SETTLEMENT AGREEMENT BETWEEN
THE UNITED STATES OF AMERICA
AND CARILION ROANOKE MEMORIAL HOSPITAL

Background

1. The parties (“Parties”) to this Settlement Agreement (“Agreement”) are the United States of America (“United States”) and Carilion Roanoke Memorial Hospital (“RMH”), located in Roanoke, Virginia.
2. This matter was initiated by a complaint filed with the United States against RMH, alleging violations of Title III of the Americans with Disabilities Act of 1990, as amended (the “ADA”), 42 U.S.C. §§ 12181–12189, and its implementing regulation, 28 C.F.R. Pt. 36. Specifically, Complainant C.W., Complainant R.W., Complainant T.G.F., and Complainant S.O., (the “Complainants”), three of whom are deaf and use American Sign Language (“ASL”) as their primary means of communication, and one of whom was a family member, alleged that RMH personnel failed to provide sign language interpretive services when necessary to ensure effective communication with the Complainants.
3. Patient C.W., the spouse of R.W., was seen at RMH Emergency Department (“ED”) on the evening of June 12, 2014, for severe abdominal pain. Upon arrival to the ED, C.W. requested the auxiliary aid or service of a qualified sign language interpreter for R.W., her companion, who is deaf. After approximately 45 minutes with no interpreter, C.W. again requested an interpreter for R.W. While in triage, C.W. again requested an interpreter for R.W. RMH attempted to locate an ASL interpreter for R.W. but was unable to do so given the time of day. C.W. was the only person who was able to communicate with R.W., which she complained was extremely difficult due to her pain and the stress of the situation. R.W alleged he was unable to understand much of their communications due to distance, lighting, and sight line obstruction. R.W. further alleged that he did not know or understand what was happening to C.W. While C.W. was taken for testing, R.W. was left in the triage room with no explanation or way to communicate with the staff.
4. R.W. alleged that the staff and Doctors ignored him, and he was not able to communicate with the medical professionals who were treating his spouse. He was also unable to support C.W. because he had no information to communicate to her.
5. T.G.F. is deaf and uses ASL as her primary means of communication. Prior to scheduled back surgery in April 2016, T.G.F. requested the auxiliary aid or service of a qualified sign language interpreter. T.G.F. alleges that RMH failed to provide her with a qualified sign language interpreter during critical pre- and post-operative phases of her treatment, including periods in which she was directed to take narcotic pain medication. T.G.F. further alleged that her access to an interpreter was limited during her four-day stay at RMH, despite frequent requests for an interpreter to assist in communicating her pain and medication-related concerns to treating staff. In contrast, RMH maintains that its medical records reveal that T.G.F. was provided with appropriate auxiliary aids or services throughout her stay, whether through an on-site ASL interpreter or via Video Remote Interpreting (“VRI”).
6. S.O. is deaf and uses ASL as her primary means of communication. During a pre-operative consultation, S.O. requested that the auxiliary aid or service of a qualified interpreter be provided for her surgery date. Although RMH did provide an interpreter on the day of S.O.’s surgery, S.O. alleged that the interpreter was unable to capture what the patient was saying and unable to translate what the doctor was saying. At a post-operative doctor’s appointment to remove drainage tubes, S.O. further alleged that RMH provided an interpreter who was not focused and failed to relay information to the doctor from S.O., forcing S.O.’s companion to interpret. As a result, S.O. complained that did not receive the proper explanation regarding the drainage tube removal and suffered unnecessary pain. In contrast, RMH maintains that its medical records reveal that RMH provided S.O. with a qualified ASL interpreter during her physician consultation as well as surgical and post-surgical process.

