Civil Rights Information Request Form – Fill Out and Use This PDF

Form Approved

OMB No. 0945-0006

Exp. Date 04/30/2017

DEPARTMENT OF HEALTH & HUMAN SERVICES

Office for Civil Rights (OCR)

Civil Rights Information Request

For Medicare Certification

Instructions: Healthcare providers applying f or participation in the Medicare Part A program must receive a civil rights clearance from OCR. Complete all fields and return this form, with the required policies and procedures, to your State Health Department, along w ith your other Medicare application materials.

I. Healthcare Provider Information

CMS Medicare Provider Number:

Name of Fac ility:

Address:

Street Number and Name
City or Town	State or Province	Z ip Code
Admin istrator 's Name:	Contact Person:
Telephone:	TOO:
FAX:	E-mail:
Type of Fac ility:	Number of employees:
	Reason fo r Application:	Circle One

CertificationOwnership

You can complete this form and submit your policies electronically via the OCR Portal a t https://ocrportal.hhs.gov/ocr/pgportal!index.jsf.

(Please note, if using the electronic Civil Rights Information Requestfor Medicare Certification Package via the Portal, yo u do not have to submit any hard copies. Your State Health Department will be info rmed that you have completed this Package and submilled 1tto OCR. No further action will be needed by y ou. 7he Porta/will guide you through completing the Package, and help you develop and submit your policies that meet your civil rights requirements.)

II. Documents Required for Submission

For guidance or to obtain san1ple policies and procedures, please visit the OCR Technical Assistance for Medicare Providers and Applicants web page at http://\\ W\\ .hhs.gov/ocr/civilrightslclearancc/indcx. html. (When Sllbmilling hard copies to your State Health Department.)

1.Assurance of Compliance Form, HH S-690 (completed, signed and dated).

2.Nondiscrimination Policy that provides for a dmission a nd se rvices without regard to race, color, national origin, disability, or age, as required by Title VI of t he C ivil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975. (C lick to see samp le policy) Learn more about the regu latory reguirements

3.Description of methods used to disseminate yo ur nondiscrimin ation policies/notices:

a)Describe where you post your No ndiscrimination Policy;

b)Include brochures, websites, pamphlets, postings, or ads with general informa tion about your services.

4.Facility admissions policy that describes eligibility requirements for your services.

5.A d escription/explanation of any policies or practices restricting or limiting your facility's admissions or services on the basis of age. In certain narrowly defined circ um sta nces, age restrictions are permitted.

Learn more about the regulato[Y reg uiremen ts

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For h ealthcare providers with 15 or more e mployees: copy of your procedures used for ha ndlin g disability discrimin ation grieva nces along with the name/title a nd telephone number of t he Section 504 coordinator. (C lick to see sample golic y) Learn more about the re gu lato[Y rcguirements

According to t he Paperwork Reduction Act of 1995, no persons are required to respond to a collection of Information unless It displays a valid OMB control number. The valid OMB control number for this Information collection Is 0990­0243. The t ime required to complete th is Information collection Is estimated to average 8 hours per response, Includ ing the t ime to review Instructions, search existing data resources, gat her the data needed, and complete and review the Information collection . If you have comments concerning the accuracy of the t ime est lmate(s) or suggestions for Improving this form, please write to: U.S. Department of Health & Human Services, OS/OCI O/PRA, 200 Independence Ave., S. W., Suite 336­E, Washington D.C. 20201, Attention : PRA Reports Clearance Officer

Form Approved

OMB No. 0945­0006

Exp. Date 04/30/2017

DEPARTMENT OF HEALTH & HUMAN SERVICES

Office for Civil Rights (OCR)

Civil Rights Information Request

For Medicare Certification

II. Documents Required for Submission (Continued)

For guidance or to obtain sample policies and procedures, please visit the OCR Technical Assistance for Medicare Providers and Applicants web page at httn://www.hhs.gov/ocr/civ ilrights/clearance/indcx.html. (When submitting hard copies to your S tate Health Department)

7.

Procedures to effectively communicate with persons who are limited English proficient (LEP), including:

a)Process for bow you identify individuals who need language assistance;

b)Procedures to provide services (interpreters, written translations, bilingual staff, etc.). Include the name(s)

and telephone number(s) of your interpreter(s) and/or interpreter service(s);

c)Methods to inform LEP persons that la nguage assistance services are available at no cost to the person being served;

d)Appropriate restrictions on the use of family a nd friends as LEP interpreters;

e)A list of all written materials in other languages, if applicable. Examples may include consent and complaint forms , intake forms, written notices of eligibility criteria, nondiscrimination notices, etc. (C lick to see samg le go licx) Learn more about the regulatorx reguirements

