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# Catskill Regional Medical Center (CRMC)

**Catskill Regional Medical Center (CRMC)Resolution Agreement**

**VOLUNTARY RESOLUTION AGREEMENTBetweenOFFICE FOR CIVIL RIGHTS, REGION IIAndCatskill Regional Medical Center**
                          - BACKGROUND                              - The parties to this Voluntary Resolution Agreement (hereinafter referred to as the “Agreement”) are Catskill Regional Medical Center (hereinafter referred to as “CRMC”) located in Harris, New York and the Office for Civil Rights of the U.S. Department of Health and Human Services, Region II, New York, New York (hereinafter referred to as “OCR”).
                            - CRMC acknowledges that, as a recipient of Federal financial assistance via Title XVIII (Medicare) of the Social Security Act of 1965, 42 U.S.C. § 1395 et seq., and Title XIX (Medicaid) of the Social Security Act of 1965, 42 U.S.C. § 1396 et seq., it is subject to Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 (hereinafter referred to as “Section 504”) and its implementing regulation promulgated by the U.S. Department of Health and Human Services, 45 C.F.R. Part 84.
                            - On December 7, 2005, OCR received a complaint (OCR reference number 06-45588) from an individual (hereinafter referred to as the “Complainant”) against CRMC, alleging discrimination on the basis of disability. Specifically, the Complainant alleged that CRMC discriminated against her on the basis of disability (deaf or hard-of-hearing), by failing to provide her with a qualified sign language interpreter, in violation of Section 504.
                            - In order to resolve this matter expeditiously and without further burden or expense of government investigation or litigation, CRMC agrees to the terms of this Agreement with OCR, which Agreement addresses the issues in the complaint and reiterates CRMC’s assurance of its intention to comply with all provisions of Section 504 and its implementing regulation. CRMC’s willingness to enter into this Agreement with OCR in no way constitutes an admission of liability.
                          - CERTAIN DEFINITIONS                              - The term “ Appropriate Auxiliary Aids ” includes, but is not limited to: qualified sign language or oral interpreters; 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/TDD; videotext displays; or video interpreting services.  See  45 C.F.R. § 84.52(d)(3).
                            - The term “ CRMC Personnel ” shall mean all employees and independent contractors with contracts to work on a substantially full-time basis for (or on a part-time basis exclusively for) CRMC, including, without limitation, nurses, physicians, social workers, technicians, admitting personnel, billing staff, security staff, therapists, volunteers, and anyone else who has or is likely to have direct contact with Patients or Companions. It does not include voluntary attending physicians on the CRMC medical staff.
                            - The term “ Parties ” shall mean CRMC and OCR.
                            - The term “ Patient ” or “ Patients ” shall be broadly construed to include any individual who is seeking or receiving services from CRMC.
                            - “ Companion ” means a person who is deaf or hard-of-hearing and is one of the following: (a) a person whom the Patient indicates should communicate with CRMC Personnel about the Patient, participate in any treatment decision, play a role in communicating the Patient’s needs, condition, history, or symptoms to CRMC Personnel or help the Patient act on the information, advice, or instructions provided by CRMC Personnel; or (b) a person legally authorized to make health care decisions on behalf of the Patient; or (c) such other person with whom the CRMC Personnel would ordinarily and regularly communicate the Patient’s medical condition.
                            - The term “ Qualified Interpreter ,” “ sign language interpreter ,” “ oral interpreter ” or “ interpreter ” shall mean a person who is able to interpret competently, accurately, impartially and effectively, both receptively and expressively, using any specialized terminology necessary for effective communication in a hospital such as CRMC with a deaf or hard-of-hearing Patient or Companion. 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. Also, someone who has rudimentary familiarity with sign language or finger spelling is not a qualified sign language interpreter under this Agreement. Likewise, someone who is fluent in sign language but who does not possess the ability to process spoken communication into proper signs or to observe someone else signing and change their signed or finger spelled communication into spoken words is not a qualified sign language interpreter. A “Qualified Interpreter” may include a “relay interpreter” who has special skill and training in acting as an intermediary between a Patient or Companion and a sign language interpreter in instances when the interpreter cannot otherwise independently understand the consumer’s primary mode of communication. Notwithstanding any other provision of this Agreement to the contrary, the term “Qualified Interpreter” also may include an interpreter who provides service remotely through a video interpreting services (VIS) provider; provided that such VIS interpreter is able to interpret competently, accurately, impartially and effectively, both receptively and expressively, using any specialized terminology necessary for effective communication in a hospital with a deaf or hard-of-hearing Patient or Companion. The Parties acknowledge that a VIS interpreter is one of many auxiliary aids and services available for CRMC to provide to individuals who are deaf or hard-of-hearing, and whether effective communication may be achieved through the use of a VIS interpreter depends on the specific circumstances of the situation and of the specific individual who is deaf or hard-of-hearing.
                            - The terms “ TTY ” (teletypewriter) or “ TDD ” (telecommunications device for deaf persons) shall mean devices that are used with a telephone to communicate with persons who are deaf or hard-of-hearing or who have speech impairments by typing and reading communications.
                          - GENERAL PROVISIONS                              - Scope.  This Agreement resolves the specific issues addressed in the complaint referenced above, and is not intended to preclude or prejudice any other compliance review or complaint investigation that may be pending before OCR now or in the future. Any other compliance matters arising from subsequent compliance reviews or complaint investigations shall be dealt with and resolved separately. Notwithstanding the foregoing, OCR represents that, to its knowledge, as of the date of this Agreement, there are no other pending OCR investigations or OCR compliance reviews of CRMC regarding the subject matter of this Agreement other than the one referenced in this Agreement.
