SECTION II - GENERAL PROVISIONS

SECTION III - SPECIFIC PROVISIONS

SECTION IV - REPORTING REQUIREMENTS

SECTION I - BACKGROUND

l. MAINE MEDICAL CENTER ("MMC") is a non-profit privately owned and managed general acute care hospital that operates and is licensed under the laws of the State of Maine and principally engages in the delivery of health care services to the public in the Greater Portland area, including emergency medical care, scheduled treatment, short-term hospitalization, and health education courses.

2. MMC receives, and at all relevant times has received, Federal financial assistance administered by the U. S. Department of Health and Human Services ("HHS"), including grants awarded by the National Institutes of Health and the Substance Abuse and Mental Health Services Administration, Medicare provider payments from the Health Care Financing Administration under Title XVIII, Part A of the Social Security Act (42 U.S.C. §1395 et seq.), and Medicaid provider payments from the State of Maine Department of Human Services under Title XIX of the Social Security Act (42 U.S.C. §1396 et seq.). In 1974, MMC received a Hill-Burton construction/modernization grant of $2,924,901 for its general hospital facility under Title VI of the Public Health Service Act (42 U.S.C. §291c et seq.).

3. By reason of its receipt of Federal financial assistance, all of MMC's operations are subject to Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d et seq.) ("Title VI") and to the HHS Title VI regulations at 45 C.F.R. Part 80. The Title VI regulations prohibit a recipient of HHS assistance from pursuing policies or practices having the intent or effect of discriminating against individuals on the ground of race, color or national origin. MMC has a continuing obligation to make the services of its general hospital facility available to residents of Cumberland County without discrimination in accordance with the Hill-Burton Community Service regulations at 42 C.F.R. Part 124, Subpart G. MMC's obligation to provide uncompensated services under the Hill-Burton regulations at 42 C.F.R. Part 124, Subpart F has expired.

4. In May, 1989, the HHS Office for Civil Rights (OCR) received a letter of complaint (No. 01-89-3040) alleging that MMC had violated the Title VI and Community Service regulations by failing to provide limited English proficient patients with needed interpreter services. Without admitting any violation of the regulations, MMC entered into a Voluntary Compliance Agreement with OCR ("the 1991 Agreement") resolving the complaint.

5. In January, 1998, OCR received a letter of complaint (No. 01-98-3025) alleging similar violations of the Title VI and Community Service regulations and of the 1991 Agreement.

6. MMC contends that it has complied with the HHS regulations and the 1991 Agreement, but in order to resolve these matters expeditiously, without further burden or expense of government investigation or litigation, MMC accepts the terms stipulated in this Resolution Agreement with OCR ("Agreement") addressing such issues and reiterates its assurance of its intention to comply with all provisions of the Title VI and Community Service regulations.

7. This Agreement is a compromise of disputed issues in a government investigation. The parties to this Agreement and no other person or entity shall have standing to seek enforcement of this Agreement. This Agreement is not intended to create any right of action to enforce its terms by any third party.

8. MMC's willingness to enter into this Agreement shall not be construed as an admission or evidence that it has not complied with the Title VI or Community Service regulations or the 1991 Agreement.

9. In reliance on the promises made by MMC in this Agreement, OCR shall suspend further administrative action on Complaint No. 01-98-3025, subject to MMC's continued performance of its obligations under this Agreement, which MMC and OCR agree shall supersede and terminate the 1991 Agreement.

SECTION II - GENERAL PROVISIONS

1. Facilities Covered by Agreement. For purposes of this Agreement, MMC means the hospital located at 22 Bramhall Street in Portland known as Maine Medical Center and includes all other campuses, physician offices and other facilities that are either in the hospital, or that are owned, controlled and operated by MMC (whether in the hospital or not), as well as those which MMC creates or acquires during the term of this Agreement, and specifically includes McGeachey Hall and MMC's programs and services located within facilities at its Brighton, Falmouth and Scarborough campuses.

2. Effective Date and Duration of Agreement. This Agreement shall become effective on the date it is executed by OCR (see the SIGNATURE page) following its execution by MMC. This Agreement shall remain in effect until December 31, 2005, provided MMC continues to receive Federal financial assistance from HHS.

3. MMC's Continuing Obligation. Nothing in this Agreement is intended to relieve MMC of its obligation to comply with any and all provisions of the applicable nondiscrimination statutes and implementing regulations, whether or not specifically referenced in the Agreement.

4. Effect on Other Compliance Matters. This Agreement does not apply to any other issues, reviews, or complaints or allegations of discrimination that may be pending before OCR or any other Federal agency regarding MMC's compliance with applicable statutes or regulations enforced by OCR or another agency. This Agreement also does not preclude further OCR complaint investigations or compliance reviews of MMC. Any compliance matters arising from subsequent reviews or investigations will be addressed and resolved separately in accordance with the procedures and standards of the statute and implementing regulation applicable to the matter raised.

5. Prohibition Against Retaliation and Intimidation. MMC shall not retaliate, intimidate, threaten, coerce, or discriminate against any person who has filed a complaint, testified, assisted, or participated in any manner in the investigation of the matter addressed in this Agreement.

6. OCR's Review of MMC's Compliance with Agreement. OCR may, at any time, review MMC's compliance with this Agreement. As part of such review, OCR may require MMC to provide written reports reasonably relating to compliance hereunder, and to permit OCR to inspect the premises, interview witnesses, and examine and copy documents to determine if MMC is complying with the provisions of the Agreement. MMC agrees to retain the records required by OCR to assess its compliance with the Agreement and to submit the requested reports to OCR as specified below under REPORTING REQUIREMENTS.

