Example Of A Policy And Procedure Hhsgov Page 1of 3

Summary

Example of a Policy and Procedure | HHS.gov Page 1 of 3
HHS.gov U.S. Department of Health & Human Services
Civil Rights
Example of a Policy and Procedure for Providing Meaningful
Communication with Persons with Limited English Proficiency
POLICY AND PROCEDURES FOR COMMUNICATION WITH PERSONS WITH LIMITED ENGLISH
PROFICIENCY
POLICY:
(Insert name of your facility) will take reasonable steps to ensure that persons with Limited English
Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services,
activities, programs and other benefits. The policy of (Insert name of your facility) is to ensure
meaningful communication with LEP patients/clients and their authorized representatives involving their
medical conditions and treatment. The policy also provides for communication of information contained in
vital documents, including but not limited to, waivers of rights, consent to treatment forms, financial and
insurance benefit forms, etc. (include those documents applicable to your facility). All interpreters,
translators and other aids needed to comply with this policy shall be provided without cost to the person
being served, and patients/clients and their families will be informed of the availability of such assistance
free of charge

Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts
or formal arrangements with local organizations providing interpretation or translation services, or
technology and telephonic interpretation services. All staff will be provided notice of this policy and
procedure, and staff that may have direct contact with LEP individuals will be trained in effective
communication techniques, including the effective use of an interpreter

(Insert name of your facility) will conduct a regular review of the language access needs of our patient
population, as well as update and monitor the implementation of this policy and these procedures, as
necessary

PROCEDURES:
1. IDENTIFYING LEP PERSONS AND THEIR LANGUAGE
(Insert name of your facility) will promptly identify the language and communication needs of the LEP
person. If necessary, staff will use a language identification card (or “I speak cards,” available online at
www.lep.gov) or posters to determine the language. In addition, when records are kept of past
interactions with patients (clients/residents) or family members, the language used to communicate with
the LEP person will be included as part of the record

2. OBTAINING A QUALIFIED INTEPRETER
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Example of a Policy and Procedure | HHS.gov Page 2 of 3
(Identify responsible staff person(s), and phone number(s)) is/are responsible for:
(a) Maintaining an accurate and current list showing the name, language, phone number and hours of
availability of bilingual staff (provide the list);
(b) Contacting the appropriate bilingual staff member to interpret, in the event that an interpreter is
needed, if an employee who speaks the needed language is available and is qualified to interpret;
(c) Obtaining an outside interpreter if a bilingual staff or staff interpreter is not available or does not speak
the needed language

(Identify the agency(s) name(s) with whom you have contracted or made arrangements) have/has
agreed to provide qualified interpreter services. The agency’s (or agencies’) telephone number(s) is/are
(insert number (s)), and the hours of availability are (insert hours)

Some LEP persons may prefer or request to use a family member or friend as an interpreter. However,
family members or friends of the LEP person will not be used as interpreters unless specifically requested
by that individual and after the LEP person has understood that an offer of an interpreter at no charge to
the person has been made by the facility. Such an offer and the response will be documented in the
person’s file. If the LEP person chooses to use a family member or friend as an interpreter, issues of
competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the
family member or friend is not competent or appropriate for any of these reasons, competent interpreter
services will be provided to the LEP person

Children and other clients/patients/residents will not be used to interpret, in order to ensure confidentiality
of information and accurate communication

3. PROVIDING WRITTEN TRANSLATIONS
(a) When translation of vital documents is needed, each unit in (insert name of your facility) will
submit documents for translation into frequently-encountered languages to (identify responsible staff
person). Original documents being submitted for translation will be in final, approved form with updated
and accurate legal and medical information

(b) Facilities will provide translation of other written materials, if needed, as well as written notice of the
availability of translation, free of charge, for LEP individuals

(c) (Insert name of your facility) will set benchmarks for translation of vital documents into additional
languages over time

4. PROVIDING NOTICE TO LEP PERSONS
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(Insert name of your facility) will inform LEP persons of the availability of language assistance, free of
charge, by providing written notice in languages LEP persons will understand. At a minimum, notices and
signs will be posted and provided in intake areas and other points of entry, including but not limited to the
emergency room, outpatient areas, etc. (include those areas applicable to your facility).Notification will
also be provided through one or more of the following: outreach documents, telephone voice mail menus,
local newspapers, radio and television stations, and/or community-based organizations (include those
areas applicable to your facility)

5. MONITORING LANGUAGE NEEDS AND IMPLEMENTATION
On an ongoing basis, (insert name of your facility) will assess changes in demographics, types of
services or other needs that may require reevaluation of this policy and its procedures. In addition, (insert
name of your facility) will regularly assess the efficacy of these procedures, including but not limited to
mechanisms for securing interpreter services, equipment used for the delivery of language assistance,
complaints filed by LEP persons, feedback from patients and community organizations, etc. (include
those areas applicable to your facility)

Content created by Office for Civil Rights (OCR)
Content last reviewed on July 26, 2013
https://www.hhs.gov/civil-rights/for-providers/clearance-medicare-providers/example-poli... 5/22/2019

Medical conditions and treatment. The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to …

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