                            - Non-Waiver.  Failure by OCR to enforce this entire Agreement or any provision thereof with respect to any deadline or any other provision shall not be construed as a waiver of OCR’s right to enforce other deadlines or any provision of this Agreement.
                            - No Admission of Non-Compliance.  This Agreement shall not be construed as an admission or evidence that CRMC has not complied with Section 504 or its respective implementing regulation with respect to the allegations in the complaint.
                            - Effective Date and Term of the Agreement.  The Parties agree that this Agreement shall become effective as of the date that both Parties have signed it (the “Effective Date”). This Agreement shall remain in effect for eighteen (18) months following the Effective Date of this Agreement, plus any period of time extended by OCR in accordance with Section E.7 of this Agreement (the “Term”). At such time, this Agreement shall terminate, provided that CRMC is in substantial compliance with this Agreement, as determined by OCR, in its sole judgment, upon its review of the Compliance Reports (as such term is defined in Section J.1 of this Agreement) and any other information received by OCR whether received in accordance with Sections C.6 and/or C.7 of this Agreement or from any other source. Notwithstanding the Term of this Agreement, CRMC acknowledges that it shall comply with Section 504 for so long as it continues to receive Federal financial assistance.
                            - No Discrimination or Retaliation.  The Parties agree that there shall be no discrimination or retaliation of any kind against any person because he or she provided any testimony or otherwise assisted OCR during the investigation of this complaint or because he or she in the future may participate in any manner in any investigation, proceeding or hearing regarding this complaint investigation or regarding compliance with this Agreement.
                            - Records; Data Requests.  Throughout the Term of this Agreement, CRMC agrees to retain all records specified in this Agreement and to provide the written documentation required by this Agreement. CRMC also agrees to provide such other information as may be requested and reasonably necessary to assure OCR that the provisions of the Agreement have been fulfilled.
                            - Review of Compliance.  OCR may, at any time, review CRMC’s compliance with this Agreement. As part of such review, OCR may require written reports, interview witnesses and/or examine and copy CRMC documents. CRMC agrees to retain the records required by OCR to assess CRMC’s compliance with the Agreement. OCR shall maintain the confidentiality of all documents, files and records received from CRMC and shall not disclose their contents except where necessary in formal enforcement proceedings or where otherwise required by law.
                            - Notice of Non-Compliance.  During the duration of this Agreement, if at any time OCR determines that CRMC has failed to comply with any provision of this Agreement, OCR shall notify CRMC in writing. The notice shall include a statement of the basis for OCR’s determination and shall allow CRMC thirty (30) days either: (a) to explain in writing the reasons for its actions and describe the remedial actions that have been or shall be taken to achieve compliance with this Agreement; or (b) to dispute the accuracy of OCR’s findings. On notice to CRMC, OCR may shorten the thirty (30) day period if it determines that a delay would result in irreparable injury to the Complainant or to other affected parties. If CRMC does not respond to the notice, or if, upon review of CRMC’s response, OCR finds that CRMC has not substantially complied with the terms of the Agreement, OCR may, refer the matter to the Department of Justice or, as it deems appropriate, initiate legal proceedings to enforce this Agreement upon notice to CRMC.
                            - Technical Assistance.  OCR agrees to provide appropriate technical assistance to CRMC regarding compliance with this Agreement, as requested and as reasonably necessary.
                            - Modifications; Entire Agreement.  This Agreement may only be modified by mutual agreement of the Parties in writing. This Agreement constitutes the entire agreement by the Parties and no other statement, promise or agreement, either written or oral, made by either Party or any agents of a Party, that is not contained in this written Agreement, including any attachments, shall be enforceable.
                            - Severability.  In the event that a court of competent jurisdiction determines that any provision of this Agreement is unenforceable, such provision shall be severed from this Agreement and all other provisions shall remain valid and enforceable; provided, however, that if the severance of any such provision materially alters the rights or obligations of the Parties, 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.
                            - Compliance with Applicable Laws.  Any modification or amendment of this Agreement does not affect CRMC’s independent responsibilities under any applicable Federal, state or local laws or regulations.
                          - GENERAL OBLIGATIONS                              - Disability Nondiscrimination.  CRMC shall provide deaf or hard-of-hearing Patients and Companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of CRMC as required by Section 504.
                            - Nondiscrimination by Association.  CRMC shall not deny equal services, accommodations, or other opportunities to any individual because of the known relationship of the person with someone who is deaf or hard-of-hearing.
                          - PROVISION OF APPROPRIATE AUXILIARY AIDS                              - Appropriate Auxiliary Aids.  CRMC shall provide to deaf or hard-of-hearing Patients and Companions any appropriate auxiliary aids that may be necessary for effective communication.
                            - General Assessment Criteria.  CRMC shall consult with individual Patients who are deaf or hard of hearing and Companions wherever possible to determine what type of auxiliary aid or interpretive service is needed to ensure effective communication. While consultation is strongly encouraged, the ultimate decision as to what measures to take to ensure effective communication rests in the hands of CRMC, provided that the method chosen results in effective communication. The assessment made by CRMC Personnel shall take into account all relevant facts and circumstances, including without limitation the following:		                               - the nature, length, and importance of the communication at issue;
                              - the individual’s communication skills and knowledge;
                              - the Patient’s health status or changes thereto;
                              - the Patient’s and/or Companion’s request for or statement of the need for an auxiliary aid; and
                              - 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).

