United States of America v. Swedish Edmonds Hospital - Settlement Agreement

IV. EQUITABLE RELIEF

A. Prohibition of Discrimination

18. Nondiscrimination.  Swedish Edmonds shall provide appropriate Auxiliary Aids and Services, including Qualified Interpreters, where such aids and services are necessary to ensure effective communication with Patients and Companions who are Deaf or Hard of Hearing.  Pursuant to 42 U.S.C. § 12182(a), the Hospital shall also provide Patients and Companions who are Deaf or Hard of Hearing with the full and equal enjoyment of the services, privileges, facilities, advantages, and accommodations of the Hospital as required by this Agreement and the ADA.

19. Discrimination by Association.  Swedish Edmonds shall not deny equal services, accommodations, or other opportunities to any individual because of the known relationship of that person with someone who is Deaf or Hard of Hearing.  See 42 U.S.C. § 12182(b)(1)(E).

20. Retaliation and Coercion.  Swedish Edmonds shall not retaliate against or coerce in any way any person who made, or is making, a complaint according to the provisions of this Agreement or exercised, or is exercising, his or her rights under this Agreement or the ADA. See 42 U.S.C. § 12203.

B. Effective Communication

21. Appropriate Auxiliary Aids and Services.  Consistent with 42 U.S.C. § 12182(b)(2)(A)(iii), Swedish Edmonds will provide to Patients and Companions who are Deaf or Hard of Hearing any appropriate Auxiliary Aids and Services that are necessary for effective communication after making the assessment described in paragraphs 22-23 of this Agreement.  Appropriate Auxiliary Aids and Services will be provided as soon as practicable (without compromising patient care), except that the provision of on-site interpreters must be within the time frame described in paragraph 30 of this Agreement.

22. General Assessment Criteria.  The determination of appropriate Auxiliary Aids and Services, and the timing, duration, and frequency with which they will be provided, will be made by the Hospital in consultation with the person with a disability.  The assessment made by Hospital Personnel will take into account all relevant facts and circumstances, including, for example, the individual’s communication skills and knowledge, and the nature and complexity of the communication at issue.  To guide this determination, the Hospital will provide all Patients or Companions who are Deaf or Hard of Hearing with a notice of available services at Registration, through the completion of the complete the Communication Assessment Tool.  The existing Communication Assessment Tool will be revised as soon as is practicable to reflect that such services are provided free of charge.  In addition,  nursing will complete the Sensory Deficit screening in EPIC.  Swedish Edmonds will ensure that it provides the Communication Assessment Tool to all new patients at intake at either the regular admissions desk or the Emergency Department within thirty (30) business days of the Effective Date of this Agreement.

23. Time for Assessment.  The determination of which appropriate Auxiliary Aids and Services are necessary, and the timing, duration, and frequency with which they will be provided, must be made:

• (a) at the time an appointment is scheduled for the Patient who is Deaf or Hard of Hearing or;

• (b)        on the arrival of the Patient or Companion who is Deaf or Hard of Hearing at the Hospital, whichever is earlier.

Hospital Personnel will perform an assessment informed by the information collected as described in paragraph 22 as part of each initial inpatient assessment and document the results in the Patient’s medical chart. It is not necessary to perform the assessment for each subsequent visit to the Hospital or to require the Patient to request auxiliary aids and services for each subsequent visit to the Hospital.  In the event that the initial form of communication is not effective or circumstances change (see paragraph 28, below), Hospital Personnel will reassess which appropriate Auxiliary Aids and Services are necessary, in consultation with the person with a disability, where possible, and provide such aid or service based on the reassessment.

24. Assistive Device Point Persons.  Swedish Edmonds will designate the hospital Bed Control Employees as Assistive Device Point Persons.  At least one such employee or his or her designee (typically the nursing supervisor) will always be on duty and available to Hospital staff, Patients, and Companions twenty-four (24) hours a day, seven (7) days a week, to answer questions and provide appropriate assistance regarding immediate access to, and proper use of, the appropriate Auxiliary Aids and Services, including Qualified Interpreters.

• The  Assistive Device Point Persons will know where the appropriate auxiliary aids are stored and how to operate them and will be responsible for their, replacement, and distribution.  Clinical Engineering will be responsible for the maintenance and repair of the auxiliary aids.

