September 12, 2024 - San Juan Capestrano Hospital

Dear Ms. [REDACTION] and Ms. [REDACTION]:

The Office for Civil Rights (OCR) has completed its investigation of the complaint filed by [REDACTION] on behalf of [REDACTION] sister-in-law, [REDACTION], alleging that San Juan Capestrano Hospital (the Hospital) engaged in unlawful discrimination on the basis of [REDACTION] disability (deafness). Specifically, the complaint alleged that the Hospital failed to provide [REDACTION] auxiliary aids and services (sign language interpreter) necessary to ensure effective communication with [REDACTION] during a court-ordered psychiatric evaluation on or around the date of [REDACTION].

OCR conducted its investigation under Section 504 of the Rehabilitation Act of 1973, as amended, 29 U.S.C. § 794 (Section 504), and its implementing regulation, found at 45 C.F.R. Part 84, and Section 1557 of the Patient Protection and Affordable Care Act, 42 U.S.C. § 18116 (Section 1557), and its implementing regulation found at 45 C.F.R. Part 92. Section 504 prohibits discrimination on the basis of disability by recipients of Federal financial assistance (FFA). Section 1557 similarly prohibits discrimination on the basis of disability in health programs or activities that receive Federal financial assistance. The Hospital is a recipient of FFA through its participation in Title XVIII and XIX of the Social Security Act of 1965 (Medicare and Medicaid) and is, therefore, obliged to comply with Section 504 and Section 1557.

The purpose of this investigation was to determine whether the Hospital discriminated against [REDACTION] on the basis of [REDACTION] disability by failing to provide a sign language interpreter when [REDACTION] presented to the Hospital for a court-ordered psychiatric evaluation. Based on the results of the investigation, OCR concluded that the Hospital violated Section 504 and Section 1557. The Hospital failed to take appropriate steps to ensure that communication with [REDACTION] was as effective as communication with persons who are not deaf or hard-of-hearing and by failing to provide auxiliary aids and services necessary to ensure effective communication with [REDACTION].

In this letter, we identify our findings of fact, conclusions of law, and steps the Hospital needs to take to remedy the violations.

Background

The Hospital is a 172-bed private short-stay psychiatric center located in the metropolitan area of San Juan, Puerto Rico. The Hospital offers acute inpatient services for adults and adolescents struggling with a range of mental health illnesses and substance abuse concerns. The Hospital has been in operation for 26 years and offers various treatment services in its outpatient clinics in eleven different locations throughout the island. On its website, the Hospital describes itself as the leading organization in mental health services in Puerto Rico, the Caribbean, and Latin America.¹ 

The Hospital is owned and operated by Acadia Healthcare (Acadia). Acadia provides behavioral health services in inpatient psychiatric hospitals, specialty treatment facilities, residential treatment centers, outpatient clinics, and therapeutic school-based programs. As of June 30, 2022, Acadia operates 250 behavioral healthcare facilities in 39 states and Puerto Rico.²

[REDACTION] was a deaf adult who used Puerto Rican Sign Language (PRSL) as [REDACTION] primary means of communication. [REDACTION] attended several schools, including special education and schools for the deaf, where [REDACTION] learned PRSL. According to interviews with [REDACTION], [REDACTION] had a very limited ability to read and write and a limited ability to read lips and vocalize.

OCR’s Investigation

[REDACTION], submitted a complaint to OCR on [REDACTION], alleging that the Hospital conducted a psychological evaluation of [REDACTION] on [REDACTION], but that hospital staff could not communicate effectively with [REDACTION]. On [REDACTION], after receiving additional information regarding [REDACTION] allegations, OCR notified the Hospital that it had initiated an investigation of the complaint under Section 504 and Section 1557. OCR’s letter also requested data from the Hospital concerning the allegations of the complaint, including a detailed response to the allegations, copies of [REDACTION] medical records, policies, procedures and practices, notices, signs, and available resources and auxiliary aids for deaf and hard-of-hearing patients.

