SETTLEMENT AGREEMENT BETWEEN THE UNITED STATES OF AMERICA AND AND
PROVIDENCE HOLY CROSS HOSPITAL
USAO # 2018V01344, DJ # 202-12C-659

1. BACKGROUND
1. The parties to this Settlement Agreement (“Agreement”) are the United States of America (the “United States”) and Providence Health System – Southern California, which operates the Providence Holy Cross Medical Center (hereinafter “Providence Holy Cross”).
2. Providence Holy Cross is a hospital that provides inpatient and outpatient treatment programs, located at 15031 Rinaldi Street, Mission Hills, California, 91345.
3. The United States Attorney’s Office for the Central District of California (“USAO”), a component of the Department of Justice, initiated an investigation of Providence Holy Cross under Title III of the Americans with Disabilities Act (“ADA”), 42 U.S.C. §§ 12181–12189, as amended, and its implementing regulations, 28 C.F.R. Part 36, upon the receipt of a complaint, USAO No. 2018V01344, DOJ No. 202-12C-659. The complaint alleged that Providence Holy Cross failed to provide effective communication to a patient who is deaf, and instead relied on his adult children to interpret for him over the course of several consecutive days and for important procedures including surgery.
4. The United States and Providence Holy Cross have reached an agreement that is in the parties’ best interests, and that the United States believes is in the public interest, to resolve this matter on mutually agreeable terms. The parties have therefore voluntarily agreed to the terms of this Settlement Agreement.
2. DEFINITIONS
5. The term “auxiliary aids and services” includes qualified interpreters onsite or through video remote interpreting (VRI) services; notetakers; real time computer-aided trans-cription 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).
6. The term “effective date” means the date of the last signature below.
7. The term “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 Providence Holy Cross, whether as an inpatient or an outpatient.
8. 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).
9. The term “qualified interpreter” means an interpreter who, via a VRI service or an onsite 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.
3. TITLE III COVERAGE AND DETERMINATIONS
10. The Department of Justice is authorized under 42 U.S.C. § 12188 and 28 C.F.R. Part 36, Subpart E, to investigate complaints to determine compliance with Title III of the ADA. Ensuring that health care providers do not discriminate on the basis of disability is an issue of general public importance. Title III authorizes the United States 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 involves a pattern or practice of discrimination or that raises issues of general public importance. 42 U.S.C. §§ 12188(a)(2), 12188(b), 12212; 28 C.F.R. §§ 36.502, 503, 506.
11. The complainant, who is deaf, is an individual with a disability within the meaning of the ADA. 42 U.S.C. § 12102; 28 C.F.R. § 36.104.
12. 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 any person who owns, operates, leases, or leases to a place of public accommodation. 42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a). 
13. The Providence Holy Cross facility is a place of public accommodation within the meaning of Title III of the ADA, 42 U.S.C. § 12181(7)(F), 28 C.F.R. § 36.104. Accordingly, Providence Holy Cross, which owns and operates the facility, is a public accommodation obligated to comply with the requirements of Title III. Id.
14. Pursuant to the ADA, Providence Holy Cross 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 from other individuals because of the absence of auxiliary aids or services, unless the public accommodation can demonstrate that taking those steps would fundamentally alter the nature of the goods and services being offered, or would result in an undue burden. 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303(a). Providence Holy Cross shall furnish appropriate auxiliary aids and services where necessary to ensure effective communication. 28 C.F.R. § 36.303(c).
15. The complaint alleges that Providence Holy Cross discriminated against an individual who is deaf, S.G., who sought care from Providence Holy Cross. Specifically, the complaint alleges that Providence Holy Cross failed to provide or offer S.G. auxiliary aids or services over the course of four consecutive days of medical tests and procedures, as well as during a surgical procedure that occurred two days after this four-day period. S.G.’s adult daughter M.D. requested an ASL interpreter for her father when he was admitted, but one was never provided. Staff told M.D. that the hospital had a VRI machine, but said that it was not in their department and never procured it. As a result, M.D. had to remain at the hospital with S.G. almost 24 hours a day to interpret for him so that he could communicate with staff, understand medical consultations, and provide required consents related to surgery. M.D. was even required to be present to interpret for the patient immediately prior to procedures, which required her to wear a hairnet and mask. M.D. stated that she struggled to interpret for her father because she did not know medical terminology that Providence Holy Cross was using. She also stated that she had to take a week off from work to assist her father, and that the process exhausted her and caused her significant stress. S.G.’s adult son J.G., who lived in Connecticut, also traveled across the country to assist. This required booking expensive last minute flights and missing work.
