SETTLEMENT AGREEMENT BETWEEN
THE UNITED STATES OF AMERICA AND
SPOTSYLVANIA MEDICAL CENTER d/b/a
SPOTSYLVANIA REGIONAL MEDICAL CENTER

U.S. DEPARTMENT OF JUSTICE DJ # 202-79-329

BACKGROUND

1. The parties ("Parties") to this Settlement Agreement ("Agreement") are the United States of America ("United States") and Spotsylvania Medical Center, Inc. d/b/a Spotsylvania Regional Medical Center ("SRMC"), a hospital located in Fredericksburg, Virginia. SRMC is a wholly-owned, indirect subsidiary of HCA Holdings, Inc. and is among the facilities within the healthcare network commonly referred to as the HCA Virginia Health System.
2. This matter was initiated by a complaint filed with the United States against SRMC, alleging violations of title III of the Americans with Disabilities Act of 1990, as amended (the "ADA"), 42 U.S.C. §§ 12181-12189, and its implementing regulation, 28 C.F.R. Part 36. Specifically, MG, the complainant, who is deaf and uses American Sign Language ("ASL") as her primary means of communication, alleged that SRMC failed to provide sign language interpretive services when necessary to ensure effective communication.
3. Between June 23, 2010 and September 8, 2014, FS -- MG's Mother -- had complex medical issues and required nine hospital admissions to SRMC. During FS's multiple admissions to SRMC, MG was FS's healthcare surrogate, and spent significant time with her at the facility.
4. During September 2015, MG made three visits to SRMC's Emergency Department ("ED") as a patient for hypertension.
5. MG alleges that SRMC failed to furnish her with a qualified ASL interpreter during FS's nine hospitalizations, including during end of life events. MG further alleges that during her visits to SRMC's ED, SRMC failed to furnish her with an ASL interpreter. As a result of SRMC's failure to provide effective communication, MG alleges that she often did not understand the care and medical decisions being considered for her mother's or her own care. During both FS's and MG's hospitalizations, MG also alleges that SRMC utilized MG's family members and friends as communication facilitators.
6. This Agreement is neither an admission of liability by SRMC nor a concession by the United States that its claims are not well founded. By entering into this Agreement, SRMC denies the allegations in paragraphs 5 and 13, or to any violation of law, liability, fault, misconduct or wrongdoing in connection with those allegations. The Parties have determined that the complaint filed with the United States can be resolved without litigation and have agreed to the terms of this Agreement.

INVESTIGATION AND FINDINGS

7. The United States Attorney for the Eastern District of Virginia ("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 SRMC'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 for persons aggrieved and a civil penalty.
8. Ensuring that medical care providers do not discriminate on the basis of disability is an issue of general public importance. The United States is authorized to investigate alleged violations of Title III of the ADA 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(b).
9. MG is deaf and as such is an individual with a "disability" within the meaning of the ADA. 42 U.S. C. § 12102; 28 C.F.R. § 36.104.
10. WS is MG's brother, and TG and AG are MG's sons, and RD is MG's friend and, as such, all have 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.
11. SRMC is a hospital licensed by the Commonwealth of Virginia. SRMC is a "public accommodation" within the meaning of title III of the ADA, 42 U.S.C. § 12181(7)(F); 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 of a public accommodation. 42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a). Discrimination includes failing to take such steps as necessary to ensure that no individual with a disability is excluded, denied services, segregated, or otherwise treated differently than any other individual because of the absence of auxiliary aids and services. 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303.
13. On the basis of its investigation, the U.S. Attorney's Office has determined that:
    1. SRMC had an obligation to provide auxiliary aids and services to ensure effective communication with MG during FS's hospitalizations at SRMC because as FS's daughter, she is FS's "companion" pursuant to the ADA Regulations. 28 C.F.R. § 36.303.
    2. FS was admitted to SRMC nine times from June 23, 2010 through her death on September 8, 2014, including a twelve-day admission from December 22, 2012 through January 3, 2013, a five-day admission from March 29, 2014 through April 3, 2014, and a three-day admission from September 5, 2014 through September 8, 2014.
    3. SRMC failed to furnish a qualified sign language interpreter or otherwise provide an effective method of communicating with MG during numerous consequential and complex interactions.
    4. Because SRMC failed to provide a qualified sign language interpreter, the hospital's staff relied upon MG's family members and friends, WS, TG, AG and RD, to facilitate communication with MG.
    5. SRMC had an obligation to furnish MG with appropriate auxiliary aids and services in a timely manner to ensure effective communication during her three visits to SRMC's ED as a patient in September 2015. 28 C.F.R. § 36.303. SRMC failed to meet this obligation for these three visits. Because SRMC failed to provide a qualified sign language interpreter, SRMC relied upon family members and friends to facilitate communication during these three hospital visits.
14. SRMC's failure to provide appropriate auxiliary aids and services to ensure effective communication with MG violates 42 U.S.C. § 12182(b)(2)(A)(iii); 28 C.F.R. § 36.303.
15. SRMC's reliance upon MG's family members and friends (i.e., TG, WS, AG and RD) to facilitate communication with MG violates 42 U.S.C. § 12182(b)(1)(E) and 28 C.F.R. § 36.303(c)(3), and as such, they are aggrieved individuals. 42 U.S.C. § 12188(2)(B); 28 C.F.R. § 36.504(a)(2).
16. The Parties have determined that the complaint filed with the United States can be resolved without litigation and have agreed to the terms of this Agreement.

