Hospitals, long term care facilities and other facilities funded by the Department of Health and Human Services (HHS) should audit and tighten their visitation, employment and other policies, oversight and training about federal prohibitions against religious or other discrimination in response to guidance issued by the HHS Office of Civil Rights (OCR) on January 25, 2024 and other developments signaling heightened exposures to religious discrimination liabilities and enforcement.

The January 25, 2024 guidance titled FAQs on Patient Visitation at Certain Federally Funded Entities and Facilities (FAQ) reiterates that hospital, long-term care and other facilities receiving funding under HHS-regulated programs must have and enforce written policies to prohibit and ensure their facility visitation policies do not discriminate based on religion or other prohibited grounds at all times including during a public health emergency. Part of a series of recent guidance and other actions by HHS demonstrating its commitment to enforce federal civil rights religious and other discrimination prohibitions, the FAQ warns covered facilities and providers to ensure their ability to defend their facilities’ compliance with these and other federal civil rights laws and regulations.

Section 1557 & Other Rules Prohibit Religious & Other Discrimination

CMS regulations generally prohibit hospitals, long term care facilities, and critical access hospitals from restricting, limiting, or otherwise denying visitation privileges based on race, color, national origin, religion, sex, gender identity, sexual orientation, or disability and require these facilities have written visitation policies, procedures, and practices regarding such prohibitions. These and other civil rights prohibitions generally apply to facilities receiving funding from HHS adminstered programs including:

• Hospitals and health clinics
• Medicaid and Medicare agencies
• Alcohol and drug treatment centers
• Extended care facilities
• Public assistance programs
• Nursing homes
• Adoption agencies and
• Day care, mental health and senior citizen center

Additionally, other federal civil rights laws also prohibit discrimination based on race, color, national origin, sex (including sexual orientation and gender identity), age, and disability in certain federally funded programs.

HHS OCR January 25 Warning Against Facilities Visitation Religious Discrimination

OCR published the January 25, 2024 FAQ in response to directives announced in the Biden-Harris Administration’s recently announced U.S. National Strategy to Counter Antisemitism.  The FAQ reminds covered facilities OCR enforces CMS regulations prohibiting religious and other discrimination and provides examples of the following “concerning” fact patterns where OCR feels facilities need to use extra care to ensure adequate consideration of the religious needs of patients and other individuals when implementing visitation policies and procedures.

• Hospitals prevented family members from bringing patients Kosher food or halal food that met the patient’s religious dietary restrictions while allowing other visitors to bring patients food items.
• Members of certain religious groups were subjected to more rigorous screening processes and/or denied opportunities for visitation based on the patient’s and/or visitor’s religious affiliation.   
• Hospitals adopted policies during the COVID-19 pandemic that allowed patients to visit with family members or friends but prohibited them from visiting with clergy. 

This guidance also contains information OCR intends to help covered facilities and entities effectively communicate with patients and others regarding their visitation policies, procedures, and practices.

Previous HHS OCR Religious Discrimination Enforcement

The January 25, 2024 FAQ is not the first time OCR has warned HHS-funded and regulated health care and other facilities against discriminatory facilities access policies or actions. 

During the COVID-19 Pandemic emergency, OCR published OCR’s policies for protecting conscience and religious freedom during COVID-19. In addition, on December, 26, 2020, for instance, OCR warned facilities against religious discrimination when it announced its resolution of a religious discrimination complaint against Mt. Sinai Health System in New York (Mt. Sinai) that required Mt. Sinai to ensure clergy access to patients for religious purposes during the COVID-19 pandemic systemwide.

The Ms. Sinai resolution agreement resulted after OCR investigated an August 5, 2020 complaint filed by a Jewish community advocacy organization that alleged that several hospitals in various hospital systems in New York, including Mt. Sinai in Manhattan, were denying Jewish patients access to clergy and engaging in other discrimination in both COVID and non-COVID units.

In one instance at Mt. Sinai, the complaint alleged that when a Jewish patient asked for his rabbi to visit to assist in the location of Kosher food that the patient had been unable to access at the facility, hospital staff told the patient that his rabbi could not visit due to concerns about COVID-19.

