Ensuring access to LEP patient population

We are in the process of preparing for our Operational Site Visit (OSV). Can you please tell us how we can demonstrate we ensure access to the Limited English Proficiency (LEP) patient population?

Chapter Four – Required and Additional Health Services, of the Health Resources and Services Administration (HRSA) Health Center Program Compliance Manual (Compliance Manual, Chapter Four) requires health centers that serve a substantial proportion of patients with Limited English Proficiency (LEP) to implement the following:

  • Develop a plan and make arrangements for interpretation and translation that are appropriate for the needs of the patient population; and
  • Provide guidance to staff members with respect to cultural sensitivities and bridging linguistic and cultural differences. 

Additionally, Chapter Seven – Coverage for Medical Emergencies During and After-Hours (Compliance Manual, Chapter Seven) requires health centers to ensure patients in the LEP patient population:

  • Are informed of and able to access after-hours coverage; and
  • Receive information regarding after-hours coverage in language, literacy levels and formats appropriate to the patient population.

Health centers can demonstrate compliance with ensuring access to the LEP patient population via the following methods: 

  • Utilize bilingual staff, as appropriate.
  • Provide documentation of the completion of cultural competency training for staff.
  • Contract with an organization that provides translation services.
  • Provide evidence of translated key documents provided to patients. 
  • Ensure documented after-hours procedures include verbiage to support the following:
    • Information regarding after-hours coverage is provided in languages and literacy levels appropriate to the health center’s patient population.
    • The manner in which after-hours information is provided to patients, including those with LEP. 
    • The process for managing an after-hours call for an LEP patient. 

Health centers can conduct a self-assessment of compliance by answering the questions outlined in Chapter Four – Required and Additional Health Services, Elements b and c (Site Visit Protocol, Chapter Four), and Chapter Seven – Coverage for Medical Emergencies During and After Hours, Element c (Site Visit Protocol, Chapter 7),  in the HRSA Health Center Program Site Visit Protocol.

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