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Pacific ADA Center
Healthcare and the ADA Webinar
Who Let the Dogs (and Miniature Horses) In? Service Animals in Health Care Facilities
Thursday, May 28, 2020
2:30-4:00 p.m. ET

>> LEWIS KRAUS: Welcome to the Healthcare and the ADA Inclusion of Persons with Disabilities webinar series.  I'm Lewis Kraus, your moderator for the series.  This series of webinars is brought to you by the Pacific ADA Center on behalf of the ADA National Network. 

The ADA National Network is made up of 10 regional centers that are federally funded to provide training, technical assistance and other information as needed from the Americans with Disabilities Act. 

You can reach your ADA center by dialing 1‑800‑949‑4232.

Realtime captioning is provided for this webinar, the captions can be accessed by choosing the CC icon in the meeting control toolbar.  To toggle that meeting control toolbar on, press the alt key once and press it again a second time. 

As always the speakers will only have audio.  The audio is broadcast through your computer.  Make sure the speakers are turned on our headphones plugged in.  You can adjust the sound by navigating to the audio settings on the bottom panel.  You can adjust the sound by sliding the sound bar left or right in the audio tab.

If you do not have sound capabilities on your computer or prefer to listen by phone, you can dial 1‑669‑900‑9128 or 1‑646‑558‑8656 and use the webinar ID760‑897‑977.  And do recognize this is not a toll‑free number, and also I wanted to mention that the webinar is being recorded and you can access it on the ADA presentations website next week in the archive section of the healthcare part.  This Webinar Series is intended to share issues and promising practices in healthcare accessibility for people with disabilities.  The series topics cover physical accessibility, effective communication and reasonable modification of policy issues under the Americans with Disabilities Act of 1990, the ADA.  Upcoming sessions are available at ADApresentations.org under the schedule tab, then follow healthcare.  These monthly webinars occur on the 4^th Thursday of the month, 2:30 Eastern, 1:30 central, 12:30 mountain and 11:30 Pacific time.  Notices go out two weeks before the next webinar and open that webinar to registration.  You can follow along on the webinar platform with the slides if you are not using the webinar platform, you can download a copy of today's PowerPoint presentation at the healthcare schedule web page of ADApresentations.org.  At the conclusion of today's presentation, there will be an opportunity for everyone to ask questions.  You may submit your questions using the chat area within the webinar platform.  The speakers and I will address them at the end of the session, so feel free to submit them as they come to your mind during the presentation.

To submit your questions, you can go to the chat area text box or you can press alt‑H and enter your text in that chat area.  If you are listening by phone and not logged into the webinar, you can ask your questions by emailing them to adatech@ADAPacific.org. 

If you have experience of any technical difficulties during the webinar, you can send a private chat message to the host by typing in the chat window.  Type your comment in the text box and enter, and if you're using keyboard only, you can use alt‑H to access the chat box by those keyboard keys.  You can also let us know of any problems by emailing us at adatech@AdaPacific.org.  Or call us at 510‑285‑5600. 

Today's ADA National Network Learning Session is titled "Who Let the Dogs (and Miniature Horses) In? Service Animals in Health Care Facilities"

500,000 service dogs assist people with disabilities across the country.  Under the Americans with Disabilities Act or the ADA, service animals must be given access to places their human handlers go, including healthcare facilities.  Service animals become more common, healthcare professionals are more likely to come in contact with them in doctor's offices, hospitals and other medical settings.  During this webinar we will address the definition of service animals, places a service animal can and cannot visit with his or her handler, the questions that can be asked of the person with a disability and how to interact with a service animal.  We also will review a sample service animal policy for healthcare facilities.  As a healthcare provider, this webinar will help you understand the ADA service animals and the implementation of procedures that will enhance your ability to provide comprehensive patient‑centered care.  Today's speaker is Pam Williamson.  Pam is the assistant director of the Southeast ADA Center.  Burton Blatt Institute of Syracuse University and the Southeast ADA Center is a member of the ADA National Network.  Ms. Williamson has extensive knowledge of the Americans with Disabilities Act to facilitate voluntary compliance with the ADA.  Supported employment, special education services and aging populations.  She also contributed to the development and implementation of three online courses, ADA Basic Building Blocks at adabasics.org, at your service welcoming customers with disabilities, and the ADA Title II tutorial at ADAtitleII.org.  Pam, I'm going to turn it over to you.

>> PAM WILLIAMSON: Thank you, Lewis, I greatly appreciate that introduction.  And I look forward to talking with all of you today about service animals.  We often get to talk to our Department of Justice colleagues and they said when they first wrote the regulations for service animals almost 30 years ago now, they thought this is a one‑and‑done, service animals will be easy.  Thirty years later we're now looking at it going... you know, there's more to this than we realized.  So this is what we're going to talk about today.  Just so you will know for accessibility purposes, and also for my own accommodation, I do have assistance with the slides today.  So I will be asking our tech assist person to advance the slides for me by saying "next slide, please."  So if you will go ahead and advance the slide for me.  As Lewis said, we do have some learning objectives for today, and we will going to look at the definition of service animals.  We're going to talk about the questions that can be asked about a service animal.  We're going to identify the places that a service animal can and cannot visit with his or her handler.  And then we're going to talk about how to interact appropriately with the service animal and its handler and then talk about a couple of sample service animal policies.  Next slide, please.

As you know, this is a product of the ADA National Network.  I just want to remind you that if you have any questions about service animals after today's session, please do call your regional center at 1‑800‑949‑4232 or visit the website at www.ADATA.org.  Next slide.  And a shout‑out to funders without whom we would not be able to do these webinars.  We are funded by the Administration on Community Living, and NIDILRR, the National Institute on Disability, Independent Living, and Rehabilitation Research.  And we do thank them for their funding.  Next slide, please.

Okay.  We're going to take a few minutes and take a brief look at the Americans with Disabilities Act.  I'm sure there are many seasoned folks on the webinar with us today who, you know, know this stuff, but this is always a good refresher.  And the reason for that is if we go back to the basics and go back to the foundation of the ADA, it really helps us to look at the issue of service animals in context, and if you're talking with a healthcare provider or another organization, it also may be helpful to you to have some talking points about why this is important.  And last but not least, it also would help organizations when setting policy, to understand the depth and breadth of the ADA.  Next slide, please. 