DEFINITIONS

17. 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).
18. The term "SRMC Personnel" means all employees, both full and part-time, and employees of independent contractors with contracts to work for or with SRMC, including, without limitation, nurses, physicians, social workers, activities department employees, administrative staff, technicians, admitting personnel, billing staff, security staff, therapists, and volunteers, who have or are likely to have direct contact with Patients or Companions as defined herein.
19. The term "qualified interpreter" means an interpreter who, via a 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.
20. The term "Patient" shall be broadly construed to include any individual who is seeking or receiving the goods, services, facilities, privileges, advantages, or accommodations of SRMC.
21. 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).
22. "Patient medical files, records or charts" means the medical files and related records for an individual patient, including both the paper and electronic records.

EQUITABLE RELIEF

A. Prohibition of Discrimination

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

26. Appropriate Auxiliary Aids and Services. Pursuant to 42 U.S.C. § 12182(b)(2)(A)(iii), SRMC will provide to Patients and Companions, who are deaf or hard of hearing, any appropriate auxiliary aids and services that are necessary for effective communication after making the assessment described in paragraph 27 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 36 of this Agreement. SRMC will advise Patients and Companions who require auxiliary aids or services, in writing, that these are available throughout the Patient's stay.
27. 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 SRMC in consultation with the person with a disability. The assessment made by SRMC 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. SRMC's Communication Assessment Form is attached to this Agreement as Exhibit A. SRMC shall ensure that a completed Form is obtained from each individual patient or companion who agrees to complete the Form. SRMC shall provide assistance in completing the Form at the Patient's or Companion's request. After being completed, the Form(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 SRMC but is expected at SRMC during the patient's stay, SRMC Personnel shall provide the patient with the contact information of SRMC Personnel who can assist the companion in completing the Form. As part of this Agreement, SRMC agrees that if at any point during a patient's stay, a companion identifies himself or herself as deaf or hard of hearing, SRMC shall promptly provide him/her with the Form, if it has not done so already.
28. 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 SRMC learns that a Patient or Companion who is deaf or hard of hearing will be using its services or on the arrival of the Patient or Companion who is deaf or hard of hearing at SRMC, whichever is earlier. SRMC Personnel will perform an assessment (see paragraph 27) as part of each initial inpatient assessment and document the results in the Patient's medical chart. SRMC Personnel will reassess, as appropriate, 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.
29. ADA Administrators. SRMC will designate at least one employee as an ADA Administrator and will have someone designated to act in his absence such that someone will always be on duty and available twenty-four (24) hours a day, seven (7) days a week, to answer questions and provide appropriate assistance regarding prompt access to, and proper use of, the appropriate auxiliary aids and services, including qualified interpreters. The ADA Administrator or his designee will know where the appropriate auxiliary aids are stored and how to operate them and will be responsible for their maintenance, repair, replacement, and distribution. SRMC will circulate and post broadly within SRMC the name, telephone number, function, and office location of the Administrator(s), including a TTY telephone number, through which the ADA Administrator or designee on duty can be contacted twenty-four (24) hours a day seven days a week by Patients and Companions who are deaf or hard of hearing. The SRMC Risk Manager, in consultation with the ADA Administrator, will be responsible for the complaint resolution mechanism described in paragraph 31 of this Agreement. The ADA Administrator will be designated by SRMC no later than 30 days following execution of this Agreement and will be subject to approval by the U.S. Attorney's Office.
30. Auxiliary Aid and Service Log. SRMC will maintain a log in which requests for qualified interpreters on site or through video remote services will be documented. The log will indicate the time and date the request was made, the name of the Patient or Companion who is deaf or hard of hearing, the time and date of the scheduled appointment (if a scheduled appointment was made), the auxiliary aid or service provided, and the time and date the appropriate auxiliary aid or service was initially provided. If no auxiliary aid or service was provided, the log shall contain a statement why the auxiliary aid and service was not provided. The log should include the identity of the SRMC personnel who conducted the assessment and made the determination. Such logs will be maintained by the ADA Administrator or designee for the entire duration of the Agreement, and will be incorporated into the semi-annual Compliance Reports as described in paragraph 55 of this Agreement.
31. Complaint Resolution. SRMC will establish a grievance resolution mechanism for the investigation of disputes regarding effective communication with Patients and Companions who are deaf or hard of hearing. SRMC will maintain records of all grievances regarding effective communication, whether oral or written, made to SRMC and actions taken with respect thereto. At the time SRMC completes its assessment described in paragraph 27 and advises the Patient and/or Companion of its determination of which appropriate auxiliary aids and services are necessary, SRMC 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. A written response to any grievance filed shall be completed promptly, but no later than within seven (7) days of receipt of the complaint. Copies of all grievances related to provision of services for Patients or Companions who are deaf or hard of hearing and the responses thereto will be maintained by the ADA Administrator or designee for the entire duration of the Agreement, and will be incorporated into the semi-annual Compliance Reports as described in paragraph 55 of this Agreement.
32. Prohibition of Surcharges. All appropriate auxiliary aids and services provided by SRMC will be provided free of charge to the Patient or Companion who is deaf or hard of hearing.
33. Record of Need for Auxiliary Aid or Service. SRMC will take appropriate steps to ensure that all SRMC Personnel are made aware of a Patient or Companion's disability and auxiliary aid and services needed so that effective communication with such person will be achieved. These steps will include designating this information in the medical record. The patient's medical record shall be conspicuously labeled (such as with a sticker, indicator, or label on the cover) to alert SRMC 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

