OCR # 01-20-377622 I. Parties to Agreement The Parties to this Voluntary Resolution Agreement (“Agreement”) are: the U.S. Department of Health and Human Services (“HHS”), Office for Civil Rights (“OCR”), pursuant to its jurisdictional authority under Section 504 of the Rehabilitation Act of 1973 (“Section 504”), 29 U.S.C. § 794, and its implementing regulation, 45 C.F.R. Part 84, and Section 1557 of the Patient Protection and Affordable Care Act (“Section 1557”), 42 U.S.C. § 18116, and its implementing regulation, 45 C.F.R. Part 92, and MCR Health, Inc. (MCR), a nonprofit organization in Florida operating as a Federally-Qualified Health Center (“FQHC”), which provides medical, behavioral health, and dental services II. Background This matter was initiated upon a Complaint filed with OCR by an individual (the “Complainant”) who is deaf and utilizes American Sign Language (“ASL”) as her primary means of communication, alleging that MCR failed to provide appropriate auxiliary aids and services when necessary to ensure effective communication with her during her spouse’s medical appointment on March 5, 2020, when she accompanied her husband. The Complainant alleges that she provides care to her husband when he is sick and wanted to be a part of his appointment with new a cardiology practice following hospital discharge. The Complainant further alleges that MCR previously provided the Complainant with ASL interpreters at her request when she was a patient of MCR but denied the Complainant’s request for an interpreter for her spouse's medical appointment. As a result of this complaint, OCR initiated an investigation of MCR’s compliance with Section 504 and Section 1557 with regard to the Complainant’s allegations, including a review of MCR’s policies and procedures for ensuring communication with companions who are deaf or hard of hearing are as effective as communication with companions without disabilities when they accompany patients to medical appointments. MCR denies the allegations. MCR’s willingness to enter into this Agreement with OCR does not constitute an admission of wrongdoing or liability under Section 504 or Section 1557. The Parties have come to a mutual understanding about the provision of appropriate auxiliary aids and services to ensure effective communication with individuals with disabilities, including companions with disabilities. The Parties have determined that this matter can be resolved promptly and without further burden or the expense of additional investigation, enforcement proceedings, or litigation. MCR agrees to the terms stipulated in this Agreement and affirms that it fully intends to comply with all applicable provisions of Section 504 and Section 1557. III. Jurisdiction OCR is responsible for enforcing Section 504, 29 U.S.C. § 794(a), and its implementing regulation, 45 C.F.R. Part 84, which prohibit discrimination on the basis of disability in any program or activity receiving financial assistance from HHS. OCR is also responsible for enforcing Section 1557, 42 U.S.C. § 18116, and its implementing regulation, 45 C.F.R. Part 92, which prohibit discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. The Section 1557 implementing regulation provides that, except as provided in Title I of the Patient Protection and Affordable Care Act (ACA), an individual shall not, on the grounds prohibited under Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, or Section 504 of the Rehabilitation Act of 1973, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any health program or activity, any part of which is receiving federal financial assistance from HHS, or under any program or activity that is administered by HHS under Title I of the ACA or by any entity established under Title I of the ACA. MCR is a recipient of financial assistance from HHS, including 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 thus subject to the requirements of Section 504. 45 C.F.R. § 84.2. As a health program or activity receiving financial assistance from HHS, MCR is subject to Section 1557. See 45 C.F.R. § 92.3. Under Section 504, Section 1557, and the relevant implementing regulations, no qualified individual with a disability shall be excluded from participation in, be denied the benefits of, or be subjected to discrimination by reason of disability in any health program or activity receiving financial assistance from HHS. 29 U.S.C. § 794; 42 U.S.C. § 18116; 45 C.F.R. §§ 84.4(a), 84.52(a)(1); 45 C.F.R. § 92.2. Specifically, a recipient of HHS financial assistance shall provide appropriate auxiliary aids to persons with impaired sensory, manual, or speaking skills, where necessary to afford such persons an equal opportunity to benefit from the service in question. 45 C.F.R. § 84.52(d); 45 C.F.R. § 92.102(b). Furthermore, a covered health program or activity shall take appropriate steps to ensure that communications with individuals with disabilities are as effective as communications with others in health programs and activities, in accordance with the standards found at 28 C.F.R. §§ 35.160 through 35.164 (regulation implementing Title II of the Americans with Disabilities Act (“ADA”)). 