The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) is charged with the investigation of complaints of discrimination by health care facilities that receive federal financial assistance (including accepting Medicare/Medicaid funds). The enforcement process begins with a complaint, usually from a patient or group of patients, who are often supported by an advocacy group or represented by a lawyer. Often times, the process ends with a “Voluntary Resolution Agreement,” which is essentially a settlement agreement, which spells out the Remedial Actions the healthcare facility has agreed to take.

As Compliance Counsel for Vocalink, I have read more than a few Voluntary Resolution Agreements. What stands out to me in every one is how closely the “Remedial Actions” mirror what is already there for facilities with compliant Language Access Programs. That says two things to me:

1.    Having a compliant Language Access Program effectively prevents the “Pound of Government-Enforced Cure” found in a Voluntary Resolution Agreement; and

2.    We can learn a lot about what needs to be in a compliant Language Access Program by reviewing Voluntary Resolution Agreements.

So, what types of things can we find in a typical Voluntary Resolution Agreement?

·         Designating of Coordinator to be responsible for coordinating the facility’s efforts to comply with the law;

·         Implementing a Grievance Procedure for addressing complaints of discrimination on the basis of disability or national origin;

·         Notifying patients, companions, hospital personnel and the public about the facility’s non-discrimination policies and language access services policies and procedures;

·         Providing language access services, including appropriate auxiliary aids and services and qualified interpreters;

·         Designating a Program Administrator for the Language Access Program;

·         Implementing appropriate policies and procedures regarding language access services, including detailed specifications for the use of in-person, over-the-phone, and video-remote interpreting services and strict limitations on the use of family and friends as interpreters; and

·         Implementing training for facility personnel.

Of course, Voluntary Resolution Agreements usually include payment of a monetary penalty and months or years of government review and scrutiny … all the more reason to start with a compliant Language Access Program.

An Ounce of Prevention is Worth a Pound of Government-Enforced Cure