Language Assistance Plan Template

Language Assistance Plan Template

Use this template to create your Language Assistance Plan. Refer to the Guidance for Developing the Language Assistance Plan (LAP) for a description of what to include, resources, and examples.

Template Contents
Introduction 1
Section 1. Purpose and Policy Statement2
Section 2. Definitions 3
Section 3. Implementation and Responsibilities 4
Section 4. Needs Assessment 5
Section 5. Efforts to Improve Language Assistance Services 6
Section 6. Notice of Language Assistance Services 11
Section 7. Complaint Process 12
Section 8. Staff Training 13
Section 9. Monitoring, Evaluation, and Continuous Improvement 13

Department of Public Health, Substance Abuse Prevention and Control

Required Content for the Language Assistance Plan

• Required Content – Noted in BLUE
• Recommended/Additional Content – Noted in BLACK text and can be modified or omitted
• Comments – Noted in ORANGE ITALICS text are included for clarification or direction.
Note: Provider agencies may use “client” or “patient” depending on your standard language

Introduction
This Language Access Plan (LAP) formalizes the commitment by Behavioral Health Services to strengthen language access, advance equity, provide support to underserved communities, and combat discrimination based on national origin.
Behavioral Health Services (BHS) is a not-for-profit community-based healthcare organization. It provides substance use withdrawal management, residential, outpatient, recovery bridge housing, and prevention services along with mental health, and other related health services to the residents of Southern California. Since 1973, BHS has expanded its services to meet the comprehensive needs of its clients. It now provides services from 22 sites located throughout Los Angeles County. BHS is
committed to providing services regardless of culture, age, gender, sexual orientation, spiritual beliefs, socioeconomic status, and language capabilities. The Language Assistance Plan (LAP) will assist in both augmenting and adding to established language assistance protocols. Through this effort, we hope to expand available substance use services to communities with language access barriers. The language assistance plan will apply to three SUD Outpatient programs located in three different SPA’s in the cities of Hollywood, Pomona, and Wilmington.

This LAP applies to the following agency sites (include the full address):

Name of Site and Full Address: Located in Service Planning Area (SPA):

BHS Hollywood Outpatient Recovery Center - 6838 W Sunset Blvd,
Los Angeles, CA 90028 SPA 4

BHS Wilmington Outpatient Recovery Center - 1318 North Avalon
Boulevard, Suite A, Wilmington, CA 90744 SPA 8

BHS American Outpatient Recovery Center - 2180 West Valley
Blvd, Pomona, CA 91768 SPA 3

Section 1. Purpose and Policy Statement

A. PURPOSE
This plan serves as a central document to guide all staff at Behavioral Health Services in implementing language assistance services.
The plan reflects what is currently available and required AND where we intend to expand our efforts for equitable language assistance services.
This plan will reflect the goals and values of Behavioral Health Services, which emphasize respect, dignity, and cultural competency in all interactions. By enhancing and expanding our language assistance services, we aim to achieve better outcomes for all individuals, regardless of language background, in accessing substance use services.

B. POLICY STATEMENT
To ensure that services at Behavioral Health Services are accessible to individuals with limited English proficiency. To comply with federal, State, and local laws and regulations, our policy is to offer language assistance services at no cost to eligible members and without undue delay to individuals with limited English proficiency (LEP) or other communication barriers, ensuring they have equal access to all our programs, benefits, services, and activities.
Language assistance will be targeted to three outpatient sites but available across all of BHS's SUD programs including, admissions, assessments, treatment planning, counseling sessions, care coordination, and other behavioral health services. BHS is committed to regularly assessing the effectiveness of our language assistance services. Feedback from individuals served and other stakeholders will be used to continuously improve the accessibility and quality of services.