                                                                      §                        In the event that communication is not effective, CRMC Personnel shall reassess which appropriate auxiliary aids are necessary, in consultation with the person with a disability, where possible.

                            - Time for Assessment                                - Scheduled Appointments.  In consultation with the Patient or Companion, per Section E.2 above, CRMC Personnel shall determine which appropriate auxiliary aids are necessary to ensure effective communication, and the timing, duration, and frequency with which they will be provided, at the time an appointment is scheduled for the deaf or hard-of-hearing Patient or the Patient with a deaf or hard-of-hearing Companion. CRMC Personnel shall perform and document, in the deaf or hard-of-hearing Patient’s medical chart, a communication assessment as part of each initial in-patient assessment.
                              - Non-Scheduled Incidents.  In consultation with the Patient or Companion, per Section E.2 above, the determination of which appropriate auxiliary aids are necessary to ensure effective communication, and the timing, duration, and frequency with which they will be provided shall be made by CRMC Personnel upon the arrival of the deaf or hard-of-hearing Patient or Companion at the CRMC. CRMC Personnel shall perform and document, in the deaf or hard-of-hearing Patient’s medical chart, a communication assessment as part of each initial in-patient assessment.
                            - Continuation of Provision of Appropriate Auxiliary Aids.  After conducting the assessment described in Section E.2 above, CRMC shall continue to provide appropriate auxiliary aids to the deaf or hard-of-hearing Patient or his or her Companion, in accordance with Sections F.1 and F.2 of this Agreement, during the entire period of the Patient’s hospitalization and subsequent visits without requiring subsequent requests for the appropriate auxiliary aids by the Patient or Companion. CRMC Personnel shall keep records that reflect the ongoing provision of appropriate auxiliary aids to deaf or hard-of-hearing Patients and Companions, such as notations in the Patients’ medical charts.
                            - Medical Concerns.  Nothing in this 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 any Patient’s medical condition.
                            - Determination Not to Provide Appropriate Auxiliary Aid.  If, after conducting the assessment as described in Section E.2. of this Agreement, CRMC determines that the circumstances do not warrant provision of an appropriate auxiliary aid, CRMC Personnel shall so advise the person requesting such aid and shall document the date and time of the denial, the name and title of the CRMC Personnel who made the determination, and the basis for the determination. A copy of this documentation shall be provided to the deaf or hard-of-hearing Patient (and Companion, if applicable and appropriate); shall be maintained with the Auxiliary Aid Log described in Section E.7 of this Agreement; and shall be placed in the Patient’s medical chart.
                            - Auxiliary Aid Log.  For eighteen (18) months following the Effective Date of this Agreement (unless such time period is extended by OCR’s providing written notice to CRMC of such extension), CRMC shall keep a log (which may be one log or the aggregate of multiple logs) of appropriate auxiliary aids it provides (the “Auxiliary Aid Log”). A copy of the Auxiliary Aid Log shall be attached to the Compliance Reports as described in Section J.1 of this Agreement and shall include the following information:	                               - the time and date each appropriate auxiliary aid is provided;
                              - the time and date a request is made for an appropriate auxiliary aid by a deaf or hard-of-hearing Patient or Companion (if a request is made by such Patient or Companion);
                              - the time and date CRMC Personnel requests an appropriate auxiliary aid;
                              - a code which identifies the deaf or hard-of-hearing Patient (and Companion, if applicable and appropriate);
                              - the time and date of the scheduled appointment (if a scheduled appointment was made); and
                              - the nature of the appropriate auxiliary aid provided; or a statement that the appropriate auxiliary aid was not provided, the reason why it was not provided and whether an alternative was provided (if so, identify the alternative).

