NEWSLETTER Volume Ten - Number Nine September 2014 When Service Animals Meet Healthcare Seeing Eye Dogs or guide dogs 1 have long been used as service animals to help those with limited or no visual ability. Service dogs can be specialized into those canines that serve as hearing dogs, 2 seizure response dogs 3 who act when his human companion experiences a seizure, and dogs that help those with physical disabilities handle many tasks of daily living. The application of the Americans with Disabilities Act 4 recognizes that service dogs 5 can fulfill a valuable role for those with developmental or intellectual disabilities. So too, they have become a vital member of the household of those with serious mental health or emotional problems, helping such individuals get through the activities of life on a daily basis. 6 Service animals are not restricted to dogs. Mini horses, 7 monkeys, and other animals can serve as service animals also. Yet another cohort involves pet therapy animals. Accompanied by handlers, pet therapy animals visit homebound clients, patients in hospitals and residents in nursing facilities. They are a source of joy and comfort to many they visit. Additionally, pet therapy animals can be incorporated into treatment plans for those with chronic ailments and mental health or behavioral health issues. While there are many positive attributes to service animals, there can be challenges. A hypothetical case illustrates what can happen when a patient presents with a service animal and the healthcare system is ill-equipped to address the needs of the patient and service canine. RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 1
The Hypothetical Case of Renatta Edwards At 3:30 pm on a Friday afternoon, 68 year-old Renatta Edwards presented at the community hospital emergency department. She told the triage nurse that she had a longstanding history of mental health issues and that she decided to go to the hospital because she wanted to hurt herself. The triage nurse contacted the nurse manager for the Emergency Department and she quickly came to meet Ms. Edwards. My colleague told me that you were not feeling well and that you had thoughts about hurting yourself. Is that correct? asked the nurse manager. Ms. Edwards replied, Yes. I was thinking of cutting my wrists again and taking all of my medication at one time. The nurse manager said, Thank you for telling me what is happening. I am going to have a behavior health care provider meet with you as soon as possible. Meantime, make yourself comfortable here. One of our emergency room technicians will be with you. I see you have a dog with you. Is the dog a pet or a service animal? Ms. Edwards said, This is Lenny. He is my service dog. He has been with me for three years. He is the reason I did not hurt myself. I cannot imagine what would happen to Lenny if I was gone. The emergency physician examined Ms. Edwards. Is anything bothering you physically? Are you having any pain? Any discomfort? she asked. Ms. Edwards responded, Not really. I have chronic pain from arthritis in my left elbow and my right knee. It is controlled with non-prescription medication. As the emergency room physician was leaving the examination area, Brian Furst, M.S.W. arrived to see Ms. Edwards. He introduced himself as being a behavioral health provider whose firm was under contract with the community hospital to assist patients in need of psychiatric and behavioral health services. After speaking with Ms. Edwards and conferring with the emergency physician Mr. Furst concluded that Ms. Edwards was in need of inpatient mental health services. RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 2
I think you need inpatient treatment in a secure facility, Ms. Edwards, said Mr. Furst. He continued, I have a bed for you at a very good facility that is located 25 miles from here. I will arrange for your transportation and admission. As he got up to leave the examination area Mr. Furst said to the nurse manager, Ah Sue. I will assume you will take care of placing the dog in a shelter or getting a family member to take the animal. We don t allow animals at our shop. Ms. Edward became visibly upset and started to cry. You can t do that. You can t take Lenny from me. He is my service animal. He is not a pet. I can t function without him. Please! You don t understand. Mr. Furst responded, Sorry. But rules are rules. You will be just fine. Lenny will be okay, too. The nurse manager called Janice Cousins, the oldest daughter of Renatta Edwards and asked her to come to the hospital and pick up Lenny. What do you people think you are doing? You cannot separate them. She cannot function without that dog. Please find her a location that will take her and the dog. This decision will make her condition worse. I am going to contact her psychologist and have her call you, said Ms. Cousins. Shelley Thomsen, Ph.D., called the hospital and spoke with the nurse manager in the emergency department. She reiterated what the patient and her daughter had said regarding the service animal. When the nurse manager would not reverse the decision, Dr. Thomsen asked the hospital operator to connect her with the risk manager. After three rings, Dr. Thomsen got a record message indicating that the risk manager was not available and that all calls were being transferred to patient relations. Dr. Thomsen spoke with the patient relations representative who said, We follow established protocol Dr. Thomsen. Certainly, if the patient is unhappy she can file a formal grievance with our organization. Ms. Edwards was taken to the behavioral facility and placed in a secure unit under observation for suicidal ideation. She seemed to become withdrawn. Periodically, she would have bouts of crying and moaning. RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 3