The complaint also alleged Mt. Sinai denied another Jewish patient access to a spiritual care volunteer when she requested a spiritual care volunteer after giving birth to a stillborn baby. The organization explained to OCR that religious visitation was important to their community because rabbis provide assistance with prayer rituals, including end-of-life rituals; spiritual comfort; translation services for those members of their community who do not speak English; and with other needs specific to their faith tradition.

According to OCR, its Conscience and Religious Freedom Division (CRFD) responded by offering Mt. Sinai technical assistance accepted by Mt. Sinai to ensure that its visitation policy was consistent with best practices under federal guidance, which Mt. Sinai accepted. This acceptance of technical assistance likely played a big role in Mt. Sinai’s avoidance of penalties based on the complaint.

In response to this technical assistance, Ms. Sinai reportedly updated its visitation policies to address identified religious discrimination concerns. The updated Mt. Sinai visitation policy applies to all seven of its hospital locations, including Mt. Sinai Hospital in Manhattan.

Under the updated visitation policy, visiting clergy are to comply with the safety policies in place, which include COVID-19 screening, proper use of hand sanitizer and hand washing, and wearing of an approved face mask.  Visitors also continue to be required to visit during designated hours, unless an exception, such as an imminent end-of-life situation, applies. Mt. Sinai clarified that, although its visitation policy did not say so explicitly, one of the two visitors permitted to visit a patient each day could be a clergy member. Mt. Sinai then updated its visitation policy to include that clarification. Additionally, the updated visitation policy now includes an exemption to out of state quarantine requirements for end-of-life visitations provided that proper precautions are taken, which allows clergy to be with patients in imminent end-of-life circumstances, even if they travel to Mt. Sinai from out of state.

In announcing the resolution, then Director of OCR Roger Severino, commended Mt. Sinai Health System for modifying its policy to clarify that patients can receive safe clergy access for religious purposes during the COVID-19 pandemic, concluding, “We applaud the hospital for ensuring that it will treat the needs of the body without sacrificing the needs of the soul.”

In addition to these and other guidance and enforcement activities, HHS has engaged in a number of other actions to combat religious discrimination over the past several months. For instance, HHS:

• Offers training on HHS’s antidiscrimination laws to medical schools nationwide to train future health care providers;
• Offers support for Holocaust survivors by helping to ensure they receive person-centered trauma care through the Administration for Community Living;
• Holds listening sessions with Jewish and Muslim chaplains on religious discrimination in healthcare settings to promote increased cultural and religious competence in healthcare settings, including through multifaith partnerships;
• Issued a toolkit of resources for those working with and supporting individuals and communities emotionally impacted by the recent escalation of conflict between Israel and Hamas created by Substance Abuse and Mental Health Services Administration (SAMHSA);
• Joined numerous other agencies in marking International Holocaust Remembrance Day on January 27, 2024; and
• Launched a digital campaign led by members of the President’s Council on Sports, Fitness & Nutrition to encourage the public to share personal stories of how activities like sports or cooking have promoted connection, inclusion, and cross-community solidarity.

OCR also has taken specific steps to prevent and punish antisemitic, Islamophobic, and related forms of discrimination and bias as prohibited discrimination based on ancestry or national origin. In September, 2023, for instance, HHS joined seven other federal agencies in clarifying, for the first time in writing, that Title VI of the Civil Rights Act of 1964 prohibits discrimination based on shared ancestry or ethnic characteristics, including certain forms of antisemitic, Islamophobic, and related forms of discrimination and bias, in federally funded programs and activities. HHS continues to take other steps to raise awareness of Title VI and other civil rights laws—both among entities that are prohibited from discriminating in these ways, and by informing communities of their rights to be free from discrimination. For example, HHS translated its information about Title VI into Arabic, Hebrew, Punjabi, Spanish, Urdu, and Yiddish.

