Voluntary Resolution Agreement Between the U.S. Department of Health and Human Services Office for Civil Rights (OCR) and Chi St. Vincent Hot Springs

OCR TRANSACTION NUMBER: 20-362473

I. Introduction

The parties to this Voluntary Resolution Agreement (the “Agreement”) are the United States Department of Health and Human Services, Office for Civil Rights (“OCR”), and CHI St. Vincent Hot Springs (“CHI St. Vincent Hot Springs” or “CHI St. Vincent”), located at 300 Werner Street, Hot Springs, Arkansas 71913. This Agreement resolves OCR Transaction Number: 20-362473. The Complainant alleged CHI St. Vincent discriminated against her on the basis of her disabilities (deafness and Usher Syndrome) when it failed to provide her with appropriate auxiliary aids to ensure effective communication during her visit to the Emergency Department on September 1, 2019, in violation of Section 504 of the Rehabilitation Act of 1973 and Section 1557 of the Patient Protection and Affordable Care Act.

CHI St. Vincent receives Federal financial assistance (“FFA”) through its participation in Medicare, Title XVIII of the Social Security Act, 42 U.S.C. § 1395 et seq., and Medicaid, Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq. programs and is subject to Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794, and its implementing regulations, 45 C.F.R. Part 84 (“Section 504”). Section 504 prohibits discrimination on the basis of disability in any program or activity receiving FFA.

Furthermore, as a health program that receives FFA through the Medicaid and Medicare programs, CHI St. Vincent is obligated to comply with Section 1557 of the Patient Protection and Affordable Care Act, 42 U.S.C. § 18116 and its implementing regulations, 45 C.F.R. Part 92 (“Section 1557”). Section 1557 prohibits health programs and activities that receive FFA from HHS from implementing policies and practices that discriminate, or have the effect of discriminating, against individuals on the grounds of race, color, national origin, age, sex, or disability.

Parties to the Agreement:
1. United States Department of Health and Human Services, Office for Civil Rights; and
2. CHI St. Vincent Hot Springs.
Jurisdiction:
Purpose of the Agreement: To resolve these matters without further burden or the expense of litigation, CHI St. Vincent agrees to the terms within this Agreement and affirms that it will comply with all provisions of Section 504 and Section 1557. CHI St. Vincent’s willingness to enter into this Agreement with OCR in no way constitutes an admission of liability and demonstrates CHI St. Vincent’s ongoing efforts to accommodate individuals with disabilities. The promises, obligations or other terms and conditions set forth in this Agreement constitute the exchange of valuable consideration between CHI St. Vincent and OCR. The actions described in this Agreement fully address the issues described in the complaint.

II. Definitions

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

“Patient” means any individual who is seeking or receiving health care or other services from CHI St. Vincent or the employees under its supervision or control and its contractors who coordinate and/or provide patient care services, including the registration team members.
“CHI St. Vincent” and/or “CHI St. Vincent staff” means employees under CHI St. Vincent Hot Spring’ supervision or control and its contractors who coordinate and/or provide patient care services, including but not limited to physicians, registered nurses, physical therapists, occupational therapists, and administrative staff members.
“Appropriate Auxiliary Aids and Services” includes qualified interpreters on-site or through video remote interpreting (VRI) services; note takers; real-time computer aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunications products and systems, text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunication devices; videotext displays; accessible electronic and information technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard of hearing. 28 C.F.R. § 35.104; 45 C.F.R. § 36.303(f).
“Companion” means a family member, friend, or associate of a Patient who, along with the Patient, is an appropriate person with whom CHI St. Vincent should communicate. 28 C.F.R. § 35.160(a)(2).
“Qualified Interpreter” means an interpreter who, via a video remote interpreting (VRI) service or an onsite-appearance, adheres to generally accepted interpreter ethics principles, including client confidentiality; and is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary. Qualified interpreters include, for example, sign language interpreters, oral transliterators, and cued-language transliterators. 28 C.F.R. § 35.104. Not all interpreters are qualified for all situations. For example, an interpreter who is qualified to interpret using American Sign Language (ASL) is not necessarily qualified to interpret orally. Someone who has only a rudimentary familiarity with sign language or finger spelling is not a Qualified Interpreter under this Agreement. Likewise, someone who is fluent in ASL but unable to translate spoken communication into ASL or to translate signed communication into spoken words is not a Qualified Interpreter. Someone who is fluent in Signed English, but is unable to interpret using ASL is not qualified to interpret for an individual who communicates using ASL.
“Video Remote Interpreting” or “VRI” means an interpreting service that uses video conference technology over dedicated lines or wireless technology offering high-speed, wide-bandwidth video connection that delivers high-quality video images. 28 C.F.R. § 35.104.