                                                                      §                        As part of the Auxiliary Aid Log, CRMC also shall collect information regarding the response times, as described in Section F.3 of this Agreement, for each request for an interpreter, as well as the qualifications (certification levels) of each interpreter who responds to a request to interpret. Such Auxiliary Aid Log shall be retained by CRMC throughout the Term of this Agreement.
                          -                              - 504 Coordinator.  Within sixty (60) days after the Effective Date of this Agreement, CRMC shall reaffirm its designation of a staff person as its Section 504 coordinator, who shall effectively implement the provision of this Agreement, including without limitation:		                               - ensuring that training required by this Agreement is completed;
                              - developing and disseminating specific procedures to fully implement this Agreement;
                              - drafting, maintaining, and providing all reports required by this Agreement;
                              - analyzing data collected in the Auxiliary Aid Log and implementing any corrective action plan, if warranted; and
                              - being able to answer questions and provide appropriate assistance regarding immediate access to, and proper use of, appropriate auxiliary aids required by this Agreement.
                            - Complaint Resolution.  CRMC shall develop a Patient Grievance/Complaint Policy and Process for the resolution of concerns or grievances/complaints raised by deaf or hard-of-hearing Patients and Companions regarding effective communication. CRMC shall notify deaf or hard-of-hearing Patients and Companions of CRMC’s complaint resolution mechanism, to whom complaints should be made, and the right to receive a written response to the complaint if requested. CRMC shall use the 504 Coordinator and other appropriate CRMC Personnel to respond to and address any concerns or grievances/complaints raised by deaf or hard-of-hearing Patients and Companions regarding effective communication as soon as reasonably possible, with a goal of resolving all such matters raised while the Patient is in CRMC so that effective communication is provided while the Patient is in CRMC. CRMC shall promptly provide the deaf or hard-of-hearing Patient and/or Companion a written response to the complaint, but no later than thirty (30) days after the resolution of the grievance/complaint. CRMC shall maintain records of all grievances/complaints regarding effective communication with deaf or hard-of-hearing Patients and Companions, whether oral or written, including copies of all complaints or notes reflecting oral complaints, made to CRMC and actions taken with respect thereto throughout the Term of this Agreement.
                            - Prohibition of Surcharges.  All appropriate auxiliary aids required by this Agreement shall be provided free of charge to the deaf or hard-of-hearing Patient and/or Companion. Nothing in this section shall prohibit CRMC from seeking reimbursement for the furnishing of auxiliary aids from third-party payors, if appropriate.
                            - Notice of Available Appropriate Auxiliary Aids to Individuals Who Do Not Request Such Aids.  If a deaf or hard-of-hearing Patient and/or Companion does not request appropriate auxiliary aids, but CRMC Personnel have reason to believe, after conducting the assessment described in Section E.2 of this Agreement, that such person would benefit from appropriate auxiliary aids for effective communication, CRMC shall specifically inform the deaf or hard-of-hearing Patient and/or Companion that appropriate auxiliary aids are available free of charge.
                            - Communication with Patients and Companions.  CRMC shall take appropriate steps to ensure that all CRMC Personnel having contact with a deaf or hard-of-hearing Patient and/or Companion are made aware of such person’s disability so that effective communication with such person will be achieved.
                            - Data Collection; Monitoring of Performance; Feedback Forms.  CRMC shall collect data on the effectiveness of the appropriate auxiliary aid provided and the performance of a qualified interpreter provided. CRMC shall also prepare a form, subject to the review and approval of OCR in accordance with Section H.2 of this Agreement, requesting feedback concerning the timeliness and effectiveness of interpreter services and other appropriate auxiliary aids. Such feedback form shall be provided to each deaf or hard-of-hearing Patient or Companion who was provided an interpreter or other appropriate auxiliary aid. CRMC shall develop a convenient process to allow such Patients or Companions to complete and return the feedback forms; the Patient/Companion shall choose whether or not to avail himself or herself of that opportunity. For some Patients or Companions, limited written English proficiency may be a barrier to understanding or completing the form. CRMC shall offer assistance, including additional interpreter services, where necessary for Patients or Companions to complete the form. Outpatients who receive services on an ongoing basis do not need to receive a feedback form after every visit. CRMC shall use the feedback forms that it does receive for monitoring and evaluating the performance of each interpreter and the other appropriate auxiliary aids it provides to deaf or hard-of-hearing Patients and Companions. CRMC shall maintain the completed feedback forms throughout the Term of this Agreement.
                          - PROVISION OF SIGN LANGUAGE AND ORAL INTERPRETERS                              - Circumstances under which Interpreters shall be Provided.  As necessary for effective communication, CRMC shall provide qualified sign language interpreters to deaf or hard-of-hearing Patients and Companions whose primary means of communication is sign language. As necessary for effective communication, CRMC shall also provide qualified oral interpreters to deaf or hard-of-hearing Patients and Companions who rely primarily on lip reading. The determination of when such interpreters shall be provided to such Patients and/or Companions shall be made as set forth in Section E.2 of this Agreement. The following are examples of circumstances when it may be necessary to provide interpreters:		                               - determination of a Patient’s medical, psychiatric, psychosocial, nutritional, and functional history or description of condition;
                              - provision of a Patient’s rights, informed consent, or permission for treatment, and current condition;
                              - determination and explanation of a Patient’s diagnosis or prognosis, and current condition;
                              - explanation of procedures, tests, treatment, treatment options, or surgery;
                              - 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);
                              - explanation regarding follow-up treatments, therapies, test results, or recovery;
                              - blood donations or aphaeresis (removal of blood components);
                              - discharge planning and discharge instructions;
                              - provision of mental health evaluations, group and individual therapy, counseling, and other therapeutic activities, including but not limited to grief counseling and crisis intervention;
                              - explanation of complex billing or insurance issues that may arise;
                              - educational presentations, such as classes concerning birthing, nutrition, CPR, and weight management;
                              - religious services and spiritual counseling provided by CRMC;
                              - explanation of living wills or powers of attorney (or their availability); and
                              - any other circumstance in which a qualified sign interpreter is necessary to ensure a Patient’s rights provided by law.

