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Privacy / Nondiscrimination Policy

Privacy Policy

This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review it carefully.

Providence Adult Day Health is committed to protecting the confidentiality of your medical information and is required by law to do so. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment, and health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

“Protected health information” is information about your health care generated by Providence personnel or by your doctor to assist in planning, documenting, improving, and communicating the care and treatment you received here.

Health Care Providers covered by this notice

This Notice of Privacy Practices applies to Providence Adult Day Health, and its personnel, volunteers, students and trainees. It also applies to other health care providers that come to the centers to care for clients such as therapists, and other health care providers not employed by Providence.

Uses and Disclosures

Providence Adult Day Health may use or disclose your protected health information as follows:

  • For Treatment: The center may disclose all or any portion of your medical record to your attending physician, consulting physician(s), nurses, technicians, medical students and other health care personnel who are involved in your care. Your physician may also share your health care information with other physicians in their practice. For example, a doctor treating you for a broken leg may need to know if you have diabetes because it may interfere in the healing process. The center may also disclose medical information about you to people outside of the center who may be involved in your medical care after you leave the center, such as home health care agencies, nursing homes, rehabilitation therapists, or others that are involved in your continued care.
  • Additional treatment related uses and disclosure include:
  • Appointment Reminders: We may also disclose your medical information when contacting you to remind you of day health attendance. These reminders may be made by phone and messages left on voicemail unless you specifically ask us to communicate with you through a different method.
  • Family Members and Others Involved Your Care: We may release medical information about you to a member of your family, a relative, a close friend, or any other person you identify who is directly involved in your health care, or to someone who helps pay for your care. In addition, we may disclose medical information about you to disaster relief organizations so family can be notified about your condition and location in the hospital.
  • For Payment: Providence may use and disclose medical information about you for the purpose of determining coverage, billing, claims management, medical data processing, and reimbursement. The information may be released to an insurance company, a third party payer or other entity involved in the payment of your medical bill upon your prior authorization obtained on the “SCSA” form. We may also tell your health plan about services or treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the services.
  • For Health Care Operations: We may use and disclose medical information about you in order to support the business activities of our organization. These uses and disclosures are necessary to run the centers and make sure that all of our clients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many Providence Adult Day Health patients to decide what additional services we should offer, what services are not needed, and whether certain new procedures are effective. We may also disclose information to your doctor, nurse, or other personnel for quality review, training and learning purposes. We may also combine the medical information we have with medical information from other health care organizations to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from the set of medical information so others may use it to study health care and health care services without learning the names of specific clients.
  • Health care operations may include, but not limited to the following examples:
  • Fund Raising: We may use health care information about you to contact you in an effort to raise money for the center and its operations.
  • Public Health and Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. We may also use and disclose medical information about you to prevent or control disease or injury.
  • Contracted Service Providers: We will share your protected health information with business associates who perform various activities for the center. Examples included patient satisfaction survey companies, accreditation authorities to name a few. If we do disclose medical information to a business associate they are required by their contract to keep all information confidential.
  • Additional uses and disclosures include:
  • Coroners, Medical Examiners, Funeral Directors, and Organ Donation: We may disclose your protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person, determine the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties.
  • Health-Related Benefits and Services: We may also use and disclose your protected health information, as necessary, to provide you with information about health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about services we offer or to send you information about services that we believe may be beneficial to you.
  • Research: We may use and disclose limited medical information for research projects, such as studying the effectiveness of a treatment you received. Research proposals at Providence Adult Day Health go through a review process to establish protocols and ensure patient privacy prior to disclosing your health information.

We may disclose your protected health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person, determine the cause of death, or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may also use and disclose your protected health information, as necessary, to provide you with information about health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about services we offer or to send you information about services that we believe may be beneficial to you. We may use and disclose limited medical information for research projects, such as studying the effectiveness of a treatment you received. Research proposals at Providence Adult Day Health go through a review process to establish protocols and ensure patient privacy prior to disclosing your health information.

