SETTLEMENT AGREEMENT BETWEEN
THE UNITED STATES OF AMERICA AND
DOCTORS HOSPITAL AT RENAISSANCE, LTD.

U.S. DEPARTMENT OF JUSTICE DJ # 202-74-390; USAO# 2015V01468

BACKGROUND

1. The parties ("Parties") to this Settlement Agreement ("Agreement") are the United States of America ("United States") and Doctors Hospital at Renaissance, Ltd. ("DHR"), a Texas limited partnership.
2. DHR provides a comprehensive, fully integrated, healthcare delivery system serving metropolitan area of McAllen, Texas as well as Hidalgo, Cameron, and Starr County, Texas. DHR owns and operates multiple facilities in McAllen, Texas. This agreement applies to all DHR medical service facilities.
3. This matter was initiated by a lawsuit filed by Rolando Perez and Miriam Perez against DHR, alleging violations of Title III of the Americans with Disabilities Act (the "ADA"), 42 U.S.C. §§ 12181-12189, and its implementing regulation, 28 C.F.R. Part 36 and Section 504 of the Rehabilitation Act. Specifically, Rolando Perez and Miriam Perez alleged that DHR personnel failed, beginning with their daughter's treatment for cancer in January 2011, to provide sign language interpretive services when necessary to ensure effective communication with Rolando Perez and Miriam Perez, who are deaf.
4. Rolando Perez and Miriam Perez (hereinafter "the Perez's" collectively) are the primary caretakers of their daughter who received cancer treatments at DHR for several years. Miriam is deaf and uses sign language as her primary means of communication. Rolando is hard of hearing.
5. The Perez's alleged they were unable to effectively communicate with DHR's doctors and medical personnel during their daughter's four-day stay at DHR in January 2011. Thereafter, the Perez's daughter required monthly chemotherapy treatment at DHR and at times, their daughter was hospitalized for up to four days due to reactions from the chemotherapy treatment. The chemotherapy treatments lasted through 2014. During these treatments, the Perez's alleged at various times they were unable to effectively communicate with DHR's doctors and medical personnel and on several occasions, allege Miriam was forced to use a family member to translate what was being said by doctors at DHR and medical personnel.
6. DHR denies the allegations and contends that Rolando Perez regularly communicated effectively to his daughter's physician verbally both in DHR and at the physician's non-DHR clinic. DHR further also contends that Rolando Perez regularly verbally communicated effectively with DHR staff during his daughter's stays at DHR. DHR came to believe that the family wanted Miriam Perez's brother to translate at treatments where Mr. Perez was not present and at no time forced the Perez's to use Mrs. Perez's brother as an interpreter.

   INVESTIGATION AND FINDINGS

   The United States Department of Justice ("Department") and the U.S. Attorney for the Southern District of Texas ("SDTX") are authorized under 42 U.S.C.§ 12188 and 28 C.F.R. Part 36, Subpart E, to investigate the allegations of the complaint in this matter to determine DHR's compliance with Title III of the ADA. The U.S. Attorney's Office has the authority to, where appropriate, negotiate and secure the full range of relief available under Title III of the ADA, including equitable/injunctive relief, requiring the provision of auxiliary aids and services, and seeking monetary damages and a civil penalty.
7. Miriam Perez is an individual with a "disability" within the meaning of the ADA. 42 U.S. C. § 12102; 28 C.F.R. § 36.104. Minor child M.P. is the daughter of the Perez's and as such has a known relationship or association with an individual with a disability. 42 U.S.C. 12182(b)(1)(E); 28 C.F.R. § 36.205.
8. DHR is a private, community-owned for-profit limited partnership, which owns and operates medical facilities, licensed by the State of Texas. DHR is a "public accommodation" within the meaning of Title III of the ADA, 42 U.S.C. § 12181(7)(F), and its implementing regulation at 28 C.F.R. § 36.104, because it owns and operates places of public accommodation, including hospitals and professional offices of health care providers. 42 U.S.C. 12181(7)(F).
9. The ADA prohibits discrimination on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations by a public accommodation. 42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a).
10. On the basis of its investigation, the SDTX determined that DHR denied the Perez's appropriate auxiliary aids and services necessary for effective communication during the above-referenced cancer treatments of their daughter, M.P., at DHR, in violation of 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303. DHR fully cooperated in the SDTX investigation in this matter and denies the allegations made by the Perez's. This Agreement is neither an admission of liability by DHR nor a concession by the United States that the claims are not well founded.
11. The Parties have determined that the allegations of the Perez's alleged in Cause No. 7:13-cv-124 against DHR and investigated by SDTX can be resolved without litigation and have agreed to the terms of this Agreement. By entering into this Agreement, DHR does not admit the allegations made by the Perez's in Cause No. 7:13-cv-124, or to any violation of law, liability, fault, misconduct or wrongdoing in connection with said allegations.

