Scottsdale Healthcare – Osborn (SHO) Resolution Agreement


Between the

Transaction Number: 05–30818


I.  Introduction

II.  Definitions

III.  General Provisions

IV.  General Obligations

V.  Specific Provisions

VI.  Signatures

I.     Introduction

This Resolution Agreement (“Resolution Agreement”) is entered into by the United States Department of Health and Human Services, Office for Civil Rights (“OCR”) and Scottsdale Healthcare – Osborn (“SHO”) a 337–bed full–service hospital, accommodating at full capacity 100,000 patients per year; and a trauma center, serving approximately 50,000 emergency room patients per year. This Agreement resolves OCR transaction number 05–30818, which is a complaint filed by Mrs. Yita Harrison and which was opened by OCR on February 3, 2005 regarding this issue:

Whether SHO provides appropriate auxiliary aids to provide deaf or hard of hearing persons with an equal opportunity to benefit from services. [45 C.F.R. § 84.52 ]

  1. Parties to the Agreement

1.      United States Department of Health and Human Services, Office for Civil Rights

2.      Scottsdale Healthcare – Osborn

  1. Jurisdiction
    SHO receives Federal financial assistance through its participation in the Medicare program and is subject to Section 504 of the Rehabilitation Act, 29 U.S.C. § 794 (“Section 504”), and its implementing regulations, 45 C.F.R. Part 84. Section 504 prohibits discrimination on the basis of disability in any program or activity receiving Federal financial assistance.
  2. Background
    OCR initiated an investigation of SHO to determine whether SHO provides appropriate auxiliary aids to deaf or hard of hearing persons such that they may have an equal opportunity to benefit from the services the hospital provides. SHO expressed a willingness to voluntarily resolve the issues in this complaint.
  3. Purpose of Agreement
    To resolve these matters expeditiously and without further burden or the expense of additional investigation or litigation, SHO agrees to the terms stipulated in this Agreement and affirms its assurance of compliance with all provisions of Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. § 794 and its implementing regulation, 45 C.F.R. Part 84. The promises, obligations or other terms and conditions set forth in this Agreement constitute the exchange of valuable consideration between SHO and OCR.
    The actions described in this Agreement fully address the issues described in the complaint. It is understood and agreed by OCR that SHO’s agreement to take the steps outlined herein was reached prior to issuance of findings by OCR. This Resolution Agreement shall not be deemed or construed to be an admission or evidence of any violation of any law or regulation or of any liability or wrongdoing on the part of SHO or its staff.

   II.     Definitions

For the purpose of this Agreement, the terms listed below shall have the following meaning:

A.   Patient shall be broadly construed to mean any individual who is seeking or receiving health care services, including such services as the opportunity to donate blood, attend health education classes or discuss billing.

B.   Qualified Interpreter shall include “sign language interpreters,” “oral interpreter”, or other “interpreters” who are 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. 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.” Also, 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 signing and translate 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 specific skill and training in acting as an intermediary between a Patient and a Companion and a sign language interpreter in instances when the interpreter cannot otherwise independently understand the consumer’s primary mode of communication.

C.   Qualified Note Taker shall mean a note taker who is able to transcribe voice communications competently, accurately, and impartially, using any specialized terminology necessary to effectively communicate 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.

D.   Appropriate Auxiliary Aids include, but are not limited to, qualified sign language or oral interpreters, qualified note–takers, computer–assisted real time transcription services, written materials, telephone handset amplifiers, assistive listening devices and systems, telephone compatible hearing aids, closed caption decoders, open and closed captioning, and teletypewriters (“TTY’s”).

E.    Companion means a person who is (1) deaf or hard of hearing and who accompanies a deaf or hard of hearing Patient, or (2) deaf or hard of hearing and who accompanies a hearing Patient, or (3) hearing and who accompanies a deaf or hard of hearing Patient; and who is (i) legally authorized to make health care decisions on behalf of the Patient, or (ii) designated by the Patient to communicate, or circumstances otherwise indicate should communicate, with Hospital personnel about the Patient, the Patient’s needs, condition, history, or symptoms, or (iii) authorized to help the Patient act on information or instructions by Hospital personnel, or (iv) the Patient’s next of kin or health care surrogate or such person with whom the Hospital personnel ordinarily and regularly communicate concerning the Patient’s medical condition.

