The Scenario
Ryan is a Veteran who suffers from post-traumatic stress disorder (PTSD) following his tours of duty overseas. He is also the father of a newborn girl, who is scheduled for a well-child visit at your practice. On the day of his daughter’s visit, Ryan brings with him Ollie, his well-trained, 70-pound American pit bull, without letting your office know beforehand.
You see Ryan walking in with Ollie leashed and his wife holding their daughter. Some of the children in the waiting area immediately cower from the animal, while others approach to pet it.
How would you handle this situation in accordance with the laws and regulations regarding service animals but also meet the needs of your patients?
Animals can be trained to guide blind people through hazardous street intersections, provide psychiatric therapy to Veterans suffering from PTSD, and alert diabetics of hypoglycemic and hyperglycemic events. During the pandemic, humans found a way to train dogs to sniff out people with COVID-19 with relatively high accuracy within a crowd. Today, the increased use of service animals by people with disabilities in the U.S. is likely due to the passing of the Americans with Disabilities Act of 1990 (ADA), which protects people with disabilities from discrimination by places of public accommodation or in public entities and workplaces.
Medical offices, facilities and hospitals are considered places of public accommodations and must usually accommodate patients with disabilities who use service animals under the ADA. While few health-related establishments may be exempted from the ADA requirements, the U.S. Department of Justice (DOJ) filed a Statement of Interest on May 17, 2022, clarifying its position that even blood plasma donation centers are “public accommodations” under the expansive purpose of Title III of the ADA.
Because states may have additional protections for people with disabilities, the questions below focus on the requirements from the ADA. For state-specific laws, see the Animal Legal & Historical Center, which maintains a database of service animal laws.
1. What is a service animal?
A service animal, under the ADA, is defined as a dog that has been individually trained to do work or perform tasks for an individual with a disability. The task(s) performed by the dog must be directly related to the person's disability. The dog must be trained to take a specific action when needed to assist the person with a disability.
2. What are some examples of work a service animal provides?
- A person with diabetes may have a dog that is trained to alert him when his blood sugar reaches high or low levels.
- A person who uses a wheelchair may have a dog that is trained to retrieve objects for them.
- A person with depression may have a dog that is trained to perform a task to remind them to take their medication.
- A person with PTSD may have a dog that is trained to lick their hand to alert them to an oncoming panic attack.
- A person who has epilepsy may have a dog that is trained to detect the onset of a seizure and then help the person remain safe during the seizure.
3. In Ryan’s scenario, how would you know his pit bull is a service animal?
The ADA does not restrict the type of dog breeds that can be service animals. A service animal may not be excluded based on assumptions or stereotypes about the animal's breed or how the animal might behave. The DOJ guidance states that in situations where it is not obvious that the dog is a service animal, staff may ask only two specific questions:
- Is the dog a service animal required because of a disability?
- What work or task has the dog been trained to perform?
Staff are not allowed to:
- Request any documentation for the dog,
- Require that the dog demonstrate its task, or
- Inquire about the nature of the person's disability.
The ADA does not require service animals to wear a vest, ID tag or specific harness that would identify them as service animals. If a particular service animal behaves in a way that poses a direct threat to the health or safety of others, has a history of such behavior, or is not under the control of the handler, that animal may be excluded. If an animal is excluded for such reasons, staff must still offer their goods or services to the person without the animal present.
4. What is an emotional support or therapy animal?
Under the ADA, emotional support, facility and therapy animals DO NOT qualify as service animals.
Emotional support animals (sometimes called comfort or companion animals) help reduce either a person’s identified emotional symptoms or some effect of a person’s disability by providing companionship to its owner. These animals are typically used by only its owner (handler) and are afforded some protection under federal housing laws; some states do allow these animals into places of public accommodations.
