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HomeMy WebLinkAbout2324-22 Language Access (FINAL 1_8_25) Audit Report Language Access Program: Low compliance risk, but better coordination and guidance needed To request this information in an alternate format, please call (541) 330-4674 or send email to internal.audit@Deschutes.org Take survey by clicking here Language Access—#23/24-22 January 2025 Table of Contents: 1. Introduction ....................................................................................... 1 Background ..................................................................................................................... 2 2. Findings ............................................................................................... 6 Finding 1: There was some risk of noncompliance with federal language access rules. ............................................................................................................................ 6 Finding 2: Language access portions of the Civil Rights Act policy did not provide clear guidance. .............................................................................................. 8 Finding 3: The County didn’t know what language access services were needed and provided across the organization. ..................................................................... 9 Finding 4: Without procedures, translated documents were not readily available and contracts were underused and uncoordinated. ............................................ 10 Finding 5: Bilingual employees bore the burden of unclear policies and procedures. ............................................................................................................... 12 3. Audit Conclusion ............................................................................. 15 4. Management Response .................................................................. 16 5. Appendix A: Objective, Scope, and Methodology ........................ 18 Objectives and Scope ................................................................................................... 19 Methodology ................................................................................................................. 19 6. Appendix B: Department of Justice Language Access Assessment and Planning Tool and Deschutes County Status ......... 20 Policy Best Practices ..................................................................................................... 20 Implementation Plan Best Practices ........................................................................... 27 Procedures Best Practices ........................................................................................... 36 Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Highlights: Why this audit was performed: Vital county services cannot be provided without effective communication, even with those who do not speak English. We recommended that County Administration: assign responsibility for language access. update the Civil Rights Act policy to provide clear guidance. create a language access plan. add mandatory procedures to the policy. create a policy for the bilingual program. Low compliance risk, better coordination and guidance needed The audit objective was to determine whether the County complied with language access rules related to translation and interpretation services and whether those services were effectively and efficiently provided. What we found: The County provided services for people who need language access. But there were still some areas where language access could be improved. Unclear guidance and procedures around language access services led to confusion and inconsistency. This uncertainty resulted in staff hesitation to use contract translators and interpreters, which in turn placed an undue burden on bilingual employees. County staff were not able to answer basic questions such as how much are we doing, how much should we be doing, and can we do it more efficiently. We found that: • There was some risk of noncompliance with federal language access rules. • Language access portions of the Civil Rights Act policy did not provide clear guidance. • The County didn’t know what language access services were needed and provided across the organization. • Without procedures, translated documents were not readily available and contracts were underused and uncoordinated. • Bilingual employees bore the burden of unclear policies and procedures. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 1 of 36 1. Introduction The County provides essential services to community members. We all count on the County to be there during medical emergencies and times when we feel threatened or have been victims of crime. We count on them to keep us healthy during critical times like pandemics, but also day-to-day when we visit restaurants or if we live in a neighborhood that is not connected to a sewer system. The County can’t provide these services without effective communication. Most people in the County use English to communicate, but there are some people who need language access services such as translation and interpretation to communicate with County officials. The County provided services for people who need language access. It hired bilingual staff and contracted with translation and interpretation providers. Customer service staff had access to auxiliary kits with tools for providing access such as a tablet that connected to on-demand interpretation services. But there were still some areas where language access could be improved. Unclear guidance and procedures around language access services led to confusion and inconsistency. This uncertainty resulted in staff hesitation to use contract translators and interpreters, which in turn placed an undue burden on bilingual employees. County staff were not able to answer basic questions such as how much are we doing, how much should we be doing, and can we do it more efficiently. The Deschutes County Audit Committee authorized a review of language access in the Internal Audit Work Plan for Fiscal Years 2024 and 2025. Audit objectives, scope, and methodology can be found in Appendix A. