SETTLEMENT AGREEMENT

BETWEEN

THE UNITED STATES OF AMERICA

AND

ST. JOSEPH HOSPITAL OF NASHUA, N.H. AND SJ PHYSICIAN SERVICES, INC.

D.J. NO. 202-47-49

 




1.         This action was initiated by a complaint filed with the United States against St. Joseph Hospital of Nashua, N.H. ("the Hospital"), and SJ Physician Services, Inc. ("SJ Physician Services"). 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.

2.         The Hospital is an acute care hospital located at 172 Kinsley Street in Nashua, New Hampshire. It also provides emergency services at a satellite location in Milford, New Hampshire. SJ Physician Services also is located at 172 Kinsley Street in Nashua, New Hampshire and has other locations in southern New Hampshire. It provides outpatient physician services.

3.         The complainants in this matter, [redacted], who are both deaf, 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.

4.         The Hospital and SJ Physician Services are each a "public accommodation" as defined in 42 U.S.C. § 12181(7)(F) and its implementing regulation, 28 C.F.R. § 36.104, because each is a private entity that operates a place of public accommodation.

5.         The ADA prohibits public accommodations, including hospitals and professional offices of health care providers, from discriminating on the basis of disability in the full and equal enjoyment of their goods, services, facilities, privileges, advantages or accommodations. 42 U.S.C. § 12182(a); 28 C.F.R. § 36.201(a).

6.         The complainants allege that the Hospital and SJ Physician Services discriminated against them and their children by failing to provide them with the full and equal enjoyment of the goods, services, facilities, privileges, advantages or accommodations provided by the Hospital and SJ Physician Services. Specifically, the complainants allege that the Hospital and SJ Physician Services failed to provide appropriate auxiliary aids and services when necessary for effective communication. [redacted] use American Sign Language as their primary means of communication. The complainants allege that they were unable to communicate adequately with Hospital and SJ Physician Services Personnel while they or their children were receiving medical treatment on various occasions between 2005 and 2008 because the Hospital and SJ Physician Services did not provide sign language interpreters. Rather, on multiple occasions, [redacted] allege that they were required to rely upon inadequate or inappropriate auxiliary aids. On some occasions, [redacted] attempted to assist [redacted] in communicating. [redacted] is not a qualified interpreter and did not wish to serve as an interpreter for her husband. On other occasions, they allege that their children were asked to serve as interpreters. None of their children is a qualified interpreter.

7.         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 and SJ Physician Services violated title III of the ADA and its implementing regulation by discriminating against the complainants by failing to provide appropriate auxiliary aids and services when necessary for effective communication.

8.         The Hospital and SJ Physician Services dispute that they discriminated against the complainants and expressly deny any liability. The Hospital and SJ Physician Services allege that they provide appropriate auxiliary aids and services, and received no complaints directly from the complainants concerning the effectiveness of the communications. Without conceding the allegations of the United States, or the possible defenses of the Hospital and SJ Physician Services, 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 or SJ Physician Services. 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.

9.         The parties hereby agree to the following:

DEFINITIONS

10.       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 to the deaf or hard-of-hearing that may have come into use or will come into existence in the future. 28 C.F.R. § 36.303.

11.       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 and with whom the public accommodation is authorized to communicate in compliance with the Health Insurance Portability and Accountability Act of 1996 ("HIPAA") and regulations as well as New Hampshire law governing the privacy of health information. Nothing in this Settlement Agreement shall be construed to require the Hospital or SJ Physician Services to provide auxiliary aids or services, keep records, or take any other actions with respect to a Companion unless the Companion is either: (1) deaf or hard-of-hearing or (2) a Companion of a Patient (as that term is defined in this Settlement Agreement).

12.       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.

13.       The term "Effective Date of this Settlement Agreement" means the date of the last signature on this Settlement Agreement.

14.       The term "Personnel" shall mean: all employees and independent contractors with contracts to work on a substantially full-time or part-time basis for the Hospital or SJ Physician Services, 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 or SJ Physician Services. The term "Hospital Personnel" only refers to employees, independent contractors or physicians when they are working at, employed by, or seeing/treating patients at the Hospital.

15.       The term "in-service" shall include, without limitation, such means of training or familiarization of Personnel as are customarily utilized by the Hospital or SJ Physician Services, including, without limitation, written policies and procedures, videotapes, training materials, training sessions, seminars, conferences, and the like.

16.       The term "Parties" shall mean: the Hospital, SJ Physician Services, 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.