Facilities & Other Organizations Also Face Rising Employment Religious Discrimination Risks

Religious discrimination in facilities access is not the only religious discrimination concern impacting health industry and other businesses. Title VII of the Civil Rights Act of 1964 prohibits discrimination based on religion and requires employers to reasonably accommodate an employee’s religious observance or practice, unless an accommodation would impose an undue hardship. The Civil Rights Act prohibits discrimination in any aspect of employment, including hiring, firing, pay, job assignments, promotions, layoff, training, fringe benefits, and any other term or condition of employment. It also prohibits:

• Forcing an employee to participate (or not participate) in a religious activity as a condition of employment;
• Subjecting an applicant or employee to offensive remarks about a person’s religious beliefs or practice or other harassment that creates a hostile or offensive work environment or results in an adverse employment decision or other job detriment or certain other types of harassment, whether by the victim’s supervisor, a supervisor in another area, a co-worker, or someone who is not an employee of the employer, such as a client or customer;
• Workplace or job segregation based on religion including religious garb and grooming practices;
• Failing to reasonably accommodate an employee’s religious beliefs or practices, unless doing so would cause a burden that is substantial in the overall context of the employer’s business taking into account all relevant factors, including the particular accommodation at issue and its practical impact in light of the nature, size, and operating cost of the employer; and
• Retaliating against an employee or applicant based on good faith exercise of his right to be free from religious discrimination or cooperation in investigations or other protected activities.

The duty to provide religious accommodation applies not only to schedule changes or leave for religious observances, but also to such things as dress or grooming practices that an employee follows as part of the employee’s religious reasons such as wearing particular head coverings or other religious dress or hairstyles or facial hair. It also includes an employee’s observance of a religious prohibition against wearing certain garments such as pants or miniskirts. 

Under the Civil Rights Act, the obligation to provide religious accommodation generally applies unless the employer demonstrate that the accommodation of the employee’s religious beliefs or practices would cause undue hardship to the employer. The burden of proving an undue hardship rests on the employer, who must show that the accommodation burden is substantial in the overall context of an employer’s business, taking into account all relevant factors in the case at hand, including the particular accommodation at issue and its practical impact in light of the nature, size and operating cost of the employer. The Supreme Court’s 2023 decision in Groff v. DeJoy, 143 S. Ct. 2279 (2023), makes clear that employers should not expect to meet this burden unless more than a “de minimis cost” or other burden is proven. Rather, employers denying a request for religious accommodation must be prepared to produce evidence proving the accommodation burden “is substantial in the overall context of an employer’s business” “taking into account all relevant factors in the case at hand, including the particular accommodations at issue and their practical impact in light of the nature, size and operating cost of an employer.” Id. See also EEOC Notice Concerning the Undue Hardship Standard in Title VII Religious Accommodation Cases.

The EEOC’s lawsuit and resulting recently announced settlement with Blackwell Security Services, Inc. (Blackwell) is illustrative of one common scenario in which these religious discrimination cases often arises. On January 31, 2024, the EEOC announced Blackwell Security Services, Inc. will pay $70,000 and provide other relief to settle the EEOC’s religious discrimination lawsuit that charged Blackwell wrongfully refused to accommodate a Muslim employee’s religious practice of wearing a beard in observance of his religious beliefs. Shortly after Blackwell hired the employee, the EEOC alleged that a Blackwell supervisor told the employee company policy required all employees be clean-shaven. When the employee requested an exemption from the policy to accommodate his religious practice, Blackwell told him to shave his beard or be terminated even though the EEOC determined accommodating his religious practice would impose no cost or operational burden on the business. To avoid losing his job, the employee complied and shaved his beard, causing him significant distress. Under the consent decree resolving the EEOC lawsuit, Blackwell will pay $70,000 in compensation to the now-former employee. Blackwell will also provide training to relevant management employees on federal laws prohibiting religious discrimination and will report any additional complaints of religious discrimination to the EEOC for the decree’s duration.

The EEOC charge and lawsuit against Blackwell is one of a deluge of religious discrimination charges filed with the EEOC in recent years. In fact, EEOC enforcement data shows that religious discrimination charges received by the EEOC soared from 2,111 in 2021 to 13,814 in 2022 while over the same period settlements rose from 146 in 2021 to 730 in 2022.

