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DEPARTMENT of HEALTH and HUMAN SERVICES Fiscal Year 2007 Office for Civil Rights Justification of Estimates for Appropriations Committees DEPARTMENT OF HEALTH & HUMAN SERVICES OFFICE OF THE SECRETARY Voice - (202) 619-0403 TDD - (202) 619-3257 Fax - (202) 619-3818 http://www.hhs.gov/ocr/ Director Office for Civil Rights 200 Independence Ave., SW Rm 506F Washington, DC 20201 Dear Reader: I am pleased to present the Office for Civil Rights’ (OCR) performance-based Fiscal Year 2007 Congressional Justification. Consistent with the Secretary’s policy guidance, this budget request continues support for the President’s and Secretary’s priority initiatives and reflects the goals and objectives in the Department’s FY 2005-2010 Strategic Plan. This justification includes the FY 2007 Annual Performance Plan and FY 2005 Annual Performance Report as required by the Government Performance and Results Act of 1993, along with a direct link of the budget discussion with program performance. OCR’s requested budget will ensure our ability to protect the public’s right to equal access and opportunity to participate in and receive services in all the Department of Health and Human Services’ (HHS) programs without facing unlawful discrimination, and to protect the privacy of individuals with respect to their personal health information. OCR’s performance objectives are in line with HHS’s objectives for transforming the healthcare system and protecting life, family, and human dignity, including: increasing access to high quality, effective health care; promoting the economic selfsufficiency and well-being of vulnerable families, children and individuals; and reducing disparities in ethnic and racial health outcomes. Lastly, our Program Assessment Rating Tool (PART) submission to the Office of Management and Budget demonstrates our continued commitment to effectively and efficiently use our human capital to achieve results in support of our nondiscrimination and privacy compliance mission. OCR has made considerable progress in achieving results to support HHS-wide initiatives to improve the health and well-being of the public. To keep up this momentum during FY 2006 and FY 2007, as in FY 2005, individual performance plans at all levels of OCR’s leadership and staff will be focused on achieving the goals and objectives set out in our performance plan and PART submission. In this way, everyone in OCR will be working together to achieve our shared objectives in protecting civil rights and the privacy of health information. Winston Wilkinson, J.D. Director (This page intentionally left blank) DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS FY 2007 Budget Table of Contents Page Letter from OCR Director ......................................................................................................1 Organization Chart...................................................................................................................4 PERFORMANCE BUDGET OVERVIEW Statement of Mission...............................................................................................................5 Discussion of Strategic Plan....................................................................................................5 Overview of Performance..................................................................................................... 10 Overview of Budget Request................................................................................................ 13 PART Summary Table ......................................................................................................... 14 BUDGET EXHIBITS Appropriation Language....................................................................................................... 15 Amounts Available for Obligation ...................................................................................... 16 Summary of Changes............................................................................................................ 17 Budget Authority by Activity............................................................................................... 18 Budget Authority by Object.................................................................................................. 19 Salaries and Expenses........................................................................................................... 20 Authorizing Legislation........................................................................................................ 21 Appropriations History ......................................................................................................... 22 BUDGET NARRATIVE Activity Header Table........................................................................................................... 23 Statement of Budget Request................................................................................................ 23 Program Description............................................................................................................. 23 Performance Analysis........................................................................................................... 25 Rationale for Budget Request............................................................................................... 25 PERFORMANCE DETAIL Summary of Measures .......................................................................................................... 53 Detail of Performance Analysis............................................................................................ 53 Changes and Improvements over Previous Years ................................................................ 56 SUPPLEMENTAL MATERIAL Detail of Full-Time Equivalent Employment (FTE) ............................................................ 59 Detail of Positions................................................................................................................. 60 Performance Budget Crosswalk ........................................................................................... 61 SPECIAL REQUIREMENTS .................................................................................................. 65 3 Department of Health and Human Services Office for Civil Rights Director Winston A. Wilkinson Principal Deputy Robinsue Frohboese Office of General Counsel, Civil Rights Division Edwin Woo Deputy Director, Civil Rights Deputy Director, Management Operations Deputy Director, Privacy (Vacant) Joanne Chiedi (Vacant) 10 Regional Offices 4 PERFORMANCE BUDGET OVERVIEW Statement of Mission The Department of Health and Human Services (HHS), through the Office for Civil Rights (OCR), promotes and ensures that people have equal access to and opportunity to participate in and receive services from all HHS programs without facing unlawful discrimination, and that the privacy of their health information is protected while ensuring access to care. Through prevention and elimination of unlawful discrimination and by protecting the privacy of individually identifiable health information, OCR helps HHS carry out its overall mission of improving the health and well-being of all people affected by its many programs. By statute and regulation, OCR has the responsibility to be a key steward of the integrity of any HHS program for which Federal financial assistance has been authorized, to ensure that such funds do not support unlawful discrimination. HHS administers a nearly $640 billion budget from which Federal financial assistance is provided to a vast array of health and human service programs. HHS programs are administered by and through a wide array of government, non-profit, and private entities. These programs and services affect the quality of life and well-being of virtually everyone in the United States. In addition, under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, OCR