17.       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) or SJ Physician Services, as well as deaf or hard-of-hearing individuals seeking to use any other health care goods or services provided by the Hospital or SJ Physician Services, 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 or SJ Physician Services regarding past, present or future health care services, such as scheduling appointments, obtaining test results, and discussing billing issues.

18.       The term "qualified note-taker" shall mean: one who is able to take notes effectively and accurately, using any necessary specialized vocabulary and terminology.

19.       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.

20.       The term "Standards" shall mean: the ADA Standards for Accessible Design, as set forth at 28 C.F.R. Part 36, App. A (1994).

21.       The term "TTY's" or "TDD's" shall mean: devices either portable or fixed 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

22.       Non-Discrimination The Hospital and SJ Physician Services 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, as required by the ADA. Pursuant to 42 U.S.C. § 12182(a), the Hospital and SJ Physician Services will also provide Patients and Companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the Hospital and SJ Physician Services as required by this Settlement Agreement and the ADA. The Hospital and SJ Physician Services shall not deny their 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.

23.       Retaliation and Coercion The Hospital and SJ Physician Services agree 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

24.       Appropriate Auxiliary Aids and Services Pursuant to 42 U.S.C. § 12182 (b)(2)(A)(iii), the Hospital and SJ Physician Services 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

25.       Establishment of Program to Provide Appropriate Auxiliary Aids and Services Within 120 days of the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services will design and institute a program to implement the provisions of this Settlement Agreement, including without limitation:

a.         developing, coordinating, and overseeing the development of specific procedures to implement fully this Settlement Agreement;

b.         scheduling, announcing, and promoting all training required by this Settlement Agreement;

c.         coordinating the community outreach required by this Settlement Agreement;

d.         modifying medical and intake forms as necessary to ensure that the Hospital and SJ Physician Services make the communication determination required by this Settlement Agreement for each Patient or Companion, including developing a communication determination form; and

e.          developing a plan for drafting, maintaining, and providing all reports required by this Settlement Agreement.

26.       Program Administrator The Hospital and SJ Physician Services shall designate a Program Administrator 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. The Program Administrator, or a suitably trained designee during non-business hours shall be available twenty-four (24) hours a day, seven (7) days a week. Such Program Administrator 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 and SJ Physician Services will circulate broadly within the Hospital and SJ Physician Services the names, telephone numbers, functions, and office location of such Program Administrator, including a TTY telephone number that may be called by Patients and Companions in order to obtain the assistance of such Program Administrator. The Program Administrator 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 Administrator will be responsible for the complaint resolution mechanism described in paragraph 38 of this Settlement Agreement. The Program Administrator will be designated by the Hospital and SJ Physician Services no later than 30 days following the Effective Date of this Settlement Agreement. The position of Program Administrator is not required to be a full time position nor are the duties described herein required to be the Program Administrator´s sole responsibilities, provided that the requirements of paragraph 26 are otherwise satisfied. The Hospital and SJ Physician Services may assign other duties to the Program Administrator.

27.       Review of New and Modified Policies The Hospital and SJ Physician Services shall submit copies of all additional 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 and SJ Physician Services will adjust these proposed policies and procedures to reflect any comments or concerns identified by the United States. The United States will not unreasonably withhold its approval of proposed policies and procedures.

Provision of Appropriate Auxiliary Aids and Services

28.       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 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 and SJ Physician Services will develop a form for conducting this determination no later than sixty (60) days following the Effective Date of this Settlement Agreement. The determination made by Personnel will take into account all relevant facts and circumstances, including without limitation the following:

a.         the nature, length, and importance of the communication at issue;

b.         the individual´s communication skills and knowledge;

c.         the Patient´s health status or changes thereto;

d.         the Patient´s and/or Companion´s request for or statement of need for an interpreter or other specific auxiliary aid or service;

e.         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

f.          the availability at the required times, day or night, of appropriate auxiliary aids and services.

29.       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 or SJ Physician Services becomes aware that the Patient or Companion is en route to either location in an emergency situation; or (3) the time the Patient or Companion initially comes in contact with Personnel who are otherwise primarily responsible for coordinating and/or providing patient care services. 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) and that the Patient or Companion may require auxiliary aids or services in order to achieve effective communication, Hospital Personnel will make reasonable efforts to conduct a determination in advance of the Patient or Companion´s arrival and seek to have auxiliary aids and services available as soon as practicable after the Patient or Companion´s arrival at the Hospital.

