[Federal Register Volume 69, Number 152 (Monday, August 9, 2004)]
[Notices]
[Pages 48243-48246]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 04-18098]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Secretary


Office for Civil Rights; Statement of Organization, Functions, 
and Delegations of Authority

    Part A, Office of the Secretary, Statement of Organization, 
Functions, and Delegations of Authority for the Department of Health 
and Human Services, Chapter AT, Office for Civil Rights (OCR), as last 
amended at 65 FR 193279-81, dated April 11, 2000, is being amended to 
primarily realign the OCR Headquarters functions. The Changes are as 
follows:
    I. Under Chapter AT, Office for Civil Rights (OCR), delete in its 
entirety and replace with the following:

AT.00 Mission
AT.10 Organization
AT.20 Functions

    Section AT. Mission: OCR conducts public education, outreach, 
complaint investigation and resolution, and other compliance activities 
to prevent and eliminate discriminatory barriers, to ensure the privacy 
of protected health information, and to enhance access to HHS-funded 
programs. 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 by maintaining public trust and confidence that 
the health care system will maintain the privacy of protected health 
information while ensuring access to care. These OCR 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 protect the privacy of health 
information. The Department's goal of providing quality health and 
human services cannot be met when individuals do not receive these 
services as a result of practices that violate their fundamental rights 
of nondiscrimination or privacy.
    Section AT.10 Organization: The Director of the Office for Civil 
Rights reports to the Secretary and is responsible for overall 
coordination of the Department's civil rights and Health Insurance 
Portability and Accountability Act (HIPAA) Privacy Rule compliance and 
enforcement activities. The Director also serves as the Secretary's 
Special Assistant for Civil Rights. The Office is comprised of the 
following components:

 Office of the Director (ATA)
 Office of the Deputy Director for Civil Rights (ATB1)
 Office of the Deputy Director for Health Information Privacy 
(ATB2)
 Office of the Deputy Director for Management Operations (ATB3)
 Regional Offices for Civil Rights (ATD1 through ATDX)

    Section AT.20 Functions: A. Office of the Director (ATA). As the 
Department's chief officer for the enforcement of civil rights and the 
HIPAA Privacy Rule, and as adviser to the Secretary on civil rights and 
the HIPAA Privacy Rule, the Director: Is responsible for the overall 
leadership and operations of the Office for Civil Rights; establishes 
policy and serves as adviser to the Secretary on civil rights issues 
and the HIPAA Privacy Rule, including intra-departmental activities 
aimed at incorporating civil rights and HIPAA Privacy Rule compliance 
into programs the Department administers and/or operates directly; 
represents the Secretary before Congress and the Executive Office of 
the President on matters relating to civil rights and the HIPAA Privacy 
Rule; sets overall direction and priorities of the Office through 
budget requests, strategic planning, and results-oriented operating and 
performance plans; maintains liaison with other Federal departments and 
agencies charged with civil rights enforcement responsibilities and 
compliance with the HIPAA Privacy Rule; coordinates with the White 
House on civil rights, the HIPAA Privacy Rule and related policies; 
maintains liaison with the Congress in coordination and consultation 
with the Assistant Secretary for Legislation; and determines policies 
and standards for civil rights and HIPAA Privacy Rule investigations, 
enforcement and voluntary compliance and outreach programs in 
coordination with the Secretary and other Federal agencies.
    A Principal Deputy Director performs duties with the authority of 
the Director as delegated by the Director, assists in coordination and 
integration of the functions of all Deputy Directors, including cross-
cutting activities such as media, public, and inter-governmental 
relations, and acts for the Director in his/her absence.
    B. Office of the Deputy Director for Civil Rights (ATB1). This 
office is headed by a Deputy Director who reports to the Director, OCR. 
The Deputy Director for Civil Rights oversees civil rights program 
operations, policy development, and public education and outreach 
activities nationwide.
    The Office of the Deputy Director for Civil Rights includes 
operations, policy and public education and outreach functions that are 
managed through cross-functional teams that focus on: (1) Title VI of 
the Civil Rights Act of 1964, the Multi-Ethnic Placement Act (MEPA), 
Title VI and XVI of the Public Health Service Act (Hill-Burton 
Community Services Assurance provisions), Section 1808 of the Small 
Business and Job Protection Act, and Title IX; (2) Disability, Age and 
other nondiscrimination statutes and regulations; and (3) Medicare pre-
grant certification reviews, program reporting, surveys and civil 
rights training.
    These teams develop policy and assist in implementation of OCR's 
civil rights compliance and enforcement program; plan and coordinate 
OCR's high priority civil rights program initiatives; advise OCR staff 
nationwide on case development and quality; assist in developing 
negotiation, enforcement, and litigation strategies; identify training 
needs and design civil rights-specific training programs for OCR staff; 
review challenges to OCR civil rights findings; conduct policy and HHS 
program-related research; coordinate OCR's government-wide 
responsibilities for implementation of Age Discrimination Act 
requirements; develop civil rights surveys, and provide civil rights 
and program advice to OCR staff nationwide, other HHS components and 
external stakeholders.
    Through the team structure, the Office of the Deputy Director for 
Civil Rights also provides technical assistance to and conducts pre-
grant reviews of health care providers seeking Medicare certification 
and other program participation funded by the Department to determine 
their ability to comply with civil rights requirements; provides 
guidance and assistance to OCR Regional Offices to ensure uniform and 
efficient implementation of pre-grant processing policies and 
procedures; maintains civil rights assurance of compliance forms for 
permanent reference; and maintains liaison with and provides civil 
rights technical assistance and advisory services to HHS Operating 
Divisions (OPDIVS), as well as national advocacy, beneficiary, and