During the course of our investigations, OCR interviewed:

• [REDACTION], [REDACTION], as well as [REDACTION]; and
• Five Hospital staff who were involved or interacted with [REDACTION] on [REDACTION], 2021, including the Admissions Unit Coordinator, Registered Nurse, Evaluating Physician, Patient Advocate and Grievances Compliance, and the Human Resources Director.

OCR also reviewed extensive records, including:

• [REDACTION] Hospital medical records;
• The Hospital’s relevant policies, practices, procedures, signs and notices, and description of relevant training materials;
• Contacts with sign language interpreting agencies; and
• [REDACTION] records concerning [REDACTION] and [REDACTION] minor children.

Summary of the Facts

On [REDACTION], the [REDACTION], conducted a home visit with [REDACTION] and [REDACTION] minor children after it received a report indicating that [REDACTION] was involved in a domestic incident with a family member. [REDACTION] had provided services to [REDACTION] since [REDACTION]. Following its home visit, [REDACTION]. According to the [REDACTION], when they visited the home, [REDACTION] was [REDACTION] and [REDACTION]. After observing [REDACTION], an agency social worker recommended that a family member obtain an emergency court order to have [REDACTION] evaluated by a psychiatrist.

On [REDACTION], [REDACTION], [REDACTION], requested and received a 408-court order³ with the help of [REDACTION]. According to interviews with witnesses and [REDACTION] hospital records, [REDACTION] health insurance carrier contacted the Hospital the following day to arrange for [REDACTION] evaluation and ambulance service. [REDACTION] health insurance representative informed the Hospital beforehand that [REDACTION] was deaf and needed a sign language interpreter. On [REDACTION], [REDACTION] was transported to the Hospital via ambulance for a psychiatric evaluation. Upon arrival, [REDACTION] was taken to an isolated hallway behind closed doors, without [REDACTION], to wait for the evaluation. Immediately after [REDACTION] arrival at the Hospital, [REDACTION] informed a receptionist that [REDACTION] required a sign language interpreter. At a later point in the visit, [REDACTION] asked a nurse about the status of the request for a sign language interpreter. According to [REDACTION], the nurse told [REDACTION] that the Hospital was working on providing [REDACTION] with an interpreter.

According to the Hospital, staff held a joint session with [REDACTION] and [REDACTION]. [REDACTION] asserts [REDACTION] was not present at the discharge meeting or during interactions between the Hospital staff and [REDACTION] and [REDACTION] does not know how the staff communicated with [REDACTION]. However, according to [REDACTION], an interpreter was never provided. The Hospital informed OCR that, as a result of the evaluation, the Hospital determined that [REDACTION] did not meet the criteria for a psychiatric admission and would benefit from outpatient treatment. After leaving the Hospital, [REDACTION] brought [REDACTION] home. [REDACTION] informed OCR that on [REDACTION], [REDACTION].

In a position statement submitted to OCR, the Hospital denied that it discriminated against [REDACTION] on the basis of [REDACTION] disability and asserted that Hospital staff communicated effectively with [REDACTION] throughout [REDACTION] evaluation process.

The Hospital does not dispute that on [REDACTION], [REDACTION] was transported via ambulance to the Hospital pursuant to a 408 court order for a psychiatric evaluation, and that [REDACTION] was accompanied at the Hospital by [REDACTION]. The Hospital’s intake document for [REDACTION], dated [REDACTION], identifies [REDACTION] as deaf.⁴ The intake document also states that [REDACTION] refuses to use hearing aids and wishes to communicate via “signos” (the cultural reference in Puerto Rico to sign language). The intake document and [REDACTION] health record do not identify any additional efforts the Hospital made to ascertain [REDACTION] primary method of communication and whether an interpreter was needed.

