January 16, 2020
HHS OCR Secures Voluntary Resolution with CHRISTUS Trinity Mother Frances Health System to Strengthen its Provision of Auxiliary Aids and Services to Individuals Who Are Deaf or Hard of Hearing
The U.S. Department of Health and Human Services (HHS), Office for Civil Rights (OCR), has entered into a Voluntary Resolution Agreement (VRA) with CHRISTUS Trinity Mother Frances Health System (CHRISTUS TMF) resolving a compliance review concerning the rights of patients who are deaf or hard of hearing, to ensure that they receive effective communication.
Through this agreement, CHRISTUS TMF affirms that it will comply with its obligations under Section 504 of the Rehabilitation Act of 1973 (Section 504) and Section 1557 of the Affordable Care Act (Section 1557) to provide appropriate auxiliary aids and services to persons who are deaf or hard of hearing.
CHRISTUS TMF is a faith-based, not-for-profit organization that includes six hospitals and over thirty clinics and outpatient centers in Texas. CHRISTUS TMF receives federal financial assistance through its participation in the Medicare and Medicaid programs and is subject to the requirements of Section 504 and Section 1557.
OCR initiated the compliance review after it received a complaint, on behalf of a CHRISTUS TMF patient, that a CHRISTUS TMF clinic and hospital failed to provide adequate or timely interpreter services despite multiple requests. OCR subsequently received information from additional patients alleging deficiencies in CHRISTUS TMF's provision of auxiliary aids and services to individuals who are deaf or hard of hearing. These allegations led OCR to conduct a broad review of CHRISTUS TMF's policies and procedures regarding its obligations under Section 504 and Section 1557.
As a result of OCR's investigation and review, CHRISTUS TMF and OCR have agreed that CHRISTUS TMF will take steps to strengthen the provision of auxiliary aids and services, including:
- Performing communication assessments at patient intake and reassessing communication effectiveness regularly;
- Improving and upgrading its review, assessment, and provision of qualified interpreters, including in-person and by video remote interpreting;
- Providing annual staff training on effective communication;
- Submitting reports to OCR regarding CHRISTUS TMF's ongoing compliance activities, on which OCR will provide CHRISTUS TMF with substantive technical assistance and feedback; and
- Conducting outreach to local disability groups on the available auxiliary aids and services that CHRISTUS TMF provides to individuals who are deaf or hard of hearing.
Director Roger Severino, Director of OCR said, "Good healthcare starts with effective communication and this agreement helps eliminate unnecessary barriers to equal treatment for persons who are deaf of hard of hearing."
Click to read the CHRISTUS TMF Voluntary Resolution Agreement.
More information on OCR resources, federal resource, and other organization resources related to effective communication with individuals with a disability may be found at: www.hhs.gov/civil-rights/for-individuals/special-topics/hospitals-effective-communication/disability-resources-effective-communication/index.html.
For additional information on OCR's work on effective communication for persons who are deaf or hard of hearing, visit: www.hhs.gov/civil-rights/for-individuals/disability/effective-communication/index.html.
To learn more about Section 1557 of the Patient Protection and Affordable Care Act, visit www.hhs.gov/civil-rights/for-individuals/section-1557/index.html.
To learn more about civil, conscience and religious freedom, and health information privacy rights in health and human services or to file a complaint, visit us at www.hhs.gov/ocr.
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Last revised: January 16, 2020