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provider groups, and to other Federal departments and agencies with 
respect to civil rights outreach programs, initiatives, and mandates.
    C. Office of the Deputy Director for Health Information Privacy 
(ATB2). This office is headed by a Deputy Director who reports to the 
Director, OCR. The Deputy Director for Health Information Privacy 
oversees HIPAA Privacy Rule program operations, policy development and 
administrative rule-making, public education and outreach activities 
nationwide and coordination of OCR nationwide Privacy Rule compliance 
activities and the application of policies to ensure consistency in 
interpretation and compliance enforcement.
    The Office of the Deputy Director for Health Information Privacy 
includes operations, policy and public education and outreach functions 
that are managed through cross-functional teams.
    These teams develop policy and assist in implementation of OCR's 
HIPAA Privacy Rule compliance and enforcement program; plan and 
coordinate OCR's high priority HIPAA Privacy Rule program initiatives; 
staff HIPAA and Privacy Rule intra- and inter-agency work groups; 
review challenges to OCR HIPAA Privacy Rule findings; conduct policy 
and HHS program-related research; advise OCR staff nationwide on case 
development and quality; assist in developing negotiation, enforcement, 
and litigation strategies; identify training needs and design HIPAA 
Privacy Rule-specific training programs for OCR staff; develop HIPAA 
Privacy Rule surveys; identify key issues and develop guidance to 
support public speaking requirements related to the HIPAA Privacy Rule; 
develop educational materials as well as other documentation to address 
public information requirements; and provide HIPAA Privacy Rule and 
program advice to OCR staff nationwide, other HHS components and 
external stakeholders.
    D. Office of the Deputy Director for Management Operations (ATB3). 
This office is headed by a Deputy Director who reports directly to the 
Director, OCR. The Deputy Director coordinates the day-to-day 
operations of headquarters and the regions, overseeing management 
operations, management policy, administrative contacts, budget, 
information technology, program management data analysis and human 
resources activities, including OCR's internal coordination 
responsibilities.
    The Deputy Director for Management Operations oversees performance 
accountability and results management, resource planning, budget and 
performance integration, information technology, management policy and 
operations; and acts as senior advisor on matters that cross functional 
areas such as EEO, labor relations, etc.
    The Deputy Director for Management Operations leads the Office for 
Civil Rights headquarters resource management functions as well as 
regional management operations. The Deputy is responsible for the 
development and implementation of OCR management strategies, business 
processes and standard operating procedures that fully support the 
attainment of OCR program goals and mission critical initiatives.
    In coordination with the Deputy Director for Civil Rights and the 
Deputy Director for Health Information Privacy, the Office of the 
Deputy Director for Management Operations works to ensure fair, 
responsible and effective allocation of resources in order to achieve 
maximum benefit for the organization as a whole.
    The Deputy Director, working through cross-functional teams, is 
responsible for performance accountability, results management, and 
quality assurance initiatives to maximize effectiveness and efficiency 
of OCR programs. The Deputy Director oversees the development of 
outcome-oriented management strategies and associated support systems 
such as performance program measurement and assessment systems, 
information resources systems and other program support systems.
    The Deputy Director oversees the formulation and execution of OCR's 
annual budgets and financial operating plans and is responsible for 
ensuring that OCR effectively integrates its performance metrics and 
budget processes to support decision-making related to funding 
constraints and program results.
    As part of the budget and performance integration and performance 
accountability functions, the deputy Director leads the development of 
data collection processes to ensure that OCR is able to measure its 
performance consistent with its commitments made as part of the 
Government Performance and Results Act; and directs the development and 
utilization of systems for the establishment and tracking of more 
effective benchmarks for performance and the cost effectiveness of 
OCR's results.
    The Deputy Director for Management and Operations provides 
leadership to the OCR executive team for the development of the key 
management objectives that drive the continuous improvement and 
updating of the OCR strategic vision and attendant organizational 
change requirements. This Deputy develops and implements action plans 
to ensure that OCR's management functions fully support its mission 
needs.
    The Office of the Deputy Director for Management Operations 
includes responsibility for the following functions: (1) Budget and 
Performance Integration; (2) Performance Accountability and Results 
Measurement; (3) Management Policy; (4) Information Systems and Data 
Analysis; (5) Executive Secretariat and Program Support; and (6) 
Regional Operations. OCR Regional Managers report to the Deputy 
Director for Management Operations.
    1. Budget and Performance Integration. Staff working on this 
function develop OCR's annual integrated budget and performance plan, 
incorporating a results, program quality and cost effectiveness focus 
into development and execution of integrated performance-based budgets 
and into the ongoing assessment and management of OCR's resource 
requirements.
    2. Performance Accountability and Results Management. Staff working 
on this function oversee OCR's implementation of the performance 
objectives set in its annual integrated budget and performance plan. 
This includes establishing measures for organizational performance and 
setting regional and HQ component targets as a share of nationwide 
results-centered objectives. Staff working on this function monitor and 
report to the Director on accomplishments in meeting program results 
and program efficiency objectives.
    The staff work on a day-to-day basis with regional offices in 
managing resources to achieve performance measures and provide 
assistance to the regions in accessing OCR Civil Rights and Privacy 
Rule policy and program operations technical assistance provided by 
staff of the Deputy Directors for Civil Rights and Health Information 
Privacy. Staff working on this function also ensure that all OCR staff 
performance plans incorporate the results and metrics set in the OCR 
integrated performance budget and in OCR leadership's performance 
contract and Senior Executive Service (SES) plans.
    3. Management Policy. Staff working on this function serve 
collectively as OCR's internal consultant and source of expert 
technical assistance on: organizational development; strategic 
planning; standards of conduct and ethics (Deputy Ethics Officer);

