Policies

Upon initial observance of or a request to be accompanied by a service animal, notify (FILL IN TITLE/POSITION OF PERSON RESPONSIBLE FOR DETERMINING WHETHER THE ANIMAL MEETS THE DEFINITION OF A SERVICE ANIMAL AND WHETHER THE FACILITY CAN ACCOMMODATE THE REQUEST)

1- Unless it is readily apparent that an animal is trained to do work or perform tasks for an individual with a disability, the individual may only be asked the following two questions to determine whether an animal qualifies as a service animal:

• Is the animal required because of a disability; and, 
• What work or task has the animal been trained to perform.

2- Individuals accompanied by a service animal may not be asked:

• About the nature or extent of their disability;
• To provide documentation of the disability;
• To provide a demonstration of the service animal’s work or task; or,
• To provide proof that the animal has been certified, trained, or licensed as a service animal.

1. A service animal must be under the control of its handler at all times.

• The handler must ensure that the service animal is not out of control. Examples of “out of control” behaviours include, but are not limited to, being disruptive or aggressive, excessive barking, growling, wandering off-leash, approaching other people, jumping or sitting on furniture, or other behaviours which interferes with the facility’s ability to carry out its business operations.

2. The handler is responsible for the care of the service animal at all times.

• This includes but is not limited to, toileting, exercise, feeding, grooming, and veterinary care.
• Clean-up of the service animal’s urine, feces, or other bodily fluids is the responsibility of its handler and should be followed by standard Environmental Services disinfection protocols.

3. A service animal must be on a harness, leash, or other tether, unless:

• The handler’s disability prevents the use of a harness, leash, or other tether; or,
• The use of a harness, leash, or other tether would interfere with the service animal’s safe, effective performance of work or tasks.
• If the service animal is unable to be on a harness, leash, or other tether, it
• must be otherwise under the handler’s control (e.g., voice control, signals, or other effective means).
• Dogs in Training: Dogs that are being trained as service animals must be on a leash.

4. A handler may designate another responsible adult (not to include FACILITY NAME personnel) to maintain care and control of the service animal.

• A service animal may not be left alone or unsupervised at any time while on FACILITY NAME premises. This includes being left alone in an exam or patient room while the handler is receiving care or treatment in another room or location.

When appropriate, FACILITY NAME personnel shall request a patient accompanied by a
service animal to identify an individual who is willing and able to maintain care and control
of the service animal in the event the patient is unable to do so.

1. FACILITY NAME is not responsible for the care or control of a service animal.

• FACILITY NAME staff and volunteers are not permitted to assume responsibility for a service animal.

2. In the event a patient is unable to maintain care and control of the service animal and
has not identified an individual willing and able to assume care and control of the
service animal:

• For outpatient, nonemergent services, the patient will be offered an opportunity to reschedule services for a time when they are able to make appropriate arrangements for another responsible adult to maintain care and control of the service animal.
• For patients in the Emergency Department or who have been admitted as an inpatient, the (INSERT TITLE/POSITION OF RESPONSIBLE INDIVIDUAL) shall inform the patient of the obligation to make appropriate arrangements for care and control of the service animal, including the option to:
  • identify an appropriate individual who is willing and able to come to the facility and take possession of the service animal within a reasonable period of time;
  • to make arrangements for the service animal to be transported to a kennel or boarding facility of their choosing; or
  • if the patient is unable to make arrangements for care and control of the service animal, the facility will DESCRIBE SPECIFIC STEPS TO BE TAKEN TO PROVIDE A SAFE PLAN FOR CARE AND CONTROL OF THE SERVICE ANIMAL.)’
• The patient should be informed that they will be responsible for any costs associated with transporting, boarding, and caring for the service animal.

1. An individual may be asked to remove a service animal from FACILITY NAME premises if:

• The service animal is out of control and the handler does not take effective action to control it;
  • In circumstances where a service animal’s behavior is in response to a provocation or injury, the handler may be given a reasonable opportunity to gain control of the service animal.
  • If the handler asserts that the service animal was provoked or injured, or if there is reason to suspect that provocation or injury has occurred, the (INSERT TITLE/POSITION) shall be notified and appropriate action taken to ensure the safety of patients, visitors, and staff, as well as the service animal. This may include requesting the provocateur to leave the area;
• The service animal is not “housebroken”;
• The use of the service animal would fundamentally alter the nature of the goods, services, facilities, privileges, advantages, or accommodations provided by FACILITY NAME
  • “Fundamentally altered” means a change that is so significant it alters the nature of the facility or services offered.
• The service animal poses a direct threat to the health and safety of others.
  • The (INSERT TITLE/POSITION) or the Physician or other licensed healthcare provider responsible for the care of the patient shall make an individualized assessment of the service animal, the patient, and the situation and ascertain:
    • The nature, duration, and severity of the risk;
    • The potential for harm to occur; and
    • Whether reasonable modifications of policies, practices, or procedures or the provision of auxiliary aids or services may mitigate the risk.
  • This assessment is based on the service animal’s actual behavior or history and not on fears or generalizations about how a particular animal or breed might behave.

