Non-Discrimination Policy

It is the policy of Confluence Health to provide equal access to its facilities and services without unlawful discrimination on the basis of race, color, national origin, disability, age, sex, sexual orientation, gender identity or expression, creed, religion, marital status, veteran or military status, or any other status protected by law.

This policy applies to all members of the workforce, including employees, medical staff members, contracted service providers, volunteers, representatives, and any other individuals providing services on behalf of Confluence Health.

PROCEDURE:

1. Nondiscrimination. Confluence Health will treat all patients and visitors receiving or participating in services with equality and in a welcoming manner that is consistent with the Patient Nondiscrimination Policy ("Policy").
2. Notice. Confluence Health will provide notices to patients regarding this Policy and its commitment to providing access to and the provision of services in a nondiscriminatory manner pursuant to Section 1557 of the Affordable Care Act.
3. Reasonable Accommodations. Confluence Health will inform patients of the availability of and make reasonable accommodations for patients consistent with Federal and state requirements. This includes, for example, informing patients of their right to appropriate auxiliary aids and services such as qualified language interpreters for non-English speaking patients and sign language interpreters for hearing-impaired patients and how to obtain these aids and services. Aids and services will be provided free of charge and in a timely manner when such aids and services are necessary to ensure an equal opportunity to participate to individuals with disabilities or to provide meaningful access to individuals with limited English proficiency.
4. Visitation Rights. Confluence Health will afford visitation rights to patients free from discrimination and will ensure that visitors receive equal visitation privileges consistent with patient preferences.
5. Provision of Services. Staff will determine eligibility for and provide services, financial aid, and other benefits to all patients in a similar manner, without subjecting any individual to separate or different treatment.
6. Complaints and Grievances. Any person who believes that he, she, or another person has been subjected to discrimination which is not permitted by this Policy, may file a complaint using Confluence Health's Customer Feedback and Grievance Policy, which will provide prompt and equitable resolutions of grievances. Any staff receiving a patient or visitor discrimination complaint will advise the complaining individual that he or she may report the problem to Risk Management and file a complaint without fear of retaliation. Staff are prohibited from retaliating against any person who opposes, complains about, or reports discrimination, files a complaint, or cooperates in an investigation of discrimination or other proceeding under Federal, state, or local anti-discrimination law.
7. Compliance. Confluence Health's Compliance Officer or designee is responsible for coordinating compliance with this Policy. Confluence Health has designated its HIPAA Privacy Officer to coordinate efforts under Section 1557 of the Affordable Care Act, including the investigation of any grievance related to Section 1557.

REFERENCES AND RELATED DOCUMENTS:

• A. Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations at 45 CFR part 92
  B. RCW 49-60-030
  C. CARF Medical Rehabilitation Standards Manual
  D. Related policy: Confluence Health Customer Feedback and Grievance Policy

1. RELATED AND CONTACT INFORMATION:
   1. For questions about the accessibility of our programs or facility, contact:
      Corporate Compliance Officer at 509-663-8711 ext 4720 or our TDD number can be accessed through the main switchboard at 509-662-1511.
   2. Where to file a complaint directly with the U.S. Department of Health and Human Services
      Region X – Seattle (Alaska, Idaho, Oregon, Washington)
      Regional Manager, Office for Civil Rights
      U.S. Department of Health and Human Services
      2201 Sixth Avenue – Suite 900
      Seattle, WA 98121-1831
      Voice Phone (206) 615-2290
      FAX (206) 615-2297
      TDD (206) 615-2296
      https://archive.hhs.gov/ocr/regmail.html
2. GRIEVANCE PROCEDURE: If the concern cannot be immediately resolved the following procedure will be followed:

   It is the policy of Confluence Health (CH), to respond to patient concerns and grievances in a timely, efficient, and consistent manner. Patients are encouraged to communicate concerns about the quality of services provided, potential safety issues, potential actions prohibited by Federal or state law or any other matter that relates to patient service. The information received will be utilized as part of CH's continuous quality improvement of patient service and satisfaction.
   
   Any person who believes a patient has been subjected to unlawful discrimination may file a grievance under this policy and procedure. It is against the law for Confluence Health to retaliate against anyone who opposes discrimination, files a grievance, or participates in the investigation of a grievance.

   Click here to download a copy of the Confluence Health Nondiscrimination Notice and Language Access Services

   1. Patient Complaint: A complaint is a concern that can be readily resolved, includes most billing issues (simple questions regarding their bills, requesting clarification on a bill, etc.), is related to lost/damaged patient belongings (an item that is found and returned at time of concern), or involves a minor complaint about quality of services provided.

   2. Patient Grievance: A patient grievance is a written or verbal complaint that is made to CH by a patient or the patient's representative, regarding the patient's care, abuse or neglect, unlawful discrimination, or issues related to CH's compliance. A patient care complaint is considered a grievance when it cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution. Billing issues may rise to the level of a grievance if the complaint centers on 42 CFR 489 which concerns basic Medicare applicability and agreements.

   3. Sources of Feedback and Grievances: Customer/patient comments, compliments, complaints and grievances are collected via written "How Are We Doing?" forms, telephone calls, written complaints, in person concerns, and patient surveys.