     III.     General Provisions

A.   Facilities Covered by Agreement. This Agreement covers the hospital of Scottsdale Healthcare ? Osborn (a hospital owned by Scottsdale Healthcare and located at 7400 E. Osborn Road, Scottsdale, AZ 85251).

B.   Suspension of Administrative Actions. Subject to the continued performance by SHO of the stated obligations and required actions contained in this Agreement and in conformity with Section III.H., an agreement to comply with the terms of this Agreement, OCR shall suspend administrative actions on OCR Transaction Number 05–30818.

C.   Effective Date and Term of the Agreement. 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 two hundred ten (210) days following the Effective Date of this Agreement (the “Term”). At such time, the Agreement will terminate, provided SHO is in substantial compliance with the Agreement. Notwithstanding the Term of this Agreement, SHO acknowledges that it will comply with Section 504 of the Rehabilitation Act for so long as it continues to receive Federal financial assistance.

D.   SHO’s Continuing Obligation. Nothing in this Agreement is intended to relieve SHO of its continuing obligation to comply with other applicable non–discrimination statutes and their implementing regulations, including Section 504 and its implementing regulation at 45 C.F.R. Part 84.

E.    Effect on Other Compliance Matters. The terms of this Agreement do not apply to any other issues, investigations, reviews or complaints of discrimination that are unrelated to the subject matter of this Agreement and that may be pending before OCR or any other Federal Agency. Any unrelated compliance matter arising from subsequent reviews or investigations will be addressed and resolved separately. This Agreement also does not preclude further OCR compliance reviews or complaint investigations. OCR shall review complaints against SHO that are received after the Effective Date of this Agreement. Nothing in this paragraph shall be construed to limit or restrict OCR’s statutory and regulatory authority to conduct compliance reviews or complaint investigations.

F.    Prohibition Against Retaliation and Intimidation. SHO shall not retaliate, intimidate, threaten, coerce or discriminate against any person who has filed a complaint, assisted or participated in any matter in the investigation of matters addressed in this Agreement.

G.   OCR’s Review of SHO’s Compliance with Agreement. OCR may, at any time, review SHO’s compliance with this Agreement. As part of such review, OCR may require SHO to provide written reports, permit inspection of hospital facilities, interview witnesses and examine and copy documents. SHO agrees to retain records required by OCR to assess its compliance with the Agreement and to submit the requested reports to OCR.

H.   Failure to Comply with the Terms of Agreement. If at any time OCR determines that SHO has failed to comply with any provision of this Agreement, OCR shall notify SHO in writing. On notice to SHO, OCR may shorten the time frame outlined below, if it determines that a delay would result in irreparable injury to the complainant or other affected parties.

The notice shall include a statement of the basis for OCR’s determination and will allow SHO fifteen (15) days to either explain in writing the reasons for its actions and describe the remedial actions that have been or will be taken to achieve compliance with this Agreement or provide information that would cause OCR to review or change its determination. If SHO does not respond to the notice or, if upon review of SHO’s response, OCR finds that SHO has not complied with any provision of this Agreement, OCR may, upon notice to SHO:

1.     re–open the investigation;

2.     issue a Letter of Findings documenting the area of non–compliance;

3.     initiate administrative enforcement proceedings to suspend or terminate Federal financial assistance;

4.     refer the matter to the U.S. Department of Justice with a recommendation that appropriate proceedings be brought for enforcement; or

5.     initiate any other applicable proceedings under Federal law.

I.     Non–Waiver Provision. 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 provisions of this Agreement.

J.     Entire Agreement. This Agreement constitutes the entire understanding between SHO and OCR in resolution of OCR Transaction Number 05–30818. Any statement, promise or agreement not contained herein shall not be enforceable through this Agreement.

K.   Modification of Agreement. This Agreement may be modified by mutual agreement of the parties in writing.

L.    Effect of SHO Program Changes. SHO reserves the right to change or modify its programs, so long as SHO ensures compliance with Section 504 of the Rehabilitation Act and its implementing regulation at 45 C.F.R. Part 84 and other applicable federal statutes and the provisions of this Agreement. Significant program changes that may affect compliance with this Agreement or any applicable statutes and regulations within OCR’s jurisdiction must be reported to OCR promptly.