34. 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, the SRMC 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 SRMC conducts its initial and periodic assessments of a patient;
    3. Explaining medical conditions, treatment options, tests, medications, surgery and other procedures;
    4. Providing a diagnosis and recommendation for treatment;
    5. Communicating with a patient during treatment, including physical and occupational therapies, testing procedures, and during physician's rounds;
    6. Obtaining informed consent for treatment;
    7. Providing instructions for medications, pre- and post-surgery instructions, post-treatment activities and follow-up, treatments;
    8. Providing mental health services, including group or individual counseling for patients and family members;
    9. Providing information about blood or organ donations;
    10. Discussing powers of attorney, living wills and/or complex billing and insurance matters;
    11. During educational presentations;
    12. Discussing discharge planning and discharge instructions; and
    13. When SRMC provides religious services and spiritual counseling.
35. Chosen Method for Obtaining Interpreters.

    Within thirty (30) days after execution of this Agreement, SRMC will identify one or more interpreter services and will make appropriate arrangements with said services to provide qualified on site interpreters as well as VRI services at the request of SRMC. SRMC will establish internal procedures for ordering interpreting services that is consistent with the interpreter or interpreter agencies' procedures. At a minimum, all of SRMC's requests for interpreters, including the time, date and location, will be confirmed in writing at the time of the request. If the hospital receives verbal confirmation or speaks with the vendor regarding the hospital's request for an interpreter, this information will be documented in the Interpreter's Log. SRMC will retain a copy of all written correspondence with interpreting services. Additionally, for the duration of this Agreement, SRMC will file a copy of its written correspondence with interpreters and interpreting agencies in the Auxiliary Aid and Service Log discussed in paragraph 30.

