Section 940.100  Definitions

 

The following terms have the meaning ascribed to them here whenever the term is used in this Part:

 

Act – the Language Assistance Services Act [210 ILCS 87].

 

Department – the Department of Public Health. (Section 10 of the Act)

 

Health facility – a hospital licensed under the Hospital Licensing Act or a long-term care facility licensed under the Nursing Home Care Act.  (Section 10 of the Act)

 

Interpreter – a person fluent in English and in the necessary language of the patient or resident, who can accurately speak, read, and readily interpret the necessary second language, or a person who can accurately sign and read sign language.  (Section 10 of the Act)

 

Language or communication barrier – either of the following:

                                   

With respect to spoken language, barriers that are experienced by limited-English-speaking or non-English-speaking individuals who speak the same primary language, if those individuals constitute at least 5% of the patients or residents served by the health facility annually.

                                   

With respect to sign language, barriers that are experienced by individuals who are deaf and whose primary language is sign language.  (Section 10 of the Act)

 

Section 940.110  Referenced Materials

 

The following Illinois laws are referenced in this Part:

 

a)         Hospital Licensing Act [210 ILCS 85]

 

b)         Nursing Home Care Act [210 ILCS 45]

 

c)         Illinois Administrative Procedure Act [5 ILCS 100]

 

d)         Interpreter for the Deaf Licensure Act of 2007 [225 ILCS 443]

 

(Source:  Amended at 33 Ill. Reg. 8484, effective June 2, 2009)

 

Section 940.120  Language Assistance Services

 

A health facility shall ensure access to health care information and services for limited-English-speaking or non-English-speaking residents or patients or deaf residents or patients.  To meet this requirement, a health facility shall do the following:

           

a)         Adopt and review annually a policy for providing language assistance services to patients or residents with language or communication barriers.  The policy shall include procedures for providing, to the extent possible as determined by the facility, the use of an interpreter whenever a language or communication barrier exists, except where the patient or resident, after being informed of the availability of the interpreter service, chooses to use a family member or friend who volunteers to interpret.  The procedures shall be designed to maximize efficient use of interpreters and minimize delays in providing interpreters to patients or residents.  The procedures shall ensure, to the extent possible as determined by the facility, that interpreters are available, either on the premises or accessible by telephone, 24 hours a day.  The facility shall annually transmit to the Department of Public Health a copy of the updated policy and shall include a description of the facility’s efforts to ensure adequate and speedy communication between patients or residents with language or communication barriers and staff.

 

b)         Develop, and post in conspicuous locations, notices that advise patients or residents and their families of the availability of interpreters, the procedure for obtaining an interpreter, and the telephone numbers to call for filing complaints concerning interpreter service problems, including, but not limited to, a TTY number for persons who are deaf or hard of hearing.  In a hospital, the notices shall be posted, at a minimum, in the emergency room, the admitting area, the facility entrance, and the outpatient area.  In a long-term care facility, the notices shall be posted in the facility entrance.  Notices shall inform patients or residents that interpreter services are available on request, shall list the languages most commonly encountered at the facility for which interpreter services are available, and shall instruct patients to direct complaints regarding interpreter services to the Department of Public Health, including the telephone numbers to call for that purpose.

                       

c)         Notify the facility's employees of the language services available at the facility and train them on how to make these language services available to patients or residents.  In addition, a health facility may do one or more of the following:

 

1)         Identify and record a patient's or resident's primary language and dialect on one or more of the following:  a patient medical chart, hospital bracelet, bedside notice, or nurse card.

 

2)         Prepare and maintain, as needed, a list of interpreters who have been identified as proficient in sign language according to the Interpreter for the Deaf Licensure Act of 2007 and a list of the languages of the population of the geographical area served by the facility.

 

3)         Review all standardized written forms, waivers, documents, and informational materials available to patients or residents on admission to determine which to translate into languages other than English.

 

4)         Consider providing its nonbilingual staff with standardized picture and phrase sheets for use in routine communications with patients or residents who have language or communication barriers.

 

5)         Develop community liaison groups to enable the facility and the limited-English-speaking, non-English-speaking, and deaf communities to ensure the adequacy of the interpreter services.  (Section 15 of the Act)

 

(Source:  Amended at 33 Ill. Reg. 8484, effective June 2, 2009)

 

Section 940.130   Qualifications of Interpreters

 

a)         Interpreters shall have the ability to translate the names of body parts and to describe completely symptoms and injuries in both English and in the necessary second language, or in sign language.  (Section 10 of the Act)

 

b)         Interpreters may include members of the medical or professional staff.  (Section 10 of the Act)

 

Section 940.140   Complaints

 

a)         A person who believes that the Act or this Part may have been violated may submit a complaint to the Department.  The complaint may be submitted in writing, by telephone, or in person.

