HOW HEALTH CARE FACILITIES ARE AFFECTED BY LAWS THAT APPLY TO SERVICE ANIMALS
Health care facilities—hospitals, clinics, doctors’ and dentists’ offices, laboratories, imaging services, and others—are covered under the ADA (see Technical Assistance Letter from the US Department of Justice, 1993, Appendix I) and considered places of public accommodation. Title III of the ADA requires that places of public accommodation, including health care facilities, modify their policies and practices to permit the use of a service animal by a person with a disability, unless doing so would create a fundamental alteration or a direct threat to the safety of others or to the facility. For example: a service animal may howl through the night and prevent people from sleeping, or it may, in a nonthreatening manner, block a health care provider from administering care to a client. In contrast, a direct threat would occur were a service animal to growl at or bite someone or “get underfoot” and impede a person’s safe travel.
State or local government-owned or funded facilities and service providers have similar responsibilities under Title II of the ADA, which has provisions similar to Title III. Facilities and service providers that are owned or funded by the federal government (such as Veteran’s Administration facilities and programs) have responsibilities under Section 504 of the Rehabilitation Act, which are also similar to ADA Title III provisions. Health care programs and facilities owned by religious organizations may be exempt from federal law. For information about the status of any facility, contact the US Department of Justice ADA Information Line at 800-514-0301.
Since service animals meet disability-related needs, they might be found in various areas of the health care system, accompanying persons with disabilities who are employees, patients, visitors, instructors, volunteers, students, or others. Health care facilities may receive conflicting directives about having animals on the premises. States and localities might have laws that also affect service animals. When these laws conflict with federal laws, the law that provides greater protection to the person with the disability is the law that prevails; that is, the law that is less restrictive for the person with the disability takes precedence. When conflicting federal laws affect health care facilities, contact the US Department of Justice as above for clarification about the facility’s responsibilities.
IDENTIFICATION OF PERSONS WITH DISABILITIES AND SERVICE ANIMALS
CERTIFICATION AND OTHER MYTHS
Public accommodations often have concerns about how to ensure that an animal is really a service animal, fearing that persons will try to present their pets as service animals. The intent of the ADA is not to put a public accommodation into the role of policing the legitimacy of a person’s claim of disability or of an animal’s function. Rather, its aim is to ensure that the goods and services of a public accommodation are readily accessible to persons with disabilities, regardless of their types of disabilities or the assistive equipment they might use.
A popular belief is that “legitimate” service animals must be “certified.” Some trainers offer certification, but without uniform standards for this process, it merely represents the opinion of an evaluator that the animal is capable of doing the work for which it was trained. Certification is not a guarantee of quality or predictability of behavior. The ADA prohibits public accommodations from requiring “certification” or proof of an animal’s training, or proof of a person’s disability, for the purposes of access.
There is no legal requirement that a service animal wear special equipment or tags. Service animals usually wear the equipment necessary for the work they do; this might be simply a collar and leash. Some localities offer licensing tags for pets and for service animals, but these cannot be required for the purposes of access under the provisions of the ADA.
Health care facilities, like other places of public accommodation, are advised by the US Department of Justice Civil Rights Division to accept the verbal reassurance of the person that he or she has a disability (and is protected by the ADA), and that the animal is a service animal. Unnecessary inquiry into the nature of the disability, or requiring “proof” or identification of the person’s disability or the animal’s training, is prohibited by the ADA and other federal nondiscrimination laws. Minimal inquiry is best; this acknowledges the privacy needs of the person with a disability.
Subsequent observation of the behavior of the animal should help in assessing whether the animal constitutes a direct threat to health or safety or a fundamental alteration to the nature of the business. If the animal’s presence or behavior creates such a direct threat or fundamental alteration, it does not have to be tolerated by the health care facility. Although “misbehavior” does not necessarily indicate that an animal does not meet the definition of service animal, the health care facility has recourse to protect itself by requiring the removal of the animal from the premises if its presence or behavior creates a direct threat to safety or a fundamental alteration.
