SETTLEMENT AGREEMENT

BETWEEN

THE UNITED STATES OF AMERICA

AND

FRISBIE MEMORIAL HOSPITAL

D.J. NO. 202-47-52

This action was initiated by a complaint filed with the United States against Frisbie Memorial Hospital (“the Hospital”). The complaint was investigated by the Department of Justice and the United States Attorney’s Office for the District of New Hampshire under the authority granted by section 308(b) of the Americans with Disabilities Act of 1990 ("ADA"), 42 U.S.C. § 12188.
The Hospital is an acute care facility located at 11 Whitehall Road in Rochester, New Hampshire.
The complainants in this matter, [redacted], are individuals with disabilities within the meaning of the ADA, 42 U.S.C. § 12102(2) and its implementing regulation at 28 C.F.R. Part 36. [redacted] is deaf and [redacted] is hard-of-hearing.
The Hospital is a “public accommodation” as defined in 42 U.S.C. § 12181(7)(F) and its implementing regulation, 28 C.F.R. § 36.104, because it is a private entity that operates a place of public accommodation, specifically, a hospital.
The ADA prohibits public accommodations, including hospitals, from discriminating on the basis of disability in the full and equal enjoyment of the goods, services, facilities, privileges, advantages or accommodations. 42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a).
The complainants allege that the Hospital discriminated against them by failing to provide them with the full and equal enjoyment of the Hospital’s goods, services, facilities, privileges, advantages or accommodations and by failing to provide appropriate auxiliary aids and services when necessary for effective communication. [redacted] is deaf and uses American Sign Language as her primary means of communication. The complainants allege that [redacted] was unable to communicate adequately with Hospital Personnel while she was receiving medical treatment at the Hospital in July of 2005 because she was not provided with sign language interpreters, she was required to use inadequate or inappropriate auxiliary aids, and Hospital Personnel did not know how to operate auxiliary aids. The complainants further allege that, in some instances, [redacted] was required to rely upon [redacted] to assist her in communicating about her medical concerns.
The United States has conducted an investigation of the complainants’ allegations. The Hospital has cooperated in that investigation. As a result of the investigation, the United States takes the position that the Hospital violated title III of the ADA and its implementing regulation by discriminating against the complainants.
The Hospital disputes the complainants’ factual allegations and the claim that it discriminated against the complainants and expressly denies any liability. Without conceding the allegations of the United States or the complainants, or the possible defenses of the Hospital, all parties agree that it is in their best interests to resolve this matter promptly and without protracted litigation. This Settlement Agreement shall not be construed as an admission of liability by the Hospital. In consideration of the terms of this Settlement Agreement, the United States agrees to refrain from undertaking further investigation or from filing a civil suit in this action, except as provided in paragraphs 85 and 86. In entering this Settlement Agreement, the United States has specifically taken into consideration a variety of issues related to interpreter availability that are unique to New Hampshire, as well as the New Hampshire Seacoast area.
The parties hereby agree to the following:

DEFINITIONS

The term "Appropriate Auxiliary Aids and Services" includes, but is not limited to: qualified sign language, oral, relay or tactile interpreters, video interpreting services, qualified note-takers, computer-assisted real time transcription services, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, closed caption decoders, open and closed captioning, TTY’s, acquisition or modification of equipment or devices, universal sound signalers, sonic blink strobe receivers, telephone signalers, and other methods of delivering effective communication that may have come into use or will come into existence in the future. 28 C.F.R. § 36.303.
The term “Companion” means 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 with respect to the Patient’s medical condition or medical advice.
The term “deaf” shall refer to persons who are deaf, late-deafened or hard-of-hearing. The term “hard-of-hearing” includes persons who have a hearing deficit and who may or may not primarily use visual aids for communication and may or may not use auxiliary aids.
The term “Effective Date of this Settlement Agreement” means the date of the last signature on this Settlement Agreement.
The term "Hospital Personnel" shall mean: all employees and independent contractors with contracts to work on a substantially full-time basis for the Hospital (or on a part-time basis for the Hospital), including, without limitation, nurses, physicians, social workers, technicians, admitting personnel, receptionists, telephone operators, billing staff, security staff, therapists, and all volunteers, who have or are likely to have direct contact with Patients or Companions. The term also includes all affiliated physicians or other health care professionals who have medical staff privileges that permit them to see and/or treat Patients at the Hospital.
The term “in-service” shall include, without limitation, such means of training or familiarization of Hospital Personnel as are customarily utilized by the Hospital including, without limitation, written policies and procedures, videotapes, training materials, training sessions, seminars, conferences, and the like.
The term “Parties” shall mean: the Hospital and the United States, acting by and through the Department of Justice and the United States Attorney’s Office for the District of New Hampshire.
The term “Patient” shall be broadly construed to include any deaf or hard-of-hearing individual (or individual accompanied by a deaf or hard-of-hearing Companion) who is seeking or receiving health care services, including mental health services, from the Hospital (whether on an inpatient or outpatient basis), as well as deaf or hard-of-hearing individuals seeking to use any other goods or services provided by the Hospital, such as the opportunity to donate blood or attend health education classes. The broad construction of this term also includes (but is not limited to) deaf or hard-of-hearing individuals seeking to communicate with representatives of the Hospital regarding past, present or future health care services, such as scheduling appointments, obtaining test results, and discussing billing issues.
The term “qualified note-taker” shall mean: one who is able to take notes effectively and accurately, using any necessary specialized vocabulary and terminology.
The terms "qualified sign language interpreter," "oral interpreter," or "interpreter" shall mean: an interpreter who is able to interpret competently, accurately, and impartially, both receptively and expressively, using any specialized terminology necessary for effective communication in a hospital setting to a Patient or a Companion who is deaf or hard-of-hearing, given that individual’s language skills and history. Not all interpreters are qualified for all situations. For example, an interpreter who is qualified to interpret using American Sign Language is not necessarily qualified to interpret orally. Someone who has only a rudimentary familiarity with sign language or finger spelling is not a "qualified sign language interpreter" under this Settlement Agreement. Likewise, someone who is fluent in sign language but who does not possess the ability to process spoken communication into the proper signs or to observe someone else signing and change his or her signed or finger-spelled communication into spoken words is not a qualified sign language interpreter. 28 C.F.R. § 36.104.
The term "Standards" shall mean: the ADA Standards for Accessible Design, as set forth at 28 C.F.R. Part 36, App. A (1994).
The term "TTY's" or "TDD's" shall mean: devices that are used with a telephone to communicate with persons who are deaf or hard-of-hearing by typing and reading communications.

PROHIBITION OF DISCRIMINATION

Non-Discrimination The Hospital will provide Appropriate Auxiliary Aids and Services, including qualified sign language interpreters, where such aids and services are necessary to ensure effective communication with Patients and Companions and do not impose an undue burden on the Hospital or fundamentally alter its services, as required by the ADA. Pursuant to 42 U.S.C. § 12182(a), the Hospital will also provide Patients and Companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the Hospital as required by this Settlement Agreement and the ADA. The Hospital shall not deny its services, privileges, facilities, advantages, and accommodations to anyone based on the fact that the person is deaf or hard-of-hearing or is associated with someone known to be deaf or hard-of-hearing, as required by the ADA.
Retaliation and Coercion The Hospital agrees not to retaliate against or coerce in any way any person who made or is making a complaint according to the provisions of this Settlement Agreement or is exercising his or her rights under this Settlement Agreement or the ADA.