So what is the ADA?  So this year is the 30^th anniversary of the ADA.  It's a civil rights law.  And it was passed in 1990.  And it was all about promoting equal opportunity for people with disabilities in the areas of employment, state and local government agencies, access, and by private businesses.  The goal of the ADA is always full inclusion of people with disabilities in all aspects of American society.  I want us to look at that term "civil rights" briefly.  Because civil rights, according to the legaldictionary.net is a term that refers to basic rights that are given to an individual by the laws of the government.  And this is regardless of race, nationality, color, gender, age, religion or disability.  And we often think of these things in the light of equal citizenship, equal protection under the law, due process, and equal access.  So when we talk about the ADA, we always need to remember, it's in that equal opportunity/equal access framework.  In other words, it's a civil right to be able to have access to our communities.  So therefore disabilities rights are civil rights and we need to keep that in mind.  Next slide, please.

So under the ADA this were four goals that Congress stated, and they were that we have... that we assure the equality of opportunity, full participation, independent living and economic self‑sufficiency.  And as you heard earlier, over 500,000 people in the United States use a service animal in order to assist them with some disability‑related issue.  So therefore, for many people with disabilities, having a service animal allows them to take full advantage of these four goals that we set out in the ADA.  And we need to remember that, again, these four goals are the foundational areas of our law and what makes it work.  Next slide, please.

Today we are going to specifically talk to Title II which applies to state and local government programs, and Title III, which applies to public accommodations or private businesses, including non‑profit groups.  So if you're interested in service animals as related to employment, please visit www.ADATA.org and you'll access a document there that talks about service animals as a reasonable accommodation.  Next slide, please.

So under ADA Title II, or state and local government agencies, some examples of healthcare facilities might be hospitals that are operated by a state or local government, public healthcare clinics, county departments of health, or state operated mental health clinics or mental health hospitals.  Next slide, please. 

Under ADA Title III are public accommodations.  Some examples of healthcare facilities could be private hospitals, and these could be for‑profit or nonprofit or not‑for‑profit or care clinics, doctor's office, mental health care providers and dentist offices.  Next slide, please.  So as we get ready to talk more about service animals today, we need to look at a term that is in the ADA called "reasonable modification."  And reasonable modification is used in both ADA Title II and ADA Title III.  And the plain language definition is really adjusting or modifying policies, practices or procedures, if needed, so that a person with a disability can access good services, the building or facilities, privileges, advantages, or accommodations.  Next slide, please.

And this is where service animals come in, because under the ADA a service animal is part of this reasonable modification of policy practice or procedure.  So generally, according to the regulations written by U.S. Department of Justice, any public entity or private businesses must modify its policies, practices or procedures to permit the use of a service animal by an individual with a disability.  Next slide, please.

So what are service animals?  Let's go to the next slide. 

A service animal is a dog that is individually trained to do work or perform tasks for the benefit of the individual with a disability, and this could be a physical disability, a sensory disability, such as a person who may be deaf or blind, psychiatric disability and intellectual disability or any other type of mental disability.  The keywords here is individually trained and the dog also has to be able to perform tasks, something has to be for the benefit of the individual with a disability.  We're going to talk more about this in a little bit, but one of the things I want to remind you of is that "trained" does not necessarily mean professionally trained.  The ADA does not clarify whether or not the dog has to be professionally trained or can be trained by an individual.  The key is the dog must be trained and must have ‑‑ must do certain tasks.  Next slide, please. 

Oh, the title on this slide is "Monkeys and Ferrets and Snakes... Oh My! " for those who have been around a while and working in the field of the ADA and disability‑related issues, we remember the days when there were service animals that... or animals that were being stated to be service animals, such as a service snake or a service pig or a service parrot.  And, unfortunately, that really muddied the waters.  So the ADA regulations in 2010 were modified to basically state that dogs were the only service animal.  So any species other than dogs, whether they're wild or domestic, trained or untrained, are not considered service animals under this part of the ADA.  And so unless a healthcare facility allows these types of animals in as pets, they are not covered under the ADA.  However, we do have a... a caveat for miniature horses.  Next slide, please.

In 2010, when the ADA regulations were rewritten, miniature horses were added as another type of service animal that could be provided via reasonable policy modification.  So a miniature horse... so a reasonable modification to policy would allow a person with a disability to use a miniature horse that, again, has been trained to perform certain tasks related to the disability.  This particular addition to the regulations was a compromise because there are some communities that do not believe that dogs can be used or that they are unclean and that a miniature horse was an option that could be used as a service animal.  So therefore this was included as part of the regulations.  Next slide, please.

Now, as we talked about before and I want to reemphasize again... service animals are working, they're active.  So they are not... they're not to be petted.  They're to play with anyone else.  They are there to serve the person with the disability, and that person... and that is their person.  So they must have specific actions, tasks or work that they perform.  Now, having said that, there are some animals simply just by being present, they may provide comfort, companionship, emotional support or other benefits, but they're really not trained to do anything.  And they're not considered to be service animals under the ADA.  I'll give you an example from my own life.  I have severe migraines.  My dog is very ‑‑ is a comfort to me, especially when I have migraines.  He has learned when I have migraines, that my face draws up on one side and he comes and licks it for me.  He wasn't trained to do that.  He doesn't alert me that the migraines are coming.  He just knows Mama doesn't feel good.  He is not a service animal.  Next slide, please.

Now, some examples of a service animal's work... and this is not an exhaustive list by any stretch of the imagination.  It might be providing physical support and help with balance and stability for people with mobility disabilities.  So guiding an individual who is blind or who has low vision, pulling a person's wheelchair.  So it could be retrieving or picking up items for a person with a disability.  Next slide, please.