III. General Provisions

Recipient Covered by the Agreement: This Agreement covers all patient programs, services and activities, which CHI St. Vincent administers or provides directly or through sub-recipients or contractors, throughout the Term (as defined below) of this Agreement.
Suspension of Administrative Actions: OCR shall suspend administrative action on OCR Transaction Number: 20-362473 subject to CHI St. Vincent’s continued performance of the stated obligations and required actions contained in this Agreement.
Effective Date and Term of the Agreement: This Agreement shall become effective on the date it is signed by all parties (the “Effective Date”) and will remain in effect for two (2) years after the Effective Date (the “Term”), at which point if OCR determines that CHI St. Vincent has substantially complied with the stated obligations and required actions contained in this Agreement, then OCR’s review and monitoring of this Agreement shall terminate. This Agreement may be executed in counterparts. Notwithstanding the Term of this Agreement, CHI St. Vincent acknowledges that it will comply with Section 504 and Section 1557 and other applicable Federal nondiscrimination statutes and their implementing regulations, for so long as it continues to receive FFA.
Failure to Comply with the Agreement: If OCR determines that CHI St. Vincent has failed to substantially comply with any provision of this Agreement, the parties will confer and attempt to reach agreement as to what steps may be necessary to resolve the compliance issues to both parties’ satisfaction. If an agreement is not reached, OCR may terminate this Agreement within thirty (30) calendar days’ prior written notice to CHI St. Vincent and take appropriate measures to effectuate CHI St. Vincent’s compliance with Section 504 and Section 1557. Such measures may include OCR reopening its investigation of CHI St. Vincent’s compliance with Section 504 and Section 1557. OCR may incorporate into its reopened investigation any relevant evidence of noncompliance with the Agreement and any relevant evidence obtained by OCR prior to signing of the Agreement. OCR may also exercise all rights available under Section 504 and Section 1557, including, but not limited to issuing noncompliance findings and the initiation of enforcement proceedings to terminate Federal financial assistance to CHI St. Vincent.
Effect on Other Compliance Matters: The terms of this Agreement do not apply to any other issues, reviews, investigations 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 shall be addressed and resolved separately. Nothing in this Agreement shall be construed to limit or restrict OCR’s statutory and regulatory authority to conduct future complaint investigations and compliance reviews related to CHI St. Vincent and the subject matter of this Agreement. This Agreement does not address or resolve issues involved in any other complaint investigation, compliance review, or administrative action under Federal laws by other Federal Agencies, including any action or investigation under Section 504 and Section 1557.
Prohibition Against Retaliation and Intimidation: CHI St. Vincent shall not retaliate, intimidate, threaten, coerce or discriminate against any person who has filed a complaint or who has assisted or participated in the investigation of any matter addressed in this Agreement.
OCR’s Review of CHI St. Vincent’s Compliance with the Agreement: OCR may review CHI St. Vincent’s compliance with this Agreement at any time while the Agreement is in effect. As part of such review, with reasonable prior written notice to CHI St. Vincent, OCR may require written reports, access to witnesses, copies of documents, and/or inspection of CHI St. Vincent’s facilities. Throughout the duration of this Agreement, CHI St. Vincent agrees to retain records related to services for deaf individuals; complaints made regarding effective communication made to CHI St. Vincent; all contracts, maintenance reports, and issues regarding services CHI St. Vincent provides to deaf individuals; and related documents. These documents may be used by OCR to assess CHI St. Vincent’s compliance. OCR will maintain the confidentiality of all documents, files and records received from CHI St. Vincent; and will not disclose their contents except where necessary in formal enforcement proceedings or where otherwise required by law.
Non-Waiver Provision: OCR’s failure 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.
Entire Agreement: This Agreement constitutes the entire understanding between CHI St. Vincent and OCR in the resolution of OCR Transaction Number: 20-362473. Any statement, promise or agreement not contained herein shall not be enforceable through this Agreement.
Modification of Agreement: This Agreement may be modified by mutual agreement of the parties in writing.
Publication or Release of Agreement: OCR places no restrictions on the publication of this Agreement or its terms, which does not include any documents requested by OCR in Section III.G above.
Third Party Rights: This Agreement can be enforced only 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.
Technical Assistance: OCR will provide appropriate technical assistance to CHI St. Vincent regarding compliance with this Agreement, as requested and as reasonably necessary.
Miscellaneous: When OCR verifies that CHI St. Vincent has completed all actions contained in this Agreement, OCR shall consider all matters related to this investigation resolved and so notify CHI St. Vincent in writing.
Severability: The Parties will not, individually or in combination with one another, seek to have any court declare or determine that any portion of this Agreement is invalid, illegal, or unenforceable. In the event that a court of competent jurisdiction determines that any provision of this Agreement is unenforceable, such provision shall be severed from the 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 obligation 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 obligation initially intended to them hereunder.
Successor in Interest: This Agreement is binding on the parties, and their assigns or successors in interest, and CHI St. Vincent shall have a duty to so notify all such assigns or successors in interest of the existence and terms of this Agreement.