45 C.F.R. § 92.102(a) (incorporating 28 C.F.R. §§ 35.160 – 164). The Complainant is an individual with a disability within the meaning of Section 504, 29 U.S.C. § 705(20)(B) (incorporating the ADA definition of disability in 42 U.S.C. § 12102), and Section 1557, 45 C.F.R. § 92.102(c) (same). OCR is responsible for investigating complaints and conducting compliance reviews to determine if recipients of HHS funding operate their programs and activities in compliance with Section 504 and Section 1557. OCR has the authority, where appropriate, to negotiate and secure voluntary compliance agreements. If noncompliance cannot be corrected by informal means, OCR may take any action authorized by law. IV. Definitions For purposes of this Agreement, the terms listed below shall have the following meaning: The term “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 telecommunications 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. The term “Duration of this Agreement” means the period of time this Agreement remains in effect. The term “Effective Date of this Agreement” means the date the Agreement is signed by all Parties. The term “Patient” means any individual who is seeking or receiving health care services (whether inpatient or outpatient, including consultations, treatment, scheduling of appointments, discussion of billing issues, attending health education classes, and other health care services) from MCR. The term “Companion” means a family member, friend, or associate of a Patient who, along with the Patient, is an appropriate person with whom MCR should communicate. The term “Qualified Interpreter” means an interpreter who, via a video remote interpreting (VRI) service or an on-site appearance, 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. 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. The term “MCR personnel” means all employees, agents, and contractors working for or on behalf of MCR who have or are reasonably likely to have direct contact with Patients or Companions. The term “video remote interpreting” (“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 as provided in 28 C.F.R. § 35.160(d), as set forth in Paragraph 31. See 45 C.F.R. § 92.102(a). V. Actions To Be Taken By MCR A. Provision of Effective Communication Appropriate Auxiliary Aids and Services. Consistent with Section 504 and Section 1557, MCR will furnish appropriate auxiliary aids and services where necessary to ensure that communications with Patients, Companions, and members of the public who are deaf or hard of hearing are as effective as communications with others. In order to be effective, MCR will provide 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 individual with a disability. Policies and Procedures For Providing Auxiliary Aids and Services to Individuals with Disabilities. Within ninety (90) calendar days of the Effective Date of this Agreement, MCR shall review its policy and any related procedures and provide to OCR any revisions necessary to implement the terms of this Agreement and to ensure it is taking any necessary steps to provide effective communication with Patients and Companions who are deaf or hard of hearing, consistent with the requirements of this Agreement, Section 504, and Section 1557. MCR shall adopt and implement the revised effective communication policy within thirty (30) calendar days of receiving OCR’s approval. Prohibition of Surcharges. All appropriate auxiliary aids and services required by this Agreement will be provided free of charge to Patients and Companions who are deaf or hard of hearing. Timing of Communication Assessment and Determination. If there is any indication from an initial encounter, inquiry, request, or MCR personnel’s observations that a Patient or Companion is deaf or hard of hearing and auxiliary aids and services are necessary, MCR personnel will consult with the Patient or Companion to determine the Patient’s or Companion’s means of communication and the appropriate auxiliary aids and services. The initial assessment and determination of which appropriate auxiliary aids and services are necessary will be made at the earliest of the following: the time an appointment is scheduled, provided that the Patient or Companion communicates the need for auxiliary aids or services; the time the Patient or Companion initially comes in contact with MCR personnel. Communication Assessment Criteria. In determining what type of auxiliary aids or services are needed to ensure effective communication, MCR will take into account all relevant facts and circumstances, including the method of communication used by the individual; the nature, length, and complexity of the communication at issue; and the context in which the communication is taking place. Consistent with Section 1557, MCR will give