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CivilRightsComplianceforPatientsWhatYouNeedtoKnowandHowtoHelpYourFacilitiesComply

Objectives

•Attheendofthissessiontheparticipantwill:• IdentifyCivilRightslawasitpertainstohealthcare• Understandrecentenforcementactivity• UnderstandthecomponentsofasuccessfulCivilRightscomplianceprogram

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WHATISTHELAW?

WhatistheLaw?

• Section504oftheRehabilitationActof1973• TitleVIoftheCivilRightsActof1964• AgeDiscriminationActof1975• U.S.DepartmentofHealthandHumanServicesTitle45CodeofFederalRegulations– Parts80,84and91

• Section1557oftheAffordableCareAct• ProposedLaw HHSTitle45CFRPart92• Otherapplicablefederalrightsstatutes

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Section504

• Hearingimpaired• Centerresponsibilityforassessment,careplanning• Signlanguageinterpreterifrequested

• Centerexpense

• Languagebarriers• Centerresponsibilityforassessment,careplanning• Interpreterprovided

CivilRightsActof1964AgeDiscriminationActof1975• CivilRightsAct

• TitleVIpreventsdiscriminationbygovernmentagenciesthatreceivefederalfunding

• AgeDiscriminationAct• Doesnotcoveremploymentdiscrimination• LawstatesnopersonintheU.S.shall,onthebasisofage,beexcludedfromparticipationin,bedeniedthebenefitsof,orbesubjectedtodiscriminationunderanyprogramoractivityreceivingfederalfinancialassistance

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U.S.HHSTitle45CFRParts80,84,and91• Part80

• EffectuatestheprovisionsofTitleVIofCRAof1964• NopersonintheU.S.shallonthegroundsofrace,color,ornationaloriginbeexcludedfromparticipationin,bedeniedthebenefitsof,orbeotherwisesubjectedtodiscriminationunderanyprogramoractivityreceivingfederalfinancialassistanceforDHHS

• Part84• ReferstoSection504• Noqualifiedhandicappedpersonshall,onthebasisofhandicap,beexcludedfromparticipationin,bedeniedbenefitsof,orotherwisebesubjectedtodiscriminationunderanyprogramoractivitywhichreceivesbenefitsfromfederalfinancialassistance

• Part91• Prohibitsdiscriminationbasedonthebasisofageinprogramsoractivitiesreceivingfederalfinancialassistance

AffordableCareActSection1557• 2010‐ AffordableCareAct

• Prohibitsdiscriminationonthebasisofsexinhealthcare

• ExtendedtoallindividualsenrolledincoveragethroughtheHealthInsuranceMarketplacesandcertainotherhealthcoverageplans

• AllHHShealthprogramsarecoveredbythisrule

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ProposedLaw– 45CFRPart92

• PurposeistoimplementSection1557ofACA• Prohibitsdiscriminationonthebasisofrace,color,nationalorigin,sex,age,disabilityorassociationincertainhealthprogramsandactivities

• Individualsshallnotbeexcludedfrom,bedeniedthebenefitsof,orbesubjectedtodiscriminationunderanyhealthprogramoractivitythatisadministeredbytheExecutiveAgencyoranyentityestablishedunderTitleIoftheACA

PURPOSE&DEFINITIONS

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Purpose

•Mustbeabletoprovidepropercaretopatients

•Thelawswearediscussingtodayareintendedtoprovideallpatientswithmeaningfulaccesstoservices

DiscriminationTypesAffordableCareActandProposedRule• Race• Color• Nationalorigin• Sex• Age• Disability• Association

• Cannotdiscriminateagainstanindividualonthebasisofrace,color,nationalorigin,age,disability,orsexofanindividualwithwhomtheindividualisknownorbelievedtohavearelationshiporassociation

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DiscriminationTypesAffordableCareActandProposedRule• Disability

• Visuallyimpaired• Blind,lowvision

• Hearingimpaired• Deaf,hardofhearing

• LimitedEnglishProficiency(LEP)• IndividualwhoseprimarylanguageforcommunicationisnotEnglishandwhohaslimitedabilitytoread,write,speak,orunderstandEnglish

DiscriminationTypesAffordableCareActandProposedRule• Gender• GenderIdentity

• Individual’sinternalsenseofgender,whichmaybedifferentthanthatindividual’ssexassignedatbirth– transgender

• Thewayanindividualexpressesgenderidentityisfrequentlycalledgenderexpression

• Mayormaynotconformtosocialstereotypesassociatedwithgender

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DiscriminationTypes‐ Other

• Religion• MaritalStatus• SexualOrientation• Pregnancy

• Falsepregnancy• Terminationofpregnancy• Recoveryfromchildbirthorrelatedmedicalconditions