    DEFINITIONS

12. The term "auxiliary aids and services" includes qualified interpreters on-site or through video remote interpreting (VRI) services; notetakers; real-time computer-aided 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).
13. The term "DHR Personnel" means all employees, both full and part-time, and independent contractors with contracts to work on a substantially full-time basis for DHR (or on a part-time basis exclusively for DHR) who have or are likely to have direct contact with Patients or Companions as defined herein. This includes, without limitation, nurses, physicians, social workers, technicians, admitting personnel, billing staff, security staff, therapists, and volunteers. The term "DHR personnel" does not include students, interns, or educational residents involved in hospital-based training at DHR facilities.
14. 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 translators, and cued-language translators. 28 C.F.R. § 36.104.
15. The term "Patient" shall be broadly construed to include any individual who is seeking or receiving health care services from DHR, whether as an inpatient or an outpatient.
16. 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).
17. "Effective Date of this Settlement Agreement" means the date of the last signature below.

    EQUITABLE RELIEF

    A. Prohibition of Discrimination

18. Nondiscrimination. DHR shall provide appropriate auxiliary aids and services, including qualified interpreters, where such aids and services are necessary to ensure effective communication with deaf and hard of hearing Patients and Companions. Pursuant to 42 U.S.C. § 12182(a), DHR shall also provide deaf and hard of hearing Patients and Companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of DHR as required by this Agreement and the ADA.
19. Discrimination by Association. DHR 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).
20. Retaliation and Coercion. DHR 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