has responsibility for ensuring the privacy practices of several million health care providers, plans, and clearinghouses, including those that receive Federal financial assistance through HHS, adhere to federal privacy requirements. Within this context, OCR’s mission and responsibilities are broad and inclusive and, necessarily, its activities involve many dimensions and challenges given the number of authorities for which OCR has enforcement responsibility. Discussion of Strategic Plan OCR's civil rights and health information privacy compliance objectives and cooperative activities within the Department play a crucial role in support of all eight goals of the HHS Strategic Plan, which has, as a core value, “to focus on health promotion and the prevention of disease and social problems, including the prevention and correction of unlawful discrimination in the provision of health and human services.” The protection of civil rights and individually identifiable health information advances, and is integral to, the achievement of a wide spectrum of the HHS strategic goals including, but not limited to: assisting families to achieve economic self-sufficiency and independence; improving long-term care; improving the stability and development of the Nation's children and youth; protecting and empowering specific populations (e.g., community integration and self-sufficiency for persons with disabilities); and realizing the possibilities of 21st century health care. OCR also supports a majority of the HHS Twenty Department-wide Objectives including, but not limited to: increasing access to high quality, effective health care; promoting the economic self-sufficiency and well-being of vulnerable families, children and individuals; and reducing disparities in ethnic and racial health outcomes. As stated in OCR’s Program Assessment Rating Tool (PART) submission to the Office of Management and Budget (OMB), OCR has two strategic goals to accomplish its mission. OCR’s first strategic goal is to ensure compliance and to increase awareness and understanding 5 of Federal laws requiring nondiscriminatory access to HHS programs and protection of the privacy of individually identifiable health information. This goal has two long-term measures and targets: (1) to increase the rate of resolution for civil rights and privacy cases and new Medicare application reviews to 100 percent of cases received per year by end of FY 2012 and (2) to increase the number of covered entities that make substantive policy changes as a result of OCR intervention. This goal also has an annual target: to provide information and training to 31,250 individuals per year. OCR’s second goal addresses efficiency by increasing the number of cases / reviews resolved per FTE assigned. The table entitled “Links to HHS Strategic Plan” on page eight shows how the two goals and four program objectives and one management objective in OCR’s Performance Plan support all eight “One HHS” program goals focused on protecting and improving the health and well-being of the American public. Moreover, OCR’s strategic goals, and its performance budget, also support all major priorities outlined in the Secretary’s 500-Day Plan. In particular, by ensuring that people have equal access to and the opportunity to participate in and receive services from all HHS programs without facing unlawful discrimination, and that the privacy of their health information is protected while ensuring access to care, OCR supports the Secretary’s goals of: transforming the health care system; modernizing Medicare and Medicaid; advancing medical research; securing the homeland; protecting life, family and human dignity; and improving the human condition around the world. The table titled “Links to Secretary Leavitt’s 500-Day Plan” on page nine shows how the two goals and four program objectives and one management objective in OCR’s Results Act Plan contribute to the above-stated goals in the Secretary’s 500-Day Plan. In FY 2007, within the broad and inclusive objectives of the Government Performance and Results Act (GPRA), OCR will continue to address “One HHS” program goals and high priority areas – nondiscrimination in health services programs, adoption, Temporary Assistance for Needy Families (TANF), nondiscriminatory quality health care, enhancing provision of appropriate services in the most integrated setting for individuals with disabilities, and ensuring understanding of and compliance with the HIPAA Privacy Rule. These issues have been consistently at the forefront of heightened Congressional, Departmental, and public interest during the past several years. In addition, Presidential and Secretarial priorities, continuing changes in health care delivery systems, recent research findings, media reporting, information from community-based organizations, and ongoing OCR compliance activities confirm that it is important that OCR continue, within a broadly-based compliance program, to address these key areas where substantial information indicates a high incidence of possible discrimination or the need for technical assistance on the Privacy Rule. Further, OCR’s activities concentrate on ensuring integrity in the expenditure of Federal funds by making certain that such funds support programs that ensure access by intended recipients of services free from discrimination on the basis of race, national origin, disability, age, and gender; and maintain public trust and confidence that the health care system will maintain the privacy of individually identifiable health information while ensuring access to care. In doing so, OCR’s activities enhance the quality of services funded by the Department and the benefit of those services, by working with covered entities to identify barriers and implement practices that can avoid potentially discriminatory impediments to quality services and privacy breaches. The Department’s goal of providing quality health and human services cannot be met when 6 individuals in need of services do not receive them as a result of practices that violate their fundamental rights of nondiscrimination or privacy. OCR's activities support initiatives focusing on expanding opportunities and freedom for all Americans, ensuring the privacy of individually identifiable health information, and improving the health of the public through the HHS Strategic Plan and Secretary Leavitt’s 500-Day Plan. In relation to the latter initiative, OCR’s non-discrimination and Privacy Rule activities aim to maintain and increase access to health care, improve the quality of life, and eliminate health disparities among different segments of the population. 7 Links to HHS Strategic Plan OCR’s performance plan and PART are aligned with and support the HHS Strategic Plan (see chart below). OCR PERFORMANCE GOALS/OBJECTIVES HHS STRATEGIC GOAL Goal 1: To ensure compliance and to increase awareness and understanding of Federal laws requiring nondiscriminatory access to HHS programs and protection of the privacy of individually identifiable health information. Goal 2: To enhance operational efficiency Objective A: To increase access to and receipt of nondiscriminatory quality health and human services while protecting the integrity of HHS Federal financial assistance. Objective: To increase the number of cases / reviews resolved per FTE assigned. (See note at the top of the following page.) Objective B: To protect the privacy of personally identifiable health information for healthcare consumers. Objective C: To provide information and training to representatives of health and human service providers, other interest groups, and consumers. Objective D: To increase the number of covered entities which make substantive policy change as a result of intervention and / or review. Goal 1: Reduce the major threats to the health and well- being of Americans. X X X X Goal 2: Enhance the ability of the Nation’s health care system to effectively respond to bioterrorism and other public health challenges. X X X X Goal 3: Increase the percentage of the Nation's children and adults who have access to health care services, and expand consumer choices. X X X X X X Goal 5: Improve the quality of health care services. X X X X X Goal 6: Improve the economic and social well-being of individuals, families and communities, especially t hose most in need. X X X X X Goal 7: Improve the stability and healthy development of our Nation's children and youth. X X X X X Goal 8: Achieve excellence in management practices. X X X X X Goal 4: Enhance the capacity and productivity of the Nation’s health science research enterprise. 