Gila River Health Care Corporation
Gila River Health Care Corporation
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Arizona Department of Health Services

Division of Behavioral Health Services
Gila River Regional Behavioral Health Authority Edition

Section 3.23 Cultural Competence

3.23.1 Introduction
3.23.2 References
3.23.3 Definitions
3.23.4 Procedures
3.23.4-A ADHS/DBHS Cultural Competency Framework
3.23.4-B Culturally Competent Care

3.23.4-C Organizational Support for Cultural and Linguistic Need
3.23.4-D Documenting Clinical Cultural and Linguistic Need
3.23.4-E Cultural Competency Reporting and Accountability
3.23.4-F Laws Addressing Discrimination and Respect for Diversity and Inclusion


3.23.1 Introduction
The purpose of this policy is to outline the culturally and linguistically competent framework which ADHS/DBHS has developed to meet Federal, National, State, Contract and Grant requirements. Furthermore, this policy is intended to communicate the expectations for the delivery of culturally and linguistically appropriate services.

3.23.2 References
The following citations can serve as additional resources for this content area:

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3.23.3 Definitions
CLAS Standards

Commonly Encountered LEP Groups

Cultural Competence



Health Disparities


Limited English Proficiency

Linguistic Competence

Member Information Materials


3.23.4 Procedures

3.23.4-A. ADHS/DBHS Cultural Competency Framework
Required Culturally and Linguistically Appropriate Services (CLAS) Standards

The enhanced National CLAS Standards are intended to advance health equity, improve quality, and help eliminate health care disparities by establishing a blueprint for individuals as well as health and health care organizations to implement culturally and linguistically appropriate services. The enhanced Standards are a comprehensive series of guidelines that inform, guide, and facilitate practices related to culturally and linguistically appropriate health services.

  • Principal Standard (Standard 1): Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.
  • Governance, Leadership, and Workforce (Standards 2-4): Provide greater clarity on the specific locus of action for each of these Standards and emphasizes the importance of the implementation of CLAS as a systemic responsibility, requiring the investment, support, and training of all individuals within an organization.
  • Communication and Language Assistance (Standards 5-8): Provides a broader understanding and application of appropriate services to include all communication needs and services, including sign language, braille, oral interpretation, and written translation.
  • Engagement, Continuous Improvement, and Accountability (Standards 9-15): Underscores the importance of establishing individual responsibility in ensuring that CLAS is supported, while retaining the understanding that effective delivery of CLAS demands actions across an organization. This revision focuses on the supports necessary for adoption, implementation, and maintenance of culturally and linguistically appropriate policies and services regardless of one’s role within an organization or practice. All individuals are accountable for upholding the values and intent of the National CLAS Standards.

ADHS/RBHA contracts, ADHS/Tribal Intergovernmental Agreements and T/RBHA Annual Cultural Competency plans, require adherence to all areas of the CLAS standards.

Language Access Services (LAS)
To comply with the LAS requirements, T/RBHAS and subcontracted providers must:

  • Offer language assistance to individuals, who have a limited English proficiency and/or other communication needs such as sign language interpreters and American Sign Language fluent staff, at no cost to them, to facilitate timely access to all health care and services. Inform all individuals of the availability of language assistance services clearly and in their preferred language, verbally and in writing;
  • Ensure the competence of individuals providing language assistance, recognizing that the use of untrained individuals and/or minors as interpreters should be avoided; and
  • Provide easy-to-understand print and multimedia materials and signage in the languages commonly used by the populations in the service area. Have services provided in a culturally competent manner, with consideration for members with limited English proficiency or reading skills, and those with diverse cultural and ethnic backgrounds, including those who identify with deaf culture, as well as members with visual or auditory limitations. Options include access to a language interpreter, a person proficient in sign language for the hearing impaired, and written materials available in Braille for the blind or in different formats, as appropriate..

Accessing Oral Interpretation Services
In accordance with Title VI of the Civil Rights Act, Prohibition against National Origin Discrimination, President's Executive Order 13166, T/RBHAs and their subcontracted providers must make oral interpretation services available to persons with Limited English Proficiency (LEP) at all points of contact. Oral interpretation services are provided at no charge to AHCCCS eligible persons and Non-title XIX/XXI persons determined to have a Serious Mental Illness (SMI.). Members must be provided with information instructing them how to access these services. 

Contact Gila River Behavioral Health Services at (602) 528-7100, (520) 562-3321 #7010 or 1-888-484-8526 and for hearing impaired, use TTY services at 711 or 1-800-367-8939 to access language interpretation services.

Accessing Interpretation Services for the Deaf and the Hard of Hearing
T/RBHAs and their subcontracted providers must adhere to the rules established by the Arizona Commission for the Deaf and Hard of Hearing, in accordance with A.R.S. 36-1946, which cover the following:

  • Classification of interpreters for the deaf and the hard of hearing based on the level of interpreting skills acquired by that person;
  • Establishment of standards and procedures for the qualification and licensure of each classification of interpreters;
  • Utilizing licensed interpreters for the deaf and the hard of hearing; and
  • Providing auxiliary aids or licensed sign language interpreters that meet the needs of the individual upon request. Auxiliary aids include computer-aided transcriptions, written materials, assistive listening devices or systems, closed and open captioning, and other effective methods of making aurally delivered materials available to persons with hearing loss.

