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Privacy / Nondiscrimination Policy

—Skip down to Providence's Nondiscrimination Policy

This Joint Notice of Privacy Practices (Notice) describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The Notice is being provided to you on behalf of Providence Health & Services (Providence), its medical staff and other providers (collectively referred to herein as “we” or “our”).

Providence is committed to protecting the confidentiality of your health information

We are required by law to maintain the privacy of your Protected Health Information (commonly called PHI or health information), including PHI in electronic format. We are also required to notify you of our legal duties and privacy practices regarding your health information and abide by the practices of this Notice, unless more stringent laws or regulations apply. This Notice applies to all Providence facilities, services and programs that provide healthcare to you.

Application of this Notice

The information privacy practices described in this Notice will be followed by:

  • Any healthcare professional who treats you at any of our locations.
  • All facilities, departments and units, including hospitals, surgical centers, home care, clinics and other affiliates.
  • All workforce members such as employees, medical staff, trainees, students, volunteers and other persons under our direct control whether or not they are paid by us.   
  • Other healthcare providers that have agreed to abide by this Notice of Privacy Practices.

This Notice provides detailed information about how we may use and disclose your health information with or without authorization as well as more information about your specific rights with respect to your health information.

Uses and disclosures of your health information that we may make without your authorization

To Contact You: Your information may be used to contact you to remind you about appointments, provide test results, inform you about treatment options or advise you about other health-related benefits and services.

Treatment: Your information may be shared with any healthcare provider who is providing you with healthcare services. This includes coordinating your care with other healthcare providers and providing referrals to other healthcare providers. Examples of healthcare providers who may need your information to treat you include your doctor, pharmacist, nurse, and other providers such as physical therapists, home health providers and x-ray technicians. We may share your information electronically with your healthcare providers in order to make sure they have your information as quickly as possible to treat you.

We may share your health information with any family member or friend who is involved in assisting with your healthcare. We will only do this if you agree or do not object, and will only share with them the information they need in order to help you. If you are unable to either agree or object to such a disclosure, we may disclose your healthcare information as necessary if we determine that it is in your best interest based on our professional judgment. We may disclose health information to a family member, relative, or another person who was involved in your healthcare or payment for healthcare when you are deceased if not inconsistent with your prior expressed preferences.

Payment: In order to obtain payment for your healthcare services, we may have to provide your health information to the party responsible for paying. This may include Medicare, Medicaid (state health plan) or your insurance company. Your insurance company or health plan may need your information for activities such as determining your eligibility for coverage, reviewing the medical necessity of the healthcare services provided to you or providing approval for hospital services or stays.

Healthcare Operations: Your health information may be used in order to support our business activities and to assure that quality healthcare services are being provided. Some of these activities include quality assessments, peer or employee review, training of medical personnel, licensure and accreditation, data aggregation and audits by regulatory agencies.

We may share your PHI with third parties who perform services such as transcription or billing. In those cases, we have written agreements with the third parties that they will not use or disclose your health information except if permitted by law.

We may also use your information (name, address, date of birth, department of service, treating physician, dates of treatment, outcome) for our fundraising activities. You have the right to opt out of receiving such communications.  If you do not want to receive these materials, please contact our foundation office and request that these materials not be sent to you.

Unless you object, your name and location may be included in our patient directory. If it is included, we will only share very limited information about you, such as your location in a hospital and general status, with anyone who asks about you by name. If you choose to provide your religious affiliation and do not object, we may provide your name and room number to clergy from your faith or religious community.

This Notice also describes the privacy practices of an Organized Health Care Arrangement ("OHCA") between us and certain eligible healthcare providers and organizations.  An OHCA allows legally separate covered entities to use and disclose PHI for the joint operation of the arrangement. We participate in such an arrangement of health care organizations who have agreed to work with each other to facilitate access to health information relevant to your care. For example, if you present to a hospital for emergency care and cannot provide important information about your health, the OHCA will allow us to use your PHI from our OHCA participants to treat you. When it is needed, ready access to your PHI means better care for you. We store health information about our patients in a joint electronic health record with other health care providers who participate in this OHCA. Providence and members of the OHCA must be able to share your health information freely for treatment, payment and healthcare operations purposes. For this reason, we have created the OHCA and this Joint Notice.  OHCA members may choose to have their own Notice(s).  For information about organizations participating in our OHCA, please contact the Privacy Office listed in this Notice.

Other uses and disclosures that we may make without your authorization

There are a number of ways that your health information may be used or disclosed without your authorization. Generally, these uses and disclosures are either required by law or for public health and safety purposes.

When Required by Law: We may use or disclose your health information when required by law. If this happens, we will comply with the law and will only disclose the information necessary.

Public Health: We may disclose your health information to a public health authority for public health activities. Public health activities include preventing or controlling disease, injury, disability, and responding to reports of abuse, neglect or domestic violence.  We may disclose your health information to a person or agency required to report adverse events, product defects or problems, biologic product deviations, or for product recalls, repairs or replacements. Any disclosures of this nature will be made consistent with state and federal law.

Health Oversight: We may disclose your health information to health oversight agencies for oversight activities authorized by law, such as audits, investigations, and inspections. Health oversight agencies include government agencies that oversee the healthcare system, government benefit programs, government regulatory programs and civil rights.

Legal Proceedings: We may use or disclose your health information in response to a court or administrative order in an administrative or judicial proceeding, or in response to a subpoena, discovery request or other legal process.

