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Nondiscrimination Policy

As a recipient of Federal financial assistance, Providence Health & Services – Washington/Montana Region (PH&S – WA/MT Region) does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by PH&S – WA/MT Region directly or through a contractor or any other entity with which PH&S – WA/MT Region 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, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.

Each facility/program within PH&S – WA/MT Region maintains a 504 Coordinator, a policy on discrimination, and a procedure for reporting violations; and further assures the distribution of same to all patients and clients at time of admission or program entry.

Quick links:

Contact information

In case of questions, you may either contact the Facility 504 Coordinator (see below) or you may contact the Regional 504 Coordinator for the PH&S – WA/MT Region.

Providence Sacred Heart Medical
Center & Children’s Hospital

Cheryl Thomas, Director of Risk Management
(509) 474-3000

Providence Health & Services
Dan Harris
Chief Financial Officer, WA-MT Regional 504 Coordinator
Providence Health & Services
Telephone: (425) 687-3603

TDD/Washington Relay Service: Dial 711
TDD/Montana Relay: Dial 711


Section 504 Grievance Procedure

It is the policy of Providence Health & Services – Washington/Montana Region (PH&S – WA/MT Region) not to discriminate on the basis of disability. All PH&S – WA/MT Region facilities/programs have 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 prohibits discrimination on the basis of disability in any program or activity receiving Federal financial assistance. The Law and Regulations may be examined in the office of Cheryl Thomas, Director of Risk Management, Providence Sacred Heart Section 504 Coordinator, who has been designated to coordinate compliance with Section 504.

For PH&S – WA/MT Regional Section 504 Compliance you may contact Dan Harris, Chief Financial Officer, Providence Health & Services WA/MT Regional 504 Coordinator (see contact information above).

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 any PH&S – WA/MT Region facilities/programs to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.

Procedure:

  • Grievances must be submitted to the Facility Section 504 Coordinator of the facility/program within 7 days 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 Facility 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 Regional Section 504 Coordinator will maintain the files and records of all PH&S – WA/MT Region facilities/programs relating to such grievances.
  • The Facility 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 Facility Section 504 Coordinator by writing to the PH&S – WA/MT Regional Section 504 Coordinator within 15 days of receiving the Facility Section 504 Coordinator’s decision.
  • The PH&S – WA/MT Regional Section 504 Coordinator shall issue a written decision upon review by the PH&S System Office Department of Legal Affairs in response to the appeal no later than 30 days after its filing.
  • The availability of each PH&S – WA/MT Regional Section 504 Coordinator facility or program grievance procedure does not prevent a person from filing a complaint of discrimination on the basis of disability with the US Department of Health and Human Services, Office for Civil Rights.

PH&S – WA/MT Regional Section 504 Coordinator 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 barrier-free location for the proceedings. The Facility Section 504 Coordinator will be responsible for such arrangements.

Notice of Program Accessibility

To comply with Section 504 of regulation 45 C.F.R. §84.22(f), Providence Health & Services – Washington/Montana Region (PH&S WA/MT Region) will adopt and implement procedures to ensure that interested persons, including persons with impaired vision or hearing, can obtain information as to the existence and location of services, activities, and facilities that are accessible to and usable by disabled persons.

PH&S WA/MT Region 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 off-street 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 may include:
    • Qualified sign language interpreters for persons who are deaf or hard of hearing.
    • A twenty-four hour (24) telecommunication device (TTY/TDD) which can connect the caller to all extensions within the facility and/or portable (TTY/TDD) units, for use by persons who are deaf, hard of hearing, or speech impaired.
    • Readers and taped material for the blind and large print materials for the visually impaired.
    • Flash Cards, Alphabet boards and other communication boards.
    • Assistive devices for persons with impaired manual skills.

Each PH&S – WA/MT Region facility/program will be required to identify the aids within their internal procedures that are available. Any patient or client requiring an available aid should contact the Facility Administrator and/or their designee or Facility Section 504 Coordinator (see above).

Auxiliary Aids and Services for Persons with Disabilities

Providence Health & Services – Washington/Montana Region (PH&S WA/MT Region) facilities/programs 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, at minimum, communication of information contained in important documents, including consent to treatment forms, conditions of admission forms, financial and insurance benefits forms. All necessary auxiliary aids and services shall be provided without cost to the person being served.

PH&S WA/MT Region will provide 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

  • Identification and assessment of need:
    PH&S WA/MT Region will provide notice of the availability of and procedure for requesting auxiliary aids and services through notices in our facility/program brochures and through notices posted, at minimum, in main facility entrances, emergency waiting rooms, and patient admission areas. 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.
  • Provision of Auxiliary Aids and Services:
    PH&S WA/MT 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

For persons who are deaf/hard of hearing and who use sign language as their primary means of communication, the facility/program staff handling intake/registration or the clinician as appropriate, is responsible for arranging for a qualified interpreter when needed.

