RESOLUTION AGREEMENT BETWEEN U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS, REGION III AND MID-MARYLAND MUSCULOSKELETAL INSTITUTE I. Introduction This Resolution Agreement (Agreement) is entered into by the United States Department of Health and Human Services (HHS), Office for Civil Rights (OCR) and Mid-Maryland Musculoskeletal Institute (MMI). This agreement resolves OCR transaction numbers 06-57884, 07-58228, and 07-68434 regarding the provision of auxiliary aids and services, including qualified sign language interpreters, to provide persons who are deaf or hard of hearing with an equal opportunity to benefit from services. A. Parties to the Agreement 1. United States Department of Health and Human Services, Office for Civil Rights, and 2. Mid-Maryland Musculoskeletal Institute B. Jurisdiction MMI receives Federal financial assistance through its participation in the Medicare and Medicaid programs and is subject to Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. §794 (Section 504), and its implementing regulation, 45 C.F.R. Part 84. Section 504 prohibits discrimination on the basis of disability in any program or activity receiving Federal financial assistance. Part 84 prohibits such discrimination in programs and activities receiving financial assistance from HHS. C. Background OCR initiated an investigation to determine whether MMI provides appropriate auxiliary aids and services to deaf patients after receiving a complaint on September 20, 2006, alleging that MMI failed to provide a sign language interpreter for a patient’s appointments at MMI. On October 1, 2006, OCR received a second complaint alleging that MMI had failed to provide a patient with an interpreter at a September 29, 2006 appointment. OCR received a third complaint on June 4, 2007 alleging that MMI had refused to provide a Patient with an interpreter for his appointments at MMI. MMI, which has more than 15 employees, is a medium-sized clinic in Frederick, MD with 11 doctors, 2 physician assistants, and various full-time and part-time support staff. MMI has approximately 1000 patient visits per month. Because MMI does not track the number of deaf patients seen, it is not clear how many of MMI’s patients are deaf; however, staff interviews suggest that MMI has at least six deaf patient visits per month. D. Purpose of Agreement To resolve these matters expeditiously and without the further burden or expense of additional investigation or litigation, MMI agrees to the terms stipulated in this Agreement and affirms its assurance of compliance with all provisions of Section 504 and its implementing regulation. The promises, obligations, or other terms and conditions set forth in this Agreement constitute the exchange of valuable consideration between MMI and OCR. The actions described in this Agreement fully address the issues described in the complaints. It is understood and agreed by OCR that MMI’s agreement to take the steps outlined herein was reached prior to issuance of findings by OCR. This 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 MMI or its staff. II. Definitions For the purposes of this Agreement, the terms listed below shall have the following meanings: A. Appropriate Auxiliary Aids and Services include, but are not limited to, qualified sign language, oral, or relay interpreters; qualified note-takers; computer-assisted real time transcription services; written materials; pictographs; telephone handset amplifiers; assistive listening devices and systems; telephone compatible hearing aids; closed caption decoders; open and closed captioning; and teletypewriters (TTYs, also known as TDDs); video interpreting services; and other methods of ensuring effective communication with individuals who are deaf or hard of hearing. B. Companion means a person who is deaf or hard-of-hearing and is one of the following: (a) a person whom the Patient designates to communicate with MMI on his or her behalf regarding the Patient’s condition or care; or (b) a person legally authorized to make health care decisions on behalf of the Patient; or (c) such other person with whom the MMI Personnel would ordinarily and regularly communicate the Patient’s medical condition. C. 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. D. Qualified Interpreter shall include “sign language interpreters,” “oral interpreters,” 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 health care 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 as an oral interpreter. 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 had specific skill and training in acting as an intermediary between a Patient and/or a Companion and a sign language interpreter in instances when the interpreter cannot otherwise independently understand the consumer’s primary mode of communication. E. 