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 2 of 36 Background It is the mission of Deschutes County to “enhance the lives of citizens by delivering quality services in a cost-effective manner.” The County achieves this mission by • Protecting the community through planning, preparedness, and delivery of coordinated services. • Enhancing and protecting the health and well-being of communities and their residents. • Promoting policies and actions that sustain and stimulate economic resilience and a strong regional workforce. • Supporting actions to increase housing production and achieve stability. • Providing solution-oriented service that is cost-effective and efficient. The County cannot provide these services without providing information and communicating in a language that residents, visitors, and business owners can understand. Deschutes County has a small percentage but still sizable population of people who need translation and interpretation to participate in services. According to 2022 data from the U.S. Census Bureau, there were 4,080 people in Deschutes County who spoke English less than very well. Of those people, 3,243 spoke Spanish. Populations were higher in the more urban areas of Bend and Redmond. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 3 of 36 Figure 1: Percentage of people needing language assistance in Deschutes County by Census tract Source: 2022 U.S. Census Bureau American Community Survey The County addressed language access needs in a few different ways. Bilingual Employees Deschutes County offered premium pay to bilingual employees who used their language skills during work. Bilingual employees provided direct service in languages other than English, interpretation for other employees, and/or document translation. To qualify for pay, supervisors agreed that the employee used language skills while working. Bilingual employees also had to take an oral test. Most bilingual employees received $150 per month for bilingual pay, though some qualified for $250 per month for specialized and highly skilled work like medical interpretation. These stipends were paid in addition to the employee’s regular salary. Contracted Interpreters and Translators The County had multiple contracts for interpretation and translation. Some providers were sole contractors and others Translation is a written language assistance service. Text in one language is replaced with text in another. Interpretation is an oral language assistance service. An interpreter listens to spoken messages in one language and then speaks in another language. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 4 of 36 were large companies with multiple employees who could provide on-demand services over the phone or through video conferencing. Auxiliary Kits The Health Services Department piloted a program to place on- demand interpretation kits at customer service locations. Since then, the kits have been distributed to many departments providing direct customer service including the Finance Department and Clerk’s Office. The kits include a tablet that connects to on-demand interpretation services, a point to your language sheet, a device to amplify sound for those who are hard of hearing, a whiteboard for written communications, and a magnifier for those who have trouble reading small text. Language Access Analyst Job Classification The County created a Language Access Analyst job classification to coordinate language service within departments. Analyst duties included managing departmental language access services, determining language access budget needs, delegating language access work across the department, and overseeing contracts related to translation and interpretation. In the Health Services Department, A Language Access Analyst coordinated interpretation and translation. The analyst routed services requests deciding whether to perform services in-house or through a vendor. Prior to having the Analyst in place, staff in Health Services did not make requests in a consistent manner. Some used bilingual staff and others used vendors. The Analyst created a central method to request services which increased staff confidence that someone could step in even if a vendor was unavailable. The Analyst was also able to develop relationships with vendors and knew their strengths, for example which were better at simultaneous interpretation. As of December 2024, only the Health Services Department had someone assigned to this classification. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 5 of 36 Language Access Rules and Best Practices Title VI of the 1964 Civil Rights Act prohibits national origin discrimination when information is provided only in English to people who don’t speak English. All recipients of federal funds are required to provide services to people regardless of English proficiency and must take reasonable steps to ensure meaningful access to information and services. The U.S. Department of Justice developed a Language Access Assessment and Planning Tool to assist government agencies with complying with language access portions of Title VI. Elements of the tool are not required but are helpful guidance for complying with the law. The tool includes best practices for developing a language access policy, plan, and procedures. According to the tool: • A language access policy sets forth standards, operating principles, and guidelines that govern the delivery of language appropriate services. • A language access plan is a management document that outlines how the agency defines tasks, sets deadlines and priorities, assigns responsibility, and allocates the resources necessary to come into or maintain compliance with language access requirements. It describes how the agency will meet the service delivery standards delineated in the policy directives. The plan is a roadmap that helps agencies navigate the process of setting deadlines and priorities and identifying responsible personnel. • Language access procedures are the "how to" for staff. They specify for staff the steps to follow to provide language services, gather data, and deliver services to people who need language services. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 6 of 36 2. Findings The objective of the audit was to determine whether the County complied with rules related to translation and interpretation services and whether those services were effectively and efficiently provided. Based on that review, several key issues emerged: 1. There was some risk of noncompliance with federal language access rules. 2. Language access portions of the Civil Rights Act policy did not provide clear guidance. 3. The County didn’t know what language access services were needed and provided across the organization. 4. Without procedures, translated documents were not readily available and contracts were underused and uncoordinated. 