8 X X X The PART Goal 2 objective focuses on improving operational efficiency and therefore increases the proportion of resources being devoted to all issues. As such, the operational efficiency goal supports the entire HHS Strategic Plan goals, noted above, because success under this goal will result in increased resources focused on priority issues that address the HHS goals and other initiatives such as: improved human capital management, improved financial management, and integrating budget and performance information. Links to Secretary Leavitt’s 500-Day Plan OCR’s performance plan and PART submission are aligned with and support Secretary Leavitt’s 500-Day Plan (see chart below). OCR’S PERFORMANCE GOALS/OBJECTIVES SECRETARY’S 500 DAY PLAN OBJECTIVES Transform the Healthcare System. Modernize Medicare and Medicaid. Advance Medical Research. Secure the Homeland. Protect Life, Family and Human Dignity. Improve the Human Condition Around the World. Goal 1: To ensure compliance and to increase awareness and understanding of Federal laws requiring nondiscriminatory access to HHS programs and protection of the privacy of individually identifiable health information. Goal 2: To enhance operational efficiency Objective A: To increase access to and receipt of non-discriminatory quality health and human services while protecting the integrity of HHS Federal financial assistance. Objective B: To protect the privacy of personally identifiable health information for healthcare consumers. Objective: To increase the number of cases / reviews resolved per FTE assigned. X X X X X X X X X X X X X X X X X X X X X X X X X X Objective C: To provide information and training to representatives of health and human service providers, other interest groups, and consumers. 9 Objective D: To increase the number of covered entities which make substantive policy change as a result of intervention and / or review. Overview of Performance As a result of the PART process, OCR recast the agency’s performance measures to enhance its focus on performance-oriented goals. This refinement of OCR’s performance measures will allow OCR to more consistently measure the effectiveness of its program annually and over the long-term. OCR’s internet-based Program Information Management System (PIMS), an automated case management system, captures data in real-time related to complaint processing, Medicare application reviews, outreach and technical assistance. Therefore, OCR can crosswalk measures reported previously, to its current, consolidated PART framework. In FY 2004, OCR consolidated its reporting into three objectives (Health Care, Social Services, and Community-based Services/Disability). OCR now further refines these measures to capture results on the entirety of its complaint mission areas in a more comprehensive manner. This refinement reflects OCR’s commitment to implement the President’s Management Agenda, and particularly the priority for increased budget and performance integration. OCR has organized its PART submission around two overarching strategic goals that directly support the HHS Strategic Plan and the Secretary’s 500-Day Plan: Goal I To ensure compliance and to increase awareness and understanding of Federal laws requiring nondiscriminatory access to HHS programs and protection of the privacy of individually identifiable health information. Goal II To enhance operational efficiency While this section highlights some prior measures, baselines, and targets, for a complete list of PART goals, measures, and targets see the Detail of Performance Analysis starting on page 53. * * * OCR’s first strategic goal is to ensure compliance and to increase awareness and understanding of Federal laws requiring nondiscriminatory access to HHS programs and protection of the privacy of individually identifiable health information. Under Goal I, there are four program objectives that support the broad and inclusive program goal of increasing nondiscriminatory access and participation in HHS programs and protecting the privacy of individually identifiable health information: Objective A To increase access to and receipt of nondiscriminatory quality health and human services while protecting the integrity of HHS Federal financial assistance Objective B To protect the privacy of personally identifiable health information for healthcare consumers Objective C To provide information and training to representatives of health and human service providers, other interest groups, and consumers 10 Objective D To increase the number of covered entities that make substantive policy changes or develop new policies as a result of intervention and / or review OCR’s first strategic goal has a long-term consolidated output measure and target: to increase the rate of resolution for civil rights and privacy cases and new Medicare application reviews to 100 percent of cases received per year by the end of FY 2012. That is, OCR will resolve as many cases / reviews as received each year. The average age of all open cases will be less than one year, excluding those requiring long-term monitoring and those in litigation or administrative enforcement. The actual target is on a graduated scale, which means that the annual improvement rate will decrease over time. The baseline in FY 2003 was 68.2 percent of cases resolved. In FY 2004, OCR slightly exceeded the target for that year of 78 percent. In FY 2005, OCR achieved a rate of 100.4 percent, significantly above the target for that year of 82 percent. In FY 2005, OCR hired temporary employees to assist in the review of new Medicare applications, freeing OCR’s Equal Opportunity Specialists to apply greater effort toward reducing the backlog of civil rights complaints. The backlog of new Medicare applications is now at a more manageable level. OCR has two output measures that support this long-term goal and its related performance target. The first measure is the percentage of civil rights cases and new Medicare application reviews resolved to cases received. The baseline in FY 2003 was 85.1 percent of civil rights cases and reviews resolved. In FY 2004, OCR achieved a rate of 89.1 percent, 3.6 percentage points above the target of 85.5 percent for that year. In FY 2005, OCR achieved a rate of 125.7 percent, 35.8 percentage points above the target of 89.9 percent for that year. The second measure is the percentage of privacy cases resolved to cases received. The baseline is 68.8 percent of privacy cases resolved in FY 2004 because FY 2004 was the first full year since implementation of the Privacy Rule. In FY 2005, OCR achieved a rate of 79.7 percent, 5.5 percentage points above the target of 74.2 percent for that year. Objective C has an annual output measure and target: to provide information and training to 31,250 individuals per year. The baseline in FY 2005 was 33,118. OCR’s long-term outcome measure tied to Objective D is the number of covered entities that make substantive policy changes or develop new policies as a result of OCR intervention. OCR’s performance target for this measure is to increase this number by approximately 5.0 percent per year over the FY 2005 baseline of 1,019. * * * OCR’s management goal, Goal II as submitted in PART, is to enhance operational efficiency. The long-term measure is to increase the number of cases resolved per assigned FTE. The annual effort towards achieving this measure is designed to meet the HHS Departmental goal of a 10 percent overall program improvement over three years. The target of OCR's management goal is to enhance operational efficiency and is directly tied to OCR’s efficiency measure, to resolve 50 cases each year per FTE assigned by the end of FY 2012. 