Alerting an individual who is deaf or hard of hearing to sounds.  Possibly preventing or interrupting impulsive or destructive behaviors for people with psychiatric or neurological disabilities.  And many people who ‑‑ veterans who have PTSD often have a service animal that will press up against them and alert them that they're escalating and need to get to a calmer area.  So before some type of episode occurs.  And then also, too, a service animal can alert individuals to oncoming seizures.  These are just a few examples of the many, many services that a dog might be able to provide.  Next slide, please.

It is very, very important to remember that a service animal is not a pet.  And this is one of the issues that often comes up when there are children who may have a service animal.  And in this case we have a picture of a young boy who has autism, and he has an autism service dog.  And he's at the doctor's office visiting, and you see we have Mom in the picture, and the little boy, and then the service dog and the doctor.  And the mom and the little boy and the service dog are on the floor.  The dog provides a calming presence for this little boy and therefore would be ‑‑ and has been trained to intervene on this little boy's behalf.  So therefore this would be considered a service dog.  Next slide, please.

So let's do a little comparison here.  So we have Marge, and Marge has a psychiatric disability, and her dog, Harry, can tell when her anxiety level is rising.  And he has been trained to respond by moving himself in front of Marge and nudging her away from her current location.  So Harry would be considered to be a service dog because he's trained and he knows when her anxiety level is rising, and so his task is to nudge her away from the current location.  But then we have Aaron, who also has a psychiatric disability.  Now, his dog, Will, is very good‑natured, and sometimes he can tell that Aaron is becoming anxious, but he's really not trained to do anything to help Aaron.  He just plops down and sits there and provides company.  So this is the thing, this is where you have to look at things very carefully.  And the key, again, is that the dog has been trained to respond and to provide some type of service to the individual with a disability.  Next slide, please.

So sometimes we get asked, what is the difference between a service dog or a miniature horse?  Now, service dogs are typically allowed in nearly all areas of the public, all areas where members of the public are allowed to go.  Now, as stated earlier, you know, Department of Justice regulations actually has a separate provisions about miniature horses.  So they're actually subject to a few additional considerations.  Next slide, please.

When a miniature horse is brought in as a service animal... so typically a miniature horse is going to range in height from 24 to 34 inches and way between 70 and 100 pounds.  So even though an entity may be willing to modify their policies and procedures to allow a miniature horse, there has to be some things that are looked at, and part of that is the type of miniature horse, the size and the weight.  Because a facility may or may not be able to accommodate the size of the miniature horse.  Now, there's also the need to look at the ledge mall safety requirements.  Will the miniature horse's presence compromise any safety requirements?  All of these things have to be evaluated on a case‑by‑case basis.  Next slide, please.

Again, emotional support animals are not covered by the ADA.  The mere presence of an animal is not considered to be a service, even though they may provide support to the person with multiple disabilities just by being there, they are not trained to do any specific task or any specific work.  Next slide, please.

Now, I want to discuss therapy animals briefly, because therapy animals are used in many healthcare settings.  Many years ago when I first started out in my career, I was a recreational therapist.  And we had therapy animals who came in to see the patients in the nursing home where I worked.  Everybody loved the therapy animals, especially a couple of my folks who were not able to get out of bed on a regular basis loved to have the dogs come in and snuggle with them in their bed.  It was great.  But they are not covered by the ADA.  So they are given obedience training and are going to be well‑trained, and they may provide a benefit, but it's not to the handler, not to the person bringing in the dog.  It's to the people that they are visiting.  So they're granted access by agreement.  You have an agreement with a nursing home or a Children's Hospital or a senior center, or maybe even a school.  There are many places that might allow therapy animals but, again, it's by agreement some states do allow therapy animals out in public, so you do need to check your state's laws to see if there's anything specific related to therapy animals.  Next slide, please.

Now let's get to some of the details about service animals in a healthcare facility.  Next slide, please.

So, service animals in a healthcare facility – are they allowed?  And the short answer is, yes, they are allowed, unless it creates a direct threat to other persons or there's a fundamental alteration in the nature of services.  The CDC has issued guidelines in addition to the standard ‑‑ excuse me ‑‑ the regulations that are in the ADA.  Basically service animals are allowed in hospital rooms and anywhere the public is a allowed in a healthcare facility.  Some of the places a service animal might not be allowed would be the ICU, a sterile area in a burn unit, or an operating room.  Because these are places that either there would be a fundamental alteration due to the sterile environment, or because the general public would not be allowed into the operating room.  So, now having said that, let's talk about this a little more.  Next slide, please.  There are times when a person may enter a hospital or come into the care of some type of facility and that person may not be able to care for the animal.  And sometimes difficult decisions have to be made about, you know, whether or not the animal can stay.  So let's look at those three things.  Next slide, please.  First of all, as always, evaluate everything on a case‑by‑case basis.  Is the patient able to take care of the animal?  What is the healthcare situation of the patient?  Is the patient so sick that having the animal may be disruptive to care?  Is the animal going to be able to handle the 24‑hour environment of the healthcare facility?  Also considering whether significant risk of harm exists.  Is this a sterile environment?  Is it an isolation unit?  Are there things that may happen that would be harmful even to the dog or to the patient because of this?  And then the other thing always is to determine whether or not there are reasonable modifications in policies and procedures that mitigate the risk?  Can it be worked out so a family member can come in and take care of the dog?  You know, are there things that the staff can do?  It's not always a very clear picture.  And sometimes these ‑‑ and these have to be looked at very carefully.  Next slide, please.  Now, if a patient must be separated from his or her service animal while in the healthcare facility, you must work with the person to find out what arrangements have been made for supervision or care of the animal.  Because you can't just put the animal out on the street.  So work with the person to determine what the needs are of the animal.  If a family member or friend cannot come in, it's always good, best practice, to have a conversation between the medical care team to figure out and help the patient figure out next steps.  So also, too, you'll need to make sure that there are arrangements in place to address the patient's needs in the absence of the service animal.  How are the patient's needs typically addressed by the service animal going to be addressed by the medical care staff?  Next slide.