M.  Publication or Release of Agreement. OCR places no restrictions on the publication of the terms of this Agreement. In addition, OCR may be required to release this Agreement and all related materials to any person upon request consistent with the requirements of the Freedom of Information Act, 5 U.S.C. § 552 and its implementing regulations, 45 C.F.R. Part 5.

N.   Authority of Signer. The individual who signs this document on behalf of SHO represents that he or she is authorized to bind SHO to this Agreement.

O.   Third Party Rights. This Agreement can only be enforced by the parties specified in this Agreement, their legal representatives and assigns. This Agreement shall be unenforceable by third parties and shall not be construed to create third party beneficiary rights.

P.   Miscellaneous. When OCR verifies that SHO has completed all actions contained in this Resolution Agreement, OCR will consider all matters related to this investigation resolved and so notify SHO in writing. OCR shall provide appropriate technical assistance and guidance necessary to fulfill the terms of this Resolution Agreement.

IV. General Obligations

A.   Disability Non–discrimination. SHO 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 SHO as required by Section 504.

B.   Non–discrimination by Association. SHO shall not deny equal services, accommodations, or other opportunities to any individual because of the known relationship of the individual with someone who is deaf or hard–of–hearing.

V.   Specific Provisions

A.   Recognition. SHO recognizes that deaf or hard of hearing individuals need appropriate auxiliary aids to access and fully participate in hospital care and services operated by SHO. SHO is committed to providing appropriate auxiliary aids in a timely manner to deaf or hard of hearing individuals to ensure effective communication and an equal opportunity to participate fully in the services, activities, programs and benefits administered by SHO. This includes ensuring effective communication between SHO staff members and subcontractors and deaf or hard of hearing Patients and/or Companions.

B.   Documentation of Revised Policy. Thirty (30) days from the Effective Date of this Agreement, SHO shall submit to OCR documentation of revised policies and procedures to provide effective communication to deaf or hard of hearing individuals consistent with the requirements of Section 504. The revised policies and procedures shall include a statement indicating that appropriate auxiliary aids shall be provided free of charge to the deaf or hard of hearing Patient and/or Companion. OCR shall review the revised policies and procedures within thirty (30) days. The policies and procedures shall not be implemented by SHO without the approval of OCR.

C.   Assessment for Determining Qualified Interpreter Needs. The determination of which appropriate auxiliary aids and services are necessary and the timing, duration and frequency with which they will be provided, shall be made by Hospital Personnel who are otherwise primarily responsible for coordination and/or providing patient care, in consultation with the person with the disability, where possible. The assessment will take into account all relevant facts and circumstances, including without limitation, 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 reasonably foreseeable health care activities of the Patient (e.g., medical tests or procedures, rehabilitation therapy, meetings with health care professionals or social workers, or discussions concerning billing, insurance, history, diagnosis, prognosis, self–care, and discharge, and the availability at the required times, day or night, of appropriate auxiliary aids and services).
SHO shall provide qualified interpreters to Patients and/or Companions (depending on the situation) for these general situations:

1.      explaining and describing inpatient, pre–operative, post–operative and other medical procedures;

2.      obtaining informed consent for major procedures or surgery;

3.      communicating with the Patient and/or Companion during treatment, testing, physician consultations/rounds, and pharmacological therapy or medication changes;

4.      during the discharge planning and instruction phase;

5.      discussing complex financial or insurance matters; and/or

6.      meetings with health care professionals or social workers.

D.   Specific Circumstances Under Which Qualified Interpreters will be Provided. SHO shall provide qualified interpreters to Patients and/or Companions who are deaf or hard of hearing or who have speech impairments, as necessary for effective communication. The determination of when such qualified interpreters shall be provided to Patients and/or Companions shall be made as set forth in Section V–D. The following are specific examples of circumstances when it may be necessary to provide qualified interpreters:

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

2.      provision of Patients’ rights, informed consent or permission for treatment;

3.      religious service and spiritual counseling;

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

5.      diagnosis or prognosis of ailments or injuries;

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

7.      explanations of medications prescribed (such as dosage and instructions for how and when the medication is to be taken, side effects or food or drug interactions, and explanations for when medications are modified or changed);

8.      explanations regarding follow up treatments, therapies, test results or recovery;

9.      blood donations or aphaeresis;

10. discharge instructions;