Obligations

Once the VRI system is operating, CHI St. Vincent staff shall ask the deaf Patient or Companion whether the VRI is meeting his or her communication needs and make a record of his or her response, consistent with Section IV.E. In the event that the deaf Patient or Companion cannot communicate effectively using any VRI service CHI St. Vincent elects to acquire and offer, CHI St. Vincent shall make all reasonable efforts to locate an on-site Qualified Interpreter or other auxiliary aid or service that will provide effective communication; periodically inform the deaf Patient or Companion of the status of those efforts; and document the concern and the steps taken to locate an on-site Qualified Interpreter or other auxiliary aid or service that will provide effective communication.

Appropriate Auxiliary Aids and Services: Consistent with Section 504 and Section 1557, CHI St. Vincent will furnish appropriate auxiliary aids and services where necessary to ensure effective communication with Patients or Companions with disabilities and take appropriate steps to ensure that communication with Patients, Companions, and members of the public who are deaf or hard of hearing are as effective as communication with others. CHI St. Vincent will provide appropriate auxiliary aids and services in a timely manner, in accessible formats, and in such a way so as to protect the privacy and independence of the Patient or Companion with a disability consistent with the provisions set forth in this Agreement. CHI St. Vincent will give primary consideration to the requests of Patients or Companions with disabilities when determining what types of auxiliary aids and services are necessary, but a Patient’s need to receive urgent medical care will also be given strong consideration when determining the appropriate auxiliary aids and services. 28 C.F.R. § 35.104; 28 C.F.R. § 35.160(a)(1),(b)(1),(b)(2); 45 C.F.R. § 92.102(a)-(b).
Prohibition of Surcharges: All appropriate auxiliary aids and/or services required by this Agreement will be provided free of charge to Patients and Companions who are deaf or hard of hearing. 45 C.F.R. § 92.102(b)(2).
Timing of Communication Assessment and Determination: Subject to the provisions and exceptions provided in Section IV.G. for returning Patients, CHI St. Vincent staff will perform and document a communication assessment as part of each initial Patient assessment, and reasonably reassess communication effectiveness. If there is any indication from an initial assessment, inquiry, request, CHI St. Vincent’s observations that a Patient or Companion is deaf or hard of hearing and auxiliary aids and services are necessary, CHI St. Vincent staff who are primarily responsible for coordinating and/or providing patient care services, in consultation with the Patient or Companion wherever possible, will determine which appropriate auxiliary aids and services are necessary.
Communication Assessment Criteria: In determining which type of auxiliary aids or services are needed to ensure effective communication, CHI St. Vincent shall give primary consideration to the requests of a Patient or Companion who is disabled. The determination made by CHI St. Vincent staff will take into account all relevant facts and circumstances, including without limitation the following:
1. the method of communication used by the Patient or Companion, giving primary consideration to the Patient’s or Companion’s request for or statement of need for a particular auxiliary aid or service;
2. the nature and type of healthcare services that will be delivered;
3. the nature, length, and complexity of the communication at issue;
4. the context in which the communication is taking place, including the
5. reasonably foreseeable health care activities of the Patient and the Patient’s
6. health status or changes thereto; and
7. with regard to the provision of Qualified Interpreters, the circumstances described in Sections IV.H, IV.I, and IV.J. 28 C.F.R. § 35.160(b)(2); 45 C.F.R. § 92.102(a)-(b).
Documentation of Communication Assessment Relating to Provision of Auxiliary Aids and Services: Documentation of any assessment and determination as to the provision of auxiliary aids and services will be consistently maintained in the Patient’s medical record (e.g., in the “Clinical List Update”) and include the elements contained in the Auxiliary Aid and Service Log(s), as set forth in Section IV.P. During the Term, documentation of any assessment and determination as to the provision of auxiliary aids and services will also be maintained in the Auxiliary Aid and Service Log(s), as set forth in Section IV.P. Consistent with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, 45 C.F.R. Parts 160 and 164, CHI St. Vincent shall label or make a notation in the Patient’s medical record to alert CHI St. Vincent staff to the fact that the Patient or Companion is deaf or hard of hearing and will take appropriate steps to ensure that all CHI St. Vincent staff who are reasonably likely to have contact with a Patient or a Companion are made aware of the auxiliary aid or service(s) that have been identified as necessary to communicate effectively with the Patient or Companion.