primary consideration to the request of a Patient or Companion who is deaf or hard of hearing. “Primary consideration” means that MCR will inquire as to the choice of auxiliary aid or service of the individual and will honor the expressed choice, unless MCR can demonstrate that another equally effective means of communication is available. Model Communication Assessment. For the purposes of determining appropriate auxiliary aids and services, MCR personnel may use a communication assessment substantially similar to the questions contained in the Model Communication Assessment Form attached to this Agreement as Appendix A. Documentation of Communication Assessment Relating to Provision of Auxiliary Aids and Services. Documentation of any assessment regarding the provision of auxiliary aids and services to a Patient or Companion will be maintained in the Patient’s records. Consistent with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, 45 C.F.R. Parts 160 and 164, MCR shall label or make a notation in the Patient’s record to alert MCR personnel to the fact that the Patient or Companion is deaf or hard of hearing and will take appropriate steps to ensure that all MCR personnel 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 communication assessment as described above, MCR 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 because providing the particular auxiliary aid or service would result in an undue financial or administrative burden or because an equally effective auxiliary aid or service is available, MCR personnel shall so advise the Patient or Companion requesting the auxiliary aid or service, notify the Patient or Companion of its grievance procedure, and secure an alternative means of effective communication in a timely manner. MCR shall document in the Patient’s record the basis for the determination, including the date of the determination, the name and title of the MCR personnel who made the determination, and the alternative auxiliary aid or service, if any, provided. A copy of this documentation shall be provided to the Patient or Companion upon request. MCR will also document the determination not to provide requested aid or service in the Auxiliary Aid and Service Log, as set forth in Paragraph 35. Redetermination. With respect to any subsequent visits, MCR will consult the Patient’s records to review what, if any, auxiliary aids or services may be necessary without requiring additional assessments or requests for the appropriate auxiliary aids and services by the Patient or Companion, unless the Patient or Companion indicates otherwise. MCR shall reassess its determination of which appropriate auxiliary aids and services are necessary, in consultation with the Patient or Companion, promptly after a Patient or Companion indicates that communication is not currently or has not been effective. MCR will document in the Patient’s record any instance where a Patient or Companion indicates that the auxiliary aids and services provided by MCR have not been effective; any reassessment; and the results of any redeterminations. Any alternative auxiliary aid or service provided will also be documented in the Patient’s medical record. Circumstances Under Which Qualified Interpreters Will Be Provided. MCR 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 involving complex communications when it may be necessary to provide a Qualified Interpreter to a Patient or Companion who needs a Qualified Interpreter for effective communication: obtaining a Patient’s medical history or description of symptoms and medical condition; discussing or explaining a Patient’s diagnosis, current condition, prognosis, treatment options, or recommendation for treatment; discussing or explaining procedures, tests, or treatments; discussing or explaining test results; discussing or explaining prescribed medications, instructions for how and when medication is to be taken, and possible side effects and interactions of medications; obtaining informed consent or permission for procedures, surgery, or other treatment options; communicating during treatment and testing; communicating during labor and delivery; communicating during discharge or post-operative planning and instruction; providing mental health evaluations, group or individual therapy, counseling, or other therapeutic activities, including grief counseling and crisis intervention; providing information about blood or organ donations; explaining living wills or powers of attorney (or their availability); discussing complex financial or insurance matters; providing educational presentations, such as classes concerning birthing, nutrition, CPR, and weight management; and any other circumstance in which a qualified interpreter is necessary to ensure a Patient’s rights provided by law. Video Remote Interpreting (VRI) Services Assessment Criteria. In determining whether a Qualified Interpreter via VRI service is appropriate to provide effective communication, relevant factors