11 The table on “Links to HHS Strategic Plan” on page eight shows how the two goals and four program objectives and one management objective contribute to outcomes in support of all eight “One HHS” program goals focused on protecting and improving the health and well-being of the American public. Further, for accountability purposes, OCR is taking steps to link individual performance directly to OCR’s established goals. OCR has incorporated organizational goals in all OCR leadership plans at the GS-15 level and above, and in FY 2006 will cascade these organizational goals into the performance plans for all staff. The Detail of Performance Analysis on page 53 sets forth all the measures and targets for the relevant past, present, and future fiscal years. 12 Overview of Budget Request The Office for Civil Rights requests $36,283,000 in FY 2007. This is an increase of $1,637,000 over the FY 2006 Appropriation of $34,646,000. The requested funding will allow OCR to maintain staffing at approximately 259 FTE, the same level of staffing as provided in the FY 2006 Appropriation, or 8 FTE under OCR’s FY 2005 authorized ceiling of 267 FTE. Other increases in the FY 2007 request over the FY 2006 Appropriation level are for rental cost increases and increases in shared costs; all other spending categories reflect no increases over the FY 2006 Appropriation level. This budget maintains the same programmatic focus as provided in the FY 2006 Appropriation. Specifically, the FY 2007 requested amount of $36,283,000 would enable OCR to:  Continue to address key nondiscrimination issues, including the President’s New Freedom Initiative, community-based services for persons with disabilities, racial and ethnic health disparities, and Title VI and language access, while continuing to improve responsiveness to the public’s questions about, and allegations of non-compliance with, the Privacy Rule.  Promote privacy protection in the implementation of initiatives to create integrated and interoperable electronic networks for sharing health information, consistent with Secretary Leavitt’s 500-day vision for transforming the U.S. health care system.  Meet annual targets stated in PART and remain on schedule to meet OCR’s long-range goal of matching the rate of case resolutions to complaint receipts in the year 2012. 13 Program Assessment Rating Tool Summary FY 2006 - 2007 (Dollars in Millions) Program Office for Civil Rights (OCR) FY 2006 Enacted $34.65 FY 2007 Request FY 2007 PART $36.28 FY 2006 +/FY 2007 +$1.63 Narrative Rating Moderately Effective In FY 2005, OCR underwent the PART process and presented its performance results to OMB. As reflected on the performance reporting web site, www.ExpectMore.gov, OCR earned a PART rating of “Moderately Effective.” The PART process allowed OCR an opportunity to recast its outcome goals and performance measures to more accurately reflect its results-oriented focus. Although some of the newly revised outcome goals and performance measures presented in this submission are refinements of those stated in previous submissions, OCR will continue to use the revised PART-established framework to further refine its performance measures. Based on the FY 2007 PART goals and measures, OCR exceeded its performance targets for FY 2005. Given the 2005 performance, OCR will adjust its targets to ensure they are sufficiently challenging and support continuous improvement. OCR’s PART findings concluded that OCR has a strong purpose and design, is well-managed, and that independent evaluations indicate that OCR is effective and achieving results. OCR will undertake stronger efforts to demonstrate the use of performance information in day-to-day decision-making, including partnership agreements. OCR is taking the following actions to improve performance:  Revising performance goals to ensure they are sufficiently ambitious.  Considering projected performance when making funding decisions.  Ensuring partnership agreements with other offices of Health and Human Services and other Federal agencies include attainment of long-term and annual measures. In order to meet the goals set forth in OCR’s PART submission, OCR is requesting $36,283,000 for FY 2007. 14 DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS For expenses necessary for the Office for Civil Rights, [$31,682,000] $32,969,000 together with not to exceed $3,314,000 to be transferred and expended as authorized by section 201(g)(1) of the Social Security Act from the Hospital Insurance Trust Fund and the Supplemental Medical Insurance Trust Fund. (Department of Health and Human Services Appropriations Act, 2006). 15 OFFICE FOR CIVIL RIGHTS AMOUNTS AVAILABLE FOR OBLIGATION 2005 Actual 2006 Appropriation 1 2007 Estimate Appropriation: Annual ............................................... $32,043,000 $31,682,000 $32,969,000 Enacted rescission ............................. -61,000 --- --- Enacted rescission ............................. -256,000 --- --- Enacted rescission ............................. --- -317,000 --- Subtotal, adjusted appropriation ....... 31,726,000 31,365,000 32,969,000 Subtotal, adjusted budget authority.. 31,726,000 31,365,000 32,969,000 Annual appropriation ........................ 3,314,000 3,314,000 3,314,000 Enacted rescission ............................. -26,000 --- --- Enacted rescission ............................. --- -33,000 --- Subtotal, adjusted trust funds ............ 3,288,000 3,281,000 3,314,000 35,014,000 34,646,000 36,283,000 Unobligated balance lapsing ............. - 61,000 --- --- Total obligations.............................. $34,952,000 $34,646,000 $36,283,000 Trust funds: Total Budget Authority 1 Excludes the following amounts for reimbursable activities carried out by this account: FY 2006 $400,000, FY 2007 $575,000. 16 OFFICE FOR CIVIL RIGHTS SUMMARY OF CHANGES 2006 Appropriation……………………………………………………………. Trust funds transfer……………………………………………………… Total estimated budget authority………………………………………… $31,365,000 3,281,000 $34,646,000 2007 Estimate – General funds………………………………………………… Trust funds transfer………………………………………………………. Total estimated budget authority………………………………………… $32,969,000 3,314,000 $36,283,000 Net Change………………………………………………………………. +$1,637,000 2006 Current Budget Base Change from Base (FTE) Budget Authority (FTE) Budget Authority 1. Annualization of January 2006 pay raise (259) $25,607,000 (259) +$200,000 2. Effect of January 2007 pay raise……….. (259) $25,607,000 (259) +$425,000 3. Within-grade increases, promotions, and other personnel compensation …………. (259) $25,607,000 (259) +$491,000 4. Increase in rental payments to GSA, and Service and Supply Fund, Unified Financial Management System, IT Service Center and other built-in cost increases………………………………… (259) $9,039,000 (259) +521,000 Total increases……………………………… (259) $34,646,000 (259) +$1,637,000 (259) $34,646,000 (259) +$1,637,000 Increases: A. Built-in: B. Program: None Decreases: None Net Change………………………………………. 17 OFFICE FOR CIVIL RIGHTS BUDGET AUTHORITY BY ACTIVITY 1 (Dollars in Thousands) 2005 Actual 2007 Estimate FTE Amount FTE Amount FTE Amount 214 $30,339 224 $29,964 224 $31,380 Legal Services............. 18 2,550 19 2,542 19 2,662 Program Management.. 15 2,125 16 2,140 16 2,241 247 $35,014 259 $34,646 259 $36,283 Compliance Activities.. Total Budget Authority General funds................. 1 2006 Final Appropriation $31,726 $31,365 $32,969 HI/SMI trust funds........... 