Now, I would like to introduce our speaker to get us started this morning. Ms. Laura Dixon most recently served as the Director of Risk Management and Patient Safety for the Colorado region of Kaiser Permanente. Prior to joining Kaiser, she served as the Director, Facility, Patient Safety, and Risk Management and Operations for COPEC from 2014 to 2020. In her role, Ms. Dixon provided patient safety and risk management consultation and training to facilities, practitioners, and staff in multiple states. Ms. Dixon has more than 20 years of clinical experience in acute care facilities, including critical care, coronary care, perioperative services, and pain management. Prior to joining COPEC, she served as the Director, Western Region, Patient Safety, and Risk Management for the Doctors' Company in Napa, California. In this capacity, she provided patient safety and risk management consultation to the physicians and staff for the Western United States. As a registered nurse and attorney, Laura holds a Bachelor of Science from Regis University, a Doctor of Jewish Prudence from Drake University College of Law, and a registered nurse diploma from St. Luke's School of Professional Nursing. She is licensed to practice law in Colorado and in California. We thank you so much for being here with us this morning, Laura, and I'm going to let everybody know that she is going to power through today. She's got a hoarse voice, so she may have to pause for a couple of moments to call for clear her throat there, so thank you so much for powering through to be here with us this morning, Laura. We appreciate it very much. Great. Thank you very much, Lindsay. I always like to say it. I have one of those Kathleen Turner-ish type voices when I get one of these colds. So welcome, everyone. We're talking about a very interesting subject, and in the last year or so, there's been so much back and forth between decisions through appeals courts, U.S. Supreme Court, and the federal government on laws and regulations, and it has to do with the overall umbrella topic of non-discrimination. And so that's why I think this is very timely, because there's been some new guidance that has come out from the U.S. government, but some of this is still untested, and it may still come up in some court actions. So again, I'm glad that GHA is putting on this program, because I think it's very, very timely. Well, I do have to include my disclaimer in today's program. This information is strictly that. It's informational only. It is not meant to serve as legal advice nor establish an attorney-client relationship. So please, please consult with your own counsel, professional legal representative, whether that's through your professional carrier or if you have your own attorney, especially as it relates to those issues that crop up with your hospital or within your particular state, because it may vary by what this is going to be presented today with what your state has to say. I want to start with a very brief history of Section 1557, which is where the non-discrimination comes into play, of the Affordable Care Act. Overall, the ACA, this section, prohibits discrimination from any or by any federally funded or administered health programs or activity, and that means that that would be such as the four combinations of civil rights statutes, and in particular, Title IX, that focuses on sex education and sex in general. That has been the focus of a lot of litigation, but it's not just that. It's also encompassing disabilities under the Rehab Act, and we have age discrimination and then, of course, the very protected classes overall of race, color, and national origin. Now, with this issue, there are penalties, like with everything associated, if there happens to be a violation. Could be completely taken off federal funding. You could be disbarred from doing business with the government. There is liability under the False Claim Act, where you say, hey, we did this, and in fact, you did not do it. The Department of Justice, the DOJ, is the one that enforces that, but also the Office of Civil Rights also enforces it, so you have two components that come into play as providing oversight and then any potential penalties. And back in 2016, you know, that's been eight years now, Health and Human Services put out a rule, and I admit, they did somewhat overstep their boundaries. They added to the definition of that discrimination act under sex. They added to that. They said gender identity and discrimination based on termination of pregnancy. Well, there was a judge back in 2016 that said, no, no, no, no, no, that's not what that meant to be. That's nowhere in that ruling, and that was absolutely correct. And so HHS said, you know what, you're absolutely right, we shouldn't have added that. But that's not where it ended. The judge also found they incorrectly omitted a religious exemption. And so as a result of that, most of that regulation had to have been vacated. So under that injunction from that judge, the Health and Human Services said you can't take action to enforce those prohibitions. Now, Title IX, the Title IX, that's the only one that prohibits discrimination based upon a person's biological sex. That is now included in Section 1557. So Health and Human Services comes back, it's okay, you're right, we'll update this rule, took four years to do it, and 2020, because the Supreme Court ruling came back and said, yeah, we have to uphold this, where we do have to prohibit sex discrimination based upon how that person sees themselves in their sex. And they added there's a plain meaning of sex, and under that meaning is included orientation and identity. So essentially, again, any entity that takes part in any federally funded program or works with the government can no longer discriminate, not only based upon race, color, national origin, but sex. And this is also according to those meaning of those terms under the federal rights section that is incorporated in 1557. So what was the recap of that rule? Well, now the Department of Health and Human Services had to enforce those prohibitions, and they put together a grievance procedure so that there is access to the covered entity's records if there is a complaint, and OCR has that right. It also prevented and prohibited retaliation and intimidation. And it also did one thing. It eliminated the requirement for sending notices and taglines for all significant communication. Now, this was a good thing, because some of you who were around back then and working in this area, you remember those reams of paper that we had to send out to patients that had all of this information. Well, now it's simply a tagline. So that was a good thing that came out of that. Well, we weren't done then. In January of 21, a district court ruling came back and said, we're going to repeal that definition on the basis of sex info, okay? And Health and Human Services come back and says, yeah, but understand there's still discrimination based upon sex. Well, they did take out the prohibitions on gender transition exclusions. And then they put back in the religious exemptions, that conscious objector protections, where if the provider says, you know what, what this person wants to have done goes against my religious beliefs, well, that's okay. You can still have that protection. And then they also took out the termination of pregnancy from that definition of sex discrimination. So this is one, as I mentioned, we are still in the process of trying to ferret out where are we on this? What is the final ruling? In March of 22, Health and Human Services put out that statement. They reaffirmed their support and protection for transgender youth and their families. A district court in Northern Texas issued a judgment vacating the rule and Health and Human Services. They're still trying to come up with steps in the interim to come up with that. On April of 23, they came out with another statement that still supported gender affirming care. In July of 23, they had a proposed rule to advance non-discrimination in our programs for those in the LGBTQI plus community. I have the link there for you. With any of my links, you will have to copy paste because I couldn't get the automatic connection with the slides. Well, they weren't done there because again, part of 1557 was also disability, where there's now non-discrimination on the base of disability. This went into effect July of this year, so just barely a month ago. It's 275 pages, so I've tried to narrow it down as I go through this program. It talked about multiple issues. What is a disability? I'll give you a heads up. It is interpreted very broadly. It talks also in there with disability about medical futility and disabilities. Are we withholding treatment because this person has this disability? It's just not the medical benefit to having that done. We can't do that. And then the requirements for medical equipment. I want to point out one thing with this one. Ruling came out yesterday or a notice that Office of Civil Rights is working with a New Jersey mammogram center, an imaging center, because they refuse to provide a mammogram for a patient who was in a wheelchair, and they recited as a result. Now, there was no financial penalty that I could find as a result of that, but that's what they're talking about, that we have to make sure medical equipment is adaptable for those who do have disabilities. The definition of disability, it's a physical or mental impairment, substantially limits one or more of their major life activities, that there is a record of such impairment or they are regarded as having that impairment. And this really, again, goes and restates that prohibition on discrimination. And again, this is where you, as a provider, fails to offer or deny treatment as a result of that disability. Other changes, it changed the term from handicapped to persons with disability. What does that mean? Your signs in your hospital, you have to change that wording from handicapped to persons with disability. They updated a lot of information on long COVID and how the physical and mental impairments are the result of long COVID. And they also mentioned that gender dysphoria could constitute a disability. Now, they noted this term was not included in the scope of those exclusions. In other words, it's because they didn't say but for this particular phrase. Because it's not there, then it's included. So it's kind of a process of elimination, so to speak. And again, that's approached as any other disorder or condition. They also include, of course, our qualified interpreter. They now said, of course, I'm reaffirmed, it can be onsite or video remote. That has been going on, they just reaffirmed it. And that, of course, this person has to