Implementation Report Within 150 days after the Effective Date, Halifax shall submit a written report to OIG summarizing the status of its implementation of the requirements of this CIA (Implementation Report). The Implementation Report shall, at a minimum, include:
1. the name, address, phone number, and position description of the Compliance Officer required by Section III.A.1, and a summary of other noncompliance job responsibilities the Compliance Officer may have;
2. the names and positions of the members of the Compliance Committee required by Section III.A.2;
3. the names of the Board members who are responsible for satisfying the Board of Commissioners compliance obligations described in Section III.A.3;
4. a copy of Halifax’s Code of Conduct required by Section III.B.1;
5. the number of individuals required to complete the Code of Conduct certification required by Section III.B.1, the percentage of individuals who have completed such certification, and an explanation of any exceptions (the documentation supporting this information shall be made available to OIG upon request);
6. a summary of all Policies and Procedures required by Section III.B (copies of the Policies and Procedures shall be made available to OIG upon request);
7. the following information regarding each type of training required by Section III.C:
a. a description of such training, including a summary of the topics covered, the length of sessions, and a schedule of training sessions;
b. the number of individuals required to be trained, percentage of individuals actually trained, and an explanation of any exceptions; and
c. with respect to active medical staff members, the number and percentage who completed the training, the type of training and the date received, and a description of Halifax’s efforts to encourage medical staff members to complete the training.
8. a description of: (a) the Focus Arrangements Tracking System required by Section III.D.1.a; (b) the internal review and approval process required by Section III.D.1.e; and (c) the tracking and monitoring procedures and other Focus Arrangements Procedures required by Section III.D.1; 9. a description of the Disclosure Program required by Section III.F;
Proposed Policies and Procedures Regarding New Online Content and Functionality By February 28, 2018, the recipient will submit to OCR for its review and approval proposed policies and procedures (“the Plan for New Content”) to ensure that all new, newly-added, or modified online content and functionality will be accessible to people with disabilities as measured by conformance to the Benchmarks for Measuring Accessibility set forth above, except where doing so would impose a fundamental alteration or undue burden.
a) When fundamental alteration or undue burden defenses apply, the Plan for New Content will require the recipient to provide equally effective alternative access. The Plan for New Content will require the recipient, in providing equally effective alternate access, to take any actions that do not result in a fundamental alteration or undue financial and administrative burdens, but nevertheless ensure that, to the maximum extent possible, individuals with disabilities receive the same benefits or services as their nondisabled peers. To provide equally effective alternate access, alternates are not required to produce the identical result or level of achievement for persons with and without disabilities, but must afford persons with disabilities equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement, in the most integrated setting appropriate to the person’s needs.
b) The Plan for New Content must include sufficient quality assurance procedures, backed by adequate personnel and financial resources, for full implementation. This provision also applies to the recipient’s online content and functionality developed by, maintained by, or offered through a third-party vendor or by using open sources.
c) Within thirty (30) days of receiving OCR’s approval of the Plan for New Content, the recipient will officially adopt, and fully implement the amended policies and procedures.