16. On the basis of its investigation, the United States has determined that Providence Holy Cross discriminated against S.G., M.D., and J.G. in violation of Title III of the ADA by failing to provide S.G. with auxiliary aids and services necessary for effective communication in violation of 42 U.S.C. §§ 12182(b)(2)(A)(iii), 12182(b)(1)(E), and 28 C.F.R. § 36.303. Providence Holy Cross contends that it complied with its ADA obligations with respect to S.G., M.D., and J.G., and that no discrimination in violation of the ADA occurred.   
4. REMEDIAL ACTIONS
1. Prohibition of Discrimination
17. Nondiscrimination. Consistent with the ADA, Providence Holy Cross will not discriminate against any individuals, including patients and their companions, on the basis of disability, in the full and equal enjoyment of the goods, services, facilities, privileges, advantages, or accommodations available at the Providence Holy Cross facility by excluding or providing unequal treatment to persons with disabilities. 42 U.S.C. § 12182. Providence Holy Cross also 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).
18. Communications. Providence Holy Cross shall take steps to ensure that no individual with a disability is excluded, denied services, segregated or otherwise treated differently from other individuals because of the absence of auxiliary aids or services, and will furnish appropriate auxiliary aids and services where necessary to ensure effective communication, unless taking those steps would fundamentally alter the nature of the goods and services being offered, or would result in an undue burden. 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303(a), (c).
19. Limitation Regarding Qualified Interpreters. Providence Holy Cross shall not require an individual with a disability to bring another individual to interpret for him or her. 28 C.F.R. § 36.303(c)(2).
20. Retaliation and Coercion. Providence Holy Cross 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.
21. Policy Revision. Providence Holy Cross agrees to modify its ADA policy to address and include paragraphs 17–20, 22, and 24–36 of this Agreement. Pursuant to 42 U.S.C. § 12182(b)(2)(A)(iii), this revised policy will require Providence Holy Cross to provide to deaf and hard-of-hearing patients and companions appropriate auxiliary aids and services, including qualified interpreters, to the extent necessary for effective communication as required by law and set forth in this Agreement. Providence Holy Cross agrees to modify its ADA policy to address paragraph 23 of this Agreement to provide information relative to considerations for appropriateness of use and the expected functionality and performance of Video Remote Interpreter Services. Providence Holy Cross shall send a copy of this modified policy to the United States for its approval within 30 days after the effective date of this Agreement.
2. Effective Communication
22. Appropriate Auxiliary Aids and Services. Immediately as of the effective date of this Agreement, Providence Holy Cross shall provide, free of charge, appropriate auxiliary aids and services, including qualified interpreters, to individuals who are deaf or hard of hearing and their companions whenever they are necessary to ensure effective communication for those individuals or their companions, unless taking those steps would fundamentally alter the nature of the goods and services being offered, or would result in an undue burden, such as compromising patient care. Providence Holy Cross must provide appropriate auxiliary aids and services as soon as practicable without compromising patient care, except that the provision of interpreters must be provided within the timeframe described in paragraph 25 of this Agreement.
23. VRI Services. If a VRI service is used, Providence Holy Cross shall ensure, including by contracts with service vendors, that the service 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 if it is not effective, for example due to (1) a patient’s limited ability to move his or her head, hands or arms; (2) vision or cognitive issues; (3) significant pain; (4) space limitations in the room; or (5) any other indicators that VRI is not providing effective communication. If, based on the circumstances, VRI is not providing effective communication, staff shall provide an onsite interpreter as soon as possible. Further, if the VRI device is not functioning properly and staff are unable to get the VRI device to function properly within 30 minutes after it starts to malfunction, they will call for an onsite interpreter.