PROGRAM FOR EFFECTIVE COMMUNICATION

General Obligations

Appropriate Auxiliary Aids and Services Consistent with 42 U.S.C. § 12182 (b)(2)(A)(iii), the Hospital will provide to Patients and Companions any Appropriate Auxiliary Aids and Services that may be necessary for effective communication after making the determination described in paragraph 28 of this Settlement Agreement. Appropriate Auxiliary Aids and Services will be provided as soon as practicable, except that the provision of qualified interpreters must be within the time frame described in paragraphs 44 and 45 of this Settlement Agreement.
Establishment of Program to Provide Appropriate Auxiliary Aids and Services Within 60 days of the Effective Date of this Settlement Agreement, the Hospital will design and institute a program to implement the provisions of this Settlement Agreement, including without limitation:
1. developing, coordinating, and overseeing the development of specific procedures to implement fully this Settlement Agreement;
2. scheduling, announcing, and promoting all training required by this Settlement Agreement;
3. coordinating the community outreach required by this Settlement Agreement;
4. modifying medical and intake forms as necessary to ensure that the Hospital makes the communication determination required by this Settlement Agreement for each Patient or Companion, including developing a communication determination form; and
5. developing a plan for drafting, maintaining, and providing all reports required by this Settlement Agreement.
Program Administrators Simultaneously with the establishment of the program, the Hospital shall designate two or more positions (“Program Administrators”), who shall be available twenty-four (24) hours a day, seven (7) days a week, to answer questions and provide appropriate assistance regarding immediate access to and proper use of Appropriate Auxiliary Aids and Services required by this Settlement Agreement, including providing qualified interpreters within the time frames set forth in this Settlement Agreement. Such Program Administrators shall know where the Appropriate Auxiliary Aids are stored and how to operate them and will have and exercise authority to require their maintenance, repair, replacement, and distribution. The Hospital will circulate broadly within the Hospital the names, telephone numbers, functions, and office locations of such Program Administrators, including a TTY telephone number that may be called by Patients and Companions in order to obtain the assistance of such Program Administrators. Program Administrators will respond to routine telephone inquiries about the program during normal business hours and maintain a recording system for routine inquiries received after normal business hours. The Program Administrators will be responsible for the complaint resolution mechanism described in paragraph 38 of this Settlement Agreement. The Program Administrators will be designated by the Hospital no later than 30 days following the Effective Date of this Settlement Agreement. Nothing in this Settlement Agreement shall prohibit the Hospital from including the responsibility of the Program Administrators in the job descriptions of positions that have other duties and responsibilities.
Review of New and Modified Policies The Hospital shall submit copies of all policies and procedures that are created or modified in order to comply with this Settlement Agreement for review and approval to the United States prior to the implementation of such policies and/or procedures. The United States will make its best efforts to review the proposed policies and procedures within thirty (30) days of receipt. The Hospital will adjust these proposed policies and procedures to reflect any reasonable comments or concerns identified by the United States. The United States will not unreasonably withhold its approval of proposed policies and procedures. To the extent the United States fails to complete its review within thirty days, any deadline on a Hospital obligation related to any policy or procedure that is not reviewed within thirty days shall be automatically extended by the number of days in excess of 30 days taken by the United States to complete its review.