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 health care setting to a Patient or a Companion who is deaf or hard-of-hearing, given that individual’s language skills and history. III. General Provisions A. Facilities Covered by Agreement This Agreement covers Mid-Maryland Musculoskeletal Institute (MMI), an orthopedic center with offices located at 86 Thomas Johnson Court, Frederick, MD 21702 and 1825 Howell Road, Hagerstown, MD 21740. B. Suspension of Administrative Actions Subject to the continued performance by MMI of the stated obligations and required actions contained in the Agreement and in conformity with Section III(H), Failure to Comply with the Terms of this Agreement, OCR shall suspend administrative actions on OCR Transaction Numbers 06-57884, 07-58228, and 07-68434. 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 three hundred (300) calendar days following the Effective Date of this Agreement (the Term). At such time, if OCR determines that MMI has completed all actions required by the Agreement, OCR’s review and monitoring of this Agreement shall terminate. Notwithstanding the Term of this Agreement, MMI acknowledges that it shall comply with Section 504 for so long as it continues to receive Federal financial assistance. D. MMI’s Continuing Obligations Nothing in this Agreement is intended to relieve MMI 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. This Agreement does not preclude OCR from conducting future compliance reviews of MMI or from conducting investigations of complaints filed against MMI that are received after the Effective Date of this Agreement. Nothing in this Agreement 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 MMI shall not retaliate, intimidate, threaten, coerce, or discriminate against any person who has filed a complaint or assisted or participated in any manner in the investigation of matters addressed in this Agreement. G. OCR’s Review of MMI’s Compliance with Agreement OCR may, at any time, review MMI’s compliance with this Agreement. As part of such review, OCR may interview witnesses, examine and copy documents, and require MMI to provide written reports and permit inspection of MMI facilities. Throughout the term of this Agreement, MMI agrees to retain records required by OCR to assess MMI’s compliance with the Agreement and to submit the requested records to OCR. H. Failure to Comply with the Terms of Agreement During the duration of this Agreement, if at any time OCR determines that MMI has failed to comply with any provision of this Agreement, OCR shall notify MMI in writing. The notice shall include a statement of the basis for OCR’s determination and shall allow MMI fifteen (15) working days to either: (a) explain in writing the reasons for its actions and describe the remedial actions that have been or shall be taken to achieve compliance with this Agreement; or (b) dispute the accuracy of OCR’s findings. On notice to MMI, OCR may shorten the 15-day period if it determines that a delay would result in irreparable injury to the complainant or to other affected parties. If MMI does not respond to the notice, or if, upon review of MMI’s response, OCR determines that MMI has not complied with the terms of the Agreement, OCR reserves the right to reopen its investigation of MMI’s compliance with Section 504. OCR may incorporate into its reopened investigation any relevant evidence of noncompliance with this Agreement, and any relevant evidence gathered by OCR prior to the signing of this Agreement. I. Technical Assistance OCR agrees to provide appropriate technical assistance to MMI regarding compliance with this Agreement, as requested and as reasonably necessary. J. 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 provisions of this Agreement. K. Entire Agreement This Agreement constitutes the entire understanding between MMI and OCR in resolution of OCR Transaction Numbers 06-57884, 07-58228, and 07-68434. Any statement, promise, or agreement not contained herein shall not be enforceable through this Agreement. L. Modification of Agreement This Agreement may be modified by mutual agreement of the parties in writing. M. Effect of MMI Program Changes MMI reserves the right to change or modify its programs, so long as MMI ensures compliance with Section 504 and its implementing regulation 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. N. 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 at 45 C.F.R. Part 5. O. Authority of Signer The individual who signs this document on behalf of MMI represents that he or she is authorized to bind MMI to this Agreement. P. 