COMPLIANCE 9.1 FACILITY SURVEILLANCE VIDEO CAMERA RECORDING

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

2% To provide direction for retention of video surveillance recordings in the facility,
as well as, for the destruction of same.

Procedure:

A. Video footage from surveillance cameras at a facility should be maintained and copied to
a DVD, ?ash drive or other appropriate storage device under any of the following
circumstances:

i. If such footage is related to a Probable Claim Report (PCR) matter and/or
for liability claims, as warranted;
ii. For an incident resulting in potential employment/employee disciplinary
action;
For signi?cant patient injuries as a result of a restrictive intervention, as
. warranted;
iv? For any allegations of rape, assault or other physical altercations involving
patients or residents; and
v. At the direction of the Assistant Corporate Risk Manager

Absent these circumstances, video from surveillance cameras is not required to be
maintained and may be reused or destroyed in accordance with normal video surveillance

practices of the facility.

B. Video footage from surveillance cameras shall be retained and secured if a claim is made
by a patient and/or their representatives. Such video footage will be maintained by the
facility until the case is resolved. Upon request from the Director of Claims, UHS
Insurance Department, a copy of any such video footage will be sent to the UHS
Insurance Department. The UHS Insurance Department shall notify the facility when a
claim has been concluded so the video footage may be destroyed at that time.

C. Video footage from surveillance cameras, other than related to a third party claim or
litigation related matter referenced above, should be retained according to the following

timeframes:

0 For matters associated with a PCR where no claim has been ?led, video
footage shall be maintained for a period of two (2) to three (3) years
following the date of incident, based on the statute of limitations in that
State.

For matters associated with a PCR involving a minor, video footage shall

be maintained for a period of two (2) to three (3) years following the date
of incident, based on the statue of limitations in that State. Video footage

 

 

shall not be destroyed until the Corporate Claims Department has been
noti?ed.

For matters addressed in subsection above, video footage shall be
maintained for a period of one (1) year following the date of incident.

In the event the facility receives noti?cation of a Legal Hold based upon a
potential claim, investigation, regulatory action or litigation, all relevant
video footage shall be retained until noti?ed by the UHS Legal
Department that the Legal Hold is no longer in effect.

D. The facility should maintain a log of all secured and retained video footage from
surveillance cameras to include:

The name of the patient, incident date, reason video is being retained 
PCR, employment matter, etc.) and a description of the incident.

0 The facility Risk Manager and Human Resource Director should review
the video retention log, at a minimum, each quarter and destroy videotape
that has passed set expiration times. The log shall be updated to re?ect
video footage which has been destroyed and the date of destruction.

E. In order to ensure compliance with all privacy laws and regulations and to avoid liability
associated with any potential improper retention, duplication or unintended
dissemination of retained video footage, any copies of such footage retained in
accordance with this policy should be destroyed in such a manner so the copy is not
accessible or viewable. No copies of the video footage should be maintained nor
distributed to anyone either inside or outside of the facility beyond the guidance and
instructions in this policy. Additional guidance on the use photographs and/or
recordings of patients can be found in UHS Privacy 13.0 Photographs, Videotapes, and
Other Recordings.

F. Inappropriate retention or dissemination of video footage in violation of this policy can
result in disciplinary action taken against the responsible party or parties including but
not limited to immediate termination.

Related UHS Policies:
UHS Privacy 13.0 Photographs, Videotapes, and Other Recordings

UHS Privacy 16.0 Disclosures for Law Enforcement Purposes

 

Revision Dates:
10-01-2015; 12-30-2011
Implementation Date: 12?3 0-2011
Reviewed and Approved by:
James M. Caponi, Esq., Chief Compliance Of?cer

Karen E. Johnson, Sr. Vice President, Clinical
Services BH Divisional Compliance Of?cer