• GeneticInformation• Amnesty• Statusascoveredveterans

Non‐Discrimination– SampleStatement

• Thecoveredentitycannotdenybenefitsto,orotherwisediscriminateagainstanypersononanygroundsprohibitedbyfederal,stateorlocallawsonthebasisofrace,color,religion,nationalorigin,gender,genderidentity,sexualorientation,age,disability,maritalstatus,pregnancy,ancestry,geneticinformation,amnestyorveteranstatusinadmissionto,participationin,orreceiptoftheservicesandbenefitsunderanyofitsprogramsandactivities.

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ENFORCEMENT

EvaluationoftheComplaint• OfficeofCivilRights(OCR)carefullyreviewsallcomplaintsreceived

• TheentityidentifiedinthecomplaintmustbeunderOCR’sjurisdiction

• Thecomplaintmustallegeanaction,policyorprocedurecoveredbyrelevantlawsandregulationsprohibitingdiscrimination

• Thecomplaintmustbefiledwithin180daysfromwhenthecomplainantkneworshouldhaveknownoftheallegeddiscrimination

• Consentrequiredfromcomplainantswherethenamemustberevealedinordertoinvestigate• Casewillnotproceedifcomplainantrefusestoconsent

• Complainantmaybecontactedformoreinformationtodetermineifabovecriteriaaremet

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OCRwilldismissif….

• Nolegalauthority• Complaintfailstostateaviolationofthelaw• Complaintisnotfiledtimelyandwaivernotgranted• Complaintisunclearorincomplete

• 20daystosubmitmoreinfoifrequested• Allegationshavebeenresolved• Allegationsinvestigatedandresolvedbyanotheragency• Sameallegationshavebeenfiledbythecomplainantinstateorfederalcourt

• Allegationsareforeclosedbypreviousdecisions

InvestigationProcess

• CaseOpened• Notification

• Lettersofnotificationissuedtocomplainantandcoveredentity

• InformationGathered• OCRisneutralfact‐finder• Interviewwitnesses,includingthecomplainant• Obtaindocumentation• Sitevisitswhereappropriate

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DeterminationofFindings

• InsufficientevidencetosupportconclusionthatthecoveredentityfailedtocomplyOR

• Preponderanceofevidencesupportsrecipientfailedtocomply

• Lettersenttocomplainantandrecipientcontainsfactbasedfindings

Resolution– NonCompliance

• OCRcontactscoveredentitytonegotiatevoluntaryresolution• Writtenresolutionagreement• Describesremedialactiontoaddressareasofnon‐compliance• ImplementationmonitoredbyOCR

• Ifcoveredentityrefusestonegotiatevoluntaryresolution:• OCRinformsof30dayrequirementtoengageinnegotiations• LetterofFindingprovidingfactualandlegalbasisforfindingofnoncompliance

• Ifthecoveredentitycontinuestorefusenegotiations• OCRissuesLetterofImpendingEnforcement

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EnforcementActions

•Administrativeenforcementtosuspend,terminate,orrefusetograntorcontinuefederalfinancialassistancetotherecipient

•PossiblereferraltoDOJ•Maydeferanyneworadditionalfederalfinancialassistancetothecoveredentity

•Anissuemayoccurinonlyonecenter,butmayimpactALLcentersinportfolio

EnforcementExamples• March2013

• MDNursingHomeSettlementAgreement• Failuretoprovidesignlanguageinterpreterservicestoadeafpatient• 30monthenforcement– includedprovisionsforauxiliaryaids/services,training,outreach,advisorycommittee,monitoringandreporting

• August2015• 3deafresidentssueILnursinghome(civillawsuit)forfailuretoprovideinterpretersinorderto

communicatewithstaff,participateindailycare,orunderstandtreatmentsprovided• July2015

• VANursingHomeSettlementAgreement• Failuretoprovideauxiliaryaidsandservices• Failuretoprovideinterpreterstocommunicatewithresident’scompanionsregardingcare&treatment• 3yearenforcement‐ includedprovisionsforprovidingauxiliaryaids/servicesandinterpreters,designatedADAAdministrator,complaintresolutionprocess,training,notificationrequirements,periodiccompliancereports,monetaryfundtotrainotherVAfacilitiesonbestpractices,monetarycompensationtocomplainants

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HOWTOCOMPLY

HowtoComply

• Note:RecommendationsweareprovidingarebasedonourspecificexperienceandtheProposedAnti‐DiscriminationLaw