• Swedish Edmonds will include in the on-duty nursing supervisor’s binder (located at the Nurse Staffing Office) the name, telephone number and office number through which the on-duty  Assistive Device Point Person can be contacted twenty-four (24) hours a day seven days a week by Hospital Personnel providing services to individuals who are Deaf or Hard of Hearing.  

• The Assistive Device Point Persons will be designated by the Hospital no later than thirty (30) business days following execution of this Agreement and notice of such designation will be provided to the United States Attorney’s Office.

25. Auxiliary Aid and Service Log. Swedish Edmonds will maintain a log in which requests for qualified interpreters on-site or through video remote services for Persons who are Deaf or Hard of Hearing will be documented. The log will indicate the time and date the request was made, the name of the Patient or Companion who is Deaf or Hard of Hearing, the time and date of the scheduled appointment (if a scheduled appointment was made), the nature of the Auxiliary Aids and Service provided, and the time and date the appropriate Auxiliary Aids and Service was provided.  If no Auxiliary Aids and Service were provided, the log shall contain a statement why the Auxiliary Aids and Service was not provided. Such logs will be maintained by the Assistive Device Point Persons for the entire duration of the Agreement, and will be incorporated into the semi-annual Compliance Reports as described in paragraph 44 of this Agreement. The Hospital will implement the Auxiliary Aid and Service Log no later than thirty (30) business days following execution of this Agreement.

26. Complaint Resolution.  Swedish Edmonds will continue to utilize its established grievance resolution mechanism for the investigation of disputes regarding effective communication with Patients and Companions who are Deaf or Hard of Hearing.  In particular

• a. Swedish Edmonds will maintain records of all grievances regarding effective communication, whether oral or written, made to the Hospital and actions taken with respect thereto.  

• b. At the time Swedish Edmonds completes its assessment described in paragraphs 22-23 and advises the Patient and/or Companion of its determination of which appropriate Auxiliary Aids and Services are necessary, the Hospital will notify persons who are Deaf or Hard of Hearing of its grievance resolution mechanism, to whom complaints should be made, and of the right to receive a written response to the grievance.

• c. A written response to any grievance filed shall be completed within thirty (30) days of receipt of the complaint.

• d. Copies of all grievances related to provision of services for Patients and/or Companions who are Deaf or Hard of Hearing and the responses thereto will be maintained by the  Assistive Device Point Person(s) for the entire duration of this Agreement.

27. Prohibition of Surcharges. All appropriate Auxiliary Aids and Services required by this Agreement will be provided free of charge to the Patient and/or Companion who is Deaf or Hard of Hearing.

C. Qualified Interpreters

28. Circumstances Under Which Interpreters May be Required.  Although the determination of whether and what Auxiliary Aids and Service is appropriate to a given situation is generally up to the Hospital (as informed by its assessment (paragraphs 22 and 23) and the input or request of the Patient or Companion), some circumstances demand that the Hospital provide a qualified sign language interpreter or qualified oral interpreter to Patients or Companions who rely upon such types of communications.  Such circumstances typically arise when the communication is particularly complex or lengthy.  For example, such circumstances include, but are not limited to:

• a. Discussing a patient’s symptoms and medical condition, medications, and medical history;

• b. Explaining medical conditions, treatment options, tests, medications, surgery, and other procedures;

• c. Providing a diagnosis and recommendation for treatment;

• d. Communicating with a patient during treatment, testing procedures, and during physician’s rounds;

• e. Obtaining informed consent for treatment;

• f. Providing instructions for medications, post-treatment activities, and follow-up treatments;

• g. Providing mental health services, including group or individual counseling for patients and family members;

• h. Providing information about blood or organ donations;

• i. Discussing powers of attorney, living wills and/or complex billing, and insurance matters; or

• j. During educational presentations, such as birthing or new parent classes, nutrition and weight management programs, and CPR and first-aid training.

In such circumstances, the Hospital will presume that a qualified sign language interpreter or qualified oral interpreter is necessary for effective communication with a Patient or Companion who relies upon such auxiliary services or aids. 

29. Chosen Method for Obtaining Interpreters.  Within thirty (30) business days after execution of this Agreement, Swedish Edmonds will provide the name(s) of the interpreter services currently used by the Hospital for securing qualified on-site interpreters as well as VRI services.