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. IV. General Obligations A. Disability Non-Discrimination MMI shall provide deaf or hard of hearing Patients and/or Companions with the full and equal enjoyment of the services, privileges, facilities, advantages, and benefits of MMI as required by Section 504. B. Non-Discrimination by Association MMI 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. Provision of Appropriate Auxiliary Aids and Services A. Recognition MMI recognizes that deaf or hard of hearing Patients and/or Companions need and have a right to appropriate auxiliary aids and services to access and fully participate in health care provided by MMI. MMI is committed to providing appropriate auxiliary aids and services in a timely manner to deaf or hard of hearing Patients and/or Companions to ensure effective communication and an equal opportunity to participate fully in the benefits, activities, and programs provided by MMI. This includes ensuring effective communication between MMI’s officers, staff, contractors and subcontractors and deaf or hard of hearing Patients and/or Companions. B. Revised Policies and Procedures Within ninety (90) calendar days after the Effective Date of this Agreement, MMI shall submit to OCR documentation of revised policies and procedures to provide effective communication to deaf or hard of hearing Patients and/or Companions, consistent with the requirements of this Agreement and Section 504. The revised policies and procedures shall include, at a minimum, the following: 1. A section indicating that appropriate auxiliary aids and services shall be provided free of charge to deaf or hard of hearing Patients and/or Companions when such aids or services are necessary to ensure effective communication. 2. A section designating the name and title (for example the office manager or chief operations officer) of the individual who will make the determination of what auxiliary aid or service MMI will provide to a deaf or hard of hearing Patient and/or Companion who requests one. 3. A section indicating that MMI staff will consider the following factors in reaching the determination referred to in B.2., above: (a) the nature, length, and importance of the communication at issue; (b) the Patient’s and/or Companion’s disability and communication skills and knowledge; (c) the Patient’s health status or changes thereto; (d) the Patient’s and/or Companion’s preference or stated need for an interpreter; and (e) the reasonably foreseeable health care activities of the Patient, e.g., medical tests or procedures, rehabilitation therapy, meetings with health care professionals, or discussions concerning billing, insurance, history, diagnosis, prognosis, self care, or discharge. MMI staff, taking into account the preferences of the individual, will decide which auxiliary aid or service to provide, so long as effective communication is provided. 4. A section indicating general circumstances under which auxiliary aids and services, including but not limited to, qualified interpreters, will be provided, when necessary for effective communication. Examples include, but are not limited to: (a) determining a Patient’s medical history or obtaining a description of the Patient’s ailments or symptoms; (b) explaining and describing inpatient, outpatient, pre-operative, post-operative, and other medical procedures, tests, or treatments; (c) discussing test results; (d) discussing diagnosis, prognosis, and treatment options; (e) obtaining informed consent or permission for procedures, surgery, or other treatment options; (f) explaining reasons for, how to take, and possible side effects of medications; (g) communicating during treatment and testing; (h) communicating during discharge or post-operative planning and instruction (i) discussing complex financial or insurance matters; and (j) any other circumstances in which auxiliary aids and services are necessary to ensure a Patient’s privacy, confidentiality, or other rights provided by Federal, state or local law. 5. A Section 504 grievance procedure which incorporates due process standards and provides for the prompt and equitable resolution of complaints alleging any actions prohibited under Section 504. OCR shall review the revised policies and procedures within thirty (30) calendar days. The policies and procedures shall not be implemented by MMI without the approval of OCR. Within fifteen (15) calendar days of OCR approval, MMI shall implement them and disseminate them to MMI staff members and subcontractors. C. General Assessment Criteria MMI shall engage in an interactive process with the deaf or hard of hearing Patient and/or Companion to determine which appropriate auxiliary aids and services are needed to ensure effective communication. As part of this process, MMI shall discuss with the Patient and/or Companion, wherever possible, the type of aids and services needed and the Patient’s and/or Companion’s preference of auxiliary aids or services. MMI staff, taking into account the preferences of the individual, will decide which auxiliary aid or service to provide, so long as effective communication is provided. When determining which auxiliary aid or service is needed to ensure effective communication, MMI Personnel shall take into account all relevant facts and circumstances, including without limitation, the nature, length, and importance of the communication at issue, the