OCR’s review of the Hospital’s records and interviews with Hospital staff confirm that [REDACTION] evaluation was not conducted with a sign language interpreter. The Hospital asserted that staff involved in [REDACTION] evaluation were able to communicate effectively with [REDACTION] and that they fully understood what [REDACTION] said. The Hospital also asserted [REDACTION] did not request an auxiliary aid or service. 

The Hospital’s assertion that [REDACTION] did not request an interpreter were inconsistent with its intake form, which states that [REDACTION] wanted to communicate with sign language. During investigative interviews, Hospital staff who interacted with [REDACTION] denied that [REDACTION] had any difficulty understanding staff during the evaluation process. Staff acknowledged that [REDACTION] was deaf; however, they claimed that [REDACTION] did not communicate through the use of sign language, but instead communicated via signals, spoken voice, and reading lips and believed that a sign language interpreter would not have been effective in this case. The evaluating staff also stated that [REDACTION] told the evaluating staff that [REDACTION] was able to communicate through writing and said that [REDACTION] used [REDACTION] cell phone to type text to show to them as evidence that [REDACTION] could read and write. The evaluating staff informed OCR that [REDACTION] responded to “yes” or “no” questions by writing the questions on paper. 

During interviews, the registered nurse who was the first to evaluate [REDACTION] stated that [REDACTION] informed [REDACTION] that [REDACTION] communicated through the emission of sounds, lip reading, use of gestures, or in writing. The registered nurse also claimed that [REDACTION] informed [REDACTION] that a sign language interpreter would not be an effective way of communicating because [REDACTION] did not know sign language. However, those claims are not reflected anywhere in [REDACTION] records. Rather, [REDACTION] patient intake form indicates that [REDACTION] communicated through sign language.

With respect to the provision of auxiliary aids, the registered nurse informed OCR that [REDACTION] did not offer [REDACTION] a sign language interpreter because [REDACTION] was able to communicate effectively without one. However, the physician who evaluated [REDACTION] informed OCR that he offered [REDACTION] a sign language interpreter in writing and asked [REDACTION] if [REDACTION] knew sign language, but that [REDACTION] declined the offer and gestured that [REDACTION] did not know sign language. The physician claims that neither [REDACTION] nor [REDACTION] requested an interpreter. Neither of these representations were documented in [REDACTION] records although staff claim that requests for interpreters are documented in the patient’s medical record. OCR’s review of [REDACTION] records further revealed that the Hospital did not document that staff communicated with [REDACTION] through writing, gestures, and lip reading.

The statements by the nurse and physician that [REDACTION] did not know sign language and did not request a sign language interpreter are not only inconsistent with the hospital intake record but also with [REDACTION] discharge papers. The discharge referral, signed by the psychiatrist and the clinical physician described [REDACTION] as “deaf-and-dumb.” The referral also stated that [REDACTION] should be referred to a psychologist who is an expert in “signos.” Further, pursuant to the Hospital’s policy regarding court-ordered emergency psychiatric evaluations, the Hospital also reported to the court that it determined that [REDACTION] did not require hospitalization but recommended that [REDACTION] follow up with a psychologist expert in “signos.”

OCR’s investigation further found that the Hospital has several policies and procedures to address the provision of appropriate auxiliary aids and services to patients or potential patients who are deaf. However, the policies do not explain or specify how Hospital staff should determine whether an auxiliary aid or service is needed or the type of auxiliary aid or service needed. The policies do not identify the Hospital staff responsible for requesting or arranging for the necessary auxiliary aids and services.

OCR learned that Hospital staff were trained on the provision of auxiliary aids and services and effective communication with deaf and hard-of-hearing individuals after [REDACTION] was evaluated at the Hospital. Nonetheless, during interviews conducted after additional trainings were provided, Hospital staff demonstrated a lack of understanding of the Hospital’s legal requirement to provide auxiliary aids and services. Staff provided inconsistent responses on who is responsible for determining whether a patient requires an auxiliary aid or service. Clinical staff also stated that they heavily rely on the patient’s family members or companions to determine a patient’s needs. OCR notes that the signs and notices provided by the Hospital informing patients of the availability of auxiliary aids only contain the contact information for the Hospital’s sign language interpreting vendor. They do not inform patients of the availability of such services free of charge to the patient or companion; nor do they describe a complaint process or name a Grievance Officer.