Religion-Based Charges (Charges filed with EEOC) FY 2013 – FY 2022
	FY 2013	FY 2014	FY 2015	FY 2016	FY 2017	FY 2018	FY 2019	FY 2020	FY 2021	FY 2022*
Receipts	3,721	3,549	3,502	3,825	3,436	2,859	2,725	2,404	2,111	13,814
Resolutions	3,865	3,575	3,736	3,827	3,997	3,653	3,001	2,570	2,080	7,453
Settlements	331	268	275	266	233	151	171	144	146	730
Reasonable Cause	168	116	139	121	119	282	123	103	59	60
Monetary Benefits (Millions)**	$11.2	$8.7	$10.8	$10.1	$11.2%	$9.2	$9.9	$6.1	$9.5	$12.8
The chart represents the total number of charges filed and resolved under Title VII alleging religion-based discrimination as compiled by the Office of Enterprise Data and Analytics from data compiled from the EEOC’s Integrated Mission System.  This does not include charges filed with state or local Fair Employment Practices Agencies.  *EEOC notes, “In FY 2022, there was a significant increase in vaccine-related charges filed on the basis of religion. As a result, FY 2022 data may vary compared to previous years.”  ** Does not include monetary benefits obtained through litigation. See https://www.eeoc.gov/data/religion-based-charges-charges-filed-eeoc-fy-1997-fy-2022.

The New EEOC religious accommodation guidance issued during the COVID-19 pandemic health care emergency and demands for religious accommodation exemptions to COVID-19 mask and vaccination mandates heightened religious accommodation claims by the EEOC. Unsurprisingly, charges from these COVID-19 related and other religious accommodation claims brought since the COVID-19 pandemic health care emergency has and continues to fuel litigation, settlements and judgements. See, e.g., Children’s Hospital Pays $45K To Resolve COVID Vaccine Religious Discrimination Suit.

Furthermore, these religious sensitivities in many instances could be further heightened by the newly emerging religious and personal sensitivities, EEOC and other governmental outreach and widespread media coverage arising around religious and national origin discrimination concerns arising in relation to the latest Israeli/Palestinian conflict. See, e.g., Resolution of the U.S. Equal Employment Opportunity Commission Condemning Violence, Harassment, and Bias Against Jewish Persons in the United States; What to Do If You Face Antisemitism at Work; Anti-Arab, Anti-Middle Eastern, Anti-Muslim, and Antisemitic Discrimination are Illegal; Religious Garb and Grooming in the Workplace: Rights and Responsibilities; Fact Sheet on Religious Garb and Grooming in the Workplace: Rights and Responsibilities‘ Employment Discrimination Based on Religion, Ethnicity, or Country of Origin; Q&A for Employees: Responsibilities Concerning the Employment of Individuals Who Are, or Are Perceived to Be, Muslim or Middle Eastern; Q&A for Employers: Responsibilities Concerning the Employment of Individuals Who Are, or Are Perceived to Be, Muslim or Middle Eastern. With these and other events continuing to escalate sensitivities and awareness of federal laws against religious discrimination, health care and other organizations should act to strengthen their ability to recognize and respond defensibly to religious accommodation and other religious discrimination risks whether arising from patients and other customers, employees or others.

Act To Mitigate Religious Discrimination Risks

In the face of the prioritization that the Biden Administration generally and OCR specifically is placing on religious and national origin in connection with the current Israeli-Palestinian hostilities, all covered facilities should brace for heightened oversight and enforcement by OCR the EEOC and other federal agencies, as well as private litigants. These organizations also should guard against retaliation liability, which can result even where the discrimination claim fails.

As a starting point, health care and other organizations should begin by reviewing their existing complaint history, policies, practices, training, reporting and investigation practices within the scope of attorney-client privilege and revise these policies as needed to strengthen their defensibility.

In connection with this review, health care and other organizations should ensure that their policies, procedures and notices clearly prohibit religious discrimination as well as communicate procedures for persons that believe their religious beliefs merit accommodation or otherwise believe they are subject to religious harassment or other discrimination to communicate their request to a representative of the organization appropriately trained to receive, evaluate and respond to the accommodation request defensibly. Most organizations will want to arrange for qualified legal counsel to be readily available to assist the responsible party with these activities. 

