New Department of Health Regulation Provides Meaningful Access for Limited English Proficient Patients

October 1, 2006

Author(s): Michale Mulé

Hospitals are required to provide language assistance to limited-English-proficient (LEP) patients under state law and Title VI of the 1964 Civil Rights Act, which prohibits discrimination in access to services based on national origin.  Last year, the New York State Department of Health (DOH) established higher standards for hospitals' communication with LEP individuals and patients who are hearing and vision impaired.  DOH proposed a regulation to replace 10 NYCRR 405.7(a)(7), to make it clear that every LEP patient has a right to meaningful access to a hospital's services.  The text of this new regulation became effective on September 13, 2006.

In the previous version of the regulation, hospitals were to “manage a resource of skilled interpreters,” and to translate forms and instructions for patients receiving treatment.  The new regulation requires hospitals to develop a specific Language Assistance program to “ensure meaningful access to the hospital’s services and reasonable accommodation for all patients who require language assistance.”  This new mandate is to be accomplished with a Language Assistance Coordinator, which will oversee language assistance and is required to make progress reports to hospital administration.

Some provisions of the former regulation remain in the new version.  In both, hospitals must assure forms and instructions are available for non-English speaking groups that total more than one percent of the population in the hospital service area.  Both also require “English proficiency interpreters” to be available for inpatient and outpatient settings within 20 minutes, and to patients in the emergency service within 10 minutes of a request by at patient or their family.  They also give rural hospitals alternatives to these requirements if they take reasonable steps towards compliance and developed an effective interim plan.

The new regulation gives a detailed programmatic blueprint for hospitals.  Along with a Language Assistance Coordinator, hospitals must have policies and procedures in place to identify a patient’s need for language assistance services.  All levels of the hospital staff must receive training on providing culturally and linguistically competent service and understand how to access the hospital’s language assistance system for patients that require such services.

Hospitals are also required to manage a resource of skilled language interpreters.  In every hospital, there must be proper signage for the free language assistance services in all public locations.  Patient medical records must include their language of preference and note if the patient had refused or accepted language assistance services in the past.  Hospitals must also develop materials for all patients and potential patients describing the process to receive language assistance services.

In the previous regulation hospitals were only required to assess and identify LEP groups comprising more than one percent of the total hospital service area population.  In the new regulation, however, based on this assessment of need, each hospital is required to identify particular language groups and translate significant hospital forms and instructions into those identified languages.

Lastly, the new regulation describes who can act as an interpreter.  Family members, friends, or non-hospital personnel may not act as interpreters except when the patient agrees or the offered hospital interpreter services are refused. Children under 16 years-old can act as interpreters only in emergency circumstances.  This regulation provides greater access to hospitals for New York’s LEP population. See http://tinyurl.com/ov2I9.