INVESTIGATION AND DETERMINATIONS

7. The United States Attorney for the Western District of Virginia (“U.S. Attorney’s Office”) is authorized to investigate alleged violations of Title III of the ADA, to use alternative means of dispute resolution, where appropriate, including settlement negotiations, to resolve disputes, and to bring a civil action in federal court in any case that raises issues of general public importance. 42 U.S.C. §§ 12188(b), 12212; 28 C.F.R. §§ 36.502, 503, 506.
8. Complainants R.W., T.G.F., and S.O. are deaf and thus individuals with a “disability” within the meaning of the ADA. 42 U.S.C. § 12102; 28 C.F.R. § 36.104.
9. Complainant C.W. is R.W.’s legally cognizable “companion” pursuant to the ADA Regulations. 28 C.F.R. § 36.303(c).
10. RMH is a hospital licensed by the Commonwealth of Virginia and is a “place of public accommodation” because it is a hospital. 42 U.S.C. § 12181(7)(F), (K); 28 C.F.R. § 16.104.
11. RMH is a “public accommodation” within the meaning of Title III of the ADA, 42 U.S.C. § 12181(7)(F), (K), and its implementing regulations, 28 C.F.R. § 36.104, because it owns, operates, or leases to the RMH facility.
12. The ADA prohibits public accommodations from discriminating on the basis of disability in the full and equal enjoyment of their goods, services, facilities, privileges, advantages, or accommodations of places of public accommodation, including hospitals. 42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a). A public accommodation shall take those steps that may be necessary to ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than other individuals because of the absence of auxiliary aids and services, unless the public accommodation can demonstrate that taking those steps would fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations being offered would result in an undue burden. 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303.
13. RMH fully cooperated with the U.S. Attorney’s Office’s investigation in this matter. On the basis of its investigation, the U.S. Attorney’s Office has determined that:
1. RMH had an obligation to provide auxiliary aids and services to ensure effective communication with R.W., an individual with a disability, because as C.W.’s husband, he was C.W.’s legally cognizable “companion” pursuant to the ADA Regulations. 28 C.F.R. § 36.303(c).
2. During C.W.’s stay at RMH, she requested an ASL interpreter several times during her stay, and RMH failed to provide such qualified interpreters or other appropriate auxiliary aids or services to effectively communicate with R.W.
3. RMH had an obligation to provide auxiliary aids and services to ensure effective communication with T.G.F. because T.G.F. is an individual with a disability receiving medical services from RMH.
4. During the course of pre- and post-operative treatment for T.G.F., RMH failed to provide T.G.F. with appropriate auxiliary aids and services to meet her needs.
5. During the course of pre- and post-operative care, RMH failed to provide S.O. with appropriate auxiliary aids or services qualified to meet her needs.

DEFINITIONS

14. The term “auxiliary aids and services” includes qualified interpreters on-site or through video remote interpreting (“VRI”) services; notetakers; real-time computeraided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, including text telephones (“TTYs”), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing. 28 C.F.R. § 36.303(b)(1).
15. The term “RMH Personnel” means all employees, both full and part-time, and independent contractors with contracts to work for or with RMH, including, without limitation, nurses, physicians, social workers, administrative staff, technicians, admitting personnel, billing staff, security staff, therapists, and volunteers, who have or are likely to have patient care responsibilities or job duties that require direct contact with Patients or Companions as defined herein.
16. The term “qualified interpreter” means an interpreter who, via a video remote interpreting (“VRI”) service or an on-site appearance, is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral transliterators, and cued-language transliterators. 28 C.F.R. § 36.104.
17. The term “Patient” shall be broadly construed to include any individual who is seeking or receiving the goods, services, facilities, privileges, advantages, or accommodations of RMH.
18. The term “Companion” means a person who is deaf or hard of hearing and is a family member, friend, or associate of an individual seeking access to, or participating in, the goods, services, facilities, privileges, advantages, or accommodations of a public accommodation, who, along with such individual, is an appropriate person with whom the public accommodation should communicate. 28 C.F.R. § 36.303(c)(1)(i).
19. “Patient medical files, records, or charts” mean the medical files and related records for an individual patient, including both the paper and electronic records.

EQUITABLE & COMPENSATORY RELIEF

A. Prohibition of Discrimination

20. Nondiscrimination. RMH shall provide appropriate auxiliary aids and services, including qualified interpreters, where such aids and services are necessary to ensure effective communication with Patients and Companions who are deaf or hard of hearing. Pursuant to 42 U.S.C. § 12182(a), RMH shall also provide Patients and Companions, who are deaf or hard of hearing, with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the facility as required by this Agreement and the ADA.
21. Discrimination by Association. RMH shall not deny equal services, accommodations, or other opportunities to any individual because of the known relationship of that person with someone who is deaf or hard of hearing. See 42 U.S.C. § 12182(b)(1)(E).
22. Retaliation and Coercion. RMH shall not retaliate against or coerce in any way any person who made, or is making, a complaint according to the provisions of this Agreement, or exercised, or is exercising, his or her rights under this Agreement or the ADA. See 42 U.S.C. § 12203.