8.Procedures used to communicate effectively with individua ls who are deaf, hard of hearing, blind, have low vision, or who have other impaired sensory, manual or speaking skills, including:

a)Process to identify individu a ls who need sign langu age interpreters or other assistive services;

b)Procedures to provide interpreters and other auxiliary aids and services. Include the name(s) and telephone number(s) of your interpreter(s) and/or interpreter service(s);

c)Procedures used to communicate with deaf or hard of hearing persons over the telephone, including the telephone number of your TTY/ TDD or State Relay System ;

d)A list of available auxilia ry a ids and serv ices;

e)Methods to inform persons that interpreter or other assistive services are available at no cost to the person being served;

f)Appropriate restrictions on the use of family and friends as sign language interpreters. (Click to see samgle

ｾｌ･｡ｲｮ＠more about the regulatorx requirements

9.Notice of Program Accessibility and methods used to disseminate informa tion to patients/clients about the existence and location of services and facilities that are accessible to persons with disabilities. (Click to see samg le

ｾLearn more about the regu latorx regu irements

m. Certification

I certify that the information provided to the Office fo r C ivil Rights is true, complete, and correct to the best of my knowledge .

Name and T itle of Authorized Official

Signature

Date

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Nondiscrimination Policies and Notices

The regulations implementing Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975 require health and human service providers that receive Federal financial assistance from the Department of Health and Human Services to provide notice to patients/residents, employees, and others of the availability of programs and services to all persons without regard to race, color, national origin, disability, or age.

Applicable Regulatory Citations:

Title VI of the Civil Rights Act of 1964: 45 CFR Part 80

§80.6(d) Information to beneficiaries and participants. Each recipient shall make available to participants, beneficiaries, and other interested persons such information regarding the provisions of this regulation and its applicability to the program for which the recipient receives Federal financial assistance, and make such information available to them in such manner, as the responsible Department official finds necessary to apprise such persons of the protections against discrimination assured them by the Act and this regulation.

Section 504 of the Rehabilitation Act of 1973: 45 CFR Part 84

§84.8 Notice. (a) A recipient that employs fifteen or more persons shall take appropriate initial and continuing steps to notify participants, beneficiaries, applicants, and employees, including those with impaired vision or hearing, and unions or professional organizations holding collective bargaining or professional agreements with the recipient that it does not discriminate on the basis of handicap in violation of section 504 and this part. The notification shall state, where appropriate, that the recipient does not discriminate in admission or access to, or treatment or employment in, its programs and activities. The notification shall also include an identification of the responsible employee designated pursuant to §84.7(a). A recipient shall make the initial notification required by this paragraph within 90 days of the effective date of this part. Methods of initial and continuing notification may include the posting of notices, publication in newspapers and magazines, placement of notices in recipients' publication, and distribution of memoranda or other written communications.

(b)If a recipient publishes or uses recruitment materials or publications containing general information that it makes available to participants, beneficiaries, applicants, or employees, it shall include in those materials or publications a statement of the policy described in paragraph (a) of this section. A recipient may meet the requirement of this paragraph either by including appropriate inserts in existing materials and publications or by revising and reprinting the materials and publications.

Age Discrimination Act: 45 CFR Part 91

§91.32 Notice to subrecipients and beneficiaries. (b) Each recipient shall make necessary information about the Act and these regulations available to its program beneficiaries in order to inform them about the protections against discrimination provided by the Act and these regulations.

See Policy Example Section for examples of Nondiscrimination Policies.

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Communication with Persons Who Are Limited English Proficient

In certain circumstances, the failure to ensure that Limited English Proficient (LEP) persons can effectively participate in, or benefit from, federally­assisted programs and activities may violate the prohibition under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d, and the Title VI regulations against national origin discrimination. Specifically, the failure of a recipient of Federal financial assistance from HHS to take reasonable steps to provide LEP persons with a meaningful opportunity to participate in HHS­funded programs may constitute a violation of Title VI and HHS's implementing regulations. It is therefore important for recipients of Federal financial assistance, including Part A Medicare providers, to understand and be familiar with the requirements.

Applicable Regulatory Citations:

Title VI of the Civil Rights Act of 1964: 45 CFR Part 80

§80.3 Discrimination prohibited.

(a)General. No person in the United States shall, on the ground of race, color, or national origin be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program to which this part applies.

(b)Specific discriminatory actions prohibited. (1) A recipient under any program to which this part applies may not, directly or through contractual or other arrangements, on ground of race, color, or national origin:

(i)Deny an individual any service, financial aid, or other benefit under the program;

(ii)Provide any service, financial aid, or other benefit to an individual which is different, or is provided in a different manner, from that provided to others under the program;

(iii)Subject an individual to segregation or separate treatment in any matter related to his receipt of any service, financial aid, or other benefit under the program;

(iv)Restrict an individual in any way in the enjoyment of any advantage or privilege enjoyed by others receiving any service, financial aid, or other benefit under the program;

(v)Treat an individual differently from others in determining whether he satisfies any admission, enrollment, quota, eligibility, membership or other requirement or condition which individuals must meet in order to be provided any service, financial aid, or other benefit provided under the program;

(vi)Deny an individual an opportunity to participate in the program through the provision of services or otherwise or afford him an opportunity to do so which is different from that afforded others under the program (including the opportunity to participate in the program as an employee but only to the extent set forth in paragraph (c) of this section).