Patient and/or Companion’s disability and communication skills and knowledge, the Patient’s and/or Companion’s preference or stated need for an interpreter, the Patient’s health status or changes thereto, and the reasonably foreseeable health care activities of the Patient (e.g., medical tests or procedures, rehabilitation therapy, meetings with health care professionals, or discussions concerning billing, insurance, history, diagnosis, prognosis, self-care, or discharge). Lip reading, in some instances, may be an effective means of communication; however, it should not be relied upon as the sole or primary means of communication. Relevant factors in determining whether communication using lip reading is appropriate include: the Patient’s and/or Companion’s fluency in English; the Patient’s and/or Companion’s competency in lip reading; whether the Patient and/or Companion has residual hearing; and the nature, length, importance and complexity of the matter being discussed. In some instances, hand-written notes may be an effective means of communication. Relevant factors in determining whether communication using hand-written notes is appropriate include: the Patient’s and/or Companion’s fluency in written English, and the nature, length, importance and the complexity of the matter being discussed. D. General Circumstances When Auxiliary Aids and Services Will Be Provided The scope of this agreement is limited to services provided in MMI facilities. MMI shall provide auxiliary aids and services, including, but not limited to, qualified interpreters, to Patients and/or Companions who are deaf or hard of hearing in any situations where such provision is necessary for effective communication. Situations in which provision of auxiliary aids and services may be necessary for effective communication include, but are not limited to: 1. Determining a Patient’s medical history or obtaining a description of a Patient’s ailments or symptoms; 2. Explaining and describing inpatient, outpatient, pre-operative, post-operative, and other medical procedures, tests, or treatments; 3. Discussing test results; 4. Discussing diagnosis, prognosis, and treatment options; 5. Obtaining informed consent or permission for procedures, surgery, or other treatment options; 6. Explaining the reasons for, how to take, and the possible side effects of medications; 7. Communicating during treatment and testing; 8. Communicating during discharge or post-operative planning and instruction; 9. Discussing complex financial or insurance matters; and 10. Any other circumstances in which auxiliary aids and services are necessary to ensure a Patient’s privacy, confidentiality, or other rights provided by Federal, state, or local law. The forgoing list does not imply that a qualified interpreter must always be provided in these circumstances. Nor does it suggest that there are not other circumstances when it may be appropriate to provide qualified interpreters for effective communication. E. Initial Assessment and Ongoing Assessments The interactive process to determine which appropriate auxiliary aids or services are needed for effective communication, consistent with the General Assessment Criteria in V.C. above, shall be conducted at the time an appointment is scheduled or prior to the first appointment. Trained MMI personnel shall engage in the interactive process and document the result. If a Patient and/or Companion who is deaf or hard of hearing has an ongoing relationship with MMI and an initial assessment indicates that appropriate auxiliary aids and services are necessary for effective communication, then MMI shall provide such aids and services during subsequent Patient visits when such auxiliary aids and services are necessary for effective communication. MMI will conduct additional assessments, consistent with the General Assessment Criteria, as needed, for subsequent visits. F. Notifying Deaf or Hard of Hearing Patients and/or Companions of the Availability of Auxiliary Aids and Services Within fifteen (15) calendar days of OCR’s approval of MMI’s revised policies and procedures (see section V.B), MMI shall provide notice to deaf and hard of hearing individuals of the right to appropriate auxiliary aids and services free of charge, the process for filing and resolving grievances about such services with MMI, and the MMI staff member(s) who have been designated to provide assistance regarding access to appropriate auxiliary aids and services. The notice shall be readily and routinely available and visible in a conspicuous location on MMI’s website and at both MMI offices. Where limited written English proficiency may be a barrier to the Patient and/or Companion understanding the notice, MMI shall offer assistance, including posters and signs translated into frequently encountered languages and prominently displayed in the office and additional qualified interpreter services, where necessary to ensure effective