B. Effective Communication

23. Appropriate Auxiliary Aids and Services. Pursuant to 42 U.S.C. § 12182(b)(2)(A)(iii), RMH will provide Patients and Companions, who are deaf or hard of hearing, any appropriate auxiliary aids and services that are necessary for effective communication after making the assessment described in paragraphs 24 and 25 of this Agreement. Appropriate auxiliary aids and services will be provided as soon as practicable (without compromising patient care), except that the provision of on-site interpreters must be within the time frame described in paragraph 33 of this Agreement absent extenuating circumstances. RMH will advise Patients and Companions who require auxiliary aids or services, in writing, that these are available throughout the Patient’s stay.
24. General Assessment Criteria. The determination of appropriate auxiliary aids or services, and the timing, duration, and frequency with which they will be provided, will be made by RMH in consultation with the person with a disability. The assessment made by RMH Personnel will take into account relevant facts and circumstances, including, for example, the individual’s communication skills and knowledge, and the nature and complexity of the communication at issue. A Model Communication Assessment Form is attached to this Agreement as Exhibit A, and RMH will develop a form similar to Exhibit A within sixty (60) days of the Effective Date of this Agreement to be used at RMH. RMH shall provide a copy of the Communication Assessment Form that it develops to the United States Attorney’s Office for approval prior to RMH’s implementation of the Form, which approval shall not be unreasonably withheld. RMH shall ensure that a completed Form is obtained from each individual Patient or Companion who agrees to complete the Form. RMH shall provide assistance in completing the Form at the Patient’s or Companion’s request. After being completed, the Form(s) shall be maintained or documented in the Patient’s medical chart, whether kept in paper or electronic form. If a Patient identifies a Companion who is not presently at RMH but is expected at RMH during the Patient’s stay, RMH Personnel shall provide the Patient with the contact information of RMH Personnel who can assist the Companion in completing a Communication Assessment Form in advance of arriving at RMH and with the contact information of RMH Personnel who can assist the Companion in completing the Form at RMH (if the Form is not completed in advance). If at any point during a Patient’s stay, a Companion identifies himself or herself as deaf or hard of hearing, RMH shall promptly provide him/her with the Form, if it has not done so already.
25. Time for Assessment. The determination of which appropriate auxiliary aids and services are necessary, and the timing, duration, and frequency with which they will be provided, must be made at the time RMH learns that a Patient or Companion who is deaf or hard of hearing will be using its services, subject to the Patient’s or Companion’s availability to participate, or on the arrival of the Patient or Companion who is deaf or hard of hearing at RMH, whichever is earlier. RMH Personnel will perform an assessment (see paragraph 24) as part of each initial inpatient assessment and document the results in the Patient’s medical chart. In the event that communication is not effective, RMH Personnel will reassess which appropriate auxiliary aids and services are necessary, in consultation with the person with a disability, where possible, and provide such aid or service based on the reassessment.
26. ADA Administrators. RMH will designate at least one employee as an ADA Administrator or ADA Co-Administrators, and at least one such employee or his or her designee who has the requisite knowledge and understanding of the ADA and RMH’s ADA policies and procedures will be on site or on call twenty-four hours a day, seven days a week, to answer questions and provide appropriate assistance regarding immediate access to, and proper use of, the appropriate auxiliary aids and services, including qualified interpreters. The ADA Administrator or ADA Co-Administrators or their designees will know where the appropriate auxiliary aids are stored and how to operate them and will be responsible for their maintenance, repair, replacement, and distribution. RMH will circulate and post broadly within RMH the name, telephone number and function of the Administrator(s), including a TTY telephone number, through which the ADA Administrator or Co-Administrator or designees on site or on call can be contacted twenty-four hours a day, seven days a week by Patients and Companions who are deaf or hard of hearing. The ADA Administrator or Co-Administrators will be responsible for the complaint resolution mechanism described in paragraph 28 of this Agreement. The ADA Administrator or Co-Administrators will be designated by RMH no later than sixty days following execution of this Agreement and will be subject to approval by the U.S. Attorney’s Office, which approval shall not be unreasonably withheld.
27. Auxiliary Aid and Service Log. RMH will maintain a log in which requests for qualified interpreters on site or through video remote services will be documented. The log will indicate the time and date the request was made, the name of the Patient or Companion who is deaf or hard of hearing, the time and date of the scheduled appointment (if a scheduled appointment was made), the nature of the auxiliary aid or service provided, and the time and date the appropriate auxiliary aid or service was provided. If no auxiliary aid or service was provided, the log shall contain a statement why the auxiliary aid and service was not provided. The log should include the identity of the RMH personnel who conducted the assessment and made the determination. Such logs will be maintained by the ADA Administrator or Co-Administrator(s) for the entire duration of the Agreement and will be incorporated into the semi-annual Compliance Reports as described in paragraph 53 of this Agreement.
28. Complaint Resolution. RMH will establish a complaint resolution mechanism for the investigation of disputes regarding effective communication with Patients and Companions who are deaf or hard of hearing. RMH will maintain records of all complaints regarding effective communication, whether oral or written, made to RMH and actions taken with respect thereto. At the time RMH completes its assessment described in paragraph 24 and advises the Patient and/or Companion of its determination of which appropriate auxiliary aids and services are necessary, RMH will notify deaf and hard of hearing persons of its complaint resolution mechanism, to whom complaints should be made, and of the right to receive a written response to the grievance. A written response to any complaint filed shall be completed within fourteen days of receipt of the complaint. Copies of all complaints related to provision of services for Patients or Companions who are deaf or hard of hearing and the responses thereto will be maintained by the ADA Administrator or Co-Administrator(s) for the entire duration of the Agreement and will be incorporated into the semi-annual Compliance Reports as described in paragraph 53 of this Agreement.
29. Prohibition of Surcharges. All appropriate auxiliary aids and services required by this Agreement will be provided free of charge to the Patient or Companion who is deaf or hard of hearing.
30. Record of Need for Auxiliary Aid or Service. RMH will take appropriate steps to ensure that all RMH Personnel are made aware of a Patient or Companion’s disability and auxiliary aid and services needed so that effective communication with such person will be achieved. These steps will include designating this information in the medical record. The Patient’s medical record shall be clearly documented to alert RMH Personnel to the fact that the Patient and/or Companion is deaf or hard of hearing. The medical record shall indicate the mode of communication requested by and provided to the Patient or Companion.