Procedures

1. Patient Complaint: If the customer concern can be immediately and satisfactorily resolved by the initial recipient, the complaint is considered resolved and no further action is necessary. In these instances, enter a RLDatix Feedback Report for tracking and trending of the issue. Mark "yes" to the question "was this handled at the time of instance" and the feedback will be closed.
2. Patient Grievance: If the concern cannot be immediately resolved the following procedure will be followed:

   1. The grievance is received by a CH employee and entered to the RLDatix Feedback database. CH's governing board has delegated the resolution of the concern to a grievance committee. CH has designated this responsibility to the Care Incident Review Committee.

   2. The director or manager of the area from which the concern originated will be assigned leading investigator(s) in the RLDatix Feedback database. The investigation is considered resolved when the patient/designee is satisfied with the actions taken on his/her behalf. There may be situations where CH has taken appropriate and reasonable actions on the patient's behalf to resolve the concern but the patient or their representative remains dissatisfied with CH's actions. In these situations, CH may consider the complaint closed.

   3. Investigations of grievances will be thorough, affording all interested persons an opportunity to submit evidence relevant to the issue. Investigation records, including all attempts to resolve the complaint will be maintained in the RLDatix Feedback database. To the extent possible the investigator or investigatory team will take appropriate steps to preserve the confidentiality of files and records relating to grievances and will share them only with those who have a need to know.

   4. Initial contact will be made by CH to the complainant within 5 calendar days in writing via letter or email.

   5. Timely resolution of a concern is defined as seven days from receipt of concern to resolution response. If the concern will not be resolved in this time frame, or the investigation will not be completed within seven days, CH will inform the patient or his representative that the hospital is still working to resolve the concern in writing via letter or email. In addition, CH will inform the patient or his representative of an estimate of the number of days remaining to resolve the concern.

   6. A letter providing notice of CH's decision will be sent to the patient or his representative. This letter will include the name of the CH contact person, the steps taken on behalf of the patient to investigate the concern, the results of the investigation, and the date of completion of the investigation.

   7. Complaints/Grievances that involve Quality of care, service Recovery, Medical Legal Issues, or provider related will be referred to the Care Incident Review Committee.
      For complaints/grievances that involve allegations of unlawful discrimination on the basis of race, color, national origin, disability, age, sex, sexual orientation, creed, religion, marital status, veteran or military status, or any other status protected by law, the following additional requirements shall apply:

      1. The investigation will be coordinated by Confluence Health’s Civil Rights Coordinator.

      2. Any written notice of resolution to such a grievance will including information to the complainant of their right to pursue further administrative or legal remedies by the Confluence Health's Civil Rights Coordinator.

      3. The person filing the grievance may appeal the decision of Confluence Health by writing to the Chief Compliance Officer within 15 days of receiving a written decision. The Chief Compliance Officer shall issue a written decision in response to the appeal no later than 30 days after its filing.

   8. The patient has the right to contact the following if they are not satisfied:

   9. Washington State Dept. of Health
      Health Systems Quality Assurance
      P.O. Box 47857
      Olympia, WA 98504-7857
      Phone: 1-800-633-6828
      HSQA Complaint Intake @doh.wa.gov

   10. *For Ephrata Clinic
       The Compliance Team, Inc.
       888-291-5353
       PO Box 160
       Spring House, PA 19477

   11. Office for Civil Rights
       U.S Dept. of Health & Human Services
       200 Independence Ave SW, Room 509F, HHH Bldg. Washington, D.C. 20201
       Phone: 800-368-1019 (voice)
       800-537-7697 (TDD)

   12. Accommodations: Confluence Health will make 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, providing taped cassettes of material for individuals with low vision, or assuring a barrier-free location for the proceedings.
   13. RLDatix System Process:
       1. Confidentiality: All RLDatix information is deemed confidential and non-discoverable under the protection of our Coordinated Quality Improvement Program, per WAC 246-50-020, RCW 43.70.510 and RCW 70.41.200. Information will not be copied or otherwise disseminated unless authorized by the Risk Management Department, or procedurally required or designated.
       2. RLDatix Process:
          1. All tickets entered into RLDatix are available for trending and analysis within 24 hours of the receipt or knowledge of a concern issue will be entered into RLDatix.
          2. All CH staff are trained to enter service incident information.
          3. Assignment will be made by the Risk Management department for follow up.
          4. Managers, Directors and Administrators are trained to enter initial and follow up activity into RLDatix.
          5. All supporting documentation is retained to complete the review, resolution, and coding.
          6. Regular reports are made available to the Administrative Team, the Executive Committee, the Board, and the Medical Director as part of continuous quality improvement activities.
3. SECTION 504 NOTICE OF PROGRAM ACCESSIBILITY:
4. In accordance with Section 504, Confluence Health has Access Notices posted at all sites for interested parties, including persons with impaired vision or hearing, regarding the existence and location of services, activities, and facilities on its external customer website and in the Patient Guide.
5. Supporting Policies and Documents:
   1. Patient Rights and Responsibilities
   2. Patient Rights for Nutrition Care
   3. Policy and Procedure for Persons with Disabilities
   4. Consent Policy
   5. Patients With Communication Barriers
   6. Visitor Policy
   7. Fair Treatment
   8. Harassment-Intimidation-Free Work Environment
   9. Anti-Harassment
   10. ADA Accessibility
   11. Interpretive and Translation Services
   12. Admissions Transfers Referrals WVH
   13. Admission Criteria
   14. Speech Impaired Staff Guidelines
   15. Hearing Impaired Care of Patient
   16. Patient Grievances
   17. Grievance Process – Patient Concerns
   18. Interpreter List
   19. Sign-Language List

Last Revised: 6/21/2023