30. Provision of Interpreters in a Timely Manner.

a. Non-scheduled Interpreter Requests: A “non-scheduled interpreter request” means a request for an interpreter made by a Patient or Companion who is Deaf or Hard of Hearing less than two (2) hours before the Patient’s appearance at the Hospital for examination or treatment. For non-scheduled interpreter requests, Hospital Personnel will complete the assessment described in paragraphs 22-23 above.

• A Qualified Interpreter (via VRI) will be provided as soon as practicable, but no more than 30 minutes from the time the Hospital completes the assessment (absent exigent circumstances affecting patient care which may extend the time for providing such service).

• In the event that an on-site Qualified Interpreter is required, an interpreter will be provided as soon as practicable, but no more than two (2) hours from the time it becomes clear that a live interpreter is necessary for effective communication.

As described below in section (c) of this paragraph, the Hospital will document the on-site interpreter service’s response time, including the time of contact and the time of arrival.  Deviations from this response time will be addressed with the interpreting service provider, and performance goals will be reviewed with the U.S. Attorney’s Office very six months.  The Hospital shall not be held responsible for circumstances beyond their control in obtaining on-site interpreter services, such as delays due to weather or interpreter service response, as long as the Hospital makes all reasonable efforts to obtain on-site interpreter services in a timely manner and documents those efforts.  If no Qualified Interpreter can be located, Hospital Personnel will:

• i. Exert reasonable efforts (which shall be deemed to require no fewer than five (5) telephone inquiries and/or emails and/or text messages unless exceptional circumstances intervene) to contact any Qualified Interpreters or interpreting agencies already known to the Hospital and request their services;

• ii. Inform the Assistive Device Point Person of the efforts made to locate an interpreter and solicit assistance in locating an interpreter;

• iii.        Inform the Patient or Companion (or a family member or friend, if the Patient or Companion is unavailable) of the efforts taken to secure a Qualified Interpreter and that the efforts have failed, and follow up on reasonable suggestions for alternate sources of Qualified Interpreters, such as contacting a Qualified Interpreter known to that person; and

• iv.        Document all of the above efforts.

b. Scheduled Interpreter Requests.  A “scheduled interpreter request” is a request for an interpreter made two (2) or more hours before the services of the interpreter are required.  For scheduled interpreter requests, Swedish Edmonds Personnel will complete the assessment described in paragraphs 22-23 above in advance, and, when a Qualified Interpreter is appropriate, Swedish Edmonds will make a qualified interpreter available at the time of the scheduled appointment.  If a Qualified Interpreter fails to arrive for the scheduled appointment, upon notice that the Qualified Interpreter failed to arrive, the Hospital will immediately call the interpreter service for another Qualified Interpreter and comply with the timeframes set forth in paragraph 30(a).

c. Data Collection on Interpreter Response Time.  The Hospital will monitor and document in the Auxiliary Aid and Service Log, described in paragraph 25, the response time of each Qualified Interpreter service it uses to provide communication to Patients or Companions who are Deaf or Hard of Hearing through its established process of monitoring outside vendors. The Hospital will document and investigate, per the grievance process identified in paragraph 26, any complaints by the Patients or Companions who are Deaf or Hard of Hearing regarding the quality and/or effectiveness of services provided by the interpreter service.

31. Video Remote Interpreting (“VRI”). When using VRI services, the Hospital shall ensure that it provides:

(1) Real-time, full-motion video and audio over a dedicated high-speed, wide-bandwidth video connection or wireless connection that delivers high-quality video images that do not produce lags, choppy, blurry, or grainy images, or irregular pauses in communication;

(2) A sharply delineated image that is large enough to display the interpreter’s face, arms, hands, and fingers, and the participating individual’s face, arms, hands, and fingers, regardless of his or her body position;

(3) A clear, audible transmission of voices; and

(4) Adequate training to users of the technology and other involved individuals so that they may quickly and efficiently set up and operate the VRI. 28 C.F.R. § 36.303(f).  

VRI shall not be used when it is not effective, for example, due to: (1)  a patient’s limited ability to move his or her head, hands or arms; vision or cognitive issues; or significant pain; (2) space limitations in the room; (3) the complexity of the medial issue; or (4) any other time when there are indicators that VRI is not providing effective communication .  The VRI Decision Tree will be revised as soon as is practicable to include guidance on the circumstances just listed and indicating that live interpreter services should be requested in such circumstances.  Whenever, based on the circumstances, VRI does not provide effective communication with a Patient or Companion who is Deaf or Hard of Hearing (after it has been provided or is not available), VRI shall not be used as a substitute for an on-site Qualified Interpreter, and an on-site Qualified Interpreter shall be requested and provided.  The on-site Qualified Interpreter shall be provided within two hours from the time it becomes evident that VRI cannot provide effective communication.