7. Enforcement of Compliance with Agreement. If at any time OCR determines that MMC has failed to comply with any provision of this Agreement, OCR will notify MMC in writing. The notice shall include a statement of the basis for OCR's determination and allow MMC 15 days to explain in writing the reasons for its actions. The time frame allowed for MMC's response may be less than 15 days whenever OCR determines that a delay would result in irreparable injury to the complainant or to other affected parties. If MMC does not respond to the notice or, upon review of MMC's response, OCR finds that MMC has not complied with any provision of the Agreement, OCR may request the initiation of administrative or judicial enforcement proceedings, including a civil action in federal district court seeking specific performance of the provisions of this Agreement, or take other appropriate action to secure MMC's compliance with the applicable statute or regulation. Evidence regarding MMC's alleged violation of the applicable statute or regulation, in addition to evidence regarding MMC's alleged violation of the Agreement, may be introduced by OCR in any enforcement proceedings or other appropriate action that may be initiated. Violations of this Agreement may subject MMC to sanctions set forth in the statute or regulation authorizing enforcement or other appropriate action.

8. Non-Waiver Provision. Failure by OCR to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision herein shall not be construed as a waiver of OCR's right to enforce other deadlines and provisions of this Agreement.

9. Entire Agreement. This Agreement constitutes the entire agreement between MMC and OCR on the matters raised herein, and no other statement, promise or agreement, either written or oral, made by either party or agents of either party, that is not contained in this written Agreement, shall be enforceable.

10. Modification of Agreement. This Agreement may be modified by mutual agreement of the parties in writing.

11. Publication or Release of this Agreement. OCR places no restriction on the publication of the terms of this Agreement. In addition, OCR may be required to release the Agreement and all related materials to any person upon request consistent with the requirements of the Freedom of Information Act, 5 U.S.C. §552, and its implementing regulation, 45 C.F.R. Part 5.

12. Authority of Signer. The signer of this document for MMC represents that he or she is authorized to bind MMC to this Agreement.

SECTION III - SPECIFIC PROVISIONS

1. Policy Commitments. MMC has long recognized the special needs and concerns of all persons who are limited English proficient ("LEP persons"). For purposes of this Agreement, an "LEP person" is an individual whose primary language is not English and who cannot speak, read, write or understand the English language at the level necessary for effective communication with MMC personnel. MMC continues to commits itself to providing interpreters and other language assistance, at no cost to LEP persons, as necessary for effective communication in connection with treatment rendered by MMC to a patient and in order to ensure that LEP persons are not excluded from or denied equal access to MMC services. To that end, MMC shall always have in place policies and procedures combining the use of face-to-face and telephone interpreter services and translated materials, designed to enable effective communication with LEP persons, in languages they can understand, in MMC's programs and activities, during all hours of their operation, at every MMC location covered by this Agreement. MMC is committed to continue evaluation and improvement of these procedures, at all levels, in consultation with appropriate staff, LEP persons, community groups and their representatives and public officials. MMC's goal is to provide every LEP person served by MMC with language services necessary for effective communication. MMC further commits to take appropriate corrective action if MMC's on-going quality improvement reviews, a complaint, or other information indicates a failure by any of its personnel to adhere to MMC's LEP policy or this Agreement, or reveals other difficulties with their implementation. The following provisions detail specific actions to be taken by MMC.

2. LEP Policy. MMC shall issue, by inserting into the institutional policy manual, and shall implement a revised LEP policy, substantially similar to the policy attached to this Agreement as Exhibit A, replacing the Policy for Effective Communication with Persons with Limited English Proficiency that MMC adopted pursuant to the 1991 Agreement. MMC shall disseminate the revised LEP policy to all hospital personnel with patient contact responsibilities. Thereafter, on a biannual basis, MMC shall disseminate a reminder regarding its LEP policy to all hospital personnel with patient contact responsibilities. The reminder shall incorporate the text of the notice attached to this Agreement as Exhibit C. For purposes of this Agreement, the term "hospital personnel" shall include all MMC employees and volunteers who are directly involved in the delivery of health care services (including, without limitation, nurses, physicians, social workers, technicians, admitting personnel and therapists) and active members of the medical staff with clinical privileges who render services to hospital patients. Copies of the LEP policy shall be available to any interested person upon request.

3. Availability and Use of Interpreter Resources. MMC shall maintain sufficient interpreter resources (meaning qualified interpreters drawn from MMC's bilingual staff, from outside agencies, from telephone interpreter services, and from MMC's own Language Bank list) to provide a timely response when interpreter services are necessary for effective communication in connection with treatment rendered by MMC and/or in order for an LEP person to receive the full benefit of MMC services. MMC shall at all times have in place contracts or other arrangements with professional agencies that will promptly provide qualified in-person interpreters and telephone interpreter services when MMC bilingual staff and interpreters on MMC's Language Bank list are not available. The circumstances in which an interpreter may be necessary include, but are not limited to: (i) determination of a patient's medical history or description of ailment or injury; (ii) provision of patient's rights, informed consent or permission for treatment; (iii) explanation of living wills or powers of attorney (or their availability); (iv) explanation of diagnosis or prognosis of an ailment or injury; (v) explanation of procedures, tests, treatment, treatment options or surgery; (vi) explanation of medications prescribed including dosage as well as how and when medication is to be taken and any possible side effects; (vii) explanation regarding follow-up treatment, therapy, test results or recovery; (viii) discharge instructions; (ix) provision of psychiatric evaluation, group and individual therapy, counseling and other therapeutic activities, including grief counseling and crisis intervention; (x) resolving billing or insurance issues that may arise; (xi) classes concerning birthing, nutrition, CPR, weight management, etc.; (xii) informational presentations for patients or the public sponsored or contracted for by MMC (xiii) religious services or spiritual counseling provided at MMC; and (xiv) blood donation or apheresis. As to items (xi), (xii) and (xiii), when requested in advance by an LEP person, MMC shall either provide language translation services during such classes, programs or services or shall sponsor equivalent alternative classes, programs or services in the primary language(s) of the requesting LEP person(s).