30.       Redetermination The Hospital and SJ Physician Services shall reassess a determination of which appropriate auxiliary aids and services are necessary, in consultation with the Patient or Companion, when a Patient or Companion advises that communication has not been effective. The Hospital and SJ Physician Services will document any instances where Patients or Companions advise that the auxiliary aids and services provided by the Hospital or SJ Physician Services failed to provide effective communication. The Hospital and SJ Physician Services will document any redeterminations and the results of any redeterminations.

31.       Subsequent Patient Visits The Hospital and SJ Physician Services shall implement policies and procedures to expedite arrangements for the provision of auxiliary aids and interpretive services when a Patient or Companion requests appropriate auxiliary aids or services for subsequent scheduled visits to the Hospital and SJ Physician Services. 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 or services (or individual interpreters) provided effective communication. During a Patient or Companion´s subsequent visit, Personnel shall reference the Patient´s prior medical records, where available, as part of the Communication Determination required by paragraph 28. It is understood that all medical records may not be available for certain non-scheduled visits, such as visits to the Hospital´s emergency facilities. However, the Hospital will attempt to expedite the availability of medical records for non-scheduled visits.

32.       Medical Concerns Nothing in this Settlement Agreement shall 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, SJ Physician Services or their Personnel to take any action or inaction that would jeopardize the safety of a Patient or compromise the quality of a Patient´s medical care.

33.       Determination Not to Provide Auxiliary Aid or Service If, after conducting a determination, the Hospital or SJ Physician Services determines that the circumstances do not warrant provision of a particular auxiliary aid or service that has been requested by a Patient or Companion, Personnel will so advise the Patient or Companion requesting the auxiliary aid or service and will document the date and time of the denial, the name and title of the Personnel who made 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 only through a video interpreting service and not to provide a live interpreter when a Patient or Companion has requested a live interpreter also will be documented. It is understood that, even if the Hospital or SJ Physician Services determines that a particular auxiliary aid or service is not to be provided, some means of effective communication must be secured.

34.       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.

35.       Individual Notice in Absence of Request If a Patient and/or Companion does not request appropriate auxiliary aids or services, but 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 or services for effective communication, the Hospital and SJ Physician Services will specifically inform the Patient and/or Companion that appropriate auxiliary aids and services are available free of charge.

36.       Auxiliary Aid and Service Log The Hospital and SJ Physician Services will maintain a log of: (a) each request by a Patient or Companion for an appropriate auxiliary aid and service that is communicated to the Hospital or SJ Physician Services; (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 Personnel who performed any communication determination or redetermination; (g) the name of any Personnel responsible for determining whether or not to provide the requested auxiliary aid or service; (h) the nature of the auxiliary aid or service provided; (i) if the auxiliary aid or service provided was not the auxiliary aid or service that was initially requested, a description of the auxiliary aid or service that was provided, the reason the initially-requested auxiliary aid or service was not provided, and a statement indicating whether or not the Patient or Companion agreed that the auxiliary aid or service that was provided was effective; (j) the time and date the appropriate auxiliary aid and service was provided, and (k) a statement that an 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.

37.       Communication with Patients and Companions After the determination described in paragraph 28, the Hospital and SJ Physician Services will take appropriate steps to ensure that all Personnel having direct contact with a Patient or a Companion are made aware of such person´s need for an auxiliary aid or service so that effective communication with such person will be achieved. In addition, the Hospital and SJ Physician Services will take appropriate steps to ensure that all Personnel having contact with a Patient or Companion are aware of: (a) the policies and procedures of the Hospital and SJ Physician Services implementing this Settlement Agreement and the ADA; (b) the policies and procedures of the Hospital and SJ Physician Services 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.

38.       Complaint Resolution The Hospital and SJ Physician Services will maintain an effective complaint mechanism for the resolution of disputes regarding effective communication with Patients and Companions. The Hospital and SJ Physician Services will maintain records of all complaints regarding the lack of effective communication, whether oral or written, made to the Hospital and SJ Physician Services and actions taken with respect thereto. The Hospital and SJ Physician Services will notify Patients and Companions of their complaint resolution mechanisms, 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 a complaint, the Hospital and SJ Physician Services 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 and the responses thereto will be maintained by the Program Administrators for the entire duration of the Settlement Agreement. To satisfy the requirements of this paragraph related to the maintenance of an effective complaint mechanism and records of complaints made and actions taken in response thereto, the Hospital and SJ Physician Services may, at their option utilize their current complaint handling/grievance process and their current occurrence reporting software.