be able to interpret effectively, accurately, and impartially. And that's both what they hear coming in, and then what is repeated to you as a provider. And of course, using any specialized vocabulary, they have to be aware of it. And we have a lot in medicine. What are our terms? What does that mean? What does morbidly obese mean? And that's why it's so important that we understand that specialized vocabulary. Auxiliary aids, they reaffirmed, if you have fewer than 15 employees, you still have to provide those aids and services. We're not exempt from that. And then again, medical diagnostic equipment, as I mentioned, with that person who needed the mammogram, that they had to make it accessible not only to her, but persons of size also. I talked in there, the new rule on reproductive health, and this is a little bit different, but I wanted to bring it in because it does go into nondiscrimination and Affordable Care Act and how we treat individuals. In June of this year, 2024, HHS put out a rule that talked about the use or disclosure of protected health information that you as a covered entity would have when you get a request for those records by someone, usually it's law enforcement or some other agency, that is trying to conduct a civil, criminal or administrative investigation into imposing liability upon a patient because of reproductive health services they obtained from you. And they broadened it. That said, just because a person comes to you and asks for help in getting or facilitating anything to do with reproductive health where it's lawful within your state, then that outside entity cannot come in and try and get those records in order to prosecute that person who may be from another state where it is not legal. So they really tighten the controls here. Again, it also prohibits disclosure of that information. If they are, you know, they call you up and they say, hey, we're calling about this person. We understand they got care in your area and we want to know what happened. Normally under HIPAA, you could have disclosed that. You could have. Well, now HHS is tightening the controls and security and confidentiality of reproductive health. And so, again, this applies where you reasonably determine that some of the following conditions that I'm going to be talking about exist. You have to be compliant by the end of this year and you must update your notice of privacy practices by February of 2026. I have that rule there and there's the link for that rule that you can get it. So here are some of the required conditions in order for this to happen. The care is okay in your state. It's lawful. Under the circumstances it was provided, it's lawful. That care is protected or even required not only by your state law, but by federal and U.S. Constitution. And it was provided by you or business associates that they got that request for those records under the presumption that the care was lawful. Now there's an exception to that. Unless you know, you have factual knowledge or can show that the information that this person is trying to get from you or that the care you provided was not lawful. So here are some examples of where you can disclose it. And you don't have to worry about this. It's when you are using it to defend yourself. Either a professional misconduct or negligence or administrative action. The Board of Medicine has called up and said, hey, we have this complaint and this is what we're working on. Usually that comes from the patient. Again, you're trying to defend yourself where you might have liability. The other exception is when the Office of Inspector General, they contact you and they're doing an audit for healthcare oversights. So the outcome from all of this rule is that there has to be an attestation from the person or entity that is requesting this information other than, again, the Office of Inspector General or you're using it to defend yourself in a malpractice case, say. So you have to get a signed attestation from the individual or the entity that's asking for it that we're not using this for an improper purpose or prohibited use. And that applies healthcare oversights, law enforcement purposes, that's a big one, disclosures to coroners or even medical examiners. And this is what the attestation looks like. I have the link there for you. Again, the people who are asking for your records, your information, have to fill this out and get it to you. This is the form. HHS has put it together for us so we don't have to do this. So you might want to download it and have it handy. And this is where you'll have to start training your providers or even in health information management. If you're getting these, maybe they want to just reach back out to you and say, what do we do in this situation? So what do we have to do? Again, you have to revise your notice of privacy practices, saying we are here to support reproductive healthcare privacy. There are certain disclosures that maybe we do have to make to law enforcement, but this is a carve out where it's got a little extra privacy. And it's, again, only permitted where you believe that an individual obtained health care in three circumstances. Disclosure is not subject to prohibition. It's required by law. And it meets all the applicable conditions, otherwise, that you have to disclose it. So you've got, let's say you get a pregnant person who comes into your hospital and they have a gunshot wound. Well, under law, you have to disclose that, that you treated this person for a gunshot. Now let's say law enforcement comes back and says, well, you know, they're from our state and our state does not permit end of pregnancy in our state, termination of a pregnancy. So therefore we want all those records. That's not going to cut it because you have to disclose the information on the gunshot wound. But the pregnancy, the reproductive health information that requires that at a station and honestly work with your law, your counsel, because you probably say, I'm not going to disclose that. It has nothing to do with that gunshot wound to her foot. It's not going to happen. So that was one of the new laws that came out. It has not been tested in courts. I'll be curious to see if there's any issues that arise from it. But to my knowledge, I haven't been able to find any court cases yet that really determined it, whether state law, federal or appeals or even higher. All right. Now let's go on to the OCR section. Now some of this is going to be, again, repeated based upon what I've said, but I want to go deep a little bit more. So overall, non-discrimination, Affordable Care Act back in 2016, that addressed non-discrimination, that we cannot discriminate against a person based upon those protected classes, race, color, national origin, sex, age or disability in certain programs and activities. This is the first time a federal law did broadly prohibit sex discrimination in our health care programs. It applies to any individual who participates in those with Medicare, Medicaid. Maybe there's something under state law that still gets some of those federal subsidies. And it doesn't have to just be healthcare. It can be other health or other issues that they're participating. And of course, these are those that are administered under Title I. Now, previously said health insurance also offered in the marketplace. Some of those requirements, especially certain disclosures, for some reason they didn't apply to health insurance companies, and I don't know why. So this really covers those that apply to hospitals, rehab centers, health clinics, and all of those that I just mentioned, but not insurance companies, which is very surprising because in a roundabout way, some of your state-run services do obtain federal funds. So I'll be curious to see if that goes any further. Now, again, what's a healthcare provider? A hospital or entity primarily engaged in health services or coverage. And all of these operations are considered part of your program. It includes hospitals and medical departments, believe it or not. So that includes your cafeteria, your gift shop. That's included under this. It includes sex discrimination. Again, you cannot force a provider to do something that goes against their religious beliefs. But it did more than just that. It enhanced what we have to do for language assistance for those with limited English proficiency. So we can communicate with those people, whether they don't have good grasp on the English language or they have a disability that prohibits them from hearing us. And it affects, of course, hospitals, anybody that takes Medicare or Medicaid. Now, CMS did, we dovetail some of the requirements in section 1557 into the patient rights section and the conditions of participation. Joint Commission also added it because they felt this is just too crucial for care of a patient, that we're gonna add that into there. And it's in their communication standards. So that's why you might wanna consider adding this section into your patient rights statement regarding prohibition on sex discrimination. So essentially we can't segregate, we can't deny, we can't delay care based upon all of those protected classes. And I already mentioned that the covered entity is everybody. Yet, if you have a health insurance that receives federal assistance, such as Medicaid, then yes, they are included. Those that participate in the ACA marketplace, Medicare Advantage, all of those must, but your straight blue cross blue shield, it doesn't apply to them. And I only say blue cross blue shield because that's one of the more common ones. But it doesn't apply to your employees in the hiring and firing of them. That's separate employment discrimination laws. The reason that they really put this into place is we wanna make sure everybody has access to quality and affordable healthcare. And that's why they felt this helped achieve what the goal of the Affordable Care Act was. It expanded access, cut down those barriers, and helped reduce our health disparities. So again, the new rule on discrimination effective July of this year, asterisk means I have it in the appendix for you. The link is what you look like. Those, you're held to the same non-discrimination standard for those who receive federal financial support. In short, Part B payments, not just Part A for hospitals, but Part B also. And as providers, you have to proactively let your people know what is required. Language assistance, that it's available at no cost to those who come in. Accessibility services available at no cost to them. Telehealth, it has to be accessible to those who have limited English proficiency and disabilities. That means sign language. It prohibits discrimination based on sex. We have to maintain our protections again