5. Bilingual employees bore the burden of unclear policies and procedures. Finding 1: There was some risk of noncompliance with federal language access rules. According to federal meaningful access standards associated with Title VI, Deschutes County was likely required to provide language access including translated documents. Meaningful access standards include: • Size of the population: According to 2022 U.S. Census Bureau data, the Deschutes County population needing language access was above the 1,000-person threshold for providing advance document translations in Spanish: 3,243. • Frequency of contact: Many people did not have frequent and predictable contact with the County. Exceptions Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 7 of 36 included Health Services Department clients, people in custody at a detention facility, or people on parole or probation. These programs may need more extensive language services. • Importance of the service: Some County programs did not have life or death implications, but others did, including services provided by the Health Services Department, Sheriff’s Office, and the 911 District. • Available resources: As a large entity, the County was likely not able to make claims about limited resources. Deschutes County had some risk of noncompliance with federal requirements for language access. It had a plan for providing service to people who need language access that included some translated documents and access to on-demand interpretation services. But the plan did not include strategies for identifying and translating vital documents or meaningful notice about language access services. According to a survey of County leadership, one-third of departments/offices proactively identified and translated documents required for meaningful access. These included Community Justice, Office of the District Attorney, Fair and Expo Center, Health Services, Property Management, and Solid Waste, but did not include the Sheriff’s Office or 911. Notices about the availability of interpretation services were not easy to find and not posted at customer service counters across the County. A federal Civil Rights Act notice was posted in a corner of the Deschutes Service Building near the bathroom and the online notice was hard to find in the Risk Management portion of the website. Neither mentioned language access. Requirements for a language access program may have been overlooked because no specific person was accountable for or oversaw the program. The County Civil Rights Act policy made a deputy county administrator responsible for language access compliance. However there were two deputies and the policy did not make it clear which was responsible. Vital Documents are documents that include information that is critical to receiving service. They may include application forms, notices of eligibility or denial, important instructions, and legal documents related to the service or program. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 8 of 36 Recommendation 1: The County Administrator should assign responsibility for the language access program to a specific person. Finding 2: Language access portions of the Civil Rights Act policy did not provide clear guidance. The policy did not clearly explain why and how to comply with federal rules about language access. The U.S. Department of Justice Language Access Assessment and Planning Tool includes best practices for a language access policy but the County Civil Rights Act policy, GA-16, did not include many of the elements. Though it included a general policy statement specific to language access, other elements could be improved: • The section on authority was included in the general Civil Rights Act section and not specific to language access. • The policy included definitions for Limited English Proficiency, translation, and interpretation, but not other relevant terms such as bilingual staff and vital documents. • Compliance language made “the County” or “programs” responsible for implementation instead of staff. There was also confusion between the policy and the language access plan. Many best practice policy elements were included in the plan section of the policy. As with Finding 1, shortcomings in the policy may be due to there being no one is assigned responsibility for language access. See Appendix B for more details about how the Deschutes County policy met best practice standards in the Language Access Assessment and Planning Tool. Recommendation 2: Administration should update the Civil Rights Act policy to provide clearer guidance and include best practices. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 9 of 36 Finding 3: The County didn’t know what language access services were needed and provided across the organization. The County’s language access plan did not address the elements in the Language Access Assessment and Planning Tool. For example, the plan did not include: • A description of the timeframe, objectives, and benchmarks to allow for accountability. • Funding needed to achieve goals. • Staff training needs related to providing language access. • A plan to notify the community about language access or collaboration with community organizations. • A plan to monitor and evaluate performance, and, if appropriate, modify the policy or plan. Perhaps most importantly, elements that would have identified need and how many resources the County should provide were either problematic or missing. The section of the plan that identified the need or demand for language access was based on U.S. Census Bureau data which may undercount the number of people needing language access service. The plan also did not include a description of current language access services. It would be difficult for the County to quantify this information because the County’s financial information system did not provide reports on translation services. Ultimately, without a strong plan in place, the County risked coming out of compliance with federal Civil Rights Act language access requirements. As with Finding 1, missing elements in the plan may be due to there being no one is assigned responsibility for language access. See Appendix B for more details about how the Deschutes County plan met best practice standards in the Language Access Assessment and Planning Tool. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 10 of 36 Recommendation 3: Administration should create a language access plan based on the Language Access Assessment and Planning tool. Finding 4: Without procedures, translated documents were not readily available and contracts were underused and uncoordinated. The Language Access Assessment and Planning Tool includes a recommendation for procedures to explain how to: • respond to telephone calls from people needing language access. • track, and record language preference information. • inform people about available language assistance services. • identify the language needs. • procure interpreter services. • use bilingual staff and which staff are authorized to provide in-language service. • obtain translations of documents. There was not a County-wide procedure for language access. Both the Communications Team and Health Services had procedures in place that directed staff to provide translation and interpretation. But neither provided the detailed instructions outlined in the tool. A SharePoint page referred employees with questions to their own departments, and departments to the communications team. In contrast, Washington County had county-wide procedures that included how to decide which documents to translate, when to provide interpretation, and how to work with vendors. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 11 of 36 Figure 3: Washington County Translation Decision Guide Source: Washington County Oregon Language Assistance Procedure Two employees discussed problems with documents that were not readily translated. A District Attorney employee spoke about a court appearance letter in English. The letter included a note at the end about availability in Spanish, but a person would have to skim the entire letter in English to find it. An employee at the jail observed that it took a long time to get the court appointed attorney letter translated into Spanish and the County relied on employees to interpret the form in the meantime. Staff usage of contracted vendors was inconsistent and uncoordinated. • Cost was a barrier to using contract interpreters. Some staff were reluctant to use interpreters because there was not a budget for it. Other staff relied on phone app interpretation programs or friends and family of the person seeking service instead of using contract interpreters. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 12 of 36 • Departments/offices did not use the same vendors for translation and interpretation and the County processed invoices with multiple vendors each month; at times up to eight different vendors. In April 2024, the County conducted a competitive procurement for on-demand interpretation with input from all departments. But as of November 2024, no County staff used the contract. • A review of contracts for the vendors who received the most County funds revealed inconsistencies and expired agreements. In some cases, different departments had separate contracts with the same vendor, though the contracts were similar in scope and price. Some contracts had expired and were still being used. Recommendation 4: Administration should add mandatory county-wide procedures to the language access policy. Finding 5: Bilingual employees bore the burden of unclear policies and procedures. Bilingual staff improve customer service and outcomes. We interviewed a random sample of bilingual employees, all of whom said people reacted positively and were grateful when they learned they could speak to a County employee in their preferred language. Other benefits included better health and compliance outcomes, preference for speaking with a bilingual employee to using an interpreter, and the advantage of speaking with someone who came from a common culture. A Deputy Sheriff said speaking Spanish during a traffic stop increased safety by allowing them to keep their hands free. Using a phone for an interpreter requires holding the device, which makes stops more dangerous. The Language Access Assessment and Planning Tool recommends having a policy for bilingual pay, but Deschutes County did not have one. Instead, stipends were included in employee bargaining Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 13 of 36 agreements without criteria or expectations for frequency of use or skill level required. Most bilingual employees found the opportunity to use their language skills fulfilling. They felt supported when providing services in Spanish, though some mentioned they could benefit from more language training or by having more bilingual staff. Almost all employees said they did not feel pressure to provide interpretation in situations for which they were not qualified. Despite feeling positive about their role, some bilingual employees also were overstretched or provided services without receiving a bilingual stipend. Bilingual staff in other departments were asked more frequently to use their skills to assist other agencies or departments. In most cases, they were happy to help but it was extra work on top of their regular duties. • An employee at the Office of the District Attorney spoke about being asked to interpret for the Sheriff’s Office. Another District Attorney employee said the Circuit Court sent people over for help in Spanish when the court didn’t have Spanish speaking staff. • A Deputy Sheriff helped interpret for Code Enforcement staff when assisting them on calls. • Two Deputy Sheriffs mentioned dispatch had a list of Spanish speakers and would send deputies who speak Spanish on calls that may have otherwise gone to other agencies such as City of Bend or Oregon State Police. • One employee got so many requests to interpret for coworkers that they were considering giving up the pay differential because it took up so much time. They said colleagues preferred to come to them instead of using the on-demand interpreter. They talked to their supervisor about it but did not want to be seen as a complainer. Bilingual stipends were not consistently tied to skill level or Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 14 of 36 frequency of use. • There were two levels of bilingual pay for most employees. Level one was for basic bilingual services with level two reserved for frequent use in specialized circumstances like medical or legal interpretation. Human Resources developed a score card for supervisors to document which employees were eligible for level two pay. Most people receiving level two were in the Health Services Department and were certified medical interpreters. Two people received level two pay outside of Health. One of the employees had a score card on file, but the information was discretionary and could have applied to many of the people receiving level one pay. The other person receiving level two pay didn’t have a score card. • The Sheriff’s Office had three qualifying levels which were based on when deputies could testify about evidence they heard or read in Spanish. Despite the three documented levels, the bargaining agreements for Sheriff’s Office employees only had one level of pay. • Non-represented employees earned bilingual pay in practice but there was not a formal policy or procedure for determining their pay. Instead, their pay was tied to the American Federation of State, County and Municipal Employees (AFSCME) agreement. • Two departments relied on staff to translate documents without providing a bilingual stipend. One director said they would research whether the employee qualified but the other director said the work was not frequent enough. • Most employees received bilingual pay close to the time they were hired, but some worked for a while before receiving the stipend. In two cases, the supervisor of these employees was aware they were bilingual and did not help them to apply for the differential when they were first hired. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 15 of 36 Bilingual pay did not increase between 2019 and 2024. If cost of living increases were applied during this time, the monthly stipend for level one pay would have increased from $150 per month to $181 per month. As with Finding 1, the lack of a bilingual policy may be due to there being no one is assigned responsibility for language access. Recommendation 5: Create a policy for the bilingual program that clarifies selection/hiring, testing, expectations, and compensation. 3. Audit Conclusion Residents, visitors, and businesses rely on the County for vital services. These cannot be provided without effective communication. The County provided language access services including hiring bilingual employees and contracting for translation and interpretation. However, services were not coordinated or evaluated for efficiency and effectiveness. There was also some risk of noncompliance with federal rules for language access. We recommended that County Administration: 1. assign responsibility for the language access program to a specific person. 2. update the Civil Rights Act policy to provide clearer guidance and include best practices. 3. create a language access plan based on the Language Access Assessment and Planning tool. 4. add mandatory county-wide procedures to the language access policy. 5. create a policy for the bilingual program that clarifies selection/hiring, testing, expectations, and compensation. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 16 of 36 4. Management Response ADMINISTRATION December 19, 2024 To: Elizabeth Pape, County Internal Auditor From: Nick Lelack, County Administrator Subject: Response to Language Access Audit Report This letter provides the County Administrator’s written response to the Language Access Audit. The Auditor’s recommendations from the report and County Administration’s responses are listed below. Recommendation 1: The County Administrator should assign responsibility for the language access program to a specific person a) Management position concerning recommendation:  Concurs  Accepts Risk b) Comments: We agree with the auditor’s recommendation. I will assign responsibility of the language access program to a specific person. c) Estimated date of resolution: February 1, 2025. d) Estimated cost to implement recommendation: Staff time to evaluate capacity and organizational alignment with other functions. Recommendation 2: Administration should update the Civil Rights Act policy to provide clearer guidance and include best practices a) Management position concerning recommendation:  Concurs  Accepts Risk b) Comments: We agree with the auditor’s recommendation. Administration will update the Civil Rights Act Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 17 of 36 policy to provide clearer guidance and include best practices. c) Estimated date of resolution: July 1, 2025. d) Estimated cost to implement recommendation: Staff time. Recommendation 3: Administration should create a language access plan based on the Language Access Assessment and Planning tool a) Management position concerning recommendation:  Concurs  Accepts Risk b) Comments: We agree with the auditor’s recommendation. Administration will create a language access plan based on the Language Access Assessment and Planning tool. c) Estimated date of resolution: December 1, 2025. d) Estimated cost to implement recommendation: Staff time. Recommendation 4: Administration add mandatory county-wide procedures to the language access policy. a) Management position concerning recommendation:  Concurs  Accepts Risk b) Comments: We agree with the auditor that consistent procedures are important, but want to evaluate the development of county-wide procedures and their potential operational impact with department heads before we make a determination about if they will be included in a future policy update. c) Estimated date of resolution: July 1, 2025. d) Estimated cost to implement recommendation: Staff time. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 18 of 36 Recommendation 5: Create a policy for the bilingual program that clarifies selection/hiring, testing, expectations and compensation. a) Management position concerning recommendation:  Concurs  Accepts Risk b) Comments: We agree with the auditor’s recommendation. Administration will work with HR to develop a bilingual program policy. It is likely that this policy will be applicable to non-represented positions. c) Estimated date of resolution: December 1, 2025. d) Estimated cost to implement recommendation: Staff time. Sincerely, Nick Lelack, County Administrator 5. Appendix A: Objective, Scope, and Methodology The County Internal Auditor was created by the Deschutes County Code as an independent office conducting performance audits to provide information and recommendations for improvement. Audit findings result from incidents of non-compliance with stated procedures and/or departures from prudent operation. The findings are, by nature, subjective. The audit disclosed certain policies, procedures and practices that could be improved. The audit was neither designed nor intended to be a detailed study of every relevant system, procedure, or transaction. Accordingly, the opportunities for improvement presented in the report may not be all-inclusive of areas where improvement may be needed and does not replace efforts needed to design an effective system of internal control. Management has responsibility for the system of internal Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 19 of 36 controls, including monitoring internal controls on an ongoing basis to ensure that any weaknesses or non-compliance are promptly identified and corrected. Internal controls provide reasonable but not absolute assurance that an organization’s goals and objectives will be achieved. Objectives and Scope The overall objective of the audit was to determine whether the County complied with rules related to translation and interpretation services and whether services were effectively and efficiently provided. The audit was conducted in the Fall of 2024. Methodology Audit procedures included: • Interviewing all staff who used auxiliary kits and a random sample of bilingual staff. We coded interviews to draw qualitative conclusions. Because the bilingual employee sample was random and representative, results can be extrapolated to the population. • Surveying department heads and elected officials about language access in their programs. • Reviewing Census data to calculate the number of Deschutes County residents needing language assistance. • Assessing the County Civil Rights Act policy against Title VI meaningful access criteria and the US Department of Justice Language Access Assessment and Planning Tool. We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We “Audit objectives” define the goals of the audit. Audit procedures are created to address the audit objectives. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 20 of 36 believe that the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives. (2018 Revision of Government Auditing Standards, issued by the Comptroller General of the United States.) 6. Appendix B: Department of Justice Language Access Assessment and Planning Tool and Deschutes County Status We compared the Deschutes County Civil Rights Act policy and the language access plan within the policy to best practices in the Department of Justice Language Access Assessment and Planning Tool. The following tables outline best practices and assess Deschutes County status. Policy Best Practices A language access policy sets forth standards, operating principles, and guidelines that govern the delivery of language appropriate services. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 21 of 36 Policy Criteria Deschutes County Implementation Status A General Policy Statement This section explains the goals and expectations of the agency in terms that bind the agency and its employees. Example: “It is the policy of this agency to provide timely meaningful access for [people who need language access] to all agency programs and activities. All personnel shall provide free language assistance services to [people needing language access] whom they encounter or whenever [person who needs language access] requests language assistance services. All personnel will inform members of the public that language assistance services are available free of charge to [people who need language access] and that the agency will provide these services to them.” Deschutes County, as a recipient of federal funds, must ensure that people with limited English proficiency have access to its programs, benefits, services, and activities. No person should be deprived of such access because of their language skills or English proficiency. PARTIAL This statement should be in the policy instead of the plan. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 22 of 36 Policy Criteria Deschutes County Implementation Status Purpose and Authority This section provides the legal basis or administrative authority for the agency policy and may explain the nexus between the policy directives and the agency’s mission. Example: “The purpose of this policy is to establish effective guidelines, consistent with Title VI of the Civil Rights Act of 1964 and Executive Order 13166, for agency personnel to follow when providing services to, or interacting with, individuals who have limited English proficiency (LEP). Following these guidelines is essential to the success of our mission to [insert].” The Civil Rights Act of 1964 (the Act) is federal legislation that prohibits discrimination on the basis of race, color or national origin in federally funded programs, services and activities. Title VI has also been implemented to require that persons with limited English proficiency have meaningful access to programs, services, and activities; and that decision making processes are designed to avoid, minimize, or mitigate adverse environmental effects, including social and economic effects, on communities of color and low-income populations. Other federal and state legislation prohibits discrimination based on disability, religion, age, sex, sexual orientation, gender identity, or source of income. PARTIAL This statement is part of the Civil Rights plan and does not specifically address language access. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 23 of 36 Policy Criteria Deschutes County Implementation Status Language Assistance Measures This section sets forth the standards for language assistance services to be provided to individuals. Language assistance measures should be written in a manner that requires staff compliance consistent with the agency’s culture. The measures define acceptable methods of communication with [people who need language access]. Example: In the sample general policy statement, the decree that all personnel “shall provide free language assistance services to individuals whom they encounter or whenever a person requests language assistance services” and describes the standards for how and when the agency must communicate with [people who need language access].” Deschutes County employs a wide variety of strategies to solicit, consider, and incorporate the perspectives of diverse populations in policy and decision- making processes… Ensuring that printed materials, such as public notices and records, meeting and hearing schedules, minutes and supporting documents, web content, and other written communications can be made available in both traditional and alternative formats, including large text, electronic, audio, braille, and multiple languages upon request. PARTIAL This statement is part of the Civil Rights plan instead of a language access policy. The language does not include interpretation. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 24 of 36 Policy Criteria Deschutes County Implementation Status Staff Compliance This section describes the responsibility of each division, unit, or staff member. Example: the sample general policy statement above denotes that “all personnel” are required to provide free language assistance services to [people who need language assistance] and must inform the public about available language assistance services. All programs of Deschutes County are subject to this policy regardless of funding source. Individual grants and programs may carry additional requirements. PARTIAL This statement is part of the Civil Rights plan instead of a language access policy. References “programs” and not “staff” Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 25 of 36 Policy Criteria Deschutes County Implementation Status Definitions The policy directive may also explain any terms referenced in the policy. These terms may include agency-specific classifications of bilingual staff, interpreter, language assistance services, Limited English Proficiency, primary language, translation, vital documents, etc. Residents with Limited English Proficiency (LEPJ are people who do not speak English as their primary