11. provision of mental health evaluations, group and individual therapy, counseling and other therapeutic activities;

12. explanation of complex billing or insurance issues that may arise; and/or

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

E.    Initial Assessment and Ongoing Assessments. The initial assessment will be made at the time an appointment is scheduled or on the arrival of the Patient and/or Companion at the Hospital, whichever is earlier. Hospital Personnel will perform and document a communication assessment as part of each initial inpatient assessment. Completion of communication assessments will be documented in the patient medical record.
If a Patient and/or Companion who is deaf or hard of hearing or who has a speech impairment has an ongoing relationship with the Hospital, the provision of appropriate auxiliary aids or services will be considered as part of each routine assessment of an inpatient or on a regular basis with respect to other Patients and/or Companions. Hospital Personnel shall keep appropriate records that reflect the ongoing assessments, such as notations in the Patient medical record.

F.    Notifying Deaf or Hard of Hearing Individuals of the Availability of Auxiliary Aids. SHO shall provide notice to deaf or hard of hearing individuals of the right to appropriate auxiliary aids free of charge; the process for filing and resolving grievances about such services with SHO; and the SHO staff member(s) who have been designated to provide assistance regarding immediate access to, and proper use of, appropriate auxiliary aids required by this Agreement. The notice shall include:

1.      the Scottsdale Healthcare Patient Bill of Rights and Responsibilities (including complaint procedures), signs and placards;

2.      written policy statements or other materials notifying deaf or hard of hearing individuals of the availability of auxiliary aids; and

3.      publication of such written policy statements in a Hospital–wide communication piece (such as the web site or quarterly newspaper inserts).

G.   Request for an Interpreter. If a deaf or hard of hearing Patient and/or Companion requests an interpreter, one shall be provided so long as the determination of the need for an interpreter is in accordance with Section IV.C of this Agreement.

H.   Interpretation Services.

1.      SHO shall provide interpretation services for deaf or hard of hearing individuals who need such assistance to communicate effectively with SHO staff so as to obtain equal opportunity in participating and receiving health care services from SHO. SHO may utilize any of the following language resources, to the extent such resources result in effective communication:

§        Qualified sign language and/or oral interpreters;

§         Staff interpreters;

§         Interpreters available through contracted interpreter agencies, including but not limited to, community organizations;

§        SHO interpreter phone banks;

§        Volunteer interpreter programs; and

§        Video interpretation services (“VIS”) that use video conference technology over high–speed internet lines.

2.      If SHO uses VIS technology, it shall meet the following performance standards:

§        High–quality, clear, delay–free, motion–free 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’s/Companion’s heads, 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.

3.      SHO shall ensure that appropriate Hospital Personnel shall be trained, available, and able to operate and connect the VIS system quickly and efficiently at SHO at all times. Training shall include attention to the limitations of VIS technology, such as with respect to (i) Patients that have a limited ability to move their heads, hands, or arms; vision problems; cognitive or consciousness issues; or pain issues; (ii) Patients that may be moved to areas of the Hospital that do not have a dedicated high–speed Internet line; (iii) Patients who will be treated in a room where space considerations mitigate against the use of the VIS. In circumstances where limitations of the VIS technology mitigate against its use, SHO shall conduct another Initial/Ongoing Assessment (per Section V–E) in order to reassess the need for an alternate auxiliary aid or interpretive service to ensure effective communication.

4.      SHO shall ensure that, pursuant to Section V–D of this Agreement, regardless of the type of auxiliary aid provided, communication with deaf and hard of hearing Patients and/or Companions is effective.

5.      SHO will develop and ensure that the one centralized telecommunication number is available 24–hours per day, 7 days per week, for interpreter requests. SHO will ensure that the centralized telecommunications office maintains a list identifying all available qualified interpreters, telephone language lines and other services and resources.

6.      SHO will revise its policies and procedures to ensure that supervisor or manager authorization or approval is not required prior to, or as a condition of, fulfilling and processing any requests for qualified interpreter services.

I.     Interim Services. SHO agrees that between the time an interpreter is requested and when an interpreter arrives, Hospital Personnel will continue to try to communicate with the Patient and/or Companion who is deaf or hard of hearing or who has a speech impairment for such purposes and to the same extent as they would have communicated with the person but for the hearing impairment, using all available methods of communication. SHO agrees that supervisory or managerial authorization or approval will not be required as a condition precedent of fulfilling a request for qualified interpreter services.

