Policy AD-630 Patient Discrimination Complaints 2021-06-09

Purpose

The purpose of this policy is to ensure compliance with federal law governing discrimination against patients on the basis of race, color, national origin, sex (including sexual orientation and gender identity), age or disability.

Policy

It is the policy of Westside Family Healthcare not to discriminate on the basis of race, color, national origin, sex (including sexual orientation and gender identity), age, or disability. Westside Family Healthcare (Westside) has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 1557 of the Affordable Care Act (42 U.S.C. § 18116) and its implementing regulations at 45 C.F.R. pt. 92, issued by the U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR). Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability in certain health programs and activities.

As a Federally Qualified Health Center receiving funding from HRSA and as a Medicare provider, Westside must and does meet the nondiscrimination requirements contained in Section 1557 of the Affordable Care Act (ACA), which requires compliance of all health programs and activities receiving federal financial assistance or contracts of insurance from HHS. Westside has designated the Chief Operating Officer as its Section 1557 Coordinator.  Section 1557 and its implementing regulations may be examined at the main Westside administrative office by contacting the Section 1557 Coordinator, as detailed in the procedures below.

Any person who believes someone has been subjected to discrimination on the basis of race, color, national origin, sex, age or disability may file a grievance with Westside under this policy and the procedures contained herein. It is against the law for Westside Family Healthcare to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance. Westside also notifies the complainant of their right to pursue further legal or administrative remedies, including filing a complaint with HHS OCR.

Scope

All Westside personnel must comply with the organization’s nondiscrimination policy.  The Section 1557 Coordinator and President & Chief Executive Officer are responsible for ensuring that Westside’s grievance procedures, as outlined in this policy, are followed appropriately.

Definitions

None.

Procedures

Westside has designated the following individual as its Section 1557 Coordinator:

Chris Fraser, Chief Operating Officer

Telephone: 302-656-8292

Fax: 302-656-8982

Email: chris.fraser@westsidehealth.org

Accessibility of ACA Nondiscrimination Law and Regulations

• 1. Westside assures access, upon request, to Section 1557 of the Patient Protection and Affordable Care Act (42 USC 18116) and its implementing regulations 45 CFR 92, issued by the Office for Civil Rights (OCR), Department of Health and Human Services (HHS).
  2. Section 1557 of the Affordable Care Act (ACA) and 45 CFR 92 may be examined in the main Westside Family Healthcare administrative office at 300 Water Street, Suite 200, Wilmington, DE 19801 by contacting Westside’s Section 1557 Coordinator, using the details provided above.  
  3. Additionally, PDFs of these documents can be found online as follows:
     1. Section 1557 of the ACA, 42 U.S. Code § 18116 – Nondiscrimination https://www.govinfo.gov/content/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap157-subchapVI-sec18116.pdf
     2. 42 CFR 92 – Nondiscrimination in Health Programs and Activities https://www.govinfo.gov/content/pkg/FR-2016-05-18/pdf/2016-11458.pdf

Discrimination Complaint Process

• 1. Any person who believes they have suffered from or witnessed prohibited discriminatory actions in the provision of Westside services on the basis of race, color, national origin, sex (including sexual orientation and gender identity), age, or disability may submit a complaint and participate in Westside’s internal grievance process.
  2. Grievances must be submitted to the Section 1557 Coordinator within 30 days of the date the person filing the grievance becomes aware of the alleged discriminatory action.
     1. Westside may extend the 30-day period if the individual can show good cause for the delay.
  3. The complaint must:
     1. be in writing, containing the name and address of the person filing it, and
     2. state the problem or action alleged to be discriminatory and the remedy or relief sought.

Investigation of a Discrimination Complaint

• 1. The Westside Section 1557 Coordinator (or her/his designee) conducts an investigation of the discrimination complaint.
  2. This investigation may be informal, but it will be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint.
  3. The Section 1557 Coordinator maintains the files and records of Westside Family Healthcare relating to such grievances.
  4. To the extent possible, and in accordance with applicable law, the Section 1557 Coordinator takes appropriate steps to preserve the confidentiality of files and records relating to grievances and shares them only with those who have a need to know.

The Section 1557 Coordinator issues a written decision on the grievance, which is:

• 1. based on a preponderance of the evidence,
  2. sent no later than 30 days after its filing, and
  3. includes a notice to the complainant of their right to pursue further administrative or legal remedies.

The person filing the grievance may appeal the decision of the Section 1557 Coordinator.