for us as care providers, for our religious freedom and conscious objection. And it applies to those non-discrimination principles when a patient has a patient care decision support tool. So if you're using AI in any of your decisions, your clinical decision support, take a step and look at those. Make sure you're mitigating any possible discrimination and the use of those support tools. On to sexual discrimination that includes based upon individual sex and pregnancy and their related conditions. Including here, the definitions. Okay, what's gender identity? That's how the person internally sees themselves. Could be a combination, neither. That could be totally different than what they're assigned at birth. Now, gender expression is how they of course express themselves. How do they hold themselves out? Because that might not conform to what we normally see with that particular gender. Gender identity, that's a person whose identity is different, a transgender, than what they're assigned at birth. And there have been studies out there that show people won't get care because of the perceived discrimination or reaction from providers. Overall, health insurers cannot discriminate against clients based upon those and treat those consistent with their gender identity. That means we have to make sure they have access. In short, again, they expanded that definition of sex characteristics with the pregnancy, the related conditions, sexual orientation, identity. All of that was expanded. Now again, there's a nationwide injunction that CMS cannot enforce this as it relates to the expanded definitions right now. That doesn't mean it won't be released. That injunction won't be released. So it may be best at this point to just work with your counsel, with your staff, to determine how are we going to meet this if this injunction is lifted. So I just put a few examples in here on prohibited discrimination. Breast cancer programs, you can't refuse to treat men who have breast cancer because female patients would feel uncomfortable. You cannot create that hostile environment for those who are transgendering. You can't put them in one room if they identify with a different gender. You can't deny, believe it or not, you can't deny a pep to a male patient or a prosthetic exam to a female patient. Just saying, that's what that was. Now the protected classes. These are the ones who've been around forever that we're very familiar with. This includes hospital, physician, SNF. Any covered entity cannot discriminate based upon those protected classes, race, color, national origin. You cannot assign patients to certain rooms based upon their race. Citizenship, here's an example. You can't require a mother to disclose her citizenship when she's coming in for services for her child. So it still covers those who are in the US whether they are there lawfully or not. National origin, here's just an example. We have a hospital emergency department. Mother with limited English proficiency, they didn't give her a Spanish interpreter when she wanted one. Instead, no, let's use your 13-year-old because the kid's there for a dog bite anyway, he can interpret. They didn't also properly translate the discharge instructions or explain them in Spanish so mom would know what to do. This is one based upon race. Here we have a patient who was ignored, an African-American female. She had to wait in the lobby for over an hour and while she was waiting, a white male came in, was treated first even though she had the appointment and his appointment was after hers. They didn't have any legitimate reason for doing that. Age discrimination, we can't deny benefits. We can't deny healthcare services based upon age unless there is an age distinction authorized by law. So here's an example. You've got a physician's practice. They said no to a 62-year-old male because they only accept patients under the age of 16. You also can provide different treatment. When your medical literature, those experts out there have said, yeah, that's reasonable, they don't need it. For example, I've gone in for one of my annual tests and said, okay, you're now at the age where our medical literature says you no longer need this. I can still get it if I want it and I would have to of course find a provider who's willing to do it but the practice can say, we're not doing that anymore based upon your age. That's okay because the literature supports it. Other ones, 82-year-old, they said, you're not eligible for an organ transplant because yeah, you're not gonna live very long. That's not permitted. Maybe you've got a separate wing in your hospital and all of these were cases that OCR had published. There was a separate wing for geriatrics. The patients had less supervision, less recreational opportunities than other patients in the hospital. 72-year-old said, no mammogram, that's not safe for a patient of your age. That's how they put it to her. Not that the medical literature didn't support it but no, it was not safe for her. And then limited English proficiency, those taglines. Well, as you mentioned, we do have some questions and I'll be the first one, Lindsay, would you take care of that? I'm happy to, I'll get this one up here on your screen. Okay, this one should now be on your screen that says, when I walk around our facility, I see multiple signs regarding translation services and your options here, yes, no, or prefer not to answer. And then if you did miss our initial introduction, we will also pause for a few moments to address your questions for Laura throughout when we do these polling questions as well. And I do see a couple of questions, Laura. I was trying to give you a second to rest your voice there before I dove into the questions here. Okay, this first, and I'm assuming that you're gonna be getting to this part here as well, but it says for patients who do not speak English, are we required to provide a number for them to call for assistance? I will get to that, good question, good question. Okay, and then is there a poster size or font size requirement for the non-discrimination notices? Yes, yes to both of those. And CMS has some already developed for you. And yes, it does talk about the font size. Okay, let's see. Are there federal requirements on screen size for sign language interpreters? Oh, screen size for the interpreters? It has to be, and again, I'll get to this, but just in a nutshell, I think the font, and just so I can clear this up, there is examples of the posters in the appendix. The regulation spell out the font, and I think it's 12 point. And then as far as the screen size, it's more, can they see the interpretation clearly? And they're more interested actually in does it stop and start? Is it a good quality connection? So nothing is literally lost in translation that it doesn't stop and start, stop and start. They want that good connection. The size, I've seen them as small as a 10 inch tablet. When I worked at one company, we called it the green monster because you had to wheel it in, but it was just like a laptop computer screen. And it worked perfectly. They didn't have any issues. The connection was great and translation went perfect. It was fine. So they don't mention anything. I think if you're on your cell phone, they might have an issue with that. But like a tablet, maybe more than enough. They don't absolutely specify the minimum length. Just kind of look at it. Could you see what was going on? Could you understand what that interpreter was saying to you? So I hope that answered it. And this question here was just kind of thoughts that I'm going to bring up. There's no right answer. Perfect. And then there's a couple more here. And I think that you may be getting to these in this section as well, but how many languages is an organization required to have tag-ons for in a significant publication? Yes. And there's depends on which state. There are four states. And yes, I'll get to that, that have to have 17. Everybody else is 15 and I'll show you how to get to that list. Okay. And then as Laura gets to some of this information that you may have put in your questions for already, if you have additional questions, don't hesitate to come back to the Q&A and type those in if you need further explanation or just have additional questions. And then this question here, can a bilingual staff member provide translation to a patient? Yes, with a caveat. And again, I'll kind of go to that. But yeah, especially if you have bilingual nurses or physicians or one of those, it's great because they understand the medical terminology and really are good at working with patients to make it so they're aware. It's that limited English proficiency where they don't have to be MD or an RN to understand what he is saying to me. What do you mean I have to dilate my pupils? What does that mean? They're the best ones to have absolutely available. Okay. And then this is the last question here that says, when you were speaking about the, you cannot deny a male, a pat for a male patient, but then in the preceding slides, say that patients must be treated consistent with their gender identity. Can you clarify whether CMS would pay for women's health related services to a patient identifying as a man? Yes. As long, there's gotta be a rationalization in there that they identify as this gender and they are wanting this process. Now, how that happens, that's beyond my understanding, but just, it's like, I can't do a pap on you because you don't have a vagina. How do I do this? That's where the medical literature could help support the denial of that service and saying, I would love to do it. I just don't have a way to do it. Okay. And then, yep, let's see. Look, I think this is the last question here. Are we no longer able to refuse care based on futility? No. Again, that's a good, strong discussion that you have to have. We see this a lot and I wanna put it with the children where perhaps there is an infant that is brought in and the ability to save that child, it must be based on a medical decision rather than, well, you know, they're not gonna live past four years old. Why are you doing this? I'm not going to do that because they're not gonna live that long. That can't be the basis for the denial. It's gotta be a medical reason that, okay, we could do it, but this is what will result and our medical literature won't support it. That's a very, very fine line for medical futility. You can't base the futility on the disability. You know, it's like, yeah, I could take out your spleen, but you're still going to lose that gangrenous leg. This is what I need to do. And that's as much as they have done it. Usually, again, it addresses the pediatric situations where the child has some extensive disabilities and