Statutory and Regulatory Background

Section 504 provides that a qualified individual with a disability shall not, by reason of disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives Federal financial assistance. 29 U.S.C. 794; see also 45 C.F.R. § 84.4(a). The regulation further provides:

A recipient, in providing any aid, benefit, or service may not . . . on the basis of disability^[5]: . . . (i) Deny a qualified person with a disability the opportunity to participate in or benefit from the aid benefit or service . . ..

45 C.F.R. § 84.4(b)(1)(i). The Section 504 regulations in effect at the time of the events also provides: “[i]n providing health, welfare, or other services or benefits, a recipient may not, on the basis of handicap . . . [d]eny a qualified handicapped person these benefits or services.” 45 C.F.R. § 84.52(a)(1). The regulation further provides:

A recipient to which this part applies . . . 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)(1). Finally, the regulation provides that “auxiliary aids may include . . . interpreters . . . and other aids for persons with impaired hearing.” 45 C.F.R. § 84.52(d)(3).⁶

The Section 504 regulation defines “individual with a disability” as an individual who:

• has a physical or mental impairment which substantially limits one or more major life activities,
• has a record of such an impairment, or
• is regarded as having such impairment.

29 U.S.C. 705(20)(B); see also 45 C.F.R. § 84.3(j)(1)(i)-(iii). The term “qualified”, with respect to an individual with a disability, means an individual “who meets the essential eligibility requirements for the receipt of health, welfare, and social services.” 45 C.F.R. § 84.3(k)(4).⁷

Section 1557 provides that an individual shall not be excluded from participation in, be denied the benefits of, or be subjected to discrimination on the grounds prohibited under Title VI of the Civil Rights Act of 1964, 42 U.S.C. 2000d et seq. (race, color, national origin), Title IX of the Education Amendments of 1972, 20 U.S.C. 1681 et seq. (sex), the Age Discrimination Act of 1975, 42 U.S.C. 6101 et seq. (age), or Section 504 of the Rehabilitation Act of 1973, 29 U.S.C. 794 (disability), under any health program or activity, any part of which is receiving federal financial assistance; any program or activity administered by the Department under Title I of the Act; or any program or activity administered by any entity established under such Title. 42 U.S.C. 18116(a).

The regulation implementing Section 1557 in effect at the time of the events provides:

Any entity operating or administering a program or activity under this part shall take appropriate steps to ensure that communications with individuals with disabilities are as effective as communications with others in such programs or activities, in accordance with the standards found at 28 CFR 35.160 through 35.164.

45 C.F.R. § 92.102(a)⁸

. . .

Auxiliary aids and services include:

• Interpreters on-site or through video remote interpreting (VRI) services, as defined in 28 CFR 35.104 and 36.303(f); note takers; real-time computer-aided transcription services; written materials; exchange of written notes; telephone handset amplifiers; assistive listening device; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning, including real-time captioning; voice, text, and video-based telecommunication products and systems, text telephones (TTYs), videophones, and captioned telephones, or equally effective telecommunications devices; videotext displays; accessible information and communication technology; or other effective methods of making aurally delivered information available to individuals who are deaf or hard-of-hearing; and
• Readers; taped texts; audio recordings; Braille materials and displays; screen reader software; magnification software; optical readers; secondary auditory programs; large print materials; accessible information and communication technology; or other effective methods of making visually delivered materials available to individuals who are blind or have low vision.