36. Provision of Interpreters in a Timely Manner.
    1. Non-scheduled Interpreter Requests: A "non-scheduled interpreter request" means a request for an interpreter made by a Patient or Companion who is deaf or hard of hearing with less than two (2) hours advance notice. For non-scheduled interpreter requests, SRMC Personnel will complete the assessment described in paragraph 27 above. The interpreter shall be provided no more than (a) two hours from the time SRMC completes the assessment if the service is provided through a contract interpreting service or a staff interpreter who is located off-site or (b) 15 minutes from the time SRMC completes the assessment if the service is provided through a Video Remote Interpreting service as described in paragraph 37 below. Deviations from this response time will be addressed with the interpreting service provider, and performance goals will be reviewed with the U.S. Attorney's Office. If no interpreter can be located, SRMC Personnel will take the following additional steps:
       1. SRMC Personnel will exert reasonable efforts (which shall be deemed to require no fewer than five (5) telephone inquiries and/or emails and/or text messages unless exceptional circumstances intervene) to contact any interpreters or interpreting agencies already contracted with SRMC and request their services;
       2. Inform the ADA Administrator of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;
       3. Inform the Patient or Companion 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; 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, SRMC will complete the assessment described in paragraph 27 above in advance, and, when an interpreter is appropriate, SRMC 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, SRMC will immediately call an interpreter service for another qualified interpreter.
    3. Data Collection on Interpreter Response Time and Effectiveness. SRMC will monitor the performance of each qualified interpreter it uses to provide communication to Patients or Companions who are deaf or hard of hearing by monitoring their response time and seeking feedback from the individual who requires the services of the interpreter. As part of the Auxiliary Aid and Service Log, described in paragraph 30, SRMC shall collect and maintain information regarding response times and effectiveness for requests for interpreters.
37. 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, SRMC 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. 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 SRMC'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 in which case the determination that VRI is not effective shall count as the completion of assessment for timing purposes. Further, if the VRI device is not functioning properly and SRMC's staff is unable to get the VRI device to function properly within 30 minutes of when it started to malfunction, it will call for an on-site interpreter.
38. Notice to Patients and Companions, Who are Deaf or Hard of Hearing. As soon as SRMC Personnel have determined that a qualified interpreter is necessary for effective communication with a Patient or Companion who is deaf or hard of hearing, SRMC will inform the Patient or Companion of the current status of efforts being taken to secure a qualified interpreter on his or her behalf. SRMC 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 SRMC's obligation to provide qualified interpreters in a timely manner as required by paragraph 36 of this Agreement.
39. Other Means of Communication. SRMC agrees that between the time an interpreter is requested and the interpreter is provided, SRMC Personnel will continue to try to communicate with the Patient or Companion who is deaf or hard of hearing for such purposes and to the same extent as they would have communicated with the person but for the disability, using all available methods of communication, including using sign language pictographs. This provision in no way lessens SRMC's obligation to provide qualified interpreters in a timely manner as required by paragraph 36 of this Agreement.
40. Restricted Use of Certain Persons to Facilitate Communication. SRMC 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. SRMC 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.
41. Individuals May Revise Their Communication Requests. If a Patient or Companion indicates to SRMC Personnel that he or she wants an interpreter after failing to request one on the Deaf or Hard of Hearing Communication Request Form, SRMC Personnel shall provide the services of an interpreter.

D. Telephones and Related Equipment

42. Telephones in Patient Rooms. Within sixty (60) days of the Effective Date of this Settlement Agreement:
    1. Portable access technology – defined. SRMC will make available portable access technology. Such technology, as referred to in this section, shall include TTY's with printout capability, other electronic devices, visual notification devices for incoming telephone calls, volume control telephones, and telephones that are hearing aid compatible. SRMC will ensure that each volume control telephone complies fully with § 704.3 of the 2010 Standards.
    2. Portable access technology - general obligation. SRMC 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. In units of SRMC where patients normally do not have telephones in their rooms, if hearing patients are given access to common area telephones other than the public phones identified in this Settlement Agreement, SRMC will maintain appropriate portable access technology that can be used by Patients and Companions so that such persons have equal access to make outgoing calls and receive incoming calls as do hearing persons.
    3. Electrical Outlets. Each patient room with a telephone shall have an electrical outlet within sufficient distance of the telephone connection to facilitate the use of a TTY device.
    4. Timeliness. Within sixty (60) days of the Effective Date of this Settlement Agreement, SRMC will make the equipment required by this section available within thirty (30) minutes of a Patient's arrival in a patient room when requested, regardless of the hour of the day or night. SRMC will notify all relevant Personnel of the availability and location of this equipment.
43. Televisions and Caption Decoders. Within sixty (60) days of the Effective Date of this Settlement Agreement, SRMC will ensure that Patients and Companions with who are deaf or hard of hearing have priority use of televisions with closed captioning capabilities. 28 C.F.R. § 36.303(e).