J.     Provision of Interpreters in a Timely Manner.

1.      Scheduled appointments. For scheduled appointments (appointments scheduled two or more hours in advance, or four or more hours if the appointment is scheduled between the hours of 8 p.m. and 8 a.m. or on a weekend or holiday), SHO shall make a qualified interpreter available at the time of appointment, if necessary for effective communication.

2.      Non–scheduled Incidents. “Non–scheduled incidents” refer to all situations not covered by the definition of “scheduled appointments.” For “non–scheduled incidents,” SHO shall make a qualified interpreter available as soon as practicable. However, the time within which the interpreter is provided shall be no more than: (a) two hours from the time the request is made to SHO’s centralized Interpreter Service line for an off–site contracted interpreter or off–site staff interpreter; or, (b) 30 minutes from the time the Patient’s and/or Companion’s request is made if the service is provided through VIS or a staff interpreter who is on–site at the time of the request or need for an interpreter.

K.   Restricted Use of Certain Persons to Facilitate Communication. Due to confidentiality, potential emotional involvement and other facts that may adversely affect the ability to facilitate communication, SHO shall never require or coerce a family member, Companion, external or unaffiliated case manager, advocate or friend of a Patient who is deaf or hard of hearing to interpret or facilitate communications between Hospital Personnel and such Patient and/or Companion.

L.    Procedures for Obtaining Qualified Interpreters. SHO will take the following steps, in order, when it receives notice that a Patient and/or Companion requires sign language or oral interpreters for effective communication, until a qualified interpreter is secured or the steps have been exhausted:

1.      Request an interpreter (he or she must be qualified to interpret for the specific Patient and/or Companion who will be using the services) from either the list of qualified staff interpreters or from agencies with whom SHO has an ongoing contract for qualified sign language or oral interpreter services;

2.      If SHO is unable to obtain an available qualified interpreter either from the list of qualified staff interpreters or from an interpreter agency with which it has an ongoing contract for interpreter services, then SHO shall exert reasonable efforts to contact any freelance interpreters or other interpreting agencies already known to SHO and request their services; and

3.      Inform the Patient and/or Companion, who is deaf or hard of hearing or who has a speech impairment (or, if unavailable, the person’s Companion(s)) of the efforts taken to secure a qualified interpreter and the efforts that have failed and follow up on reasonable suggestions for alternate sources of interpreters, such as contacting an interpreter known to that person.

M.  Staff Interpreters. SHO may, but shall have no obligation to, satisfy its obligations under this Agreement by hiring or otherwise contracting with qualified staff interpreters. Staff interpreters must meet the definition of “qualified interpreters.” Patients and/or Companions who are provided with staff interpreters must have the same level of coverage (for both duration and frequency) as SHO is otherwise obligated to provide under this Agreement. If a staff interpreter is not available when needed, SHO will follow the procedures set forth above to obtain the services of a qualified interpreter.

N.   Telephones and Technology. SHO will provide a TTY at each public telephone location in or adjacent to an emergency department, recovery room or waiting room. To satisfy this provision, SHO can permanently install the required TTY’s or make available a sufficient number of portable TTY’s. SHO will make portable access technology available to Patients and/or Companions who are deaf or hard of hearing or who have speech impairments and who are admitted to (or are accompanying Patients who are admitted to) rooms equipped with a telephone.

O.   Notice to Hospital Personnel and Physicians. SHO shall publish, in an appropriate form, a policy statement regarding the Hospital’s policy for effective communication with persons who are deaf or hard of hearing or who have speech impairments.

P.   Training of Hospital Personnel. SHO will provide documentation that Hospital staff and employees and affiliated physicians receive training on its revised policies and procedures for ensuring effective communication with deaf and hard of hearing Patients and/or Companions.

Such training shall be sufficient in content to train Hospital Personnel as to access of the Program, use of and methods for obtaining an interpreter and sensitivity to the needs of the deaf community. Such training shall include topics such as the various degrees of hearing and speech impairment, language and cultural diversity in the deaf community; dispelling myths and misconceptions about persons who are deaf, hard of hearing, or have speech impairments; identification of communication needs of persons who are deaf or hard of hearing or who have speech impairments; the proper use and role of qualified interpreters; procedures and methods for accessing sign language and oral interpreter agencies and free lance interpreters; the existence at SHO of a Program Office and use of TTY through telephone relay service providers; and third party resources that can provide additional information about persons who are deaf or hard of hearing.

