SETTLEMENT AGREEMENT
UNDER THE AMERICANS WITH DISABILITIES ACT
BETWEEN
THE UNITED STATES OF AMERICA
AND
GRADY MEMORIAL HOSPITAL

BACKGROUND

1. The parties ("Parties") to this Settlement Agreement ("Agreement") are the United States of America ("United States") and Grady Memorial Hospital ("Grady"), located in Atlanta, Georgia.
2. The Parties have agreed that the terms of this Agreement are limited to the Emergency Care Center of Grady ("ECC").
3. This matter was initiated by a complaint filed with the United States against Grady, alleging violations of title III of the Americans with Disabilities Act (ADA), 42 U.S.C. §§ 12181-12189, and its implementing regulation, 28 C.F.R. Part 36. Specifically, the Complainant, who is deaf, (the "Complainant") alleged that Grady failed to provide sign language interpretive services when necessary to ensure effective communication. Complainant uses sign language as his primary means of communication.
4. Complainant M.R. is a deaf man who was treated in the Emergency Care Center after falling from a ladder. M.R. remained in the ECC for approximately six hours. On multiple occasions during his ECC visit, M.R. requested a sign language interpreter. However, he was not provided with a live interpreter or video remote interpreting at any point during his ECC stay. Because no interpreter or VRI was provided during this visit, M.R. relied upon his deaf friend to interpret for him. His deaf friend said that he attempted to read lips and then sign to M.R., but he did not understand most of what was being communicated. M.R. was in a lot of pain, and felt as though he did not know what was going on. He was discharged with instructions and medication, but did not fully understand what he needed to do once he left the ECC.

   INVESTIGATION AND FINDINGS

5. The United States Attorney's Office, Northern District of Georgia ("U.S. Attorney's Office"), is 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 the Hospitals' compliance with title III of the ADA. It has the authority to bring civil actions to enforce title III of the ADA.
6. Complainant is an individual with a "disability" within the meaning of the ADA. 42 U.S.C. § 12102; 28 C.F.R. § 36.104.
7. Grady is a non-profit corporation, licensed by the State of Georgia. Grady 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.
8. 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).
9. On the basis of its investigation, the U.S. Attorney's Office has determined that Grady denied the Complainant appropriate auxiliary aids and services necessary for effective communication during treatment at Grady, in violation of 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303.

   DEFINITIONS

10. The term "auxiliary aids and services" includes qualified interpreters on-site or through video remote interpreting (VRI) services; note takers; 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).
11. The term "Emergency Care Center" (ECC) means the area of the hospital equipped and staffed for the prompt treatment of acute illness, trauma, or other medical emergencies.
12. The term "ECC Personnel" means all employees of Grady working in the ECC, both full and part-time, and independent contractors with contracts to work on a substantially full-time basis for Grady (or on a part-time basis of 20 hours or more per week exclusively for Grady), including, without limitation, nurses, physicians, social workers, 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.
13. 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.
14. The term "deaf or hard-of-hearing Patient" shall be broadly construed to include any individual who is deaf or hard-of-hearing and is seeking or receiving health care services from the Hospital's ECC.
15. 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).
16. Effective Date of this Settlement Agreement" means the date of the last signature below.

    EQUITABLE RELIEF

    A. Prohibition of Discrimination

17. Nondiscrimination. Grady 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), the Hospital 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 the Hospital as required by this Agreement and the ADA.
18. Retaliation and Coercion. Grady 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