Next slide, please.  Now, it is not... let me back up.  In the media today, we often see articles about various service animals, and occasionally we see negative press about service animals.  And that really is disappointing, because service animals provide such a benefit to people with disabilities.  So it's always good to know the questions that can be asked, and these questions can be asked when the information is not obvious.  The first question is... is this animal needed because of a disability?  Now, the person does not have to give you their whole medical history.  All the information about the disability.  They can say, I need this animal to help me with my disability.  And we must take that at face value and we must have trust that the answer is accurate and correct.  And then the other question is:  What work or task has the animal been trained to do?  So, you know, when a person has a psychiatric disability, you can't necessarily see that.  So, you know, the person might say, you know, the dog helps keep me calm in stressful situations.  So those are the kinds of things they can talk about.  Another thing might be for a person who is deaf or hard of hearing, you know, the dog alerts me to sounds so that I can be sure that, you know, I'm getting the notices that I need in order to be able to respond.  Those are the kinds of things that you can ask and possibly some answers that you can expect.  Next slide, please.

Now, if it's a parent, if you can see that a person has a disability, for example, you've got a person who is using a wheelchair and they have a dog and the dog is pulling them along, that is very obvious as to what is going on.  The dog is assisting the person and pulling their wheelchair.  The dog may have other tasks that it performs, but at that point in time, the primary task is pulling the person in a wheelchair.  So we don't need to go into a deep dive on these questions.  So we need... so if something is there and you can see it, go with it.  Next slide, please.

Now, there are some things you cannot ask.  And you cannot ask for any documents, certificates, proof, or any details about the individual's disability or the animal's training.  So, you know, we talked about earlier some of the responses you might get.  So, you know, if a person says, I have a disability and my dog retrieves things for me, that's enough.  And so, you know, a person doesn't have to say, you know, I've got... so I have... I'm a double amputee below the knee and I wear prosthetics and the dog provides support for me.  They don't have to give that detail.  So next slide, please.

Now, there are some things you can expect from a person with a disability and the service animal.  Next slide, please.  The service dog or miniature horse must be housebroken.  Now, on this slide you have a picture of a beagle looking at a sign that says "toilet" with an arrow pointing right.  I must admit, I got this picture because I have two beagle nephews and love them dearly, and one of them probably would read that sign to you.  But the bottom line here is that the service dog or miniature horse must always be housebroken.  And, you know, that means being able to, you know, take the dog out or take the horse out.  Some of the horses may have the small bags underneath.  So there are different ways that you can know that the dog is housebroken.  Or a miniature horse.  Next slide, please.

The regulations also state that the service animal must have a harness, leash or tether, unless the individual, because of the disability, is unable to use a leash or the leash would interfere with the animal's work.  So there are some people who don't have the manual dexterity in order to be able to hold on to a leash or if they were to hold on to wrap the leash around their wrist or arm there's a risk of falling.  But also, too, sometimes for dog that is are seizure alert dogs, a leash may interfere with their ability to be able to get to ‑‑ if the cue is to get up to a person and put their paws on their shoulder or their face to their face, then that may interfere.  But regardless of that, even if a service animal does not have a leash on and is not tethered, it must still be under control by voice command or hand signals.  The bottom line is a service animal must always be under control of the handler.  Next slide, please.  A lot of questions we get from various places is... well, shouldn't that service animal have a vest on?  The answer is no.  Because it is not required under the ADA.  Now, many service animals do wear harnesses or vests or something that identifies them as working animals.  But it's not required.  And also, too, you know, just because a person has printed off or paid for some type of certificate or documentation from an online service does not mean it's legitimate.  So, you can't ask for or require certificates or documents or proof of the service animal status or training.  Some people may have this, but, again, not required.  Next slide, please.  Now, there are times when a service animal may need to be excluded.  And a service dog or miniature horse can be excluded if it's not housebroken or it's not under the control of the handler.  So I've personally had an example of when I was at a conference one time and someone presented their animal as a service dog, and the service dog started attacking other service dogs and got loose and started running through the conference area.  Even though a love dogs, that was a very scary time.  And so any time an animal is running around, jumping on people, growling, snapping, and cannot be controlled, it is the right of the public entity or the public accommodation to ask for the animal to be removed from the situation.  But here is the key... you're removing the animal, not the person.  So those are the things ‑‑ that's the thing to remember, is the animal must be removed, not the person.  Next slide, please.

So the fear of employees or other people's fear of animals or allergies are not valid reasons to exclude service animals.  Now, the example I'm getting ready to share with you actually was an employment situation.  We had a ‑‑ I worked in a disability organization and we had a person who had a service animal, and then we had another person who was terrified of dogs of any kind.  And although the service animal was well‑trained, was one of the most docile dogs I had ever met, the person who was afraid of animals literally could not be in the same room without just freezing up.  And so what we did in that situation is that we were able, because of our office set‑up, to accommodate both parties by putting one on one side of the large office area and one in a separate area of offices, and then the only time that they may have to interact was in a staff meeting, and at that point in time the person with the service animal made the decision on her own that she would leave her service animal in her office behind a gate while she was in a staff meeting.  Because it was such an issue.  So, you know, you have to get creative sometimes.  And you have to think beyond just, you know, this area that you may be in.  What kinds of things can be done, because a person with an allergy or a person with a fear is not necessarily going to rise to the level of disability under the ADA.  Next slide, please.  We talked about earlier, a couple slides ago that you're excluding the animal, not the person.  So just remember that the person must always have the opportunity to continue to access the goods and services and participate in the activity even without their service animal.  Next slide.

We talked about care and supervision and I want to address this even more here, because even in a hospital or healthcare situation, the individual with a disability is still responsible for the care and supervision of their service animal.  The staff at a healthcare facility do not have to feed, water or walk the service animals.  Healthcare workers in the healthcare setting are never ever required to do this under the ADA.  Having said that, though, if you have got ‑‑ if you're in a situation where the facility accepts pets and it's part of the normal service, maybe in an Alzheimer's care center or something of that nature, then, of course, you want to accommodate the service animal as well as the other dogs in the facility.  But typically healthcare staff are not required to provide the care or supervision.  Now, I want to address this further because in recent weeks, there has been an article floating around on the news and in social media about a nurse who chose to take care of a veteran's service dog.  The veteran was a gentleman who was blind.  He went into the hospital.  It happened to be for COVID‑19.  And he thought he was going to be in and out, go to the emergency room and be in and out and he was there for 19 days.  And a nurse chose to take care of his service animal and to set up something at the hospital so that the service animal could stay with him.  This hospital and this nurse chose to go above and beyond the ADA.  Remember, the ADA is always a baseline.  But it's not required and you should not expect it of a hospital or other healthcare facility.  Next slide, please.  Now, although it's not required, a healthcare facility may choose to provide a relief area where the individuals can take their service animals.  You know, they've got to take care of their business somewhere.  So this is always something good to look at.  And even though it's not required, it is good customer service.  Next slide, please.