Section 2. Definitions
Auxiliary Aids and Services: Equipment such as assistive listening devices, text telephones,
videophones, video text displays, and other accessible electronic information technology; notetakers, qualified interpreters and written materials for individuals who are deaf or hard of hearing; taped texts, qualified readers, and Braille translations and large print materials for individuals who are blind or have low vision.
Bilingual Staff: Staff who understand and communicate fluently in two languages (generally, as used here, English and another language).
Certified Bilingual Staff: A bilingual staff member who is:
• Proficient in speaking and understanding both English and at least one other language,
including any necessary specialized vocabulary, terminology, and phraseology; able to communicate directly, and accurately.
• Able to communicate impartially with patients who are LEP/non-English speaking in their primary language.
• Determined to have passed a proficiency examination conducted by an authorized process demonstrating proficiency in both English and the required non-English language and possesses a language proficiency certificate.
Critical Informing (or vital) Documents: Paper or electronic written materials that contain
information critical to the patient’s ability to access and benefit from services provided by Behavioral Health Services or as required by law.
Interpretation: The act of listening to a communication in one language (source language) and orally converting it to another language (target language) while retaining the same meaning, accurately conveying the content, register, and tone without additions, deletions, or changes, while maintaining
appropriate cultural relevance.
Language Access: The right of individuals with Limited English Proficiency (LEP) to receive timely, meaningful access to federally and state-funded programs and services.
Language Assistance Services: Services that assist LEP individuals in understanding or
communicating with Behavioral Health Services, including interpretation, translation, sight translation, and others as appropriate.
Limited English Proficient (LEP): An individual who does not speak English as their primary language and who has a limited ability to read, write, or understand English.
Non-English (NE): Refers to individuals whose preferred language is not English. Interpretation or translation services must be used to effectively communicate program information and requirements.
Sign language is included in this definition.
Primary Language: The language in which an individual is most effectively able to communicate.

Preferred Language: The spoken, signed, and/or written language an individual indicates they prefer to use to access a program or activity meaningfully. The individual, not staff, must determine a
person's preferred language.
Qualified Interpreter: A person with advanced oral or signing proficiency in their working languages who adheres to the interpreter's code of ethics and confidentiality, and who can interpret effectively, accurately, and impartially both receptively and expressively, using any necessary specialized vocabulary. This neutral third party has been determined to be qualified by a formal certifying body.
Qualified Translator: A person with advanced written proficiency in their working languages,
knowledge of professional practices, and adherence to the translator's code of ethics who has been determined to be qualified by a formal certifying body. Threshold Languages: Los Angeles County Medi-Cal threshold language, or a language that meets the County’s threshold of 5% for the total Medi-Cal beneficiary population.
Translation: The process of replacing written text from one language (source language) into an equivalent written text in another language (target language), while preserving the meaning, register, and tone of the message (e.g., translating documents).
Provide additional definitions of terminology used in your language assistance plan, including key terms that describe language assistance service.
Language Line: virtual translation services available to program staff and clients served.

Section 3. Implementation and Responsibilities

Implementation and oversight of language access services at Behavioral Health Services will involve a team comprised of staff, and/or committee(s) for developing strategies to effectively address unmet language assistance needs, formalize relevant policies and procedures for standardizing language assistance operational processes, and carrying out ongoing monitoring and evaluation of the LAP.
Our agency has identified the following team responsible for carrying out LAP implementation activities:
Staff Name (Position)/Committee Role/Responsibility
Efrain Marquez, QA / Language Access
Coordinator

Monitor the implementation of the Language
Access Plan. Serves as the point of contact for
language access questions or concerns. Tracks
compliance and evaluates effectiveness.

Celia Aragon, Director / Staff training &
Compliance

Ensure bilingual staff understand language plan comply with procedures.

Raunda Jones, Director / Equity Officer Ensure activities align with civil rights regulations
(e.g., Title VI of the Civil Rights Act). Monitor that language access meets equity standards.

Section 4. Needs Assessment
To determine language needs, Behavioral Health Services has completed a needs assessment. The following summarizes the key findings:

a. Description of demographic profile and non-English languages Each location (Pomona, Hollywood, and Wilmington) faces similar challenges in providing linguistically appropriate services. The primary languages of concern across all three sites are Spanish, which has the largest representation among Limited English Proficiency (LEP) clients, and Arabic, Vietnamese, and Haitian Creole. However, Wilmington faces additional language needs with Mandarin, while Hollywood has a notable need for services in Armenian and Russian.
BHS American Outpatient is located in the City of Pomona, CA. It is a diverse community, with significant numbers of individuals who speak languages other than English. The needs assessment reveals the following:
• Spanish-speaking individuals represent the largest group of non-English speakers in Pomona, accounting for approximately 45% of the community.
• Other prominent languages spoken include Arabic (15%), Vietnamese (10%), and Chinese
(8%).
BHS Hollywood Outpatient is located in a highly diverse community, and the demographic makeup plays a crucial role in identifying language assistance needs. According to the needs assessment:
• Spanish-speaking individuals are the largest group of LEP clients, making up 50% of the
population who potentially could seek SUD services.
• Other notable languages spoken include Armenian (15%), Russian (12%), Tagalog (10%), and Persian (8%).
BHS Wilmington Outpatient’s location is culturally and linguistically diverse, and the language needs for SUD services reflect this diversity. Key findings from the needs assessment include:
• Spanish-speaking individuals represent the largest group of LEP clients in Wilmington,
comprising 50% of those who potentially could seek SUD services.
• Other significant non-English languages spoken include Haitian Creole (15%), Arabic (12%), Vietnamese (10%), and Mandarin (8%).

b. Barriers or gaps in services The Language Assistance Needs Assessment highlights key barriers that potentially could hinder the provision of linguistically and culturally appropriate services to non-English speaking clients. These barriers include limited access to the language line during the screening process leading to the possibility of miscommunication and client’s exaggeration of English language skills. Another barrier is related to budget constraints that may limit the ability to hire bilingual staff, invest in training, or update multilingual materials.
To overcome these challenges, it is crucial to increase investment in language resources, staff training, and technology that supports multilingual and accessible service delivery. Secure and allocate specific funds annually for the development of multilingual materials, interpretation technology, and staff training. Addressing these gaps will ensure more equitable access to care, improve client outcomes, and align services with both legal and ethical standards for healthcare accessibility. Secure and allocate specific funds annually for the development of
multilingual materials, interpretation technology, and staff training.

c. Strategies or improvement
The strategies to improve language services will focus on enhancing language resources,
improving staff capabilities, and leveraging technology to support multilingual and accessible service delivery.
d. Staffing and other resources required To address the barriers identified in the Language Assistance Needs Assessment and provide more equitable and effective care for non-English speaking clients, including visual or hearing-impaired individuals seeking Substance Use Disorder (SUD) services, several staffing and resource improvements are necessary. These improvements will ensure that all clients, regardless of their language or communication needs, can access the full spectrum of services in a timely and culturally competent manner.

Section 5. Efforts to Improve Language Assistance Services

Behavioral Health Services will take all reasonable steps to respond in a timely and effective manner to LEP and deaf/hard of hearing persons who need assistance or information. To ensure that the language assistance services are accurate, meaningful, and effective, the mix of services (interpretation and translation) to be provided will be determined on a case-by-case basis.
BHS currently provides Language assistance services via a third-party platform that covers multiple languages and formats and is accessible to deaf/hard of hearing and visually impaired populations. BHS also purchased the translation of SUD intake forms to Braille and large print, allowing visually
impaired clients to access forms. BHS aims to provide each facility with at least one bilingual staff member certified in the local community's dominant non-English language.

A. Reaching Out to the Community

Community Engagement Activities to Reach
Non-English Speaking or LEP Individuals Status Timeline Update website and social media to reflect the agencies language
assistance resources. Planned FY 25/26 ☒Qtr 3

Maintain accurate SBAT posting of available
language assistance services. Existing FY 24/25 ☒ Qtr 2

Translation of BHS Outreach literature to local
communities for non-English languages. PlannedFY 25/26 ☒ Qtr 2