Provision of Appropriate Auxiliary Aids and Services

General Determination Criteria The 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 by the Hospital Personnel who are otherwise primarily responsible for coordinating and/or providing patient care services. This determination will be made in consultation with the Patient or Companion, wherever possible, to determine what type of auxiliary aids or services are needed to ensure effective communication. The Hospital will develop a form for conducting this determination no later than thirty (30) days following the Effective Date of this Settlement Agreement. The determination made by Hospital Personnel will take into account all relevant facts and circumstances, including without limitation the following:
1. the nature, length, and importance of the communication at issue;
2. the individual’s communication skills and knowledge;
3. the Patient’s health status or changes thereto;
4. the Patient’s and/or Companion’s request for or statement of need for an interpreter or other specific auxiliary aid or service;
5. the reasonably foreseeable health care activities of the Patient (e.g., group therapy sessions, medical tests or procedures, rehabilitation services, meetings with health care professionals or social workers, or discussions concerning billing, insurance, self-care, prognoses, diagnoses, history, and discharge); and
6. the availability at the required times, day or night, of Appropriate Auxiliary Aids and Services.
Timing of Determination The initial determination will be made at the earliest of the following: (1) the time an appointment is scheduled, provided that the Patient or Companion communicates the need for auxiliary aids or services; (2) the time the Hospital becomes aware that a Patient or Companion who may require auxiliary aids or services is en route to the Hospital; or (3) the time the Patient or Companion initially comes in contact with Hospital Personnel. Hospital Personnel will perform and document a communication determination as part of each initial Patient assessment. Completion of communication determinations, including copies of any determination form used, will be documented in the Patient's medical record. In all instances where Hospital Personnel become aware that a Patient or Companion is en route to the Emergency Department (by ambulance or otherwise), Hospital Personnel will make reasonable efforts to conduct a determination in advance of the Patient or Companion’s arrival and seek to have Appropriate Auxiliary Aids and Services available as soon as practicable after the Patient or Companion’s arrival at the Hospital.
Redetermination The Hospital shall reassess its determination of which Appropriate Auxiliary Aids and Services are necessary, in consultation with the Patient or Companion, when a Patient or Companion indicates that communication has not been effective. The Hospital will document any instances where Patients or Companions indicate that the auxiliary aids and services provided by the Hospital failed to provide effective communication. The Hospital will document any redeterminations and the results of any redeterminations.
Subsequent Patient Visits The Hospital shall implement policies and procedures to expedite arrangements for the provision of Appropriate Auxiliary Aids and Services when a Patient or Companion requests Appropriate Auxiliary Aids and Services for subsequent visits to the Hospital. Hospital Personnel shall keep appropriate records that reflect the provision of auxiliary aids and services to Patients and Companions, such as notations in Patients’ medical charts. Such records should document whether or not any particular auxiliary aids and services (or individual interpreters) provided effective communication. During a Patient or Companion’s subsequent visit, Hospital Personnel shall reference the Patient’s prior medical records, where available, as part of the Communication Determination required by paragraph 28.
Medical Concerns Nothing in this Settlement Agreement will require that an electronic device or equipment constituting an appropriate auxiliary aid be used when or where its use may interfere with medical or monitoring equipment or may otherwise constitute a threat to the Patient’s medical condition. Similarly, nothing in this Settlement Agreement shall be construed to require the Hospital or Hospital Personnel to take any action or inaction (including without limitation delaying or refraining from assessing or treating a Patient) if taking the action or inaction would jeopardize the safety of a Patient, adversely affect the Patient’s condition, interfere with sound medical judgment or professional practice or compromise the quality of a Patient’s medical care.
Determination Not to Provide Auxiliary Aid or Service If, after conducting a determination, the Hospital determines that the circumstances do not warrant provision of a particular auxiliary aid or service. Hospital Personnel will so advise the person requesting the auxiliary aid or service and will document the date and time of the denial, the name and title of the Hospital Personnel making the determination, and the basis for the determination. A copy of this documentation will be provided to the Patient (and Companion, if applicable); will be maintained with the Auxiliary Aid and Service Log described in paragraph 36 of this Settlement Agreement; and will be placed in the Patient’s medical chart. Any determination to provide an interpreter through a video interpreting service when a Patient or Companion has requested a live interpreter also will be documented. It is understood that, even if the Hospital determines that a particular auxiliary aid or service is not to be provided, some means of effective communication must be secured.
Prohibition of Surcharges for Patients or Companions All Appropriate Auxiliary Aids and Services required by this Settlement Agreement will be provided free of charge to the Patient and/or Companion.
Individual Notice in Absence of Request If a Patient and/or Companion does not request Appropriate Auxiliary Aids or Services, but Hospital Personnel have reason to believe, after conducting the determination described in paragraph 28 of this Settlement Agreement, that such person would benefit from Appropriate Auxiliary Aids and Services for effective communication, the Hospital will specifically inform the Patient and/or Companion that Appropriate Auxiliary Aids and Services are available free of charge.
Auxiliary Aid and Service Log The Hospital will maintain a log of: (a) each request for an Appropriate Auxiliary Aid and Service; (b) the type of auxiliary aid or service requested; (c) the time and date the request is made; (d) the name of the Patient (and Companion, if applicable); (e) the time and date of the scheduled appointment (if a scheduled appointment was made); (f) the name of the Hospital Personnel who performed any communication determination or redetermination; (g) the name of any Hospital Personnel responsible for determining whether or not to provide the requested Appropriate Auxiliary Aid or Service; (h) the nature of the auxiliary aid or service provided; (i) the time and date the Appropriate Auxiliary Aid and Service was provided, or a statement that the Appropriate Auxiliary Aid and Service was not provided and the reason why the aid or service was not provided. Such logs will be maintained by the Program Administrators for the entire duration of the Settlement Agreement, and will be incorporated into the semi-annual Compliance Reports, as allowed by state and federal law, as described in paragraph 78 of this Settlement Agreement.
Communication with Patients and Companions The Hospital will take appropriate steps to ensure that all Hospital Personnel having contact with a Patient or a Companion are made aware of such person’s need for an Appropriate Auxiliary Aid and Service so that effective communication with such person will be achieved. In addition, the Hospital will take appropriate steps to ensure that all Hospital Personnel having contact with a Patient or Companion are aware of: (a) the Hospital’s policies and procedures implementing this Settlement Agreement and the ADA; (b) the Hospital’s policies and procedures governing requests for Appropriate Auxiliary Aids and Services by Patients and Companions; and (c) the role of the Program Administrators described in paragraph 26 of this Settlement Agreement.
Complaint Resolution The Hospital will maintain an effective complaint mechanism for the resolution of disputes regarding effective communication with Patients and Companions. The Hospital will maintain records of all complaints regarding effective communication, whether oral or written, made to the Hospital and actions taken with respect thereto. The Hospital will notify Patients and Companions of its complaint resolution mechanism, to whom complaints should be made, and of the right to receive a written response to the complaint. Within thirty (30) days of receipt of the complaint, the Hospital shall provide a written response to the complaint and shall provide a copy of the complaint and the response to the United States. Copies of all complaints or notes reflecting oral complaints concerning the need for or use of Appropriate Auxiliary Aids and Services and the responses thereto will be maintained by the Program Administrators for the entire duration of the Settlement Agreement. The United States has been provided a copy of the Hospital’s Grievance Policy in effect as of the Effective Date of this Settlement Agreement and acknowledges that it meets the requirements for an effective complaint resolution mechanism under this paragraph.

Provision of Qualified Interpreters

Circumstances Under Which Interpreters Will Be Provided The Hospital shall provide qualified sign language interpreters to Patients and Companions 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. Under circumstances where a qualified interpreter is not reasonably available, the provision of video interpreting services in accordance with Paragraph 49 may be sufficient to provide effective communication in some circumstances. The determination of when such interpreters shall be provided to Patients or Companions shall be made as set forth in paragraphs 28 through 30 above. The following are examples of circumstances when it may be necessary to provide interpreters:
1. determination of a Patient's medical history or description of ailment or injury;
2. provision of Patients' rights, informed consent or permission for treatment;
3. determination and explanation of Patient’s diagnosis or prognosis, and current condition;
4. explanation of procedures, tests, treatment, treatment options or surgery;
5. religious services and spiritual counseling provided by the Hospital;
6. explanation of living wills or powers of attorney (or their availability);
7. diagnosis or prognosis of ailments or injuries;
8. explanation of medications prescribed (such as dosage, instructions for how and when the medication is to be taken, and side effects or food or drug interactions);
9. determination of any condition or allergy of Patient that may affect choice of medication;
10. explanation regarding follow-up treatments, therapies, test results or recovery;
11. blood donations or apheresis (removal of blood components);
12. discharge planning and discharge instructions;
13. provision of mental health evaluations, group or individual therapy, counseling and other therapeutic activities, including, but not limited to, grief counseling and crisis intervention;
14. explanation of complex billing or insurance issues that may arise;
15. educational presentations, such as classes concerning birthing, nutrition, CPR, and weight management;
16. filing of administrative complaints or grievances against the Hospital or Hospital Personnel; and
17. any other circumstance in which a qualified sign language interpreter is necessary to ensure a Patient’s rights provided by law.
The foregoing list of circumstances is neither exhaustive nor mandatory, and shall not imply that there are not other circumstances when it may be appropriate to provide interpreters for effective communication or that an interpreter must always be provided in these circumstances.
Contract for Obtaining Interpreters The Hospital will use its best efforts to enter into a contract with one or more reputable interpreter(s) and/or interpreter agency(ies) to provide qualified interpreters at the request of the Hospital. Each such contract will, at a minimum, require the interpreter or agency to use good faith efforts to maintain a response time of one (1) hour or less (plus travel time) in at least eighty percent (80%) of non-scheduled incidents within any six (6) month period (excluding any incident when the determination call for an interpreter to be provided at a later time), measured from the time the call is placed to the interpreter or agency.
Free-Lance Interpreters Within sixty (60) days of the Effective Date of this Settlement Agreement, the Hospital will compile and maintain as current a list of all known free-lance sign language and oral interpreters who reside within forty-five (45) miles of the Hospital.
Staff Interpreters The Hospital may, but shall have no obligation to, satisfy its obligations under this Settlement Agreement by hiring or otherwise contracting with qualified staff interpreters. Staff interpreters must meet the definition of "qualified interpreters." Patients and Companions who are provided with staff interpreters must have the same level of coverage (for both duration and frequency) as the Hospital is otherwise obligated to provide under this Settlement Agreement. The Hospital may assign other duties to staff interpreters. To the extent that the Hospital does not have staff interpreters or a staff interpreter is not available when needed, the Hospital will follow the procedures set forth elsewhere in this Settlement Agreement to obtain the services of qualified interpreters.