(vii)Deny a person the opportunity to participate as a member of a planning or advisory body which is an integral part of the program.

(2)A recipient, in determining the types of services, financial aid, or other benefits, or facilities which will be provided under any such program, or the class of individuals to whom, or the situations in which, such services, financial aid, other benefits, or facilities will be provided under any such program, or the class of individuals to be afforded an opportunity to participate in any such program, may not, directly or through contractual or other arrangements, utilize criteria or methods of administration which have the effect of subjecting individuals to discrimination because of their race, color, or national origin, or have the effect of defeating or substantially impairing accomplishment of the objectives of the program as respect individuals of a particular race, color, or national origin.

Resources

For further guidance on the obligation to take reasonable steps to provide meaningful access to LEP persons, see HHS' "Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons," available at

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http://www.hhs.gov/ocr/lep/. This guidance is also available at http ://www.lep .gov/, along with other helpful information pertaining to language services for LEP persons.

Technical Assistance for Medicare and Medicare+Choice organizations from the Centers for Medicare and Medicaid for Designing, Conducting, and Implementing the 2003 National Quality Assessment and Performance Improvement (QAPI) Program Project on Clinical Health Care Disparities or Culturally and Linguistically Appropriate Services­ http ://www.cms.hhs .gov/healthplans/quality/project03.asp

Examples of Vital Written Materials

Vital written materials could include, for example:

•Consent and complaint forms .

•Intake forms with the potential for important consequences.

•Written notices of eligibility criteria, rights , denial, loss , or decreases in benefits or services, actions affecting parental custody or child support, and other hearings.

•Notices advising LEP persons of free language assistance.

•Written tests that do not assess English language competency, but test competency for a particular license, job, or skill for which knowing English is not required .

•Applications to participate in a recipient's program or activity or to receive recipient benefits or services.

Nonvital written materials could include:

•Hospital menus.

•Third party documents, forms , or pamphlets distributed by a recipient as a public service.

•For a non­governmental recipient, government documents and forms .

•Large documents such as enrollment handbooks (although vital information contained in large documents may need to be translated).

•General information about the program intended for informational purposes only.

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Auxiliary Aids and Services for Persons with Disabilities

Applicable Regulatory Citations:

Section 504 of the Rehabilitation Act of 1973: 45 CFR Part 84

§84.3 Definitions

(h)Federal financial assistance- means any grant, loan ... or any other arrangement by which [DHHS] makes available ... funds; services ...

(j)Handicapped person- means any person who has a physical or mental impairment which substantially limits one or more major life activities, has a record of such an impairment, or is regarded· as having such an impairment.

(k)Qualified handicapped person means ­ (4) With respect to other services, a handicapped person who meets the essential eligibility requirements for the receipt of such services.

§84.4 Discrimination prohibited

(1)General. No qualified handicapped person shall, on the basis of handicap, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives or benefits from Federal financial assistance.

Discriminatory actions prohibited-

(1)A recipient, in providing any aid, benefits, or service, may not, directly or through contractual, licensing, or other arrangements, on the basis of handicap:

(i)Deny a qualified handicapped person the opportunity to participate in or benefit from the aid, benefit, or service;

(ii)Afford a qualified handicapped person an opportunity to participate in or benefit from the aid, benefit, or service that is not equal to that afforded other;

(iii)Provide a qualified handicapped person with an aid, benefit, or service that is not as effective as that provided to others;

(iv)Provide different or separate aid, benefits, or services to handicapped persons or to any class of handicapped persons unless such action is necessary to provide qualified handicapped persons with aid, benefits, or services that are as effective as those provided to others;

(v)Aid or perpetuate discrimination against a qualified handicapped person by providing significant assistance to an agency, organization, or person that discriminates on the basis of handicap in providing any aid, benefit, or service to beneficiaries of the recipients program;

(vi)Deny a qualified handicapped person the opportunity to participate as a member of planning or advisory boards; or

(vii)Otherwise limit a qualified handicapped person in the enjoyment of any right, privilege, advantage, or opportunity enjoyed by others receiving an aid, benefit, or service.

Subpart F­ Health, Welfare and Social Services

§84.51 Application of this subpart

Subpart F applies to health, welfare, or other social service programs and activities that receive or

benefit from Federal financial assistance ...

§84.52 Health, welfare, and other social services.