                                                                      §                        The foregoing list of circumstances is not exhaustive and does not imply that there are not other circumstances when it may be appropriate to provide interpreters for effective communication. This list also is not intended to imply that an interpreter must always be provided in these and/or other circumstances.

                            - Provision of Qualified Interpreters Throughout a Hospitalization.  During a hospitalization, it shall not be necessary for the deaf or hard-of-hearing Patient to renew the request for a qualified interpreter or other appropriate auxiliary aid. CRMC shall provide notice to all deaf or hard-of-hearing Patients and Companions of its policy to provide qualified interpreters and other appropriate auxiliary aids throughout a hospitalization without the need for continual separate requests for such aids. CRMC shall make qualified interpreters available during a hospitalization in the circumstances set forth in F.1 and F.2 of this Agreement.
                            - Provision of Interpreters in a Timely Manner                                - Non-Scheduled Interpreter Requests.  For any situation that is not a scheduled appointment, CRMC shall make an interpreter available as soon as possible, but in no case later than the time periods required by the New York State Department of Health (“NYSDOH”) in its regulation at 10 N.Y.C.R.R. § 405.7(a)(7)(ix)(a) (“[I]nterpreters and persons skilled in communicating with . . . hearing-impaired individuals shall be available to patients in the inpatient and outpatient setting within 20 minutes and to patients in the emergency service within 10 minutes of a request to the hospital administration by the patient, the patient's family or representative or the provider of medical care. The Commissioner of Health may approve time limited alternatives . . . regarding interpreters and persons skilled in communicating with vision and/or hearing-impaired individuals for patients of rural hospitals”);  provided ,  however , that if the Commissioner of NYSDOH has approved a time limited alternative for CRMC in accordance with 10 N.Y.C.R.R. § 405.7(a)(7)(ix)(a), then: (i) CRMC shall provide OCR with a copy of any documentation received from NYSDOH regarding the approval and terms of such time limited alternative; and (ii) CRMC shall comply with the terms of such time limited alternative during the time period specified by NYSDOH. Notwithstanding the foregoing, in the event that the Commissioner of NYSDOH approves a time limited alternative for CRMC which would permit CRMC to make an interpreter available within any time period that exceeds two (2) hours, CRMC nonetheless shall make an interpreter available within two (2) hours from the time of the Patient/Companion’s request for an interpreter or CRMC’s request for an interpreter, whichever is earlier.
                              - Scheduled Interpreter Requests.  For scheduled events, CRMC shall make a qualified interpreter available at the time of the scheduled appointment. If an interpreter fails to appear for the scheduled appointment, CRMC shall take whatever additional actions are necessary to make a qualified interpreter available to the deaf or hard-of-hearing Patient and/or Companion.
                            - Notice to Deaf or Hard-of-Hearing Patients and Companions.  As soon as CRMC Personnel have determined that a qualified interpreter is necessary for effective communication with a deaf or hard-of-hearing Patient or Companion, CRMC shall inform such a person (or a family member or friend, if such person is not available) of the current status of efforts being taken to secure a qualified interpreter on his or her behalf. CRMC shall provide additional updates to the Patient or Companion as necessary until an interpreter is secured. Notification of efforts to secure a qualified interpreter does not lessen CRMC’s obligation to provide qualified interpreters in a timely manner as required by Section F.3 this Agreement.
                            - Other Means of Communication.  CRMC agrees that between the time an interpreter is requested and the time an interpreter arrives at the CRMC to interpret, CRMC Personnel shall continue to try to communicate with the deaf or hard-of-hearing Patient or Companion for such purposes and to the same extent as they would have communicated with the person but for the disability, using all available methods of communication, including using sign language pictographs. This provision in no way lessens CRMC’s obligation to provide qualified interpreters in a timely manner as required by Section F.3 of this Agreement.
                            - 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, CRMC shall never require or coerce a family member, case manager, advocate, or friend of a deaf or hard-of-hearing Patient or Companion to interpret or facilitate communications between CRMC Personnel and such Patient or Companion, except that such person may provide such assistance if all four (4) of the following factors are present:	                               - such person wishes to provide such assistance;
                              - the Patient or Companion provides written agreement to the use of such person to interpret or facilitate communication;
                              - the Patient or Companion has been made aware of the full range of communication facilitating options available free of charge; and
                              - such use is necessary or appropriate under the circumstances, giving appropriate consideration to any privacy issues that may arise;

                                                                      §                        provided; however, that in time-sensitive life-threatening situations, CRMC may rely upon communications through a Companion until a qualified interpreter is obtained.