may include: 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; the Patient or Companion has limited ability to move his or her head, hands, or arms; the Patient has cognitive limitations, consciousness issues or pain issues; here are multiple people in a room and the information exchanged is highly complex or fast-paced; the Patient or Companion may move repeatedly to areas of MCR that do not have a designated high-speed internet line; the Patient will be treated in a room where there are space restrictions; and whether the VRI can be provided in accordance with the performance standards described in Paragraph 31. Standards for Providing Video Remote Interpreting (VRI). Whenever a Qualified Interpreter via VRI service is provided or used, MCR shall ensure that it provides the VRI service in accordance with the following standards: 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; 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; A clear, audible transmission of voices; and Adequate training to users of the technology and other involved individuals so that they may quickly and efficiently set up and operate the VRI service. Once the system is operating, MCR personnel shall ask the Patient or Companion whether the VRI service is meeting his or her communication needs and make reasonable efforts to make a record of his or her response. In the event that the Patient or Companion cannot communicate effectively using any VRI service MCR elects to acquire and offer, MCR 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 Patient or Companion of the status of those efforts; and document the concern and the steps taken to locate an on-site Qualified Interpreter. For the duration of this Agreement, MCR will monitor the effectiveness of the VRI service and, if applicable, address any deviations with the VRI service provider. Restricted Use of Adults Accompanying a Patient or Companion to Interpret or Facilitate Communication. MCR shall not require or coerce a Patient or Companion who is deaf or hard of hearing to bring another individual to interpret or facilitate communications between MCR personnel and such Patient or Companion. MCR shall not rely on an adult accompanying a Patient or Companion to interpret or facilitate communication except in either of the following circumstances: In an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available. This provision applies to exigent circumstances where any delay in providing immediate services to the individual could have life-altering or life-ending consequences and is not intended to obviate the obligation to provide a Qualified Interpreter or other auxiliary aids and services in typical and foreseeable emergencies that are part of the normal operations of a hospital. If a 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 person for such assistance is appropriate under the circumstances. In such circumstances, MCR shall advise the Patient or Companion that Qualified Interpreters or other auxiliary aids and services are available without charge and shall give appropriate consideration to any relevant issues and concerns that may arise, such as privacy and confidentiality. MCR will document such a request in the Patient’s medical record. Restricted Use of Minors to Interpret or Facilitate Communication. MCR shall not rely on a minor accompanying a Patient or Companion to interpret or facilitate communications between MCR personnel and a Patient or Companion except in an emergency involving an imminent threat to the safety or welfare of an individual or the public where there is no interpreter available. Timeframe for Providing Qualified Interpreters. MCR shall ensure that it provides Qualified Interpreters in a timely manner, as set forth below: Scheduled Appointments. MCR shall make a Qualified Interpreter available at the time of the scheduled appointment. Upon notice that the a Qualified Interpreter is not available or failed to arrive, MCR will take reasonable steps to locate another Qualified Interpreter as soon as they are made aware that the requested interpreter will not be provided. Walk-Ins or other non-scheduled encounters. MCR will provide a Qualified Interpreter, via an on-site appearance or VRI service, as soon as practicable after a request or determination that a Qualified Interpreter is necessary. When providing a Qualified Interpreter via VRI, MCR personnel will set up the VRI equipment and connect to the VRI service within thirty (30) minutes. If an on-site Qualified Interpreter is determined to be necessary pursuant to an assessment, MCR will make reasonable efforts to provide an on-site Qualified Interpreter within three (3) hours. Between the time when a Qualified Interpreter is requested and when a Qualified Interpreter is made available, MCR personnel 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. 