4. Coordinator of Interpreter Services. MMC shall at all times have designated at least one senior management staff member as its Title VI compliance officer with responsibility for overall coordination and oversight of its compliance with the Title VI and Community Service regulations and this Agreement. MMC shall also maintain, at least until December 31, 2002, a separate professional position with the title of Coordinator of Interpreter Services responsible for coordination and oversight of language assistance required for effective communications between MMC staff and LEP persons, including overseeing development and implementation of staff training on use of interpreter services, screening the qualifications and training bilingual staff and the individuals on MMC's own list of interpreters on confidentiality and interpreters' ethics, receiving and responding to complaints regarding MMC's provision of interpreter services, and related duties as assigned. The Coordinator of Interpreter Services and/or another MMC official shall act as liaison(s) between MMC and local community groups, advisory councils and associations serving LEP persons and actively seek their input on ways to improve the language services provided by MMC.

5. Training of Staff. MMC shall develop, implement and maintain a training program designed to educate hospital personnel with patient contact responsibilities on MMC's revised LEP policy and the requirements of this Agreement. The training shall also cover: (i) the importance of effective communication with LEP persons in the medical setting; (ii) how and when to assess an individual's need for interpreter services and how to access appropriate language interpreter services, including professional agency interpreters, interpreters from MMC's Language Bank list, and use of telephone interpreter services; (iii) use of interpreters when MMC staff members receive incoming calls from, or make outgoing calls to LEP persons (e.g. when scheduling appointments); (iv) circumstances and conditions under which patient family members and companions may and may not be used as interpreters; (v) the role of the Coordinator of Interpreter Services; (vi) the impact of ethnic and cultural differences on effective communication and the need for sensitivity to diversity issues; and (vii) applicable record-keeping procedures and quality improvement reporting obligations. The training shall inform hospital personnel that MMC's policy of providing in-person and telephone interpreter services to LEP persons is not limited to languages in which Exhibit C, the poster referenced in Section III(7) and other documents are printed in accordance with this Agreement. MMC may contract with an appropriate individual or agency to provide any or all of the training sessions. The training shall be targeted, at a minimum, to each of the following groups: (1) clinical directors, department heads, nursing supervisors; (2) staff and volunteers assigned to the emergency room registration desk, any admission desk for inpatient or outpatient registrations or any general information desk; (3) all triage and Emergency Department nurses and (4) the Associate Vice-President of Medical Education and on-site faculty members of participating medical and nursing schools who are responsible for student training. Current personnel identified in groups (1), (2), (3) and (4) shall receive such training by November 30, 2000. Going forward, each new employee whose job category falls in group (1), (2), (3) or (4) shall receive the training outlined above within one year of their employment, provided that MMC shall furnish them with copies of its revised LEP policy promptly upon entering employment. The training program may be combined with other training and orientation programs.

6. Interpreter Qualifications and Training. MMC shall consider fluency in English and one or more other languages spoken by LEP persons residing in its service area as a positive job qualification when selecting or assigning staff who have patient contact responsibilities. MMC shall take reasonable steps to screen self-identified bilingual staff and individuals placed on its Language Bank list of interpreters to determine that they can fluently and accurately communicate in the language(s) in which they claim proficiency, are able to interpret effectively to and from such languages and English, and understand the obligation to maintain patient confidentiality. When MMC staff have reason to believe that an interpreter from a professional agency, a telephone interpreter service, its bilingual staff or MMC's interpreter list is not qualified or properly trained to serve as an interpreter, or is hampering effective communication between MMC staff and a LEP person, MMC shall obtain another interpreter.

7. Interpreter Availability Sign. MMC shall post and maintain a sign in a size and format agreed upon by MMC and OCR, informing the public of the availability of interpreter services at all first points of patient contact. These posters shall be prominently displayed at key locations in every MMC facility, including the following:

(1) Bramhall Campus: Bramhall Information Desk, Central Registration, Pharmacy Reception, Admitting Reception, Medical Clinic (Ground Floor), Pediatric Clinic/ON Clinic (First Floor), Clinic Expansion Space (P1C), Emergency Reception, Ambulatory Surgery, Medical Records Reception Area and McGeechy Hall reception;

(2) Brighton Campus: Pre-Admission Unit, Central Registration, Pain Clinic, Brighton First Care;

(3) Family Practice Units in Portland and Falmouth: FPU Reception; and

(4) Scarborough Campus: Information desk.

The sign shall contain the following information: "Welcome. Maine Medical Center will provide interpreter services at no cost to limited English proficient patients and families. Patients do not have to provide their own interpreters. Please ask for assistance". The sign shall initially be printed at least in English, Farsi, Khmer, Russian, Serbo-Croatian (Cyrillic and Roman alphabets), Somali, Spanish and Vietnamese.