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(a)General. In providing health, welfare, or other social services or benefits, a recipient may not, on the basis of handicap:

(1)Deny a qualified handicapped person these benefits or services;

(2)Afford a qualified handicapped person an opportunity to receive benefits or services that is not equal to that offered non­handicapped persons;

(3)Provide a qualified handicapped person with benefits or services that are not as effective (as defined in§ 84.4(b)) as the benefits or services provided to others;

(4)Provide benefits or services in a manner that limits or has the effect of limiting the participation of qualified handicapped persons; or

(5)Provide different or separate benefits or services to handicapped persons except where necessary to provide qualified handicapped persons with benefits and services that are as effective as those provided to others .

(b)Notice. A recipient that provides notice concerning benefits or services or written material concerning waivers of rights or consent to treatment shall take such steps as are necessary to ensure that qualified handicapped persons, including those with impaired sensory or speaking skills, are not denied effective notice because of their handicap.

(c)Auxiliary aids. (1) A recipient with fifteen or more employees "shall provide appropriate auxiliary aids to persons with impaired sensory, manual , or speaking skills, where necessary to afford such person an equal opportunity to benefit from the service in question." (2) Pursuant to the Department's discretion, recipients with fewer than fifteen employees may be required "to provide auxiliary aids where the provision of aids would not significantly impair the ability of the recipient to provide its benefits or services ." (3) "Auxiliary aids may include brailed and taped material, interpreters, and other aids for persons with impaired hearing or vision ."

504 Notice

The regulation implementing Section 504 requires that an agency/facility "that provides notice concerning benefits or services or written material concerning waivers of rights or consent to treatment shall take such steps as are necessary to ensure that qualified disabled persons, including those with impaired sensory or speaking skills, are not denied effective notice because of their disability." (45 CFR

§84.52(b))

Note that it is necessary to note each area of the consent, such as:

1.Medical Consent

2.Authorization to Disclose Medical Information

3.Personal Valuables

4.Financial Agreement

5.Assignment of Insurance Benefits

6.Medicare Patient Certification and Payment Request

Resources:

U.S. Department of Justice at www.ada .gov

ADA Business Brief: Communicating with People Who are Deaf or Hard of Hearing in Hospital Settings at http://www.ada .gov/business.htm

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A new on­line library of ADA documents is now available on the Internet. Developed by Meeting the Challenge, Inc., of Colorado Springs with funding from the National Institute on Disability and Rehabilitation Research , this website makes available more than 3,400 documents related to the ADA, including those issued by Federal agencies with responsibilities under the law. It also offers extensive document collections on other disability rights laws and issues. By clicking on one of the general categories in the left column , for example, you will go to a catalogue of documents that are specific to the topic. http://www.dbtac.vcu .edu/adaportal//

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Requirements for Facilities with 15 or More Employees

Applicable Regulatory Citations:

Section 504 of the Rehabilitation Act of 1973:

45 CFR Part 84§84.7 Designation of responsible employee and adoption of grievance procedures.

(a)Designation of responsible employee. A recipient that employs fifteen or more persons shall designate at least one person to coordinate its efforts to comply with this part.

(b)Adoption of grievance procedures. A recipient that employs fifteen or more persons shall adopt grievance procedures that incorporate appropriate due process standards and that provide for the prompt and equitable resolution of complaints alleging any action prohibited by this part. Such procedures need not be established with respect to complaints from applicants for employment or from applicants for admission to postsecondary educational institutions.

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Age Discrimination Act Requirements

The Office for Civil Rights (OCR) of the Department of Health and Human Services (HHS) has the responsibility for the Age Discrimination Act as it applies to Federally funded health and human services programs. The general regulation implementing the Age Discrimination Act requires that age discrimination complaints be referred to a mediation agency to attempt a voluntary settlement within sixty (60) days. If mediation is not successful, the complaint is returned to the responsible Federal agency, in this case the Office for Civil Rights, for action. OCR next attempts to resolve the complaint through informal procedures. If these fail, a formal investigation is conducted. When a violation is found and OCR cannot negotiate voluntary compliance, enforcement action may be taken against the recipient institution or agency that violated the law.

The Age Discrimination Act permits certain exceptions to the prohibition against discrimination based on age. These exceptions recognize that some age distinctions in programs may be necessary to the normal operation of a program or activity or to the achievement of any statutory objective expressly stated in a Federal, State, or local statute adopted by an elected legislative body.

Applicable Regulatory Citations:

45 CFR Part 91: Nondiscrimination on the Basis of Age in Programs or Activities Receiving Federal Financial Assistance From HHS

§91.3 To what programs do these regulations apply?

(a)The Act and these regulations apply to each HHS recipient and to each program or activity operated by the recipient which receives or benefits from Federal financial assistance provided by HHS.

(b)The Act and these regulations do not apply to:

(1)An age distinction contained in that part of a Federal, State, or local statute or ordinance adopted by an elected, general purpose legislative body which:

(i)Provides any benefits or assistance to persons based on age; or

(ii)Establishes criteria for participation in age­related terms; or

(iii)Describes intended beneficiaries or target groups in age­related terms.