IMPLICATIONS OF SERVICE ANIMALS FOR INFECTION CONTROL AND RISK MANAGEMENT
Effective policy development will consider all the facility areas open to persons and the effects a service animal would have on those areas and on the persons within them. Risk assessment will be based on demonstrable factors, not on speculation about what an animal “might” do or whether an area “might” be unsafe for an animal.
It is important for health care providers to differentiate between actual risks posed by a service animal and mere inconvenience or displeasure with the presence of a service animal. Health care providers must make their goods and services available to persons accompanied by service animals without isolating, segregating, or otherwise discriminating against those persons. Published studies about risks posed by animals include zoonotic disease transmission, trauma, the triggering of allergic reactions, and disruptive or destructive behaviors. The actual risk that a service animal presents will be affected by many factors including its health and hygiene, its behavior, its contact with others, the frequency of that contact, the environment, the ability of its handler to manage its behavior, and the effects of simple preventative measures (eg, handwashing) to reduce the risk of disease transmission.
HANDWASHING FOR EMPLOYEES, CLIENTS, HANDLERS, AND VISITORS
Handwashing is an essential activity in the health care setting. Persons should wash their hands with soap and water after direct contact with the service animal, its equipment, or other items with which it has been in contact. Antimicrobial soap is not required. If there is no running water available, a waterless agent approved for use in the facility may be used.
HANDLER AND CLIENT EDUCATION
Handlers, whether employee, visitor, or patient, must understand that the animal is not allowed to come in contact with any patient’s nonintact skin (surgical sites, drainage tubes, wounds, etc). Handlers should be informed of any facility areas that are usually open to them, but which are off-limits to service animals. Facilities should not permit handlers with service animals to act as self-appointed animal-assisted therapy (“pet therapy”) providers. Education may also be required for roommates and visitors regarding their interactions with the service animal.
Staff may not be well-informed about the roles of service animals and their benefits to the persons who have them. Comprehensive staff education must be provided that includes:
- How service animals are defined
- Ownership and identification criteria
- Laws and policies that apply to service animals and their handlers.
- How to interact appropriately with persons and their service animals.
Such education is vital to prepare staff to competently and confidently address service animal issues (see Resources). Staff education should also include risk-reduction activities, such as handwashing, appropriate use of personal protective equipment (PPE), responsibilities of staff and owner for handling and cleaning issues, and amount and type of client education.
SERVICE ANIMALS IN SPECIFIC CLINICAL AREAS
A service animal may be restricted or denied access to areas where its handler would generally be allowed only when it can be demonstrated that the presence or behavior of that particular animal would create a fundamental alteration or a direct threat to other persons
or to the nature of the goods and services provided. Although it may be possible to identify certain areas where a service animal could not reasonably be permitted (eg, an operating room where gowns and masks are required to reduce contamination), other areas may be
subject to a case-by-case determination, based on the circumstances and the individual service animal. A birthing room is one example. If persons are allowed to be present without being required to observe special precautions (gowning, scrubbing, etc), it would be difficult to argue that a clean, healthy, well-behaved service animal should be denied entrance. However, if the service animal causes a fundamental alteration or direct threat, the health care facility may require that the risk be controlled. If it cannot be controlled, then the service animal may be removed from the premises. Similarly, the emergency department, intensive care unit, recovery room, and other areas may require a case-by-case determination to assess actual risk. Some facilities have a crate on site in which a service animal can be temporarily contained while the handler is in a restricted area or if the handler is unable to provide for the stewardship of the service animal.
Animals, like persons, can host a wide variety of organisms that are potential pathogens for persons and other animals. There are no substantiated, published studies that have determined the statistical risks associated with healthy, vaccinated, well-cared-for, and well-trained service animals. Nor is there substantial case reporting data to indicate that service animals pose any greater threat than the average person. Threats of infectious diseases have been well-documented in wild populations of dogs, cats, rodents, turtles, birds; nonhuman primates; laboratory animals; and in some domesticated companion animals. However, these findings do not necessarily apply to healthy, vaccinated, well-maintained service animals. Avoiding contact with animal urine and feces and good handwashing after contact with the animal can effectively reduce the risks of zoonotic disease transmission.
