Title VI - LEP Compliance Plan

1. Assessment of Language and Communication Needs of the NKY Health Service Area

The NKY Health shall assess the predominant language needs of the populations in Boone, Campbell, Grant, and Kenton Counties as needed or at a minimum of every four (4) years, starting in 2011.  This data will be kept at NKY Health administrative office at 8001 Veterans Memorial Drive, Florence, Kentucky, in the Title VI/LEP Compliance Plan Binder in the office of the Title VI Compliance Officer.  The following data shall be collected, updated, and reviewed:

a. Current census data estimates as they are made available, to determine the percent of the population in the service area that has a primary language of “other than English spoken”.

b. Survey of staff from each division on the most prevalent interpretation/translation needs.

 c. Data from the Kentucky Department of Medicaid on LEP clients.

2. Identification of Resources to Provide Effective Language Assistance

To facilitate the client's treatment and ensure effective communication to each client enabling the understanding of his/her care and make informed choices, the NKY Health shall have interpreter services and/or other adaptive equipment made available for clients and staff members.

3. Identification of Clients' Communication Needs & Notification of Clients

a. NKY Health will identify any client that needs language assistance and use the Patient Record System to record if clients have LEP or other adaptive equipment. LEP clients requiring language assistance will have their record "flagged" with the information to insure that appropriate measures are taken to provide equal access to all services and resources.

b. Language identification cards will be available at all health centers and department locations so that LEP persons may self-identify the language in which they need to communicate.

c. In intake/waiting areas, notices written in the most commonly encountered languages will be posted, which notify LEP persons of free language assistance to encourage them to self-identify.

d. Outreach documents (brochures, booklets, etc) will state, in the most commonly encountered languages, that language assistance services are available.

e. All LEP clients will be offered language assistance that is provided in a reasonably timely manner and at no cost to the client. 

4. Language Assistance Measures

a. NKY Health staff will provide interpreting services to clients who are LEP by using at least one of the following methods (in this order):

1) Use an interpreter from the list of bilingual staff if available.

2) Access the telephone interpreter service.

3) Use an interpreter from the list of qualified interpreters.

b. NKY Health will hire trained and competent bilingual staff to the extent possible.  A list of trained and competent bilingual staff will be made available to all health centers and programs.

c. NKY Health will contract with an outside interpreter service for professional telephone interpretation 24 hours a day.  Instructions for use of these services will be provided to all health centers and programs.

d. NKY Health will work with interpreters who are competent to interpret medical or other program information.  The NKY Health will use the information contained in Attachment II “Qualifications for Interpreters” as a guide in hiring interpreters.  Qualified interpreters will be made available to all health centers and programs.  Interpreters must sign confidentiality statements prior to performing these services.

1) To the extent possible, interpreters may attend competency assessment and training and become qualified as an interpreter.

2) Through coordination with Purchasing, the NKY Health will try to use the same providers to the extent possible to ensure consistency among interpretation services and translations.

e. If the LEP client believes the interpreter provided is not sufficiently qualified to provide services, the individual or responsible party may request interpreter services of a higher skill level.

f. Friends, family (including minor children), as well as individuals familiar with the LEP client should not be used as interpreters.

1) Should the LEP client decline the free interpreter services and choose to use their own interpreter, the NKY Health staff must document in the LEP client’s medical record that the offer was declined.

2) NKY Health staff should also request that a qualified interpreter monitor the interaction either via telephone or in person, to ensure accurate interpretation occurs. If this situation occurs, the NKY Health staff will instruct the phone or in-person interpreter to silently listen to the interpreted conversation. At any point where the interpreter detects an error in the interpretation, they should speak up and render a corrected interpretation. At the end of the client encounter, the NKY Health staff should instruct the interpreter to hang up or leave the office when the service is no longer needed.  If using a speaker phone, all parties should get close to the phone and speak with a higher volume and keep the door closed for privacy concerns.