E. Notice to Community

44. Policy Statement. Within ninety (60) days of the entry of this Agreement, SRMC shall post and maintain signs of conspicuous size and print at all SRMC admitting stations and wherever a Patient's Bill of Rights is required by law to be posted. Such signs shall be to the following effect (and shall include the appropriate contact information):

    Sign language and oral interpreters, TTYs, and other auxiliary aids and services are available free of charge to people who are deaf or hard of hearing. For assistance, please contact any SRMC Personnel or the Information Office at _____________(voice/TTY), room ______.

45. Website. SRMC will include on its website the policy statement described in paragraph 44 above.
46. Patient Handbook. Effective as of January 2018, SRMC will include in 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, such as: sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with caption capability or closed caption decoders, and open and closed captioning of most SRMC programs.

    Please ask your nurse or other SRMC Personnel for assistance, or contact the Information Office at ______________ (voice or TTY), room _________________.

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

Notice to SRMC Personnel and Physicians

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

    If you recognize or have any reason to believe that a Patient or a relative, close friend, or Companion of a Patient is deaf or hard of hearing, you must advise the person that appropriate auxiliary aids and services, such as sign language and oral interpreters, video remote interpreting services, TTYs, note takers, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with captioning or closed caption decoders, and open and closed captioning of most hospital 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 ________________.

    SRMC will deploy this policy on the intranet within thirty (30) days of the Effective Date of this Agreement to all SRMC Personnel and to physicians with active medical staff privileges.

G. Training

48. Training of ADA Administrator. SRMC will provide mandatory training for the ADA Administrator(s) within thirty (30) days of designation as provided in paragraph 29 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 different circumstances;
    2. the mandatory use of the Communication Assessment form in paragraph 27 and SRMC's policy entitled "Accommodating Persons Who Are Deaf or Hard of Hearing," dated November 2017;
    3. to secure qualified interpreter services as quickly as practicable when necessary;
    4. the need to document all communications with sign language interpreting services, including the order and confirmation that the service will be sending an interpreter at the time, date and location requested;
    5. to encourage clinical staff members to notify SRMC of Patients and Companions who are deaf or hard of hearing as soon as Patients schedule admissions, tests, rehabilitation, or other health care services at the SRMC;
    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. SRMC's complaint resolution procedure described in paragraph 31 of this Agreement.
49. Training of SRMC Personnel. SRMC will provide mandatory annual in-service training to all SRMC Personnel.
    1. The training will address the needs of Patients and Companions who are deaf or hard of hearing and will include the following objectives:
       1. to promptly identify communication needs of Patients and Companions who are deaf or hard of hearing;
       2. the mandatory use of the Communication Assessment form referenced in paragraph 27, entitled "Services for Persons who are Deaf or Hard of Hearing," dated November 2017, and SRMC's policy entitled "Accommodating Persons Who Are Deaf or Hard of Hearing," dated November 2017;
       3. to secure qualified interpreter services or video remote interpreting services as quickly as possible when necessary;
       4. the need to document all communications with sign language interpreting services, including the order and confirmation that the service will be sending an interpreter at the time, date and location requested; and 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) days of the Effective Date of this Agreement.
    3. New employees must be trained within thirty (30) days of their hire. A screening of a video of the original training will suffice to meet this obligation.
50. Training of Telephone Operators. All SRMC Personnel who receive incoming telephone calls from the public will receive instructions by SRMC on using TTYs or relay services to make, receive, and transfer telephone calls and will receive training generally on the existence in SRMC of an ADA Administrator, as detailed in paragraph 29 of this Agreement, and the complaint resolution process, as described in paragraph 31 of this Agreement. Such training must be provided within 90 days of the Effective Date of this Agreement and will be conducted annually thereafter.
51. Training Attendance Sheets. SRMC will maintain in electronic form for the duration of this Agreement, confirmation of training conducted pursuant to paragraphs 48-50 of this Agreement, which will include the names, signature, and respective job titles of the attendees, as well as the date and time of the training session.
52. Notice to Active Medical Staff. In addition to providing the training in paragraph 49 above, SRMC will create and send an email blast advising active medical staff of its policy on the communication needs of Patients or Companions who are deaf or hard of hearing and will invite physicians with active medical staff privileges at SRMC to complete ADA specific training. This email will direct active medical staff to SRMC's web page which will include: (1) SRMC's Policy Statement for persons working at the hospital as described in paragraph 47 and any relevant forms; and (2) a request that active medical staff notify SRMC of Patients and Companions who are deaf or hard of hearing as soon as they schedule admissions, tests, or other health care services at the hospital.
53. Use of Outside Trainer. SRMC will hire an independent agency or group to conduct the initial trainings described in this Agreement for the following positions: Senior Administrators/Hospital Executives (CEO, COO, CFO, CNO, VPs); Directors of Clinical and non-clinical departments; Managers of clinical and non-clinical departments; ADA Coordinator; ADA Coordinator Designees (Hospital Nurse Supervisors); Emergency Department Registrars; Emergency Department Director and Managers; Emergency Department Charge Nurses and Triage Nurses; Charge Nurses for Inpatient Units (hereinafter referred to collectively as the "Initial Trainees"). The Initial Trainees will thereafter be responsible for training remaining SRMC Personnel with the materials used by the independent agency. The independent agency used to train the Initial Trainees shall be subject to the approval of the U.S. Attorney's Office. For the required annual trainings thereafter, SRMC may conduct trainings of the Initial Trainees without the assistance of an independent group, but must sufficiently update and/or create training materials in order to ensure the trainings include any new developments to the ADA and its requirements. SRMC may also videotape the initial trainings for annual trainings as long as SRMC also ensures that it supplements such training with any new developments to the ADA and its requirements.