No later than December 31, 2001, and annually thereafter, MMC shall determine the need to print in additional languages the above-mentioned sign and other documents for which printed translations are required by Section III (8) and (13) of this Agreement, based on MMC's most recent patient census data. Translations into an additional language shall be printed when MMC's patient census data shows that 50 or more LEP persons speaking that language have utilized MMC services within the prior 12 months. MMC may omit translations in any language in which fewer than 50 LEP persons speaking that language have utilized MMC services within each of the two prior years.

8. Printed Translations of Other Documents. In addition to the printed translations required by Section III (7) and (13) of this Agreement, the following documents shall be initially printed at least in English, Farsi, Khmer, Russian, Serbo-Croatian (Cyrillic and Roman alphabets), Somali, Spanish and Vietnamese: (i) patient grievance procedures used to comply with applicable federal law; (ii) patient financial policies; (iii) notice of free medical care for those unable to pay; (iv) patient rights and responsibilities statement; (v) nondiscrimination notice used to comply with applicable federal law; (vi) the standard form attached as Exhibit B, to be used in conjunction with any patient consent form as an acknowledgment that the specific patient consent form has been translated by an interpreter and that the patient in fact consents to the procedure described; (vii) the "What if I don't Speak English" form attached as Exhibit C; and (viii) the inpatient brochure entitled "Services for you and your visitors--While you're in our care." MMC may substitute audio or video translations of item (viii) in lieu of printed translations.

OCR and MMC agree that it is not feasible to determine by title or category every document for which a written translation may be needed in the future. MMC agrees to translate other written materials when it can reasonably be determined that a written translation is necessary to ensure that LEP persons are not excluded from or denied equal access to MMC services. When it is necessary to convey information contained in a document and no translated version is available, MMC shall have an in-person or telephonic interpreter provide an oral translation.

9. LEP Assessment and Primary Language Identification. During its initial encounter with a patient (or any family member or companion authorized to make decisions regarding a patient's plan of care) who is not obviously fluent in English, MMC shall ascertain whether the individual is an LEP person, and, if so, the primary language spoken by the person. Ordinarily, MMC staff shall rely on the person's own assessment of his or her English proficiency in determining the need for an interpreter. MMC staff may use other English proficiency assessment tools, provided they can be administered in a manner that is sensitive to and respectful of individual dignity and privacy. MMC shall determine an LEP person's primary language by appropriate means such as use of the multi-language identification card supplied by telephone interpreter services. When MMC staff place or receive a telephone call and cannot determine what language the other person on the line is speaking, a telephone interpreter service shall be used as necessary for effective communication. An LEP patient's record shall specify his/her primary language and include the other patient encounter information referenced in Section III(12). In order to alert MMC staff to an LEP person's primary language and the need for using interpreter services, a distinctive mark or notation shall be made on the patient's history or other record that accompanies him or her during treatment.

10. Informed Right to MMC Provided Interpreters. If a patient, or a family member or companion involved in making decisions regarding a patient's plan of care, is assessed as being LEP, MMC staff will inform the person of his or her right to have a language interpreter at no cost to the patient or family member or companion. If an LEP person is literate in any of the languages in which MMC has printed the notice attached as Exhibit C, MMC shall give her/him a copy in the appropriate language. If an LEP person is not literate in any of those languages, MMC shall communicate the contents of the notice through an MMC-provided interpreter or telephone interpreter service. If the LEP person declines MMC's offer of an interpreter and instead requests that another person serve as his or her interpreter, MMC may use such other person as an interpreter if its staff reasonably ascertains that the person is willing and able to provide effective communication. MMC staff shall indicate in the patient's record that an offer of an interpreter was made and declined and enter the name of the person serving as an interpreter at the patient's request. MMC shall inform LEP persons who have declined an MMC provided interpreter that they have the right to change their minds and request an MMC provided interpreter at any subsequent time. MMC shall discourage LEP persons from using minors as interpreters. When MMC staff have reason to believe that an LEP person's preferred interpreter is hampering effective communication between MMC staff and a LEP person, MMC shall provide interpreter services.

11. Prompt Call for Interpreters. Upon completion of the assessment of a patient's English language proficiency and the determination that the patient is a person who is LEP and has not declined MMC's offer to provide an interpreter, MMC staff involved with the patient will schedule (if the patient is not then or soon to be at an MMC facility) or promptly call for an interpreter. In an urgent or emergent situation where the patient's medical condition might be compromised by waiting for an interpreter to arrive before beginning the assessment and treatment, and where use of a telephonic interpreter service is not appropriate or available, MMC shall render any necessary and appropriate medical treatment, and shall use its best efforts to provide the most effective communication possible until such time as a language interpreter arrives.

12. Recordkeeping. To the extent it has not already done so, MMC shall maintain a centralized recordkeeping system that assures the ready availability of data that includes the race and ethnicity of inpatients and outpatients served at each of its facilities and the primary language of any such inpatient or outpatient who is an LEP person. The readily available data for each LEP patient encounter shall also include the source of any interpreter used (e.g. bilingual care provider, interpreter from a professional agency, interpreter from MMC's own list of approved interpreters, telephone interpreter service, individual interpreting at LEP person's request, or other specified interpreter source) and the name of the interpreter (if available to MMC). If no interpreter is provided, the LEP patient record shall indicate the reason and document any attempts made to obtain an interpreter. As to race and ethnicity, MMC shall implement modifications of its recordkeeping system in anticipation of Federal agency reporting requirements based on the revised Office of Management and Budget (OMB) Standards for Maintaining, Collecting and Presenting Federal Data on Race and Ethnicity, at 62 Fed. Reg. 58782, 58788 (October 30, 1997). The revised OMB standards establish new race and ethnicity reporting categories, replacing those set forth in OMB Statistical Policy Directive No. 15, 43 Fed. 19269 (May 4, 1978) and in the 1991 Agreement between MMC and OCR.