3,288 3,281 3,314 Total Budget Authority $35,014 $34,646 $36,283 Excludes the following projected amounts for reimbursable activities carried out by this account: FY 2006 $400,000 and two FTE; FY 2007 $575,000 and two FTE. 18 OFFICE FOR CIVIL RIGHTS BUDGET AUTHORITY BY OBJECT 2006 Appropriation 2007 Estimate Increase or Decrease 259 $138,873 11.8 $78,313 259 $141,165 11.9 $80,691 -+$2,292 --+$2,378 $19,666,000 $20,559,000 +$893,000 Other than full-time permanent.................................... 840,000 574,000 -266,000 Other personnel compensation.................................... 200,000 300,000 +100,000 Military personnel………………………….………… 71,000 73,000 +2,000 Total, Personnel Compensation................................... 20,777,000 21,506,000 +729,000 Civilian personnel benefits.......................................... 4,791,000 5,178,000 +387,000 Military personnel benefits………………………….. 18,000 18,000 --- Benefits to Former Personnel....................................... 21,000 21,000 Subtotal, Pay Costs....................................................... 25,607,000 26,723,000 +1,116,000 Travel........................................................................... 300,000 300,000 --- Transportation of Things............................................. 17,000 17,000 --- Rental payments to GSA............................................. 3,600,000 3,676,000 +76,000 Rental payments to others........................................... 27,000 27,000 --- Communications, utilities, and others......................... 403,000 403,000 --- Printing and Reproduction........................................... 45,000 45,000 --- Services from the Private Sector.................................. 687,000 687,000 --- Purchases of goods and services from other government accounts................................................... (Service and Supply Fund payment)........................... 2,339,000 (1,694,000) 2,784,000 (1,730,000) +445,000 (+36,000) Operation and Maintenance of Facilities....................... 150,000 150,000 --- Operation and Maintenance of Equipment.................... 1,148,000 1,148,000 --- Subtotal Other Contractual Services............................. 4,324,000 4,769,000 +445,000 Supplies and Materials................................................ 274,000 274,000 --- Equipment................................................................... 49,000 49,000 --- Subtotal, Non-Pay Costs............................................... 9,039,000 9,560,000 +521,000 Total Budget Authority by object class......................... $34,646,000 $36,283,000 +1,637,000 Full-time equivalent employment................................ Average SES salary..................................................... Average GS grade....................................................... Average GS salary....................................................... Personnel compensation: Full-time permanent.................................................... 19 OFFICE FOR CIVIL RIGHTS SALARY AND EXPENSES 2006 Appropriation 2007 Estimate Increase or Decrease Full-time permanent (11.1)........................................... $19,666,000 $20,559,000 +$893,000 Other than full-time permanent (11.3).......................... 840,000 574,000 -266,000 Other personnel compensation (11.5)........................... 200,000 300,000 +100,000 Military personnel (11.7)..………………….………… 71,000 73,000 +2,000 Total, Personnel Compensation................................... 20,777,000 21,506,000 +729,000 Civilian personnel benefits (12.1)................................. 4,791,000 5,178,000 +387,000 Military personnel benefits (12.2)..………………….. 18,000 18,000 --- Benefits to Former Personnel (13.0).............................. 21,000 21,000 Subtotal, Pay Costs....................................................... 25,607,000 26,723,000 +1,116,000 Travel (21.0).................................................................. 300,000 300,000 --- Transportation of things (22.0)...................................... 17,000 17,000 --- Rental payments to others (23.2)................................... 27,000 27,000 --- Communications, utilities, and others (23.3)................. 403,000 403,000 --- Printing and Reproduction (24.0)................................... 45,000 45,000 --- Services from the Private Sector (25.2).......................... 687,000 687,000 --- Purchases of goods and services from other government accounts (25.3)............................................ (Service and Supply Fund payment)............................. 2,339,000 (1,694,000) 2,784,000 (1,730,000) +445,000 (+36,000) Operation and Maintenance of Facilities (25.4).............. 150,000 150,000 --- Operation and Maintenance of Equipment.(25.7)........... 1,148,000 1,148,000 --- Subtotal Other Contractual Services…............................ 4,324,000 4,769,000 +445,000 Supplies and Materials (26.0)........................................... 274,000 274,000 --- Subtotal, Non-Pay Costs.................................................. 5,390,000 5,835,000 +445,000 Total Salary and Expenses………………....................... $30,997,000 $32,558,000 +1,561,000 Direct FTE………………………………....................... 259 259 --- Object Class Personnel compensation: 20 OFFICE FOR CIVIL RIGHTS AUTHORIZING LEGISLATION 2006 Amount Authorized 2006 Appropriation 2007 Amount Authorized 2007 Budget Request Office for Civil Rights: P.L. 88-352; 42 U.S.C. 300s; P.L. 91-616; P.L. 92-157; P.L. 92-158; P.L. 92-255; P.L. 93-282; P.L. 93-348; P.L. 94-484; P.L. 95-567; P.L. 97-35; P.L. 103-382; P.L. 104-188; P.L. 92-318; P.L. 93-112; P.L. 94-135; P.L. 101-336; P.L. 104-191 Indefinite $34,646,000 21 Indefinite $36,283,000 OFFICE FOR CIVIL RIGHTS APPROPRIATIONS HISTORY TABLE Budget Estimate to Congress House Allowance Senate Allowance Appropriation 1998 Appropriation Trust Funds 17,216,000 3,314,000 16,345,000 3,314,000 16,345,000 3,314,000 16,345,000 3,314,000 1999 Appropriation Rescission 1% Transfer Trust Funds 17,345,000 ----3,314,000 17,345,000 ----3,314,000 17,345,000 ----3,314,000 17,345,000 -34,000 -7,000 3,314,000 2000 Appropriation Rescission 1% Transfer Trust Funds 18,845,000 ----3,314,000 18,338,000 ----3,314,000 18,845,000 ----3,314,000 18,838,000 -64,000 445,000 3,314,000 2001 Appropriation Rescission 1% Transfer Trust Funds 24,142,000 ----3,314,000 18,774,000 ----3,314,000 23,242,000 ----3,314,000 24,742,000 -51,000 --3,314,000 2002 Appropriation Rescission Rescission Rescission Transfer to GDM Trust Funds 28,691,000 --------3,314,000 28,691,000 ----— --3,314,000 28,691,000 ----— --3,314,000 28,691,000 -50,000 -23,000 -126,000 -376,000 3,314,000 30,328,000 -385,000 30,328,000 -385,000 --3,314,000 30,328,000 -385,000 -219,000 3,314,000 2003 Appropriation Transfer to GDM Rescission Trust Funds 3,314,000 — — — 3,314,000 2004 Appropriation Rescission Rescission Trust Funds Rescission Rescission 30,936,000 ----3,314,000 — --- 30,936,000 ----3,314,000 — --- 30,936,000 ----3,314,000 — --- 30,936,000 -133,000 -182,000 3,314,000 -14,000 -19,000 2005 Appropriation Rescission Rescission Trust Funds Rescission 32,042,000 ----3,314,000 --- 32,042,000 — — 3,314,000 --- 32,042,000 — — 3,314,000 --- 32,043,000 -61,000 -255,000 3,314,000 -27,000 2006 Appropriation Rescission Trust Funds Rescission 31,682,000 --3,314,000 --- 31,682,000 --3,314,000 --- 31,682,000 --3,314,000 --- 31,682,000 -317,000 3,314,000 -33,000 2007 Appropriation Trust Funds 32,969,000 3,314,000 22 DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS Budget Authority 2005 Actual 2006 Appropriation 2007 Request Increase or Decrease $35,014,000 $34,646,000 $36,283,000 $1,637,000 247 259 259 --- FTE Note: FTE level does not include two reimbursable FTE in FY 2006 and FY 2007. Statement of Budget Request The President’s appropriation request of $36,283,000 for this account represents current law requirements. No proposed law amounts are included. OCR conducts public education; outreach; complaint investigation and resolution; and other compliance activities to prevent and eliminate discriminatory barriers, to