[[Page 48245]]

management training; program and program support-related contracting; 
competitive sourcing (A-76); human capital management [e.g., staffing 
and workforce analysis, transition and succession planning, awards and 
special honors programs, support and advisory assistance to managers 
throughout OCR with liaison to the Rockville HR Center and other 
experts on sensitive personnel issues (EEO, labor and management 
relations, performance and conduct-based actions)]; delegations of 
authority; and internal controls. The Deputy Director for Management 
Operations leads, coordinates and administers OCR's ongoing 
implementation of the President's Management Agenda (PMA) objectives 
in: Strategic Management of Human Capital; Competitive Sourcing; 
Improved Financial Performance; Expanded E-Government; and Budget and 
Performance Integration. Staff working on this function work in 
coordination with others within the Office of the Deputy Director for 
Management Operations to monitor and manage the PMA objectives.
    4. Information Resources and Data Analysis. Staff working on this 
function are led by OCR's Chief Information Officer (CIO) and are 
responsible for: information resources management policy; program 
systems development, maintenance and modification; operation of the 
Program Information Management System, OCR's workflow and document 
management system; the systems security of OCR's program systems; 
reporting on workload and related resource use; design and application 
of management data reports supportive of program operations and 
management; analysis of data in PIMS; statistical analysis in support 
of program management and compliance processing; maintenance and 
updating of OCR's website; coordination of OCR Paperwork Reduction Act 
and Government Paperwork Elimination Act clearance responsibilities 
working with program staff as appropriate; development of short- and 
long-term information resource management policy and plans; and liaison 
with HHS IRM resources, including the Information Technology Service 
Center (ITSC) and the OS and HHS Chief Information Officers.
    5. Executive Secretariat and Program Support. Staff working on this 
function provide consolidated document, e-mail, telephonic, and TDD 
intake for OCR HQ and related scanning and entry and assignments to OCR 
managers for further staff assignments in PIMS (e.g., correspondence, 
complaints, and HQ outreach and public education projects). The staff 
respond to general and routine correspondence using templates developed 
for this purpose and make referrals of correspondence that is not 
within OCR's nondiscrimination or Privacy Rule jurisdiction.
    Staff working on this function also provide consolidated program 
support services (travel management, supply management, timekeeping, 
PowerPoint design, logistics liaison with OSEO, reports on phone center 
and toll-free line use and reference of calls to regional offices, and 
logistics support for OCR special projects and activities.
    E. Regional Offices for Civil Rights (ATD1 through ATDX). The 
Regional Managers, Office for Civil Rights, report directly to the 
Deputy Director for Management Operations.
    Within goals set by the Director, OCR and management policy and 
operational goals set by the Director for Management Operations, the 
Regional Manager in each of OCR's ten regions: develops and delivers a 
comprehensive regional enforcement and voluntary compliance program to 
carry out the office mission; manages staff and other resources 
allocated to the region; directs a program to meet OCR objectives in 
such areas as quantity, quality and timeliness of work products in 
investigations and voluntary compliance activities; serves as a 