Provision of Qualified Interpreters

39.       Circumstances Under Which Interpreters Will Be Provided The Hospital and SJ Physician Services 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. 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:

a.         determination of a Patient's medical history or description of ailment or injury;

b.         provision of Patients' rights, informed consent or permission for treatment;

c.         determination and explanation of Patient´s diagnosis or prognosis, and current condition;

d.         explanation of procedures, tests, treatment, treatment options or surgery;

e.         religious services and spiritual counseling provided by the Hospital or SJ Physician Services;

f.          explanation of living wills or powers of attorney (or their availability);

g.         diagnosis or prognosis of ailments or injuries;

h.         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);

i.          determination of any condition or allergy of a Patient that may affect choice of medication;

j.          explanation regarding follow-up treatments, therapies, test results or recovery;

k.         blood donations or apheresis (removal of blood components);

l.          discharge planning and discharge instructions;

m.        provision of mental health evaluations, group or individual therapy, counseling and other therapeutic activities, including, but not limited to, grief counseling and crisis intervention;

n.         explanation of complex billing or insurance issues that may arise;

o.         educational presentations, such as classes concerning birthing, nutrition, CPR, and weight management;

p.         filing of administrative complaints or grievances against the Hospital and SJ Physician Services or their Personnel; and

q.         any other circumstance in which a qualified sign language interpreter is necessary to ensure a Patient´s rights provided by law.

40.       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 nor that an interpreter must always be provided in these circumstances. Nothing in this Settlement Agreement requires the Hospital or SJ Physician Services to postpone or unduly delay events involving multiple participants (such as the events described in subparagraphs 39(e), (k), (m), (n), (o) and (p)) in the event that the Hospital or SJ Physician Services is unable to arrange for an interpreter for a particular Patient or Companion.

41.       Obtaining Interpreters The Hospital and SJ Physician Services will use reasonable 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 and SJ Physician Services which will, at a minimum, require the interpreter or agency to use its best efforts to maintain a response time of one (1) hour or less in at least seventy-five (75%) percent of non-scheduled incidents within any six (6) month period (excluding any incident when the determination calls for an interpreter to be provided at a later time), measured from the time beginning fifteen (15) minutes after a Patient or Companion requests an interpreter. In the event no such contract(s) is entered into, the Hospital and SJ Physicians Services will enter into one or more business associate agreements with reputable interpreter(s) regarding the provision of live interpreter services.

42.       Free-Lance Interpreters Within thirty (30) days of the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services will compile and make reasonable efforts to maintain as current a list of all known agencies and free-lance sign language and oral interpreters who reside within twenty-five (25) miles of the Hospital and SJ Physician Services.

43.       Staff Interpreters The Hospital and SJ Physician Services may, but shall have no obligation to, satisfy their 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 and SJ Physician Services are otherwise obligated to provide under this Settlement Agreement. The Hospital and SJ Physician Services may assign other duties to staff interpreters. To the extent that the Hospital and SJ Physician Services do not have staff interpreters or a staff interpreter is not available when needed, the Hospital and SJ Physician Services 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

44.       Scheduled Incidents For "Scheduled Incidents," where an interpreter is necessary to ensure effective communication, the Hospital and SJ Physician Services 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" at the Hospital are situations in which there are four (4) 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 six (6) 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). "Scheduled Incidents" at SJ Physician Services are situations in which the services of the interpreter are required one or more days following the day when a Patient or Companion makes a request for an interpreter. The Hospital and SJ Physician Services will immediately seek another qualified sign language interpreter upon notice that the interpreter has failed to arrive for a Scheduled Incident or that video interpreting services are unavailable or ineffective. Similarly, when making a qualified interpreter available, 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.

45.       Non-scheduled Interpreter Requests; Time Standards "Non-scheduled interpreter request" means a request for an interpreter that is made during the appearance at the Hospital and SJ Physician Services 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 and SJ Physician Services or a request that was not made sufficiently in advance to fall within the definition of "Scheduled Incidents" in paragraph 44. After receiving a non-scheduled interpreter request and determining in accordance with paragraph 28 that a live interpreter is necessary, the Hospital and SJ Physician Services shall make an interpreter available as soon as practicable. Personnel will make a request for an interpreter within approximately fifteen (15) minutes after completing the determination described in paragraph 28, above, that determines that a live interpreter is necessary. Personnel will also make such a request within approximately fifteen (15) minutes of any situation identified in paragraph 51 where video interpreting services are not effective. The Hospital and SJ Physician Services will use reasonable efforts to meet the following overall time standards for providing qualified sign language interpreters to Patients and/or Companions: approximately one (1) hour in seventy five percent (75%) 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 response time of the Hospital and SJ Physician Services exceed approximately three (3) hours. The parties will not be considered in violation of this Settlement Agreement if failure to meet non-scheduled interpreter requests within the appropriate time frame for a particular individual incident is due to the interpreter´s failure to respond in a timely fashion, provided that the Hospital and SJ Physicians Services have followed the specific steps set forth in paragraph 46 and have made reasonable efforts to communicate effectively with the deaf individual in the absence of an interpreter.