Determination Not to Provide Requested Auxiliary Aid or Service: If, after conducting the assessment as described in Section IV.D of this Agreement, CHI St. Vincent determines that it will not provide a particular auxiliary aid or service requested by a Patient or Companion who is deaf or hard of hearing based on undue financial or administrative burden, that it would fundamentally alter the medical care or services provided by CHI St. Vincent, or because an equally effective auxiliary aid or service is available, CHI St. Vincent staff shall so advise the individual requesting the auxiliary aid or service, provide a copy of CHI St. Vincent’s “Grievance Procedure,” and secure a means of effective communication in a timely manner. CHI St. Vincent shall document the basis for the determination, including the date of the determination, the name and title of the CHI St. Vincent staff who made the determination, and the alternative auxiliary aid or service, if any, that CHI St. Vincent decided to provide, in the Patient’s medical record, as set forth in Section IV.E, and in the Auxiliary Aid and Service Log, as set forth in Section IV.P. A copy of this documentation in the Patient’s medical record shall be provided to the Patient or Companion upon request in accordance with CHI St. Vincent’s policies and procedures in requesting copies of the Patient’s medical record.
Redetermination and Subsequent Visits: Once a plan for accommodation has been established, CHI St. Vincent shall not modify said plan without consulting the Patient and/or Companion. CHI St. Vincent shall reassess its determination of which appropriate auxiliary aids and services are necessary, in consultation with the Patient or Companion, regularly throughout the visit to ensure effective communication, and promptly after a Patient or Companion indicates that communication is not currently or has not been effective. CHI St. Vincent will document in the Patient’s medical record and in the Auxiliary Aid and Service Log, as set forth in Section IV.P, any instance where a Patient or Companion indicates that the auxiliary aids and services provided by CHI St. Vincent have not been effective; any reassessment; and the results of any redetermination. With respect to any subsequent visits, CHI St. Vincent will consult the Patient’s records and confirm with the Patient or Companion if any, auxiliary aids or services may be necessary.
Circumstances When Qualified Interpreters Will Be Provided: CHI St. Vincent shall provide Qualified Interpreters, on-site or through a VRI service, to Patients and Companions as necessary to ensure effective communication. The following are examples of circumstances and types of communication when it is likely necessary to provide a Qualified Interpreter:
1. obtaining a Patient’s medical history or description of symptoms and medical condition;
2. discussing or explaining a Patient’s diagnosis, current condition, prognosis, treatment options or recommendation for treatment;
3. discussing or explaining procedures, tests, or treatments;
4. discussing or explaining test results;
5. discussing or explaining prescribed medications, instructions for how and when medication is to be taken, and possible side effects and interactions of medications;
6. obtaining informed consent or permission for procedures, surgery, or other treatment options;
7. communicating during treatment and testing;
8. communicating during discharge or post-operative planning and instruction;
9. communicating during physical and occupational therapy sessions;
10. explaining living wills or powers of attorney (or their availability);
11. discussing complex financial or insurance matters; and
12. any other circumstance in which a Qualified Interpreter is necessary to ensure a Patient’s rights are protected under applicable laws.
Video Remote Interpreting (VRI) Services Assessment Criteria: In determining whether a Qualified Interpreter via VRI is appropriate to provide effective communication, relevant factors that CHI St. Vincent may be required to consider include the following:
1. the need for medical or surgical care and the requisite urgency;
2. the Patient or Companion is limited in his or her ability to see the video screen, either due to limited vision or the physical positioning of the Patient (e.g., lying in a prone position or moving frequently during a physical or occupational therapy session);
3. the Patient or Companion has limited ability to move his or her head, hands, or arms;
4. the Patient has cognitive limitations and or pain issues;
5. there are multiple people in a room and the information exchanged is highly complex or fast-paced;
6. the Patient or Companion may move repeatedly to areas of CHI St. Vincent that do not have a designated high-speed internet line;
7. the Patient will be treated in a room where there are space restrictions; and
8. whether the VRI can be provided in accordance with the performance standards described in Section IV.J.
Standards for Providing Video Remote Interpreting (VRI): Whenever a Qualified Interpreter via VRI is provided or used, CHI St. Vincent shall ensure that it provides VRI in accordance with the following standards:
1. Real-time, full-motion video and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication;
2. A sharply delineated image that is large enough to display the interpreter’s face, arms, hands, and fingers, and the participating individual’s face, arms, hands, and fingers, regardless of his or her body position;
3. A clear, audible transmission of voices; and
4. Adequate training to users of the technology and other involved individuals so that they may quickly and efficiently set up and operate the VRI. 28 C.F.R. § 35.160(d); 45 C.F.R. § 92.102(b)(2).
Restricted Use of Adults Accompanying a Patient or Companion to Interpret or Facilitate Communication: CHI St. Vincent shall not require a Patient or Companion who is deaf or hard of hearing to bring another individual to interpret for him or her. CHI St. Vincent shall not rely on an adult accompanying a Patient or Companion who is deaf or hard of hearing to facilitate communication except -