Provision of Interpreters in a Timely Manner

Scheduled Incidents For Scheduled Incidents, where an interpreter is necessary to ensure effective communication, the Hospital will have video interpreting services available at the time of the scheduled appointment or will arrange to have a live interpreter available if a live interpreter is necessary in order to achieve effective communication (including situations identified in Paragraph 51 in which video interpreting services are not effective). “Scheduled Incidents” are situations in which there are two (2) or more hours between the time when a Patient or Companion makes a request for an interpreter and when the services of the interpreter are required (or four (4) or more hours if a request is made between the hours of 8:00 p.m. and 8:00 a.m. or on a weekend or a holiday). If an interpreter fails to arrive for the Scheduled Incident, the Hospital will immediately call the interpreter service for another qualified sign language interpreter upon notice that the interpreter failed to arrive. Similarly, when making a qualified interpreter available, Hospital Personnel shall clearly identify the interpreter’s availability and make immediate efforts to locate a replacement interpreter if it appears that the original interpreter will not be able to stay throughout the Scheduled Incident.
Non-scheduled Interpreter Requests; Time Standards “Non-scheduled interpreter requests” means a request for an interpreter which is made during the appearance at the Hospital by a Patient or Companion for examination or treatment that was not scheduled prior to the time such Patient or Companion came to the Hospital. After receiving a non-scheduled interpreter request, and determining in accordance with paragraph 28 that a live interpreter is necessary, the Hospital shall make an interpreter available as soon as practicable. Hospital Personnel will make the Hospital’s request for an interpreter within fifteen (15) minutes after completing a determination described in paragraph 28, above, that determines that a live interpreter is necessary. Hospital Personnel will also make such a request within fifteen (15) minutes of any situation identified in Paragraph 51 where video interpreting services are not effective. The Hospital will meet the following overall time standards for providing qualified sign language interpreters to Patients and/or Companions. The Hospital will maintain a response time of one (1) hour (plus travel time) in eighty percent (80%) of non-scheduled interpreter requests within any six (6) month period. Whether this standard is met will be measured beginning (15) minutes after it is determined that an interpreter is required. In no event will the Hospital’s response time exceed three (3) hours, except when the Hospital has been unable to obtain the services of a live interpreter after a prompt, diligent effort to comply with all of the requirements of this Settlement Agreement.
Specific Steps for Non-scheduled Interpreter Requests Within fifteen (15) minutes after completing a determination (as described in paragraph 28) that finds that interpreting services are required, Hospital Personnel will provide video interpreting services. Within 15 minutes after completing a determination (as described in paragraph 28) that determines that a live interpreter is required, Hospital Personnel will request an interpreter (qualified to interpret for the specific individual who will be using the services) from the interpreters or agencies with whom the Hospital has an ongoing contract for qualified interpreter services. If no interpreter can be located, Hospital Personnel will take the following additional steps:
1. Hospital 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 free-lance interpreters or other interpreting agencies already known to the Hospital and request their services;
2. inform a Program Administrator of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;
3. inform the Patient or Companion (or a family member or friend, if the Patient or Companion is unavailable) of the efforts taken to secure a qualified interpreter and that the efforts have failed, and follow up on reasonable suggestions for alternate sources of interpreters, such as contacting an interpreter known to that person;
4. clearly identify the interpreter’s availability and make immediate efforts to locate a replacement interpreter if it appears that the original interpreter will not be able to stay throughout the incident; and
5. document all of the above efforts.
Provision of Qualified Interpreters Throughout a Hospitalization The Hospital will develop a policy and implement procedures to ensure that once a Patient has been admitted to the Hospital and the determination described in paragraph 28 of this Settlement Agreement has determined that a qualified sign language interpreter is necessary to achieve effective communication during the hospitalization of the Patient, qualified interpreters are made available at all events requiring substantial communication between the Patient and the Hospital Personnel. It is highly likely that such events will include post-surgical sessions, doctor rounds, discharge meetings, and other physician-Patient meetings, as well as for the performance of any tests, procedures or therapy. A Patient will not be required to renew requests for a qualified interpreter for these events. In the case of Companions, the Hospital will provide a qualified interpreter for any event that the Companion will attend provided that the Hospital Personnel are advised in a reasonably timely fashion that the Companion will be present at the event. The Hospital will provide notice to all Patients and Companions of this policy.
Data Collection on Interpreter Response Time and Effectiveness: Feedback Forms The Hospital will monitor the performance of each qualified sign language interpreter it uses to provide communication to Patients or Companions. As part of the Auxiliary Aid and Service Log, described in paragraph 36 of this Settlement Agreement, the Hospital shall collect information regarding response times for each request for an interpreter. The Hospital shall also prepare a form requesting feedback concerning the timeliness and effectiveness of interpreter services. This feedback form shall be provided to each Patient or Companion who requests an interpreter or receives the services of an interpreter. The Hospital shall use the feedback forms for monitoring and evaluating the performance of each interpreter it provides to Patients and Companions. The Program Administrators shall maintain the completed feedback forms for the term of this Settlement Agreement.
Video Interpreting Services Video interpreting services, such as the Deaf Talk service used by the Hospital, can provide immediate, effective access to interpreting services seven days per week, twenty-four hours a day in a variety of situations including scheduled incidents, emergencies, and unplanned incidents and can also be used as a stop-gap measure until a qualified interpreter is available. When using video interpreting services, the Hospital shall ensure that: (a) the service delivers high quality, clear, delay-free full-motion video and audio over a dedicated high-speed Internet connection; (b) the service provides a clear and sharply delineated picture of the interpreter’s and the Patient’s or Companion’s heads, arms, hands, and fingers, regardless of the body position of the Patient or Companion; (c) voices being transmitted are clear and easily understood; and (d) the interpreter providing video interpreting services is a qualified interpreter who is capable of communicating effectively with the Patient or Companion.
The Hospital shall ensure that its staff is trained and able to operate and connect the video interpreting services quickly and efficiently and that the services are available at the Hospital at all times. The Hospital should connect the service within fifteen (15) minutes of a determination. Moreover, the Hospital shall train staff regarding the limitations of the technology, particularly with respect to: (a) Patients who have limited ability to move their heads, hands, or arms; vision problems; cognitive or consciousness issues; or pain issues; (b) Patients who may be moved repeatedly to areas of the Hospital that do not have a designated high speed Internet line; and (c) Patients who will be treated in rooms where space considerations militate against using the service. Once the system is operating, Hospital Personnel shall ask the Patient or Companion whether the video interpreting service is meeting his or her communication needs and make a record of his or her response.
In the event that the Patient or Companion indicates that he/she is unable to communicate effectively using the video interpreting service, the Hospital Personnel will: (a) document the concern; (b) make all reasonable efforts to locate a qualified sign language interpreter or other auxiliary aid or service that will provide effective communication; (c) document all such efforts; and (d) periodically inform the Patient/Companion of the status of those efforts.
Force Majeure The foregoing response times are subject to “force majeure” events - i.e., any response time that is delayed because of a force majeure event is excluded from the determination whether the prescribed response criteria have been met. Force majeure events are events outside the reasonable control of the Hospital, the interpreter service provider or the interpreter called to respond, such as weather problems and other Acts of God, unanticipated illness or injury of the interpreter while en route to the Hospital, unanticipated Internet or telephone problems, and unanticipated transportation problems (including, without limitation, mechanical failure of the interpreter’s automobile, automobile accidents and roadway obstructions, other than routine traffic or congestion).
Modification of Performance Standards In the event that the response time standards described in paragraphs 44 and 45 of this Settlement Agreement cannot be maintained despite the Hospital’s good faith efforts, the Hospital is entitled to request the consent of the United States to such modifications of the response time standards as may be reasonable under the circumstances. The United States will consider any such request reasonably and in good faith and will not deny its approval unreasonably. Any such modification to which the parties agree will be deemed an amendment to this Settlement Agreement.
Notice to Patients and Companions As soon as Hospital Personnel have determined that an interpreter is necessary for effective communication with a Patient or a Companion, and one hour later, the Hospital will inform such person (or a family member or friend, if such person is not available) of the current status of efforts being taken to secure the Appropriate Auxiliary Aids and Services on his or her behalf. Additional updates shall be provided thereafter as necessary until such aids and services are secured. Notification of efforts to secure a qualified interpreter does not diminish the Hospital’s obligation to provide qualified interpreters in a timely manner as required by paragraphs 44 and 45 of this Settlement Agreement.
Other Means of Communication The Hospital agrees that between the time an interpreter is requested and when an interpreter arrives, Hospital Personnel will continue to try to communicate with the Patient or Companion for such purposes as they would have communicated with the person but for the hearing impairment, using all available methods of communication. Such means of communication may include, but are not limited to, video interpreting services, written notes or sign language pictographs. This provision in no way lessens the Hospital’s obligation to provide qualified interpreters in a timely manner as required by this Settlement Agreement. Once an interpreter arrives, the Hospital Personnel will ensure that the Patient or Companion has a reasonable understanding of the care already provided and the current treatment plan.
Restricted Use of Certain Persons to Facilitate Communication Due to confidentiality, potential emotional involvement, and other factors that may adversely affect the ability to facilitate communication, the Hospital shall never require or coerce a family member, companion, case manager, advocate, or friend of a Patient or Companion who is deaf or hard-of-hearing to interpret or facilitate communications between Hospital Personnel and such Patient or Companion. In any case, such person shall be used to interpret or facilitate communication only if the Patient or Companion who is deaf or hard-of-hearing does not object, if such person wishes to provide such assistance, and if such use is necessary or appropriate under the circumstances, giving appropriate consideration to any privacy issues that may arise. A Patient or Companion’s waiver of a qualified sign language interpreter under this provision must be made in the Patient’s chart or records. This provision in no way lessens the Hospital’s obligation to provide Appropriate Auxiliary Aids and Services as required under this Settlement Agreement.