46.       Specific Steps for Non-scheduled Interpreter Requests Consistent with and subject to paragraphs 49 through 51, within approximately 15 minutes after completing a determination (as described in paragraph 28) that determines that interpreting services are required, Personnel will provide video interpreting services. If the same determination determines that a live interpreter is required, Personnel also will request a live interpreter as set forth in paragraph 45. If the interpreter or agency advises Personnel that an interpreter cannot be located or provided in response to the request, and video interpreting services are either unavailable or ineffective, Personnel will take the following additional steps:

a.         Personnel will exert reasonable efforts (which shall be deemed to require no fewer than five (5) telephone inquiries) to contact any free-lance interpreters or other interpreting agencies already known to the Hospital and SJ Physician Services and request their services;

b.         inform a Program Administrator of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;

c.         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;

d.         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

e.          document all of the above efforts.

47.       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.

48.       Data Collection on Interpreter Response Time and Effectiveness: Feedback Forms The Hospital and SJ Physician Services will monitor the performance of each qualified sign language interpreter used 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 and SJ Physician Services shall collect information regarding response times for each request for an interpreter. The Hospital and SJ Physician Services 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 and SJ Physician Services shall use the feedback forms for monitoring and evaluating the performance of each interpreter provided to Patients and Companions. The Program Administrators shall maintain the completed feedback forms for the Term of this Settlement Agreement.

49.       Video Interpreting Services Video interpreting services (including the NexTalk On Demand video remote interpreting service) 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. Video interpreting services may be used when a Patient or Companion agrees that such services are appropriate. Video interpreting services also may be used in circumstances when a live interpreter is not available despite the efforts of Personnel to obtain a live interpreter pursuant to the provisions of paragraphs 44-47. Video interpreting services also may be used while Personnel are awaiting the arrival of a live interpreter. In the event that the Hospital or SJ Physician Services chooses to provide video interpreting services, when using video interpreting services, the Hospital and SJ Physician Services 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.

50.       The Hospital and SJ Physician Services 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 and SJ Physician Services at all times. The Hospital and SJ Physician Services should connect the service within approximately fifteen (15) minutes of a determination. Moreover, the Hospital and SJ Physician Services 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 and SJ Physician Services 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, 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.

51.       In the event that the Patient or Companion indicates that he/she is unable to communicate effectively using the video interpreting service, the 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.

52.       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 and SJ Physician Services, the interpreter service provider or the interpreter called to respond, such as weather problems and other Acts of God, influenza or other infectious disease outbreaks, unanticipated illness or injury of the interpreter while en route to the Hospital and SJ Physician Services, 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).

53.       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 good faith efforts of the Hospital and SJ Physician Services, the Hospital and SJ Physician Services are 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.

54.       Notice to Patients and Companions As soon as Personnel have determined that an interpreter is necessary for effective communication with a Patient or a Companion, and one hour later, the Hospital and SJ Physician Services 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 obligation of the Hospital and SJ Physician Services to provide qualified interpreters in a timely manner as required by paragraphs 44 and 45 of this Settlement Agreement.

55.       Other Means of Communication The Hospital and SJ Physician Services agrees that between the time an interpreter is requested and when an interpreter arrives, 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 obligation of the Hospital and SJ Physician Services to provide qualified interpreters in a timely manner as required by this Settlement Agreement. Once an interpreter arrives, the Personnel will ensure that the Patient or Companion has a reasonable understanding of the care already provided and the current treatment plan.

56.       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 and SJ Physician Services 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 Personnel and such Patient or Companion. Notwithstanding, the Hospital and SJ Physician Services will not refuse assistance of such person and in any case, such person may be used to interpret or facilitate communication 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 obligation of the Hospital and SJ Physician Services to provide appropriate auxiliary aids and services as are necessary under this Settlement Agreement.