Subpart B­Standards for Determining Age Discrimination

§91.11 Rule against age discrimination.

The rules stated in this section are limited by the exceptions contained in §§91.13 and 91.14 of these regulations.

(a)General rule: No person in the United States shall, on the basis of age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any program or activity receiving Federal financial assistance.

(b)Specific rules: A recipient may not, in any program or activity receiving Federal financial assistance, directly or through contractual licensing, or other arrangements, use age distinctions or take any other actions which have the effect, on the basis of age, of:

(1)Excluding individuals from, denying them the benefits of, or subjecting them to discrimination under, a program or activity receiving Federal financial assistance.

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(2) Denying or limiting individuals in their opportunity to participate in any program or activity receiving Federal financial assistance.

(c) The specific forms of age discrimination listed in paragraph (b) of this section do not necessarily constitute a complete list.

§91.13 Exceptions to the rules against age discrimination: Normal operation or statutory objective of any program or activity.

A recipient is permitted to take an action, otherwise prohibited by§ 91.11, if the action reasonably takes into account age as a factor necessary to the normal operation or the achievement of any statutory objective of a program or activity. An action reasonably takes into account age as a factor necessary to the normal operation or the achievement of any statutory objective of a program or activity, if:

(a)Age is used as a measure or approximation of one or more other characteristics; and

(b)The other characteristic(s) must be measured or approximated in order for the normal operation of the program or activity to continue, or to achieve any statutory objective of the program or activity; and

(c)The other characteristic(s) can be reasonably measured or approximated by the use of age; and

(d)The other characteristic(s) are impractical to measure directly on an individual basis.

§91.14 Exceptions to the rules against age discrimination: Reasonable factors other than age.

A recipient is permitted to take an action otherwise prohibited by§ 91.11 which is based on a factor other than age, even though that action may have a disproportionate effect on persons of different ages. An action may be based on a factor other than age only if the factor bears a direct and substantial relationship to the normal operation of the program or activity or to the achievement of a statutory objective.

§91.15 Burden of proof.

The burden of proving that an age distinction or other action falls within the exceptions outlined in §§ 91.13 and 91.14 is on the recipient of Federal financial assistance.

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Sample Policies

The next few pages contain samples of policies that you could use as guidance in developing civil rights policies and procedures for your facility. You may modify them to best reflect your procedures and methods.

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Samples for Nondiscrimination Policies

Directions:

•Use Sample One for posting in your facility and inserting in advertising or admissions packages.

•Use Sample Two for short brochures, publications, pamphlets, etc.

•Insert the appropriate words inside the parentheses and remove the parentheses.

•Make sure that the policy that you develop below is one that your facility intends to implement.

I I

Sample One (for posting in your facility and inserting in admissions packages, etc.)

ｎｯｮ､ｩｳ｣ｲｩｭｩｮｾｴｩｯｮ＠Policy

As a recipient of Federal financial assistance, (name of provider) does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, national origin, disability, or age (and any other bases that you wish to include,

such as sex, sexual orientation, gender identity, religion, creed, etc.) in admission to,

participation in, or receipt of the services and benefits under any of its programs and activities, and in staff and employee assignments to patients, whether carried out by (name of provider) directly or through a contractor or any other entity with which (name of provider) arranges to carry out its programs and activities.

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964 (nondiscrimination on the basis of race, color, national origin), Section 504 of the Rehabilitation Act of 1973 (nondiscrimination on the basis of disability), the Age Discrimination Act of 1975 (nondiscrimination on the basis of age), regulations of the U.S. Department of Health and Human Services issued pursuant to these three statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91, (and state laws or

corporate policies, etc.).

Additionally, in accordance with Section 1557 of the Patient Protection and Affordable Care Act of 2010, 42 U.S.C. § 18116, (name of provider) does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of sex (including gender identity) in admission to, participation in, or receipt of the services and benefits under any of its health programs and activities, and in staff and employee assignments, whether carried out by (name of provider) directly or through a contractor or any other entity with which (name of provider) arranges to carry out its programs and activities.

In case of questions, please contact:

Provider Name:

Contact Person/Section 504 Coordinator:

Telephone number:

TDD or State Relay number:

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Sample Two (for including in short brochures and pamphlets)

(name of provider) does not discriminate against any person on the basis of race, color, national origin, disability, or age (and any other bases you wish to include) in admission, treatment, or participation in its programs, services and activities, or in employment, or on the basis of sex in its health programs and activities. For further information about this policy, contact: (name of Section 504 Coordinator, phone number, TDD/State Relay).