communication. G. Interpreter Services When an interpreter is necessary for effective communication, MMI shall ensure that interpreters are provided in a timely manner, consistent with the following standards: Scheduled Appointments: for scheduled appointments (appointments scheduled two or more hours in advance), MMI shall make a qualified interpreter available at the time of the appointment, if an interpreter is necessary for effective communication. Non-scheduled Incidents: “Non-scheduled incidents” refer to all situations not covered by the definition of “scheduled appointments.” For non-scheduled incidents, MMI shall make a qualified interpreter available as soon as practicable, if an interpreter is necessary for effective communication. Interim Services: MMI agrees that, between the time an interpreter is requested and the time an interpreter arrives, MMI Personnel will continue to try to communicate with the Patient and/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 hearing impairment, using all available methods of communication. This section is not intended to delay the provision of appropriate medical care and services. A staff member authorized to approve and schedule interpreting services shall be available at all times during normal business hours. Types of Interpreter Services: 1. Qualified interpreters on the MMI staff; 2. Qualified interpreters who are independent contractors or employees of agencies, nonprofits, or community organizations; 3. Qualified interpreters who work through volunteer programs; or 4. Video Interpretation Services (VIS) that use video conference technology over high-speed internet wires. If VIS technology is used as one of the resources potentially available to MMI to meet its obligations under this Agreement and Section 504, the VIS technology shall meet the following performance standards: a. High quality, clear, delay-free, motion-free video and audio over a dedicated high speed internet connection; b. A clear, sufficiently large and sharply delineated picture of the qualified interpreter’s and the Patient’s/Companion’s head, hands, and fingers, regardless of the body position of the Patient/Companion; c. Clear and easily understood transmission of voices; and d. MMI staff members and contractors trained to accomplish efficient set-up and operation. H. Restricted use of Certain Persons to Facilitate Communication Due to confidentiality, potential emotional involvement, and other factors that may adversely affect the ability to facilitate communication, MMI shall never require or coerce a family member, Companion, advocate, or friend of a Patient who is deaf or hard of hearing to interpret or facilitate communication between MMI personnel and the Patient and/or Companion. I. Procedures for Obtaining Qualified Interpreters In the event that a qualified interpreter is required for effective communication with a Patient and/or Companion, MMI shall take the following steps to obtain a qualified interpreter. The steps should be taken in the order in which they are listed. 1. Request an interpreter (the interpreter must be qualified to interpret for the specific Patient and/or Companion who will be using the services) from a list of qualified interpreters maintained by MMI, from among any qualified sign language interpreters on MMI staff, or from an agency with whom MMI has an ongoing contract for qualified sign language or oral interpreter services; and 2. If MMI is unable to obtain the services of an available qualified interpreter from the resources identified in subparagraph 1, then MMI shall request an interpreter from a secondary list of qualified interpreters (agency or freelance) maintained by MMI. The preferred and secondary lists of qualified interpreters maintained by MMI shall be updated by MMI regularly, not less than once every twelve (12) months. MMI may select the agencies or individuals on the list based upon such criteria as MMI deems appropriate, so long as MMI provides a qualified interpreter for each instance where the services of such an interpreter is necessary to ensure effective communication. J. Qualified Interpreters on the MMI Staff At any time, MMI may, but shall have no obligation to, satisfy its obligations under this Agreement by hiring qualified staff interpreters and providing them to Patients and/or Companions when necessary for effective communication. Patients and/or Companions who are provided with qualified interpreters on the MMI staff must have the same level of coverage (for both duration and frequency) as MMI is otherwise obligated to provide under this Agreement. If a qualified interpreter on the MMI staff is not available when needed, MMI shall follow the procedures set forth above to obtain the services of another qualified interpreter. K. Designation of Section 504 Coordinator Within thirty (30) calendar days after the Effective Date of this Agreement, MMI shall publish, in an appropriate form, the