Telephones and Related Equipment

Public Telephones As soon as practicable but no later than sixty (60) days after the Effective Date of this Settlement Agreement, the Hospital will provide the following:
1. TTY's in public areas The Hospital will make a TTY device available wherever a telephone is made available to the public (whether public pay telephone, public closed circuit telephone, or otherwise). To satisfy this provision, the Hospital can permanently install the required TTY's or make available at least two portable TTY's. Standards §§ 4.1, 4.31.9. Each such TTY, whether permanently installed or portable, shall comply fully with §§ 4.30 and 4.31 of the Standards.
2. TTY's required in specific locations The Hospital will provide a TTY at each public telephone location in or adjacent to an emergency department, recovery room, or waiting room. Standards §§ 4.1, 4.31.9. To satisfy this provision, the Hospital can permanently install the required TTY's or make available at least two portable TTY's. Each such TTY, whether permanently installed or portable, shall comply fully with §§ 4.30 and 4.31 of the Standards.
3. Shelves and outlets Wherever portable TTY's are made available as an alternative to installed TTY's (at emergency departments, recovery rooms, and waiting rooms, and where there are banks of four or more public telephones), and wherever there is a bank of three or more public telephones, the Hospital will provide shelves and electrical outlets that comply with § 4.31.9 of the Standards.
4. Signs indicating the location of TTY's
  1. Wherever public telephones are available but TTY's are not permanently installed, the Hospital will post signs complying with the Standards. Such signs will indicate the location of the nearest portable or permanently installed TTY's; and
  2. Wherever TTY's are permanently installed, the Hospital will post signs complying with § 4.30 of the Standards to indicate their location.
5. Volume control telephones The Hospital will ensure that no less than twenty-five (25) percent of all public telephones are equipped with volume control mechanisms, plus at least one public telephone at each of the following locations: in or adjacent to emergency departments, recovery rooms, and waiting rooms. Each volume control telephone shall comply with § 4.31.5 of the Standards. The Hospital will ensure that volume control phones are dispersed among all public telephones throughout the Hospital. The Hospital will ensure that signs complying with § 4.30 of the Standards are displayed at each volume control telephone. Alternatively, if all public telephones are equipped with volume control mechanisms, the Hospital may satisfy this requirement by prominently displaying signs in diverse locations throughout the Hospital that state this fact.
6. Storage and availability of equipment Portable equipment required by this section for use in public areas shall be stored in a place or places that are readily accessible to all Hospital Personnel who have client contact at all times of the day and night. All Hospital Personnel will be notified of the storage location that is closest to their work area(s). The equipment is to be stored at the appropriate supervised location (e.g., nurses' station, admission desk, switchboard, etc.) closest to the public phone for which the equipment is to be made available. Such equipment shall be made available to Patients or Companions who are deaf or hard-of-hearing or who have speech impairments as soon as practicable but no more than fifteen (15) minutes from the time of the person’s request; except to the extent that it would compromise good medical care and/or the safety of other patients at the Hospital. Program Administrators (as discussed in paragraph 26) will be responsible for ensuring that this equipment remains readily accessible.
Telephones in Patient Rooms Within sixty (60) days of the Effective Date of this Settlement Agreement:
1. Portable access technology - defined The Hospital will make available portable access technology. Such technology, as referred to in this section, shall include TTY's with printout capability, visual notification devices for incoming telephone calls, volume control telephones, and telephones that are hearing aid compatible. The Hospital shall ensure that each volume control telephone and each visual notification device for incoming telephone calls complies fully with § 4.31 of the Standards.
2. Portable access technology - general obligation The Hospital 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 the Hospital 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, the Hospital 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 four (4) feet of the telephone connection to facilitate the use of a TTY device. The Hospital will provide a heavy-duty extension cord for any patient room that is not so equipped.
4. Timeliness Within sixty (60) days of the Effective Date of this Settlement Agreement, the Hospital will make the equipment required by this section available within thirty (30) minutes of a Patient's arrival in a patient room, regardless of the hour of the day or night. The Hospital will notify all relevant Hospital Personnel of the availability and location of this equipment.