24. Circumstances in Which Interpreters May Be Required. Although the determination of whether and what auxiliary aids and service are appropriate to a given situation is generally up to Providence Holy Cross (as informed by its assessment (paragraphs 26–27) and the input or request of the patient or companion), some circumstances demand that it provide a qualified sign language interpreter or qualified oral interpreter to patients or companions who rely on such communication, unless the arrangements under the circumstances would fundamentally alter the nature of the goods and services being offered, or would result in an undue burden, such as compromising patient care. Such circumstances that demand in-person interpreters typically arise when the communication is particularly complex or lengthy. For example, such circumstances include but are not limited to:
1. Discussing a patient’s symptoms for diagnostic purposes, and discussing medical condition, medications, and medical history;
2. Explaining medical conditions, treatment options, tests, medications, surgery, and other procedures;
3. Providing a diagnosis or recommendation for treatment;
4. Communications immediately preceding, during, and immediately after surgery or other 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;
9. Discussing powers of attorney, living wills and/or complex billing, and insurance matters; or
10. During educational presentations, such as birthing or new parent classes, nutrition and weight management programs, and CPR and first-aid training.

In such circumstances, Providence Holy Cross shall presume that a qualified sign language interpreter or qualified oral interpreter is necessary for effective communication with a patient or companion who relies on such auxiliary aids or services.

25. Provision of Interpreters in a Timely Manner. Providence Holy Cross must provide interpreters to patients who are deaf or hard of hearing in a timely manner, unless the arrangements under the circumstances would fundamentally alter the nature of the goods and services being offered, or would result in an undue burden, such as compromising patient care, in accordance with the following:
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 less than two hours before the patient’s appearance at Providence Holy Cross for examination or treatment. For non-scheduled interpreter requests, staff will complete the assessment described in paragraphs 26–27.
1. A qualified interpreter (via VRI) will be provided as soon as practicable, but no more than 30 minutes from the time Providence Holy Cross completes the assessment (absent exigent circumstances affecting patient care which may extend the time for providing such service).
2. In the event that an onsite qualified interpreter is required, an interpreter will be provided as soon as practicable, but no more than two hours from the time it becomes clear that a live interpreter is necessary for effective communication.
3. As described below in section (c) of this paragraph, Providence Holy Cross shall document the onsite interpreter service’s response time, including the time of contact and the time of arrival. Deviations from this response time shall be addressed with the interpreting service provider. Providence Holy Cross shall not be held responsible for circumstances beyond its control in obtaining onsite interpreter services, such as delays due to weather or interpreter service response, as long as it makes all the reasonable efforts described in section (a)(iv) below to obtain onsite interpreter services in a timely manner and documents those efforts.
4. If no qualified interpreter can be located, staff shall:
1. Exert reasonable efforts (which shall be deemed to require no fewer than five telephone inquiries and/or emails and/or text messages unless exceptional circumstances intervene) to contact any qualified interpreters or interpreting agencies already contracted with the hospital 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 a family member of 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 a qualified interpreter known to that person, for possible use during rescheduled or future appointments, or, if reasonably feasible under the circumstances and appropriate in light of the complexity or seriousness of the treatment involved, the appointment or procedure in question, unless taking those steps would fundamentally alter the nature of the goods and services being offered, or would result in an undue burden, such as compromising patient care;
4. 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. Staff also shall not rely on a minor child or patient to interpret except in an emergency involving an imminent threat to safety; and
5. Document all of the above efforts.
2. Scheduled Interpreter Requests. A “scheduled interpreter request” is a request for an interpreter made two or more hours before the services of the interpreter are required. For scheduled interpreter requests, Providence Holy Cross Personnel will complete the assessment described in paragraphs 26–27 below in advance, and, when a qualified interpreter is appropriate, Providence Holy Cross shall make a qualified interpreter available at the time of the scheduled appointment. If a qualified interpreter fails to arrive for the scheduled appointment, upon notice that the qualified interpreter failed to arrive, Providence Holy Cross shall immediately call the interpreter service for another qualified interpreter and comply with the timeframes in this paragraph and paragraphs 26–27.
3. Date Collection on Interpreter Response Time. Providence Holy Cross shall monitor and document in the Auxiliary Aid and Service Log, described in paragraph 32, the response time of each qualified interpreter service it uses to provide communication to patients or companions who are deaf or hard of hearing through its established process of monitoring outside vendors. Providence Holy Cross will document and investigate, per the complaint resolution process identified in paragraph 33, any complaints by the patients or companions who are deaf or hard of hearing regarding the quality and/or effectiveness of services provided by the interpreter service.
26. Communication Assessment Form. Providence Holy Cross’s staff shall provide a communication assessment form to the patient or companion who is deaf or hard of hearing at the time an appointment is scheduled if the patient or companion makes the appointment, or on the arrival of the patient or companion who is deaf or hard of hearing at the hospital, whichever is earlier, or at any subsequent time that a patient or companion who has not received the form already identifies himself or herself as deaf or hard of hearing, and shall document the results in the patient’s medical chart. A Model Communication Assessment Form is attached to this Agreement as Exhibit A, and Providence Holy Cross shall use it within 90 days of the effective date of this Agreement, to allow time for training. Providence Holy Cross may use a “Language/Communication flowsheet” in the electronic health record to obtain the information specified in the Model Communication Assessment Form, or other form similar to Exhibit A. However, any other modifications to the form require approval by counsel for the United States prior to implementation.
27. General Assessment Criteria. The determination of appropriate auxiliary aids or services, and the timing, duration, and frequency with which they will be provided, must be made in consultation with the person with a disability whenever possible. In making these determinations, Providence Holy Cross and/or its staff must take into account all relevant facts and circumstances, including, but not limited to, the following:
1. the nature, length, complexity, and importance of the communication at issue;
2. the individual’s communication skills and knowledge;
3. the patient’s health status or changes thereto; and
4. the patient’s and/or companion’s request for, or statement of need for, an interpreter.