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 Paragraphs 32 and 33. MCR will make reasonable efforts to monitor the response times for each request for a Qualified Interpreter. Auxiliary Aid and Service Denial Log(s). Within forty-five (45) calendar days of the Effective Date of this Agreement, MCR shall maintain a log, or logs, of each denial of a request for an auxiliary aid or service for a Patient or Companion as set forth in Paragraph 27, recording the time and date of the request; the name of the individual who made the request; the name of the 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; and a statement and explanation as to why the requested auxiliary aid or service was not provided. Such logs will be maintained for the Duration of this Agreement. Notice of Nondiscrimination and Availability of Auxiliary Aids and Services. MCR shall take appropriate and continuing steps to notify Patients, Companions, MCR personnel, and the public, including individuals who are deaf or hard of hearing and individuals who are blind or have low vision, of the rights and protections afforded by Section 504 or Section 1557, and the following: that it does not discriminate on the basis of disability in its g and activities; that it provides appropriate auxiliary aids and services, including qualified interpreters for individuals with disabilities and information in alternate formats, free of charge and in a timely manner, when such aids and services are necessary to ensure an equal oppoto participate to individuals with disabilities; a description of how to obtain auxiliary aids and services; the identity of, and contact information for, the Civil Rights Coordinator, designated pursuant to Paragraph 39; the availability of the grievance procedure and how to file a grievance; and how to file a discrimination complaint with OCR. MCR is also obligated to comply with federal civil rights laws that require it to take reasonable steps to provide limited English proficient (LEP) individuals meaningful access to its health programs and activities. 45 C.F.R. §§ 80.3(b)(2), 92.201. Accordingly, MCR should provide notice in appropriate languages to LEP persons in its surrounding community to allow for accessibility in its, programs, activities, and services. Training of MCR Personnel. To ensure compliance with this Agreement and the law as it relates to the provision of auxiliary aids and services, MCR agrees to conduct the following trainings within the timeframes specified in Paragraph 38. MCR shall maintain copies of the training materials and attendance records for each training. Each training will be of sufficient duration and content to train MCR personnel in the following areas relative to their responsibilities for coordinating or providing patient care: the requirement to ensure effective communication with Patients and Companions who are deaf or hard of hearing, are blind or have low vision, or have a speech disability; information regarding the types of communication disabilities, the different languages and methods of communication used by individuals who are deaf or hard of hearing, and the types of auxiliary aids and services available to ensure effective communication; procedures to promptly identify communication needs of individuals who are deaf and hard of hearing, including determining what types of auxiliary aids and services are necessary and assessing when certain auxiliary aids and services are effective in different circumstances; procedures to promptly obtain auxiliary aids and services, including how to quickly and efficiently set up and operate VRI, and the appropriate steps to take when efforts to obtain auxiliary aids and services are unsuccessful or communication is not effective; procedures for documenting communication assessments and requests for auxiliary aids and services in the Patient’s record and the Auxiliary Aid and Service Log, where appropriate; the availability and proper use of auxiliary aids and services to communicate by telephone for individuals who are deaf or hard of hearing, including the use of video relay services (VRS) and text telephones (TTY); MCR’s grievance procedure; and any other applicable requirements of this Agreement. Timeframe for the Provision of Training MCR Personnel. Within sixty (60) calendar days of the OCR’s approval of the effective communication policies and procedures described in Paragraph 21, and on an annual basis thereafter for the Duration of this Agreement, MCR will provide mandatory training for all MCR personnel, including: the patient services representatives (PSR), charge nurses, physicians, nurses, and others responsible for coordinating and/or providing patient care services. Training of New MCR Personnel. Within sixty (60) calendar days of their start date at MCR, all new MCR personnel will receive training regarding the availability and use of auxiliary aids and services for Patients and Companions, and regarding the process for assessing the need for such services and the process for obtaining same. Other MCR personnel in positions or departments not previously identified