Now, we always want to remind folks that in addition to the ADA there may be state or local laws that apply.  And if a state or local law has something in it that makes it better for people with disabilities, it's going to override the ADA.  But if the ADA is better for a person with a disability, it is always going to override the state or local law.  Laws vary state to state especially where service animals are concerned.  So I encourage you to check your own state's laws to find out if there are certain things allowed in your state that may not be allowed somewhere else, because you always want to make sure that you're in line with both federal, state and local laws.  Next slide, please.  I want to talk about surcharges, because obviously, you know, all of us like to make sure that we are watching our dollars, and we want to make sure that we understand that extra fees cannot be imposed on individuals who are using service animals.  Because service animals are not pets.  It's always a good idea, if you use a healthcare facility for something, check your bill carefully.  Most healthcare facilities aren't going to add an extra charge.  This is usually ‑‑ we usually see this happening in places like hotels.  But you want to always be sure, because a service animal is there to provide some kind of ‑‑ do some task for the individual with a disability.  So we want to be sure that under ‑‑ that everyone understands and remembers this.  The other thing, too, is, if a person's service animal does cause any type of damages, then if you normally charge any guests or customers coming in for damages to a place, you can also pass on that cost to the individual with a disability if their service animal has any ‑‑ causes any damage.  Next slide, please.

We're now going to talk about service animal policies and procedures.  If you can take me to the next slide.

The ADA regulations do not require a service animal policy.  However, it is best practice and highly recommended.  So many, many years ago I had somebody tell me that if it's not in writing, it really doesn't matter.  Because if you don't have a policy in writing, it makes it difficult to follow and makes it more difficult to enforce.  Also, having a policy in writing limits the guesswork.  Because everyone can have access to the same information and know how it needs to be applied.  Next slide, please.  Now, the Michigan Department of Health and Human Services has a fantastic service animal policy, and also some forms.  Now, these are all available to you in the PowerPoint.  So if you have not yet downloaded the information, I encourage you to do so.  Because this information actually has been shared across the state of Michigan with their various state entities.  And they have the policy for hospitals and facilities on this arrival checklist.  They have different questions about what service ‑‑ you know, the basic questions about what services the animal will provide, do you have someone... will you be able to care for the animal while they're here.  All those things that need to be in place.  And then if for some reason the animal does need to be excluded from the facility, either because the patient is in ICU or some other reason, then they have a very good step‑by‑step process for doing this.  I recommend this ‑‑ taking a look at these policies, the examples, because they're very well‑done and they are very much in line with ADA.  Next slide, please.  The U.S. Department of Justice also has a sample policy in one of its settlement agreements.  This was with a doctor's office where a service animal was being denied entrance into the doctor's office.  So this is a good policy to follow.  It is more basic than some of the other ones that other hospitals have put together, but because it comes from the U.S. Department of Justice, you will know that it has at least been through that enforcement agency's oversight and will be a good thing for you to look at.  When you go to the settlement agreement, you will need to go to Attachment A, because that's where the actual service animal policy is located.  Next slide, please. 

Another healthcare system, and for my colleagues in California, kudos to your group in Stanford Health Care, because they have an excellent service animal policy.  We have a link to the policy summary with service animals at the Stanford Health Care facilities and a link to the full policy.  And their policy actually covers service animals and comfort and emotional support dogs.  So they actually have decided to go above and beyond the ADA and look at those issues.  Because they understand the importance that a pet may have in a person's life and want to provide that option.  Next slide, please.  Another service animal policy is from Johns Hopkins in Maryland.  And they have this ‑‑ actually you're planning the visit.  So it's very helpful both for a patient who may have a service dog but also a visitor who may have a service dog, they address both issues.  And I highly recommend looking at their policy.  All of these policies, again, are just examples.  You know, I can't put a check mark on one over the other, but I do recommend looking at policies that have already been put in place in order to address the issues related to service animals.  I will give you another example of a way not to do things from a personal experience.  I actually was hospitalized myself back in January and was in an isolated room, and I was talking with the nurse in charge, and when he found out what I did, he said, what do you know about service animals?  Well, you can imagine the conversation that ensued.  But I looked at him and I said, does the hospital have a service animal policy?  He says, we do not.  This is one of the largest healthcare organizations in the state of Georgia, and yet it does not have a service animal policy.  And I did my own research after leaving the hospital and have found that out.  So, you know, he told me that because they did not have a service animal policy that they had had some issues with people, you know, bringing in different kinds of animals and they had to allow them because they didn't have anything that said they couldn't.  So, again, that policy and those procedures and putting those into place are very, very important.  And I want to encourage you to take a look at these.  Next slide, please. 

I have several resources for you.  I am not going to go over these in‑depth, because I do want to take time to answer your questions, but I will have Gabe move me to the next slide so you can get an example.  Actually, Gabe, if you'll go two more slides, that would be great.  One more.  There we go.  I have put these together for you specific to healthcare facilities.  And they are divided up by the organization or the federal government agency that put them together.  There are about five or six slides, maybe a few more with resources.  I encourage you to take these, look at them.  They are comprehensive and they will give you a lot of good information.  And you can get us past the resources and then I think we're about to Q&A.

One more... or are we at the end?  Lewis, I think we're at Q&A.

>> LEWIS KRAUS: Thank you so much, Pam.  That was a great presentation.  All right, everyone, remember this is a chance to submit your questions in the chat window.  And we'll go through them right now.  So here is your first question, Pam.  Someone asked for a policy, is there something we can reference regarding the number of service animals person can have?  We have a customer that brings six service dogs.