they're saying, no, we're not gonna give them dialysis. No, no, we're not gonna give them dialysis because they happen to have trisomony X or something like that. That cannot be the basis for the denial. Okay, and I think maybe this is the last question before I'll end this poll here. And if you have other questions, we'll hold those for the next polling question. But it says, is it a recommendation or a requirement to financially incentivize the bilingual staff who are qualified to interpret? Oh, that's up to you guys. You can certainly do that if you want. CMS isn't gonna touch that with a 10-foot pole because that's all employee. Okay. There are the results from that polling question. Wonderful, all right, so let's talk these signs. Why, why do we have them? Because every once in a while, you'll get a patient in who doesn't speak English or doesn't speak it well enough. And so now being able to see that, it's like, oh, I can get this for free. Okay, somebody's there to help me out. I don't know how many of you have traveled overseas and had the wonderful experience of having to go get healthcare while you're overseas. It can be challenging and it really gives you a good perspective on what patients go through here when they don't speak their native language. It can be very frustrating and very scary also. So what must you do? You have to put the top 15 tags within your state of those languages spoken. There are four states plus the District of Columbia where there are 17, and thank you, Colorado, where I am, we're one of them. They're just simple short statement that non-English patients, you have a right to have language assistance services at no charge. And that's where you wanna put it, in those areas where they're gonna first walk in the door. Could be ED, maybe OB, admitting even outpatient treatment centers. Have those taglines up there so they know I can get it. Many of the requirements in OCR, which is what we're talking about right now, overlap with the conditions of participation in patient rights. And essentially you cannot delay nor deny services, translation services to those patients who need it. Here's an example of just what that tagline looks like. You know, this is what you have. They're available, they're no charge, just let us know. So finding your taglines, OCR has a document that's already listed them. It's available here at this link, copy paste to type it in however you wish to. Go to appendix A, and that's where the list will pop up. Now you don't have to use this list if you have your own, but that source must be a reasonable basis to rely upon that source. Otherwise make life easy and just use the OCR's list. So again, every language in those states and all the 50 states, If you are one of those five, I include the District of Columbia, they have 17, they will combine them in the last one. That's why I just wanted to give you an idea about what one looked like. Or if Colorado, those are the others. And they list out the number of individuals for your state. Where else do you want to put it? There could be other, maybe on your website, you want to put that on there, on your homepage, because it does mention in there, shall post the notice of these taglines in significant publications and communications targeted to beneficiaries. So that's how you might want to put it onto your website. How does a patient access these aids and services? So far as interpreters, you have to provide a qualified interpreter in a timely manner. When oral interpretation is a good way for this person to get health care, free of charge, we can't require them to have their own. No family member, unless it's an absolute down, right off emergency. Because we can't rely on that child, unless it's again, life threatening. And your qualified interpreter isn't available. So let's say the patient walks into the ER, the child is with them. And all you can really say, what's the person's name, what's going on? And you know, whatever information, but otherwise, you need to get that interpreter down there. So unqualified bilingual staff, that's a good question. I'm glad someone brought it up. What is a qualified interpreter? Well, that's more than just being fluent. Because this shows us we have to have a qualified interpreter who can be culturally competent, follow accepted ethical principles on confidentiality and privacy. Why is it important? Because if you have somebody who doesn't speak English, and we don't give them those interpreters during those critical portions, then it's deemed to be a denial of meaningful access to health care. And that's a violation of federal law. And as you can see, again, they really pick down on some of these words. So it's not meaningful. And the Federal Register has a definition of what is a qualified interpreter. And again, that is someone who is proficient in speaking and understanding both languages. That may be vocabulary, terminology, phraseology, and they can effectively, accurately and impartially communicate with that person in their primary language. So let's say you have a patient who comes into ER. The triage nurse can use that language line through the telephone. Maybe the social worker immediately calls a live interpreter in for that patient. That's great. They come into ED. Maybe they want their adult daughter to interpret. That's fine. That's okay. Adult. The patient has to be informed, hey, we'll get you an interpreter at no cost. It's free to you. And if so, the patient says, nope, I want my daughter to do it. If you can, have them sign that waiver so they understand and make sure it's in their language, it's translated into their language. And that can be an appropriate substitution. Again, an adult language, adult individual, and the patient understands they can have this free of charge. Again, there is also hearing and vision interpreters where as far as doing that, they have to do it either remote or in person, adhere to the standards, and can use, again, the correct phraseology and terminology. Now, for the question that came up, can I give the person a phone number? I would be extremely careful in doing that. That is our responsibility to provide the interpreter. So, we pretty much need to get that person on the phone and say, this is how we can do this, is what we have available right now. So, we need to be giving that phone number and doing the phone call ourselves rather than, hey, you call them. That might be seen as passing off the responsibility to the patient. So, here's my next question, Lindsay. Okay, let's get that one up here on the screen for you. I think I'm actually going to read this first part and then I'll put the question up here for you. This says, South Hospital is an urban facility with very non, very few non-English speaking patients. Over the past 10 months, there has been an influx of refugees. South had three employees of the same nationality, one clinical, one in food service, and one in housekeeping. Can South utilize all three persons for translation if needed? And so, there's that question on the screen. Your option's yes or maybe would want to confirm ability to translate correctly or no, find another way. And again, we do have a few questions, Laura. Good, good. Do the interpreter signs posted need to be in English and in Spanish? What type of posters? I mean, are you talking about patient rights? Most likely. It says the interpreter signs, but I'm not sure. I mean, that's what the taglines are. The taglines are you have the right to have an interpreter present in your language at no charge. So, I guess I'm not too clear what other signs would be there. My state, there's probably not one hospital you can't walk into where it's not in English and right next to it is Spanish because that's our highest level of our non-English speaking patients. Otherwise, then the taglines are next to them. Otherwise, you run out of wall space. Okay. And then, let's see. Do we need to make the top 15 languages available to the patient via translation services, but then also produce all consents, notices, et cetera, in those 15 languages as well? That's a good question. You're going to have to look at, okay, what are you asking for written consent for? I mean, when you're talking surgeries where you might want to get that translated into that language. It could be a one-off. So, hopefully, you don't have stacks and reams of 17 different languages of consent forms. Use the analysis of how often does it occur and how soon can I get this consent translated? Otherwise, we do have to provide consent in that language. And I would take the initiative to get into that language when it starts, your numbers are starting to click up in that particular language. It's a good way just to avoid any issue because not only could it be an OCR issue, but sure enough, that will be the one time something goes wrong with that surgery and a good plaintiff or strong plaintiff's attorney could come back and say, you didn't have informed consent. You denied them the right to know in writing what you were going to do to them. I've seen it happen once. Okay, this next question says, regarding family as interpreter, if a patient refuses the resources and will only use their family, are we not required to utilize that family so that we are not violating patient rights? If that's what the patient wants, use them again. Document it somehow. You have the right to have an interpreter at no cost. And be done with it. Now, one thing, just going to keep on an aside, that I understand you want to use your daughter or your son. I get that. I want to make sure for your safety that it's done. What I'm saying is getting to you. So you might want to have the interpreter handy. Just say, yeah, what they're telling them is correct. That's an option just so you're comfortable. But again, if the patient absolutely refuses that interpreter, you're going to have to go by their wishes. Just again, document it that you've got that coverage for yourself. Okay. And then this goes back. Let's see. Is it still allowed to get a waiver from the patient if he or she wants to use a non-qualified interpreter? I think you answered that. But then does the waiver need to be in the language of the patient? What happens if the patient insists on using a minor? Then, I mean, that's a tough one. Because you're putting that minor into a really bad situation. It's not you. It's their family. And I mean, I've had experience, a friend of mine, she was 14 and her mom wanted her to translate for her while her mom was in stage cancer. And she couldn't tell her mom, mom, you're dying. She couldn't do it as a 14-year-old. So she fibbed to her mom. And that's really a hazard that we're going to have to work around. Again, we just need to make sure for