C. Qualified Interpreters

31. Circumstances Under Which Interpreters Will Be Provided. Depending on the complexity and nature of the communication, a qualified interpreter may be necessary to ensure effective means of communication for Patients and Companions. When an interpreter is needed, RMH shall provide qualified sign language interpreters to Patients and Companions who are deaf or hard of hearing and whose primary means of communication is sign language, and qualified oral interpreters to such Patients and Companions who rely primarily on lip reading as necessary for effective communication. Examples of circumstances when the communication may be sufficiently lengthy or complex so as to require an interpreter include the following:
1. Discussing a Patient’s symptoms and medical condition, medications, and medical history;
2. When RMH conducts its initial and periodic assessments of a Patient;
3. Explaining medical conditions, treatment options, tests, medications, surgery, and other procedures;
4. Providing a diagnosis and recommendation for treatment;
5. Communicating with a Patient during treatment, including physical and occupational therapies, testing procedures, and during physician’s rounds;
6. Obtaining informed consent for treatment;
7. Providing instructions for medications, pre- and post-surgery instructions, post-treatment activities, and follow-up treatments;
8. Providing mental health services, including group or individual counseling for Patients and family members;
9. Providing information about blood or organ donations;
10. Discussing powers of attorney, living wills, and/or complex billing and insurance matters;
11. During educational presentations;
12. Discussing discharge planning and discharge instructions; and
13. When RMH provides religious services and spiritual counseling.
32. Chosen Method for Obtaining Interpreters. Within thirty days after execution of this Agreement, RMH will identify one or more interpreter services and will make appropriate arrangements with said services to provide qualified on site interpreters as well as VRI services at the request of RMH. RMH will establish internal procedures for ordering interpreting services that are consistent with the interpreter or interpreter agencies’ procedures. When requested more than five days before an appointment, RMH’s requests for interpreters, including the time and date, will be confirmed in writing at the time of the request. RMH will consider an order for interpreting services to be complete only after receiving written or oral confirmation from the interpreting service that an interpreter will be provided at the time and date requested. RMH will maintain a copy of all written confirmations for interpreting services for a period of three years. For the duration of this Agreement, RMH will file a copy of its written correspondence with interpreters and interpreting agencies in the Auxiliary Aid and Service Log discussed in paragraph 27.
33. Provision of Interpreters in a Timely Manner.
1. Non-Scheduled Interpreter Requests. A “non-scheduled interpreter request” means a request for an interpreter made by a Patient or Companion who is deaf or hard of hearing with less than four hours’ notice before the services of the interpreter are required (or less than six hours if a request is made between the hours of 8:00 PM and 8:00 AM or on a weekend or Federal holiday). For non-scheduled interpreter requests, RMH Personnel will complete the assessment described in paragraphs 24 and 25 above. The interpreter shall be provided as soon as practical but no more than four hours from the time RMH completes the assessment if the service is provided through a contract interpreting service or a staff interpreter who is located off-site, or no more than ninety minutes from the time RMH completes the assessment if the service is provided through a Video Remote Interpreting service as described in paragraph 34 below. As a Level 1 Trauma Center, RMH and the U.S. Attorney’s Office recognize that extenuating circumstances and occasions may arise resulting in deviations from this response time. Those occasions and performance goals will be reviewed with the U.S. Attorney’s Office. If no interpreter can be located, RMH Personnel will take the following additional steps:
1. RMH Personnel will exert reasonable efforts (which shall be deemed to require no fewer than three telephone inquiries and/or emails and/or text messages unless exceptional circumstances intervene) to contact any interpreters or interpreting agencies already known to RMH and request their services;
2. Inform the ADA Administrator(s) of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;
3. Inform the Patient or Companion (or a family member or friend, if the Patient or Companion is unavailable) of the efforts taken to secure a qualified interpreter and that the efforts have failed, and follow up on reasonable suggestions for alternate sources of qualified interpreters, such as contacting a qualified interpreter known to that person; and
4. Document all of the above efforts.