ensure the privacy of individually identifiable health information, and to enhance access to quality HHS-funded programs. Program Description As the primary defender of the public's right to nondiscriminatory access to and receipt of federally funded health and human services, OCR works to ensure equal opportunity for all to access the wide range of services available and that the privacy of their health information is protected while ensuring access to care. Through prevention and elimination of unlawful discrimination and by protecting the privacy of individually identifiable health information, OCR helps HHS carry out its overall mission of improving the health and well-being of all people affected by the Department’s many programs. OCR assesses compliance with nondiscrimination and Privacy Rule requirements by processing and resolving complaints. In addition, OCR also conducts pre-grant and preventative compliance reviews; monitoring of corrective action plans; and public education, outreach, voluntary compliance, training, technical assistance, and consultation activities as additional means of achieving compliance with nondiscrimination and Privacy Rule requirements. OCR is comprised of compliance, policy, legal counsel, and program management staff. The majority of OCR's staff works on frontline civil rights nondiscrimination and Privacy Rule compliance activities, largely in OCR's regional offices. In support, a cadre of headquarters analysts provides program and policy coordination and initiatives to enhance program effectiveness and efficiency. OCR allocates staff time to mandated complaint investigations, Medicare pre-grant reviews, and OCR-initiated compliance activities (e.g., compliance reviews, public education, outreach, voluntary compliance, and technical assistance). Staff time spent on OCR-initiated compliance activities focuses on particularly compelling, high profile, or systemic issues that benefit the greatest number of people possible. The issues surfaced in complaints and pre-grants also address public civil rights and privacy concerns. 23 Investigations of compliance, public education, outreach, voluntary compliance, technical assistance, training, consultation, and collaborative project activities are each equally significant methods by which OCR achieves corrective action and prevention of unlawful discrimination and Privacy Rule non-compliance. OCR uses these methods interchangeably and with flexibility to address the unique compliance circumstances facing individual HHS grantees, service providers, and other covered entities, with an emphasis on prevention and voluntary compliance. In some cases, public education and outreach may better serve the purpose of achieving compliance than a review or audit activity. In other instances, an investigation or review may be deemed the best means for achieving a positive compliance outcome. Each of the activities that are identified as results or indicators in this report are planned, substantive, and part of an overall compliance strategy that requires significant staff time and resources. 24 Performance Analysis For each objective in the FY 2007 performance plan, OCR set targets for each of the measures in relation to this FY 2007 President’s Budget request. If OCR receives funding below this level, it will adjust its targets accordingly. Performance Goal Increase the rate of resolution for civil rights and privacy cases and new Medicare application reviews received each year to 100% per year by the end of FY 2012. Increase the number of individuals who are, or represent, health and human service providers, other interest groups, and consumers to whom OCR provides information and training. Increase the number of covered entities that make a substantive policy change or develop new policies as a result of OCR intervention and/or review. Results OCR has met or exceeded its annual target since establishing the baseline in FY 2003 and is on schedule to achieve this goal in the timeframe specified. Context As the Department’s law enforcement agency responsible for resolving complaints of non-compliance, OCR’s performance measures are the rate of civil rights and privacy complaint cases resolved and new Medicare application reviews completed each year to cases / reviews received. Output measures are appropriate for OCR since its functions are primarily investigating and resolving complaints and ensuring compliance with privacy and civil rights laws. OCR has established 31,250 as From FY 2005 through its annual target for this measure FY 2012, OCR will provide and is on schedule to achieve information and training to the goal in this and subsequent 31,250 individuals annually, fiscal years. who are, or represent, health and human services providers, other interest groups, and consumers. OCR established the baseline in By increasing the number of FY 2005 (1,019 covered covered entities that make entities) and developed substantive policy changes or ambitious future targets develop new policies as a according to the framework result of OCR intervention, developed in OCR’s PART. OCR has a measurable outcome to assess its impact on the population it serves. Rationale for Budget Request Since implementation of the Privacy Rule in 2003, which more than tripled the number of complaints filed with OCR, case resolution has not been able to keep pace with the receipt of new health information privacy and civil rights’ complaint receipts. Although the backlog of unresolved complaints will continue to grow in the short term, OCR’s ambitious achievement of its PART goals will enable it to reduce the growing backlog in future years with a goal of finally eliminating it. 25 The following tables illustrate OCR’s projected receipt and complaint resolution workload for Privacy Rule and civil rights discrimination complaints, along with preventative compliance review workload (primarily new Medicare application reviews) from FY 2005 through FY 2007. Complaint Workload – Privacy Rule FY 2005 FY 2006 Actual Projected Beginning Inventory 3,482 4,853 Complaints Received 6,756 6,750 Total Workload 10,238 11,603 Complaints Resolved 5,385 5,640 Ending Inventory 4,853 5,963 FY 2007 Projected 5,963 6,750 12,713 5,810 6,903 Complaint Workload – Civil Rights FY 2005 FY 2006 Actual Projected Beginning Inventory 1,655 1,663 Complaints Received 3,046 3,100 Total Workload 4,701 4,763 Complaints Resolved 3,038 2,725 Ending Inventory 1,663 2,038 FY 2007 Projected 2,038 3,150 5,188 2,815 2,373 Workload – New Medicare Application Reviews (Pre-Grants) Beginning Inventory New Reviews Total Workload Reviews Resolved Ending Inventory FY 2005 Actual 2,429 2,466 4,895 3,890 1,005 FY 2006 Projected 1,005 2,550 3,555 2,810 745 FY 2007 Projected 745 2,600 3,345 2,890 455 As OCR reported in its FY 2006 Congressional Justification, Privacy Rule complaints since implementation of the Rule in April 2003 have far exceeded original expectations. Complaints received in FY 2004 and FY 2005, the first two full years since implementation of the Privacy Rule, together totaled 13,173, or 25 percent more than forecasted at the time the Rule was implemented. In its FY 2006 Congressional Justification, OCR projected a gradual leveling off of Privacy Rule complaints in FY 2005 and FY 2006 to 6,602 and 6,735 per year respectively. An analysis of OCR’s Privacy Rule complaint receipt data over the past twelve months confirms a leveling off of complaint volume to approximately 6,750 per year in the FY 2005 – FY 2007 period. 