Outpatient Medical and Health Care Facilities

Access Equals Opportunity Your Guide to the Americans with Disabilities Act

Outpatient Medical and Health Care Facilities
FOREWORD

The Americans with Disabilities Act (ADA) calls for businesses to make their facilities, goods, and services accessible to all people with disabilities.  The ADA is good business because access for everyone is the key to attracting new customers and retaining those you now serve.

This Guide will help you work creatively to comply with requirements of the public accommodations section of the Act for existing businesses.  It contains suggestions for readily achievable-cheap and easy-methods for removing architectural barriers; methods for achieving effective communication; and guidance for determining whether your policies or procedures might exclude some people with disabilities.

To make sure that the Guide provides practical answers to your questions, seven Better Business Bureaus in different regions of the country brought together local business leaders and disability rights groups to discuss their concerns and questions about compliance.  Instructive answers to the most frequently asked questions are included.

The Guide was produced by the Council of Better Business Bureaus' Foundation in conjunction with the Disability Rights Education and Defense Fund (DREDF).  Initial funding was provided by the U.S. Department of Justice.  The Foundation and DREDF have joined together in a partnership for compliance to help small and mid-sized businesses understand what they have to do to comply
with the ADA. 

Copyright 1992
Council of Better Business Bureaus' Foundation

The Council of Better Business Bureaus' members are 400 national corporations and more than 150 Better Business Bureaus around the country whose members are 250,000 small and mid-sized businesses.  The Council's Foundation is an education and research organization.

DREDF is a national law and policy center dedicated to furthering the civil rights of people with disabilities.  It is managed and directed by people with disabilities and parents of children with disabilities.  DREDF is universally credited for their leadership in the passage of the ADA.

We are working together to promote voluntary compliance with the Act.  Businesses that fail to comply are subject to administrative complaints, lawsuits, and fines.  People in business who read this Guide will learn that compliance really is good for business.

We thank all who helped produce this Guide: the Better Business Bureaus of Austin, Boston, Denver, Fresno, New Orleans, Philadelphia, and Toledo; the participating local business and disability leaders; the staff and consultants of the Council of Better Business Bureaus, the Foundation, and DREDF; and the staff of the Civil Rights Division of the U.S. Department of Justice.

Barbara Bode, Executive Director, Council of Better Business Bureaus' Foundation

Liz Savage, National Director of Training and Technical Assistance, Disability Rights Education and Defense Fund

July, 1992

OVERVIEW OF THE AMERICANS WITH DISABILITIES ACT

Introduction

The Americans with Disabilities Act of 1990 (ADA) is the nation's first comprehensive civil rights law for people with disabilities.  The ADA changes the way America does business.

The ADA aims to eliminate discrimination against people with disabilities by ensuring equal opportunity in employment, state and local government services and programs, places of public accommodation, public and private transportation, and telecommunications.  This publication provides an overview of Title III of the Act, Public Accommodations, with a specific emphasis on
requirements for existing facilities and current service practices.

Who is protected?

Under the ADA, a person with a disability is someone with a physical or mental impairment that substantially limits one or more major life activities, or someone with a record of such an impairment, or one who is regarded as having such an impairment.

Examples of disabilities include orthopedic, visual, speech, and hearing impairments; cerebral palsy; epilepsy; muscular dystrophy; multiple sclerosis; cancer; heart disease; diabetes; mental retardation; psychiatric disability; specific learning disabilities; HIV disease (whether symptomatic or
asymptomatic); tuberculosis; drug addiction (although people who are currently illegally using drugs are not covered); and alcoholism.

What are "Public Accommodations" under the ADA?

Title III of the ADA specifies twelve types of entities that, regardless of  size, are public accommodations: places of lodging, exhibition or entertainment, public gathering, public display or collection, recreation, and exercise; private educational institutions; establishments serving food or drink; sales or rental establishments; service establishments; stations used for specific public transportation; and social service center establishments.

When must public accommodations comply with the ADA?