                            - Assessment of Interpreter Resources; Agreement.  Within sixty (60) days after the Effective Date of this Agreement, CRMC shall assess the resources available to assist CRMC with meeting its obligations under this Agreement and:	                               - enter into a contract with an individual or organization who will provide qualified sign language interpreter services to CRMC in the event that CRMC’s current provider, Sign Language Resources, Inc., is not qualified to provide sign language interpreter services in a particular situation or is not available at the times needed by CRMC;
                              - enter into a contract with an individual or organization who will provide qualified oral interpreter services to CRMC in the event that CRMC’s current provider, Sign Language Resources, Inc., is not qualified to provide oral interpreter services in a particular situation or is not available at the times needed by CRMC; and
                              - research providers of video interpreting services (VIS) to potentially serve as one of the resources available to CRMC to meet its obligations under this Agreement and Section 504. To this end, within thirty (30) days after of the Effective Date of this Agreement, CRMC shall conduct a cost-benefit analysis to determine whether it is advisable and feasible for CRMC to enter into a contractual arrangement with a VIS provider.
                            - Video Interpreting Services.  In the event that CRMC provides interpreter services through a VIS provider, CRMC shall:	                               - Ensure that the VIS provider meets the following performance standards:

                                                                      §                        the capability of providing VIS and technical assistance twenty-four (24) hours a day, seven (7) days a week, three hundred sixty-five (365) days a year, with qualified sign language interpreters promptly available on this basis who are qualified to interpret in medical situations, and who are familiar with medical terminology.

                                                                      §                        high quality, clear, delay-free full-motion video and audio over a dedicated high-speed Internet connection;

                                                                      §                        a clear, sufficiently large, and sharply delineated picture of the interpreter’s and the Patient/Companion’s heads, arms, hands, and fingers, regardless of the body position of the Patient/Companion;

                                                                      §                        clear and easily understood transmission of voices; and

                                                                      §                        non-technicians will be trained to accomplish efficient set-up and operation;

                            - Ensure that appropriate CRMC Personnel shall be trained, available, and able to operate and connect the VIS system quickly and efficiently at CRMC at all times. Training shall include attention to the limitations of VIS technology, such as with respect to:

                                                                      §                        Patients who have limited ability to move their heads, hands, or arms; vision problems; cognitive or consciousness issues; or pain issues;

                            - Patients who may be moved to areas of CRMC that do not have a designated high speed Internet line; and Patients who will be treated in rooms where space considerations mitigate against using the service.

                                                                      §                        In circumstances where the limitations of VIS technology mitigate against its use, CRMC Personnel shall conduct another assessment as required by Section E.2 of this Agreement, in order to reassess the need for an alternative auxiliary aid or interpretive service to ensure effective communication.
                          - NOTICE TO COMMUNITY                              - Policy Statement.  Within sixty (60) days after the Effective Date of this Agreement, CRMC shall post and maintain at all CRMC admitting stations, emergency departments, and wherever a Patient’s Bill of Rights is required by law to be posted signs of conspicuous size and print, which shall state to the following effect:

§                     Free sign language and oral interpreters, TTYs/TDDs and other services are available to deaf or hard-of-hearing persons. Ask us for help or contact [CRMC Contact Information].

§                     These signs shall include the international symbols for “interpreters” and “TTYs/TDDs.”

                            - Patient and Visitor Information Brochures.  CRMC shall include in all future printings of its Patient and visitor information brochures and all similar publications a statement to the following effect:

If you are deaf or hard-of-hearing, please let us know. We provide many free services including:

§                     Sign language interpreters

§                     Oral interpreters

§                     TTYs/TDDs

§                     Telephone amplifiers

§                     Note takers

§                     Written materials

§                     Other services.

We also provide these free services to your family or to other people who may be deaf or hard-of-hearing, while they are with you in CRMC.

Ask us for help or contact [CRMC Contact Information].

These brochures shall include the international symbols for “interpreters” and “TTYs”. CRMC shall also include in the handbook a description of CRMC’s complaint resolution mechanism.

                            - Website.  Within thirty (30) days after the Effective Date of this Agreement, CRMC shall include on any website it maintains the statement described in Section G.2 of this Agreement.
                            - Format of Notices.  Within ninety (90) days after the Effective Date of this Agreement, CRMC shall make the following written materials it provides to hearing patients available in American Sign Language (ASL) using videotape, DVD, or CD-ROM format:

                            - The Patients’ Bill of Rights;
                            - Health care directives pamphlet;
                            - Information regarding CRMC’s policies and procedures governing free sign language interpreter services and other appropriate auxiliary aids, including a summary of the rights provided by this Agreement;
                            - Grievance and complaint resolution procedures; and
                            - Notice of Privacy Practices.

                                                                      §                        Within thirty (30) days after receiving OCR approval in accordance with Section H.2 of this Agreement of the feedback form described in Section E.13 of this Agreement, CRMC shall make the content of the feedback form available to Patients and Companions in ASL using DVD or CD-ROM format.
                          - VIII. DEVELOPMENT OF POLICIES AND PROCEDURES AND NOTICE TO CRMC PERSONNEL AND PHYSICIANS

1.                  **Publication of Policies and Procedures.** CRMC shall publish, in an appropriate form, written policies and procedures regarding CRMC’s policy for effective communication with persons who are deaf or hard-of-hearing. The policies and procedures shall include, but not be limited to, language to the following effect:

§                     If you recognize or have any reason to believe that a patient, relative, or a close friend or companion of a patient is deaf or hard-of-hearing, you must advise the person that appropriate auxiliary aids such as sign language and oral interpreters, TTYs, note takers, 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 CRMC programs shall be provided free of charge. If you are the health care provider responsible for the patient’s care, you must take reasonable and necessary steps to ensure that such aids and services are provided when appropriate. All other CRMC personnel should direct that person to [add CRMC contact information]. This offer and advice must likewise be made in response to any overt request for appropriate auxiliary aids.