safety it is being translated correctly. You can also say, I'm sorry, are regulations requiring an adult be present? And that's where I would have your counsel really work with you to make sure there's not a state law you're violating. Because that minor could be an emancipated minor too. Not usual, but could be. And then this says, it has been our understanding that 10% is the threshold for forms in the patient's language. Is that still accurate? I haven't heard the 10%. That could very well be. I haven't read that within the OCR regs or anything with CMS about 10%. That could still be an effect. I just have not read that. Okay. Who determines what or who is a qualified interpreter? Does the federal government have a certification program or something to support? For example, someone may be fluent in both English and Spanish, but may not recognize translated like you were talking about medical terminology. Right. And that's where it helps if you have a healthcare provider who can do that. Yes, there is certification. And I have those resources here that we'll cover briefly as we get near the end of the program. There is a certification. And you might want to look into those because they have to go through testing to ensure if they're going to be a medical translator or a legal translator. I've had to use legal translations in the past, and they're certified. The court goes through and they make sure they're all certified. And so, yeah, they do have to get that certification under certain circumstances. And again, having the certification, it's a little extra bonus that you are comfortable that this person is, quote, qualified. But CMS, OCR does not require them to be certified, only qualified. Okay. Then the last couple ones here that I see, and this came in anonymously, so I may need a little bit more information on this one, but it says for consents, what if you use an interpreter to review the consent, even if it is not in the patient's language? It might be pushing it. And the last thing you want is for CMS to come in and say, wait a minute, this person doesn't speak English. Why is this only in English? And they signed it. Then CMS goes to OCR and says, hey, by the way, we've noticed this isn't occurring in their language. So really be careful with that. I couldn't promote it. I probably upset some of my colleagues when I said this isn't in their language. We can't use this. It's worthless. I would get it translated. Okay. And then is this regarding patients with MCR or Medicaid or for everyone? If you accept any federal funds, Medicare, Medicaid, definitely, definitely. The CMS regs are, if you accept Medicare, Medicaid, it applies across the board. Doesn't matter. Probably OCR, OCR is going to focus on those federally funded programs. But again, they kind of added in some of the insurance companies on some of those that do accept the state funded programs. We have a few here are state funded. It is through a national organization. And they accept those funds to help. So they have to. Again, your straight Cigna, Blue Cross, Blue Shield, Aetna, whatever it is, it doesn't. These don't apply to them for some reason. Now, most of the companies have done it. Like I get mine all the time from Blue Cross, Blue Shield. I get the taglines every time they send out a piece of correspondence. I get those taglines attached. Okay. And then this is, is it enough to indicate on the patient's chart, no interpreter needed during registration and admission? Or is it required in this step to write who will interpret? So, okay. Would you repeat that question for me, Lindsay? Yeah. And Gretchen, we made a little bit more clarification here for me as this question came in. It says, is it enough to indicate on the patient's chart that no interpreter is needed during registration and admission? Or is it required in this step, who will interpret? If they don't need it. Yeah. Yeah. I would say don't need or want an interpreter. Now, of course, it can always be, if the physician is talking to them, the nurses are talking to them, and they're getting this blank look, maybe it would be beneficial to have one on standby. Just are you understanding what I'm saying? Because again, we have terminology that sometimes doesn't translate the same way in those languages. I would, again, just be aware that if that's what's going to happen, the patient needs to say, I don't want an interpreter. Okay. And then can providers translate for others or only their conversations? No, they can translate for others. Absolutely. And then should the patient sign both the English and other language? Yes. Okay. That's an easy one. Yes. I would get signatures on both. And then it says, would you recommend having the forms translated in a linear format? I'm not clear on what the question is, so I'm going to have to beg off on that one. I'm sorry. Yeah. I'm not sure if that just means like line for line or, and Tamela said that came from me, but if you need further clarification, let us know on that one. And then the last question I see here is, do you have to provide a live in-person interpreter or is a telephone service appropriate? Telephone service is fine. Again, as long as you have good connection. Yeah. Because there is, I think it used to be called the AT&T language line. I think that's who had it. And now with our visual, sometimes that works out better, being able to see the person as you're talking to them. But yes, the telephone service is more than appropriate. Okay. I'm going to end this poll here and share those results. And then if we have additional questions, we'll capsize that in the next poll. Okay. So let's talk about this. Okay. The certification, those who've asked, there you go. Certification is not required, but there is a board of certification for medical interpreters. And there are two of them. One is the, again, the CHI, Certified Healthcare Interpreter. Then there is the core entry, that's the entry level, core certification. Every interpreter should have at least some core certification. If you can, it will show compliance with a joint commission. Also under standard seven that we are providing qualified interpreters. So I have just some of what these pictures look like, their websites. Now with your core, the nice thing is on some of these, your human resources person can go online and verify that yes, indeed, they do have this core certification. There is also the national board of certifiers. Again, the CMI is definitely the best, but then you also have the qualified medical interpreter. Minority languages, again, they don't have an exam. It's an oral exam, not a written exam. But again, this kind of helps give you an idea of where do we go to get one of these or what should we expect? You do have options. Again, the remote video interpreting services. It is a web-based system, computer screen. Just don't use that low quality remote interpreting services because things could get lost or missed. And you can also use it for limited English proficiency. Same requirements, real-time full motion over a dedicated high-speed wide bandwidth video. They don't want lags. They don't want choppiness. I always like to put in, what's the difference between interpreter and translator? Interpreter is oral. Translator is written. In the federal register, they have a definition on qualified translator. Again, follows the same principles of your oral for interpretation that they do have those ethics and privacy that they have to follow. And they're like interpreters, there is certification if you want to use that one. But again, it's not the only way. On the Code of Ethics, OCR does talk about those on what they expect the translators and also the interpreters to do and have this as far as just keep it to yourself and make sure that you are doing it correctly. There's free publications on how you buy these, getting it right, which one works for you. And then again, you can verify their status. Okay, so those are some of the resources on interpreters with that particular situation. Housekeeping, food service, they may be out there, but they may not have, you know, they may not meet the ethical requirements. Keeping it confidential and then also the qualified, translating it correctly. So when this question came in, it's like, get on the phone and use the translation services by phone. Because the other individuals just, they weren't up to the requirements. And also, we were afraid they wouldn't misinterpret it. So the language access rule here, plan here, excuse me. 68 million of us in the US speak another language, and this is at home. This meets the definition of limited English proficiency. It's not their preferred language. That means there may be a limited ability to write and read it and understand it. So they put out a regulation, Health and Human Services. They actually came together with 35 agencies, and so they put together a revamped language access plan. So that really, when it comes time to these life-saving services that Health and Human Services pays for, there's greater access, and that we can reduce that racial or ethnic disparities or even eliminate it. They reference AHRQ's guidelines for the hospitals, which does mention there are barriers and how they impact adverse events, and that affects our limited English proficiency patients more often than English-speaking patients. So they did find that using a family member or friends or non-qualified staff just to get by really could result in adverse events because we don't have or take into account their cultural beliefs and their traditions. Maybe they defer to an authority figure. Maybe it's a specific gender that, nope, my daughter can't make any decisions, only my son can make decisions for me, or vice versa, depending, again, on the culture. So as far as persons with disability, HHS, Health and Human Services, Medicare and Medicaid, they recognize that the requirement for effective communications for those disabilities still falls under Section 1557 and the ADA. So the overall goal here is that we wanna make sure we have timely, quality assistance for those folks. And again, reinforcing Title VI, that we are prohibited from discrimination against race, color, national origin, and disability. So that's why we have to have reasonable steps to make sure we get these folks reasonable interpretation. So what this plan and policy development did, and a lot of this is up to Health and Human Services, they have to come up with and put together a plan and policies that was supposed to be out in May of this year. Haven't quite seen it yet, but they are working on it. And really it did work to identify actions that help us implement all 10 elements of this plan. Now they did get input from the healthcare environment