>> PAM WILLIAMSON: Wow, this is called "stump the trainer."  (chuckling) Actually, the U.S. Department of Justice has addressed this.  Because I think I looked at this question earlier.  So the U.S. Department of Justice in its 2010 document frequently asked questions about service animals and the ADA.  It states that a person might be able to have more than one service animal but here is... hold on just a minute.  Let me pull that up so I can tell...

Basically what the U.S. Department of Justice says is that it is possible that a person might have more than one service animal.  And to do different tasks.  And an example that they give is that a person who has a visual disability and a seizure disorder may use one service animal to assist with wayfinding and being able to navigate the area and another service animal that is trained to perform as a seizure alert dog.  Now, they do not actually go above the number two on the number of service animals, and I have not seen that addressed as more than two service animals in other places.  Lewis, do you remember any guidance on that?  Because two is usually the limit I have seen, but that's just because that is what has been put out by the U.S. Department of Justice.

>> LEWIS KRAUS: I haven't seen anything one way or another about that one, but I would say this... take the tenets that Pam just described to you.  And if you apply the two questions to each of the animals, that might help you in the conversation with this individual.  Because it is a case‑by‑case basis.  There might be a multiple items that each animal might deal with each item.  But if not, then that would actually clarify it.  For example, we have had an instance of someone who had a couple of service animals when asked they said that the first service animal did a particular task and the second service animal interpreted for the first service animal.  That obviously would not be a definition of the service animal.  The service animal has to do the task for the person, not for the other service animal.

>> PAM WILLIAMSON: Right.  I am getting ready to put a link to the frequently asked questions about service animals and the ADA in the chat area, and if you'll reference question 13, that will give you information straight from the Department of Justice.  Next question.

>> LEWIS KRAUS: Let me read the next one.  It says... what does the ADA ‑‑ what are the ADA guidelines in regards to a service animal going in the shower with a handler?  We operate a recreational facility and we have had multiple complaints.  We have a user who brings their, quote, service dog in the shower with them.  The shower is communal and not individual stalls.

>> PAM WILLIAMSON: Again, the ADA states that the service animal is allowed to go basically anywhere the public goes unless it's going to be a fundamental alteration to the service or a direct threat.  So if you've got concerns, then there is... you would need to look and make a decision whether it is fundamentally altering the experience, and are there reasonable modifications in place that would allow this person to still be able to take a shower, because the dog may be allowing ‑‑ the dog may be supporting that person in the shower in some way and providing assistance.  If it's a direct threat you need to look at that issue and assess on a case‑by‑case basis.  That is a threshold.  And it's typically... direct threat is typically defined as significant risk of substantial harm, and there is a four‑part process that you have to go through in order to look at that and do the analysis.  Now, if you have more questions about direct threat, I would encourage you to contact the ADA Center and talk to an information specialist who can really get into more of the details with you as to what that might look like. 

>> LEWIS KRAUS: Okay.  Next question:  What should we do when a patient has no one to walk or feed the service animal during the stage.  They're concerned about liability, if something happens to a dog during a walk.  I think Pam covered that, but I don't know if you wanted to say something else regarding that.

>> PAM WILLIAMSON: I would like to reiterate the point that the ADA does say that the service dog must be in control ‑‑ must be under the control of the handler at all times.  So if the person is not able to control the dog, you know, that is when it is best practice to bring in various people.  Is there a social worker at the hospital that can help find alternate placement while the person is in the hospital?  If there's not a family or friend nearby.  Sometimes you do have to get creative sometimes, and as we all know, you know, there are situations when a person is in the hospital and they may or may not be able to make decisions.  And sometimes you have to make sure that you document everything, but, again, the service dog... if they choose to go above and beyond, that's fine.  But it's not required, and therefore that's when a plan needs to be put in place in consultation with the patient.

>> LEWIS KRAUS: Next question... and this is... I don't know what ‑‑ this is an interesting sign here from the universe.  Two straight questions from different people about a similar topic, which is... what if service dogs come to the facility in a stroller?  Can you have somebody come in with animals in a stroller?

>> PAM WILLIAMSON: You know, it's very interesting question, because the U.S. Department of Justice actually really addressed this in a little broader way.  But basically what the U.S. Department of Justice has said is that a service dog must have all four paws on the floor unless the service that they are providing cannot be provided from the floor.  So, for example, let's say that a person who has seizures actually has a small dog.  So I'll use a Chihuahua as an example, because that's the smallest I can think of right now, that actually has been trained to alert them to the seizures, and part of the training has been so that the dog actually may ride up on their shoulder or be close to their face so that they can lick their face.  That's something I have seen before.  It really is going to ‑‑ really that's where questions come in, and, you know, what... and, Gabe, if you can get me back to that page, I can tell you... so if you can get me back to those two questions, I would appreciate it.  But, yeah, that's really when those questions come in.  Because you want to know what the dog ‑‑ what service is the dog providing?  Because it's going to ‑‑ I'm not going to say the dog cannot provide a service from a stroller, but I do think that the question is very legitimate at that point.  So is this animal needed because of the disability?  And what work or task has the dog been trained to do?  But typically Department of Justice has said that four paws on the floor at all times.  Next question.  And you'll note why I'm asking this.  What would you recommend if there was an individual with three dogs, two certified dogs and one emotional support animal, but the landlord is flat‑out refusing to acknowledge this because they're saying their building is above a meat market and therefore no animals are allowed?

>> PAM WILLIAMSON: Well, okay, this is a situation where I'm thinking ‑‑ I'm hoping that the ‑‑ if the person can put in the chat area if the landlord is just like an apartment or a rental or is this a business.  Because the answer varies depending on what situation it is.  If it is a... you know, someone that has two service dogs and then an emotional support animal and it's a rental housing type situation, that's covered under the Fair Housing Act.  And so we would ‑‑ and those rules are different, and I will be honest, that is not as much my area of expertise, so I would definitely suggest calling the 1‑800‑949‑4232 so you can talk to an information specialist.  If it is an office situation, again, that's going to go back to employment and potential reasonable accommodation and could potentially come down to, you know, the contract between the employer and the office management and allowing a reasonable ‑‑ and working out the reasonable accommodation with the employee.