45 C.F.R. § 92.102(b)(1).

• When an entity is required to provide an interpreter under paragraph (b) of this section, the interpreting service shall be provided to individuals free of charge and in a timely manner, via a remote interpreting service or an onsite appearance, by an interpreter who

1. Adheres to generally accepted interpreter ethics principles, including client confidentiality; and
2. Is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary, terminology and phraseology.

• An interpreter for an individual with a disability for purposes of this section can include, for example, sign language interpreters, oral transliterators (individuals who represent or spell in the characters of another alphabet), and cued language transliterators (individuals who represent or spell by using a small number of handshapes).

45 C.F.R. § 92.102(b)(2)-(3).⁹

The type of auxiliary aid or service that is necessary to ensure effective communication will vary depending upon the method of communication used by the individual; the nature, length, and complexity of the communications involved; and the context in which the communication is taking place. See 45 C.F.R. § 92.102(a) (incorporating 28 C.F.R. 35.160(b)(2)). As a result, a covered entity should meaningfully consult with each deaf or hard-of-hearing person to determine what auxiliary aids are necessary to provide effective communication in his or her particular situation. This decision should be based on an individualized assessment of the person’s communication needs and a determination regarding what is necessary to ensure effective communication, such that an otherwise qualified person with a disability is not denied benefits or services.¹⁰ 

Findings

OCR concludes that the Hospital subjected [REDACTION] to discrimination in violation of Section 504 and Section 1557. Specifically, the Hospital failed to take appropriate steps to ensure that communication with [REDACTION] was as effective as communication with persons who are not deaf or hard-of-hearing and failed to provide auxiliary aids and services necessary to ensure effective communication with [REDACTION].

To find a violation of Section 504 and Section 1557, the preponderance of the evidence must establish that: (1) [REDACTION] was a qualified individual with a disability; (2) The Hospital is an entity subject to Section 504 and Section 1557; and (3) [REDACTION] was excluded from participation in, or denied the benefits of, the Hospital’s services by reason of [REDACTION] disability.¹¹

• REDACTION was a qualified individual with a disability.

The overwhelming weight of the evidence indicates that [REDACTION] was a person who was deaf and substantially limited in the ability to hear and speak. [REDACTION] met the definition of a person with a disability pursuant to Section 504 and Section 1557. Interviews with family members¹² of [REDACTION] corroborated that [REDACTION] primary method of communication was PRSL and that [REDACTION] required a PRSL interpreter for all but basic and brief interactions with hearing individuals. The Hospital’s intake record also indicates that the Hospital was aware of [REDACTION] limited ability to hear. OCR further finds that [REDACTION] met the essential requirements for the receipt of a mental health evaluation from the Hospital and was, therefore, a “qualified” individual with a disability under Section 504 and Section 1557. As a result, the Hospital had an obligation under Section 504 and Section 1557 to ensure that [REDACTION] had the opportunity to benefit from the mental health evaluation that was provided.

• The Hospital is an entity subject to Section 504 and Section 1557.

The Hospital participates in the Medicare and Medicaid programs, OCR accordingly concludes that the Hospital is subject both to Section 504, as a recipient of Federal financial assistance from HHS under 45 C.F.R. § 84.2, and to Section 1557, as a health program or activity under 45 C.F.R. § 92.2.

• The Hospital failed to provide REDACTION with appropriate auxiliary aids where necessary to provide effective communication and afford [REDACTION] an equal opportunity to participate in and benefit from the Hospital’s services.

Based on its investigation, OCR determined that the Hospital did not provide auxiliary aids and services where necessary to ensure that [REDACTION] had effective communication during [REDACTION] emergency psychiatric evaluation on [REDACTION]. Specifically, OCR determined that the Hospital’s did not provide effective communication with [REDACTION] in connection with [REDACTION] psychiatric evaluation.

OCR has concluded based on the weight of the evidence, that [REDACTION] required a sign language interpreter in order to communicate effectively with the evaluating staff at the Hospital. As explained more fully above, the evidence demonstrates that: 1) [REDACTION] primary form of communication was sign language; 2) [REDACTION] needed a sign language interpreter to communicate effectively with others; and 3) the complex nature of a psychiatric evaluation and importance of communication to conducting such an evaluation.