and health and human services, such as human resources and health administrators. There were 10 elements that they were looking at. One, we have to look at assessment, what are our needs and our capacity? Do we have these assistance services available? What's available in translation? How about policy procedures and practice? How are we gonna give notice of this assistance at no cost? Staff training, and then of course accountability, that they're going to consult with health and human services partners, give digital information, and then assurances that those who are getting funding are having it. Now this plan is still in process. So don't be surprised if we start to see a little bit more coming out of it. Okay, now the notice requirements and auxiliary aids, and that brings me to my third question, Lindsay. Okay, let's get that one up here on the screen. Okay, and this says, due to limited number of disabled patients or those with limited English proficiency, our facility has only one sign regarding notice of rights, has multiple signs regarding notice of rights, only provide the notice in paper form on admission or in emergency department, or not sure what our facility has regarding a notice. And then while you are still completing that polling question here, it looks like there's just a couple of questions. And this first one says, why is the form required to be signed in English and in the language of the patient? That's a very good question. And I'm going to be blunt here, it's a CYA for you, because then you can show, hey, this is what we told this patient and they agreed to it. But it is also that one last opportunity for that non-English speaking patient to read in their language. Hey, this is what's going to happen. This is what we plan to do. And that you understand this comes with no 100% guarantees. So it's really, it helps, it's twofold. It gives that final notice to the patient and it protects you saying we did what we could do under the circumstances, just like any other patient. Okay, and then if a patient insists on the interpreter being in person, are we then required to get one or is the phone or iPad still sufficient? Yeah. If you don't have the resources, like you're a smaller hospital, you have one interpreter and they're tied up another room and you need to have this care now. You need to do it now. The phone is fine. You can do it. Of course, you're going to do everything you can to get the person there face-to-face. Hey, we're wasting valuable time for your health. This is what we have to do now. So it's kind of an overall assessment of what's going on at that time. You know, when they're in the emergency room and they've got a steel pipe sticking out of their side. Yes, I've seen that. And some of you probably have too. There's no time to get that person there in person. It's like, here, this is what we have by audio and video that we can use to get it to them. They'll look at the overall situation. Was it practical? Was it reasonable to use other alternatives? Okay, and then the last question says, do staff need to have that qualified status as interpreter? Yeah, that's where you kind of have to evaluate how good is your staff? I mean, it is, and I'm just going to use Spanish for ease. That's what we have a lot here. We used a lot of the RNs on other floors because we knew they could interpret. In fact, I used an RN from the ER when I had to have translation for a patient in the ICU. It was great because, yeah, they knew what they were saying. If you have any little concerns, like again, using non-medically trained individuals, you might want to ask for just clarification on what are they saying to the patient? How do you do that? Have someone who is clinically trained just to make sure that's why. Do they have to have certification? They have to be qualified to do that. That's what they're looking at. Can they translate what's being said correctly to and from the patient and the provider? That's what they mean by qualified. Okay, and then the last question here says, regarding significant communications, are we required to use the 15 languages versus the top two? You have to have the resources available in your 15 or 17 languages. Again, if you're finding more patients coming in for three or four, you may need to reevaluate that. And how are you going to get that information communicated? I think that answers the question as far as the top two. Maybe you want to repeat that or we could take it offline, Lindsay. Yeah, and Connie asked how that question comes from you. So if you need additional clarification or maybe have a specific instance for your organization, don't hesitate to let us know. And I'll give everyone our contact information at the end of today's presentation so you can always follow up with additional questions as well. And here's a comment here to the polling question that says that we post in each facility registration area and also a copy is provided in the registration packets. Perfect. And then there's the rest of those results. Great. Okay, multiple signs, very good. Okay. So the notice, you have to have a notice. It must be posted. It's just, again, this is how you know you're right and that they're aware of what the law does say. So this is the content, very simple. We don't discriminate based upon all of those items in healthcare programs and activities. When? Well, do it when they arrive at the hospital and now Health and Human Services does say should be done on a continuing basis. OCR, there is a sample. I have it in the appendix and that you can put up there. It's for other covered entities, not just you as a hospital, maybe your physicians. And it does follow pretty well what's in the CMS conditions of participation for patient rights. So what's included? Auxiliary aids and services, qualified interpreters available, no charge and timely. And it's in other formats. So what does that mean? Braille, don't forget our visually impaired patients. Maybe we have to put this in Braille. There is a definition, federal register when auxiliary aids and services are required. So for example, you might wanna put it in large print, whiteboards for intubated patients. Believe it or not, that could be a way for them to communicate. Magnifying glasses, closed captioning, telephone with amplifiers, qualified interpreters. I've already talked about that. Braille materials, qualified readers. Health and Human Services gets a little bit overboard sometimes, but they also talk about other items. Voice, text, accessible electronic and information technology, computerized assisted transcription services and more. In other words, you're speaking and automatically comes up. We probably all have it on our cell phones when we wanna do a text and we're not supposed to text and drive, so we use the microphone. That's an example of that computerized assisted transcription. So the notice says, first off, language services are available, but there also has to be a notice on filing a complaint. And the rule does require you to have this information electronically, especially if you're a newly constructed or altered facility such as ADA, make sure those with wheelchairs can get in and out and those who have other disabilities. So they're blind, how do they get in? On your elevator keypad, is it in Braille so the patients know where to go? Again, there is a sample notice in English that you'll wanna translate. I have the link there for you and it takes everything that this is the notice that's available to you and also how do you file agreements? They're available in many languages. It has the tagline, notice of discrimination and statement of non-discrimination. So here's just examples of some disability based upon, again, a disability. This patient was visually impaired. They wanted the consent to be accessible to her and I can do electronically in large print so that I can read it very clearly. Hospital said, nope, I'm not gonna do it. Here's one where they had hearing impaired individuals sign with language interpreters, but it was a really bad video relay and they operated it through an unreliable internet connection. It was blurry. So they figured, okay, yes, you have it, but it's not worth anything. It's really not. Another part of that happens to be grievances. We've got some of these questions coming fast and furious together. So let's see what you put. I think this is our last major one. Yes, absolutely. Okay, this one's now on your screen and it says all our staff, including physicians and support staff have received information and or orientation as to what to do when a patient wants to complain about fair treatment. Yes, no, or prefer not to answer. And then the only question I see right now, Laura, is just a clarification here. Do the notices have to be in all 15 languages or 17 languages? The tagline, what they're saying is if you want translation services, they're available, no cost, blah, blah, blah. That's what has to be in all 17 languages. I showed that picture that I showed on one slide. Then if the patient does request, let's say it's number six or seven down the list, you might wanna have one or two standby so you can give them the notice of their rights and privacy, all of that in their language. We have to be able to translate that information into their language. Again, otherwise, if you've got 15 of all of those notices, you're gonna have no wall space in your hospital. Let's face it. So just have it available if you know it's needed so you can give them this proper translation service for those notices. So in answer to your question, no, you do not have to post them in all 15 languages. The taglines, yes. All right. Hopefully that answers it. Yeah, and I think this other question that just came in now that says, do we need to have taglines in the top 15 languages on all significant communications? Say that again. I'm gonna pull that back up here. Sorry. No, you're good. Okay, do we need to have taglines in the top 15 languages on all significant communications? Okay, the taglines, just so I can go back, the taglines, just to clear up, are just simply, if you require or want translation services available, no charge, let us know. That's the tagline. The notice, those significant communications, you're gonna know when you've got a patient who, again, speaks one of those, not one or two languages, but a little bit further down, and it's a significant communication, an informed consent for surgery. To me, that's a significant communication. You need to get that into their language so they understand. It helps that you can show, yes, I have a patient who speaks Tagalog, for example, and I have their rights translated into their language, and I'm available to give it to them when they come