2. Scheduled Interpreter Requests. A “scheduled interpreter request” is a request for an interpreter made four or more hours before the services of an interpreter are required (or six or more hours if a request is made between the hours of 8:00 PM and 8:00 AM or on a weekend or a Federal holiday). For scheduled interpreter requests, RMH will complete the assessment described in paragraph 24 above in advance, and when an interpreter is appropriate, RMH will make a qualified interpreter available at the time of the scheduled appointment. If an interpreter fails to arrive for the scheduled appointment, upon notice that the interpreter failed to arrive, RMH will take reasonable steps to locate another qualified interpreter as soon as they are made aware that the requested interpreter will not be provided.
34. Video Remote Interpreting (“VRI”). VRI can provide immediate, effective access to interpreting services in a variety of situations including emergencies and unplanned incidents. When using VRI services, RMH shall ensure that it provides: (1) real-time, full-motion video and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication; (2) a sharply delineated image that is large enough to display the interpreter’s face, arms, hands, and fingers, and the participating individual’s face, arms, hands, and fingers, regardless of his or her body position; (3) a clear, audible transmission of voices; and (4) adequate training to users of the technology and other involved individuals so that they may quickly and efficiently set up and operate the VRI. 28 C.F.R. § 36.303(f). VRI shall not be used when it is not effective due to, for example, a Patient’s limited ability to move his or her head, hands, or arms; vision or cognitive issues; significant pain; or due to space limitations in the room. If, based on the circumstances, VRI is not providing effective communication after it has been provided or is not available due to circumstances outside of RMH’s control, VRI shall not be used as a substitute for an on-site interpreter, and an on-site interpreter shall be provided in accordance with the timetable set forth above, unless extenuating circumstances make the timetable unreasonable to meet as determined by the U.S. Attorney’s Office after good faith discussions with CRMH.
35. Notice to Patients and Companions who Are Deaf or Hard of Hearing. As soon as RMH Personnel have determined that a qualified interpreter is necessary for effective communication with a Patient or Companion who is deaf or hard of hearing, RMH will inform the Patient or Companion (or a family member or friend, if the Patient or Companion is not available) of the current status of efforts being taken to secure a qualified interpreter on his or her behalf. RMH will provide additional updates to the Patient or Companion as necessary until an interpreter is secured. Notification of efforts to secure a qualified interpreter does not lessen RMH’s obligation to provide qualified interpreters in a timely manner as required by paragraph 33 of this Agreement.
36. Other Means of Communication. RMH agrees that between the time an interpreter is requested and the interpreter is provided, RMH Personnel will continue to try to communicate with the Patient or Companion who is deaf or hard of hearing for such purposes and to the same extent as they would have communicated with the person but for the disability, using all available methods of communication, including using sign language pictographs. This provision in no way lessens RMH’s obligation to provide qualified interpreters in a timely manner as required by paragraph 33 of this Agreement.
37. Restricted Use of Certain Persons to Facilitate Communication.
1. RMH shall not require an individual with a disability, including a Companion, to bring another individual to interpret for him or her.
2. RMH will not rely on an adult friend or family member of the individual with a disability to interpret except in an emergency involving an imminent threat to the safety of an individual or the public where there is no interpreter available; or where the individual with a disability specifically requests that the adult friend or family member interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances. 28 C.F.R. § 36.303(c)(3).
3. RMH will not rely on a minor child or a patient to interpret except in an emergency involving an imminent threat to the safety of an individual or the public where there is no interpreter available. Id. § 36.303(c)(4).
38. Individuals May Revise Their Communication Requests. If a Patient or Companion indicates to RMH Personnel that he or she wants an interpreter after failing to request one on the Communication Assessment Form, RMH Personnel shall provide the Patient or Companion with a new Communication Assessment Form. RMH Personnel shall then comply with the requirements of paragraphs 24 and 25 as if the Patient or Companion had originally requested an interpreter. Both the original Communication Assessment Form and the new one shall be documented in the Patient’s medical chart.