Telephones and Related Equipment

57.       Public Telephones As soon as practicable but no later than sixty (60) days after the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services will provide the following:

a.          TTY's in public areas The Hospital will make a TTY device available wherever a telephone is made specifically and exclusively available to the public (whether public pay telephone, public closed circuit telephone, or otherwise) ("public telephone"). To satisfy this provision, the Hospital and SJ Physician Services can permanently install the required TTY´s or make available a sufficient number of 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.

b.         TTY's required in specific locations The Hospital will provide a portable TTY in or adjacent to each of the following: the emergency department, the intensive care unit waiting room, and the public phone bank near the parking garage. SJ Physician Services will provide a portable TTY in or adjacent to its urgent care center waiting room. Each such TTY, whether permanently installed or portable, shall comply fully with §§ 4.30 and 4.31 of the Standards.

c.         Shelves and outlets Wherever portable TTY's are made available pursuant to this Settlement Agreement, the Hospital and SJ Physician Services will provide shelves and electrical outlets that comply with § 4.31.9 of the Standards.

d.         Signs indicating the location of TTY's

i.         Wherever public telephones are available but TTY's are not permanently installed, the Hospital and SJ Physician Services will post signs complying with the Standards. Such signs will indicate the location of the nearest portable or permanently installed TTY's; and

ii.         Wherever TTY's are permanently installed, the Hospital and SJ Physician Services will post signs complying with § 4.30 of the Standards to indicate their location.

e.         Volume control telephones The Hospital and SJ Physician Services 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 and SJ Physician Services will ensure that volume control phones are dispersed among all public telephones throughout the Hospital and SJ Physician Services. The Hospital and SJ Physician Services 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 and SJ Physician Services may satisfy this requirement by prominently displaying signs in diverse locations throughout the Hospital and SJ Physician Services that state this fact.

f.         Storage and availability of equipment Portable equipment required by this section for use in public areas shall be stored in places that are readily accessible to all Personnel who have client contact at all times of the day and night. All 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, 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 and SJ Physician Services. Program Administrator (as discussed in paragraph 26) will be responsible for ensuring that this equipment remains readily accessible.

58.       Telephones in Patient Rooms Within sixty (60) days of the Effective Date of this Settlement Agreement:

a.         Portable access technology - defined The Hospital and SJ Physician Services 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 and SJ Physician Services shall ensure that each volume control telephone and each visual notification device for incoming telephone calls complies fully with § 4.31 of the Standards.

b.         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 in each such unit 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.

c.         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.

d.         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

59.       Televisions and Caption Decoders Within thirty (30) days of the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services 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).

60.       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.

61.       Duty to Provide Visual Programs in a Manner That is Accessible to Persons With Hearing Impairments

a.         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.

b.        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.

c.         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.

d.         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

62.       Client Education The Hospital and SJ Physician Services 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.

63.       Acquisition of Additional Equipment In addition to the equipment required above, the Hospital and SJ Physician Services shall purchase and/or rent such additional equipment as is reasonably needed to replace defective units as soon as practicable. The Hospital and SJ Physician Services 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

64.       Policy Statement Within sixty (60) 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. SJ Physicians Services will post an equivalent sign in all waiting areas and in a prominent location on its website.

65.       Advertisements Within sixty (60) days of the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services will take appropriate steps to publicize in the community their commitment to provide all of its services to Patients and Companions. These publications can be part of the Hospital´s patient centered care initiative. 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 and SJ Physician Services, which advertisements will include a statement that 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 and SJ Physician Services. Annually thereafter, the Hospital and SJ Physician Services shall take reasonable steps to publicize the existence of the Program to the deaf and hard-of-hearing community.

66.       Patient Guide The Hospital will include in all future printings 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, 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 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.

67.       Information Made Available in ASL Within sixty (60) days of the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services will make the following information available in American Sign Language (ASL) using videotape, DVD, or CD-ROM format:

a.         the Patient´s Bill of Rights;

b.         health care directives;

c.         information regarding the policies and procedures of the Hospital and SJ Physician Services governing free sign language interpreter services, including the contents of the feedback forms concerning the effectiveness and timeliness of interpreters that the Hospital and SJ Physician Services provide; and

d.         complaint resolution procedures.