  • As Required By Law: We may use and disclose medical information about you when required to do so by federal, state or local law. For example if abuse or neglect is suspected or known, the appropriate government agency will be notified. We are also required to give information to workers’ compensation programs about work related injuries.
  • Military, National Security and Intelligence Activities: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel:
  • for activities deemed necessary by appropriate military command authorities;
  • for the purpose of determining of your eligibility for benefits by the Department of Veterans Affairs; or
  • to a foreign military authority if you are a member of that foreign military service. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities including protective services to the President or others
  • Legal Proceedings, Lawsuits and Disputes: We may disclose your protected health information in response to a court order, subpoena, or search warrant. You will receive advanced notice about this disclosure in most situations so you will have the chance to object to sharing your medical information.

Other Uses of Medical Information

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. You also have the right to revoke your authorization at any time. This request must be done in writing. If you withdraw your permission, we will no longer use or disclose medical information about you for the reasons covered in your original authorization. Understand that we are unable to take back any disclosures we have already made with your permission.

Your Rights Regarding your Medical Information

You have the following rights regarding your protected health information:

  • Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. This will include medical and billing records. Under Federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. If you request a copy of your medical record, a reasonable fee may be charged.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by Providence will review your request and the denial. Providence will comply with the outcome of this second review.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Business Manager (see address listed below).

  • Right to Amend: If you feel that the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by Providence Adult Day Health.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In          addition, we may deny your request if you ask us to amend information that:

  • was not created by us, unless the person or entity that created the information is no longer available to make the amendment;
  • is not part of the medical information kept by or for Providence Adult Day Health;
  • is not part of the information which you would be permitted to inspect and copy; or
  • is accurate and complete.

To request an amendment, your request must be made in writing and submitted to Business Manager (see address listed below). In addition, you must include a reason that supports your request.

  • Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location or alternative address. For example, you can ask that we only contact you by mail at a different address. We will accommodate reasonable requests. We will not ask the reason for your request. We may, however, ask you for information as to how payment will be handled.

To request confidential communications, you must make your request in writing to the Business Manager identified at the end of this Notice. Your request must specify how or where you wish to be contacted.

  • Right to Request Restrictions. You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment, or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice

We are not required to agree to a restriction that you may request. If we believe it is in your best interest to permit the use and disclosure of your protected health information, your protected health information will not be restricted. If we do agree to the requested restriction, we will comply with your request, unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to the Business Manager identified at the end of this Notice. In your request, you must tell us:

  • what information you want to limit;
  • whether you want to limit our use, our disclosure or both; and
  • specifically, to whom you want the restriction to apply such as names of the individual(s) that you are requesting to not have access to the restricted information.
  • Right to an Accounting of Certain Disclosures: You have the right to request an "accounting of disclosures.” This right applies to disclosures for purposes other than treatment, payment, or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, family members or friends involved in your care, or for notification purposes. It further excludes uses and disclosures for treatment, payment and center operations, those authorized by you or your representative, or those required by law. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003.

To request this list or accounting of disclosures, you must submit your request in writing to the Business Manager identified at the end of this Notice. Your request must state a time period, which may be no longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

  • Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this notice. You may ask us to give you a copy of this notice at any time. You are entitled to a paper copy of this notice. Or, you can obtain a copy of this notice by calling the Business Manager at the number below.

Changes to this Notice

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The current notice will be posted in the centers, and on our web site. All new notices will include the effective date. You may also request a copy of the notice by calling the Business Manager at the number below.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Privacy Office at Providence Adult Day Health (address below), or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint.

For Additional Information regarding your Protected Health Information:

Business Manager

Providence Adult Day Health
6108 N. Astor St.
Spokane, WA 99208
(509) 482-2475

To File a Complaint or Report a Violation:

Privacy Office

Providence Adult Day Health
6108 N. Astor St.
Spokane, WA 99208
(509) 482-2475

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:

  • Section 504 Grievance Procedure
  • Notice of Program Accessibility
  • Auxiliary Aids and Services for Persons with Disabilities
  • Policy and Procedures for Communication with Persons with Limited English Proficiency
  • Hospital and Program Admission Policy and Procedures

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 Adult Day Health

Business/Privacy Office
(509) 482-2475

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.