32. Notice to Patients and Companions Who are Deaf or Hard of Hearing. As soon as Swedish Edmonds Hospital Personnel have determined that a Qualified Interpreter is necessary for effective communication with a Patient or Companion who is Deaf or Hard of Hearing, the Hospital will inform the Patient or Companion (or a family member or friend, if the Patient or Companion is not available) of the current status of efforts being taken to secure a Qualified Interpreter on his or her behalf.  Swedish Edmonds will provide additional updates to the Patient or Companion as necessary until an interpreter is secured.  Notification of efforts to secure a Qualified Interpreter does not lessen Swedish Edmonds’s obligation to provide qualified interpreters in a timely manner as required by paragraph 30 of this Agreement.

33. Other Means of Communication.  Swedish Edmonds agrees that between the time an interpreter is requested and the interpreter is provided, Hospital Personnel will continue to try 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 all available methods of communication, for example, using sign language pictographs.  This provision in no way lessens Swedish Edmonds’s obligation to provide qualified interpreters in a timely manner as required by paragraph 30 of this Agreement.

34. Restricted Use of Certain Persons to Facilitate Communication.  Swedish Edmonds will not rely on an adult friend or family member of the Patient or Companion who is Deaf or Hard of Hearing to interpret except:

• a. In an emergency involving an imminent threat to the safety of an individual or the public where there is no interpreter available; or

• b. Where the Patient or Companion who is Deaf or Hard of Hearing specifically requests that the adult friend or adult family member interpret, the accompanying adult agrees to provide such assistance, and reliance on that adult for such assistance is appropriate under the circumstances.  If the requested interpreter is not medically certified, Swedish Edmonds reserves the right to provide a medically certified interpreter at no cost; however, the requested non-certified interpreter will not be reimbursed for the time a medically certified interpreter is required. A medically certified interpreter is required for the situations listed in ¶ 34(b).

Swedish Edmonds will not rely on a minor child or Patient to interpret except in the limited circumstances described in (a) above.

D. Notice to the Community

35. Policy Statement. Within ninety (90) days of the entry of this Agreement, Swedish Edmonds shall post and maintain signs of conspicuous size and print at all Hospital admitting stations and wherever a Patient’s Bill of Rights is required by law to be posted, with substantially similar language to that provided in the Sample Posting attached as Exhibit A notifying the public of the availability of Auxiliary Aids and Services and their related rights.  These signs will include the international symbols for “interpreters” and “TTYs.”

36. Website. Swedish Edmonds will include on its website the same or substantially same policy statement.  All new and redesigned web pages, web applications, and web content (“Web Pages”) published by the Hospital must comply with the Web Content Accessibility Guidelines 2.0 level A and AA Success Criteria.

37. Patient Handbook. Swedish Edmonds will include in all future printings of its Patient Handbook (or equivalent) and all similar publications a statement to the following effect:

To ensure effective communication with Patients and their Companions who are deaf or hard-of-hearing, we provide appropriate auxiliary aids and services free of charge, such as: sign language and oral interpreters, video remote interpreting services, TTYs, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with caption capability or closed caption decoders, and open and closed captioning of most Hospital programs.Please ask your nurse or other Hospital Personnel for assistance, or contact the Information Office at ______________ (voice or TTY), room _________________.

The Hospital will also include in its Patient Handbook a description of its complaint resolution mechanism.

E. Notice to Swedish Edmonds Hospital Personnel and Physicians

38. Website.  Swedish Edmonds shall publish on its intranet a policy statement regarding the Hospital’s policy for effective communication with persons who are Deaf or Hard of Hearing. This policy statement includes, but is not limited to, language to the following effect:

If you recognize or have any reason to believe that a Patient or a relative, close friend, or Companion of a Patient is deaf or hard-of-hearing, you must advise the person that appropriate auxiliary aids and services, such as sign language and oral interpreters, video remote interpreting services, TTYs, written materials, telephone handset amplifiers, assistive listening devices and systems, telephones compatible with hearing aids, televisions with captioning or closed caption decoders, and open and closed captioning of most hospital programs, will be provided free of charge when appropriate. If you are the responsible health care provider, you must ensure that such aids and services are provided when appropriate. All other personnel should direct that person to the appropriate ADA Administrator(s) at _____________ and reachable at ________________.