The Hospital asserted that it communicated effectively with [REDACTION] through written notes, gestures, and lip reading. OCR finds that the Hospital’s use of handwritten notes, gestures, and lip reading was insufficient given the complexity of the communications required to perform a psychiatric evaluation and the centrality of communication to such an evaluation. The evidence indicates that staff questioned [REDACTION] on thoughts of aggression, suicidal ideation, desire to self-injure and harm others, issues with concentration, hallucinations, illegal drug use, history of abuse and cognitive functioning. [REDACTION] was also asked to provide details on [REDACTION] medical history, diagnoses, medications [REDACTION] was taking, and present medical symptoms and issues. These questions were complex in nature as they required [REDACTION] to understand and convey information that was critically important to the Hospital’s ability to assess [REDACTION] mental and physical status. While the exchange of handwritten notes, gestures, and lip reading may be effective in situations for limited or simple communications, these methods of communication were not appropriate, and highly unlikely to be effective for [REDACTION], given that it is uncontested that [REDACTION] was deaf and used sign language as [REDACTION] primary communication, and given the importance and centrality of communication to an emergency psychiatric evaluation. The Hospital did not give “primary consideration” to the method of communication requested by [REDACTION] as required by the regulations.

The Hospital’s policies for patients with special needs and patients with hearing loss recognize the need for services to achieve “better functioning”. The policy states that “[a]ccording to the level of hearing loss the need for an interpreter will be evaluated (Specialist in sign language)”. However, the Hospital did not follow its own policies and use a “specialist in sign language” to evaluate [REDACTION] communication needs.

The Hospital’s failure to provide the auxiliary aid requested by [REDACTION] (i.e., a sign language interpreter) violated Section 504 and Section 1557.

The Hospital has thirty (30) calendar days from the date of this letter to respond and sixty (60) calendar days from the date of this letter to negotiate a Settlement Agreement with OCR. To that end, we have enclosed a proposed Settlement Agreement for your consideration. If compliance has not been secured by the end of the 60-day negotiation period, OCR may initiate formal enforcement action by commencing administrative proceedings, or by other means authorized by law. These proceedings could result in the termination of Federal financial assistance to the covered entity.

Advisements

OCR wishes to advise you that this determination is not intended, nor should it be construed, to cover any other issues regarding civil rights compliance that may exist but were not specifically addressed during our investigation.

The filing of an administrative complaint with OCR may not fully address the complainant’s personal rights or the rights of the parties on whose behalf the complaint was filed. Under OCR procedures, the complainant is not a party to the investigation or any subsequent enforcement proceedings. The complainant may have a right to file a civil action to remedy discrimination by a recipient of Federal financial assistance or other covered entity.

The complainant may wish to consult an attorney about his/her right to pursue a private cause of action, any applicable statute of limitations, and other relevant considerations.

The complainant has the right not to be intimidated, threatened, or coerced by a covered entity or other person because he or she has made a complaint, testified, assisted, or participated in any manner in an investigation, proceeding, or hearing held in connection with a complaint.

If you have any questions, please do not hesitate to contact Linda C. Colón, Regional Manager, Eastern & Caribbean Region at (212) 264-4136. We appreciate your cooperation regarding this matter.

Sincerely, 
Melanie Fontes Rainer
Director
Office for Civil Rights

Enclosure: Settlement Agreement

Endnotes

¹ https://en.sanjuancapestrano.com/about, links to an external website, opens in a new tab. Last accessed May 5, 2023.

² https://www.acadiahealthcare.com/about, links to an external website, opens in a new tab. Last accessed April 25, 2023.