In the event that an interpreter is needed, the facility/program employee handling intake/registration, or the clinician as appropriate, contacts the interpreter service provider that has agreed to provide interpretative services to the facility/program. The Facility Section 504 Coordinator is responsible for maintaining an accurate and current listing of sign language interpreters who have agreed to provide sign language interpretation for facility/program patients. See Sign Language Interpreters Form. These listings may be obtained by contacting the appropriate Facility Administrator and/or their designee or Facility Section 504 Coordinator (see above).

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

PH&S WA/MT Region utilizes telecommunication devises for deaf persons (TDDs) and relay services for external telephone with TTY users. We accept and make calls through a relay service. The state relay service number is 711 in Washington and 711 in Montana.

For the following auxiliary aids and services, the Facility Section 504 Coordinator is responsible to provide the aids and services in a timely manner, which may include:

Note-takers; computer-aided 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.

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

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.

Each PH&S WA/MT facility/program is responsible for maintaining materials accessible to persons who are blind or have low vision: These materials may be obtained by contacting the Facility Administrator and/or their designee or Facility Section 504 Coordinator for that facility/program (see above).

For the following auxiliary aids and services, staff will contact the Section 504 Coordinator 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 are 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 the Section 504 Coordinator, who is responsible to provide the aids and services in a timely manner.

These may include writing materials; TDDs; computers; flashcards; alphabet boards; 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:

Note-takers; computer-aided 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 the Facility Section 504 Coordinator who is responsible to provide the aids and services in a timely manner.

Policy and Procedures for Communication with Persons with Limited English Proficiency

Providence Health & Services Washington/Montana Region (PH&S WA/MT Region) 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 PH&S WA/MT Region is to ensure that each of its facilities, services and programs provides 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. 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 at point of facility or program access and is available free of charge.

Language assistance will be provided at each of PH&S WA/MT Region facilities/programs, and may include use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations and State agencies providing interpretation or translation services, or technology and telephonic interpretation services. Each facility and program is responsible for defining the language assistance methods available to patients and clients and further responsible for ensuring staff is provided notice of its internal policies and procedures. Staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective use of an interpreter.

PH&S WA/MT Region will conduct a regular, regional review of the language access needs of our patient population, as well as update and monitor the implementation of and adherence to this policy within the Region. Each facility and program within the PH&S WA/MT Region will establish procedures to support the LEP policy, to include:

Procedures:

  • Identifying LEP Persons and their Language
    Prompt identification of the language and communication needs of the LEP person. This procedure shall include that 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.

  • Obtaining a Qualified Interpreter
    For LEP persons requiring interpretative services, the facility/program staff handling intake/registration, or the clinician as appropriate, is responsible for arranging for either the appropriate bilingual staff member to interpret, or obtaining an outside interpreter if a bilingual staff or staff interpreter is not available or does not speak the needed language.
  • Each Facility 504 Coordinator will:
    • Maintain an accurate and current list showing the name, language, phone number and hours of availability of bilingual staff; and
    • Maintain an accurate and current listing of outside interpreter services who have agreed to provide qualified interpreter services for facility/program patients. See Language Interpreter Services Form. These listings may be obtained by contacting the appropriate Facility Administrator and/or their designee or Facility Section 504 Coordinator (see above).

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.

  • Providing Written Translations
    • Each PH&S WA/MT facility/program will identify a responsible staff person to whom documents requiring translation will be submitted. When translation of vital documents is needed, each unit/department within the facility or program is responsible to submit the documents to the identified staff person. Original documents being submitted for translation will be in final, approved form with updated and accurate legal and medical information.
    • Facilities and programs 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.
    • Each facility or program within the PH&S WA/MT Region will set benchmarks for translation of vital documents into additional languages over time.
  • Providing Notice to LEP Persons
    Each facility or program 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 and outpatient areas. The procedure shall include how notification is provided at the facility/program and may include outreach documents, telephone voice mail menus, local newspapers, radio and television stations, and/or community-based organizations.
  • Monitoring Language Needs and Implementation
    Each facility or program will assess changes in demographics, types of services or other needs that may require reevaluation of the LEP policy and its supporting procedures on an ongoing basis. The efficacy of the procedures will be regularly assessed. The assessment is inclusive of, 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, staff, and community organizations.

Hospital and Program Admission Policy and Procedures

Providence Health & Services – Washington/Montana Region (PH&S–WA/MT) does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its admissions, programs, activities and services.

Each PH&S–WA/MT Region facility and program shall maintain admission procedures unique to the service(s) rendered and in compliance with federal and state regulations as required to maintain certification and licensing status; and to further comply with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975.

Facility and program operational procedures shall contain certain common elements:

  • Description of the type of patient/client/resident accepted (e.g., Inpatient, SNF, home health, hospice);
  • Notice of rights
  • Nondiscrimination
  • Responsibilities of the facility or program; responsibilities of the patient/client (see Patient Rights & Responsibilities)

The PH&S–WA/MT Region patients, residents and clients will be issued the appropriate facility/program operational policies and notices in addition to this PH&S–WA/MT Regional Hospital and Program Admission Policy and Procedures, as required by federal and state regulations at time of admission or program entry.