3) If the LEP chooses a friend, family or other individual to provide interpretive services and the NKY Health staff believes the individual is not sufficiently qualified to interpret the medical terminology then the NKY Health staff may choose to use their own interpreter services.

g. If an LEP client rejects the offer of free interpreter services and insists on providing their own at their own expense or using a family member, staff will document in the client's record that the offer was rejected and should have an interpreter present or have phone interpreter listen for any corrections or omissions of information.

h. NKY Health will ensure that only documents translated by approved translators are used with clients.

1) For statewide uniformity, vital documents such as consent forms, notices pertaining to reduction, denial or termination of services or benefits, and documents or forms required for use by the state Department of Public Health (DPH) Local Health Operations will be translated by the State DPH into the most commonly encountered languages.

2) Any other documents provided to NKY Health clients will be professionally translated by the NKY Health.

3) For the WIC program, the NKY Health will ensure that all written materials provided to the general public that explain the WIC Program contain the following nondiscrimination statement: 

“In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age or reprisal or retaliation for prior civil rights activity. 

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. 

To file a program discrimination complaint, a Complainant should complete Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-ComplaintForm-0508-0002-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 

1. mail: 

U.S. Department of Agriculture 

Office of the Assistant Secretary for Civil Rights 

1400 Independence Avenue, SW 

Washington, D.C. 20250-9410; or 

2. fax: 

(833) 256-1665 or (202) 690-7442; or 

3. email: 

program.intake@usda.gov 

This institution is an equal opportunity provider." 

If the material is too small to permit the full non-discrimination statement to be included, the material must at a minimum include the statement, “This institution is an equal opportunity provider” in print no smaller than the text.  FNS WIC NDS English and Spanish August, 2022

4) The NKY Health will post in client waiting areas the required notices, important information, etc., which have been translated into the most frequently encountered language(s).

5. Staff Training

a. On their start date and annually, all NKY Health staff shall receive training on Title VI and LEP with instructions on the provision of language assistance services to LEP clients.  In addition, each employee will be required to review our Title VI Policy and Compliance Form and sign the form annually.  Training shall include:

1) Training on Civil Rights and an overview of the Title VI requirements for the provision of services to LEP persons via the NKY Health Title VI Policy and Compliance Form and Title VI training slideshow.

2) A description of how employees can access the language assistance services in a timely manner.

3) An overview of how employees can work effectively with in-person interpreters and telephone interpreters.

b. To ensure competency in their ability to interpret medical information, merit system employees that function as interpreters, as well as purchased interpreter services, will be assessed and trained in language interpretation specific to the medical field.  Training records for merit system employees will be kept in Human Resources.

c. The NKY Health Human Resources office will maintain a record of new employee orientation training and annual training activities.

d. Additional information and resources are found in the Attachment I of this plan.

6. Complaint Procedures

a. Any person who believes she or he or any special class of individuals is being subjected to discrimination under Title VI may file an oral or written complaint. Person(s) may file a complaint with the NKY Health Title VI Compliance Officer, the Department for Public Health (Administration and Financial Management Division), the federal program agency and/or the Federal Department of Justice; or U.S. Department of Health and Human Services.

b. The NKY Health Title VI Compliance Officer is Pamela Millay and can be reached at pamela.millay@nkyhealth.org or at the Northern Kentucky Health Department at 8001 Veterans Memorial Drive in Florence, KY 41042 or at 859-341-4264.

c. HHS/OCR complaint document can be found at:  https://www.hhs.gov/sites/default/files/civil-rights-complaint-form-0945-0002-exp-04302019.pdf.

d. WIC Program Notification and Complaint Procedures must be used for any complaints of discrimination under Title VI by WIC clients.

e. If a client believes they have been discriminated against because of race, color, national origin, sex, age, or disability, the complaint shall be filed by writing USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or calling (800) 795-3272 or (202) 720-6382 (TTY). 

7. Plan Monitoring & Evaluation