in. Hopefully, that will help or helps address the question. Perfect. Okay, and there are the results of that question. Okay, yes. Do, do, do, do. All right. Oh, thank you, Lindsay. Our grievances and procedures. Again, we have to give information to the patient how we file agreements. This is under CMS, and there's the tag numbers. Joint Commission calls them complaint, CMS calls them agreement, so we have to have some way to address these complaints and someone to do that, someone to coordinate it, and an employee or a committee who is responsible for it. So as far as a sample policy, Health and Human Services, they have put together a policy for us, so we don't have to do that, and you just might want to add that language to your policy. Who takes care is up to you. I've heard some discussion, do we put it in compliance? Do we put it in risk management? Do we give it right to our legal counsel? That's up to you. Who's the best person or the best way that you found? Sometimes just turning over complaints to an attorney can sometimes raise concerns with the patient, like, oh, they know they did something wrong and they're trying to cover themselves. That's not correct. It just, that's the best person to handle it. So here happens to be just some sample language of that policy and how you can put one together. So what do you have to do? First off, as far as the procedure, we want to make sure you have a language access plan, have a procedure, you must do that. You must have a way to handle patients' complaints or grievances. Someone in your hospital has to investigate these, whether you call it compliance coordinator, patient advocate, risk manager, someone who goes in and investigates them, and especially those who do not comply with section 1557. You have to have prompt and equitable resolution of the grievance and then keep the patient informed. Let them know what you did and when you addressed the complaint. Now the patient has to file that grievance within six months of the act of discrimination, the last act or 180 days. And of course we don't retaliate against them. All that's going on in the investigation or anyone who helps in the investigation. But the grievance must be in writing, include the name of the person who's filing the complaint and their address, how do you reach them? And really, what is their beef? What is their complaint? What are they complaining about? The coordinator or advocate, whoever it is, has to look into that complaint. And they also have to keep files and records for you with the entity. What happened? Who did you talk to? Who was involved in this issue? Because they have to have an opportunity to reply and submit evidence based upon that complaint. And then the coordinator issues a written decision back to the patient and advise them, hey, you have the right to pursue further legal action if that is what you want to do. And they always have the option to file a complaint also with OCR at any time, as long as it's within that 180 day time period. There is a website, how patients can do that. And they can send it in email, snail mail, however it is that it gets in. Usually they'll go right into the complaint portal and file it there. But they have to have the name of that provider who was involved that they believe had a violation. So that's how it will look for a patient when they pull it out. And as far as anything going forward, You as a covered entity who has financial assistance, you have to have an assurance that when you are doing your application for Medicare and Medicaid, that there are assurances that you will comply with 1557 requirements. It's called form HHS 690 in asterisk I have it at the appendix. So for some final OCR training, there are materials for you to communicate with your staff. Maybe you've got hospital, excuse me, clinics that you are responsible for also. They're geared to helping you understand what needs to be in the policy and procedure. They even have a PowerPoint presentation also that if you wanted to use it, you can use it at no charge. So that's for you who are going or have the responsibility to train your folks on. This is what's required. So I just go ahead and wrap it up with just some of the cases from OCR on exam bills. So here we have a patient putting them in the wrong room. This was a transgender patient. They filed a complaint on discrimination on the basis of sex on the assignment of their rooms. So what happened as a result of this is that the hospital had to go back in and revise their admission policy and do training on it also. So that during the intake opportunity, intake time, patients had the chance to identify what's your preferred name and how do you identify? In fact, most of the hospitals that I've been in lately, that's just there. That's how they identify them. How do you wish to be called? He, she, they, them, et cetera. They also, this hospital said, okay, we're going to revise our room policy to make sure that these assignments are appropriate and especially for a transgender patient. And then we're going to go out and train our staff and make sure that we're diligent and observant on derogatory statements and any adverse treatment that might happen. This one unfortunately happened in my state. We had a transgender individual, Colorado Women's Wellness Connection Program. Now this was a federally funded program through our state. And this program denied a mammogram because they were transitioning from male to female rather than female over to male. And they said, nope, we're not going to do that because this was for uninsured or underinsured individuals. And they were primarily funded through a National Breast Cervical Cancer Early Detection Program. Well, that's administered through CDC. And under the program, CDC's position was, we're only going to cover individuals who are genetically female. Well, the OCR came in and said, eh, no, that's supposed to go to all grantees for federal funding. And that included this wellness program. So now the program had to go back and reevaluate who they were going to administer and make sure that for women, transgender women who have or are currently taking hormones, that yes, indeed, they are covered and entitled to receive these mammograms. This one, some of you may have heard about this one. There was a complaint from a man who was getting transportation services for his doctor's appointment. And this was a private service that gave these transportation services. Well, multiple drivers came to harass him because he had some feminine gender expression. So OCR comes in and they do the investigation and they investigate staff, contracted drivers, and said, you know what? You can't do that. Remember, this is part of also under CMS. As a hospital, and especially the board, is responsible for all the contracts. In other words, they have to know what's there and be responsible to make sure that the contractors are also abiding by the laws. And so under this one, they came back and said, you know what? You need to sit down with these drivers and say, that's not okay. You cannot do that. And so the particular facility and doctor's hospital in particular put together safety measures so that this discriminatory treatment was immediately stopped. In fact, they actually changed over to a different driver service as a result of it. Now, here we have, it's a little bit different. We have a victim of domestic violence, which is a male. And he came in because his partner was physically abusive to him. And there was a complaint because some of the ER staff wasn't exactly sensitive to this situation, made some very rude comments. And they said, well, because he's a male, no, not necessarily. We're not gonna believe that. So OCR comes in and does an investigation and said, yeah, no, that's not okay. And the hospital had to go back over its abuse protocol, make it gender neutral, so that when there are issues of domestic abuse and you have mandatory reporting within your state, you still have to do that. You still have to identify him, assess him, and treatment. Well, this is kind of an interesting one. Get an 18-year-old patient, identified female to male, transgender male, filed a lawsuit against the hospital and the ED and the doctors alleging discrimination, came in for extreme pain down in the reproductive areas of his organ. Again, this was female to male. Well, the hospital personnel on admission put on the wristband F, despite saying, I am male, on arrival. And of course, then the clerks are back there whispering amongst themselves, gee, you waited a real long time to be seen, so is it really that bad? So necessarily, of course, he felt this very hostile environment and a very painful exam. But finally, the patient's mom, who came in with him, said, you know what? You need to stop. Even though the patient's saying, that hurts, please stop, they continued with this very painful exam. So once admitted, the patient does get admitted to the hospital and patient said, you know what, that's not okay. So they did file a discriminatory action. And it just gets even better because then they found outside on his door said he was treated by an OBGYN implicating female. After the exam, the doctor didn't even change gloves and then came up and examined the mouth and eyes. And was only, only after mom suggested, does he have an STI, that the physicians agreed to write a prescription to improve his condition. While the federal cause of action in this one was upheld. Because the patient was simply denied the benefits of that program. And it was discriminated against. Then there was a state claim on top of that. This one came in and said, you know what? That's a violation of our human rights act within our own state. And essentially it just said, any person of full extent and equal opportunity and enjoyment of goods and services, et cetera. So not only was the hospital found liable, but the physician under both federal and state laws. Now that's why it's very important on how we have to train and be diligent on what's going on within our hospital. So we don't have to face these two together. All right, so just a quick updates with the overlap of the CMS and the OCR. So OCR said, we're gonna take parts of those. I'm sorry, CMS said we'll take part of OCR and put it into our conditions. Well, they finally said, you know what? That's not probably a good idea because when one changes, the other one has to go back in and change. And just at the beginning, you saw and heard all of the changes that were going on with OCR and whether it's disability or productive rights, anything, and how many changes. And CMS honestly just couldn't keep up with them. So now they said, gonna leave it on regulation and that's OCR 1557. And again, just because