name, title, telephone number, functions and office location of the Section 504 Coordinator. The Section 504 Coordinator shall be available to answer questions and provide appropriate assistance to MMI staff and the public regarding immediate access to, and proper use of, the appropriate auxiliary aids and services required by this Agreement. The Section 504 Coordinator shall oversee and ensure the quality of the services provided by the interpreters it uses L. Notice to and Training of MMI Personnel Within one hundred fifty (150) calendar days after the Effective Date of this Agreement, MMI shall provide training to all MMI Personnel who have patient contact, 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 MMI Personnel to promptly identify communication needs and preferences of persons who are deaf or hard of hearing, and to secure appropriate, effective auxiliary aids and services, including qualified interpreter services, as quickly as possible when necessary. Such training shall include topics such as the various degrees of hearing impairment, sensitivity to the needs of the deaf community, language and cultural diversity in the deaf community, dispelling myths and misconceptions about persons who are deaf or hard of hearing, identification of communication needs of persons who are deaf or hard of hearing, the proper use and role of qualified interpreters, and procedures and methods for accessing qualified interpreters. VI. Reporting A. Compliance Reports On the dates detailed in Section VI-B of this Agreement, MMI shall provide a written report (“Compliance Report”) to OCR regarding the status of its compliance with this Agreement. The Compliance Report shall include data contained in Attachment A and may take the form of Attachment A. B. Submission of Compliance Reports MMI shall submit the aforementioned Compliance Reports to OCR within thirty (30) days after the end of each of the following periods: (1) six (6) months after the Effective Date of this Agreement (covering the preceding six-month period) and (2) eight (8) months after the Effective Date of this Agreement (covering the preceding eight-month period). C. Maintenance of Records MMI 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 these records throughout the terms of this Agreement. D. Additional Documentation Within two hundred forty (240) calendar days of the Effective Date of this Agreement, MMI shall provide OCR with the following: 1. A letter certifying that the distribution of materials required by Section V-B of this Agreement has occurred. The letter shall specify the date(s) that such distribution occurred, and the persons to whom the materials were distributed; 2. A letter certifying that the training described in Section V-N has been completed. The letter shall specify the date(s), time(s), and location(s) of the training, the person(s) conducting the training, the content of the training, and the names and titles of those participating in the training; 3. Documentation that MMI has completed the actions required in Paragraphs G through L of Section V of this Agreement. VII. Signatures _________________________________ ________________ Quinten M. Davis Date Chief Operating Officer Mid-Maryland Musculoskeletal Institute ________________________________ ________________ Paul F. Cushing Date Regional Manager, Region III U.S. Department of Health & Human Services Office for Civil Rights Attachment A Compliance Report to the Office for Civil Rights 1. General Obligations Attach copy of updated policy and procedures for effective communication with deaf or hard-of-hearing Patients and/or Companions, which shall include: a. policy statement; b. procedural steps and sequence for obtaining a qualified interpreter; c. call lists and schedule for all qualified interpreters available; d. the policy, procedure and steps implemented by the Section 504 Coordinator to oversee and ensure the quality of the services provided by the qualified interpreters. 2. Communication and Training Include a copy of training information, details, sign-in sheet, and other documentation of staff training on revised policy and procedures for effective communication with deaf or hard-of-hearing Patients and/or Companions. Also attach copy of detailed communication updates, newsletter announcements, intranet announcements, email announcements, etc. 3. Provision of Interpreter Services Data Attach documentation as to total number of requests for interpreting services received by MMI, the total number of qualified interpreters provided, the sources of the qualified interpreter, the number of untimely responses for requests for interpreters, and actual response times for all requests. Also submit supporting documentation as to qualified interpreter contracts, qualified interpreter call lists and schedules (for in-house qualified interpreters), and other supporting information to clarify the information in the compliance report.