21. Appropriate Auxiliary Aids and Services. Pursuant to 42 U.S.C. § 12182(b)(2)(A)(iii), DHR will provide to deaf or hard-of-hearing Patients and Companions any appropriate auxiliary aids and services that are necessary for effective communication after making the assessment described in paragraphs 23-24 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 32 of this Agreement. DHR will advise Patients and Companions who require auxiliary aids or services that these are available throughout the Patient's hospitalization as requested by the Patient.
22. 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 DHR in consultation with the person with a disability. The assessment made by DHR Personnel will take into account all 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 DHR will develop an assessment similar to Exhibit A within thirty (30) days of the Effective Date of this Agreement to be used at DHR. DHR shall provide a copy of the Communication Assessment ("Assessment") that it develops to the SDTX for approval prior to DHR's implementation of the Assessment. DHR shall ensure that a completed Assessment is obtained from each individual Patient or Companion who agrees to participate in the Assessment. DHR shall provide assistance in completing the Assessment at the Patient's or Companion's request. After being completed, the Assessment(s) shall be maintained in the Patient's medical chart, whether kept in paper or electronic form. If a Patient identifies a Companion who is not presently at DHR but is expected at DHR during the patient's stay, DHR Personnel shall provide the Patient with the contact information of DHR Personnel who can assist the Companion in requesting communication assistance in advance of arriving at DHR. If at any point during a Patient's stay, a Companion identifies himself or herself as deaf or hard of hearing, DHR shall promptly administer the Assessment, if it has not done so already.
23. 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 an appointment is scheduled for the deaf or hard-of-hearing Patient or on the arrival of the deaf or hard-of-hearing Patient or Companion at DHR, whichever is earlier. DHR Personnel will perform an assessment (see paragraph 22) as part of each initial inpatient assessment and document the results in the Patient's electronic medical chart. In the event that communication is not effective, DHR 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.
24. ADA Administrators. DHR will designate at least one employee at DHR as an ADA Administrator or ADA Co-Administrators. An ADA Administrator will be on-call twenty-four (24) hours a day, seven (7) 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 will know where the auxiliary aids are stored and how to operate them and will be responsible for their maintenance, repair, replacement, and distribution. DHR will circulate and post broadly within the DHR the title, telephone number, function, and office location of the Administrator(s), including a TTY telephone number, through which the ADA Administrator or Co-Administrator on duty can be contacted by deaf or hard-of-hearing Patients and Companions. The ADA Administrator or Co-Administrators will be responsible for the complaint resolution mechanism described in paragraph 27 of this Agreement. The ADA Administrator or Co-Administrators will be designated by DHR no later than 30 days following execution of this Agreement.
25. Auxiliary Aid and Service Log. DHR 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 deaf or hard-of-hearing Patient or Companion, 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. Such logs will be maintained by the ADA Administrator for the entire duration of the Agreement, and will be incorporated into the semi-annual Compliance Reports as described in paragraph 50 of this Agreement.
26. Complaint Resolution. DHR will establish a grievance resolution mechanism for the investigation of disputes regarding effective communication with deaf and hard-of-hearing Patients and Companions. DHR will maintain records of all grievances regarding effective communication, whether oral or written, made to DHR and actions taken with respect thereto. At the time DHR completes its assessment described in paragraphs 22-23 and advises a Patient and/or Companion of its determination of which appropriate auxiliary aids and services are necessary, DHR will notify deaf and hard-of-hearing persons of its grievance resolution mechanism, to whom complaints should be made, and of the right to receive a written response to the grievance. An investigation letter will be sent to the Patient and/or Companion within seven (7) business days and a written response to any grievance filed shall be completed within thirty (30) calendar days of receipt of the complaint. Copies of all grievances related to provision of services for deaf or hard-of-hearing Patients and/or Companions and the responses thereto will be maintained by the ADA Administrator for the entire duration of the Agreement and will be incorporated into the semi-annual Compliance Reports as described in paragraph 50 of this Agreement.
27. Prohibition of Surcharges. All appropriate auxiliary aids and services required by this Agreement will be provided free of charge to the deaf or hard-of-hearing Patient and/or Companion.
28. Record of Need for Auxiliary Aid or Service. DHR will take appropriate steps to ensure that all DHR 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 electronic medical record. The patient's medical record shall be conspicuously labeled (such as with a sticker, indicator, or label on the cover) to alert DHR 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

