A Law Every Hospital Should Know, Complying with OCR Section 1557

A Law Every Hospital Should Know, Complying with OCR Section 1557 and the CMS Hospital CoPs: Discrimination; Interpreters, 2 Required Signs, Assistive Devices, and More

This webinar will discuss a law that applies to all hospitals, including critical access hospitals, and other healthcare providers such as physician offices and nursing homes. Have you posted the required two signs, amended the patient rights statement, trained your staff, and implemented your policies yet? Have you selected an employee, such as a patient advocate, to address any grievances on discrimination?

The law addresses a civil rights law for healthcare providers and others and addresses nondiscrimination, required signs and notices, interpreters, and more under Section 1557 of the Affordable Care Act. It forbids discrimination based on sex, race, color, national origin, age, and disability. It builds on long-standing and familiar Federal civil rights laws. This program will discuss case law regarding several issues important to hospitals and the recent federal register with changes by the OCR to comply with these including not requiring hospitals to perform an abortion if against their religious beliefs and issues related to gender.

OCR has issued a guidance memo on May 20, 2020, on translation services during the COVID-19 pandemic and reminds hospitals that this law is NOT waived. OCR provides a number of recommendations that will be discussed. This also includes designating a person on every shift to be responsible to make sure language access services are coordinated at every stage of contact from intake to admission to discharge. This includes having documents translated regarding COVID-19 information and testing and treatment in plain language and in another language that is prevalent in that area.

This program will also cover the CMS proposed changes to the hospital CoPs to implement this new law under the proposed Hospital Improvement Rule. CMS noted there were no prohibitions in the hospital CoPs on gender identities which can be a barrier to seeking care. Numerous studies have shown the impact of perceived discrimination when seeking care. Many reports, including an IOM report, found that many lesbian, gay, bisexual, and transgender patients refrain from disclosing sexual orientation or gender to their health care provider.

This webinar will also discuss some proposed changes to OCR Section 1557 and these proposed changes were 204 pages long. These exclude discrimination based upon gender identity and termination of pregnancy from the definition of sex discrimination. This was done to comply with the findings of a court case. It would also make changes to the notice and tagline requirements.

Hospitals are required to have a policy on nondiscrimination and must educate their staff. Patients must be notified in a language they can understand and how to file a complaint if they encounter discrimination. Interpreters must be qualified and this will be explained.

This program will help meet the education requirements to ensure your employees know and follow this law. Have you made the required policy changes? Has staff been educated on these new policies which include physicians and mid-level providers? Do you have the requisite signposted? Do you provide information contained in the 15 or so taglines so patients are aware of their right to an interpreter? Have you designated an employee (civil rights coordinator) to work with patients who file a grievance?  Case scenarios will be discussed. Resources will be provided such as a list of each state’s 15 taglines and OCR has these in 64 languages. Sample notice to be posted and a sample grievance procedure will also be provided.

• Recall that CMS has proposed changes to the hospital CoPs regarding the Section 1557 rules on nondiscrimination
• Discuss that hospitals are required to post a sign regarding nondiscrimination
• Describe that the hospital must have 15 taglines so patients are aware they are entitled to an interpreter at no cost
• Recall that the Office of Civil Rights is the main enforcer of Section 1557
• Discuss that the hospital must have a person in charge to work with patients who file a grievance related to nondiscrimination

• Interpreters
• Discrimination prevention
• 2 required signs
• Proposed changes
• Revision of complaint policy
• Required person to handle complaints
• Policies required
• Training required
• Assistive devices such as magnifying glasses
• Revised admission process
• OIG cases against hospitals

• Risk Manager
• Patient Advocates
• Consumer Advocates
• Healthcare Attorneys
• Compliance Officer
• Chief Medical Officer
• CEO
• COO
• CNO
• Nurse Managers
• ED Managers
• Physicians
• Mid Levels
• Policy Committee
• Nurses
• Nurse Supervisors
• Director of Registration
• Director of Physician Office Practices
• Human Resources
• The person in charge of Interpreting Services
• Director of Education
• Anyone else involved in complying with federal laws and the hospital CoPs