19. Appropriate Auxiliary Aids and Services. Pursuant to 42 U.S.C. § 12182(b)(2)(A)(iii), Grady will continue to 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 20-21 of this Agreement. Appropriate auxiliary aids and services will continue to 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 28 of this Agreement. Grady will continue to advise Patients and Companions who require auxiliary aids or services that these are available throughout the Patient's hospitalization as requested by the Patient.
20. 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 Grady based on the assessment. The assessment made by ECC 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. Grady will use electronic equivalents, similar to Exhibit A, within sixty (60) days of the Effective Date of this Agreement at the Hospital's ECC.
21. Time for Assessment. The initial determination of which appropriate auxiliary aids and services are necessary, and the timing, duration, and frequency with which they will be provided, will be made at the time of registration of the deaf or hard-of-hearing Patient or Companion at the ECC, or at the time of the first contact with an attending clinician, whichever occurs first. ECC Personnel will perform an assessment (see paragraph 20) as part of each initial ECC assessment and document the results in the Patient's medical chart. If the ECC Personnel know or should know that communication is not effective, ECC Personnel will reassess which appropriate auxiliary aids and services are necessary, in consultation with the person with a disability, where possible, and provide the aid or service available based on the reassessment.
22. Auxiliary Aid and Service Log. Grady will continue to maintain a log (or electronic equivalent) in which all requests for qualified interpreters on site or through video remote services are documented. The log will also indicate the time and date the request was made, the interpreter identification, the start and end time of the interpreting services, the duration of the services, and the name of the deaf or hard-of-hearing Patient or Companion. The order in which patients are seen in the ECC is based on acuity, not time of arrival. Nothing herein shall be construed to require Grady to prioritize the order in which patients are seen on factors other than acuity. If Language Interpretive Services personnel become aware that 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 for the entire duration of the Agreement, and will be incorporated into the semi-annual Compliance Reports as described in paragraph 39 of this Agreement.
23. Complaint Resolution. Grady will utilize their established grievance resolution mechanism for the investigation of disputes regarding effective communication with deaf and hard-of-hearing Patients and Companions. Grady will maintain records of all grievances regarding effective communication, whether oral or written, made to Grady and actions taken with respect thereto. At the time Grady completes its assessment described in paragraphs 20-21 and advises Patient and/or Companion of their determination of which appropriate auxiliary aids and services are necessary, Grady will notify deaf and hard-of-hearing persons of their grievance 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 grievance filed shall be completed within thirty (30) 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 Patient-Family Experience Department for the entire duration of the Agreement.
24. Prohibition of Surcharges. All appropriate auxiliary aids and services required by this Agreement will continue to be provided free of charge to the deaf or hard-of-hearing Patient and/or Companion.
25. Record of Need for Auxiliary Aid or Service. Grady will take appropriate steps to ensure that all ECC 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 records and a request that all emergency transportation services notify Grady when a patient being transported is deaf or hard of hearing.

    C. Qualified Interpreter

26. 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 visitors. When an interpreter is needed, Grady 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. Explaining medical conditions, treatment options, tests, medications, surgery and other procedures;
    3. Providing a diagnosis and recommendation for treatment;
    4. Communicating with a patient during treatment, testing procedures, and during physician's rounds;
    5. Obtaining informed consent for treatment;
    6. Providing instructions for medications, post-treatment activities and follow-up, treatments;
    7. Providing mental health services, including group or individual counseling for patients and family members;
    8. Providing information about blood or organ donations; and
    9. Discussing powers of attorney, living wills and/or complex billing and insurance matters.
27. Chosen Method for Obtaining Interpreters. Within thirty (30) days after execution of this Agreement, Grady will provide a list of the interpreter services it currently contracts with to provide qualified on site interpreters as well as VRI services at the request of Grady.
28. Provision of Interpreters in a Timely Manner.
    1. ECC Interpreter Requests: An "ECC interpreter request" means a request for an interpreter made by a deaf or hard-of-hearing Patient or Companion in the ECC. For ECC interpreter requests, ECC Personnel will complete the assessment described in paragraphs 20-21 above. The interpreter shall be available no more than (a) two hours from the time the Hospital complete the assessment if the service is provided through a contract interpreting service or a staff interpreter who is located off-site or (b) 30 minutes from the time the Hospital complete the assessment if the service is provided through a Video Remote Interpreting service as described in paragraph 29 below. Deviations from this response time will be addressed with the interpreting service provider, and performance goals will be reviewed with the United States Attorney's Office.
    2. Data Collection on Interpreter Response Time and Effectiveness. Grady will monitor the performance of each qualified interpreter service it uses to provide communication to deaf or hard-of-hearing Patients or Companions through their established process of monitoring outside vendors. As part of the Auxiliary Aid and Service Log, described in paragraph 22, Grady shall collect information regarding response times for each request for interpreters in the ECC.
29. 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, Grady shall ensure that they provide: (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; or significant pain; or due to space limitations in the room. Within 30 days of the Effective Date of this Agreement, Grady will continue to maintain the VRI requirements set forth in this section. Grady 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 Grady'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.
    1. Volume of VRI. Grady will add speakers, if necessary, to its VRI systems to ensure appropriate volume.
    2. Location of VRI. Grady will provide VRI in areas that are free from interferences such as loud noises and heavy patient traffic.
30. Notice to Deaf or Hard-of-Hearing Patients and Companions. As soon as ECC Personnel have determined that a qualified interpreter is necessary for effective communication with a deaf or hard-of-hearing Patient or Companion, Grady 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. Grady 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 Grady's obligation to provide qualified interpreters in a timely manner as required by paragraph 28 of this Agreement.
31. Other Means of Communication. Grady agrees that between the time an interpreter is requested and the interpreter is provided, ECC 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 Grady's obligation to provide qualified interpreters in a timely manner as required by paragraph 28 of this Agreement.