29. 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, DHR 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 DHR 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, testing procedures, and during physician's rounds;
    6. Obtaining informed consent for treatment;
    7. Providing instructions for medications, pre- and 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, such as birthing or new parent classes, nutrition and weight management programs, and CPR and first-aid training;
    12. Discussing discharge planning and discharge instructions; and
    13. When DHR provides religious services and spiritual counseling.
30. Chosen Method for Obtaining Interpreters. DHR has identified and uses the services of one or more interpreter services to provide qualified on site interpreters, as well as VRI services when interpreter services are not available or appropriate. To the extent not already done, DHR will establish internal procedures for ordering interpreting services that are consistent with the interpreter or interpreter agencies' procedures. At a minimum, all of DHR's requests for interpreters, including the time and date, will be confirmed in writing at the time of the request. Further, DHR will consider an order for interpreting services to be complete only after receiving written confirmation from the interpreting service that an interpreter will be provided at the time and date requested. For the duration of this Agreement, DHR will file a copy of its written correspondence with interpreters and interpreting agencies in the Auxiliary Aid and Service Log discussed in paragraph 26.
31. 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 deaf or hard-of-hearing Patient or Companion less than two (2) hours before the Patient's appearance at the DHR for examination or treatment. For non-scheduled interpreter requests, DHR Personnel will complete the assessment described in paragraphs 22-23 above. The interpreter shall be provided no more than (a) two (2) hours from the time DHR completes the assessment if the service is provided through a contract interpreting service or a staff interpreter who is located off-site, or (b) thirty (30) minutes from the time DHR completes the assessment if the service is provided through a Video Remote Interpreting service as described in paragraph 33 below. Deviations from this response time will be addressed with the interpreting service provider, and will be incorporated into the semi-annual Compliance Reports as described in paragraph 49 of this Agreement. DHR Personnel will:
       1. Exert reasonable efforts (which shall be deemed to require no fewer than three (3) telephone inquiries and/or emails and/or text messages unless exceptional circumstances intervene) to contact any interpreters or interpreting agencies already known to DHR and request their services;
       2. Inform the ADA Coordinator of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;
       3. Inform the Patient or Companion (or 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 two (2) or more hours before the services of the interpreter are required. For scheduled interpreter requests, DHR Personnel will complete the assessment described in paragraphs 22-23 above in advance, and, when an interpreter is appropriate, DHR 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, DHR will immediately arrange for another qualified interpreter.
    3. Data Collection on Interpreter Response Time and Effectiveness. DHR will monitor the performance of each qualified interpreter service it uses to provide communication to deaf or hard-of-hearing Patients or Companions by monitoring their response time and seeking feedback from the individual who requires the services of the interpreter.
32. 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, DHR 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, for example, to 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. DHR is currently providing VRI services. DHR is not responsible for power outages or service interruption due to acts of God or third party problems. 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 DHR's control, other effective auxiliary aids and/or services, such as an on-site interpreter, shall be used. If an on-site interpreter is used, DHR shall use its best efforts to ensure the interpreter is provided in accordance with the timetables set forth above.
33. Notice to Deaf or Hard-of-Hearing Patients and Companions. As soon as DHR Personnel have determined that a qualified interpreter is necessary for effective communication with a deaf or hard-of-hearing Patient or Companion, DHR 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. DHR 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 DHR's obligation to provide qualified interpreters in a timely manner as required this Agreement.
34. Other Means of Communication. DHR agrees that between the time an interpreter is requested and the interpreter is provided, DHR Personnel will continue to try to communicate with the deaf or hard-of-hearing Patient or Companion 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 DHR's obligation to provide qualified interpreters in a timely manner as required by this Agreement.
35. Restricted Use of Certain Persons to Facilitate Communication. DHR 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. DHR 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.
36. Individuals May Revise Their Communication Requests. If a Patient or Companion indicates to DHR Personnel that he or she wants an interpreter after failing to request one at the time of the Assessment, DHR Personnel shall provide the Patient or Companion with a new Assessment. DHR Personnel shall then comply with the requirements of paragraphs 23 and 24 as if the Patient or Companion had originally requested an interpreter. Both the original Assessment and the new one shall be kept in the patient's medical file.