39. Notice to Personnel.  Swedish Edmonds’s policy for effective communication with persons who are Deaf or Hard of Hearing will be accessible to all Hospital Personnel and Active Members of the Hospital Medical Staff.  The policy will also be provided to all newly hired Hospital Personnel and all Active Members of the Hospital Medical Staff upon their affiliation or employment with the Hospital.

F. Training

40. Training of  the Assistive Device Point Persons. Swedish Edmonds will provide mandatory training for the Assistive Device Point Persons as designated in paragraph 24 of this Agreement. Such training will occur within sixty (60) business days of designation of the Assistive Device Point Persons unless such training has been provided in accordance with Swedish Edmonds’s training schedule within the same calendar year of the Effective Date of this Settlement. Such training will be sufficient in duration and content to train Assistive Device Point Persons in the following areas:

• a. to promptly identify communication needs of Patients and Companions who are Deaf or Hard of Hearing and which Auxiliary Aids and Services are effective in which situations;

• b. to secure Qualified Interpreter services as quickly as possible when necessary;

• c. to encourage Active Members of the Hospital Medical Staff to notify the  Assistive Device Point Persons  and the Nursing Supervisor of Patients and Companions who are Deaf or Hard of Hearing as soon as Patients schedule admissions or other health care services at the Hospital;

• d. to use, when appropriate and available, flash cards and/or pictographs (in conjunction with any other available means of communication that will augment the effectiveness of the communication);

• e. how and when to use VRI services;

• f. making and receiving calls through a VRI service; and

• g. the Hospital’s complaint resolution procedure described in paragraph 26 of this Agreement.

41. Training of Hospital Personnel. Except for Active Members of the Hospital Medical Staff, who are governed by paragraph 43 of this Agreement, Swedish Edmonds will provide mandatory in-service training to all Hospital Personnel who have contact with patients.

• a. The training will address the needs of Patients and Companions who are Deaf or Hard of Hearing and will include the following objectives:

  • i. to promptly identify communication needs of Patients and Companions who are Deaf or Hard of Hearing;

  • ii. to secure Qualified Interpreter services or VRI services as quickly as possible when necessary;

  • iii. to use, when appropriate, flash cards and/or pictographs (in conjunction with any other available means of communication that will augment the effectiveness of the communication).

  • iv. how and when to use VRI services; and

  • v. making and receiving calls through a VRI service.

• b. Such training must be provided within ninety (90) days of the Effective Date of this Agreement, unless such training has been provided within the same calendar year of the Effective Date of this Settlement in accordance to Swedish Edmonds training schedule and annually thereafter.

• c. New employees must be trained in the same manner within thirty business (30) days of their hire.

42. Training Attendance Records. Swedish Edmonds will maintain for the duration of this Agreement, confirmation of training conducted pursuant to paragraphs 40-41of this Agreement, which will include the names and respective job titles of the attendees, as well as the date and time of the training session.

43. Training of Active Members of the Hospital Medical Staff.  Swedish Edmonds will provide Active Members of the Hospital Medical Staff a hard copy of its policy on the communication needs of Patients or Companions who are Deaf or Hard of Hearing by delivering it to their office addresses.  The policy shall be accompanied by a cover letter that:

• a. indicates the additional availability of the policy on the intranet,

• b. invites the recipient to reach out to the Assistive Device Point Persons if they have questions about the policy; and

• c. requests that if and when they become aware that a Patient or Companion who is Deaf or Hard of Hearing will be visiting the Hospital for health care services, that they promptly notify the Nursing Supervisor of the expected visit

G. Reporting, Monitoring, and Violations

44. Compliance Reports. Beginning six months after the Effective Date of this Agreement and every six (6) months thereafter for the entire duration of the Agreement, Swedish Edmonds will provide a written report (“Compliance Report”) to the U.S. Attorney’s Office regarding the status of its compliance with this Agreement. The Compliance Report will include data relevant to the Agreement, including but not limited to:

• a. the information required in Auxiliary Aid and Service Log described in paragraph 25.