2. A service animal may not be arbitrarily excluded because:

• FACILITY NAME personnel may be able to perform the same services that the service
  animal does (e.g., retrieving dropped items and guiding an otherwise ambulatory person to the restroom) or otherwise perceive a lack of need for the service animal during the patient’s/visitor’s stay at FACILITY NAME; or
• Other patients, visitors or staff in the area are allergic to the service animal.
  • When an individual who is allergic to the service animal and an individual who uses a service animal must spend time in the same room or building, they are both accommodated by being assigned, if possible, to different locations within the room or different rooms within the building.
• Other patients, visitors, or staff are fearful of animals.
• Of the service animal’s breed, unless the service animal in question has a history of aggressive or disruptive behavior.

3. When a service animal is properly excluded, the individual with a disability shall be given the opportunity to obtain goods, services, and accommodations from FACILITY NAME without having the service animal on FACILITY NAME premises.

1. Permitted: An individual with a disability is permitted to be accompanied by their service
animal in all areas of FACILITY NAME in which that individual would otherwise be allowed
without taking additional precautions to prevent transmission of infectious agents. This
generally includes all common areas that are generally open to the public, as well as
admissions and discharge areas, the emergency department, inpatient and outpatient
rooms, examining and diagnostic rooms, clinics, rehabilitation therapy areas, the
pharmacy, restrooms, and all other areas at FACILITY NAME where healthcare personnel,
patients, and visitors are permitted without taking added precautions. The requirements
regarding care and control of the service animal, set forth in Section IV.C above, apply in
all such instances.

2. Not Permitted: A service animal may be excluded from limited-access areas that employ
general infection-control measures.

• General infection-control measures that dictate such limited access include
  • a. The area is required to meet environmental criteria to minimize the risk of disease transmission;
  • b. Strict attention to hand hygiene and absence of dermatologic conditions; and,
  • c. Barrier protective measures (e.g., using gloves, wearing gowns, and masks) are indicated for persons in the affected space.
• At this time, the (INSERT NAME OF DEPARTMENT/RESPONSIBLE INDIVIDUAL) has identified the following areas and units as meeting this criteria:
  • a. All operating rooms and perioperative area,
  • b. Procedural areas where sterile procedures are performed,
  • c. All ICUs, rooms of patients on airborne or droplet precautions, and units with a high number of immunosuppressed patients.
• In addition to the foregoing, service animals may be excluded from areas where
  additional safety measures beyond routine PPE are required or where the service
  animal may be exposed to a hazardous environment, including but not limited to
  locations where diagnostic imaging, general radiology procedures, radiation
  therapy, or laser procedures are performed.
• Exceptions may be made on a case-by-case basis depending on the service
  provided by the service animal and needs of the patient.
• FACILITY NAME and the (INSERT NAME OF DEPARTMENT/RESPONSIBLE INDIVIDUAL
  IDENTIFIED IN F.2. ABOVE) reserve the right to modify the list of identified areas and
  units at any time in compliance with federal and state law, in furtherance of this
  Policy or to ensure the safety of patients, visitors, staff and service animals
  accompanying patients or other individuals.

3. Dogs in Training: Dogs in training are not considered service animals under Federal law. Individuals with a disability and persons who are authorized to train service animals for individuals with a disability may take their dogs, for the purpose of training them as service animals, only in areas where the general public is permitted. The dog must be on a leash and, when required by State law, be identifiable as a guide dog, signal dog, or service dog in training.

1. Service animals are not permitted to come in contact with the patient’s non-intact skin, such as surgical sites, drainage tubes, and wound

2. All FACILITY NAME personnel must wash their hands or disinfect with alcohol hand-rub after direct contact with the service animal.

3. Injuries to or caused by a service animal are reported to (INSERT TITLE/POSITION). The injured party shall be referred to the appropriate area for medical evaluation and care. All injuries involving an animal shall be promptly reported to Security and Risk Management.

4. Sanitation Policy: Standard cleaning procedures are sufficient following occupation of an area by a service animal.

1. FACILITY NAME does not require an individual with a disability to pay a surcharge or security deposit related to the service animal.
2. An individual may be charged for damage caused by their service animal.
3. Dogs in Training: Trainers may be liable for damage caused by the dog-in-training.

1. FACILITY NAME permits the use of miniature horse by an individual with a disability if the miniature horse has been individually trained to do work or perform tasks for the benefit of the individual with a disability, unless consideration of the following factors indicates that the miniature horse should not be permitted into a specific facility:

• The type, size, and weight of the miniature horse and whether the facility can
  accommodate these features;
• Whether the handler has sufficient control of the miniature horse;
• Whether the miniature horse is housebroken; and
• Whether the miniature horse’s presence in a specific facility compromises legitimate
  safety requirements that are necessary for safe operation.

2. Sections IV.A – IV.G of this policy, excluding those relating to dogs in training, also apply to
miniature horses.

1. When a patient/visitor requests that FACILITY NAME make an exception to this Policy to permit the use of an animal other than a service dog or miniature horse (e.g. emotional support/comfort animal, companion animal, pet), the Associate Director or Administrator on Duty shall be notified. The Associate Director or Administrator on Duty shall determine an appropriate response based on an individualized assessment of the situation and the nature of the services involved.
2. If the use of the animal is permitted, Sections IV.A – IV.G of this policy, excluding those relating to dogs in training, shall apply at all times to the non-service animal.