    D. Telephones and Television

37. Telephones in Patient Rooms. Within sixty (60) days of the Effective Date of this Settlement Agreement:
    1. Portable access technology – defined. DHR will make available portable access technology. Such technology, as referred to in this section, may 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. DHR will ensure that any volume control telephone complies fully with § 704.3 of the 2010 Standards.
    2. Portable access technology - general obligation. DHR 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 the technical capabilities to facilitate the use of a TTY device. If such TTY devices require the use of an electrical outlet, the telephone cord shall be sufficiently long to allow connection of the TTY and the telephone receiver, pursuant to § 704.4 of the 2010 standards.
    4. Timeliness. Within sixty (60) days of the Effective Date of this Settlement Agreement, DHR will make the equipment required by this section available within sixty (60) minutes of a Patient's arrival in a patient room, regardless of the hour of the day or night. DHR will notify all relevant DHR Personnel of the availability and location of this equipment.
38. Televisions and Caption Decoders. Within sixty (60) days of the Effective Date of this Settlement, DHR 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).
39. Directions for Use. Clearly stated directions for use of the closed caption capability shall be 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

40. Policy Statement. Within ninety (90) days of the entry of this Agreement, DHR shall post and maintain signs of conspicuous size and print at all DHR admitting stations, the emergency department, and wherever a Patient's Bill of Rights is required by law to be posted. Such signs shall be to the following effect:

    INTERPRETERS AVAILABLE

    You have access to interpretation services 24/7 at no personal cost to you… For more information, please call the Director of Interpreter Services at [phone number] or DHR House Supervisor at [phone number]. You may also visit the Guest Relations department in person, which is located in the first floor or the Main Hospital from 8:00 a.m. – 8:00 p.m. Monday through Friday, and 8:00 a.m.-5:00 p.m. Saturday and Sunday. Additionally you may ask any red coat Guest Relations team member for assistance from 8:00 a.m. – 8:00 p.m. seven days a week.

41. Website. DHR will include on its website the policy statement described in paragraph 40 above.
42. Patient Handbook. DHR will include in all future printings (meaning any Patient Handbooks printed following the entry date of this Agreement) of its Patient Handbook (or equivalent) and all similar publications a statement to the following effect:

    INTERPRETERS AVAILABLE

    You have access to interpretation services 24/7 at no personal cost to you… For more information, please call the Director of Interpreter Services at [phone number] or DHR House Supervisor at [phone number]. You may also visit the Guest Relations department in person, which is located in the first floor or the Main Hospital from 8:00 a.m. – 8:00 p.m. Monday through Friday, and 8:00 a.m.-5:00 p.m. Saturday and Sunday. Additionally you may ask any red coat Guest Relations team member for assistance from 8:00 a.m. – 8:00 p.m. seven days a week.

    DHR will also include in its Patient Handbook a description of its complaint resolution mechanism.

    F. Notice to DHR Personnel and Physicians

43. DHR shall publish on its intranet a policy statement regarding DHR'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 DHR 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 at _____________ and reachable at ________________.

    DHR will publish this policy on the intranet within thirty business (30) days of the Effective Date of this Agreement.

    G. Training

44. Training of ADA Administrator. DHR will provide mandatory training for the ADA Administrator(s) within sixty business (60) days of designation as provided in paragraph 25 of this Agreement. 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 which situations;
    2. to administer the Assessment as described in paragraphs 22-23 of this Agreement;
    3. to secure qualified interpreter services as quickly as possible when necessary;
    4. maintenance of the Auxiliary Aid and Service Log;
    5. to encourage medical staff members to notify DHR of deaf and hard-of-hearing Patients and Companions as soon as Patients schedule admissions, tests, surgeries, or other health care services at the DHR.
    6. 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).
    7. how and when to use video remote interpreting services;
    8. making and receiving calls through TTYs and the relay service; and
    9. DHR's complaint resolution procedure described in paragraph 27 of this Agreement.

    Such training must be provided within 120 business days of the Effective Date of this Agreement.