B. Identifying the Preferred Language.
An important first step in improving language services is determining how Behavioral Health
Services staff identify when an individual may need language assistance services. All persons applying for services at a BHS SUD treatment facility are interviewed and assessed for
admission to the appropriate program/facility and level of care. All persons must meet medical necessity admission criteria for admission to any BHS SUD program, as well as any general admission criteria that may apply. Medical necessity must be consistently applied to ensure equitable access to services. The American Society of Addiction Medicine (ASAM) Criteria is applied to determine the individual’s suitability for services and proper level of care placement. Medical necessity can only be determined after a biopsychosocial assessment such as the ASAM assessment, which includes an SUD diagnosis. Medical necessity determination must be verified
and approved by a Licensed Practitioner of the Healing Arts (LPHA) via a face-to-face interview with the patient, or a face-to-face review with registered or certified SUD counselor who conducted the assessment with the patient. Medical necessity determinations must be performed in a timely manner, in conformance with the standards set by the ultimate payer of services. Unless more stringent requirements are set by a particular insurance company, BHS will
use the standards set by Los Angeles County Substance Abuse Prevention and Control (SAPC) (see Procedures below) to determine the timeframes in which medical necessity must be established for all patients admitted to BHS treatment programs. Special Populations Pregnant Women & Injection Drug Users: Federal priority guidelines for SUD treatment admission give preference to pregnant substance use users, pregnant injecting drug users, and any parenting
female substance and injection drug users. However, a specific level of care is not prescribed and thus the appropriate setting and level of care for this population needs to be consistent with the ASAM criteria, with consideration of the ability to accommodate the physical stresses of pregnancy (e.g., climbing stairs, performing chores, bed rest when medically required, etc.) and the need for safety and support during this period. Level of care determinations need to be based on individualized and multidimensional ASAM assessments and may lead to placement recommendations in the residential or outpatient setting, depending on clinical need. When appropriate for admission, BHS will provide preference to pregnant women following this priority
admission order: • Pregnant injection drug users • Pregnant substance users • Injection
drug users • All others.

Document language preference and any resultant interpretation in the patient record. If a patient refuses interpretation services, staff will document in the patient’s record that free interpretation services were offered and declined.
C. Providing Language Assistance Services
Behavioral Health Services currently has or will have the following interpretation and/or bilingual language assistance services available to LEP individuals, through the use of certified bilingual employees, and/or contract interpreter services, including telephonic interpretation services, as appropriate.
Type of Language Assistance Languages Available Timeline

Certified Bilingual Staff for Direct
Services Spanish for each facility Planned FY 25/26 ☒ Qtr 4

Armenian Existing FY 24/25 ☒Qtr 3

Bilingual staff to assist with screening or
other non-counseling services.

Spanish Existing FY 24/25 ☒ Qtr 2

Qualified Interpreters (in-person/virtual)
Vendor Name: Language Line Vendor Contact: Partnership Health plan Existing FY 24/25 ☒Qtr 1

Qualified Interpreters (telephone)
Vendor Name: Language Line
Vendor Phone: Partnership Health plan

Type of Language Assistance Languages Available Timeline

Auxiliary Aids and Services

SUD Intake Forms in Braille and large print

Each facility currently identifies bilingual staff and informs co-workers of available services if needed. The Language Line is available to all staff if needed through a secure communication portal. Staff can request the Braille or Large Print forms from the BHS corporate office and returned when services are complete. All staff are made aware of the services and protocols during quarterly meetings. Direct services staff (e.g., counselors, clinicians, etc.) who report bilingual abilities will be asked to test proficiency via language assessment platform. If proficiency is certified, the employee will be designated as a Certified Bilingual Staff and incentivized for bilingual capabilities accordingly. At this time, non-direct service staff are not certified and are therefore, not receiving incentives, it is BHS’s intention to include non-direct service staff in the certification and incentivization process in the near future.

D. Translation of Written Materials
Critical informing/vital documents are paper or electronic materials that are critical for individuals to equitably access the agency’s services, programs, and activities, or contains information about procedures and processes required by law. They generally fall into two broad categories: specific written communication regarding a matter between an individual and the agency; and documents
primarily geared towards the general public or a broad audience. The classification of a document as 'critical informing' is determined by the potential negative impact on an LEP individual if the information is not provided accurately or promptly.
i. The following critical informing documents are available in non-English languages. If an
individual needs or requests these materials contact your primary counselor to process
submission.
Documents available on the SAPC website in non-English languages:
• Patient Handbook
• Patient Handbook & Patient Handbook Acknowledgement Form*

• Complaint/Grievance/Appeal Notices and Forms*
Documents to be translated by SAPC into non-English languages and posted on the SAPC website English languages:
• Release of Information (Spring 2025)
• Patient Bill of Rights poster (Spring 2025)
Critical Informing Documents Languages Available Timeline

Privacy Practices*

Spanish

Braille / large Print Existing

ii. Other Documents
Name of Document Languages Available Timeline Client Handbook Spanish Existing FY 24/25