1. In an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available; or
2. Where the Patient or Companion who is deaf or hard of hearing specifically requests that the accompanying adult interpret or facilitate communication; the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances. 28 C.F.R. § 35.160(c)(1), (2); 45 C.F.R. § 92.102(a).
Restricted Use of Minors to Interpret or Facilitate Communication: CHI St. Vincent shall not rely on a minor accompanying a Patient or Companion to interpret or facilitate communications between CHI St. Vincent staff and a Patient or Companion except in an emergency involving an imminent threat to the safety or welfare of an individual or the public, or where there is no Qualified Interpreter available. 28 C.F.R. § 35.160(c)(3); 45 C.F.R. § 92.102(a).
Qualified Interpreters: CHI St. Vincent will develop and implement a process to ensure that any interpreter with whom it contracts is qualified, consistent with the definition of Qualified Interpreter in Section II.E.
Training: To ensure compliance with this Agreement and the law as it relates to the provision of auxiliary aids and services, during the Term, CHI St. Vincent agrees to conduct annual training to all CHI St. Vincent staff, as defined in Section II.B, regarding Section 504, Section 1557, and the provision of auxiliary aids to persons who are deaf or hard of hearing. The training shall occur within ninety (90) calendar days after the training materials are finalized and approved by OCR (the “Finalized Date”), in accordance with the provisions of Section V.A. All new CHI St. Vincent staff will receive training within the later of, sixty (60) calendar days of their start date at CHI St. Vincent, or ninety (90) calendar days following the Finalized Date.
Timeframe for Providing Qualified Interpreters: CHI St. Vincent shall ensure that it provides Qualified Interpreters in a timely manner, as set forth below. 28 C.F.R. § 35.160(b)(2); 45 C.F.R. § 92.102(b)(2).
Any deviations from the applicable response times will be documented in the Auxiliary Aid and Service Log, as described in Section IV.P, and then addressed with the interpreting service provider, as appropriate.
1. Request for Qualified Interpreter for a non-scheduled incident. For all nonscheduled incidents, CHI St. Vincent will provide a Qualified Interpreter, via an on-site appearance or VRI, as soon as practicable after a request or determination that a Qualified Interpreter is necessary. Between the time when a Qualified Interpreter is requested and when a Qualified Interpreter is made available, CHI St. Vincent staff will inform the Patient or Companion of the current efforts being taken to secure a Qualified Interpreter and continue to communicate with the Patient or Companion who is deaf or hard of hearing for such purposes and to the same extent as they would have communicated with the person but for the disability, using the most effective means of communication available where appropriate. Notification of the efforts to secure a Qualified Interpreter does not lessen CHI St. Vincent’s obligation to provide a Qualified Interpreter as required by this Agreement. Efforts to communicate with the Patient or Companion in the interim shall not involve the use of accompanying adults or minors to interpret or facilitate communication, except under the limited circumstances specified in Section IV.K and IV.L.
2. Request for Qualified Interpreter for scheduled events. For all scheduled events when there is at least twenty-four (24) hours’ notice in advance of the time when an interpreter is required, CHI St. Vincent shall make a Qualified Interpreter available at the time of the scheduled event. Even when there are fewer than twenty-four (24) hours from the request to the scheduled event, CHI St. Vincent will make reasonable efforts to provide an on-site Qualified Interpreter for the scheduled event. If an on-site Qualified Interpreter is necessary, but not available, and it is medically appropriate to do so, CHI St. Vincent may make arrangements, with the Patient’s agreement, to reschedule the appointment within forty-eight (48) hours of the request to a time when an on-site Qualified Interpreter can be appropriately scheduled. If an on-site Qualified Interpreter fails to arrive for the appointment, CHI St. Vincent shall immediately arrange for another Qualified Interpreter within the timeframes specified in this Section.
Auxiliary Aid and Service Log(s): Within one hundred and twenty (120) calendar days of the Effective Date of this Agreement, CHI St. Vincent shall document and maintain a log, or logs, of each request for an auxiliary aid or service by a Patient or Companion who is deaf or hard of hearing, recording the time and date of the request; the name of such individual who made the request; the name of such individual for whom the auxiliary aid or service is being requested (if different from the requestor); the specific auxiliary aid or service requested; the time and date of the request and, if applicable, the scheduled event; the time and date the auxiliaryaid or service was provided; the type of auxiliary aid or service provided if different from what was requested; any deviations from the response times specified in Section IV.O, and, if applicable, a statement and explanation as to why the requested auxiliary aid or service was not provided, including a description of any alternative auxiliary aid or service provided by CHI St. Vincent. Such logs will be maintained for the duration of this Agreement.