13. Complaints. The Coordinator of Interpreter Services or other Title VI Compliance Officer shall be designated to receive and respond to questions or concerns about the adequacy or availability of interpreter services or of translated documents at MMC facilities.

The Coordinator of Interpreter Services or other Title VI Compliance Officer shall provide any person who wishes to file a complaint regarding such matters with a copy of the patient grievance procedure that MMC uses to comply with 42 C.F.R. §482.13. If an LEP complainant is literate in any of the languages in which MMC has printed its patient grievance procedure, MMC shall give her/him a copy of the procedure in the appropriate language. Otherwise, MMC shall communicate its contents in accordance with Section III(10), above.

The Coordinator shall also give any person who wishes to file a complaint a copy of the OCR brochure "How to File a Complaint with OCR" in the language in which that person speaks, if a translation is available. If no translation of the OCR brochure is available, the Coordinator shall direct the person to contact the OCR at 1-(800)368-1019 (voice) or 1-(800)537-7697 (TDD).

14. Bi-annual Review, Reports and Consultant. MMC shall review, on a bi-annual basis, whether the communications needs of LEP persons are being met by the resources provided by MMC and whether those resources need to be changed or expanded, and prepare a written report, available to any interested person on request, of its review activities, follow-up actions, and the status of MMC's compliance with the terms of this Agreement. During calendar years 2002 and 2004, MMC shall carry out such review under the supervision of an Independent Consultant, with appropriate expertise, to be selected by MMC and acceptable to OCR. In conducting its review, the Independent Consultant shall employ a methodology developed by MMC and acceptable to OCR. The methodology shall include:

(i) obtaining and reviewing reports from the Coordinator of Interpreter Services, Title VI Compliance Officer and other MMC officials;

(ii) making on-site visits to MMC facilities;

(iii) reviewing patient records (redacted as necessary for patient confidentiality), including patient encounter data and related documentation, interpreter logs and MMC contracts and billings for interpreter services, and other administrative and financial records;

(iv) sending written questionnaires to and/or interviewing present or former MMC patients and staff;

(v) holding public and private meetings with local community and advocacy groups, advisory councils, associations and government agencies; and

(vi) other self-audit procedures that allow MMC to ascertain whether staff are adhering to the LEP policy and the terms of this Agreement.

MMC shall provide staff support for and bear the entire cost of the Independent Consultant, including any interpreter services needed for effective communication between the Independent Consultant and LEP persons.

SECTION IV - REPORTING REQUIREMENTS

1. Within 90 days after this Agreement becomes effective, MMC shall submit to OCR:

(a) a certification that MMC has adopted and disseminated its revised LEP policy in accordance with Section III(2);

(b) a certification that the translated sign in the agreed size and format has been posted in accordance with Section III(7); and

(c) a proposed patient grievance procedure to comply with applicable federal law. MMC shall print the patient grievance procedure in the languages identified in Section III(8) of this Agreement within 120 days after OCR determines that the proposed grievance procedure is acceptable.

2. Within 120 days after this Agreement becomes effective, MMC shall submit to OCR:

(a) a proposed agenda for training of staff in accordance with Section III(5);

(b) a schedule of training sessions for the year 2000; and

(c) a certification that MMC has printed the initial translations of documents listed in the first paragraph of Section III(8) and copies of the English and translated versions of those documents; and

(d) a certification that MMC staff have begun giving LEP persons informed notice of their right to interpreter services in accordance with Section III(10).

3. Within 90 days after the close of calendar year 2001, 2002, 2003 and 2004, MMC shall submit a compliance report to OCR containing:

(a) a certification that MMC is maintaining a centralized recordkeeping system that assures the ready availability of data that includes the race and ethnicity of inpatients and outpatients served at each of its facilities and the primary language of any such inpatient or outpatient who is an LEP person in accordance with Section III(12), along with computer printouts of such data in a manner and format to be determined considering the capabilities of the system;

(b) a certification that MMC's Coordinator of Interpreter Services is providing persons who wish to file complaints with copies of the appropriate translated form of MMC's patient grievance procedure, or communicating its contents through an MMC-provided interpreter or telephone interpreter service, and providing copies of the OCR complaint brochure/or telephone contact numbers, in accordance with Section III(13);

(c) any MMC patient census data on which MMC has based a determination to print additional translations of documents, or to omit such translations, in accordance with Section III(7), and copies of any English and translated versions of such documents not previously submitted to OCR;

(d) the number of LEP patients, by language group, who accessed MMC services in each MMC department during the prior calendar year;

(e) the number of LEP patients for whom interpreter services were used by language group, and within each language group by source of interpreter used (e.g. bilingual staff, interpreter from a professional agency, interpreter from MMC's own list of approved interpreters, telephone interpreter service, individual interpreting at LEP person's request, or other specified sources);

(f) MMC's expenditures for interpreter services, by language group and, within each group, by affiliation of interpreter, as classified in Section (III)(12);

(g) an account of any questions or concerns about the adequacy or availability of interpreter services or of translated documents at MMC that have been raised with the Coordinator of Interpreter Services and any complaints received by MMC under its patient grievance procedure, or filed elsewhere, regarding such matters, in accordance with Section III(13), and the disposition thereof;

(h) a report of the staff training conducted in accordance with Section III(5), indicating the date of the training, the name of the trainer or organization providing training and the names and job categories of the individuals in attendance; and

(i) an account of liaison efforts by the Coordinator of Interpreter Services and other MMC staff seeking input from local community groups, advisory councils and associations serving LEP persons on ways to improve language services provided by MMC in accordance with Section III(4).