    D. Notice to Community

32. Signage. Grady shall continue to use its existing signs (see Exhibit B) and maintain them at prominent locations in the ECC including in the Triage, Registration, and Waiting Areas. Such signs shall be of conspicuous size.
33. Website. Grady will include on their websites the policy statement described in Exhibit C.
34. Patient's Bill of Rights. Grady will include in all future printings of its Patient Bill of Rights (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, such as sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, , telephones compatible with hearing aids, televisions with captioning or closed caption decoders, and open and closed captioning of most hospital programs, will be provided free of charge when appropriate.

    Please ask your nurse or other Hospital Personnel for assistance.

    Grady will also include in their Patient Handbooks a description of their complaint resolution mechanism.

    E. Notice to ECC Personnel and ECC Physicians

35. Grady shall publish on their intranet a policy statement regarding the Hospitals' 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, telephones compatible with hearing aids, televisions with captioning, and open and closed captioning of most hospital 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 contact Language Interpretive Service or the appropriate department.

    Grady will post this policy on the intranet within sixty (60) days of the Effective Date of this Agreement to all ECC Personnel and both employed and affiliated physicians (physicians with practicing or admitting privileges), and to all new ECC Personnel and newly employed or affiliated physicians upon their affiliation or employment with Grady.

    F. Training

36. Training of ECC Personnel. Grady shall continue providing mandatory in-service training to all ECC Personnel. Grady will use best efforts to train independent contractors who provide direct patient care and work more than 20 hours per week exclusively for Grady. Grady may provide the training required under this Agreement through appropriate computer-based training approaches.
    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 one hundred twenty (120) days of the Effective Date of this Agreement.
    3. New employees to the ECC must be trained within thirty (30) days of their hire. Further, all ECC Personnel must renew their training annually.
37. Training Attendance Sheets. Grady will continue to maintain in electronic form for the duration of this Agreement, confirmation of training conducted pursuant to paragraph 36 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.
38. Training of Affiliated Physicians. Grady will create and send an email blast advising affiliated physicians working in Grady's ECC of their 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 the Hospital to complete computerized training. This email will direct affiliated physicians to Grady's web page which will include Grady's Policy Statement for persons working at Grady as described in paragraph 33 and any relevant forms.

    G. Report, Monitoring, and Violations

39. Compliance Reports. Beginning six months after the Effective Date of this Agreement and every six months thereafter for the entire duration of the Agreement, Grady will provide written reports ("Compliance Report") to the U.S. Attorney's Office regarding the status of their compliance with this Agreement. 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 or electronic equivalents described in paragraph 22; and
    2. the number of complaints received by Grady 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.

    Grady will maintain records to document the information contained in the Compliance Report and will make them available, upon request, to the U.S. Attorney's Office.

40. Complaints. During the term of this Agreement, Grady 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 Grady 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 (20) days of the date Grady 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 Grady relevant to the allegation. Grady will reference this provision of the Agreement in the notification to the U.S. Attorney's Office.

    H. Compensatory Relief for Complainants and Release

41. Within ten (10) days after receiving the complainant's signed release, Grady will send a check in the amount of $5,000 for the Complainant. This check is compensation to the Complainant pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in paragraph 4. The checks shall be mailed to:

    Aileen Bell Hughes
    Assistant United States Attorney
    United States Attorney's Office
    Northern District of Georgia
    75 Spring Street, S.W., Suite 600
    Atlanta, Georgia 30303

42. Hospital will not withhold taxes from the monetary award and the Complainant will accept full responsibility for taxes due and owing, if any, on such funds. Hospital will issue to the Complainant an IRS Form 1099 reflecting the amount paid to the Complainant.

    I. Enforcement and Miscellaneous

43. Duration of the Agreement. This Agreement will be in effect for two years from the Effective Date.
44. Enforcement. In consideration of the terms of this Agreement as set forth above, the U.S. Attorney's Office agrees to refrain from undertaking further investigation or from filing a civil suit under title III of the ADA related to the allegations in paragraph 4, except as provided in paragraph 45. 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 Grady 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.
45. 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 Grady, and the parties will attempt to resolve the concern(s) in good faith. The United States will allow Grady thirty days from the date it notifies Grady 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.
46. 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.
47. 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.
48. 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.
49. The effective date of this Settlement Agreement is the date of the last signature below.
50. 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.