>> LEWIS KRAUS: I would also encourage you, if your questions here are ‑‑ do not involve service animals or service animals in the hospital or healthcare settings, that is what we're really focusing on here.  Definitely call your regional ADA Center, because everyone across the country, we're all equipped to answer these questions.  This will not be your only chance to get a question answered here.  The questions are answered for free, they're confidential.  It's straightforward to do.  So we'll put that phone number up in the chat area again for you to get the 1‑800‑949‑4232.  Next question, Pam.  Can a service animal be restricted from a company remaining with an admitted patient in a hospital during this pandemic?

>> PAM WILLIAMSON: I'm sorry, Lewis.  Can you re‑read the question.  Part of my audio dropped out.

>> LEWIS KRAUS: Sure.  Can a service animal be restricted from a company and remaining with an admitted patient in the hospital during this pandemic?

>> PAM WILLIAMSON: Okay, again, so what you have to look at is the situation as a whole.  And if the service animal is there with a patient with a disability and the ‑‑ and the patient needs the service animal while in the hospital and can keep it under control, then the service animal should be able to accompany the person into the hospital.  But if there is... if the ‑‑ of course, we have ‑‑ unless it's a fundamental alteration or a direct threat.  And the direct threat assessment, again, is a very detailed assessment on whether or not there is that substantial risk or harm that may be to others.  So that would need to be an assessment that would be made on a case‑by‑case basis depending on the situation.  And also too when it comes back to the handler, you know, is the person able to provide the care to the service animal that is needed or is it... or do other arrangements need to be made? 

>> LEWIS KRAUS: The next question has to do with allergies and what about allergies.  If they have an allergy to dairy, for example, which isn't a disability, necessarily, but the animal is trained to identify it, is this covered?

>> PAM WILLIAMSON: Remember, the ADA is about equal opportunity for people with disabilities.  In order to be covered by the ADA, the person must meet the definition of disability.  So that allergy to dairy needs to be assessed and looked at to see if a person is going to meet the definition of disability under the ADA.  And, again, that's a case‑by‑case basis and needs to be looked at in that individual case.  There are instances of when a person does have an allergy, and this has come up with peanut allergies where it might rise to the level of definition of disability under the ADA because the person you know, goes into anaphylactic shock and it can possibly kill them and affects their respiratory system.  And being able to breathe is a major life activity.  And so I'm not going to say allergies are never covered, but, again, just like everything else, there has to be ‑‑ it has to be looked at, you know, as to whether or not it's substantially limiting one or more major life activity.

>> LEWIS KRAUS: Next question:  I thought the airlines were trying to limit to two ‑‑ I'm assuming service animals ‑‑ but wanted to have something to reference.

>> PAM WILLIAMSON: The airlines are actually covered under the Air Carrier Access Act, and we do have information, specialists that can answer the question, or you can call the U.S. department of ‑‑ excuse me ‑‑ the Federal Aviation Administration for that information.  But, yeah, that's covered under the Air Carrier Access Act, not the ADA.

>> LEWIS KRAUS: And another question:  As a hard of hearing person I would like to get a service dog, however I have a 13‑year‑old daughter who loves dogs, but at home how the family works out the relationship with the service animal being at home, at work, is the animal a pet, one is at home and their vest is off.

>> PAM WILLIAMSON: If I understand your question correctly, it's basically... you know, once the dog is at home and you choose to take the vest off, they're not working, you know, service animals... I mean, service animals either need to be trained by the individual or an organization, and it depends on how they're trained, and, you know, what it is to whether or not, you know, they're working.  Many service animals are trained that when they have their harness on, they're working.  When their harness is off, they're not working at that time, and then, you know, you can play with them.  But that's based on training, different people and different organizations do it different ways.  So that's something if you're interested in learning more about, I would encourage you to contact a service dog organization in your area that can provide guidance.

>> LEWIS KRAUS: what if someone a disability continues to bring a service animal, running around, growling at staff and other patients to the hospital?  What can the hospital do legally to prevent this from continually happening?  The patient has ignored all requests to keep the service animal at home.

>> PAM WILLIAMSON: I'm going to answer this from the perspective of the ADA.  As we discussed earlier, if a service animal is growling, snapping, biting, disruptive in any way, and that way you can... you can always ask that the service animal be removed, even at that time.  So you can ask that the service animal be removed and allow the person to stay and to take advantage of the services that are being provided.  So this is where your policies and procedures are very useful, and if you don't have policies and procedures as best practice, I encourage you to get some in writing.  And legally, if there are other things you can do, that's best taken up with your general counsel, because the ADA does say you can exclude the animal.  But, you know, there may be procedures at a state or local level that need to be looked at in order to, you know, take those steps in order to make it happen.

>> LEWIS KRAUS: I would add one little caveat we like to say around here, that the person has the rights, the dog does not have...

>> PAM WILLIAMSON: Thank you, Lewis, yes.

>> LEWIS KRAUS: Next question.  Are service animals in training also considered service animals and allowed in places of public accommodations in employment settings?

>> PAM WILLIAMSON: That is an excellent question.  Actually, that varies state by state.  Service animals in training are allowed in some states to be in public and not in others.  So that is something that needs to be reviewed at your state level.  And in some cases it may even need to go down to the local level, you know, if the state doesn't have a law, does the local level have a law?  Those are covered at the state level and it will vary state to state.  And this is where calling your regional ADA Center would be very helpful because they will know about ‑‑ potentially know and the state and local laws that apply in this case, you know, versus the ADA as a whole, which does not address service animals in training.  

>> LEWIS KRAUS: Next question:  Are there changes our modifications being made for COVID‑19 in use of service animals in hospital settings?