2.                  **OCR Review and Approval.** CRMC shall send the new policies and procedures referenced in Sections E.2 and H.1 of this Agreement, as well as the patient grievance/complaint policy described in Section E.9, the feedback form described in Section E.13, and the auxiliary aid log described in Section E.7, to OCR within sixty (60) days after the Effective Date of this Agreement. Upon receipt, OCR shall review the new policies and procedures within thirty (30) days. The new policies and procedures shall not be implemented by CRMC without the approval of OCR.

3.                  **Distribution of Policies and Procedures.** Within thirty (30) days after receiving OCR approval in accordance with Section H.2 of this Agreement, CRMC shall distribute, by mail, email or other means, the new policies and procedures referenced in Sections E.2. and H.1 of this Agreement, as well as the patient grievance/complaint policy described in Section E.9, the feedback form described in Section E.13, and the auxiliary aid log described in Section E.7, to all CRMC Personnel. CRMC shall also distribute the policies and procedures, by mail, email or other means, to all new CRMC Personnel upon their employment or affiliation with CRMC. In addition, the policies and procedures shall also be distributed, by mail, email or other means, to all CRMC Personnel on an annual basis.
                          - TRAINING

 .                   **Training of 504 Coordinator.** Within sixty (60) days after receiving OCR approval in accordance with Section H.2 of this Agreement, CRMC shall provide special mandatory training for the 504 Coordinator and any other CRMC personnel who are designated to assist the 504 Coordinator with his/her responsibilities under this Agreement. Such training shall be sufficient in duration and content to train the 504 Coordinator and such CRMC personnel in:

                            - the health care needs of the deaf or hard-of-hearing;
                            - the various degrees of hearing impairment, language, and cultural diversity in the deaf or hard-of-hearing community;
                            - identification of communication needs of persons who are deaf or hard-of-hearing;
                            - the unique needs and problems encountered by late-deafened individuals;
                            - the psychological implications of deafness and its relationship to interaction with hearing health care professionals;
                            - recommended and required charting procedures governing requests for appropriate auxiliary aids;
                            - types of appropriate auxiliary aids available in the community and CRMC;
                            - the proper use and role of qualified interpreters, including how to operate any video interpreting services equipment at CRMC;
                            - making and receiving calls through TTYs;
                            - CRMC’s complaint resolution policy and process described in Section E.9 of this Agreement; and
                            - any other applicable requirements of this Agreement.

A.                 **Training of Other Key Personnel.** Within ninety (90) days after receiving OCR approval in accordance with Section H.2 of this Agreement, CRMC shall provide training to CRMC employees who fall into the following categories: social workers, patient relations staff, care coordinators, nurse managers, charge nurses, billing office customer service representatives, clinical nurse specialists, telephone operators, patient registration staff and other employees as determined by CRMC. This training may be delivered by one or more in-service training methods. The training shall address the special needs of deaf or hard-of-hearing Patients and Companions and shall include the following objectives:

                            - the requirements of Section 504 to ensure effective communication with deaf or hard-of-hearing Patients and Companions;
                            - the terms of this Agreement;
                            - the importance of the use of qualified interpreters and other appropriate auxiliary aids in providing services to deaf or hard-of-hearing Patients and Companions;
                            - types of communication modes and types of appropriate auxiliary aids;
                            - the identity and role of the 504 Coordinator and any CRMC Personnel designated to assist the 504 Coordinator;
                            - CRMC’s policy on and tips on assessing the communication needs of deaf or hard-of-hearing Patients and Companions;
                            - the use of the TTY/TDD devices and the New York State Relay Service;
                            - if appropriate, how to operate any video interpreting services equipment at CRMC; and
                            - CRMC’s procedures implemented to comply with this Agreement and other procedures specific to the employee’s employment category.

Annually thereafter, CRMC shall supplement this training so as to remind such employees of the requirements of the Agreement, reinforce their previous learning and to address any issues or problems that may be arising. CRMC shall provide the training specified above to new CRMC employees who fall into the categories identified in this Section I.2 within thirty (30) days after the commencement of their services for CRMC. A screening of a video of the original training shall suffice to meet this obligation.

B.                  **Training of Substantially all Employees in the Identified Categories.** CRMC shall use its best efforts to provide the training identified above in Sections I.1 and I.2 to substantially all of those employees within the identified time frame. The Parties recognize that certain employees may be on leave of absence or in similar categories which may prevent such employees from being trained within the identified time frame.

C.                 **Training of Emergency Room Personnel.** CRMC also shall provide annual in-service training to the non-physician employees in the CRMC emergency rooms on: (a) promptly assessing the communication needs of deaf or hard-of-hearing Patients; (b) securing the services of qualified interpreters as quickly as possible; (c) if appropriate, how to operate any video interpreting services equipment at CRMC and (d) the use of other aids to augment effective communication with deaf or hard-of-hearing Patients.