H. Reporting, Monitoring, and Violations

54. Training Materials. Within sixty (60) days of the effective date of this Agreement, SRMC will provide the United States with a copy of all training materials used to train its staff, training attendance sheets required in Paragraph 51, above, and photographs of the notices posted in its offices pursuant to this Agreement.
55. Compliance Reports. Beginning six months after the Effective Date of this Agreement and every six months thereafter for the entire duration of the Agreement, SRMC will provide a written report ("Compliance Report") to the U.S. Attorney's Office regarding the status of its compliance with this Agreement. The Compliance Report will include data relevant to the Agreement, including but not limited to:
    1. the Auxiliary Aid and Service Log described in paragraph 30; and
    2. the number of complaints received by SRMC from Patients and Companions who are deaf or hard of hearing regarding auxiliary aids and services and/or effective communication, and the resolution of such complaints including any supporting documents, as described in paragraph 31.

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

56. Complaints. During the term of this Agreement, SRMC 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 SRMC failed to provide auxiliary aids and services to Patients or Companions who are deaf or hard of hearing, or otherwise failed to provide effective communication with such Patients or Companions. Such notification must be provided in writing via certified mail within twenty (20) days of the date SRMC 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 SRMC relevant to the allegation. SRMC will reference this provision of the Agreement in the notification to the U.S. Attorney's Office.

I. Compensatory Relief for Complainants and Release

57. Within ten (10) days after receiving the complainants' signed releases (a blank release form is at Exhibit B) and completed W-9s, SRMC will send six checks as follows: (1) in the amount of one hundred and ten thousand dollars ($110,000.00) made out to Complainant MG (with her full name on the check); (2) in the amount of five thousand dollars ($5,000) made out to TG (with his full name in the check); (3) in the amount of three thousand ($3,000) made out to AG (with his full name on the check); (4) in the amount of two thousand ($2,000) to RD (with her full name on the check); and (5) in the amount of one thousand ($1,000) dollars to WS (with his full name on the check). These checks are compensation to the aggrieved parties pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in paragraphs 2 and 5 above. The checks shall be mailed to:

Financial Litigation Unit
United States Attorney's Office for
Eastern District of Virginia
101 W. Main Street #8000
Norfolk, VA 23510

A copy of the checks shall be sent to:

Steven Gordon
Assistant United States Attorney
2100 Jamieson Avenue
Alexandria, VA 22314

J. Enforcement and Miscellaneous

58. This Agreement will be in effect for three (3) years from the Effective Date.
59. In consideration of the terms of this Agreement as set forth above, the Attorney General agrees to refrain from undertaking further investigation or from filing a civil suit under title III of the ADA related to the allegations in paragraphs 2 and 5, except as provided in paragraph 60. 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 SRMC 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.
60. 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 the requirements thereof has been materially violated by instituting a civil action in the U.S. District Court. If the United States believes that this Agreement or the requirements thereof have been materially violated, it will raise its claim(s) in writing with SRMC, and the parties will attempt to resolve the concern(s) in good faith. The United States will allow SRMC thirty (30) days from the date it notifies SRMC 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.
61. 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.
62. 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. SRMC has a duty to so inform any such successor in interest of this Agreement.
63. Failure by the United States to seek enforcement of this Agreement pursuant to its terms with respect to any instance or provision shall not be construed as a waiver to such enforcement with regard to other instances or provisions.
64. The effective date of this Settlement Agreement is the date of the last signature below.
65. 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.