Spanish Existing FY 24/25

iii. Translation is conducted by Language Line and is validated to ensure accuracy of translation by Language Line. Certified Bilingual Staff identifies written materials that need to be translated to ensure meaningful access to materials.
Translated forms are added to BHS forms library with form ID and date for tracking.
Section 6. Notice of Language Assistance Services Behavioral Health Services includes notices in prominent locations (e.g., website, lobby/reception, brochures, etc.) on the availability of Language Assistance Services for non-English speaking or LEP individuals in prominent locations.

a. Notice of Adverse Benefit Determination (NOABD) sent to patients must include the required Language Assistance Taglines notifying them that no-cost language assistance services are available. Language Assistance Taglines can be found on SAPC’s Provider Manuals, Bulletins, and Forms webpage.
b. Post notices regarding the availability of language assistance must include the following information in, at minimum, the Los Angeles County threshold languages:
Notice on Availability of Language Assistance Services If you speak languages other than English within the Los Angeles County threshold languages, free language assistance services may be available to you at no cost. Appropriate auxiliary aids and services to provide information in accessible formats are also available at no cost. Call 1-310-679-9126 or speak to one of our staff to get assistance.
Behavioral Health Services will also inform established referral sources and stakeholders of available Language Assistance Services.
Bilingual staff members will be identified via badges to improve accessibility and awareness amongst treatment team and population served. Program post informational materials about Language Line
within program and provide information on website. Prospective clients and current clients will be asked about preferred languages prior to and during treatment, and offered appropriate services accordingly.
Section 7. Complaint Process Patients requesting to file a complaint about language access services at Behavioral Health Services
can do so by following BHS’s grievance process: A resident who feels their rights have been violated or has a complaint about decisions made by program staff should begin the grievance process by contacting the Program Director. The Program Director shall meet with the client within three (3) days of the request and attempt to resolve the problem. The Program Director shall investigate the matter and make and communicate his/her decision to the resident within three (3) days of the meeting. If the
client is unsatisfied with the decision, they can request an appeal from the BHS compliance
department. Patients may also make a complaint directly to SAPC by going to the SAPC website or contacting SAPC directly:
http://ph.lacounty.gov/sapc/NetworkProviders/ClinicalForms/AQI/ComplaintGrievanceForm.docx
Submit the complaint by:
• Email to: SAPCmonitoring@ph.lacounty.gov
• Call: (626) 299-4532
• Fax to: (626) 458-6692
• Mail to:
Substance Abuse Prevention and Control, Contract and Compliance Section
1000 South Fremont Avenue, Building A9 East, 3rd floor
Alhambra, California 91803

Patients who need the complaint form in an alternate format (e.g. another language, large print, braille, or audio) should call 1-888-742-7900, select option 7. For more information on the problem resolution process, please refer to your patient handbook or visit
http://publichealth.lacounty.gov/sapc/PatientPublic.htm

Section 8. Staff Training

Language Assistance Training Timeline

Behavioral Health Services will require language assistance service training annually for SUD direct service staff. The training will cover how to access interpretation services and communications skills when working with LEP individuals.

Section 9. Monitoring, Evaluation, and Continuous Improvement Behavioral Health Services will conduct ongoing monitoring, evaluation, and continuous improvement
of the LAP, policies, and procedures and updates at least every three years. LAP updates include a reassessment of the language needs of patients and the surrounding community, a review of the information submitted by agency staff about the non-English languages encountered, updates to policies and procedures, and consultation with stakeholders, as appropriate. Behavioral Health Services will regularly conduct the following monitoring and evaluation activities: Monitoring/Evaluation/Continuous Improvement Activity Timeline

Review and update the availability of certified bilingual staff. Monitoring/Evaluation/Continuous Improvement Activity Timeline
Track the use of language assistance services, including inputs onto CalOMS/myEvolv Monitoring/Evaluation/Continuous Improvement Activity Timeline

Identify when staff are not following the language assistance protocol Monitoring/Evaluation/Continuous Improvement Activity Timeline

Review and update Language Assistance Plan
Behavioral Health Services conducts quarterly service delivery perception of care surveys to current clients, as well as regular outcomes tracking for former clients. BHS will plan to incorporate information about language assistance to gather efficacy data.