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CivilRightsComplianceElements

• Coordinator• Policies&Procedures• Postings• Training• IdentificationofServices• ProvisionofServices• InvestigationofGrievances•Monitoring

CivilRightsCoordinator

• DesignateaCivilRightsCoordinator• Corporate• Eachbusinesslocation

• ResponsibleforoversightoftheCivilRightsProgramelements

• Responsibleforinvestigatinggrievancesallegingnon‐compliance

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Policies&Procedures

• InadditiontoinformationinyourCodeofConduct,EmployeeHandbook,ResidentsRightsPolicyandotherstandardpolicies:

• DevelopwrittenpoliciestoaddressCivilRightsProgram• Non‐Discrimination• Grievanceprocess• CommunicationwithLEPPersons• ProcedureforAuxiliaryAids

Postings• NoticeofNon‐Discrimination

• CoveredEntity(CE)doesnotdiscriminate• CEprovidesappropriateauxiliaryaidsandservices

• IncludingQualifiedInterpretersandinformationinalternateformats• Freeofchargeandinatimelymanner

• CEprovideslanguageassistanceservices• Howtoobtainaidsandservices• Identificationofresponsibleemployeeandcontactinformation• Availabilityofgrievanceprocedure/howtofileagrievance• HowtofilediscriminationcomplaintwithOCR• Englishlanguageand15toplanguagetaglines

• Taglines:shortstatementsinnon‐Englishthatindicatetheavailabilityoflanguageassistanceservicesfreeofcharge

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RecommendedPostings

• AdditionalPostings• Recommended,butnotRequired

• SeparateCivilRightsGrievancePosting• ConfidentialDisclosureProgram(e.g.,hotline)

• Note:RecommendationsarebasedontheProposedAnti‐DiscriminationLaw

Training

•Whoshouldbetrained?• Allstaff

• Locationlevel• Corporatelevel

• Contractors(e.g.,physiciansandphysicianextenders)• Regularvolunteers(e.g.,weekly,monthly)thatarelikelytocomeincontactwithpatients

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Training

• Howtrained?• On‐Line• Classroom• CollectAcknowledgment• OtherMethods(e.g.,intranetpostings,corporatenewsletters)

• Frequency?• UponHire• Annually• Periodicasnecessary

Training– OtherResources

•DedicatedIntranetPage• Links

• HowtoarrangeforInterpreterServicesandLanguageAssistance• ReferenceGuides

• CueCardsandotherlanguageaids• FAQs• StateResources• TrainingInformation• CorporateCivilRightsContactInformation

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IdentificationofServices• Pre‐Admission

• Disabilitiesorcommunicationbarriersshouldbedocumentedinthepre‐admissionassessment• E.g.,hardofhearing,LEP,signlanguageneeds

• Admission• Admissionpacketincludesnoticeofnon‐discrimination• Documentpatient’sunderstandingofinterpreterservicesthatareavailablefreeofcharge• Documentuseoffamilymember,advocate,orfriendofresidentthathasbeendesignatedasaninterpreter• Documentmethodofcommunicationwithpatient’scompanion

• Designeetocommunicatewithstaffonpatient’sbehalf• Anypersonwithwhomstaffwouldnormallycommunicateregardingthepatient’scare,conditionortohelppatientactontheadvice,information,orinstructionsfromstaff

• Considerspecificadmissionform• Ongoing

• SpecificCarePlan• Monitorfornewormodifiedservices

ProvisionofServices‐ LEP• LanguageAssistanceRequirements

• Musttakereasonablestepstoensuremeaningfulaccessforthepatient• Mustbeprovidedfreeofcharge,beaccurateandtimely,andprotecttheprivacyoftheLEPindividual

• InterpreterServices• Telephonicorvideoremoteinterpreter(VRI)

• Arrangecontractinadvance• HIPAABusinessAssociate

• Ensurestafftrainedonaccesstovendor/system• On‐siteinterpreterortranslatorservices

• Arrangecontractinadvance• HIPAABusinessAssociate

• Ensurestafftrainedonprocessforarrangingservices

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QualifiedInterpreters‐ LEP

• Qualified Interpreters• On‐siteorthroughVideoRemoteInterpreting(VRI)• Abletointerpreteffectively,accurately,andimpartially,bothreceptivelyandexpressively,usinganynecessaryspecializedvocabularyOR