4. Within 60 days of its receipt of any preliminary or final report from its Independent Consultant on the 2002 or 2004 bi-annual review conducted under Section III(14), MMC shall submit to OCR a copy of the report and a proposed schedule of actions responsive to any recommendations contained therein. OCR shall have access to, and the right to copy, documents and other information obtained by the Independent Consultant during a bi-annual review.

Copies of documentation required to be submitted to OCR under Section IV shall be available to any interested person upon request, following their submission to OCR, after names or other information that would identify individual patients and their families have been redacted.

SECTION V - SIGNATURES

MAINE MEDICAL CENTER

/s/Vincent Conti

By _________________________ Date: ________________

President

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,

OFFICE FOR CIVIL RIGHTS, REGION I

/s/Caroline J. Chang July17, 2000

By _________________________ Date: ________________

Regional Manager

EXHIBIT A

Maine Medical Center Institutional Policy

POLICY FOR FOREIGN LANGUAGE INTERPRETER SERVICES

1. Policy

Maine Medical Center (Hospital) recognizes the special needs and concerns of individuals who are members of linguistic and cultural minority groups and are limited English proficient (LEP). The Hospital understands that LEP individuals may require interpreter services in clinical and administrative settings to obtain equal access to health care. Accordingly, it is Hospital policy to maintain a system reasonably designed to provide staff with access to interpreter services during all hours of operation. This policy outlines guidelines and procedures for the use of foreign language services.

2. Procedure

2.1 Coordinator of Interpreter Services. The Coordinator of Interpreter Services is responsible for the overall operation of foreign language interpreter resources and is available to assist staff in interpreting policy and procedures relevant to interpreter access. However, every staff member providing medical treatment or other services to LEP patients is responsible for ensuring compliance with this policy and for accessing appropriate interpreter services for an individual LEP patient.

2.2 LEP Assessment and Primary Language Identification. Staff members should ascertain as soon as practical whether a patient, or family member or companion involved in making decisions regarding a patient's plan of care, is an LEP person, and if so, the primary language spoken by that patient. Under ordinary circumstances, this assessment should take place during the scheduling, pre-admissions or admissions processes. Ordinarily, MMC staff shall rely on the person's own assessment of his or her English proficiency in determining the need for an interpreter. Staff members should not feel uncomfortable about initiating inquiries about a person's language proficiency. Appended as Appendix 1 is a copy of the "Language Line Language Identification Card," which is available throughout the Hospital and may be used to help identify a person's language.

2.3 Recording of LEP Information. At registration, the primary language of every LEP patient shall be ascertained and recorded in the Hospital's computerized patient files. Staff members should also record each LEP patient's primary language in the patient's chart. In order to alert other staff to a patient's primary language and the need for using an interpreter or a bilingual staff member, a distinctive mark or notation shall be made on the patient's history or other record that accompanies him or her during treatment.

2.4 Informed Right to Hospital Provided Interpreter. When a patient, or a family member or companion involved in making decisions regarding a patient's plan of care, is first assessed as being LEP, hospital personnel will inform the person of his or her right to have a language interpreter at no cost to the patient or family member or companion. If the LEP person is literate in one of the languages in which the notice "What If I Don't Speak English" attached as Appendix 3 is translated, the person will be given a copy of said notice in the appropriate language. If the LEP person is not literate in any of the languages in which Appendix 3 is translated, staff will arrange to have the contents of the notice communicated to the LEP person through an MMC-provided interpreter, telephone interpreter service, or, if the LEP person has declined the hospital's offer of interpreter services (see section 2.5 below), through the individual serving as an interpreter at the LEP person's request. In a subsequent visit or admission by that LEP person, Hospital personnel having their first encounter with that person shall verify that he or she has received the notice attached as Appendix 3 in his or her language, or had its contents orally communicated to him or her through an interpreter, as contemplated by this paragraph.

2.5 Use of Family Members or Patient Provided Interpreters. If the LEP patient declines the hospital's offer of an interpreter and instead requests that a family member, companion, advocate, case manager, friend or other person be used to facilitate communication, such other person may be used if a staff member reasonably ascertains that the person is willing and able to provide for effective communication. Staff should be alert to situations in which use of a family member or friend to interpret might invade that patient's privacy or impede communication of medical information. Staff should make a notation in the patient's record that an offer of an interpreter was made and declined and enter the name of the person serving as interpreter at the patient's request. LEP patients who have opted to use a family member or companion in lieu of a Hospital provided interpreter shall be informed they have the right to change their mind and request a Hospital provided interpreter at any subsequent time. The use of minors as interpreters should be avoided unless in emergent or urgent circumstances or where the communication is limited to simple, straightforward matters such as scheduling an appointment or confirming a patient's address and telephone number. When MMC staff have reason to believe that an LEP person's preferred interpreter is hampering effective communication between MMC staff and a LEP person, MMC shall provide interpreter services.