45. Training of DHR Personnel. Except for affiliated physicians, who are governed by paragraph 49 of this Agreement, DHR will provide mandatory training to all DHR Personnel.
    1. The training will address the needs of deaf and hard-of-hearing Patients and Companions 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 ninety (90) business days of the Effective Date of this Agreement.
    3. New employees must be trained within thirty (30) days of their hire.
46. Training of Telephone Operators. All DHR Personnel who receive incoming telephone calls from the public will receive instructions by DHR on using TTYs or relay services to make, receive, and transfer telephone calls and will receive training generally on the existence in DHR of an ADA Administrator, as detailed in paragraph 25 of this Agreement, and the complaint resolution process, as described in paragraph 27 of this Agreement. Such training must be provided within sixty (60) business days of the Effective Date of this Agreement and will be conducted annually thereafter.
47. Training Attendance Sheets. DHR will maintain for the duration of this Agreement, confirmation of training conducted pursuant to paragraphs 45-46 of this Agreement, which will include the names and respective job titles of the attendees, as well as the date and time of the training session.
48. Training of Affiliated Physicians. DHR will advise affiliated physicians of its policy on the communication needs of Patients or Companions who are deaf or hard of hearing and will invite all physicians who are affiliated with DHR (admitting or surgical privileges, etc.) to complete training. The advisement will direct affiliated physicians to the DHR web page which will include: (1) DHR's Policy Statement for persons working at DHR as described in paragraph 41 and any relevant forms; and (2) a request that physicians' staff members notify DHR of any deaf and hard-of-hearing Patients and Companions, as soon as the Patients/Companions schedule admissions, tests, surgeries, or other health care services at DHR.

    H. Reporting, Monitoring, and Violations

49. Compliance Reports. Beginning six months after the Effective Date of this Agreement and every six months thereafter for the entire duration of the Agreement, DHR will provide a written report ("Compliance Report") to the SDTX regarding the status of its compliance with this Agreement. SDTX shall provide DHR with a template for the Compliance Report. The Compliance Report will include data relevant to the Agreement, including but not limited to:
    1. the information required in Auxiliary Aid and Service Log described in paragraph 26.
    2. the number of complaints received by DHR from deaf and hard-of-hearing Patients and Companions regarding auxiliary aids and services and/or effective communication, and the resolution of such complaints including any supporting documents.
    3. Current versions al all training materials used to train DHR Personnel, training attendance sheets as required above, and photographs of the notices posted in DHR's facilities pursuant to this Agreement.

    DHR will maintain records to document the information contained in the Compliance Reports and will make them available, upon request, to the SDTX.

50. Complaints. During the term of this Agreement, DHR will notify the SDTX if any person files a lawsuit, complaint or formal charge with a state or federal agency, alleging that DHR failed to provide auxiliary aids and services to deaf or hard-of-hearing Patients or Companions or otherwise failed to provide effective communication with such Patients or Companions. Such notification must be provided in writing via certified mail within twenty business (20) days of the date DHR 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 DHR relevant to the allegation. DHR will reference this provision of the Agreement in the notification to the SDTX.

    J. Enforcement and Miscellaneous

51. Duration of the Agreement. This Agreement will be in effect for three (3) years from the Effective Date.
52. Enforcement. 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 in this matter, except as provided in paragraph 53. 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 DHR 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.
53. Compliance Review and Enforcement. 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 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 DHR, and the parties will attempt to resolve the concern(s) in good faith. The United States will allow DHR thirty (30) days from the date it notifies DHR 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.
54. Entire Agreement. 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.
55. Binding. 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. Each party has a duty to so inform any such successor in interest.
56. Non-Waiver. Failure by any party 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.
57. The effective date of this Agreement is the date of the last signature below.
58. This Agreement may be executed in counterparts, each of which constitutes an original and all which constitute on and the same Agreement. Electronically transmitted signatures shall constitute acceptable, binding signatures for purposes of this Agreement.
59. Given that this agreement is not an admission of liability by DHR, nothing in this document or any investigation or discussions leading up to the creation of this document can be used in any court or hearing for any purpose whatsoever, other than to enforce any provision herein. The sole purpose of this document is to make sure DHR, in concert with the Southern District of Texas, continues to provide first rate quality service to all of its patients, including those that fall under the ADA.