language and have limited ability to read, write, speak, or understand English. For purposes of this plan, translation refers to written communication and interpretation refers to spoken and signed communication. Translation and Interpretation are also defined. PARTIAL Definitions are included in the Civil Rights plan instead of a language access policy. Does not include definitions for bilingual staff, language assistance services, primary language, or vital documents. Staff Training A policy directive on staff training may dictate the frequency, curriculum, and target personnel for ongoing training. For example, this policy directive may mandate training particular to management, interpreters, translators, or frontline staff who encounter [people who need language assistance]. The County periodically offers Spanish language classes within its catalog of training opportunities that are open to all staff members with supervisor approval. Additional training opportunities in language and interpretation may also be offered on occasion at the discretion of individual departments. NOT IMPLEMENTED Training section refers to training in Spanish proficiency instead of training about how to provide language access. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 26 of 36 Policy Criteria Deschutes County Implementation Status Bilingual Staff A policy directive on bilingual staff may state a policy that second language skills are a desired characteristic, prescribe the hiring process for bilingual staff, provide the mechanism for designating jobs as bilingual, when and how to test the competency of prospective or current bilingual staff, define which staff are “bilingual,” and/or additional remuneration for bilingual staff. When warranted, general recruitments may specify a preference for bilingual capabilities. If approved by management, and subject to any applicable collective bargaining agreement, staff filling bilingual positions may be eligible for supplemental pay. PARTIAL Does not include details about the process for hiring staff, how to designate jobs as bilingual, or how to test for competency. Performance Measurement A policy directive on performance measurement may order the frequency and manner of monitoring and oversight. For example, an agency may elect to conduct an audit of language assistance services on an annual basis. Go to Plan None NOT IMPLEMENTED Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 27 of 36 Implementation Plan Best Practices A language access plan is a management document that outlines how the agency defines tasks, sets deadlines and priorities, assigns responsibility, and allocates the resources necessary to come into or maintain compliance with language access requirements. It describes how the agency will meet the service delivery standards delineated in the policy directives. The plan is a roadmap that helps agencies navigate the process of setting deadlines and priorities and identifying responsible personnel. Plan Criteria Deschutes County Implementation Status Identification of persons charged with implementing the plan A plan should describe the management staff, workgroup, committee, or other agency staff who will be responsible for creating and overseeing the policy directives, developing and modifying the language access plan, and establishing and implementing operational procedures. The plan should also detail the chains of command for authority and oversight and explain any coextensive responsibility and coordination with other agencies, divisions, and offices. Administration of Deschutes County's Civil Rights Title VI Program of this plan is housed with the Deputy County Administrator. PARTIAL There are two deputy county administrators and neither has explicit responsibility for language access. Prior to 2020, when the language access plan was drafted, there was only one deputy county administrator. In contrast, Washington County tasked its Chief Equity and Inclusion Officer with Title VI and language access compliance. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 28 of 36 Plan Criteria Deschutes County Implementation Status Identification and assessment of communities A plan should address what resources will be needed to assess the number or proportion of eligible [people who need language assistance] from each language group in an agency service area and the resources that will be needed to provide language assistance services. The plan should also outline the work needed to install or maintain systems for data collection and management. Plan uses 2018 U.S. Census Bureau data to identify the population needing language assistance. It includes Health Services Department clients, but not other departments that serve or interact with people who need translation or interpretation. NOT IMPLEMENTED 2022 U.S. Census Bureau data is available. Census data may undercount people needing language access. People might misreport their proficiency because they want to defend their ability to speak English, or they may not trust the government with the information. There are also barriers to collecting data from people who do not speak English well. The Lane County Public Works Department used staff surveys to measure demand. The Lane County Health Department surveys clients about need. Lane County committed to more systematic efforts to capture the frequency of contact with people needing language access. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 29 of 36 Plan Criteria Deschutes County Implementation Status A description of the timeframe, objectives, and benchmarks for work to be undertaken Not included. NOT IMPLEMENTED Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 30 of 36 Identification of funding and procurement issues and the steps needed to address them. Not included. NOT IMPLEMENTED The County spent an average of $59,000 per year on contract translation and interpretation and $91,000 on bilingual pay without quality data about need or effectiveness. Information about how much was spent on contract translation and interpretation was unreliable. The financial information system included a code for interpretation, but not translation. Vendors who were paid with the interpretation code were also paid using other object codes including contracted services, court reporter, professional, and public information. To identify payments associated with translation and interpretation, we selected all vendors with payments using the interpretation object code, identified vendors with more than $5,000 in total payments and then selected all payments to Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 31 of 36 Plan Criteria Deschutes County Implementation Status those vendors regardless of object code. There was not any tracking of how often auxiliary kits were used. According to interviews with staff using the kits, they were used infrequently: at most a handful of times per year, but some were never used. Most staff reported that the kits were easy to use, but there was one instance when the prior vendor did not respond to a request for on-demand interpretation and staff had to use a phone app instead. Despite having kits available, some staff still relied on phone apps or family members, including minors, for interpretation. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 32 of 36 Plan Criteria Deschutes County Implementation Status Notice of language assistance services A plan should also describe how the agency intends to implement the changes needed to inform [people needing language access] of the benefits, programs, and services for which they may be eligible and the available language assistance services. Plan lists examples of programmatic outreach in Spanish. Plan includes a public notice document about the Civil Rights Act. Information about civil rights will be posted on the website and paper copy notices to the public posted in a public area. PARTIAL Instead of listing programmatic outreach, the plan should outline how the public will be informed about language access. The public notice document is about civil rights in general and does not mention translation or interpretation services. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 33 of 36 Plan Criteria Deschutes County Implementation Status Training staff on policies and procedures A plan will identify training needs and explain how they will be addressed. The County periodically offers Spanish language classes within its catalog of training opportunities that are open to all staff members with supervisor approval. Additional training opportunities in language and interpretation may also be offered on occasion at the discretion of individual departments. NOT IMPLEMENTED Training section should be about training staff to implement the language access plan, not about increasing Spanish proficiency. Training is inconsistent. Out of 21 departments, only Property, Health, and 911 provide training to employees about providing translation and interpretation. Staff were confused about who to contact with questions about language access. Take the auxiliary kit program for example. One staff member coordinated contractor selection, another updated the program, and another did the initial training. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 34 of 36 Plan Criteria Deschutes County Implementation Status Monitoring and updating the plan, policies, and procedures A plan will explain the agency’s approach to monitoring how it provides services to [people who need language access] individuals, how it monitors plan performance, and the process for reviewing, and, if appropriate, modifying current language access plans, policies, and procedures. None NOT IMPLEMENTED Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 35 of 36 Plan Criteria Deschutes County Implementation Status Collaborating with communities and other stakeholders Organizations that have significant contact with [people needing language access], such as schools, religious organizations, community groups, and groups working with new immigrants can be very helpful in linking [people who need language access] to an agency’s programs and its language assistance services. The plan can include provisions for creating and conducting outreach and the actions needed to implement an effective system to gather feedback and involve outside entities or individuals in the review process. Since the previous Title VI policy update in 2019, County staff have made additional outreach efforts, including sharing social media content in both English and Spanish and launching a new Facebook page, El Condado de Deschutes, that will provide content to the public in Spanish. Staff has also engaged culturally specific local media to bolster existing outreach efforts. Communications staff, in coordination with the County's IT Department, has also worked to improve the ease with which website content can be translated and will continue to prioritize these efforts. NOT IMPLEMENTED The plan addressed communication channels rather than engagement with communities. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor Page 36 of 36 Procedures Best Practices Language access procedures are the "how to" for staff. They specify for staff the steps to follow to provide language services, gather data, and deliver services to people who need language services. According to the Tool, language access procedures often explain the following: • How staff are to respond to telephone calls from [people needing language assistance]. • How staff together, track, and record language preference information. • How staff inform [people needing language assistance] about available language assistance services. • How staff will identify the language needs of [people who need language assistance]. • How staff are to respond to correspondence (letters and email) from [people who need language assistance]. • How staff will procure in-person interpreter services. • How staff will access telephone or video interpreter services. • How to use bilingual staff for services and which staff are authorized to provide in-language service. • How to obtain translations of documents. • How staff will process language access complaints. NOT IMPLEMENTED Deschutes County does not have procedures to address these topics. Language Access—#23/24-22 January 2025 Deschutes County Office of the Internal Auditor The mission of the Office of Internal Audit is to improve the performance of Deschutes County government and to provide accountability to residents. We examine and evaluate the effectiveness, efficiency, and equity of operations through an objective, disciplined, and systematic approach. The Office of Internal Audit: Audit committee: Elizabeth Pape – County Internal Auditor Daryl Parrish, Chair – Public member Aaron Kay – Performance Auditor Phil Anderson – Public member Jodi Burch – Public member Phone: 541-330-4674 Joe Healy – Public member Email: internal.audit@deschutes.org Summer Sears – Public member Web: www.deschutes.org/auditor Kristin Toney – Public member Patti Adair, County Commissioner Charles Fadeley, Justice of the Peace Lee Randall, Facilities Director Please take a survey on this report by clicking this link: https://forms.office.com/g/CKmRFz805B Or use this QR Code: If you would like to receive future reports and information from Internal Audit or know someone else who might like to receive our updates, sign up at http://bit.ly/DCInternalAudit.