• b. the information maintained in the complaint records described in paragraph 26, including the number of complaints received by Swedish Edmonds from Patients and Companions who are Deaf or Hard of Hearing regarding Auxiliary Aids and Services and/or effective communication, and the resolution of such complaints including any supporting documents.

Swedish Edmonds will maintain records to document the information contained in the Compliance Reports and will make them available, upon request, to the U.S. Attorney’s Office.

45. Complaints. During the term of this Agreement, Swedish Edmonds will notify the U.S. Attorney’s Office if any person files a lawsuit, complaint, or formal charge with a state or federal agency, alleging that Swedish Edmonds failed to provide Auxiliary Aids and Services to Patients or Companions who are Deaf or Hard of Hearing or otherwise failed to provide effective communication with such Patients or Companions. Such notification must be provided in writing via certified mail within twenty (20) business days of the date Swedish Edmonds received notice of the allegation and will include, at a minimum, the nature of the allegation, the name of the person making the allegation, and any documentation of the allegation provided by the complainant.  Swedish Edmonds will reference this provision of the Agreement in the notification to the U.S. Attorney’s Office.

46. Remuneration.  Within  thirty (30) business days after receiving the executed Agreement, and the Complainant's signed release (a Blank Release Form is at Exhibit B), Swedish Edmonds will send by FedEx, a check in the amount of three thousand ($3,000) dollars made out to Complainant J.P.  This check is remuneration to the Complainant pursuant to 42 U.S.C. § 12188(b)(2)(B). The check shall be mailed to:

Christina Fogg
Assistant United States Attorney
700 Stewart Street, Suite 5220
Seattle, WA  98101

I.  Enforcement and Miscellaneous

47. Duration of the Agreement. This Agreement will be in effect for three (3) years from the Effective Date.

48. Enforcement. In consideration of the terms of this Agreement as set forth above, the United States agrees to refrain from undertaking further investigation or from filing a civil suit under title III in this matter, except as provided in paragraph 49.  Nothing contained in this Agreement is intended or shall be construed as a waiver by the United States of any right to institute proceedings against Swedish Edmonds for violations of any statutes, regulations, or rules administered by the United States or to prevent or limit the right of the United States to obtain relief under the ADA for violations unrelated to this matter.

49. Compliance Review and Enforcement. The United States may review compliance with this Agreement at any time and can enforce this Agreement if the United States believes that it or any requirement thereof has been violated by instituting a civil action in U.S. District Court.  If the United States believes that this Agreement or any portion of it has been violated, it will raise its claim(s) in writing with Swedish Edmonds, and the parties will attempt to resolve the concern(s) in good faith.  The United States will allow Swedish Edmonds thirty (30) business days from the date it notifies the Hospital of any breach of this Agreement to cure said breach, prior to instituting any court action to enforce the ADA or the terms of the Agreement.

50. Entire Agreement. This Agreement and the attachments hereto constitute the entire agreement between the parties on the matters raised herein, and no other 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, shall be enforceable.  This Agreement is limited to the facts set forth herein and does not purport to remedy any other potential violations of the ADA or any other federal law.

51. Binding. This Agreement is final and binding on the parties, including all principals, agents, executors, administrators, representatives, successors in interest, beneficiaries, assigns, heirs, and legal representatives thereof. Each party has a duty to so inform any such successor in interest.

52. Non-Waiver. Failure by any party to seek enforcement of this Agreement pursuant to its terms with respect to any instance or provision shall not be construed as a waiver to such enforcement with regard to other instances or provisions.

53. Effective Date.  The effective date of this Settlement Agreement is the date of the last signature below.

54. Execution. This Agreement may be executed in counterparts, each of which constitutes an original and all of which constitute one and the same Agreement. Electronically transmitted signatures shall constitute acceptable, binding signatures for purposes of this Agreement.

FOR THE UNITED STATES:
/s/ Christina Fogg Christina Fogg Assistant United States Attorney United States Attorney’s Office Western District of Washington 700 Stewart Street, Suite 5220 Seattle, Washington 98101-1271 Phone:  (206) 553-7970 christina.fogg@usdoj.gov	10/10/14 Date
FOR SWEDISH EDMONDS:
/s/ ___________ Chief Executive	10/3/14 Date