COMPLIANCE 9.0

CONDUCTING INTERNAL INVESTIGATIONS

Scope:
All subsidiaries of Universal Health Services, Inc., including facilities and UHS
of Delaware Inc. and their personnel.
Purpose:

Procedures for Conducting Internal Compliance Investigations.

Policy:
UHS is committed to full compliance with applicable state, federal and local laws.
The Chief Compliance Officer shall have the responsibility and authority to conduct and oversee
independent compliance investigations to detect possible violations of the law, with legal
guidance of the UHS Office of General Counsel and/or outside counsel as appropriate. The
extent of the investigation will vary depending upon the matter investigated.
Procedure:
1. The Chief Compliance Officer shall commence and/or oversee investigations on all
compliance-related matters within seven (7) days following receipt of the report
indicating a matter warranting investigation.
2. The Chief Compliance Officer may delegate the investigation responsibilities but will
retain ultimate supervision and responsibility for all compliance investigations.
3. The investigation may include, but is not limited to:
a. reviewing and preserving documents related to the matter;
b. interviewing appropriate individuals;
c. reviewing policies and procedures applicable to the matter;
d. collaborating with an internal UHS of Delaware or facility authority, as needed;
and
e. engaging an outside consultant or authority to assist in the investigation, as
needed. PLEASE NOTE: The use of outside counsel for an investigation
requires the authorization of the General Counsel’s Office or the Chief
Compliance Officer.
4. If a significant compliance violation is found, the Chief Compliance Officer and/or
Division Compliance Officer shall develop and implement a corrective action plan, in
consultation with the Facility Compliance Officer and, if needed, with other departments

 within the facility or UHS of Delaware, such as Human Resources or the Office of
General Counsel.
5. All investigation methods and findings pursuant to the investigation must be documented.
Copies of supporting documents should be attached to all reports.
a. If the investigation findings do not substantiate the allegation or matter, the
investigation will be closed by the Chief Compliance Officer. Documentation
regarding the investigation will be filed and maintained by the Chief Compliance
Officer and the applicable Facility Compliance Department for a minimum of
seven (7) years after the investigation has closed and will be subject to the
requirements of Compliance Policy 12.0 Compliance Document Retention.
b. If a compliance violation is found, all documentation related to the investigation
will be maintained as an "open" investigation until a corrective action plan has
been completed and the matter has been resolved, at which time the investigation
will be closed by the Chief Compliance Officer. Once closed, the investigation
file will be filed and maintained by the UHS Corporate Compliance Office and
the applicable Facility Compliance Department for a minimum of seven (7) years
after the investigation has been closed and will be subject to the requirements of
Compliance Policy 12.0 Compliance Document Retention.
6. For investigations implicating a facility CEO, the Chief Compliance Officer shall notify
the Divisional President, the CEO’s Regional Vice-President, and Human Resources to
decide who shall conduct the investigation. For investigations implicating the FCO, the
Chief Compliance Officer shall notify the CEO of the facility and the Chief Compliance
Officer and/or Division Compliance Officer will conduct and coordinate the
investigation. For investigations implicating the Division Compliance Officer, the Chief
Compliance Officer will conduct and coordinate the investigation. Investigations
implicating the Chief Compliance Officer will be handled by the UHS Office of General
Counsel.

 
 
 
 

Revision Dates:  
10-01-2015; 10-26-2012 
Implementation Date:   10-21-2010 
Reviewed and Approved by: 
UHS Compliance Committee