D.                 **Training Attendance Sheets.** CRMC shall maintain documentation of all training conducted pursuant to Section I of this Agreement, which shall include the names and respective job titles of the participants, as well as the date and location, if applicable, of the training session.

E.                  **Training of Medical and Allied Health Staff.** CRMC shall annually conduct one or more training sessions on the communication needs of persons who are deaf or hard-of-hearing and shall invite all medical and allied health staff to attend. CRMC shall provide training videotapes that contain substantially similar information to any affiliated physician upon request.

F.                  **Written Materials.** Within sixty (60) days after receiving OCR approval in accordance with Section H.2 of this Agreement, CRMC shall distribute, by mail, email or other means, a set of materials to all medical and allied health staff. These materials shall contain at least the following: (a) CRMC’s new policies and procedures developed in accordance with Sections E.2. and H.1 of this Agreement, as well as the patient grievance/complaint policy described in Section E.9, the feedback form described in Section E.13, and the auxiliary aid log described in Section E.7; and (b) a request that physician staff members notify CRMC of those deaf or hard-of-hearing Patients and Companions as soon as they schedule admissions, tests, surgeries, or other health care services at CRMC. CRMC shall also distribute such materials to all new medical and allied health staff members upon their affiliation with CRMC.
                          - REPORTING AND MONITORING

 .                   **Compliance Reports.** On the dates detailed in Section J.2 of this Agreement, CRMC shall provide a written report (“Compliance Report”) to OCR regarding the status of its compliance with this Agreement. The Compliance Report shall include data relevant to the Agreement, including but not limited to:

                            - the number of requests for qualified interpreters received by CRMC from, or on behalf of, deaf or hard-of-hearing Patients and Companions;
                            - the number of times a qualified interpreter was provided by CRMC;
                            - the number of times CRMC denied a request for a qualified interpreter and the reason for the denial;
                            - the number of times CRMC requested a qualified interpreter but the interpreter failed to show and, for each such situation, the reasons for the failure;
                            - in the case of a “non-scheduled interpreter request” as defined in Section F.3(a), the date and the time a qualified interpreter is requested by a deaf or hard-of-hearing Patient or Companion and the date and time the interpreter actually began interpreting for such Patient or Companion;
                            - for “scheduled interpreter requests,” as discussed in Section F.3(b), CRMC shall report the time and date of the appointment and the time the interpreter arrived.
                            - an explanation of the reasons for the delay in obtaining a qualified interpreter in those cases where: (1) in the case of a “non-scheduled interpreter request,” the time the interpreter actually begins interpreting for a deaf or hard-of-hearing Patient or Companion exceeds the time period permitted under Section F.3(a) of this Agreement; or (2) in the case of a “scheduled interpreter request,” the time the interpreter arrives at CRMC, is more than one (1) hour later than the time of the scheduled appointment; and
                            - the number of complaints received by CRMC by deaf or hard-of-hearing Patients and Companions regarding appropriate auxiliary aids and/or effective communication and a notation as to whether or not CRMC considers the matter(s) resolved.

A.                 **Submission of Compliance Reports.** CRMC shall submit the aforementioned Compliance Reports to OCR within sixty (60) days after the end of each of the following periods: (a) three (3) months after the Effective Date of this Agreement; (b) nine (9) months after the Effective Date of this Agreement (covering the preceding six (6) month period); and (c) fifteen (15) months after the Effective Date of this Agreement (covering the preceding six (6) month period).

B.                  **Maintenance of Records.** CRMC shall maintain appropriate records to document the information contained in the Compliance Reports and shall make them available, upon request, to OCR and shall retain those records throughout the Term of this Agreement.

C.                 **Additional Documentation.** CRMC shall provide OCR with the following:

                            - Within forty-five (45) days after receiving OCR approval in accordance with Section H.2 of this Agreement, copies of CRMC’s new policies and procedures developed in accordance with Sections E.2. and H.1 of this Agreement, as well as the patient grievance/complaint policy described in Section E.9, the feedback form described in Section E.13, and the auxiliary aid log described in Section E.7;
                            - Within forty-five (45) days after receiving OCR approval in accordance with Section H.2 of this Agreement, a letter certifying that the distribution of materials to CRMC Personnel required by Section H.3 of this Agreement has occurred. The letter shall specify the date(s) that such distribution occurred, and the categories of persons to whom the materials were distributed.
                            - Within seventy-five (75) days after receiving OCR approval in accordance with Section H.2 of this Agreement, a letter certifying that the distribution of materials to medical and allied health staff members required by Section I.7 of this Agreement has occurred. The letter shall specify the date(s) that such distribution occurred, and the categories of persons to whom the materials were distributed;
                            - Within one hundred five (105) days after receiving OCR approval in accordance with Section H.2 of this Agreement, a letter certifying that the training described in Section I of this Agreement has been completed. The letter shall specify the date(s), time(s) and location(s) of the training, person(s) conducting the training, the content of the training and the names and titles of those participating in the training; and
                            - Within seventy-five (75) days after the Effective Date of this Agreement, a copy of the contracts entered into by CRMC in accordance with Section F.7 of this Agreement.

**SIGNATURES**

The individuals signing this document represent that they are authorized to bind the undersigned entities to this Agreement.

 

 

 

Content last reviewed July 26, 2013