Captioning and Decoders

Televisions and Caption Decoders Within thirty (30) days of the Effective Date of this Settlement Agreement, the Hospital will develop a policy to ensure that Patients and Companions with hearing impairments have priority use of televisions with closed captioning capabilities. 28 C.F.R. § 36.303(e).
Clearly stated directions for use of the closed caption capability shall be included in the Patient Guide or otherwise made available in each patient room or public area containing a television with captioning capability. The directions for operating the closed caption function shall also accompany all closed caption decoders for standard television sets.
Duty to Provide Visual Programs in a Manner That is Accessible to Persons WithHearing Impairments
1. It is expressly agreed that the Hospital does not have an obligation to provide captions on any program broadcast over the public airways or commercial cable television services, where such captions are not already integrated into the program.
2. Beginning no later than sixty (60) days from the Effective Date of this Settlement Agreement, if the Hospital solicits a third party, parent company, or affiliated health care provider to produce or provide video programs that may be broadcast within the Hospital to Patients or Companions, the Hospital will ensure that the program is captioned, unless, under the circumstances, doing so would impose an undue burden. 28 C.F.R. § 36.303. Commercial videos available to the general public shall not be subject to this requirement.
3. Beginning no later that sixty (60) days from the Effective Date of this Settlement Agreement, if the Hospital produces internally a pre-recorded program for broadcast to Patients and Companions within the Hospital, the Hospital will ensure that the program is made accessible to Patients and Companions, whether by captioning such program or by providing a transcript or sign language interpreter whenever it is viewed by a Patient or Companion. If the program is not captioned, the method of access delivery must be tailored to the needs of the Patient or Companion. For instance, if the person does not know sign language, the Hospital may provide effective communication through a transcript. In most circumstances, captioning will be regarded as providing effective communication with all deaf or hard-of-hearing persons, regardless of the communication skills and history of such persons (though repeated screenings may be necessary, if the deaf or hard-of-hearing person cannot read English at the rate required to keep pace with the audible portion of the program). If, however, the contents of a program are sufficiently important to require precise communication of its contents, the Hospital will take additional measures to ensure effective communication.
4. Beginning no later than sixty (60) days from the Effective Date of this Settlement Agreement, if the Hospital produces its own live broadcasts for Patients and Companions, it will make the majority of such programs accessible to Patients and Companions. Captioning is one way, but not the only way, to accomplish this objective. The Hospital can also choose to provide sign language interpreters (if the deaf or hard-of-hearing person uses sign language), written scripts prepared in advance of the live broadcast, or Hospital Personnel that assist in making the broadcast accessible. In order to determine which programs should be captioned, the Hospital may prioritize and consider such factors as the importance and length of the program, as well as any significant difficulty or expense in captioning the program or displaying the captions, given the location of its filming or viewing.

Miscellaneous Technology Provisions

Client Education The Hospital shall ensure that each Patient and Companion who is provided with portable access technology is appropriately directed as to the proper use of such equipment.
Acquisition of Additional Equipment In addition to the equipment required above, the Hospital shall purchase and/or rent such additional equipment as is reasonably needed to replace defective units as soon as practicable. The Hospital shall also monitor developments in technology and shall upgrade such equipment when and if it deems it reasonable and appropriate to do so.

NOTICE TO COMMUNITY

Policy Statement Within thirty (30) days of the Effective Date of this Settlement Agreement, the Hospital shall add the following statement to the signs it has posted throughout the emergency room and admitting areas notifying persons with difficulty hearing or speaking to ask a staff member for help: Sign language and oral interpreters, TTY’s, assistive listening devices, and/or other Auxiliary Aids and Services are available free of charge to Patients and Companions who need them for effective communication. For assistance, please contact any Hospital personnel or the program office at ____________ (voice/TTY), room ____________. International signs for accessibility, including the international symbols for “interpreters” and “TTY’s,” will be posted near the policy. This statement also shall be placed in a prominent location on the Hospital’s website.
Advertisements Within sixty (60) days of the Effective Date of this Settlement Agreement, the Hospital will take appropriate steps to publicize in the community the Hospital's commitment to provide all of its services to Patients and Companions. Such publicity shall be deemed satisfied by the purchase of reasonable advertising space at least twice in newspapers of general circulation serving the same community as is served by the Hospital, which advertisements will include a statement that, consistent with federal law, all Appropriate Auxiliary Aids and Services, including qualified sign language interpreters, TTY's, and assistive listening devices, will be provided free of charge upon request, and include appropriate instructions regarding access to the program office at the Hospital. The Hospital shall post this statement on its website within sixty (60) days of the Effective Date of this Settlement Agreement. Annually thereafter, the Hospital shall take reasonable steps to publicize the existence of the program to the deaf and hard-of-hearing community.
Patient Guide The Hospital will include in all future printings (if any) of its Patient Guide (or equivalent) and all similar publications a statement to the following effect: "To ensure effective communication with Patients and their Companions who are deaf or hard-of-hearing or who have speech impairments, consistent with federal law, we provide Appropriate Auxiliary Aids and Services free of charge, such as: sign language and oral interpreters, TTY's, note-takers, computer-assisted real time transcription services, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, closed caption decoders, and open and closed captioning of most Hospital programs. Please ask your nurse or other Hospital Personnel for assistance, or contact the program office at _________________ (voice or TTY), room __________." The Patient Guide (if printed in the future) shall also include a description of the Hospital’s complaint resolution mechanism. The Hospital shall provide all Patients or Companions who come into contact with Hospital Personnel at the Emergency Department with a copy of this Guide as soon as practicable after their arrival at the Emergency Department. The information required by this paragraph shall be included on the Hospital’s website within sixty (60) days of the Effective Date of this Settlement Agreement.
Information Made Available in ASL Within 120 days of the Effective Date of this Settlement Agreement, the Hospital will make the following information available in American Sign Language (ASL) using videotape, DVD, or CD-ROM format:
1. the Patient’s Bill of Rights;
2. health care directives;
3. information regarding the Hospital’s policies and procedures governing free sign language interpreter services, including the contents of the Hospital’s feedback form concerning the effectiveness and timeliness of interpreters that the Hospital provides; and
4. complaint resolution procedures.
Alternatively, the Hospital can comply with this provision by offering to have this information interpreted into ASL by a qualified interpreter or via a video interpreting service, provided that this is documented in the Patient’s medical records.