resource to the HHS Regional Directors on civil rights and Privacy Rule 
matters; disseminates and implements OCR policies and procedures; 
establishes priorities for work assigned to the civil rights attorney 
in the regional attorney's office; determines compliance of recipients 
of Federal financial assistance with nondiscrimination regulations and 
of covered entities under the health Information Privacy Rule; 
initiates voluntary compliance; approves, disapproves, and monitors 
implementation of voluntary compliance and corrective plans; approves, 
disapproves, and monitors State agency Methods of Administration; 
determines the most effective enforcement method, including 
conciliation of differences between complainants and recipients; 
recommends to the Director administrative and/or judicial enforcement 
actions when voluntary compliance cannot be obtained; participates in 
headquarters policy and program development; prepares regional budget 
proposal and supporting resource and work measurement justification; 
implements final budget allotment for region; implements the part of 
annual integrated budget and performance plans and financial operating 
plans pertaining to the conduct of complaint investigations, 
compliance, reviews, voluntary compliance activities, staff training 
and other regional office activities; coordinates with the Freedom of 
Information Officer and OCR headquarters on information requests and 
news media inquiries; establishes and maintains effective relations 
with offices of Governors, mayors, county officials, and other key 
State and local officials, and furnishes advice and assistance to them 
in civil rights and Privacy Rule matters; strives to develop mutually 
beneficial Federal-State-local partnerships; responds to Congressional 
inquiries as appropriate and in accordance with Office for Civil Rights 
protocol; implements court decisions as they pertain to OCR's program; 
and provides input into and implements OCR's affirmative action plan.
    OCR's regional Program Information Management staff provide the 
Regional Manager with evaluative reports and advice concerning the 
Regional Office's achievement of its overall goals and objectives, 
specifically with regard to: The quantity of compliance activities 
completed; the completion of compliance actions within established time 
frames; and the achievement of change for beneficiaries. These staff 
also monitor regional attainment of integrated budget and performance 
objectives and targets set for the region; oversee regional resource 
planning; conduct regional data collections; provide for support 
services and computer input; assess and assist in meeting regional 
training needs; serve as liaison to OSEO and HR Center for services 
such as personnel, space and supply acquisition and utilization and 
maintenance; and directly provide support for OCR-managed systems and 
operations such as PIMS (workflow, document and correspondence 
control), office safety, and travel.
    A. Investigative Functions--Under its enforcement authorities the 
Regional Office serves as a complaint intake unit. When complaints are 
received, the Office conducts complaint investigations of health and 
human services institutions to eliminate unlawful discrimination and 
ensure equal opportunity for the beneficiaries of Federal financial 
assistance provided by the Department of Health and Human Services; and 
the Office further seeks to ensure that covered entities are in 
compliance with the Privacy Rule implementing the health information 
privacy protections of the Health Insurance Accountability and 
Portability Act (HIPAA). In addition, the Office determines civil 
rights compliance by entities that receive federal financial 
assistance; advises the