SERVICE ANIMAL HEALTH
If a service animal is epidemiologically linked to an infection or outbreak, the animal should be examined by a veterinarian. Assumptions about the service animal’s health should not be made by nonveterinary health care providers. If disease transmission occurs because of inadequate use of prudent prevention techniques (such as handwashing), then appropriate interventions should be developed on the basis of the findings. If a service animal does exhibit a condition that presents a direct threat to the health or safety of others, then the animal may be removed, restricted, or denied access to the area, or additional information may be required about the animal if it is necessary to protect public health and safety. For example, it may be possible that proof of rabies vaccination in service dogs for the purpose of access would be allowable in an area with a high prevalence of dog rabies, if it could be demonstrated that requiring such documentation was necessary to protect public health and safety. Consult the US Department of Justice ADA Information Line, (800) 514-0301, for guidance about initiating restrictive policies.
No special housekeeping methods are needed, provided there is no contamination with animal urine, feces, vomit, or blood (organic debris). If the animal contaminated the area, the cleanup procedures should be performed by using appropriate personal protective equipment (PPE). Gloves are the minimum protection that should be used. The spill should be removed with
paper towels, which should be placed in a plastic bag in the trash container, similar to the disposal of diapers. After removal of the organic debris, the area of the spill should be cleaned with a facility-approved disinfectant, following label instructions for adequate contact time
to ensure disinfection.
Allergic reactions to the animal can occur among staff or other clients. Avoiding or limiting contact with the service animal’s saliva, dander, and urine will help mitigate allergic reactions. According to the American Academy of Allergy, Asthma & Immunology, dog or cat allergies occur in approximately 15% of the population. If the allergy is severe enough to cause impairments that substantially limit one or more major life activities (ie, causes a disability as defined in the ADA), both the person with the allergy and the person with the service animal are protected by the ADA, and the facility is obligated to ensure their access to its goods and services. If the effects of the allergy do not meet the definition of disability, the ADA does not protect the person with the allergy and the facility does not have an ADA obligation toward the person who has the allergy.
STEWARDSHIP OF THE SERVICE ANIMAL: ITS CARE AND BEHAVIOR MANAGEMENT IN THE HEALTH CARE FACILITY
The ADA specifies that the care and behavior management (stewardship) of the service animal is the responsibility of the handler. Because of the many health benefits a service animal can provide, facilities may elect to support the presence of the animal by providing a system to obtain emergency stewardship when the patient needs help but has no one to assist with the animal’s care. In-house or community volunteer services, animal welfare organizations, community service organizations, animal caregivers (eg, veterinary, boarding, grooming, or walking/sitting services), and dog training and breed fancy clubs may be among the resources available to help provide stewardship for a client’s service animal. Legal services should be consulted regarding any formal consent needed when the handler transfers responsibility for service animal stewardship to a facility representative. Other issues that must be addressed on a case-by-case basis include, but are not limited to, exercise of the animal, cleanup of excrement in the toileting area, and storage of the animal’s food and water.
It would be a reasonable modification of policies and practices to identify an area accessible to the handler where the service animal could toilet and to permit the service animal to be exercised by another person, if the handler was unable.
TEMPORARY CONFINEMENT OF THE SERVICE ANIMAL PROVIDED BY THE HEALTH CARE FACILITY
If the handler is unable to care for his or her service animal while receiving treatment or services from a facility, the facility may elect to provide a crate or other containment for the animal for a short term (24 hours or less). This situation brings up many issues that must
be addressed, such as cleaning and disinfection of the crate during and after use, as well as feeding, watering, and exercising the animal during its confinement. These issues should be discussed with the facility’s risk management or legal department for guidance about facility and personal liability, insurance considerations, necessary handler consent, and other related factors.
When facilities provide or contract to provide housing, such as that provided for significant others or for clients undergoing outpatient treatment, the facility is obligated to permit the use of service animals by persons with disabilities, unless the service animals create fundamental alterations or safety hazards. This is covered by provisions of the ADA or of the Fair Housing Amendments Act.