Therapy animals (sometimes called facility animals) provide therapeutic contact to one or more patients. These animals are typically trained to work with groups of people and be tolerant of various environments. They are used clinically, such as in hospital recovery settings or post-traumatic event counseling. Unlike assistance animals, therapy animals can be owned by a facility or another third party who provides the animal as a therapeutic tool to multiple people.
5. Does the ADA require service animals to be professionally trained?
No. People with disabilities have the right to train the dog themselves and are not required to use a professional service dog training program.
6. Are service-animals-in-training considered service animals under the ADA?
No. Under the ADA, the dog must already be trained before it can be taken into public places. However, some state or local laws, such as in Louisiana, do protect animals that are still in training.
7. Who is responsible for the care and supervision of a service animal?
The handler is responsible for caring for and supervising the service animal, which includes toileting, feeding, grooming and veterinary care. Covered entities are not obligated to supervise or otherwise care for a service animal.
8. Can people bring more than one service animal into a public place?
Generally, yes. Some people with disabilities may use more than one service animal to perform different tasks. For example, a person who has a visual disability and a seizure disorder may use one service animal to assist with way-finding and another that is trained as a seizure alert dog. Other people may need two service animals for the same task, such as a person who needs two dogs to assist him or her with stability when walking. Staff may ask the two permissible questions about each of the dogs. If both dogs can be accommodated, both should be allowed in.
9. What are some risk mitigation techniques to help my practice?
Always ask yourself if the patient is being treated differently because of the presence of a service animal. Are other options available? Can you see the service animal team first and thus limit the time in the waiting room? Can the service animal team wait in the exam room?
Scheduling. Make your policies about pets and service animals clear to the public. Encourage patients to let your practice know if they intend to bring in a service animal. If they do, consider accommodating the patient by offering an early or late appointment.
Documentation. The patient with a service animal should not be treated differently. When accommodating patients, document that the patient was accommodated and the facts surrounding the accommodation. Consider having senior management make determinations of whether to exclude an animal. If exclusion is warranted, properly document the patient’s medical record to explain the circumstances leading up to the exclusion.
Emergencies. During public health emergencies or public disasters, some facilities and practices may need to see patients who have service animals. Have policies for these situations to ensure that staff do not inadvertently discriminate against a person with disability.
Policy and training. The information in this article and in the Medical Interactive CME/CNE course described below can be used to develop a policy that conforms to the ADA and state regulations. Training staff regularly and documenting this training can help you avoid penalties, fines, and potential damages associated with violating the ADA.
Patients’ request for service animal prescriptions. While a prescription or doctor’s note isn’t required for a patient with a disability to legally use a service animal, patients may nonetheless request that their providers give a note or a prescription. Healthcare providers are allowed (but not required) to provide such a note documenting the patient’s need for a service animal because of a disability.
If a provider is unable to determine based on his medical judgement and expertise that a service animal is necessary or helpful to the patient because of their disability, simply decline to provide a note or a prescription. However, if a provider chooses to give the patient a note or a prescription, based on their experience and expertise, consider the following:
• Document the medical rationale regarding the patient’s medical condition that justifies the use of a service animal.
• Ask the patient if they would like their medical condition listed on the note or form before doing so.
• If a patient brings in their own form and the provider chooses to fill it out, make a copy of the form and document it into the patient’s medical record.
If a patient does not have a disability warranting a service animal, they may nonetheless ask for an emotional support animal prescription or note. The same risk mitigation tips would apply. The healthcare provider should determine whether an emotional support animal is warranted, based on the provider’s medical judgement and training.
10. Where can I find more information?
Many questions that have been asked regarding service animals have been answered by the U.S. Department of Justice and can be found here.
Medical Interactive Community offers an education activity, “Patients With Service Animals: Concerns and Risk Issues,” that LAMMICO insureds may access free of charge via their Member account. The course addresses issues relating to service animals, service animal etiquette and various risk mitigation strategies that can help your practice avoid potential discrimination suits. Log in as a Member at lammico.com to access this course.