CMS is on site and they see something, they can still go to OCR and let them know. So again, to participate in Medicare, you have to agree to follow all the civil rights acts. And that's any prohibition on discrimination based upon their protected class, disability, age, and sex. Now CMS said, we know there is nothing written in our condition of participation on gender identities. They know that. But they also recognize that can be a barrier to patients seeking care because they know it's out there. The 2011 IOM report did even mention that. And that's been what, 13 years ago and it still happens. You know, where we have some patients who are denied care or given inadequate care, just bad behavior, discriminatory behavior, just between nationalities for those treated for osteoarthritis at a VA facility. Minorities, they probably may not get preventive vaccinations. So we still have to have a policy that we will not discriminate based upon our classes, that patients, their support persons have to be informed on such rights in a language they can understand. So all of you, great questions. Do I have to have these rights translated into their language? And the answer is probably yes. And tell them how they file a complaint. And if they found discrimination. So you would take that one notice of patient rights and make sure if you get a patient in that language that you can hand it to them. Joint commission, they have resources. And this is really directed to the LGBTQI community. It helps them understand what's available. And it's also available to you to really help advance that communication. So as I just close this out, just again, some sample notice on non-discrimination accessibility on what you wanna include. And I have many more in the appendix for you. There's like 14 pages or so for you. I don't wanna do too much, but I do wanna wrap this up. Here we have Ronnie. Transgender male, female to male five years ago. Had a panhysterectomy bilateral mastectomies. Came to the ED, severe abdominal pain, many months. This is a different one than that case that I'd mentioned. He didn't get care because he's been to this hospital before and it was not a pleasant experience by any means. So they found possible endometriosis in his abdominal cavity. They did schedule an exploratory lab for the next morning and it was overheard through the admissions, do I put her into a two bedroom with another female? So you're the risk manager or you're the compliance coordinator. What's the first thing you wanna do in the situation? How would you advise them to proceed? And so Lindsey, I guess I'll have them put that into the chat box if that's okay. And just some of these resources again, here's that regulation on disability. I did include the name, the phone number for the person. If you go to these memos, usually at the end, when you get down there, it'll tell you who do you contact for questions. So again, this is one on the HIPAA regulation on disclosure of our reproductive health information. Further information on disclosures, how we get to those, the fact sheets. Otherwise, try to give you as many of those internet links and what they apply to. So I'll take it back to that. We're at good timing. You may get 30 minutes back. Otherwise, Lindsey, if you wanna go through questions, we got time to do that. Okay, absolutely. Okay. So this says, can you just clarify again, what was said about providers translate for others? Is that even if they are not qualified to interpret? Okay, so then that's your, again, you have to determine, is this person qualified? And how do you do that? What can they do? I mean, what language are they, what's their experience with that language? For example, I worked with a surgeon who, he worked down in Mexico on some of the free clinics. Would I want him translating? No. Okay, he was down there working, but he also had the benefit of other translators down there. He spoke some smattering of Spanish, but not enough that you would feel comfortable for him to be able to communicate effectively. Now, when I have a physician who was maybe raised in that language, very fluent in English also, then yeah, that's probably the person I'd wanna know and use. It doesn't have to be just a blank, oh, you're a nurse, you speak some Spanish, come on in. You need to make sure or have some level of comfort on how are they translating? Can they do it appropriately? I can probably go into a Mexican restaurant and order a meal. That's the limit of my Spanish. Do not put me in a room to try and translate. I can't do it because I don't know the proper words in Spanish to English and vice versa. I just don't know it. So that's really kind of gotta work with the person on knowing is this the correct translation? And I'm sorry, they don't give us any other clear guidance on that other than to make sure, again, they are doing it accurately. Okay, and then should gender identity questions be asked at registration or by the clinical team? That's where you can ask it at admission. How do you wish to be, how do you, what's the word I'm thinking of the phrase? How do you identify as yourself, male, female, et cetera? Are those very basic questions. How do you wish to be addressed? I see it when I just go to my doctor anymore and I'm filling out my intake form. How do you wish to be addressed? That's fine, you can do it then. It saves time when it's done initially as long as it's done non-discriminatorily and we're probably, I can probably identify that you know what I'm talking about, where they say they're born male, they identify as female and then you see the rolling of the eyes of your admissions clerk. Hopefully that doesn't happen anymore, but that's how you can identify. How do you identify yourself? That's okay for admissions. Okay, I don't see any other questions or comments here saying that they would place Ronnie in a private room, I see that a couple of times here. Yeah, I think you've all got it, that's great. And again, if there's any questions after the fact, just send them to Lindsay, she's real good about getting them to me and I'll do my best on getting back. Again, if it's a state law, you're gonna have to go through your own state council or in-house council on that one. I do see just a comment here that says, we had a process to certify our employees as interpreters. It was through our interpreter services department and it covered us and took pressure off employees who may have been fluent in a language, but were uncomfortable being allowed to translate. Oh, that's great, that is really nice. You know, and just because they work in housekeeping or food service, doesn't mean they're not educated. Doesn't mean they're not educated, that they're not up on medical terminology because in their country, they might've been a nurse or other healthcare provider. So just because they work there now, doesn't mean they don't understand it. So that's great that you have that option to have that qualified and make sure they are doing adequate translation. That's great. Absolutely. Okay, and I did just go ahead and post some comments here for you all in the chat. And Laura, I know you mentioned at the end of your slides here, you have, I'm not even sure how many additional slides of resources, I'm sure there are many. Laura's also always great about including those resources. I know you mentioned earlier, I saw one question in the chat asking for a specific link. And just to clarify, I know Laura mentioned it, the links themselves. So if you open the PDF document, you're not gonna be able to click on that and it would not open a browser or a webpage from there, but you can copy and paste that link into your browser and then it should work from there. If for some reason you come across a link that it does not work whenever you copy and paste, of course, let us know. We'll be happy to investigate that for you and get you a separate link for whatever it may be that you're looking for there. But you will all receive an email tomorrow morning. I just like to note that it does come from educationnoreplyatzoom.us. And because it comes from that Zoom email, it does seem to get called in your spam or quarantine folders pretty often. So if you don't see that in your inbox in the morning, just check those additional folders. And if it's still not there, and you would like to just go back and listen to the recording, you can also just use the same Zoom link that you're using to join the live presentation today to also access that recording. And then just remember that the recording is available for 60 days. And when you click on that Zoom link, it will prompt you to enter your information and that will send an email to us to approve your recording access request. And then we approve those very quickly, but we ask that you give us one business day to do that. And then also included in that email tomorrow morning will be a link to the slides. But I did go ahead and provide that link there for you in the chat as well. And then if you're joining us as a member of the Georgia Hospital Association, please pay special attention to the survey link that will be included in that email tomorrow morning. That is how you will obtain your certificate of attendance and any information regarding continuing education credits. And then if you're joining us as a member of a partner state hospital association, unfortunately, GHA is not able to offer CEs to members of other state hospital associations, but your associations would have additional information available to you regarding CEs that they may be offering for today's session. So please don't hesitate to reach out to your contacts there. And then as Laura mentioned, if you do have any additional questions, you can always reach us at education at gha.org. We'll be happy to get those questions over to Laura and she's wonderful about being very timely and thorough in her response as well. You do see her content information here on the screen, but I encourage you to reach out to us at education at gha.org. Thank you, Laura, so much for powering through today. I know it was probably not the easiest with your voice and we hope that you just feel better. And we thank you so much as always for your time and information that you share with us. And thank you to our attendees for your wonderful questions and for joining us today. And we look forward to having you all back with us for future sessions and hope you have a wonderful week. Thank you so much. Thank you, everyone. Thank you, Lindsay. Thank you, bye-bye.

Risk Management

Patient Safety

Section 1557

Affordable Care Act

Non-discrimination

Healthcare

Federal Funding

Gender Identity

Sexual Orientation

Compliance

Language Assistance

Disability Adaptations

Legal Requirements