³ Puerto Rico Law 408 allows anyone who considers that another person over the age of 18 is facing a psychiatric emergency and does not want to receive services voluntarily, to request the Court to be detained for a maximum of 24 hours to be evaluated by a team of mental health professionals. The team examines the person and determines the appropriate treatment, which may include involuntary hospitalization. The criteria established by the law for temporary detention is the person poses a danger to themselves, others, or property; does not want to receive treatment voluntarily; and has had a mental health crisis within 24 hours prior to the request.

⁴ The intake document was completed by a hospital call center staff member with the information provided by a representative of [REDACTION] health insurance carrier.

⁵ Where this letter cross-references regulatory provisions that use the term “handicap,” “handicap” means “disability”. The terms “handicap” and “disability” are used interchangeably in this letter.

⁶ OCR has published revised Section 504 regulations that were effective on July 8, 2024. 89 Fed. Reg. 40066 (May 9, 2024). The definition of auxiliary aids and services is codified in the revised Section 504 regulation at 45 C.F.R. § 84.10.

⁷ The definition of disability is codified in the revised regulations at 45 C.F.R. § 84.4; the definition of “qualified individual” is codified in the new rule at 45 C.F.R. 84.10.

⁸ OCR has published revised Section 1557 regulations that were effective on July 5, 2024. 89 Fed. Reg. 37522 (May 6, 2024). The effective communication requirements are codified in the revised regulation at 45 C.F.R. § 92.202.

⁹ OCR has published revised Section 504 regulations that were effective on July 8, 2024. 89 Fed. Reg. 37522 (May 6, 2024). The effective communication requirements are codified in the new rule at 45 C.F.R. 92.201.

¹⁰ The Department of Justice’s guidance explains that “effective communication is particularly critical in health care settings where miscommunication may lead to misdiagnosis and improper or delayed medical treatment.” Generally, the practice of exchanging hand-written notes between a healthcare provider and a deaf or hard-of-hearing individual will likely be effective only for brief and relatively simple face-to-face conversations. The Department of Justice has advised that for more complicated and interactive communications, such as discussion of symptoms or treatment options with patients, it may be necessary to provide a qualified sign language interpreter. In addition, the process of writing back and forth can be arduous and time-consuming for both the provider and the patient. As a result, such messages may be abbreviated, resulting in incomplete communication. See ADA Business Brief: Communicating with People Who Are Deaf or Hard of Hearing in Hospital

Settings, U.S. Department of Justice, http://www.ada.gov/hospcombr.htm, links to an external website

¹¹ See Brooklyn Ctr. for Indep. of the Disabled v. Metro. Transp. Auth., 11 F.4th 55, 61 (2d Cir. 2021) (identifying three-part test for a violation of Section 504); Francois v. Our Lady of the Lake Hospital, Inc., 8 F.4th 370, 378 (5th Cir. 2021) (identifying three-part test for stating a prima facie case of discrimination under Section 504). “Such exclusion, denial, or discrimination occurs when a hospital fails to provide ‘appropriate auxiliary aids and services’ to a deaf patient, or a patient's deaf companion, ‘where necessary to ensure effective communication.” Silva v. Baptist Health S. Fla., Inc., 856 F.3d 824, 831 (11th Cir. 2017); see also Biondo v. Kaledia Health, 935 F.3d 68, 74 (2d Cir. 2019) (denying summary judgment because reasonable jury could find that individual denied “an equal opportunity to benefit from” the hospital’s services given individual’s limitations with written English, the length of REDACTION hospital stay, and the procedures performed and information imparted during REDACTION stay) (quoting 45 C.F.R. § 84.52(d)(1)).

¹² [REDACTION] informed OCR that [REDACTION] was familiar with [REDACTION] communication abilities based on [REDACTION] personal history with [REDACTION], that [REDACTION] used sign language to communicate and that he had witnessed [REDACTION] communicating with a sign language interpreter in court. [REDACTION] father stated that sign language was [REDACTION] primary language and that he had witnessed [REDACTION] communicating in sign language numerous times.