Client Setup
Phase 2 — Documentation Audit
Language Access Plan, policies, notices, translated documents
Language Access Plan
Written Language Access Plan (LAP) — formal, signed document on file
Required by: EO 13166 · Title VI DOJ Guidance · HUD LEP Guidance
Four-Factor LEP Analysis — documented assessment of LEP population needs
Required by: EO 13166 DOJ Guidance · Title VI
LAP Review / Update Cycle — documented schedule for annual or bi-annual review
Required by: EO 13166 (federal agencies: every 4 years)
ACA Section 1557 Compliance Documents
Nondiscrimination Notice — posted in visible locations AND included in significant communications
Required by: ACA § 1557 (45 C.F.R. § 92.8)
Taglines in 15+ Languages — written notice of free language assistance in top languages of service area
Required by: ACA § 1557 for covered healthcare entities
Patient Rights Translations — HIPAA Notice of Privacy Practices translated into LEP languages
Required by: HIPAA (45 C.F.R. § 164.520) · ACA § 1557
QA, Compliance, and Operational Policies
Translation Quality Assurance Policy — documented process for reviewing translated materials before distribution
Best practice · Required by ISO 17100 for LSPs · Defensible in OCR complaints
Language Access Complaint Procedure — written process for receiving and resolving language access complaints
Required by: Title VI · ACA § 1557 · EO 13166
Vital Documents Inventory — list of all documents that require translation per applicable regulation
Required for LAP completion · Title VI · EO 13166
Staff Language Access Training Records — documentation of staff trained on LAP, interpretation policies, prohibited practices
Best practice · Required for EO 13166 LAP completeness
Section Notes
Phase 3 — Credential Audit
Interpreter and translator certifications, expiration tracking, background verification
Certification & Credential Checks
Interpreter Certification (CHI / CMI / CCHI / ATA) — at least one certified interpreter per primary LEP language
Required by: ACA § 1557 "qualified interpreter" standard · HIPAA
No Prohibited Interpreter Use — no use of minor children, untrained staff, or family members as interpreters in critical contexts
Explicitly prohibited by: ACA § 1557 (medical) · ADA · Court Interpreter Act (legal)
Credential Expiration Tracking — process for monitoring certification renewal dates
Best practice · Required for CMI/CHI re-certification
Background Verification on File — background checks for interpreters with access to vulnerable populations (minors, patients)
Required by most healthcare and court-based contracts
Interpreter / Translator Roster
NameCertificationLanguage PairExpires
Section Notes
Phase 4 — Operational Audit
Workflows, MT QA, HIPAA language access, data practices
Translation Workflows
Machine Translation + Human Post-Editing — MT output reviewed by a qualified human before distribution
Required for compliance-critical docs · ACA § 1557 qualified interpreter/translator standard
LinguaGnosis™ or Equivalent QA Scoring — scored MT quality analysis applied before any translated document is used
Best practice · OCR-defensible quality trail
Document Version Control — translated documents versioned and dated to match source updates
Best practice · Required for HIPAA document management
Language Access Service Delivery
24/7 or On-Demand Telephonic Interpretation Access — available for all patient/client encounters where LEP may be present
Required by: ACA § 1557 (healthcare) · Title VI · HUD LEP (housing)
LEP Population Flagged in Records — client/patient records include preferred language and LEP status
Required for meaningful access under Title VI · HIPAA data accuracy
Language Access at Intake / First Point of Contact — LEP individuals identified and language services offered before any service interaction
Required by: Title VI · EO 13166 · ACA § 1557
Data Privacy & HIPAA Language Access
Business Associate Agreement (BAA) with Interpreter Vendors — signed BAA with any vendor accessing PHI through interpretation
Required by: HIPAA (45 C.F.R. § 164.502(e))
Google Translate / Unauthorized MT Use Policy — staff prohibited from using unvetted MT for patient-facing communications
Best practice · OCR has cited Google Translate use in complaints
Section Notes