Providence Holy Cross shall document in the patient’s medical chart its consultation with the patient or companion and its consideration of the above factors. Examples of circumstances in which it may be necessary to provide interpreters include, but are not limited to: obtaining a patient’s medical history or description of ailment; explaining or discussing a patient’s diagnosis or prognosis; explaining or discussing follow-up care, including a patient’s or companion’s questions regarding the patient’s condition and/or previous or future procedures, tests, and/or treatment; and medications prescribed.

28. Record of Need for Auxiliary Aid or Service. Providence Holy Cross shall take appropriate steps to ensure that appropriate staff are made aware of a patient’s or companion’s disability and auxiliary aids and services needed so that effective communication with such person shall be achieved. These steps will include designating this information in the medical record. The patient’s medical record shall be conspicuously labeled (such as with a sticker, indicator, or label on the cover) to alert appropriate staff 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.
29. Reassessment. If communication is not effective, Providence Holy Cross will reassess, in consultation with the patient or companion, as applicable, which auxiliary aids and services are needed to ensure effective communication, and will document the results in the patient’s medical chart in accordance with paragraphs 27–28. For VRI, Providence Holy Cross will consider the factors described in paragraph 23.
30. Ongoing Relationship. If a patient or companion has an ongoing relationship with Providence Holy Cross, for subsequent visits, Providence Holy Cross will determine what auxiliary aids or services may be needed by the patient or companion and provide such auxiliary aids or services to the patient or companion as appropriate. Providence Holy Cross will keep appropriate records that reflect the ongoing provision of auxiliary aids and services to patients and companions, such as notations in a patient’s medical charts.
31. ADA Coordinator. Providence Holy Cross shall designate (and replace, as necessary to ensure the position is continually filled) at least one employee to serve as an ADA Coordinator. The ADA Coordinator shall have the authority to commit Providence Holy Cross to comply with the ADA, including but not limited to providing auxiliary aids and services to a patient or companion. The ADA Coordinator or his/her designee shall be available at all hours that Providence Holy Cross operates to answer questions and provide appropriate assistance regarding appropriate auxiliary aids and services necessary for effective communication, including qualified interpreters.
1. The ADA Coordinator will know where the auxiliary aids are stored, how to obtain aids or services, and how to operate the aids. The ADA Coordinator or his/her designee will be responsible for the maintenance, repair, replacement, and distribution of any auxiliary aids.
2. Providence Holy Cross shall include in its intranet and phone directory, and post broadly within the Providence Holy Cross facility, the name, telephone number, function, and office location of the ADA Coordinator, through which the ADA Coordinator or his/her designee can be contacted 24 hours a day, seven days a week by hospital staff who provide services to individuals who are deaf or hard of hearing;
3. The ADA Coordinator shall also be responsible for the complaint resolution mechanism described in paragraph 33 of the Agreement.
4. Providence Holy Cross shall designate the ADA Coordinator no later than 180 days following the effective date of this Agreement, subject to approval by the USAO.
32. Auxiliary Aid and Service Log. Within 90 days of the effective date of this Agreement, to allow time for training, Providence Holy Cross shall maintain a log of each request for an auxiliary aid or service, including requests for qualified interpreters and for video remote services. The log may be a part of or created and produced through functionality of the electronic health record.  The log will record:
1. the time and date of the request;
2. the name of the individual who made the request;
3. the name of the individual for whom the auxiliary aid or service was requested (if different than the requestor);
4. the specific auxiliary aid or service requested; the time and date for immediate use (emergent need) or for the scheduled appointment (if one was made);
5. the time and date the auxiliary service was provided;
6. the type of auxiliary aid or service provided;
7. if applicable, a statement that the requested auxiliary aid or service was not provided, along with the reason it was not provided; and
8. the identity of the Providence Holy Cross staff who conduct each assessment and made each determination.