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Example of a Policy and Procedure for Providing Meaningful Communication with Persons with Limited English Proficiency

POLICY AND PROCEDURES FOR COMMUNICATION WITH PERSONS WITH

LIMITED ENGLISH PROFICIENCY

POLICY:

(Insert name of your facility) will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The policy of (Insert name of your facility) is to ensure meaningful communication with LEP patients/clients and their authorized representatives involving their medical conditions and treatment. The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment forms, financial and insurance benefit forms, etc. (include those documents applicable to your facility). All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients/clients and their families will be informed of the availability of such assistance free of charge.

Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services. All staff will be provided notice of this policy and procedure, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective use of an interpreter.

(Insert name of your facility) will conduct a regular review of the language access needs of our patient population, as well as update and monitor the implementation of this policy and these procedures, as necessary.

PROCEDURES:

1.IDENTIFYING LEP PERSONS AND THEIR LANGUAGE

(Insert name of your facility) will promptly identify the language and communication needs of the LEP person. If necessary, staff will use a language identification card (or "I speak cards," available online at www.lep.gov) or posters to determine the language. In addition, when records are kept of past interactions with patients (clients/residents) or family members, the language used to communicate with the LEP person will be included as part of the record.

2.OBTAINING A QUALIFIED INTEPRETER

(Identify responsible staff person(s), and phone number(s)) is/are responsible for:

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(For a, •, c laelow, choose onll' whallt appllc•••• lo ••••

facllltv)

(a)Maintaining an accurate and current list showing the name, language, phone number and hours of availability of bilingual staff (provide the list);

(b)Contacting the appropriate bilingual staff member to interpret, in the event

that an interpreter is needed, if an employee who speaks the needed language is available and is qualified to interpret;

(c)Obtaining an outside interpreter if a bilingual staff or staff interpreter is not available or does not speak the needed language.

(Identify the agency(s) name(s) with whom you have contracted or made arrangements) have/has agreed to provide qualified interpreter services. The agency's (or agencies') telephone number(s) is/are (insert number (s)), and the hours of availability are (insert hours).

Some LEP persons may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the LEP person will not be used as interpreters unless specifically requested by that individual and after the LEP person has understood that an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the person's file. If the LEP person chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided to the LEP person.

Children and other clients/patients/residents will not be used to interpret, in order to ensure confidentiality of information and accurate communication.

3.PROVIDING WRITTEN TRANSLATIONS

(a)When translation of vital documents is needed, each unit in (insert name of your facility) will submit documents for translation into frequently­encountered languages to (identify responsible staff person). Original documents being submitted for translation will be in final, approved form with updated and accurate legal and medical information.

(b)Facilities will provide translation of other written materials, if needed, as well as written notice of the availability of translation, free of charge, for LEP individuals.

(c)(Insert name of your facility) will set benchmarks for translation of vital documents into additional languages over time.

4.PROVIDING NOTICE TO LEP PERSONS

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(Insert name of your facility) will inform LEP persons of the availability of language assistance, free of charge, by providing written notice in languages LEP persons will understand. At a minimum, notices and signs will be posted and provided in intake areas and other points of entry, including but not limited to the emergency room, outpatient areas, etc. (include those areas applicable to your facility). Notification will also be provided through one or more of the following: outreach documents, telephone voice mail menus, local newspapers, radio and television stations, and/or community­based organizations (include

those areas applicable to your facility).

5.MONITORING LANGUAGE NEEDS AND IMPLEMENTATION

On an ongoing basis, (insert name of your facility) will assess changes in demographics, types of services or other needs that may require reevaluation of this policy and its procedures. In addition, (insert name of your facility) will regularly assess the efficacy of these procedures, including but not limited to mechanisms for securing interpreter services, equipment used for the delivery of language assistance, complaints filed by LEP persons, feedback from patients and community organizations, etc. (include those areas applicable to your facility).

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Bilingual Individuals

(center location here)

(As of (month and vear submitting information)

Staff Members:

We currently have:

Dno staff members available who are qualified to speak and/or interpret a language other than English.

Dthe following staff member(s) who are qualified to speak and/or interpret a language other than English:

Name:

Title: Phone Number: Language(s) spoken: Hours of Availability:

Name:

Title: Phone Number: Language(s) spoken: Hours of Availability:

Contractors:

The Director of Clinical Services, (First Name, Last Name -phone number), is responsible for maintaining a list of local bilingual interpreters/translators.

The Director of Clinical Services has chosen the following interpreter/translator to ensure that qualified persons with Limited English Proficiency (LEP) can adequately communicate with Hospice staff members.

Company/Organizatio

n:

Contact Person: Address: Address: City/State/Zip: Voicemail:

Fax:

Email:

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Example of a Policy and Procedure for Providing Auxiliary Aids for Persons

with Disabilities

AUXILIARY AIDS AND SERVICES FOR PERSONS WITH DISABILITIES

POLICY:

(Insert name of your facility) will take appropriate steps to ensure that persons with disabilities, including persons who are deaf, hard of hearing, or blind, or who have other sensory or manual impairments, have an equal opportunity to participate in our services, activities, programs and other benefits. The procedures outlined below are intended to ensure effective communication with patients/clients involving their medical conditions, treatment, services and benefits. The procedures also apply to, among other types of communication, communication of information contained in important documents, including waivers of rights, consent to treatment forms, financial and insurance benefits forms, etc. (include those documents applicable to your facility). All necessary auxiliary aids and services shall be provided without cost to the person being served.