“NO PETS” POLICIES
“No pets” policies may not be applied automatically to service animals. Legally, service animals are not considered “pets.” Facilities must be able to demonstrate that the presence or behavior of an animal would create a fundamental alteration or direct threat in the area in question.
Persons accompanied by service animals may be informed of any areas that are off-limits to service animals. This may occur when the person enters the facility and should be done in a polite and respectful manner. Policies must be communicated to the person in a way that is accessible and understandable for that person (eg, verbal, print, sign language interpreted, or lip-read). If a person with a service animal must have access to an area that is off-limits to service animals, it is the responsibility of the person to provide alternate stewardship for the animal during the time he or she is in the area. See also Stewardship of the Service Animal:
Its Care and Behavior Management in the Health Care Facility and Temporary Confinement of the Service Animal Provided by the Health Care Facility.
INCIDENTS INVOLVING SERVICE ANIMALS AND FIRST AID
Any injuries caused by a service animal must be evaluated and treated promptly by medical personnel following protocols for the type of injury, in an emergency department or urgent care facility, if necessary. Report the injury to the owner of the animal and to the local enforcement agency (often this is Animal Control), which can obtain vaccination verification and enforce animal control regulations. Any incident involving a service animal, whether the service animal caused the incident or was affected by the incident, must be comprehensively documented. If a service animal damages property, the handler may be held responsible for those damages, provided a policy already exists—and is enforced—that would require payment if a person caused similar damages. If a service animal is injured, prompt evaluation and treatment of injuries should be provided by a veterinarian.
Service animals provide persons with disabilities a dignified way to remain integrated in their communities. In the 80 years that service animals have been trained and used in the United States, there is no appreciable body of evidence to suggest that healthy, vaccinated, well-trained service dogs pose any threat to public health and safety that is significantly greater than the risks posed by the general public. Through a literature review and queries to the CDC, the US Department of Justice Civil Rights Division, APIC, and Delta Society (NSDC), no reported clusters or epidemics of incidents have been attributed to service animals. This absence of data implies that the health and behavior management of service dogs has generally been adequate to control their risks as sources of zoonoses. Additional research about the specific effects of service animals on public health and safety, including species related information, is necessary to develop more sophisticated risk-management guidelines and recommendations for health care practices.
Service animals meet their handler’s disability-related needs, often more efficiently than other persons or equipment. They provide their handlers with enhanced functional ability and quality of life. All health care workers and ancillary staff that have contact with patients or the public must understand their rights and their obligations to persons with disabilities who are accompanied by service animals. Welcoming persons with service animals into health care facilities is not just the law—it is good community support.
Any information provided in this SOAR about the laws that apply to service animals is intended only as technical assistance. It is not legal advice, and is not binding on APIC or Delta Society.
REFERENCE: APIC State-of-the-Art Report: The implications of service animals in health care settings
(EXCERPTS): Susan L. Duncan, RN
The 1997, 1998, and 1999 APIC Guidelines Committees
The Association for Professionals in Infection Control and Epidemiology, Inc (APIC), is a multidisciplinary organization of more than 12,000 health care professionals who practice infection control and epidemiology within a variety of health care settings. Delta Society is a national not-for-profit organization founded in 1977 that promotes the benefits of animals to human health through research, education, and programs.
The National Service Dog Center (NSDC) is a Delta Society program that focuses on the health benefits of service animals for persons with disabilities. The NSDC provides service animal–related education and consultation to researchers, health care providers, persons with disabilities, trainers, policy makers and enforcers, and the general public. Interest in service animals as viable health care interventions has risen dramatically, as evidenced by the increase in requests to the NSDC for information—from a few thousand requests per year in 1995 to more than 34,000 per year in 1999.
During the last 2 decades, service animals that are trained to help persons with disabilities have been making more frequent appearances in health care settings. After a long history of banning animals from these environments, many health care providers now endorse the presence of these animals in clinical and public settings. This APIC State of the Art Report (SOAR) examines the prevailing laws, scientific literature, and anecdotal data about service animals. The document gives an overview of the roles of service animals and their implications for health care providers. This SOAR will also suggest ways to develop prudent policies and practices for infection control and risk management.