IV.  Specific Provisions

A.       Compliance Reports. On the dates detailed in Section VI.B of this Agreement, SHO 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:

    1. the number of requests for qualified interpreters received by SHO from deaf or hard of hearing Patients and Companions.
    2. the number of times a qualified interpreter was provided by SHO;
    3. the number of times SHO denied a request for a qualified interpreter and the reason for the denial;
    4. the number of times SHO requested a qualified interpreter but the interpreter failed to show and, for each such situation, the reasons for the failure;
    5.  in the case of a “non–scheduled interpreter request,” 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 qualified interpreter actually began interpreting for such Patient or Companion;
    6. for “scheduled interpreter requests,” SHO shall report the time and date of the appointment and the time the qualified interpreter arrived.
    7. an explanation of the reasons for the delay in obtaining a qualified interpreter; and
    8. the number of complaints received by SHO 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 SHO considers the matter(s) resolved.

B.        Submission of Compliance Reports. SHO shall submit the aforementioned Compliance Reports to OCR within thirty (30) days after the end of each of the following periods: (1) three (3) months after the Effective Date of this Agreement; (2) six (6) months after the Effective Date of this Agreement (covering the preceding six (6) month period). These reports may take the form of Attachment A.

C.       Maintenance of Records. SHO 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.

D.       Additional Documentation. SHO shall provide OCR with the following:

  1. Within one hundred twenty (120) days after the Effective Date of this Agreement, a letter certifying that the distribution of materials required by Section V–F of this Agreement has occurred.
  2. Within one hundred twenty (120) days after the Effective Date of this Agreement, a letter certifying that the training described in Section V–P 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
  3. Within one hundred twenty (120) days after the Effective Date of this Agreement, SHO shall submit to OCR documentation that it has completed the actions required in Sections V–B of this Agreement.


/s/ Alan B. Kelly
Alan B. Kelly
General Counsel for Scottsdale Healthcare

Date: 01/30/08_

/s/ Michael F. Kruley
Michael F. Kruley
Regional Manager
U.S. Department of Health & Human Services
Office for Civil Rights - Region IX

Date: 02/07/08

Exhibit A


Compliance Report to the Office for Civil Rights


1.      General Obligations
Attach copy of updated Qualified Interpreter policy, procedure, and documentation, which should include:

a.      policy statement;

b.     purpose;

c.      procedural steps and sequence for obtaining a qualified interpreter;

d.     call lists and schedule for all qualified interpreters available;

e.      specify policy, procedure and steps taken from Interpreter Services Manager to oversee and ensure quality assurance and review of qualified interpreters.

2.      Communication and Training
Attach copy of detailed communication updates, newsletter announcements, intranet announcements, email announcements, etc.
Also include a copy of training information, details, sign–in sheet, and other documentation of staff training on revised Qualified Interpreter policy, procedure, and staffing.

3.      Provision of Interpreter Services Data
Attach documentation as to total number of requests for interpreting services received by the entire hospital, the total number of interpreters provided, the source of the interpreter, the number of untimely responses for requests for interpreters, and actual response times for all requests that exceeded such criteria during the period.
Please also submit supporting documentation as to interpreter contracts, interpreter call lists and schedules (for in–house interpreters), and other supporting information to clarify the information in the quarterly report.

Sample Compliance Report Template

Time Period :                                to

Date and Time of Qualified Interpreter Request

Date and Time of Denial of Qualified Interpreter Request by SHO

Date and Time of Arrival of Qualified Interpreter Provided by SHO

Date and Time of No Show By Qualified Interpreter To Be Provided by SHO

Time Period (in minutes) Between Non–Scheduled Qualified Interpreter Request and Arrival

Time Period (in minutes) Between Scheduled Qualified Interpreter Request and Arrival

Reasons for Delay in the Arrival of Qualified Interpreter

Complaint Received by SHO Regarding Appropriate Auxiliary Aids

































Content created by Office for Civil Rights (OCR)
Content last reviewed on July 26, 2013