V. Reporting Requirements

CHI St. Vincent agrees to provide OCR with the following:

No later than ninety (90) calendar days after the Effective Date of this Agreement, a copy of CHI St. Vincent staff training materials regarding effective communication and the provision of auxiliary aids to Patients or Companions who are deaf or hard of hearing for OCR review and approval. No later than thirty (30) calendar days following receipt of any requested revisions from OCR, CHI St. Vincent will revise and resubmit.
At one hundred eighty (180) calendar days, twelve (12) months, and twenty four (24) months after the Effective Date of this Agreement, an attestation signed by CHI St. Vincent’s CEO attesting that all CHI St. Vincent staff have completed the training required by Section IV.N;
No later than one hundred eighty (180) calendar days after the Effective Date of this Agreement, the criteria and assessment process used by CHI St. Vincent to ensure all on-site sign language interpreters employed by, or contracted with, CHI St. Vincent are qualified (as set forth herein) and a list of all sign language interpreters reviewed by CHI St. Vincent;
At one hundred eighty (180) calendar days, twelve (12) months, and twenty-four (24) months after the Effective Date of this Agreement, a copy of CHI St. Vincent’s Auxiliary Aid and Service Log, as described in Section IV.P;
At one hundred eighty (180) calendar days, twelve (12) months, and twenty-four (24) months after the Effective Date of this Agreement, letters from CHI St. Vincent to OCR describing:
1. the number and type of grievances and complaints filed by or on behalf of Patients (pursuant to this Agreement, Section II, Definitions) alleging discrimination on any protected basis under Section 504 or Section 1557, with CHI St. Vincent and/or a member of its staff and/or with any Federal, state or local agency, medical board or licensing entity, and
2. the status and/or outcome of each such grievance/complaint; and
No later than ninety (90) calendar days after the Effective Date of this Agreement, copies of the Nondiscrimination Policy published in CHI St. Vincent’s pamphlets, brochures, website and/or other existing promotional material.

VI. Signatures

The individuals signing below represent that they are authorized to execute this Agreement and legally bind the parties to this Agreement.

/s/ Chad S. Aduddell

Chad S. Aduddell, Market CEO
CHI St. Vincent Hot Springs

Date: 10/12/2022

/s/ Marisa M. Smith

Marisa M. Smith, Ph.D., Regional Manager
Office for Civil Rights, Southwest Region
U.S. Department of Health and Human Services

Date: 10/13/2022

Voluntary Resolution Agreement Between the U.S. Department of Health and Human Services Office for Civil Rights (OCR) and Chi St. Vincent Hot Springs

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