2.6 Circumstances Requiring Interpreter Services. Interpreter services should be provided in all circumstances where necessary for effective communication in connection with treatment rendered by the Hospital to a patient and/or in order for the patient to receive the full benefit of the Hospital services. Examples of circumstances in which interpreters should generally be used include the following:

(i) determination of a patient's medical history or description of ailment or injury;

(ii) provision of patient's rights, informed consent or permission for treatment;

(iii) explanation of living wills or powers of attorney (or their availability);

(iv) explanation of diagnosis or prognosis of an ailment or injury;

(v) explanation of procedures, tests, treatment, treatment options or surgery;

(vi) explanation of medications prescribed including dosage as well as how and when medication is to be taken and any possible side effects;

(vii) explanation regarding follow-up treatment, dietary restrictions, therapy, test results or recovery;

(viii) discharge instructions;

(ix) provision of psychiatric evaluation, group and individual therapy, counseling and other therapeutic activities, including grief counseling and crisis intervention;

(x) resolving billing or insurance issues that may arise

(xi) classes concerning birthing, nutrition, CPR, weight management, etc.;

(xii) informational presentations for patients or the public sponsored or contracted for by MMC;

(xiii) religious services or spiritual counseling provided at MMC; and

(xiv) blood donation or apheresis.

As to items (xi), (xii) and (xiii), when requested in advance by an LEP person, MMC shall either provide language translation services during such classes, programs or services or shall sponsor equivalent alternative classes, programs or services in the primary language(s) of the requesting LEP person(s).

2.7 Prompt Call for Interpreters. Upon completion of the assessment of the patient's English language proficiency and the determination that the patient is a person who has LEP (and who has not declined an offer for Hospital provided interpreter), staff should schedule (if the patient is not then or soon to be at the hospital) or promptly call for an interpreter to be provided by the resources identified in section 2.9 below.

2.8 Emergencies. In an urgent or emergent situation where the patient's medical condition might be compromised by waiting for an interpreter to arrive before beginning the assessment and treatment, and where use of a telephonic interpreter service is not appropriate or available, staff should render any necessary and appropriate medical treatment, and should use their best efforts to provide the most effective communication possible until such time as a language interpreter arrives.

2.9 Interpreter Services Resources. Maine Medical Center makes available to patients and providers four interpreter services options:

2.9.1. On site Interpreters

2.9.1.1. RRPinterpret. RRPinterpret is a community interpreter service located at Catholic Charities Maine as part of Refugee and Immigration Services. RRPinterpret requires that each individual interpreter request is to be faxed to the agency to a dispatch number provided on their Interpreter Request Form with at least 48 hours advance notice of the scheduled appointment. An RRPinterpret staff person will confirm the provision of an interpreter to the designated Hospital location by return fax of the form. A sample of the form is appended as Appendix 4. Additional copies of forms may be obtained from the Coordinator of Interpreter Services at 871-4983 or by calling RRPinterpret at 871-7437 ext. 126

2.9.1.2 The Maine Medical Center "Language Bank". The Language Bank comprises a list of Hospital employees, volunteers and other persons deemed qualified to serve as interpreters and who may be available to provide on-site interpreting on an emergency/ urgently-needed basis and on a scheduled basis. The list is compiled and distributed to departments throughout the Hospital by the Coordinator of Interpreter Services and is updated on a quarterly basis. Staff persons may consult the list and locate an interpreter who is listed by name, gender, language and hours of availability. A copy of the Language Bank billing form is appended as Appendix 5. It is the duty of the interpreter to complete and sign the form; have the appropriate staff person authorize the interpreter's designated period of activity; and submit the form to the Coordinator of Interpreter Services.

2.9.2. Telephone Interpreter Services

2.9.2.1 The Language Line (formerly AT&T). The Language Line is a nationwide telephonic interpretation service, providing access to trained interpreters in 140 languages. The Language Line is readily available 24 hours a day, 365 days a year, and allows a staff person to access foreign language interpreters by phone within minutes of placing a call. A provider may use an ordinary telephone; however, a speakerphone is preferable and these are readily available throughout the Hospital. The Language Line number is 1-800-xxx-xxxx. The Hospital access identification code number is ID# xxxxxx. A copy of The Language Line instruction card with code number is attached as Appendix 6.

2.9.2.2 Pacific Language Line. The Pacific Language Line is an additional telephonic interpreter service similar to The Language Line. In the same way, it allows immediate phone access to a trained interpreter around the clock. The Pacific Language Line number is 1-800-xxx-xxxx. The access code number is also ID# xxxxxx. A copy of the Pacific Language Line instruction card with Hospital code number is appended as Appendix 6.

2.10 Translating Written Communications. A number of commonly used Maine Medical Center forms have been translated into the predominant foreign languages associated with Hospital patients. In addition, whenever MMC is required to obtain a written informed consent to treatment from a patient, staff should use the form attached as Appendix 2 to document that the consent form to which it is attached has been translated into the LEP patient's primary language. When it is necessary to convey information contained in a document and no translated version is available, Hospital personnel shall arrange to have an in-person or telephonic interpreter provide an oral translation. As may be the case with English speaking persons, not all LEP persons can read and write in their native language. In that event, one of the above interpreter services shall be used to communicate information in written documents orally. Please contact the Coordinator of Interpreter Services for more information or translated forms.

2.11 Additional Translations of Written Materials. The Hospital will have other written materials printed in foreign languages when it can reasonably be determined that a printed translation is necessary to ensure that LEP persons are not excluded from or denied equal access to MMC services. Hospital personnel who identify other written materials that might be appropriate for translation should contact the Coordinator of Interpreter Services.