Organizations should consider adopting carefully crafted and documented internal procedures for receiving, investigating and responding to religious accommodation request in a manner that promotes their organization’s ability to demonstrate each request is assessed in accordance with the law free from the inappropriate application of assumptions or stereotypes about what constitutes a religious belief or practice or what type of accommodation is appropriate. Organizations should train managers and supervisors to grant religious accommodation requests whenever possible and to refer any questions about the appropriateness or response to any religious accommodation request to the designated responsible party.

When faced with a request for a religious accommodation which the organization believes cannot be implemented without undue hardship, most organizations will want to seek the advice of legal counsel while exploring opportunities to allow the requested or an alternative accommodation on a temporary basis pending further exploration of the requested more permanent accommodation. Appropriate communication and documentation processes also are important. In addition, all organizations will want to ensure that their organization takes appropriate steps to prevent and defend against potential retaliation claims.

For More Information

We hope this update is helpful. For more information about these or other health or other legal, management or public policy developments, please contact the author Cynthia Marcotte Stamer via e-mail or via telephone at (214) 452 -8297. 

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About the Author

Recognized by her peers as a Martindale-Hubble “AV-Preeminent” (Top 1%) and “Top Rated Lawyer” with special recognition LexisNexis® Martindale-Hubbell® as “LEGAL LEADER™ Texas Top Rated Lawyer” in Health Care Law and Labor and Employment Law; as among the “Best Lawyers In Dallas” for her work in the fields of “Labor & Employment,” “Tax: ERISA & Employee Benefits,” “Health Care” and “Business and Commercial Law” by D Magazine, Cynthia Marcotte Stamer is a practicing attorney board certified in labor and employment law by the Texas Board of Legal Specialization and management consultant, author, public policy advocate and lecturer widely known for 35 plus years of health industry and other management work, public policy leadership and advocacy, coaching, teachings, and publications.

A Fellow in the American College of Employee Benefit Counsel, Co-Chair of the American Bar Association (“ABA”) International Section Life Sciences and Health Committee and Vice-Chair Elect of its International Employment Law Committee, Chair-Elect of the ABA TIPS Section Medicine & Law Committee, Past Chair of the ABA Managed Care & Insurance Interest Group, Scribe for the ABA JCEB Annual Agency Meeting with HHS-OCR, past chair of the ABA RPTE Employee Benefits & Other Compensation Group and current co-Chair of its Welfare Benefit Committee, and Chair of the ABA Intellectual Property Section Law Practice Management Committee, Ms. Stamer is most widely recognized for her decades of pragmatic, leading-edge work, scholarship and thought leadership on heath benefit and other healthcare and life science, managed care and insurance and other workforce and staffing, employee benefits, safety, contracting, quality assurance, compliance and risk management, and other legal, public policy and operational concerns in the healthcare and life sciences, employee benefits, managed care and insurance, technology and other related industries. She speaks and publishes extensively on these and other related compliance issues.

Ms. Stamer’s work throughout her career has focused heavily on working with health care and managed care, life sciences, health and other employee benefit plan, insurance and financial services and other public and private organizations and their technology, data, and other service providers and advisors domestically and internationally with legal and operational compliance and risk management, performance and workforce management, regulatory and public policy and other legal and operational concerns. Author of a multitude of highly regarded publications on HIPAA and other medical record and data privacy and scribe for the ABA JCEB Annual Meeting with the HHS Office of Civil Rights, her experience includes extensive involvement throughout her career in advising health care and life sciences and other clients about preventing, investigating and defending EEOC, DOJ, OFCCP and other Civil Rights Act, Section 1557 and other HHS, HUD, banking, and other federal and state discrimination investigations, audits, lawsuits and other enforcement actions as well as advocacy before Congress and regulators regarding federal and state equal opportunity, equity and other laws. 

For more information about Ms. Stamer or her health industry and other experience and involvements, see www.cynthiastamer.com or contact Ms. Stamer via telephone at (214) 452-8297 or via e-mail here. 

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