All staff will be provided written notice of this policy and procedure, and staff that may have direct contact with individuals with disabilities will be trained in effective communication techniques, including the effective use of interpreters.

PROCEDURES:

1.Identification and assessment of need:

(Name of facility) provides notice of the availability of and procedure for requesting auxiliary aids and services through notices in our (brochures, handbooks, letters, print/radio/television advertisements, etc.) and through notices posted (in waiting rooms, lobbies, etc.). When an individual self- identifies as a person with a disability that affects the ability to communicate or to access or manipulate written materials or requests an auxiliary aid or service, staff will consult with the individual to determine what aids or services are necessary to provide effective communication in particular situations.

2.Provision of Auxiliary Aids and Services:

(Insert name of your facility) shall provide the following services or aids to achieve effective communication with persons with disabilities:

A.For Persons Who Are Deaf or Hard of Hearing

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(i)For persons who are deaf/hard of hearing and who use sign language as their primary means of communication, the (identify responsible staff person or position with a telephone number) is responsible for providing effective interpretation or arranging for a qualified interpreter when needed.

In the event that an interpreter is needed, the (identify responsible staff person) is responsible for:

(Fo• a, •, c ••low, choose ｯｮｬｾ＠whallt appllc•••• lo pout

,_cllllv)

(a)Maintaining a list of qualified interpreters on staff showing their names, phone numbers, qualifications and hours of availability (provide the list);

(b)Contacting the appropriate interpreter on staff to interpret, if one is available and qualified to interpret; or

(c)Obtaining an outside interpreter if a qualified interpreter on staff is not available. (Identify the agency(s) name with whom you have contracted or made arrangements) has agreed to provide interpreter services. The agency's/agencies' telephone number(s) is/are (insert number(s) and the hours of availability). [Note: If video interpreter services are provided via computer, the procedures for accessing the service must be included.]

(ii)Communicating by Telephone with Persons Who Are Deaf or Hard of Hearing

[Listed below are three methods for communicating over the telephone with persons who are deaf/hard of hearing. Select the method(s) to incorporate in your policy that best applies/apply to your facility.]

(Insert name of facility) utilizes a Telecommunication Device for the Deaf (TDD) for external communication. The telephone number for the TDD is (insert number). The TDD and instructions on how to operate it are located (insert location) in the facility; OR

(Insert name of provider) has made arrangements to share a TDD. When it is

determined by staff that a TDD is needed, we contact (identify the entity e.g., library, school or university, provide address and telephone numbers); OR

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(Insert name of facility) utilizes relay services for external telephone with TTY users. We accept and make calls through a relay service. The state relay service number is (insert telephone for your State Relay).

(iii)For the following auxiliary aids and services, staff will contact

(responsible staff person or position and telephone number), who is responsible to provide the aids and services in a timely manner: Note­takers; computer­aided transcription services; telephone handset amplifiers; written copies of oral announcements; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning; telecommunications devices for deaf persons (TDDs); videotext displays; or other effective methods that help make aurally delivered materials available to individuals who are deaf or hard of hearing.

(iv)Some persons who are deaf or hard of hearing may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the person will not be used as interpreters unless specifically requested by that individual and after an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the person's file. If the person chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided.

NOTE: Children and other residents will not be used to interpret, in order to ensure confidentiality of information and accurate communication.

B.For Persons Who are Blind or Who Have Low Vision

(i)Staff will communicate information contained in written materials concerning treatment, benefits, services, waivers of rights, and consent to treatment forms by reading out loud and explaining these forms to persons who are blind or who have low vision [in addition to reading, this section should tell what other aids are available, where they are located, and how they are used].

The following types of large print, taped, Brailed, and electronically formatted materials are available: (description of the materials available). These materials may be obtained by calling (name or position and telephone number).

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(ii)For the following auxiliary aids and services, staff will contact

(responsible staff person or position and telephone number), who is responsible to provide the aids and services in a timely manner: Qualified readers; reformatting into large print; taping or recording of print materials not available in alternate format; or other effective methods that help make visually delivered materials available to individuals who are blind or who have low vision. In addition, staff is available to assist persons who are blind or who have low vision in filling out forms and in otherwise providing information in a written format.

C.For Persons With Speech Impairments

To ensure effective communication with persons with speech impairments, staff will contact (responsible staff person or position and telephone number), who is responsible to provide the aids and services in a timely manner:

Writing materials; typewriters; TDDs; computers; flashcards; alphabet boards; communication boards; (include those aids applicable to your facility) and other communication aids.