The log shall be maintained by the ADA Coordinator for the entire duration of the Agreement, and shall be incorporated into the compliance reports described in paragraph 47 of this Agreement.

33. Complaint Resolution. Providence Holy Cross shall establish a complaint resolution mechanism for the investigation of disputes regarding effective communication with patients and companions who are deaf or hard-of-hearing.
1. Providence Holy Cross shall maintain records of all complaints regarding effective communication, whether oral or written, made to Providence Holy Cross, and actions taken with respect to them.
2. At the time Providence Holy Cross completes its assessment described in paragraphs 26–27 and advises the patient and/or companion of its determination of which appropriate auxiliary aids and services are necessary, Providence Holy Cross shall 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 complaint.
3. If any patient or companion is dissatisfied with the provision of auxiliary aids or services by Providence Holy Cross, then that person may lodge a complaint with the ADA Coordinator selected in accordance with paragraph 33.
4. The ADA Coordinator must provide a written response to the patient or companion within 14 days after receipt of any such complaint absent exigent circumstances.
5. Copies of all complaints related to the provision of auxiliary aids or services to deaf or hard-of-hearing patients or companions and the responses to them will be maintained by the ADA Coordinator for the duration of this Agreement.
3. Qualified Interpreters
34. Documentation. All of Providence Holy Cross’s requests for interpreters, including the time, date, and location, must be confirmed in writing at the time of the request, and a log of all such requests with this information must be maintained in the Auxiliary Aid and Service Log. In addition, if Providence Holy Cross receives verbal confirmation or speaks with the vendor regarding its request for an interpreter, this information must also be documented in the Auxiliary Aid and Service Log. Providence Holy Cross shall retain a copy of all written correspondence with interpreting services.
35. Notice to patients and companions of Efforts to Secure Effective Communication. As soon as Providence Holy Cross staff have determined that a qualified interpreter is necessary for effective communication with a patient or companion who is deaf or hard of hearing, Providence Holy Cross shall 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. Providence Holy Cross shall 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 Providence Holy Cross’s obligation to provide qualified interpreters in a timely manner as required by paragraph 25 of this Agreement.
4. Notice to Patients and Personnel
36. Policy Statement. Within 60 days after the effective date of this Agreement, Providence Holy Cross shall have posted in the reception or waiting area, examination room, and wherever a patient’s Bill of Rights is required by law to be posted, signs of conspicuous size and print stating:

In compliance with the Americans with Disabilities Act (ADA), qualified interpreters and other auxiliary aids and services are available free of charge to people who are deaf or hard-of-hearing.

These signs shall include the international symbol for “interpreters” shown below:

Additionally, Providence Holy Cross shall list the name and contact information for ADA Coordinator and any other person(s) to whom a patient or companion should speak to request auxiliary aids or services. The signs shall also contain the following statement:

For more information about the Americans with Disabilities Act (ADA), call the Department of Justice's toll-free ADA Information Line at 1-800-514-0301 (voice), 1-833-610-1264 (TTY), or visit the ADA Home Page at archive.ada.gov.