NOTICE TO PERSONNEL AND PHYSICIANS

68.       The Hospital and SJ Physician Services shall publish, in an appropriate form, a written policy statement regarding the policy of the Hospital and SJ Physician Services for effective communication with Patients or Companions for use by persons working at the Hospital and SJ Physician Services. 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 [the Hospital] [SJ Physician Services´] 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 and SJ Physician Services will distribute this document within thirty (30) days of the Effective Date of this Settlement Agreement to all Personnel and both employed and affiliated physicians (physicians with practicing or admitting privileges), and to all new Personnel (including newly employed or affiliated physicians) upon their affiliation or employment with the Hospital and SJ Physician Services. In addition, this statement will also be distributed to all Personnel (including all employed and affiliated physicians) on an annual basis.

TRAINING

69.       Training of Program Administrator The Hospital and SJ Physician Services will provide special mandatory training for the Program Administrator 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 Administrator in:

a.         the health care needs of the deaf and hard-of-hearing;

b.         the various degrees of hearing impairment, language, and cultural diversity in the deaf community;

c.         identification of communication needs of persons who are deaf;

d.         the unique needs and problems encountered by late-deafened individuals;

e.         the psychological implications of deafness and its relationship to interaction with hearing health care professionals;

f.         recommended and required charting procedures governing requests for auxiliary aids and services;

g.         types of auxiliary aids and services available in the community and at the Hospital and SJ Physician Services;

h.         the proper use and role of qualified sign language interpreters;

i.          making and receiving calls through TTY´s and the relay service;

j.          the complaint resolution procedure described in paragraph 38 of this Settlement Agreement; and

k.         any other applicable requirements of this Settlement Agreement.

70.       Training of Emergency Department Personnel The Hospital will make available special mandatory in-service training to Hospital Personnel who have Patient responsibility and who work in the emergency department or volunteer and have direct patient contact. The training will address the special needs of Patients and Companions and will include the following objectives:

a.         to promptly identify communication needs and preferences of deaf or hard-of-hearing persons;

b.         to conduct the determination required by paragraph 28 of this Settlement Agreement;

c.         to meet all of the documentation obligations set forth in this Settlement Agreement;

d.         to secure qualified interpreter services as quickly as possible when necessary; and

e.         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.

71.       Training of Physicians The Hospital and SJ Physician Services will make available (either on site or in collaboration with other acute care hospitals in southern New Hampshire) specialized mandatory in-service training to all physicians (including affiliated physicians) who do not receive the training discussed in paragraph 70. This training will include the following objectives:

a.         to promptly identify communication needs and preferences of Patients and Companions;

b.         to secure qualified interpreter services as quickly as possible when necessary; and

c.         to ensure that their staff members notify the Hospital and SJ Physician Services 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 and SJ Physician Services.

Such training must be made available no later than 120 days after the Effective Date of this Settlement Agreement and will be conducted annually thereafter. The Hospital and SJ Physician Services will make reasonable and appropriate efforts to encourage physician attendance at these training sessions.

72.       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:

a.         to promptly identify communication needs and preferences of Patients and Companions;

b.         to secure qualified interpreter services as quickly as possible when necessary; and

c.         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.

73.       Training of Telephone Operators All 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 and SJ Physician Services of Program Administrator, 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.

74.       Training of Other Key Personnel The Hospital and SJ Physician Services will also make available special ADA training to the following 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. Personnel responsible for billing and insurance issues who routinely interact with Patients and Companions will receive special training on the availability of auxiliary aids and services and the existence in the Hospital and SJ Physician Services of Program Administrator, 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.

75.       Training of New Employees The Hospital and SJ Physician Services will make available the training specified above to new Personnel within thirty (30) days after the commencement of their services for the Hospital or SJ Physician Services. 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.

76.       Training Attendance Sheets With respect to all of the training described in paragraph 69-75 of this Settlement Agreement, the Hospital and SJ Physician Services will maintain, for the duration of this Settlement Agreement, notices identifying the time, date, and location of the training, as well as documentation confirming attendance. Although all of the training described in paragraphs 69-75 should be conducted live whenever possible, the Hospital and SJ Physician Services may satisfy the training requirement for individuals who are unable to attend live training sessions by showing a video of the original training or making the training available in an electronic format.

REPORTING, MONITORING, AND VIOLATIONS

77.       Patient Feedback The Hospital and SJ Physician Services 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 Personnel, and response times.