26 OCR has also experienced a greater than anticipated increase in receipts of civil rights complaints since FY 2004. In its FY 2006 Congressional Justification, OCR noted that the number of civil rights complaints received in FY 2004 and FY 2005 was 21 percent and 19 percent higher per year respectively than was projected in the FY 2005 Congressional Justification. Nonetheless, OCR’s increased projections of civil rights complaints in the FY 2006 Congressional Justification have proven conservative for FY 2005, as current data show that complaint volume for FY 2005 was almost 3 percent greater than had been forecasted. This contrasts with the data for FY 2006, however, where the volume for civil rights complaint receipts is now projected to be 4 percent less than anticipated in the FY 2006 Congressional Justification. OCR’s analysis of the last twelve months’ data suggests that while the volume of civil rights complaints will continue to increase at a higher rate than Privacy Rule complaints, the rate of increase is slowing considerably. OCR projects a 1.6 percent increase from FY 2006 to FY 2007 in civil rights complaint receipts. As a result of the increased complaint receipt volume for both Privacy Rule and civil rights complaints over the past two years, case resolution has not kept pace with the increased volume of complaint receipts. In the ten year period from 1994-2003, prior to implementation of the Privacy Rule, OCR resolved on average just under 70 percent of each year’s complaint workload (cases carried into the year plus allegations newly received in each year). In FY 2005, OCR’s resolution rate against total workload was 62 percent, and current projections indicate the rate may fall below 60 percent in both FY 2006 and FY 2007. Because complaint resolution has not kept pace with increases in complaint receipts, the percentage of OCR’s workload that is composed of older unresolved complaints has continued to increase. In FY 2005, 38 percent of the year’s total workload was composed of backlogged complaints compared to 30 percent in FY 2004. Based on current projections, this rate will exceed 40 percent in FY 2006 and FY 2007. By the end of FY 2007 OCR anticipates a backlog of over 9,000 combined Privacy and civil rights complaints and new preventative compliance Medicare application reviews (pre-grants). In addressing this challenge, OCR anticipates achieving greater efficiencies in case resolution due to its FY 2004 reorganization and improved case management techniques. In FY 2007 OCR will identify competency gaps in critical positions to enhance staff performance and serve as a tool for management to remedy gaps in skill sets and to more efficiently deploy appropriate staff resources. OCR will continue to focus on other ways to enhance efficiencies, for example, in the summer of FY 2005, OCR hired temporary employees to assist in the resolution of preventative compliance reviews, freeing OCR’s Equal Opportunity Specialists to apply greater effort toward reducing the backlog of civil rights complaint receipts. This resulted in a reduction in the backlog of 400 civil rights complaints. To do so, OCR applied FTEs and associated funding for positions not yet filled after staff departures due to a buy-out opportunity associated with a reorganization in late FY 2004 and early FY 2005. This effort allowed OCR to achieve the 56.4 percent resolution rate for FY 2005 cited above. Through these efforts, and in the context of the anticipated leveling off in the volume of new complaints as described above, OCR has established an output measure and target for FY 2007, as reported in this budget submission and in OCR’s FY 2007 PART submission, to achieve a 27 receipt to resolution ratio for aggregated complaints and new Medicare application reviews of 92 percent, with a long-term goal, factoring in a 3.3 percent productivity rate increase each year, to achieve a 100 percent equilibrium between receipts and resolutions / reviews by the end of 2012. The requested funding level will sustain OCR’s efforts to achieve this equilibrium by the target date. Achieving this long-term performance goal is critical to OCR’s efforts to apply resources to reduce and finally eliminate the currently growing backlog of complaints and preventative compliance reviews. The following section highlights some of OCR’s successes resulting from the wide range of activities in which OCR is involved in its efforts to ensure compliance with federal laws requiring nondiscrimination and the protection of individually identifiable health information. OVERVIEW OF OCR ACTIVITIES OCR will implement its civil rights and privacy of health information compliance activities through a comprehensive compliance and public education and outreach program. The program includes: Complaint Processing Preventative Compliance Reviews, Medicare Pre-Grant Reviews, and Monitoring Public Education, Outreach, and Voluntary Compliance In addition, OCR will ensure the integrity and efficiency of its compliance activities by conducting: Policy-making and Coordination Legal Advisory Support for Policy Program Management and Operations Support COMPLIANCE ACTIVITIES COMPLAINT PROCESSING OCR is responsible for investigating complaints of civil rights discrimination or noncompliance with privacy regulations within its jurisdiction that are filed with the office. This responsibility is based on the Department's regulations implementing the various nondiscrimination statutes and the Department of Justice (DOJ) coordinating regulations requiring compliance agencies, such as OCR, to establish procedures for the prompt processing and disposition of complaints alleging discrimination. It also derives from numerous other statutory and regulatory authorities including the Americans with Disabilities Act (ADA) regulations and the Privacy Rule pursuant to HIPAA. 28 I. Civil Rights A. Disabilities 1. The Americans with Disabilities Act (ADA), Olmstead, and the New Freedom Initiative OCR is involved in a variety of efforts to increase the independence and quality of life of persons with disabilities, including those with long-term needs. Most notably, OCR has played a critical role in the Administration's New Freedom Initiative that was announced in February 2001, and implemented through an Executive Order issued on June 19, 2001 (E.O.13217). The Executive Order commits the United States to a policy of community integration for individuals with disabilities and calls upon the Federal Government to work with states to implement the ADA regulation requiring that qualified individuals with disabilities be provided with services “in the most integrated setting appropriate to their needs,” as interpreted by the U.S. Supreme Court in Olmstead v. L.C. The Executive Order calls for swift implementation of the Olmstead decision and full enforcement of Title II of the ADA through investigations, complaint resolution, and the use of alternative dispute resolution. As part of the Executive Order, the President directed the Secretary of HHS to coordinate the activities of other Federal agencies. At the Secretary's direction, OCR coordinated the efforts of nine Federal agencies in a rigorous self-evaluation, with public input, of their policies, programs, statutes, and regulations to determine whether any should be revised or modified to improve the availability of community-based services for qualified individuals with disabilities. This coordinated effort led to the production of Delivering on the Promise, a comprehensive compilation of the reports of nine Federal agencies outlining more than 400 specific steps the agencies will implement to support community living for the nearly 54 million Americans living with disabilities. OCR, on behalf of the Department, has sole responsibility for fulfilling certain specific commitments in Delivering on the Promise. Since 1999, when the Olmstead decision was issued, OCR has received approximately 700 complaints and resolved approximately 500 complaints filed by individuals and organizations alleging individual and systemic violations of the Title II integration regulation of the ADA. OCR has successfully resolved a number of these complaints by working extensively with states to assist them in complying with the requirements of the ADA. The work of OCR has helped move individuals from institutional to community settings and has helped others avoid institutionalization. During FY 2007, OCR's investigation and resolution of Olmstead-related complaints as well as its public education and direct technical assistance to the states will continue to underscore the Administration's commitment and the Department's Federal Government leadership and coordinating role of improving access to community-based services for people with disabilities. The following are specific examples of OCR Olmstead complaint investigation outcomes and their impact. 