• Hasdemonstratedproficiencyin,andhasaboveaveragefamiliaritywithspeakingorunderstanding,bothspokenEnglishandatleastoneotherspokenlanguage• ForanLEPindividual,abletointerpreteffectively,accurately,andimpartially,bothreceptivelyandexpressively,toandfromsuchlanguageandEnglish,usinganynecessaryspecializedvocabulary

InterpreterOptions‐ LEP

• OtherOptions• Bi‐lingualstaff

• Consider24/7needsfortranslation• Backupmethodshouldbeavailable

• Familymembers/companions• ItemstoConsider

• Confidentialityconcerns• ShouldbeHIPAAdesignee

• Emotionalinvolvement• Otherfactorsthatmayadverselyimpactcommunication

• Ifused,documentinwriting

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InterpreterRestrictions‐ LEP• Acoveredentitymaynot:

• RequireanLEPtoprovideowninterpreter• RelyonanadultaccompanyinganLEPindividualtointerpretunless:

• Emergencyinvolvinganimminentthreattosafetyandwelfareofindividualandnoqualifiedinterpreterisavailable

• LEPindividualspecificallyrequestsaccompanyingadulttointerpret• Relyonminorchildtointerpretunless:

• Emergencyinvolvinganimminentthreattosafetyandwelfareofindividualandnoqualifiedinterpreterisavailable

• Note: AnLEPindividualisnot requiredtoacceptlanguageassistanceservices

ProvisionofServices– Deaf/HardofHearing

• Furnishappropriateauxiliaryaidsandservicestoensureeffectivecommunication• Personwithdisability• Companionswithdisabilities

• Qualifiedinterpreters(signlanguage)• On‐Site

• Arrangecontractinadvance• HIPAABusinessAssociate

• Ensurestafftrainedonprocessforarrangingservices• VideoRemoteInterpreting(VRI)

• Arrangecontractinadvance• HIPAABusinessAssociate

• Ensurestafftrainedonaccesstovendor/system

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AuxiliaryAids

• InterpreterServicesaren’ttheOnlyOption• AdditionalAidsandServicesAvailable• ItemstoConsider

• Whatisthepatientcomfortableusing?• Familymemberneeds• StaffEducationonobtainingservices• Ensureitemsavailableinadvance

AuxiliaryAidsandServicesHearingImpaired/LEP• Notetakers• Computer‐aidedtranscriptionservices•Writtenmaterials• Exchangeofwrittennotes• Telephonehandsetamplifiers• Assistivelisteningdevices• Telephonescompatiblewithhearingdevices• Closedcaptiondecoders

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AuxiliaryAidsandServicesHearingImpaired/LEP• Openandclosedcaptioning,includingreal‐timecaptioning• Voice,text,andvideo‐basedtelecommunicationproductsandsystems

• Texttelephones(TTYs),videophones,captionedtelephones• Videotextdisplays• Accessibleelectronicandinformationtechnology

• Telephones,informationkiosks,transactionmachines,internetsites,multimedia

AuxiliaryAidsandServicesVisuallyImpaired• Qualifiedreaders• Tapedtexts• Audiorecordings• Braillematerialsanddisplays• Magnificationsoftware• Opticalreaders• Secondaryauditoryprograms(SAP)• Largeprintmaterials• Accessibleelectronicandinformationtechnology

• Telephones,informationkiosks,transactionmachines,internetsites,multimedia

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ServiceAnimals

• Serviceanimalsreferstodogs• Reasonableaccessmustbeprovidedtotheresident

• Residentmustbeabletocarefortheanimal• Theresidentisresponsibleforanycostassociatedwiththeanimal’swellbeing

• Theanimalmustbecontrolled• Itisnotreasonabletoexpectstafftocarefortheanimalorforthecentertopayforveterinarianbills,animalfood,litterboxesandlitter,etc.

Monitoring

• MonitorCivilRightsProgramElements• InterviewCivilRightsCoordinatorandsampleofstaff

• Knowledgeofprogramrequirements• Howtoidentifyinterpreterorlanguageassistanceservices• Didyoureceiveanygrievances,howresolved?

• Checkfortraining– Employees,VendorsandVolunteers• Observeifrequiredpostingsareinplace• Reviewdocumentationatpre‐admission• Reviewadmissionpacketdocumentation– noticeofnon‐discrimination• Reviewsampledocumentationofinterpreterservicesdiscussion/formuponadmission

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OTHERRESOURCES

Resources

• OCRWebsite• http://www.hhs.gov/civil‐rights/index.html

• ADAWebsite• http://www.ada.gov/

• ContactInfo• SueSmithsue.smith@genesishcc.com• LauraLoftislaura.loftis@genesishcc.com

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QUESTIONS?