herein shall be provided with comparable training as necessary. A screening of a video of any of the trainings provided above will suffice to meet this obligation. VI. Other Nondiscrimination Obligations Designation of Civil Rights Coordinator. Within fifteen (15) calendar days of the Effective Date of this Agreement, MCR shall designate at least one employee to be responsible for: the coordination of MCR’s efforts to comply with Section 504 and Section 1557; the investigation of any grievance communicated to MCR alleging discrimination on the basis of disability; knowing where auxiliary aids are stored and how to operate any auxiliary aid; the maintenance, repair, replacement, and distribution of any auxiliary aid; providing a contact person during operating hours to answer questions and provide appropriate assistance regarding immediate access to, and proper use of, the appropriate auxiliary aids and services, including Qualified Interpreters, from MCR personnel, Patients, and Companions; and MCR’s compliance with the terms of this Agreement set forth here, including coordinating and/or conducting trainings, maintaining records, providing compliance reports and logs, and creating and modifying policies and procedures. Retaliation and Coercion. MCR shall not retaliate against or coerce in any way any person who made or is making a complaint or exercised or is exercising his or her rights under Section 504 or Section 1557, or who has assisted or participated in the investigation of any matter covered by this Agreement. VII. Reporting and Monitoring Unless otherwise provided, all notices, reports or other such documents required by this Agreement shall be submitted to the HHS Office for Civil Rights, New England Region, by email to Susan.Rhodes@hhs.gov. Records. MCR shall maintain appropriate records to document the information required by this Agreement, and shall make them available to OCR within thirty (30) days of a written request throughout the duration of this Agreement. Complaints. For the duration of this Agreement, MCR shall notify OCR if any person files a lawsuit, written complaint, or formal charge against MCR with a state or federal agency, alleging that MCR failed to provide auxiliary aids or services to deaf or hard of hearing Patients or Companions or otherwise failed to ensure effective communication with such Patients or Companions. Such notification must be provided in writing via certified mail within thirty (30) calendar days of the date MCR receives notice of the allegation and must include, at a minimum, the nature of the allegation, the name of the person making the allegation, and any documentation possessed by MCR relevant to the allegation. MCR will reference this provision of the Agreement in the notification to OCR. Compliance Report. MCR shall provide an initial written report (“Compliance Report”) to OCR regarding the status of its compliance within nine (9) months of the Effective Date of this Agreement and a second Compliance Report within eighteen (18) months of the Effective Date of this Agreement (covering the preceding nine-month period. Required Content for Compliance Reports. Each Compliance Report shall include appropriate documentation of the steps MCR has taken to comply with each term of this Agreement, including: any revised policies and procedures; the distribution of policies and procedures; the training required by this Agreement, including the training materials and attendance records; a list of any grievances and/or complaints filed by Patients or Companions regarding the provision of auxiliary aids and services, including any allegations of discrimination on the basis of disability related to the provision of auxiliary aids and services, with such list to include a description of the allegations, the date filed, the status and/or outcome of each grievance or complaint, and a copy of the grievance itself; a copy of the Auxiliary Aid and Service Denial Log(s) described in Paragraph 35; a report showing the utilization of Qualified Interpreters during the reporting period; and a description of how the Civil Rights Coordinator, monitors compliance with this Agreement and its effective communication policies and procedures. VIII. Enforcement Duration of this Agreement. This Agreement shall terminate in two (2) years from its Effective Date, provided OCR determines that MCR demonstrated compliance with this Agreement, at which point OCR’s review and monitoring of this Agreement shall terminate. Compliance Review and Enforcement. OCR may review compliance with this Agreement at any time during the term of this Agreement as set forth in Paragraph 46. If OCR believes that MCR has failed to comply with this Agreement, they will notify MCR in writing and the Parties will attempt to resolve the issue(s) in good faith. OCR will allow MCR sixty (60) calendar days from the date they notify MCR to cure said failure to comply. If OCR determines they are unable to reach satisfactory resolution of the issue(s), OCR may take any action authorized by law to secure compliance with Section 504 and Section 1557. 