Law Enforcement: We may use or disclose your health information for law enforcement purposes. Examples include (1) responding to legal processes; (2) providing limited information to identify or locate a suspect; (3) providing information about crime victims; (4) reporting suspicion that death has occurred as a result of criminal conduct; (5) reporting a crime which occurred on our premises; and (6) for medical emergencies, reporting where it appears likely a crime occurred.

Preventing a Serious Threat:  We may use or disclose your health information if we believe in good faith that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or of the public.  Disclosure may only be made to a person reasonably able to prevent or lessen the threat.

Coroners, Funeral Directors, and Organ Donation: We may disclose your health information to a coroner or medical examiner for identification purposes, determining cause of death or other legally required duties. We may disclose your health information to a funeral director in order to permit him/her to perform his/her duties.  We may disclose your information to facilitate an organ, eye or tissue donation.

Research: We may disclose your health information to researchers, provided that the research has been approved by an Institutional Review Board and/or a Privacy Board, and the research protocols have been approved to ensure your privacy. We may disclose healthcare information about you to people preparing to conduct a research project.

Military Activity and National Security: We may disclose the health information of Armed Forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. We may also disclose your health information to authorized federal officials to conduct national security and intelligence activities, including the provision of protective services to the President or others legally authorized to receive information.

Inmates/Arrestees: We may use or disclose your health information to a correctional institution or law enforcement official if you are an inmate of a correctional facility or are in custody and the information is necessary to treat you or protect the health and safety of you, other inmates, employees at the correctional facility or others.

Workers’ Compensation: We may use or disclose your health information as necessary to comply with workers’ compensation laws and other similar legally established programs.

Disaster Relief: We may disclose healthcare information about you to an entity assisting in a disaster relief effort so that your family and friends can be notified about your condition, status, and location. 

Uses and disclosures of your health information that we may make with your authorization

Certain uses and disclosures of your health information, including marketing, sale of health information or release of psychotherapy notes, will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent that we have already taken action in reliance on the authorization.

Uses and disclosures not otherwise described in this Notice will be made only with your written authorization.

Federal and state laws may place additional limitations on the disclosure of your health information for drug or alcohol abuse treatment programs, sexually-transmitted diseases, or mental health treatment programs.  When required by law, we will obtain your authorization before releasing this type of information.

Your Rights

Right to Request Restrictions: You have the right to ask us to place restrictions on the way we use or disclose your health information for treatment, payment, or healthcare operations. We will consider your request but are not required to agree to the restriction (except as described below). If we agree to a restriction, we will not use or disclose your health information in violation of that restriction, unless it is needed for an emergency.  If a restriction is no longer feasible, we will notify you.  

Right to Restrict Disclosure to Health Plans: You may request in writing, at the time of service, that we not disclose information to health plans where you have paid for items or services out of pocket in full. We must agree not to disclose this information to your health plan if certain conditions are met.

Confidential Communications: We will accommodate reasonable requests to communicate with you about your health information by different methods or alternative locations. For example, if you are covered on a health plan but are not the subscriber, and would like your health information sent to a different address than the subscriber, we can usually do that for you.

Breach Notification:  You have the right to receive notification of breaches of your health information as required by law. 

Access to Your Health Information: You have the right to receive a copy of your health information that we maintain, with some limited exceptions. You may request access to your information in writing and you may request a copy of your information in electronic format. We reserve the right to charge a reasonable fee for the cost of producing and providing your health information. You have the right to request that your health information be sent to any person or entity, such as another doctor, caregiver or online personal health record.

Amendment of Your Health Information: You have the right to ask us to amend any of your health information. You need to request this amendment in writing and submit it to the facility’s medical records department. We may deny your request in certain situations, such as when the health information in your records was created by another provider or if we determine your information is accurate and complete. Any denials will be in writing. You have the right to appeal our denial by filing a written statement of disagreement.

Accounting of Certain Disclosures: You have a right to a listing of the disclosures we make of your health information, except for those disclosures made for treatment, payment, or healthcare operations, or those disclosures made pursuant to your authorization. The type of disclosures typically contained in a listing would be disclosures made for mandatory public health purposes, law enforcement, legal proceedings, or for other required reporting such as birth and death certificates.

Exercising Your Rights: To exercise any of the above rights or if you need to share your health information with someone for purposes other than those listed here, contact the appropriate medical records department.

Questions and Complaints

If you have questions or are concerned that any of your privacy rights have been violated, please contact our Privacy Officer at 1-855-768-7145. You also have the right to complain to the Secretary of Health and Human Services at:

Office for Civil Rights – AK, WA, OR, MT
U.S. Department of Health and Human Services
2201 Sixth Avenue - M/S: RX-11
Seattle, WA 98121-1831

Office for Civil Rights – CA
U.S. Department of Health and Human Services
90 7th Street, Suite 4-100
San Francisco, CA  94103

You will not be retaliated against for filing a complaint.

Changes to Joint Notice of Privacy Practices

We reserve the right to change the terms of our Notice at any time. New Notice provisions will be effective for all protected health information that we maintain. You may view a copy of our most current Notice on our website at www.providence.org, or request a current copy from the medical records department, privacy officer, or registration staff at any time.   

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.

Compliance Office

Providence Emilie Court Assisted Living
24 E 8th Ave.
Spokane, WA 99202
Phone: (509) 474-2550

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.