NOTICE TO HOSPITAL PERSONNEL AND PHYSICIANS

The Hospital shall publish, in an appropriate form, a written policy statement regarding the Hospital's policy for effective communication with Patients or Companions for use by persons working at the Hospital. 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, 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, TTY’s, 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 or closed captioning of most hospital programs, will be provided free of charge if such aids or services are necessary to ensure effective communication. 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 Program Administrator at ____ and reachable at ______. This offer and advice must likewise be made in response to any overt request for Appropriate Auxiliary Aids or Services.

The Hospital will distribute this document within thirty (30) days of the Effective Date of this Settlement Agreement to all Hospital Personnel and both employed and affiliated physicians (physicians with practicing or admitting privileges), and to all new Hospital Personnel (including newly employed or affiliated physicians) upon their affiliation or employment with the Hospital. In addition, this statement will also be distributed to all Hospital Personnel (including all employed and affiliated physicians) on an annual basis.

TRAINING

Training of Program Administrators The Hospital will provide special mandatory training for the Program Administrator(s) within sixty (60) days of designation as provided in paragraph 26 of this Settlement Agreement. Such training will be sufficient in duration and content to train the Program Administrators in:
1. the health care needs of the deaf and hard-of-hearing;
2. the various degrees of hearing impairment, language, and cultural diversity in the deaf community;
3. identification of communication needs of persons who are deaf;
4. the unique needs and problems encountered by late-deafened individuals;
5. the psychological implications of deafness and its relationship to interaction with hearing health care professionals;
6. recommended and required charting procedures governing requests for Appropriate Auxiliary Aids and Services;
7. types of auxiliary aids and services available in the community and Hospital;
8. the proper use and role of qualified sign language interpreters;
9. making and receiving calls through TTY’s and the relay service;
10. the Hospital’s complaint resolution procedure described in paragraph 38 of this Settlement Agreement; and
11. any other applicable requirements of this Settlement Agreement.
Training of Emergency Department Personnel The Hospital will provide special mandatory in-service training to Hospital Personnel (other than physicians or other members of the Hospital Medical Staff who are not employed by the Hospital, to whom the training shall be offered under paragraph 71) who have Patient responsibility and who work or volunteer in the emergency department. The training will address the special needs of Patients and Companions and will include the following objectives:
1. to promptly identify communication needs and preferences of deaf or hard-of-hearing persons;
2. to conduct the determination required by paragraph 28 of this Settlement Agreement;
3. to meet all of the documentation obligations set forth in this Settlement Agreement;
4. to secure qualified interpreter services as quickly as possible when necessary; and
5. to use, when appropriate, flash cards, pictographs, and a video interpreting service (in conjunction with any other available means of communication that will augment the effectiveness of the communication).
Such training must be provided no later than 90 days after the Effective Date of this Settlement Agreement and will be conducted annually thereafter.
Training of Physicians The Hospital will provide specialized mandatory in-service training to all physicians who are members of the Hospital’s active medical staff and who do not receive the training discussed in paragraph 70. This training will include the following objectives:
1. to promptly identify communication needs and preferences of Patients and Companions;
2. to secure qualified interpreter services as quickly as possible when necessary; and
3. to ensure that their staff members notify the Hospital and the Program Administrators about Patients and Companions as soon as possible after scheduling admissions, tests, surgeries, or other health care services at the Hospital.
Such training must be offered no later than 120 days after the Effective Date of this Settlement Agreement and will be required for each active medical staff member in conjunction with the initial or biennial recredentialling process.
Training of Psychiatric Personnel and Social Workers The Hospital will provide specialized mandatory in-service training to Hospital Personnel with Patient responsibility who work in the Department of Psychiatry (or its equivalent) or are members of the Social Work Department (or its equivalent). This training will include the following objectives:
1. to promptly identify communication needs and preferences of Patients and Companions;
2. to secure qualified interpreter services as quickly as possible when necessary; and
3. to facilitate appropriate interaction between Patients and other patients, when appropriate (e.g., group therapy sessions and other times when interaction with persons other than Hospital Personnel is encouraged).
Such training must be provided no later than 120 days after the Effective Date of this Settlement Agreement and will be conducted annually thereafter.
Training of Telephone Operators All Hospital Personnel who receive incoming telephone calls from the public will receive special instructions on using TTY’s or relay services to make, receive and transfer telephone calls, and will receive training generally on the existence in the Hospital of Program Administrators, as detailed in paragraph 26 of this Settlement Agreement, and the complaint resolution process, as described in paragraph 38 of this Settlement Agreement. Such training must be provided no later than 60 days after the Effective Date of this Settlement Agreement and will be conducted annually thereafter.
Training of Other Key Personnel The Hospital will also provide special ADA training to the following Hospital Personnel not otherwise trained as provided above: all clinical directors and nursing supervisors; personnel who staff the admissions desk (or its equivalent for in-patient registration), a central registry desk (or its equivalent for out-patient registration), and/or a general information desk; all triage nurses and other triage professionals; and heads of each department in which communication with Patients and Companions occurs. Hospital Personnel responsible for billing and insurance issues who routinely interact with Patients and Companions will receive special training on the availability of Appropriate Auxiliary Aids and Services and the existence in the Hospital of Program Administrators, as described in paragraph 26 of this Settlement Agreement. Such training must be provided no later than 120 days after the Effective Date of this Settlement Agreement and will be conducted annually thereafter.
Training of New Employees The Hospital will provide the training specified above to new Hospital Personnel within thirty (30) days after the commencement of their services for the Hospital. Such training must be comparable to training provided to specific departments as necessary. A screening of a video of the original training will suffice to meet this obligation.
Training Attendance Sheets The Hospital will maintain, for the duration of this agreement, attendance sheets of all training conducted pursuant to paragraphs 69-75 of this Settlement Agreement, which will include the names and respective job titles of the attendees, as well as the date, time, and location of the training session. Although all of the training described in paragraphs 69-75 should be conducted live whenever possible, the Hospital may satisfy the training requirement for individuals who are unable to attend live training sessions by showing a video of the original training.