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 as may be necessary to restore the Parties as closely as possible to the relative rights and obligation initially intended to them within the Agreement. IX. Other Provisions Facilities Covered By This Agreement. This Agreement is applicable to all facilities providing health care and related services that are or become owned, operated, or controlled by MCR. A list of these facilities can be found at Appendix B. In consideration of the terms of this Agreement, OCR agrees to refrain from undertaking further investigation or taking steps toward instituting a civil suit or administrative action in OCR #01-20-377622 against MCR based on the allegations lodged against MCR, except as provided in Paragraph 47. Except as related to the above-mentioned complaints, nothing contained in this Agreement is intended or shall be construed as a waiver by OCR of any right to institute proceedings against MCR for violations of any statutes, regulations, or rules administered by OCR or to prevent or limit the rights of OCR to obtain relief under Section 504 or Section 1557. This Agreement does not constitute a finding by OCR that MCR is in full compliance with Section 504 and Section 1557. This Agreement is not intended to remedy any other potential violations of Section 504 Section 1557, or any other law that is not specifically addressed in this Agreement, including any other claims for discrimination on the basis of disability. Nothing in this Agreement relieves MCR of its continuing obligations to comply fully with the requirements of Section 504 and Section 1557. Nothing in this Agreement shall be construed or deemed as an admission by MCR of any liability or fault regarding any of Complainant’s factual allegations that MCR engaged in any wrongful or illegal activity, that any of OCR’s allegations, including but not limited to those relating to the Complainant, are true, or that any person suffered any injury as a result of the events as alleged by OCR, and nothing in this Agreement shall be construed as a waiver by MCR to defend against any allegation claiming that MCR violated any statutes, regulations, or rules administrated by OCR or to prevent or limit the right of MCR to challenge any claim alleging noncompliance under Section 504 or Section 1557. This Agreement shall not be offered or received in evidence in any action or proceeding in any court or other tribunal as an admission or concession of liability or wrongdoing of any nature on the part of MCR except in an action by OCR challenging MCR’s compliance with this Agreement. Entire Agreement. This Agreement constitutes the entire agreement between the Parties on the matters raised here, and no prior or contemporaneous statement, promise, or agreement, either written or oral, made by either party or agents of either party, that is not contained in this written agreement, including attachments, is enforceable. This Agreement can only be modified by mutual written agreement of the Parties. Changing Circumstances. During the term of this Agreement, there may be a change in circumstances such as, for example and without limitation, an increased or decreased availability of Qualified Interpreters or developments in technology to assist or improve communications with persons who are deaf, deaf-blind, or hard of hearing. If MCR determines that such changes create opportunities for communicating with Patients and Companions more efficiently or effectively than is required under this Agreement, or create difficulties not presently contemplated in the provision of auxiliary aids and services, MCR may propose changes to this Agreement by presenting written proposals to OCR. Such changes may be made to the Agreement if OCR upon review, grant their approval in writing, which approval will not be unreasonably withheld or delayed. Binding. This Agreement is final and binding on MCR, including all agents, administrators, representatives, employees, successors, and assigns. In the event that MCR seeks to sell, transfer, or assign substantially all of its assets during the term of this Agreement, then, as a condition of such sale, transfer, or assignment, MCR will provide written notification to the successor, buyer, transferee, or assignee of all obligations remaining under this Agreement for the remaining term of this Agreement. Non-Waiver. Failure by OCR to seek enforcement of any provision of this Agreement is not a waiver of the agencies’ respective right to enforce any provision of this Agreement. Headings. The headings in this Agreement are for convenience only and shall not affect in any way the language of the provision to which they refer. Execution of Agreement. The undersigned represent that they have been fully authorized to enter into and execute this Agreement under the terms and conditions contained