Two days later Dr. Thomsen was finally able to speak with both the psychologist and the psychiatrist caring for Ms. Edwards. Sorry that we could not speak with you previously, but we need written authorization to do so, said the psychiatrist. Dr. Thomsen carefully explained why the service animal was such an important component of the care plan for Ms. Edwards. Without that dog I think you will find that Ms. Edwards will continue to deteriorate, said Dr. Thomsen. Well, I have to agree with you that I have seen continued deterioration since she got here, said the psychologist. He continued, I know that the unit nursing team is opposed to the presence of service animals, but in this instance I think we should reconsider. After further discussion, the psychiatrist said to her colleague, the clinical psychologist and to Dr. Thomsen, Okay. Let s give it a try. I will discuss the plan with the nurse manager. Arrangements were made to feed, water and walk Lenny. There was no disruption in patient care for others in the behavioral unit. After several days of treatment, Ms. Edwards was discharged home with a plan that included ongoing treatment with Dr. Thomsen and a psychiatrist in the community. What I went through should never happen to anyone else. I needed Lenny more then at any other time and their insensitive response made my situation worse, said Ms. Edwards to her daughter and to Dr. Thomsen. She continued, I asked my attorney to come over this afternoon and she and I are going to discuss what can be done to fix this problem. Subsequent to her discussion with her attorney, Ms. Edwards filed a formal complaint with her state s human rights commission, the mental health advocate for the state and the accrediting body for the hospital and the behavioral health center. She also submitted formal complaints with the state licensing agency for both facilities as well as the Centers for Medicare and Medicaid. A written grievance was also filed with the hospital. Somehow the media got hold of the story and it made it to the evening news on three news outlets. RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 4
Observations on the Hypothetical Case of Renatta Edwards Several issues emerge in the Renatta Edwards case. A lack of a clear service animal policy and procedure at the hospital, and at the behavioral health center are a focal point of concern. There was a lack of understanding on the part of the behavioral health provider contracted to do so-called psych evaluations. The case revealed the absence of a loss prevention process to manage the concurrent issue when the risk manager was out of the hospital. The patient relations representative appeared unaware of applicable federal and state laws dealing with the use of service animals. Suggesting that the patient could file a grievance, while correct, was a step that could have been averted with an appropriate risk management response. There was an assumption that the patient s adult daughter would take the service animal. Further, there was an assumption that there was an animal shelter readily available to take a service animal when the patient was moved to the behavioral health facility. None of the professionals seemed to listen to what the patient was saying. The care providers underestimated the impact on the patient of removing the support provided by the service animal. One can well ask, why no one thought to seek out an appropriate behavioral facility that permitted inpatients to be accompanied by a service animal. The case gave rise to an array of legal, regulatory and reputational risks. One should not minimize the cost of defending enforcement actions brought by the U.S. Department of Justice under the Americans with Disabilities Act (ADA) or a state human rights office. Similarly, one should not be dismissive of the time and expense associated with accreditation bodies completing unannounced visits based on a patient complaint involving a claimed standards violation. Well-publicized and visible federal and state inquiries are apt to have a negative impact on the reputation of a healthcare organization. The result could be a loss of market share and reduced income. While there was much uncertainty whether the facilities would permit the patient to have her service animal, one may well ask what limitations may be imposed to curtail access to service animals? Beyond restrictions based on infection RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 5
prevention and safety, are there other allowable constraints on the presence of a service animal? These questions were not addressed in the hypothetical case. However, these open items merit consideration by healthcare facilities. Risk Management Strategies for Service Animals in Healthcare Service animals fulfill an important role in the lives of many individuals. Not only supplying companionship and assistance with the activities of daily living, the service animal can help those who significant emotional, psychological and behavioral conditions. No doubt there is ever present the opportunity for someone to abuse the system, by feigning that a dog is a service animal when in fact the canine is a household pet. But a few bad apples should not prevent the appropriate use and deployment of service animals. There are many strategies to consider to lessen potential risks associated with service animals, including the following: 1. Start with a Comprehensive Service Animal Policy and Procedure. Design a policy and procedure that considers the various settings in which service animals may be present in the healthcare organization. Identify potential restrictions, such as isolation units. Factor in the types of service animals that are permitted in each setting. Consider practical issues such as feeding and watering the service animal as well as exercising and waste elimination. Identify who will be responsible for such activities. Do not assume that just anyone including a volunteer is qualified to handle these tasks with a service animal. Contemplate the following items as well: Federal ADA requirements for reasonable accommodation State antidiscrimination laws National standards State standards Advice from experts on service animals Withdrawing service animals that are out of control or pose a direct threat 8 Exceptional circumstances Internal communication algorithm on service animal questions Chain of command for questions on use of or separation from a service animal RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 6