• 1. An appeal may be made in writing to the President & Chief Executive Officer of Westside Family Healthcare within 15 days of receiving the Section 1557 Coordinator’s decision.
  2. The President & Chief Executive Officer shall issue a written decision in response to the appeal no later than 30 days after its filing.

The availability and use of Westside’s grievance procedure does not prevent a person from pursuing other legal or administrative remedies, including filing a complaint of discrimination on the basis of race, color, national origin, sex (including sexual orientation and gender identity), age or disability in court or with the U.S. Department of Health and Human Services (HHS) Office for Civil Rights.

Filing a Discrimination Complaint with HHS Office for Civil Rights (OCR)

• 1. A discrimination complaint can be filed with HHS OCR as described on its web page titled “How to File a Civil Rights Complaint” at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html
  2. The complaint must:
     1. Be filed in writing by mail or e-mail or via the OCR Complaint Portal,
     2. Name the health care or social service provider involved, and describe the acts or omissions, the person believes violated civil rights laws or regulations, and
     3. Be filed within 180 days of when the person knew that the act or omission complained of occurred. OCR may extend the 180-day period if the person can show "good cause.”
  3. HHS OCR provides the following options and directions for filing discrimination complaints:
     1. Online via the OCR Complaint portal, available at https://ocrportal.hhs.gov/
     2. In writing using one of the following two approaches:
        1. Fill out the Civil Rights Discrimination Complaint Form Package. (Available in PDF format. Adobe Reader software required to fill out the complaint and consent forms.) https://www.hhs.gov/sites/default/files/ocr-60-day-frn-cr-crf-complaint-forms-508r-11302022.pdf
        2. Write a complaint using own format, which must include all elements listed by the OCR at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html
     3. Complaints in writing should be sent by email to OCRComplaint@hhs.gov or by mail to Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W. Room 509F HHH Bldg, Washington, D.C. 20201.
  4. Questions for HHS OCR can be asked by telephone at toll-free (800) 368-1019 or TDD toll-free (800) 537-7697 or by email to OCRMail@hhs.gov.

Westside Family Healthcare makes appropriate arrangements to ensure that individuals with disabilities and individuals with limited English proficiency are provided auxiliary aids and services or language assistance services, respectively, if needed to participate in this grievance process.

• 1. Such arrangements may include, but are not limited to, providing qualified interpreters, providing audio recordings of material for individuals with low vision, or assuring a barrier-free location for the proceedings.
  2. The Section 1557 Coordinator is responsible for such arrangements.
  3. Individuals needing such arrangements to participate in the grievance process should contact the Section 1557 Coordinator.

References

1. Section 1557 of the Affordable Care Act (42 U.S.C. § 18116) – Nondiscrimination
   1. Code: https://www.law.cornell.edu/uscode/text/42/18116
   2. PDF: https://www.govinfo.gov/content/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap157-subchapVI-sec18116.pdf
2. 45 CFR Part 92 – Nondiscrimination in Health Programs and Activities. Office for Civil Rights, Office of the Secretary, Department of Health and Human Services. Published 05/18/2016.  Effective 07/18/2016.
   1. Final Rule: https://www.federalregister.gov/documents/2016/05/18/2016-11458/nondiscrimination-in-health-programs-and-activities
   2. PDF: https://www.govinfo.gov/content/pkg/FR-2016-05-18/pdf/2016-11458.pdf
3. HHS Office for Civil Rights (OCR) - for Individuals
   1. Civil Rights for Individuals and Advocates https://www.hhs.gov/civil-rights/for-individuals/index.html
   2. Filing a Civil Rights Complaint, https://www.hhs.gov/civil-rights/filing-a-complaint/index.html
4. HHS Office for Civil Rights (OCR) – for Health Care
   1. Civil Rights for Providers of Health Care and Human Services https://www.hhs.gov/civil-rights/for-providers/index.html
   2. Technical Assistance for Medicare Providers and Applicants https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/technical-assistance/index.html
   3. Example of a Grievance Procedure that Incorporates Due Process Standards https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/example-grievance-procedure/index.html
   4. Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/technical-assistance/example-notice-nondiscrimination/index.html

Bostock v. Clayton County, GA, 140 S. Ct. 1731 (2020). https://www.supremecourt.gov/opinions/19pdf/17-1618_hfci.pdf

• 1. Consistent with the Supreme Court’s decision in Bostock and Title IX, beginning May 10, 2021, OCR will interpret and enforce Section 1557’s prohibition on discrimination on the basis of sex to include: (1) discrimination on the basis of sexual orientation; and (2) discrimination on the basis of gender identity.