78.       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 and SJ Physician Services 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:

a.         the number of requests for qualified sign language interpreters received by the Hospital and SJ Physician Services from Patients and Companions;

b.         the number of times a qualified sign language interpreter was provided by the Hospital and SJ Physician Services;

c.         the number of times the Hospital and SJ Physician Services denied a request for a qualified sign language interpreter and the reason for each denial;

d.         the number of requests for other auxiliary aids or services received by the Hospital and SJ Physician Services from Patients or Companions;

e.         The number of times auxiliary aids or services were provided by the Hospital and SJ Physician Services, a description of the aids or services provided, and the amount of time it took for the Hospital and SJ Physician Services to provide the auxiliary aids and services;

f.         the number of times the Hospital and SJ Physician Services specifically 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;

g.         the number of times a request for a qualified sign language interpreter was accepted by the Hospital and SJ Physician Services, but the interpreter failed to appear, and the reasons for the failure;

h.         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;

i.          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

j.          the number of redeterminations performed pursuant to paragraph 30 and the results of these redeterminations;

k.         the number of complaints received by the Hospital and SJ Physician Services from Patients and Companions regarding auxiliary aids and services and/or effective communication, and the resolution of such complaints including any supporting documents.

l.          documentation of compliance with all of the training and technology provisions of this Settlement Agreement;

m.        copies of all feedback forms referenced in paragraph 48; and

n.         copies of all logs referenced in paragraph 36.

The Hospital and SJ Physician Services 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.

79.       Complaints During the Term of this Settlement Agreement, the Hospital and SJ Physician Services will notify the U.S. Attorney´s Office if any person commences a lawsuit, complaint, charge, or grievance alleging that the Hospital and SJ Physician Services failed to provide 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 or SJ Physician Services 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 and SJ Physician Services relevant to the allegation. The Hospital and SJ Physician Services will reference this provision of the Settlement Agreement in the notification to the U.S. Attorney´s Office.

COMPENSATORY RELIEF FOR COMPLAINANTS AND RELEASE

80.       Within ten (10) days of the Effective Date of this Settlement Agreement, the Hospital and SJ Physician Services will forgive $10,000.00 in unpaid claims owed by the complainants for services rendered by the Hospital or SJ Physician Services. The debt forgiveness is considered compensation pursuant to 42 U.S.C. § 12188(b)(2)(B), for the effects of the alleged discrimination suffered as described in paragraph 6. Documentation of this debt forgiveness may be mailed or hand-delivered to: Office of the United States Attorney, 53 Pleasant Street, Fourth Floor, Concord, NH 03301, Attn: AUSA John Farley. Any debt forgiveness under this Settlement Agreement is limited to $10,000.00 and neither the Hospital nor SJ Physician Services waives any and all rights it has to pursue any additional amounts due and owing from the complainants now and in the future.

81.       Within five (5) days of receipt of proof of the debt forgiveness referenced in paragraph 80 of this Settlement Agreement, the United States will deliver to counsel for the Hospital and SJ Physician Services waivers of liability and releases in a form agreed to by the Hospital and SJ Physician Services signed by each of the complainants which include language confirming that neither the Hospital nor SJ Physician Services admits to any wrongdoing.

ENFORCEMENT AND MISCELLANEOUS

82.       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 if both of the following conditions are met: (1) the Hospital and SJ Physician Services are 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 and SJ Physician Services that the United States considers to be effective, timely and adequate.

83.       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 or SJ Physician Services 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, either 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.

84.       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 and SJ Physician Services 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.

85.       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 SJ Physician Services and the parties will attempt to resolve the concern(s) in good faith. The United States will allow the Hospital and SJ Physician Services thirty (30) days from the date it notifies the Hospital and SJ Physician Services 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.

86.       Violations If the Hospital or SJ Physician Services 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.

87.       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.

88.       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.

89.       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.

90.       Disclaimer of Liability Nothing in this Settlement Agreement shall be construed as an admission by the Hospital and SJ Physician Services 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 and SJ Physician Services except in an action challenging the compliance of the Hospital or SJ Physician Services with this Agreement.

91.       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.

92.       Availability of Settlement Agreement This Settlement Agreement may be made available to any person.

93.       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 ST. JOSEPH HOSPITAL
OF NASHUA, NH

FOR THE UNITED STATES

JOHN P. KACAVAS
United States Attorney

 

By: _____________________
Lucy C. Hodder
Rath, Young and Pignatelli, P.C.
One Capital Plaza
Concord, NH 03302

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

 

Date 

 

Date9/10/2010

FOR SJ PHYSICAN SERVICES, INC.

DR. PHILIP WILLIAMS By: _____________________
Lucy C. Hodder
Rath, Young and Pignatelli, P.C.
One Capital Plaza
Concord, NH 03302

Date 

 

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November 18, 2010