Providence Holy Cross shall notify the United States in writing when it has completed this action. If any issues arise that affect the anticipated completion date for this, Providence Holy Cross shall immediately notify the United States of the issue(s).

37. Website. Within 60 days after the effective date of this Agreement, Providence Holy Cross shall include on its website language similar to the policy statement described in paragraph 36, conspicuously linked from its main website currently accessible at: https://www.providence.org/locations/holy-cross-medical-center. Providence Holy Cross shall notify the United States in writing when it has completed this action. If any issues arise that affect the anticipated completion date for this, Providence Holy Cross shall immediately notify the United States of the issue(s). All new and redesigned web pages, web applications, and web content (“Web Pages”) published by Providence Holy Cross must act in accordance with the Web Content Accessibility Guidelines 2.0 principles of Perceivable, Operable, Understandable and Robust.
38. Patient Handbook. Providence Holy Cross will include in all future printings of its patient handbook (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 to the patient or companion, such as: sign language and oral interpreters, video remote interpreting services, TTYs, 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 Hospital programs.

Please ask your nurse or other hospital staff for assistance, or contact the information office at ___________ (voice or TTY), room ____________.
Providence Holy Cross shall also include in its patient Handbook a description of its complaint resolution mechanism described in paragraph 33.

39. Language Signs. All signs in the Providence Holy Cross facility that list the languages in which Providence Holy Cross is prepared to communicate with patients shall include ASL.
40. Intranet. Providence Holy Cross shall publish on its intranet a policy statement regarding Providence Holy Cross’s policy for effective communication with persons who are deaf or hard of hearing. This policy statement includes, 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, 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 programs, will be provided free of charge to the patient or companion 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 Coordinator(s) at _____________ and reachable at ________________.