REPORTING, MONITORING, AND VIOLATIONS

Patient Feedback The Hospital will develop a form to collect feedback from Patients and Companions regarding the provision of auxiliary aids and services. Such a form will assess Patient and Companion satisfaction with the quality of the Auxiliary Aids and Services provided, the effectiveness of communication with Hospital Personnel, and response times.
Compliance Reports Beginning three months after the Effective Date of this Settlement Agreement and every six months thereafter for the entire duration of the Settlement Agreement, the Hospital will provide a written report (“Compliance Report”) to the U.S. Attorney’s Office regarding the status of its compliance with this Settlement Agreement. The Compliance Report will include data relevant to the Settlement Agreement, including, but not limited to:
1. the number of requests for qualified sign language interpreters received by the Hospital from Patients and Companions;
2. the number of times a qualified sign language interpreter was provided by the Hospital;
3. the number of times the Hospital denied a request for a qualified sign language interpreter and the reason for each denial;
4. the number of requests for other auxiliary aids or services received by the Hospital from Patients or Companions;
5. The number of times auxiliary aids or services were provided by the Hospital, a description of the aids or services provided, and the amount of time it took for the Hospital to provide the auxiliary aids and services;
6. the number of times the Hospital denied any requests for other auxiliary aids or services, a description of the aid or service that was denied, and the reason for each denial;
7. the number of times a request for a qualified sign language interpreter was accepted by the Hospital, but the interpreter failed to appear, and the reasons for the failure;
8. the date and the time a qualified sign language interpreter was requested by a Patient or Companion, the date and time the interpreter arrived, and the date and time the interpreter actually began interpreting for such Patient or Companion;
9. an explanation of the reasons for the delays in obtaining qualified sign language interpreters in those cases where the response times failed to comply with the time frames described in paragraphs 44 and 45 of this Settlement Agreement; and
10. the number of redeterminations performed pursuant to paragraph 30 and the results of these redeterminations;
11. the number of complaints received by the Hospital from Patients and Companions regarding Appropriate Auxiliary Aids and Services and/or effective communication, and the resolution of such complaints including any supporting documents.
12. documentation of compliance with all of the training and technology provisions of this Settlement Agreement;
13. copies of all feedback forms referenced in paragraph 48; and
14. copies of all logs referenced in paragraph 36.
The Hospital will maintain appropriate records to document the information contained in the Compliance Reports and will make them available, upon request, to the U.S. Attorney’s Office, as allowed by state and federal law.
Complaints During the Term of this Settlement Agreement, the Hospital will notify the U.S. Attorney’s Office if any person commences a lawsuit, complaint, charge, or grievance alleging that the Hospital failed to provide Appropriate Auxiliary Aids and Services to 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 the Hospital 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 the Hospital relevant to the allegation. The Hospital will reference this provision of the Settlement Agreement in the notification to the U.S. Attorney’s Office.

COMPENSATORY RELIEF FOR COMPLAINANTS AND RELEASE

Within ten (10) days of the Effective Date of this Settlement Agreement, the Hospital will pay $35,000.00 in compensation to the complainants. The Hospital will send a check made out to the complainants by certified mail, return receipt requested, or via hand delivery, to the United States Attorney’s Office. This check is compensation pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in paragraph 6. The check shall be mailed to: Office of the United States Attorney, 53 Pleasant Street, Fourth Floor, Concord, NH 03301, Attn: AUSA John Farley.
Within five (5) days of receipt of the checks referenced in Paragraph 80 of this Settlement Agreement, the United States will deliver to counsel for the Hospital releases signed by each of the complainants.

ENFORCEMENT AND MISCELLANEOUS

Duration of the Settlement Agreement This Settlement Agreement will be in effect for three (3) years from the date hereof, after which time the Settlement Agreement shall end; provided, however, the Settlement Agreement shall terminate in two years from the Effective Date of this Settlement Agreement if both of the following conditions are met: (1) the Hospital is in compliance as of the second anniversary of the Effective Date of this Settlement Agreement, with all provisions and obligations set forth in the Settlement Agreement; and (2) in the event that there has been an allegation of a violation of any of the aforesaid paragraphs, there has been an investigation and response by the Hospital that the United States considers to be effective, timely and adequate.
Changing Circumstances During the term in which this Settlement Agreement will be in effect, there may be a change in circumstances such as, for example and without limitation, an increased or decreased availability of qualified sign language or oral interpreters or developments in technology to assist or improve communications with persons who are deaf or hard-of-hearing. If the Hospital determines that such changes create opportunities for communicating with Patients and Companions more efficiently or effectively than is required under this Settlement Agreement, or create difficulties not presently contemplated in the provision of Appropriate Auxiliary Aids and Services, it may propose changes to this Settlement Agreement by presenting written proposals to the United States Attorney’s Office. Such changes will then be made to the Settlement Agreement if the United States, upon review, grants its approval, which approval will not be unreasonably withheld or delayed.
Enforcement The Attorney General is authorized, pursuant to section 308(b)(1)(B) of the ADA, to bring a civil action under Title III, enforcing the ADA in any situation where a pattern or practice of discrimination is believed to exist or a matter of general public importance is raised. In consideration of the terms of this Settlement Agreement as set forth above, the Attorney General agrees to refrain from undertaking further investigation or from filing a civil suit under Title III in this matter, except as provided in paragraphs 85 and 86, below. Nothing contained in this Settlement Agreement is intended or shall be construed as a waiver by the United States of any right to institute proceedings against the Hospital 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.
Review of Compliance The United States may review compliance with this Settlement Agreement at any time and can enforce this Settlement 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 Settlement Agreement or any portion of it has been violated, it will raise its concern(s) in writing with the Hospital and the parties will attempt to resolve the concern(s) in good faith. The United States will allow the Hospital thirty (30) days from the date it notifies the Hospital of any breach of this Settlement Agreement to cure said breach, prior to instituting any court action to enforce the ADA and the terms of the Settlement Agreement.
Violations If the Hospital violates this Settlement Agreement, the United States shall have all such remedies as are allowed under the ADA. The parties agree that in any subsequent legal proceedings the court may treat any violation of this Settlement Agreement as a first violation of the ADA for the purpose of calculating civil penalties, if any.
Entire Agreement This Settlement Agreement constitutes 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 Settlement 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.
Binding This Settlement 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.
Non-Waiver Failure by any party to seek enforcement of this Settlement 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.
Disclaimer of Liability Nothing in this Settlement Agreement shall be construed as an admission by the Hospital of any liability or fault, that it engaged in any wrongful or illegal activity, that any of the United States’ allegations are true, or that any person suffered any injury as a result of the events as alleged by the United States. This Agreement shall not be offered or received in evidence in any action or proceeding in any court or other tribunal as an admission or concession of liability or wrongdoing of any nature on the part of the Hospital except in an action challenging the Hospital’s compliance with this Agreement.
Execution of Agreement The undersigned counsel represent that they have been fully authorized by their clients to enter into and execute this Settlement Agreement under the terms and conditions contained herein.
Availability of Settlement Agreement This Settlement Agreement may be made available to any person.
Severability In the event that a Court shall determine that any provision of this Settlement Agreement is unenforceable, such provision shall be severed from this Settlement Agreement and all other provisions shall remain valid and enforceable, provided, however, that if the severance of any such provision shall materially alter the rights or obligations of the Parties hereunder, they shall, through reasonable, good faith negotiations, agree upon such other amendments hereto as may be necessary to restore the Parties as closely as possible to the relative rights and obligations initially intended by them hereunder.

The undersigned AGREE to the form and content of this Agreement:

FOR FRISBIE MEMORIAL HOSPITAL

FOR THE UNITED STATES

JOHN P. KACAVAS
United States Attorney

By: _____________________
John A. Malmberg
Orr & Reno
One Eagle Square
P.O. Box 3550
Concord, NH 03302

By: _____________________
John J. Farley
Assistant U.S. Attorney
U.S. Attorney’s Office
53 Pleasant Street
Concord, NH 03301

Dated: 10/18/10

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November 23, 2010

SETTLEMENT AGREEMENT BETWEEN THE UNITED STATES OF AMERICA

AND