  • To assist individuals who want to make reports of fraud on behalf the government, the UHS Code of Conduct spells out what constitutes fraud, and urges employees to immediately report their concerns to Facility Compliance Officer the UHS Compliance Office or anonymously through using the Compliance Hotline (1-800-852-3449) or uhs.alertline.com platform, both which are accessible 24 hours a day, 365 days a year and are managed by an external company.
  • Employees who want to report a problem or concern about inappropriate or unethical actions, not related to fraud, are encouraged to reach out to their supervisors, to management, to Facility Compliance Officers, the UHS Compliance Office or anonymously through using the Compliance Hotline or online
  • UHS prohibits any form of retaliation against an employee who reports, in good faith, acts of misconduct or wrongdoing. Retaliating against someone for expressing a concern is subject to disciplinary action.

Patient Grievance Reporting

All UHS RTFs ensure that patients are informed of their rights and all available procedures for reporting any misconduct as soon as they arrive at the RTF. Patients are also able to report their concerns via the UHS Compliance Hotline/platform, however, are more likely to reach out to their Patient Advocate or other means.

  • CMS requires a very specific process to address patient grievances including how and when to follow-up with the patient after a review of the grievance itself. Facilities’ Patient Advocate (and leadership, if needed) handles patients’ grievances in accordance with these CMS requirements.
  • Each facility responds quickly to all deficiencies identified by regulators, regardless how minor.
  • Compliance and Risk Management teams promptly conduct a thorough investigation of incidents, using tools such as Root Cause Analysis, and create an action plan to reduce the possibility of similar future events. This may include enacting new policies and ensuring that all responsible parties are held accountable. When appropriate, the matter may be turned over to law enforcement.
  • Similarly, for grievances, once a report from an employee or patient is received, an appropriate person will conduct an investigation to determine the nature, scope and duration of wrongdoing. If the allegations are substantiated, a plan for corrective action will be developed and when necessary, remedial action will be implemented.
  • Corrective Action Plans and other remedial actions will typically include, among other actions, personal education and training, additional monitoring and auditing, and can involve reporting to outside agencies as required.

Each year, a compliance risk assessment is conducted, and a compliance work plan is developed to identify potential risk and prioritize compliance efforts. Such efforts include expansion of education and training offerings, improvement of program effectiveness and identification of topics for auditing and monitoring (e.g., billing, privacy of patient information, quality of care, etc.).