 

b)         A health care facility shall be provided an opportunity to resolve the complaint through an informal resolution process.  (Section 16 of the Act)

 

c)         The Department shall determine the validity of complaint by means of a complaint verification process (Section 16 of the Act) that includes:

 

1)         Reviewing the allegations of the complaint to determine whether the allegations concern a violation of one or more Sections of the Act;

 

2)         Reviewing the health care facility’s policies or procedures to determine whether the policies and procedures are in compliance with the Act;

 

3)         Reviewing statements or written communication from residents or patients, facility staff, or others to determine whether such statements or communication supports that the health care facility is not in compliance with the Act; and

 

4)         Observing actions of the health care facility to determine any noncompliance with the Act.

 

Section 940.150   Notice of Violation

 

a)         If a complaint is not resolved informally, then the Department shall serve a notice of violation of the Act upon the health facility.  (Section 16 of the Act)

 

b)         The notice of violation shall be in writing and shall:

 

1)         Specify the nature of the violation and the statutory provision alleged to have been violated;

 

2)         Inform the health facility of the action the Department may take under the Act;

 

3)         Inform the health facility of the amount of any financial penalty to be imposed;

 

4)         Inform the health facility of the opportunity for entering into a plan of correction.  (Section 16 of the Act)

 

c)         The notice shall also inform the health facility of its rights to a hearing to contest the alleged violation under the Illinois Administrative Procedure Act.  (Section 16 of the Act)

 

Section 940.160   Plan of Correction

 

a)         If the Department finds that a health facility is in violation of the Act, the health facility may submit to the Department, for its approval, a plan of correction.  (Section 17 of the Act)

 

b)         In determining whether to approve the plan of correction, the Department shall consider the following:

 

1)         Whether the plan of correction ensures access to health care information and services for limited-English-speaking or non-English-speaking residents or patients and deaf residents or patients;

 

2)         Whether the plan of correction addresses the conditions or occurrences that are the basis of the violation;

 

3)         Whether the plan of correction is specific enough to indicate corrective actions the facility will be taking or has already taken to abate, eliminate or correct the violation;

 

4)         Whether the plan of correction provides steps to avoid the violation or to prevent similar violations from recurring, including an evaluation and revision, as necessary, of policies and procedures, and staff training; and

 

5)         Whether the corrective action will be completed in a reasonable time frame, considering the seriousness of the violation, any possible harm to residents or patients, and the extent and complexity of the corrective action.

 

c)         The Department shall notify the health facility of the approval or disapproval of the plan of correction.  A notice of approval shall include the date on which the plan of correction was submitted, for the purpose of establishing the 6 month time period required in subsection (d) and in Section 17 of the Act.

 

d)         If a health facility violates an approved plan of correction within 6 months after its submission, the Department may impose a penalty on the health facility.  (Section 17 of the Act)  The Department’s decision to impose a penalty shall be based on:

 

1)         The severity of harm, including death or serious physical or mental harm, that has resulted to a resident or patient and the extent to which residents or patients have been subject to potential serious harm. 

 

2)         The gravity of the violation and the extent to which the provisions of the Act or this Part were violated, including whether the violation recurred or continued, is widespread throughout the facility or evidences a flagrant violation of the Act or this Part. 

 

3)         The extent and seriousness of any previous violations committed by the facility and the extent of diligence exercised by the facility to correct such violations, including evidence that the violations constitute a pattern of deliberate action by the facility.  The effect of any change in the ownership and management of the facility will be considered in relation to the seriousness of previous violations.

 

4)         Any possible financial benefit to the facility as a result of committing or continuing the violation.  Such benefits include, but are not limited to, avoidance of costs associated with staff salaries, consultant fees, or direct patient care services.

 

Section 940.170   Penalties

 

a)         For the first violation of an approved plan of correction, the Department shall impose a penalty of $100.  (Section 17 of the Act)

 

b)         For a second or subsequent violation of an approved plan of correction, the Department shall impose a penalty of $250.  (Section 17 of the Act)

 

c)         The total fines imposed under the Act and this Part against a health facility in a 12 month period shall not exceed $5,000.  (Section 17 of the Act)