The Arizona Commission for the Deaf and the Hard of Hearing provides a listing of licensed interpreters, information on auxiliary aids and the complete rules and regulations regarding the profession of interpreters in the State of Arizona.  (Arizona Commission for the Deaf and the Hard of Hearing or (602) 542-3323 (V/TTY).)

Contact Gila River Behavioral Health Services using TTY services at 711 or 1-800-367-8939 for accessing interpretation services for the deaf and hard of hearing. 

Translation of Written Material
T/RBHAs and their subcontracted providers must make written translated materials available, when the T/RBHA is aware that a language is spoken by 3,000 or 10% (whichever is less) of T/RBHA's members, to the commonly encountered LEP groups who are AHCCCS eligible and to persons determined to have a Serious Mental Illness. 

All vital materials shall be translated when the T/RBHA is aware that a language is spoken by 1,000 or 5% (whichever is less) of the T/RBHA’s members who also have LEP. Vital materials must include at a minimum;

  • Notice for denials, reductions, suspensions or termination of services;
  • Service plans;
  • Consent forms;
  • Communications requiring a response from the behavioral health recipient; and
  • Grievance notices; and
  • Member handbooks.

All written notices informing members of their right to interpretation and translation services must be translated when the T/RBHA is aware that 1000 or 5% (whichever is less) of the T/RBHA’s members speak that language and have LEP.

Members with LEP, whose languages are not considered commonly encountered, will be provided written notice in their primary or preferred language of the right to receive competent translation of written material.

To access written translation services, please contact Gila River RBHA at 602-528-7140.

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3.23.4-B. Culturally Competent Care
To comply with the Culturally Competent Care requirements, T/RBHAS and subcontracted providers must:

  • Recruit, promote, and support culturally and linguistically diverse representation within governance, leadership, and the workforce that are responsive to the population in the service area(s);
  • Educate and train representatives within governance, leadership, and the workforce in culturally and linguistically appropriate policies and practices on an ongoing basis. Providers with direct care responsibilities must complete mandated Cultural Competency training (see PM Section 9.1 Training Requirements and the Cultural Competence Plan).

If the behavioral health recipient requests a copy of the assessment, those documents must be provided to the behavioral health recipient in his/her primary/preferred language. Documentation in the assessment must also be made in English; both versions must be maintained in the recipient’s record. This will ensure that if any persons, who must review the recipient’s record for purposes such as coordination of care, emergency services, auditing and data validation, have an English version available.

Individual Service Plan (ISP) and Inpatient Treatment and Discharge Plan (ITDP)
The ADHS/DBHS Individual Service Plan (ISP) is intended to fulfill several functions, which include identification of necessary behavioral health services (as evaluated during the assessment and through participation from the person and his/her team), documentation of the person’s agreement or disagreement with the plan, and notification of the person’s right to a Notice of Action (See PM Section 5.1 Notice Requirements and Appeal Process for Title XIX and Title XXI Eligible Persons) or Notice of Decision and Right to Appeal (See PM Section 5.5 Notice and Appeal Requirements (SMI and Non-SMI/Non-Title XIX/XXI)), if the person does not agree with the plan. ADHS/DBHS provides the service plan templates in both English and Spanish. The individual service plan is a vital document as defined in the AHCCCS/ADHS contract, ADHS/ RBHA contracts and ADHS/TRBHA IGAs.

Service plans specifically incorporate a person’s rights to disagree with services identified on the plan. If the plan is not in the person’s preferred language, the person has not been appropriately informed of services he/she will be provided and afforded the opportunity to exercise his/her rights when there is a disagreement.

In general, any document that requires the signature of the behavioral health recipient, and that contains vital information such as the treatment, medications or notices, or service plans must be translated into their preferred/primary language if requested by the behavioral health recipient or his/her guardian.

If the primary/preferred language of the behavioral health recipient is other than English and any of the service plans have been completed in English, the provider must ensure the service plans are translated into the behavioral health recipient’s primary/preferred language for his/her signature. T/RBHAS and subcontracted must also maintain documentation of the ISP in both the preferred/primary language as well as in English.

These requirements apply also to the ITDP (Inpatient Treatment and Discharge Plan), in accordance with the 9 A.A.C. 21, Article 3.

3.23.4-C. Organizational Support for Cultural and Linguistic Need
Under ADHS/DBHS guidance, and to comply with the Organizational Supports for Cultural Competence the T/RBHAs and subcontracted providers must:

  • Establish culturally and linguistically appropriate goals, policies, and management accountability and infuse them throughout the organization’s planning and operations.

  • Conduct ongoing assessments of the organization’s CLAS-related activities and integrate CLAS-related measures into measurement and continuous quality improvement activities.

  • Partner with the community to design, implement, and evaluate policies, practices, and services to ensure cultural and linguistic appropriateness.