Hand-off communication and teach-back when patients are transferred to another entity for treatment with or without the service animal 2. Consider Administrative Items in the Service Animal Policy and Procedure. Deter false assertions that a canine or other species is a service animal. Recognize while it in generally runs contrary to ADA requirements to insist upon certification or proof that the dog is in fact a service animal, there are some legitimate questions that can be asked that are consistent ADA enforcement information: When it is not obvious what service an animal provides, only limited inquiries are allowed. Staff may ask two questions: is the dog a service animal required because of a disability, and (2) what work or task has the dog been trained to perform. Staff cannot ask about the person s disability, require medical documentation, require a special identification card or training documentation for the dog, or ask that the dog demonstrate its ability to perform the work or task. 9 Make certain that the approach developed is also consistent with applicable state law. Have in place a response plan for answers that indicate that the canine is not a service animal. 3. Consider Employee Rights and Responsibilities. Address the need for possible reasonable accommodation for staff that are allergic to, or afraid of, service animals. Contemplate how such issues should be addressed in such documents as the employee handbook, collective agreements, and medical staff bylaws. 4. Anticipate the Need for Shelter Accommodation for the Service Animal. Identify if there is a trusted friend or family member who can take in the service animal who cannot be with the patient. Identify as well local veterinary clinics or non-euthanizing shelters to provide safe accommodation for the service animal when separation from the patient is a necessity. Get important service animal demographic information if possible from the patient, such as the veterinary clinic that treats the RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 7
animal so that the temporary provider or shelter can communicate about diet, medication and other special needs for the service animal. 5. Anticipate Patient Anxiety with Separation from the Service Animal. Recognize that the patient may become distressed and anxious when separated from the service animal. Make certain to communicate who will be caring for the service animal. Consider too, alternate ways in which the patient can connect with the service animal such as through Skype, Facetime, Photos, and recordings of the animal s sounds or being able to speak the animal over a telephone. 6. Establish Documentation Practices for Use of Service Animals. Consider screening tools that capture important information on such items as up-to-date vaccination records, demographic and contact information. Capture too in EHR, EMRs, discharge and transfer forms key information on the use of service animals. Recognize that the same considerations should extent to disaster situations when healthcare facilities take in patients with service animals. 7. Education on the Service Animal Policy and Procedure. Provide mandatory and regular in-service education on the use of service animals for clinical and non-clinical personnel. Incorporate into contracts with outside service vendors such as behavioral health evaluation programs mandatory education on the use and separation of service animals. 8. Establish Patient Expectations on the Use of Service Animals. Take advantage of information kiosks, health fairs, website, social media and written brochures to inform patients about their rights and responsibilities with regard to service animals. 9. Be Poised to Respond to Adverse Events and PCEs Recognize that service animals may be the source of adverse events and potential compensatory events, including biting or scratching someone, being the vector of an infectious disease, etc. Work with patient relations on service animal-related complaints from other patients and visitors. Include in the risk management protocol a mechanism for investigating and managing such events that encompasses disclosure, apology and putting insurance carriers or captive managers on notice. Anticipate too, RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 8
potential negative media coverage. Conclusion. Service animals are a valuable resource to patients who benefit from the work of highly trained canines and other species. However, the use of service animals in certain settings may need to be curtailed when balancing the benefits with the potential risks and disruption to patient care. By examining carefully the requirements of applicable federal regulations, state law, and national practice standards, healthcare facilities can develop practical approaches to leverage the benefits of service animals while taking steps to minimize the risks associated with their presence in a healthcare setting. RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 9
1 http://www.guidedogsofamerica.org/1/ 2 http://www.neads.org/assistance-dogs/people-who-are-deaf-or-have-hearing-loss 3 https://www.pawswithacause.org/i-want-a-dog/seizure-dogs 4 See in particular Title 42, chapter 126, Untied States Code, the pubic accommodation provisions found in Title III of the ADA. See also, the ADA Regulation for Title III at 28 CFR Part 36 (2011). 5 http://www.ada.gov/qasrvc.htm 6 See. E.g. http://www.ptsd.va.gov/public/treatment/cope/dogs_and_ptsd.asp 7 http://www.ada.gov/service_animals_2010.htm 8 http://www.ada.gov/service_animals_2010.htm 9 Service Animals, http://www.ada.gov/service_animals_2010.pdf, July 2011. If you would like assistance in developing a risk management service animal policy and procedure, please contact us: www.therozovskygroup.com or (860) 242-1302 RMS NEWSLETTER ALL RIGHTS RESERVED 2014 PAGE 10