D. Telephones and Television

39. Telephones in Patient Rooms. Within ninety days of the Effective Date of this Settlement Agreement:
1. Portable access technology defined. RMH will make available portable access technology. Such technology, as referred to in this section, shall include TTY’s with printout capability, other electronic devices, visual notification devices for incoming telephone calls, volume control telephones, and telephones that are hearing aid compatible. RMH will ensure that each volume control telephone complies fully with § 704.3 of the 2010 ADA Standards for Accessible Design.
2. Portable access technology general obligation. RMH will make portable access technology available to Patients and Companions who are deaf or hard of hearing who are admitted to (or are accompanying Patients who are admitted to) rooms equipped with a telephone.
3. Electrical Outlets. Each patient room with a telephone shall have an electrical outlet within a reasonable distance of the telephone connection to facilitate the use of a TTY device.
4. Timeliness. Within ninety days of the Effective Date of this Settlement Agreement, RMH will make the equipment required by this section available within one hour of a Patient’s arrival in a patient room, regardless of the hour of the day or night. RMH will notify all relevant Personnel of the availability and location of this equipment.
40. Televisions and Caption Decoders. Within sixty days of the Effective Date of this Settlement Agreement, RMH will develop a policy to ensure that Patients and Companions with hearing impairments have priority use of televisions with closed captioning capabilities. 28 C.F.R. § 36.303(e).
41. Clearly stated directions for use of the closed caption capability shall be included in the Patient Guide or otherwise made available in each patient room or public area containing a television with captioning capability. The directions for operating the closed caption function shall also accompany all closed caption decoders for standard television sets.

E. Notice to Community

42. Policy Statement. Within one-hundred twenty days of the entry of this Agreement, RMH shall post and maintain signs of conspicuous size and print wherever a Patient’s Bill of Rights is required by law to be posted. Such signs shall be to the following effect:

Sign language and oral interpreters, TTYs, and other auxiliary aids and services are available free of charge to people who are deaf or hard of hearing. For assistance, please contact any RMH Personnel or ADA Administrator or Co-Administrator(s) at _____________(voice/TTY.

43. Website. RMH will include on its website the policy statement described in paragraph 42 above.
44. Patient Guide. RMH will include in all future printings of its Patient Guide (or equivalent) and all similar publications a statement to the following effect:

To ensure effective communication with Patients and their Companions who are deaf or hard of hearing, we provide appropriate auxiliary aids and services free of charge, such as: sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with caption capability or closed caption decoders, and open and closed captioning of most RMH programs. Please ask your nurse or other RMH Personnel for assistance, or contact the ADA Administrator or Co-Administrator(s) at ______________ (voice or TTY.

RMH will also include in its Patient Guide (or equivalent) a description of its complaint resolution mechanism.

F. Notice to RMH Personnel and Physicians

45. RMH shall publish on its intranet a policy statement regarding the RMH’s policy for effective communication with persons who are deaf or hard of hearing. This policy statement shall include, but is not limited to, language to the following effect:

If you recognize or have any reason to believe that a Patient or a relative, close friend, or Companion of a Patient is deaf or hard of hearing, you must advise the person that appropriate auxiliary aids and services, such as sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with captioning or closed caption decoders, and open and closed captioning of most hospital facility programs, will be provided free of charge when appropriate. If you are the responsible health care provider, you must ensure that such aids and services are provided when appropriate. All other personnel should direct that person to the appropriate ADA Administrator or Co-Administrator(s) at _____________ and reachable at ________________.

RMH will deploy this policy on its intranet within one-hundred twenty days of the Effective Date of this Agreement.