3. Questions and Complaints

3.1 How to Obtain Further Information. The Coordinator of Interpreter Services is located within the Department of Vocational Services, Maine Medical Center, as part of Access/ADA & Interpreter Services Coordination. For information packets, forms, billing or any further information about language and cultural assistance provided by Maine Medical Center, please call the Coordinator at 871-4983.

3.2 Where to Direct Problems or Complaints. The Coordinator of Interpreter Services or other Title VI Compliance Officer has been designated to receive and respond to questions or concerns about the adequacy or availability of interpreter services or of translated documents at MMC facilities.

The Coordinator of Interpreter Services or other Title VI Compliance Officer shall provide any person who wishes to file a complaint regarding such matters with a copy of the patient grievance procedure that MMC uses to comply with 42 C.F.R. §482.13. If an LEP complainant is literate in any of the languages in which MMC has printed its patient grievance procedure, the MMC shall give her/him a copy of the procedure in the appropriate language. Otherwise, MMC shall communicate its contents in accordance with Section 2.10, above.

The Coordinator shall also give any person who wishes to file a complaint a copy of the U.S. Department of Health and Human Services, Office for Civil Rights (OCR) brochure "How to File a Complaint with OCR" in the language in which that person speaks, if a translation is available. If no translation of the OCR brochure is available, the Coordinator shall direct the person to contact the OCR at 1-(800)368-1019 (voice) or 1-(800)537-7697 (TDD).

Effective Date: ____________________________

President

Maine Medical Center

Appendix 1

Appended as Appendix 1 is a copy of the "Language Line Language Identification Card," which is available throughout the Hospital and may be used to help identify a patient's language.

Appendix 2

ATTACHMENT TO CONSENT FORM

The attached consent form, explaining the benefits and risk of treatment, has been translated into my primary language by the individual acting as interpreter before I signed the same.

___________________________________

Signature of Patient

____________________________________

Signature of person (check box that applies)

[ ] acting as interpreter -or--

[ ] confirming the translation provided by telephonic interpreter

APPENDIX 3

WHAT IF I DON'T SPEAK ENGLISH?

Maine Medical Center offers persons who are limited English proficient (LEP) an equal opportunity to be served in all of its facilities and programs. Our policy is to communicate effectively with LEP persons through bilingual staff, in-person or telephone interpreter services and translated materials.

1. If you are not fluent in English, please let MMC know what language you speak. Interpreters are available in more than 140 languages, most of which appear on our language identification cards.

2. MMC provides interpreter services at no cost to a patient, family member or companion involved in patient care. You do not have to bring your own interpreter.

3. If you prefer to have a family member or friend interpret, MMC will respect your preference unless it would hamper effective communication. You may change your mind at any time and request an MMC interpreter. MMC strongly discourages use of minors as interpreters.

4. In addition to the interpreter services offered when you visit our facilities, MMC staff may use a telephone interpreter service to receive your incoming calls or to reach you by telephone.

5. If you need help translating English language letters, reports or other written material you receive from MMC, please ask MMC to have an interpreter assist you.

6. If you have any difficulty obtaining interpreter services at any MMC facility, please contact our Coordinator of Interpreter Services, Tel. 871-4983, TTY (207) 871-4900 at Maine Medical Center, 22 Bramhall Street, Portland, ME 04201-3175.

Appendix 4

RRPinterpret requires that each individual interpreter request is to be faxed to the agency to a dispatch number provided on their Interpreter Request Form with at least 48 hours advance notice of the scheduled appointment. An RRPinterpret staff person will confirm the provision of an interpreter to the designated Hospital location by return fax of the form. A sample of the form is appended as Appendix 4.

Appendix 5

A copy of the Language Bank billing form is appended as Appendix 5.

Appendix 6

A copy of The Language Line instruction card with code number is attached as Appendix 6.

A copy of the Pacific Language Line instruction card with Hospital code number is appended as Appendix 6.

EXHIBIT B

ATTACHMENT TO CONSENT FORM

The attached consent form, explaining the benefits and risk of treatment, has been translated into my primary language by the individual acting as interpreter before I signed the same.

___________________________________
Signature of Patient

____________________________________
Signature of person (check box that applies)

[ ] acting as interpreter -- or--

[ ] confirming the translation provided by telephonic interpreter

EXHIBIT C

WHAT IF I DON'T SPEAK ENGLISH?

Maine Medical Center offers persons who are limited English proficient (LEP) an equal opportunity to be served in all of its facilities and programs. Our policy is to communicate effectively with LEP persons through bilingual staff, in-person or telephone interpreter services and translated materials.

1. If you are not fluent in English, please let MMC know what language you speak. Interpreters are available in more than 140 languages, most of which appear on our language identification cards.

2. MMC provides interpreter services at no cost to a patient, family member or companion involved in patient care. You do not have to bring your own interpreter.

3. If you prefer to have a family member or friend interpret, MMC will respect your preference unless it would hamper effective communication. You may change your mind at any time and request an MMC interpreter. MMC strongly discourages use of minors as interpreters.

4. In addition to the interpreter services offered when you visit our facilities, MMC staff may use a telephone interpreter service to receive your incoming calls or to reach you by telephone.

5. If you need help translating English language letters, reports or other written material you receive from MMC, please ask MMC to have an interpreter assist you.

6. If you have any difficulty obtaining interpreter services at any MMC facility, please contact our Coordinator of Interpreter Services, Tel. 871-4983, TTY (207) 871-4900 at Maine Medical Center, 22 Bramhall Street, Portland, ME 04201-3175.