Title III went into effect on January 26, 1992, for all covered businesses, including small ones.  However, small businesses have been given a grace period before legal action can be taken against them.  For businesses with 10 or fewer employees and gross annual receipts of less than $500,000, the grace period extends until January 26, 1993.  This grace period does not apply to violations of the ADA's requirements for new construction or alterations.

Actions that are discriminatory

The ADA identifies actions that discriminate against people with disabilities.  In general, denial of the right to participate and unequal or separate treatment are prohibited by the ADA.  For example, a business cannot ask a person with a disability to leave because an employee or another customer is uncomfortable with that person's disability or because its insurance company conditions coverage or rates on the absence of people with disabilities.  Nor, for example, can people with disabilities be limited to attending only certain performances at a theater.

Services in an integrated setting

Title III requires that public accommodations provide their services to people with disabilities in the most integrated setting possible.

Reasonable modifications to policies, practices, and procedures

Public accommodations are required to make reasonable modifications to their policies, practices, and procedures in order to make their goods and services available to people with disabilities unless the business can demonstrate that a modification would fundamentally alter the nature of the goods or services provided.  For example, an auto rental agency with a policy requiring that the person who will be driving the vehicle must pay for the rental of the vehicle would be required to modify that policy by making an exception to allow the person with a disability who has arranged for someone else to drive to rent the vehicle using a credit card, provided the driver of the vehicle has valid driver's license.

Eligibility criteria

A public accommodation is not allowed to apply eligibility criteria for its goods or services that tend to, or that actually do, screen out people with disabilities except when the criteria are necessary to provide the goods or services that are being offered.  For example, an automobile dealer cannot
require an individual to state on a credit application whether the applicant has a disability because this information is not relevant to obtaining credit approval and could be used to exclude a customer illegally from credit eligibility.

The ADA also requires that any criteria used be applied fairly and equally to all members of the public.  It prohibits public accommodations from basing their eligibility criteria on assumptions that would unnecessarily exclude individuals with disabilities who, in fact, are eligible to participate in an
activity.

Effective communication with the public

Public accommodations are required to communicate effectively with customers or clients who are deaf or hard of hearing or who have speech or vision impairments by whatever means are appropriate.  In the ADA, the term "auxiliary aids and services" refers to the means for achieving effective communication.  This term includes sign language interpreters; written materials; assistive listening devices; Telecommunication Devices for the Deaf (TDDs); taped, brailled, or large print materials; readers; and other communication tools.

The auxiliary aid requirement is a flexible one.  The goal is to find an effective means of communication that is appropriate for the particular circumstance.  For example, interpreters are not required if a deaf customer has come into an automobile sales showroom merely to look at the latest models.  The dealer would be able to communicate general information about models available by providing brochures, exchanging notes by pen and note pad, or taking turns at a computer keyboard.  However, this means of communication may not be sufficient in complex consumer transactions such as those necessary when a deaf individual becomes serious about buying a car.

A business is not required to provide any particular auxiliary aid or service that it can demonstrate would fundamentally alter the nature of the goods or services being provided or would result in an undue burden on the business.  It must, however, provide those needed auxiliary aids and services that would not result in an undue burden.  "Undue burden" is defined as significant difficulty or expense when considered in light of a variety of factors including the nature and cost of the auxiliary aid or service and the overall financial and other resources of the business.  The undue burden  standard is intended to be applied on a case-by-case basis.

Removal of architectural barriers in existing facilities-What is "Readily Achievable"?

Public accommodations are required to remove architectural barriers-those elements of a facility that impede access by people with disabilities-to ensure access for customers, clients, or patrons where it is possible to do so in a readily achievable manner.  Examples of barriers are curbs and steps; narrow exterior and interior doorways and aisles; rest room doorways and stalls that are too narrow for use by a person who uses a wheelchair; and inaccessible drinking fountains and telephones.