29 Delaware Department of Health and Social Services and Delaware Psychiatric Center - An advocacy group filed a complaint, alleging that psychiatric hospital residents who sought discharge and whose treating professionals had determined that they could appropriately be served in the community were being inappropriately institutionalized. Through nearly four years of OCR intervention and assistance, the State took actions to address the individual and systemic issues involved in this complaint. As an outgrowth of OCR’s investigation, the State identified individuals ready for discharge from the institution, and worked with OCR to place more than 50 of these individuals into the community. Montana Department of Public Health and Human Services - OCR worked with the State, the complainant, and advocates to resolve a complaint filed on behalf of an individual with several mental and physical disabilities. The complainant alleged that she was not placed in the most integrated setting appropriate for her needs when she was moved from the community to an institutional setting. OCR initially met with State officials to assist with the development of the State’s Olmstead Plan and provided Olmstead related training to the State legislature. Once the complainant was certified as eligible for treatment in the community, OCR worked with the State and advocates to identify potential placement options for the complainant and explore the possibility of adapting the State’s community services program to meet the needs of the complainant. The complaint was ultimately resolved through the complainant’s placement in the community where she receives support services. Kansas Department of Social and Rehabilitation Services (KS-SRS) - During FY 2005, OCR’s Region VII office received twenty-three Olmstead complaints against KS-SRS. OCR provided significant technical assistance to the agency and secured relief to all complainants, who received the home and community based waiver services they had requested. Oregon Department of Human Services - OCR’s Region X staff worked with a complainant’s advocate and representatives of the Oregon Department of Human Services, county, and contractor entities to facilitate creation of an innovative duplex-based housing and services plan. Prior to OCR's involvement, the complainant was at risk of institutionalization due to inadequate supported housing resources in the existing mental health services delivery system. The stable, supported housing/services arrangement created to resolve the complaint removes the possibility of eviction/homelessness and resulting institutionalization. The complainant’s advocate reports that the complainant is now making remarkable developmental progress due to her stable situation. Based on this experience, Oregon officials have asked OCR to participate in future Olmstead work group sessions to foster inter-agency communications and cooperation. State of Tennessee - OCR worked with the State to resolve a complaint filed by a woman with cerebral palsy, who had resided in a nursing home for three years. She was approved for 12 hours/day of personal support services and moved to an apartment in the community. 30 2. Other OCR Activities to Ensure Non-Discriminatory Treatment of Individuals with Disabilities: HIV/AIDS, Accessibility, and Effective Communication In addition to enforcing Title II of the ADA, OCR enforces Section 504 of the Rehabilitation Act of 1973, which prohibits recipients of Federal financial assistance from discriminating against qualified individuals on the basis of disability. HHS recipients subject to Section 504 include many hospitals, nursing homes, mental health centers, medical providers, and human services programs. OCR is continuing its long history of using Section 504, along with other non-discrimination authorities, to respond to the HIV/AIDS epidemic and the continuing stigma and discrimination faced by some persons living with HIV and AIDS. For example, OCR works to ensure that providers who participate in the Medicaid program do not unlawfully refuse to treat persons with HIV infection who are protected by Section 504 and/or Title II of the ADA. Minorities bear a disproportionate share of the burden of these new HIV infections each year, bringing to bear OCR’s commitment to reducing health disparities in addition to our focus on disability rights and our efforts to protect the privacy of health information so important to persons with HIV. In 2005, OCR mounted a national OCR HIV/AIDS in-service Training and Conference for our staff. OCR and CDC trainers provided updates on legal authorities and new tools for investigative and outreach activity. In FY 2006 and 2007, OCR will use new tools for HIV/AIDS work developed in 2005 in conjunction with this training such as an analytic investigatory guide, a review of pertinent case law, a PowerPoint outreach presentation for lay audiences, a revised fact sheet on HIV/AIDS discrimination, and resource and referral information posted on OCR’s website. OCR’s investigative activities in this area have resulted in health care providers modifying their practices and policies to afford equal access to individuals with HIV infection. Other 504 cases have resulted in facilities establishing telecommunications services for the deaf, and making facilities more accessible. The following are a sample of OCR complaints concerning Section 504 of the Rehabilitation Act: Oakwood Annapolis Hospital in Wayne, MI - The complainant alleged that Oakwood Annapolis Hospital discriminated against him on the basis of his disability as an HIV+ individual. Specifically, the complainant was told by the Hospital when he arrived for a scheduled surgery that his surgery could not be performed at the time scheduled because the staff was not previously aware that he had AIDS and was now required to conduct certain sterilization preparations. OCR’s investigation revealed that the Hospital’s protocol to apply standard precautions consistently in the care of all patients in all patient care settings had not been properly followed. The Hospital voluntarily took corrective actions to avoid future incidents of this type by counseling staff members to consistently use a high level disinfectant that satisfies Universal Precautions protocol. The Hospital also purchased additional equipment to prevent delays associated with cleaning and disinfecting equipment. Sinai-Grace Hospital (SGH) in Detroit, MI – As a result of a complaint that alleged that SGH discriminated on the basis of disability (deafness) by failing to provide a qualified sign language interpreter as an auxiliary aid and thereby denying equal opportunity to benefit 31 from high quality health care, a systemic change was made. SGH is owned by the Detroit Medical Center (DMC), which also operates six other hospitals. As result of OCR’s technical assistance efforts, DMC revised, augmented, and refined its admissions and assessment policies and procedures to achieve effective communication with all patients and their families, including: assessment and accommodation of the needs and preferred method of communication for the patient, family member, or concerned individual who is deaf or hard of hearing and provision of qualified sign language interpreters free of charge, with a very short turn-around time, even during the middle of the night or on weekends. The DMC also ensured that brochures were made available and signs that inc