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Regional Manager on critical enforcement actions; provides assistance 
to recipients for corrective action; and monitors implementation of 
corrective plans; coordinates enforcement activities with OPDIV's 
regional officials, other Federal agencies and states and, as 
appropriate, with headquarters offices and divisions; solicits 
regional/area civil rights attorney's legal opinion on investigations 
as the Regional Manager deems appropriate; and processes all complaints 
received, including determination of jurisdiction and completeness.
    B. Voluntary Compliance and Outreach Functions--OCR's Regional 
Office staff also: Conduct reviews to assist in identifying potential 
compliance problems; negotiate voluntary compliance with recipients of 
federal financial assistance, or with respect to the Privacy Rule, with 
entities that are covered by the Rule; advise the Regional Manager on 
critical compliance matters; coordinate voluntary compliance activities 
with OPDIVs and STAFFDIVs, regional officials, State, local and other 
Federal agencies and, as appropriate, headquarters offices and 
divisions; provide assistance and outreach services to recipients, 
covered entities, beneficiaries and organizations as requested or 
referred; establish and maintain effective relationships with the 
Offices of Governors, State and local officials in order to provide 
advice and assistance to them on civil rights matters; establish and 
maintain liaison with the HHS Regional Director in carrying out 
speaking engagements, media appearances and interviews.
    Regions III and IX carry out OCR's functional responsibilities 
under an organization structure that includes field offices in 
Washington, DC and Los Angeles, CA respectively. In all regions, the 
management and supervisory structure consists of a Regional Manager and 
a Deputy Regional Manager.
    II. Continuation of Policy: Except as inconsistent with this 
reorganization, all statements of policy and interpretations with 
respect to the Office for Civil Rights heretofore issued and in effect 
prior to this reorganization are continued in full force and effect.
    III. Delegation of Authority: All delegations and redelegations of 
authority made to officials and employees of the Office for Civil 
Rights will continue in them or their successors pending further 
redelegation, provided they are consistent with this reorganization.
    IV. Funds, Personnel and Equipment: Transfer of organizations and 
functions affected by this reorganization shall be accompanied by 
direct and support funds, positions, personnel, records, equipment, 
supplies and other sources.

    Dated: July 12, 2004.
Ed Sontag,
Assistant Secretary for Administration and Management.
[FR Doc. 04-18098 Filed 8-6-04; 8:45 am]
BILLING CODE 4110-60-M