D.For Persons With Manual Impairments

Staff will assist those who have difficulty in manipulating print materials by holding the materials and turning pages as needed, or by providing one or more of the following:

note­takers; computer­aided transcription services; speaker phones; or other effective methods that help to ensure effective communication by individuals with manual impairments. For these and other auxiliary aids and services, staff will contact (responsible staff person or position and telephone number) who is responsible to provide the aids and services in a timely manner.

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Sign Language Interpreters

(center location here)

(As of (month and year submitting information)

Staff Members:

We currently have:

Dno staff members available who are qualified to interpret American

Sign Language.

D the following staff member(s) who are qualified to interpret American Sign Language:

Name:

Title:

Phone

Number:

Hours of

Availability:

Name:

Title:

Phone

Number:

Hours of

Availability:

Contractors:

The Director of Clinical Services, (First Name, Last Name ­ phone number), is responsible for obtaining an outside interpreter when required.

The Director of Clinical Services has chosen the following interpreter referral agency to ensure that qualified persons with disabilities, including those with impaired hearing, can adequately communicate with Hospice staff members:

Company/Organizatio

n:

Contact Person:

Address:

Address:

City/State/Zip:

Voicemail:

TTY:

Email:

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Example of a Notice of Program Accessibility for Describing that your

Program is Accessible to Persons with Disabilities

Section 504 Notice of Program Accessibility

The regulation implementing Section 504 requires that an agency/facility

.... .adopt and implement procedures to ensure that interested persons, including

persons with impaired vision or hearing, can obtain infonnation as to the existence and location of services, activities, and facilities that are accessible to and usable by disabled persons... (45 C.F.R. §84.22(f))

(Insert name of facility) and all of its programs and activities are accessible to and useable by disabled persons, including persons who are deaf, hard of hearing, or blind, or who have other sensory impairments. Access features include:

•Convenient off­street parking designated specifically for disabled persons.

•Curb cuts and ramps between parking areas and buildings.

•Level access into first floor level with elevator access to all other floors.

•Fully accessible offices, meeting rooms, bathrooms, public waiting areas, cafeteria, patient treatment areas, including examining rooms and patient wards.

•A full range of assistive and communication aids provided to persons who are deaf, hard of hearing, or blind, or with other sensory impairments. There is no additional charge for such aids. Some of these aids include:

o Qualified sign language interpreters for persons who are deaf or hard of hearing.

o A twenty­four hour (24) telecommunication device (TTYITDD) which can connect the caller to all extensions within the facility and/or portable (TTYITDD) units, for use by persons who are deaf, hard of hearing, or speech impaired.

o Readers and taped material for the blind and large print materials for the visually impaired.

o Flash Cards, Alphabet boards and other communication boards. o Assistive devices for persons with impaired manual skills.

If you require any of the aids listed above, please let the receptionist or your nurse know.

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Example of a Section 504 Grievance Procedure that Incorporates Due Process Standards

Section 504 GRIEVANCE PROCEDURE

It is the policy of (insert name of facility/agency) not to discriminate on the basis of disability. (Insert name of facility/agency) has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) or the U.S. Department of Health and Human Services regulations implementing the Act. Section 504 states, in part, that "no qualified handicapped person shall, on the basis of handicap, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives or benefits from Federal financial assistance." The Law and Regulations may be examined in the office of (insert name, title, tel. no. of Section 504 Coordinator), who has been designated to coordinate the efforts of (insert

name of facility/agency) to comply with Section 504.

Any person who believes she or he has been subjected to discrimination on the basis of disability may file a grievance under this procedure. It is against the law for (insert name of facility/agency) to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.

Procedure:

Grievances must be submitted to the Section 504 Coordinator within (insert timeframe) of the date the person filing the grievance becomes aware of the alleged discriminatory action.

A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.

The Section 504 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator will maintain the files and records of (insert name of facility/agency) relating to such grievances.

The Section 504 Coordinator will issue a written decision on the grievance no later than 30 days after its filing.

The person filing the grievance may appeal the decision of the Section 504 Coordinator by writing to the (Administrator/Chief Executive Officer/Board of Directors/etc.) within 15 days of receiving the Section 504 Coordinator's decision.

The (Administrator/Chief Executive Officer/Board of Directors/etc.) shall issue a written decision in response to the appeal no later than 30 days after its filing.

The availability and use of this grievance procedure does not prevent a person from filing a complaint of discrimination on the basis of disability with the U.S. Department of Health and Human Services, Office for Civil Rights.

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(Insert name of facility/agency) will make appropriate arrangements to ensure that disabled persons are provided other accommodations if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing interpreters for the deaf, providing taped cassettes of material for the blind, or assuring a barrier­free location for the proceedings. The Section 504 Coordinator will be responsible for such arrangements.

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