>> PAM WILLIAMSON: The CDC has actually put out some guidelines regarding this.  And basically at this point in time, they're just asking hospitals to follow the guidelines that have already been issued, and I have a reference to those in the resources section, because there is ‑‑ there have been guidelines that have been put together by the public health area of the U.S. Department of Health and Human Services about service animals in situations like this.  And so it's really just looking at infection control and things of that nature.  Basically, though, for right now, as far as I can tell, and all the research I have done, the... so as of today, May 28^th, the service animals are still allowed in hospitals unless, of course, there is the fundamental alteration to services or a direct threat issue.

>> LEWIS KRAUS: All right, we have a listener who actually has more information about the strollers, and says DOJ's answer to question 31 is about shopping carts and does not safe for the floor.  In that context it says generally the dog must stay on the floor or the person must carry the dog.  So that's what they found about strollers.

>> PAM WILLIAMSON: And thank you for finding the actual text in another place, and I would have defined it, there is guidance that basically says on the floor.  So thank you for finding that particular text.  That was one of the first ones I was looking for earlier.

>> LEWIS KRAUS: Next question:  Can service dogs be transferable?  Someone with a service dog passed away and gave the dog to an employee and now the employee is claiming the service dog is for them and bringing it to work.

>> PAM WILLIAMSON: That is a question I am not qualified to answer.  So Lewis, if you've got information or if not, then...

>> LEWIS KRAUS: I would say you should call the local regional ADA Center and give them the chance to research this question.  It may not be something that is very common and known, but probably there is an answer that needs to be researched and won't be able to do it here on this session.  All right.  I'm going through the messages here.  So there's a couple questions here, and I'm not sure what they mean, but COVID‑19 dogs, how many actively working in the USA or demographics?  Are you trying to find out how many ‑‑ can you clarify what that question is after?  Unless, Pam, you have a sense of what that...

>> PAM WILLIAMSON: I'm not sure I have a total sense but I think I have a guess, so I'm going to make my best guess here, Debra... excuse me ‑‑ yes, Debra, if you can fill in gaps in the chat, I would appreciate it.  I have read that there are some dogs being trained to detect COVID‑19, however, I have not seen any numbers nor have I seen any specific information about the organizations who are doing this kind of thing.  It really is just some ‑‑ it's just something that made it to the news that is happening, but like a lot of other things related to COVID‑19, it's new, it's up‑and‑coming, and it's changing.  So unless you have a more specific question, I'm not going to be able to answer much better than that.

>> LEWIS KRAUS: Then a second question also that may need clarification.  I have witnessed so many violations with individuals with service animals that really will help with making these people genuinely enforce and take responsibility for their inconsiderate illegal actions.

>> PAM WILLIAMSON: As with anything, you know, we see things happen that, you know, we know that ‑‑ we at least think or believe that they are illegal or the person is, you know, trying to pass off a dog as a service animal when we know they are not.  Unfortunately, at this point in time, there's not much that can be done.  There are some states that have chosen to try and pass fake service animal laws.  It remains to be seen as to how effective that is going to be, because, you know, it's going to be more difficult to enforce, and so it's... you know, it's really one of those things that, again, I encourage people with disabilities who have service animals to, you know, always be prepared to answer the two questions, and I personally have friends with service animals that have chosen to print out the ‑‑ one of the documents, either from the ADA National Network or Department of Justice with an explanation of what a service animal is and what ‑‑ where they're allowed to go and take it with them just as an educational piece.  Again, that's just something that they have chosen to do.  And, you know, it really comes down to the policies and procedures of a business or state or local government entity.  And, you know, being able to have those in writing so that they can be referenced and so that things can be done when they need to address the issue.

>> LEWIS KRAUS: Okay.  So we're getting a few clarifications here.  So she was saying ‑‑ she's clarifying saying I'm talking about business and government facilities that are doing illegal acceptance of true service animals.

>> PAM WILLIAMSON: I'm not sure I understand.  So I apologize.

>> LEWIS KRAUS: Illegal.

While you're writing, there's a couple items that have come in here for clarification, one from... it says that there's a link to a BBC news item about a trial that is beginning to see if dogs can sniff out coronavirus.  Now, I recognize that ‑‑ now that you've been through this session, you can recognize, is that a service animal or not you know, and would you be walking around with a service animal that is... I'm not sure if that's a service animal or if that's something that people are using in a facility to determine whether somebody comes in, whether somebody has coronavirus.  That's unclear.

>> PAM WILLIAMSON: Yeah, Lewis, a dog that would be trained to sniff out coronavirus or COVID‑19 I see in the same light as dog that would be used to sniff out cancer or something else.  They're not a service animal for a person with a disability as much as they are providing a service for the community.

>> LEWIS KRAUS: Right.  All right.  Thank you, Rebecca.  She's put in there the link for you all about the two‑page fact sheet by our ADA National Network on service animals.  Now, Debra is clarifying her question, and I think after this we'll have to end here.  The government and businesses are not complying with Title II and Title III.

>> PAM WILLIAMSON: Debra, I think it would be best if you contacted the regional ADA Center because it sounds like to me that you probably have got a more detailed question than we can answer here today and that there might be some... and the information specialist would be happy to talk that through with you. 

>> LEWIS KRAUS: All right, everyone.  Thank you so much.  We realize that many of you may have questions for Pam and apologize if you didn't get a chance to ask the question, because as we've been talking to, you can contact your regional ADA Center at 1‑800‑949‑4232 to ask your question.  You will also receive an email, the link to an online session eval after the end of this.  Please complete that evaluation for today's program.  We value your input and want to demonstrate its importance to our funder.  We want to thank Pam today for sharing her time and knowledge with us.  A reminder, today's session was recorded and it will be available for viewing next week at ADAPresentations.org in the archive section of healthcare.  Our next webinar will be on June 25^th.  You'll be joined by Nancy of Syracuse University and Mary Lee of the Disability Rights Education and Defense Fund and we'll be presenting on findings from a study examining the geographic distribution of accessible Medicaid participating primary care offices in Los Angeles County.  We hope you can join us for that.  Watch your email two weeks ahead of time for the announcement of the opening of that registration.  Once again, we thank you, Pam.  And thank you all for spending some time with us and have a good rest of your day.