herein. This Agreement may be executed in counterparts. Publication or Disclosure of Agreement. OCR places no restriction on the publication of the Agreement. In addition, OCR may be required to disclose material related to this Agreement to any person upon request, consistent with the requirements of the Freedom of Information Act, 5 U.S.C. § 522, and its implementing regulation, 45 C.F.R. Part 5. Agreed by the Parties: For MCR Health, Inc.: /s/ Name: Melvin Price, DPM Title: President & CEO Dated: 03/28/2023 For the United States Department of Health and Human Services: /s/ Susan Pezzullo Rhodes Regional Manager, New England Region Office for Civil Rights, Room 1875 JFK Federal Building Boston, MA 02203 Dated: 03/28/2023 APPENDIX A Model Communication Assessment Form We ask this information so we can communicate with you effectively. All auxiliary aids and services are provided FREE OF CHARGE. Patient’s Name: ______________________________________ Date/Time: _______________ Name of Person with Disability (if other than patient): _________________________________ Relationship to Patient: ❏ Self ❏ Family Member ❏ Friend / Companion ❏ Other: ____________________ Nature of Disability: ❏ Deaf ❏ Deaf-Blind ❏ Hard of Hearing ❏ Speech Disability ❏ Other: __________________ Do you want a sign language or oral interpreter for your visit? ❏ Yes. Choose One: ❏ American Sign Language (ASL) interpreter ❏ Tactile interpreter ❏ Signed English interpreter ❏ Oral interpreter ❏ Other. Explain: ___________________________________________ ❏ No. I do not feel an interpreter is necessary or do not want one for this visit. ❏ No. I do not use sign language. Other Auxiliary Aid or Service Requested: ❏ Assistive listening device (sound amplifier) ❏ Texting or Writing back and forth ❏ CART (Computer-Assisted Real Time Transcription Service) ❏ TTY/TDD (text telephone) ❏ Other. Explain: _________________________________________ APPENDIX B MCR Health Locations Advanced Specialty Institute 6015 Pointe West Blvd Bradenton, Florida, 34209 AMA Health Bayview Medical 5309 State Rd 64 Bradenton, FL, 34208 AMA Health Arcadia 425 Nursing Home Drive Arcadia, FL, 34266 AMA Health Gulf Coast Pediatrics Address: 5305 State Rd 64 Bradenton, FL, 34208 AMA Health Manatee 701 Manatee Ave West Suite 101 Bradenton, FL, 34205 AMA Health University 2415 University Parkway, Bldg. 3, Suite 111 Sarasota, FL, 34243 AMA Health Wauchula 508 S. 6th Avenue Wauchula, FL, 33873 AMA Health Heart & Vascular Address: 6001 21st Ave. W. Bradenton, FL, 34209 Arcadia Children's Healthcare Center Address: 1110 E. Gibson Street, Bldg. A, Arcadia, FL, 34266 Arcadia Eye Care 122 N. Brevard Avenue Arcadia, FL, 34266 Bradenton Family Medical Center 4805 26th Street W Bradenton, FL, 34207 Community Care Family Clinic 1148 E. Gibson Street, Building C Arcadia, FL, 34266 Community Care Family Clinic Counseling Services 725 N 12th Avenue, Building B Arcadia, FL, 34266 Community Care Family Healthcare Center 1110 E Gibson Street, Bldg. A, Arcadia, FL, 34266 East Manatee Health And Wellness Center 1312 Manatee Ave E. Bradenton, FL, 34208 Edgar H. Price, Jr. Children and Family Healthcare Center 12271 U.S. Hwy 301 N Parrish, FL, 34219 Health and Wellness Land o' Lakes Highschool 20360 Gator Lane Bldg. 14 Land O Lakes, FL, 34638 (closing TBD) Lawton Chiles Children And Family Healthcare Center 1515 26th Avenue E Bradenton, FL, 34208 Manatee Elementary School Based Health Center 1609 6th Ave E Bradenton, FL, 34208 Manatee Pediatrics 712 39th Street W Bradenton, FL, 34205 MCR Health Hudson Highschool 14730 Cobra Way Hudson, FL, 34669 (closing TBD) MCR Health Fruitville 170 N. Lime Avenue Sarasota, FL, 34237 MCR Health North Tuttle 220 North Tuttle Ave Sarasota, FL, 34237 MCR Health Southeast High School – School Based Health Center 1200 37th Avenue E. Bradenton, FL, 34208 North County Healthcare Center 1949 Northgate Blvd Sarasota, FL, 34234 North Manatee Family Healthcare Center 5600 Bayshore Road Palmetto, FL, 34221 North Sarasota Walk-In 1945 Northgate Blvd Sarasota, FL, 34234 Palmetto Foot & Ankle 404 7th Street West Palmetto, FL, 34221 River Landings OB/GYN 6040 53rd Avenue E, Suite A Bradenton, FL, 34203 Riverside Medical Center 300 Riverside Drive East Suite 2010 Bradenton, FL, 34208 Riverview Foot And Ankle 300 Riverside Drive East Suite 1500 Bradenton, FL, 34208 South County Medical Center 579 S. Indiana Ave, Unit A, Englewood, FL, 34223 Southeast Family Healthcare Center 919 53rd Avenue E Bradenton, FL, 34203 South Manatee Pediatrics 5108 15th St. East Suite 111 Bradenton, FL, 34203 Southwest Health Center/ Michael Bach Resource Center 5325 26th Street West Bradenton, FL, 34207 West Manatee Health Center 2318 Manatee Ave W Bradenton, FL, 34205 Whole Child Pediatrics 6040 53rd Avenue E, Suite B Bradenton, FL, 34203 Venice Pediatrics 119 Shamrock Blvd. Venice, FL, 34293 Any other facility providing health care and related services that are or become owned, operated, or controlled by MCR Health, Inc.