Caring for Patients with Limited English Proficiency (LEP)

Communication failures are among the leading causes of medical malpractice claims across all specialties. When physicians and care teams treat patients with limited English proficiency (LEP), that risk rises sharply. These patients often struggle to describe symptoms, understand diagnoses or follow care instructions, increasing the potential for misdiagnosis, delayed treatment and poor outcomes. 

Research confirms the danger. In a study conducted by the NIH, LEP patients experienced harm in 49.1% of cases, compared with 29.5% of English-proficient patients. Nearly 47% of LEP incidents resulted in moderate to serious harm or death, versus 24% among English speakers. The Joint Commission identifies communication failures—especially the failure to use qualified interpreters—as a major contributor to sentinel events. 

The implications are both clinical and legal. Miscommunication can lead to patient harm, malpractice claims and regulatory penalties. In some cases, indemnity payments in LEP-related lawsuits have reached hundreds of thousands of dollars.

According to the National Health Law Program, more than 25 million people in the U.S. — over 8% of the population — do not speak English very well, if at all. Ensuring meaningful language access is therefore not optional. It’s an essential component of safe, equitable care and a cornerstone of compliance with federal law.

Legal Framework: Section 1557 and Title VI

Federal law requires healthcare providers to take proactive steps to ensure effective communication with LEP patients. Two key statutes define these obligations:

• Title VI of the Civil Rights Act of 1964 prohibits discrimination based on national origin, which includes language.
• Section 1557 of the Affordable Care Act (ACA) builds on Title VI, mandating that covered healthcare programs and activities provide free, accurate and timely language assistance to patients and companions with LEP.

Any organization receiving federal financial assistance—directly or indirectly—is a “covered entity.” This includes hospitals, physician practices, clinics, community health centers, long-term care facilities, home health agencies, licensed insurers and plans offered on the health insurance marketplace.  As of the 2024 Final Rule, Medicare Part B is now included among covered programs, expanding the number of entities required to comply.

Updates Under the 2024 Final Rule

The Department of Health and Human Services (HHS) updated Section 1557 regulations in 2024 to restore and strengthen nondiscrimination protections. Key updates include:

• Expanded Coverage: Applies to Medicare Part B providers, as well as Parts A, C and D — and to all programs receiving HHS funds.
• Companion Access: Language assistance must also be offered to patients’ companions, such as caregivers or decision-makers, with LEP.
• Technology Standards: Defines performance criteria for audio and video remote interpreting and requires qualified human review of any machine-translated text that affects a patient’s rights, benefits or access to care.
• Training Mandate: All staff interacting with LEP patients must receive training on recognizing language needs and coordinating interpreter services.
• Enforcement Emphasis: Failure to comply can lead to civil rights investigations, loss of federal reimbursement, private litigation or monetary damages.

Requirements for Covered Entities

To meet Section 1557 standards, healthcare organizations must:

• Provide qualified interpreter services at no cost to patients with LEP.
• Translate vital documents, including consent forms, discharge instructions and notices, into the most common languages spoken in their service area.
• Train staff to identify LEP patients and arrange appropriate language assistance.
• Post notices of available services in English and the state’s top 15 non-English languages in prominent physical and online locations.
• Document each patient’s language needs and services provided in their medical record.

Providers are expected to have systems in place to accommodate interpreter requests within a reasonable timeframe — generally no later than three business days before an appointment. Video or telephone interpretation may suffice if in-person services are not feasible.

Auxiliary Aids and Services

Language access requirements also extend to individuals who are deaf, hard of hearing, blind or have low vision. Covered entities must provide auxiliary aids and services that ensure effective communication, which may include:

• For those who are deaf or hard of hearing: sign-language interpreters, captioning, note takers or assistive listening devices.
• For those who are blind or visually impaired: readers, braille materials, large-print documents or screen-reader software.

All services must be accurate, timely and free of charge.

The Role of Qualified Interpreters

Perhaps the most critical element of compliance and patient safety is the use of qualified healthcare interpreters. These professionals are trained to maintain accuracy, neutrality and confidentiality, essential for informed consent and effective care.

Using friends, family members or untrained staff as interpreters can lead to serious clinical errors and violates Section 1557 regulations. Exceptions exist only when:

1. The patient voluntarily requests to use a companion interpreter.
2. The person interpreting is at least 18 years old.
3. The provider has first informed the patient of their right to a qualified interpreter.
4. The use of a companion does not compromise accuracy or confidentiality.

All such requests must be clearly documented in the patient’s record.  Consistent use of qualified interpreters not only reduces malpractice exposure but also strengthens patient trust and satisfaction.

Notice and Documentation Requirements

Covered entities must prominently display notices of available language services, both online and in physical facilities, using 20-point font or larger. These notices should appear in English and the top 15 non-English languages in the state and must be included in:

• Nondiscrimination notices
• Privacy practices
• Intake and consent forms
• Discharge instructions
• Billing or payment communications
• Public health or emergency communications

Maintaining clear documentation of interpreter services provided is equally important. Lack of written proof that assistance was offered or used can weaken a provider’s legal defense, even if care was ultimately appropriate.

Costs and Consequences of Noncompliance

The Office for Civil Rights (OCR) enforces Section 1557. Consequences for noncompliance can include:

• Civil rights complaints leading to investigations and corrective action plans.
• Loss of federal financial assistance from Medicare, Medicaid or other HHS programs.
• Compensatory damages and civil penalties if communication failures result in harm.
• Reputational damage and loss of patient trust.

Recent enforcement examples include hospitals paying between $80,000 and $200,000 in damages and fines for failing to provide qualified interpreter services.

Recommended Steps for Compliance and Risk Reduction

To meet federal requirements and reduce malpractice risk, healthcare organizations should:

1. Develop and maintain a language access plan. 
   Define procedures for identifying LEP patients, arranging interpreter services and documenting assistance provided.
2. Use qualified interpreters and translators only. 
   Verify that interpreters meet national standards of competence and ethics.
3. Train all patient-facing staff. 
   Regularly review Section 1557 obligations, patient rights and internal reporting protocols.
4. Audit compliance annually. 
   Review posted notices, translated materials and interpreter use records.
5. Engage reputable language service providers. 
   Consider established healthcare translation vendors or free resources provided by insurers for patients with LEP.
6. Update public notices each year. 
   Ensure that both digital and physical notices meet display and language requirements.

These measures demonstrate diligence, support equitable care and serve as evidence of compliance in the event of a claim or audit.

The Bigger Picture: Communication, Equity and Safety

Language access is about more than compliance—it’s about patient safety, trust and quality of care. Clear communication allows physicians to gather accurate histories, explain risks and benefits and confirm understanding, all of which reduce preventable errors. 

Ensuring equitable care for LEP patients helps healthcare organizations fulfill both their ethical and legal responsibilities, while also reducing the likelihood of malpractice exposure and regulatory penalties.

Resources for Support

To assist with compliance and program development, consider the following:

• National Council on Interpreting in Health Care (NCIHC)
• Think Cultural Health – Language Access Tools
• National Health Law Program – Language Access Guidance

These resources provide templates, training materials and best practices to help organizations meet their obligations and deliver equitable, high-quality care to every patient.