  • Conduct regular assessments of community health assets and needs and use the results to plan and implement services that respond to the cultural and linguistic diversity of populations in the service area.

  • Create conflict and grievance resolution processes that are culturally and linguistically appropriate to identify, prevent, and resolve conflicts or complaints.

  • Communicate the organization’s progress in implementing and sustaining CLAS to all stakeholders, constituents, and the general public.

3.23.4-D. Documenting Clinical Cultural and Linguistic Need

To advance health literacy, reduce health disparities, and identify the individual’s unique needs, T/RBHAs and subcontractors must:

  • Collect and maintain accurate and reliable demographic data to monitor and evaluate the impact of CLAS on health equity and outcomes and to inform service delivery.

  • Ensure documentation of the cultural (for example: age, ethnicity, race, national origin, sex (gender), gender identity, sexual orientation, tribal affiliation, disability) and linguistic (for example, primary language, preferred language, language spoken at home, alternative language) needs within the medical records.

  • Maintain documentation within the medical record of oral interpretation services provided in a language other than English. Documentation must include the date of service, interpreter name, type of language provided, interpretation duration, and type of interpretation services provided.

3.23.4-E. Cultural Competency Reporting and Accountability

Reporting and accountability measures are intended to track, monitor, and ensure access to quality and effective care. Equity in the access, delivery, and utilization of services is accomplished by the T/RBHAs and subcontracted providers:

  • Conducting annually and ongoing strategic planning in Cultural Competency with the inclusion of national level priorities, contractual requirements, stakeholder input, community involvement and initiative development in areas, including but not limited to: Continuing Education, Training, Community Involvement, Health Integration, Outreach, Prevention, Data Analysis/Reporting, Health Literacy, and Policies/Procedures Development.

  • Capturing and reporting on language access services which include: linguistic needs (primary language, preferred language, language spoken at home, alternative language); interpretive services; written translation services; and maintaining documentation on how to access qualified/licensed interpreters and translators.

  • Assessing and developing reports quarterly, semi-annually, and annually within the areas of cultural competency and workforce development to review the initiatives, activities, and requirements impacting diverse communities, geographical services areas (GSAs), and the individuals accessing and receiving services.

Continuous and ongoing reporting provides insight to strengths, gaps, and needs within communities served by T/RBHAs and T/RBHA subcontracted providers with a goal of health and wellness for all.

3.23.4-F. Laws Addressing Discrimination and Diversity
T/RBHAs and provider agencies must abide by the following referenced federal and state applicable rules, regulations and guidance documents:
  • Title VI of the Civil Rights Act prohibits discrimination on the basis of race, color, and national origin in programs and activities receiving federal financial assistance.
  • Department of Health and Human Services – Guidance to Federal Financial Assistance Recipients Regarding Title VI Prohibition Against National Origin Discrimination affecting Limited English Proficient Persons.
  • Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on race, color, religion, sex, or national origin by any employer with 15 or more employees. (The Civil Rights Act of 1991 reverses in whole or in part several Supreme Court decisions interpreting Title VII, strengthening and improving the law and providing for damages in cases of intentional employment discrimination.)
  • President’s Executive Order 13166 improves access to services for persons with Limited English Proficiency. The Executive Order requires each Federal agency to examine the services it provides and develop and implement a system by which LEP persons can meaningfully access those services consistent with, and without unduly burdening, the fundamental mission of the agency.
  • State Executive Order 99-4 and President's Executive Order 11246 mandates that all persons regardless of race, color, sex, age, national origin or political affiliation shall have equal access to employment opportunities.
  • The Age Discrimination in Employment Act (ADEA) prohibits employment discrimination against employees and job applicants 40 years of age or older. The ADEA applies to employers with 20 or more employees, including state and local governments. The Older Workers Benefit Protection Act (Pub. L. 101-433) amends the ADEA to prohibit employers from denying benefits to older employees
  • The Equal Pay Act (EPA) and A.R.S. 23-341 prohibit sex-based wage discrimination between men and women in the same establishment who are performing under similar working conditions.
  • Section 503 of the Rehabilitation Act prohibits discrimination in the employment or advancement of qualified persons because of physical or mental disability for employers with federal contracts or subcontracts that exceed $10,000. All covered contractors and subcontractors must also include a specific equal opportunity clause in each of their nonexempt contracts and subcontracts.
  • Section 504 of the Rehabilitation Act prohibits discrimination on the basis of disability in delivering contract services.
  • The Americans with Disabilities Act prohibits discrimination against persons who have a disability.  Providers are required to deliver services so that they are readily accessible to persons with a disability.  T/RBHAs and their subcontracted providers who employ less than fifteen persons and who cannot comply with the accessibility requirements without making significant changes to existing facilities may refer the person with a disability to other providers where the services are accessible.  A T/RBHA or its subcontracted provider who employs fifteen or more persons is required to designate at least one person to coordinate its efforts to comply with federal regulations that govern anti-discrimination laws. 

 For more information about culturally competent services or to report a complaint regarding culturally competent services, please contact Gila River RBHA at 602-528-7140.

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3.23 Cultural Competence
Last Revised: 5/15/2014
Effective Date:

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