G. Training

46. Training of ADA Administrator. RMH will provide mandatory training for the ADA Administrator(s) within ninety days of designation as provided in paragraph 26 of this Agreement or approval of the trainer by the U.S. Attorney’s Office as described in paragraph 51 of this Agreement, whichever is later. Such training will be sufficient in duration and content to train the ADA Administrator(s) in the following areas:
1. To promptly identify communication needs of Patients and Companions who are deaf or hard of hearing and which auxiliary aids are effective in different circumstances;
2. To secure qualified interpreter services as quickly as possible when necessary;
3. To encourage clinical staff members to notify RMH of Patients and Companions who are deaf or hard of hearing as soon as Patients schedule admissions, tests, rehabilitation, or other health care services at RMH;
4. To use, when appropriate, flash cards and pictographs (in conjunction with any other available means of communication that will augment the effectiveness of the communication);
5. How and when to use video remote interpreting services;
6. Making and receiving calls through TTYs and the relay service; and
7. RMH’s complaint resolution procedure described in paragraph 28 of this Agreement.
47. Training of RMH Personnel. Except for affiliated physicians, who are governed by paragraph 52 of this Agreement, RMH will provide mandatory annual in-service training to all RMH Personnel.
1. The training will address the needs of Patients and Companions who are deaf or hard of hearing and will include the following objectives:
   1. To promptly identify communication needs of Patients and Companions who are deaf or hard of hearing;
   2. To secure qualified interpreter services or video remote interpreting services as quickly as possible when necessary; and
   3. To use, when appropriate, flash cards and pictographs (in conjunction with any other available means of communication that will augment the effectiveness of the communication).
2. Such training must be provided within the same timeframe of RMH’s annual in-service requirements.
3. New employees will receive training as part of regular employee orientation, which will be created and offered by RMH within one hundred eighty days of the Effective Date of this Agreement.
48. Training of Telephone Operators. All RMH Personnel whose primary job duty is to receive incoming telephone calls from the public will receive instructions by RMH on using TTYs or relay services to make, receive, and transfer telephone calls and will receive training generally on the existence in RMH of an ADA Administrator or Co-Administrator(s), as detailed in paragraph 26 of this Agreement, and the complaint resolution process, as described in paragraph 28 of this Agreement. Such training must be provided within one hundred twenty days of the approval of the trainer by the U.S. Attorney’s Office as provided in paragraph 51 of this Agreement and will be conducted annually thereafter.
49. Training Attendance Sheets. RMH will maintain in written form for the duration of this Agreement, confirmation of required training conducted pursuant to this Agreement, which will include the names and respective job titles of the attendees, as well as the date and time of the training sessions.
50. Training of Affiliated Physicians. RMH will create and send an email advising affiliated physicians of its policy on the communication needs of Patients or Companions who are deaf or hard of hearing. This email will direct affiliated physicians to RMH’s web page, which will include: (1) RMH’s Policy Statement as described in paragraph 42 and any relevant forms; and (2) a request that physicians’ staff members notify RMH of Patients and Companions who are deaf or hard of hearing as soon as they schedule admissions, tests, or other health care services at RMH.
51. Approval of Trainer. RMH will hire an independent agency or group to conduct the initial trainings described in this Agreement. The trainer shall be subject to the approval of the U.S. Attorney’s Office, which shall not be unreasonably withheld. For the required annual trainings thereafter, RMH may conduct the trainings without the assistance of an independent group, but must sufficiently update and/or create training materials in order to ensure the trainings include any new developments to the ADA and its requirements. RMH may also videotape the initial trainings for annual trainings so long as RMH also ensures that it supplements such training with any new developments to the ADA and its requirements.

H. Reporting, Monitoring, and Violations

52. Within sixty days of the completion of the initial training required by this Agreement, RMH will provide the U.S. Attorney’s Office with a copy of all training materials used to train its staff, training attendance sheets required in Paragraph 49, above, and copies of the notices posted pursuant to this Agreement.
53. Compliance Reports. Beginning six months after the Effective Date of this Agreement and every six months thereafter for the entire duration of the Agreement, RMH will provide a written report (“Compliance Report”) to the U.S. Attorney’s Office regarding the status of its compliance with this Agreement. The Compliance Report will include data relevant to the Agreement, including but not limited to:
1. The Auxiliary Aid and Service Log described in paragraph 27; and
2. The number of complaints received by RMH from Patients and Companions who are deaf or hard of hearing regarding auxiliary aids and services and/or effective communication, and the resolution of such complaints including any supporting documents, as described in paragraph 28. RMH will maintain records to document the information contained in the Compliance Reports and will make them available, upon request, to the U.S. Attorney’s Office.
54. Complaints. During the term of this Agreement, RMH will notify the U.S. Attorney’s Office if any person files a lawsuit, complaint, or formal charge with a state or federal agency, alleging that RMH failed to provide auxiliary aids and services to Patients or Companions who are deaf or hard of hearing, or otherwise failed to provide effective communication with such Patients or Companions. Such notification must be provided in writing via certified mail within twenty days of the date RMH received notice of the allegation and will include, at a minimum, the nature of the allegation, the name of the person making the allegation, and any documentation possessed by RMH relevant to the allegation. RMH will reference this provision of the Agreement in the notification to the U.S. Attorney’s Office.