41. Notice to Personnel. Providence Holy Cross’s policy for effective communication with persons who are deaf or hard of hearing will be accessible to all hospital personnel and active members of the hospital medical staff. The policy must also be provided to all newly hired hospital personnel and active members of the hospital medical staff upon their affiliation or employment with Providence Holy Cross.
5. Training
42. Training for the ADA Coordinator. Providence Holy Cross will provide mandatory training for the ADA Coordinator and his or her designees as set forth in paragraph 31 of this Agreement. Such training materials must be provided to the USAO within 90 days after the effective date of this Agreement for review. Once approved by the USAO, the training will occur within 30 days. The USAO acknowledges that it may reasonably be necessary to extend these timelines in light of the COVID-19 pandemic and resource limitations it imposes, and agrees not to withhold consent on such extension requests unreasonably. Such training will be sufficient in duration and content to train the ADA Coordinator and his or her designees in the following areas:
1. to promptly identify communication needs of patients and companions who are deaf or hard of hearing, including when an onsite qualified interpreter is necessary;
2. to secure qualified interpreter services or VRI services as quickly as possible when necessary;
3. to use, when appropriate, flash cards and/or pictographs (in conjunction with any other available means of communication that will augment the effectiveness of the communication);
4. how and when to use VRI services, including how to make and receive calls;
5. to encourage employees to notify the ADA Coordinator or his or her designee of patients and companions who are deaf or hard of hearing as soon as patients schedule admissions or other health care services at Providence Holy Cross; and
6. Providence Holy Cross’s complaint resolution procedure described in paragraph 33 of this Agreement.
43. Training for Existing Employees. Within 90 days after the effective date of this Agreement, and annually thereafter, Providence Holy Cross shall provide mandatory ADA training for all staff who might interact with patients and/or companions. Such training, which can be provided by a third party, will be sufficient in duration and content to train the covered individuals in:
1. the various degrees of hearing impairment, language, and cultural diversity in the deaf community;
2. identification of communication needs of persons who are deaf or hard of hearing;
3. procedures for documenting requests for provision of auxiliary aids and services in patient charts;
4. types of auxiliary aids and services available and how to secure them in a timely manner;
5. the proper use and role of qualified interpreters;
6. criteria to be used in order to select an interpreter who is qualified;
7. the proper use and role of VRI services;
8. making and receiving calls through TTYs and the relay service; and
9. all other applicable requirements of this Agreement.
44. Training for New Employees. New employees must be trained within 30 days after their hire. A screening of a video of the original training described in paragraph 43 will suffice to meet this obligation.
45. Training Attendance Sheets. Providence Holy Cross shall maintain in electronic form for the duration of this Agreement confirmation of the training conducted pursuant to paragraphs 43–44 of this Agreement, which must include the names, signatures, and respective job titles of the attendees, as well as the date and time of the training session.
6. Reporting, Monitoring, and Violations
46. Training Materials. Within 120 days after the effective date of this Agreement, Providence Holy Cross shall provide the United States with a copy of all training materials used to train its staff, training attendance sheets required in paragraph 45, above, and photographs of the notices posted in its offices pursuant to this Agreement.
47. Compliance Reports.  Beginning one year after the effective date and every six months thereafter for the duration of the Agreement, Providence Holy Cross shall provide a written compliance report to the USAO regarding the status of its compliance with the terms of the Agreement. The compliance report must include data relevant to the Agreement, including:
1. the Auxiliary Aid and Service Log described in paragraph 32, which must include all information required by this Agreement including paragraphs 25(c) and 34, including identification of contractors used for the provision of auxiliary aids or services and any changes thereto; and
2. the information maintained in the complaint records described in paragraph 33, including the number of  complaints received by Providence Holy Cross 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, as described in paragraph 33.
48. Providence Holy Cross shall maintain records to document the information contained in the compliance reports and will make them available, upon request, to the USAO.
49. Private Actions. During the term of this Agreement, Providence Holy Cross shall notify the USAO if any person files a lawsuit, complaint, or formal charge with a state or federal agency, alleging that Providence Holy Cross failed to provide auxiliary aids or services, including qualified interpreters, to deaf or hard-of-hearing patients or companions. Such notification must be provided in writing via U.S. mail or electronic mail within 30 days after the date Providence Holy Cross receives notice of the allegation and must include, at a minimum, the nature of the allegation, the name of the person making the allegation, and any documentation possessed by Providence Holy Cross relevant to the allegation. Providence Holy Cross shall reference this provision of the Agreement in the notification to the USAO.
7. Compensatory Relief for Complainant and Other Individuals
49. Compensation for Complainant and Family. In exchange for specified payments, S.G., M.D., and J.G. shall sign releases that release Providence Holy Cross, affiliated entities, officers, directors, employees or other agents from any liability under the ADA related to the allegations of their complaint. Providence Holy Cross shall send by certified mail, return receipt requested, a check in the amount of $75,000.00 made out to the complainant S.G. within 10 days after receiving a release signed by S.G. In addition, Providence Holy Cross shall send by certified mail, return receipt requested, a check in the amount of $12,500.00 made out to the complainant’s daughter, M.D., within 10 days after receiving a signed release from her, and a check in the amount of $12,500.00 made out to the complainant’s son, J.G., within 10 days after receiving a signed release from him. These checks shall serve as compensation to S.G., M.D., and J.G. pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in paragraphs 3 and 15. Unless otherwise directed by the United States, the checks shall be mailed to the person specified in paragraph 57, below. 
50. Release. All persons entitled to relief under paragraph 49 must execute the release attached as Exhibit B in order to receive the compensation described in those paragraphs.
5. ENFORCEMENT AND MISCELLANEOUS
51. Duration of the Agreement. This Agreement will be in effect for three years from the effective date.
52. Consideration. In consideration of the terms of this Agreement as set forth above, the United States shall refrain from undertaking further investigation or from filing a civil suit under Title III of the ADA 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 Providence Holy Cross for violations unrelated to this matter under 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 Providence Holy Cross, and the parties will attempt to resolve the concern(s) in good faith. The United States will allow Providence Holy Cross 30 days from the date it notifies Providence Holy Cross 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 to it 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 inform any such successor in interest of this Agreement.
56. Counterparts. 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.
57. Notices. All notices, reports, and other communications to be provided to the United States in accordance with this Agreement shall be in writing and delivered by U.S. mail or electronic mail to the following, unless specified otherwise by the USAO:

Matthew Nickell
Assistant U.S. Attorney
Civil Rights Section, Civil Division
United States Attorney’s Office
300 North Los Angeles Street, Suite 7516
Los Angeles, California  90012
Email: matthew.nickell@usdoj.gov