I. Compensatory Relief for Complainants and Release

55. Within ten days after receiving the Complainants’ signed releases (a blank release form is at Exhibit B), RMH will send three checks as follows: (1) in the amount of six thousand five hundred dollars and no cents ($6,500.00) made out to Complainants R.W. and C.W.; (2) in the amount of five thousand dollars and no cents ($5,000.00) made out to Complainant T.G.F.; and (3) in the amount of two thousand five hundred dollars and no cents ($2,500.00) made out to Complainant S.O. These checks are compensation to the Complainants pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in paragraphs 3 through 6 and 13 above. The checks shall be mailed to:

Financial Litigation Unit
United States Attorney’s Office for
Western District of Virginia
310 First Street, SW
Room 906
Roanoke, Virginia 24011

A copy of the checks shall be sent to:

Krista Consiglio Frith
Assistant United States Attorney
310 First Street, SW
Room 906
Roanoke, Virginia 24011

J. Enforcement and Miscellaneous

55. This Agreement will be in effect for two years from the Effective Date.
56. In consideration of the terms of this Agreement as set forth above, the Attorney General agrees to refrain from undertaking further investigation or from filing a civil suit under Title III of the ADA related to the allegations in paragraphs 3 through 6 and 13, except as provided in paragraph 58. Nothing contained in this Agreement is intended or shall be construed as a waiver by the United States of any right to institute proceedings against RMH for violations of any statutes, regulations, or rules administered by the United States or to prevent or limit the right of the United States to obtain relief under the ADA.
57. The United States may review compliance with this Agreement at any time and can enforce this Agreement if the United States believes that it or any requirement thereof has been violated by instituting a civil action in the U.S. District Court. If the United States believes that this Agreement or any portion of it has been violated, it will raise its claim(s) in writing with RMH, and the parties will attempt to resolve the concern(s) in good faith. The United States will allow RMH sixty (60) days from the date it notifies RMH of any breach of this Agreement to cure said breach, prior to instituting any court action to enforce the ADA or the terms of the Agreement. If CRMH determines that a requirement(s) of this Agreement that is not expressly required by the ADA is unreasonable or nonfeasible after good faith attempts to operationalize it, the United States agrees to enter into good faith discussions with CRMH in the attempt to modify the requirement(s) so that it is reasonable and feasible as well as consistent with the intent of this Agreement and CRMH’s obligations under the ADA.
58. This Agreement and the attachments hereto constitute the entire agreement between the parties on the matters raised herein, and no other statement, promise, or agreement, either written or oral, made by either party or agents of either party, that is not contained in this written agreement, shall be enforceable. This Agreement is limited to the facts set forth herein and does not purport to remedy any other potential violations of the ADA or any other federal law.
59. This Agreement is final and binding on the parties, including all principals, agents, executors, administrators, representatives, successors in interest, beneficiaries, assigns, heirs, and legal representatives thereof. RMH has a duty to so inform any such successor in interest of this Agreement.
60. Failure by the United States to seek enforcement of this Agreement pursuant to its terms with respect to any instance or provision shall not be construed as a waiver to such enforcement with regard to other instances or provisions.
61. The effective date of this Settlement Agreement is the date of the last signature below.
62. This Agreement may be executed in counterparts, each of which constitutes an original and all of which constitute one and the same Agreement. Electronically transmitted signatures shall constitute acceptable, binding signatures for purposes of this Agreement.
63. This Agreement is neither an admission of liability by RMH nor a concession by the United States that its claims are not well founded. By entering into this Agreement, RMH does not admit the allegations in paragraphs 3 through 6 or 13(a)–(e), above, or to any violation of law, liability, fault, misconduct, or wrongdoing in connection with those allegations. The Parties have determined that the complaint filed with the United States can be resolved without litigation and have agreed to the terms of this Agreement.