The ADA defines "readily achievable" as "easily accomplishable and able to be carried out without much difficulty or expense."  Examples of barrier removal possibilities include providing a ramp for one or even several steps, widening doorways, reconfiguring display shelves to increase aisle width, widening bathroom doorways, moving toilet stall partitions, and installing grab bars.

The readily achievable standard does not require barrier removal that involves extensive restructuring or burdensome expense.  Required barrier removal for a particular public accommodation will depend on its financial and other resources.  The readily achievable standard is intended to be a flexible one that is applied on a case-by-case basis.

The Department of Justice (DOJ) has recommended an order of priorities for barrier removal that it urges businesses to follow.  First, provide access from parking areas, sidewalks, and entrances to the public accommodation so a person with a disability can "get through the door."  Second, provide access to those areas where goods and services are provided.  Third, provide access to rest room facilities when they are open to the public.  Fourth, take other measures to provide access to the goods, services, or facilities.

The questions and answers in this Guide are organized according to priorities.

Landlord and tenant-Allocation of responsibility for complying with Title III of the ADA

Both the landlord who owns the building where a public accommodation is located and the tenant who owns or operates the public accommodation are responsible for compliance with Title III.  They may allocate between themselves the responsibility for meeting their mutual obligations however they wish.

Allocation of responsibilities between landlord and tenant for removing barriers when readily achievable, providing auxiliary aids and services, and modifying policies, both in common areas as well as within places of public accommodation, may be determined by the lease or other contract between the parties.  Alterations clauses in a lease often spell out what a tenant is allowed to do within leased space, while compliance clauses allocate responsibility to one party or another for compliance with federal, state, and local laws.

Tenants are advised to review ADA obligations with their landlords.  Those tenants who are entering into new leases should negotiate and allocate responsibility for ADA compliance with their landlord.  Failure to determine, allocate, and execute ADA responsibility may result in either the tenant's or landlord's liability for noncompliance.

Accessibility Guidelines

The Americans with Disabilities Act Accessibility Guidelines (ADAAG) issued by the Architectural and Transportation Barriers Compliance Board can serve as a guide for identifying the various kinds of measures that can be taken to remove barriers and as a guide for how best to remove them.

If there are steps to the front entrance and the front door is very narrow, businesses must provide a ramp and widen the door according to ADAAG standards if it is readily achievable to do so.  If it is not readily achievable to follow the ADAAG standards for ramps and doorways, public accommodations must take other safe, readily achievable measures, such as installation of a slightly narrower door or a narrower door or a slightly steeper ramp than that permitted by the ADAAG.  Although these barrier removal measures would not meet the ADAAG standards for alterations, they would nevertheless afford significant access for many customers or clients.

Where some elements of a facility come very close to meeting the ADAAG standards and others fall far short, public accommodations are advised to put first priority on removing the barriers that most deviate from ADAAG standards.  For example, if the front entrance already has a ramp that is just slightly steeper than that permitted by the ADAAG and the front door is just slightly narrower than that permitted by the ADAAG, but elements in interior areas that serve clients or customers are wholly inaccessible, public accommodations should turn their attention first to the barriers that are the biggest impediments for their customers or clients.  They should remove those that can be removed in a readily achievable manner before turning their attention to elements that deviate only slightly from the ADAAG standards.

It is a good idea for public accommodations to become familiar with the full array of access concerns that the ADAAG addresses.

For a free copy of the ADAAG contact:
Architectural and Transportation Barriers Compliance Board
1331 F. Street, NW, Suite 1000
Washington, DC  20004-1111
(800)USA-ABLE (Voice/TDD)

Barrier removal and effective communication-A continuing obligation

Readily achievable barrier removal is a continuing obligation.  Barrier removal that was not readily achievable initially may later be required because the public accommodation has more resources available.  Therefore, a public accommodation must continually monitor its accessibility as well as its financial and other resources and engage in barrier removal as new measures become readily achievable.

Achieving effective communication for people with disabilities is also a continuing obligation.  Auxiliary aids that were not required initially because they pose an undue burden may be required later in light of changing resources or changing technologies.

Alternative methods

If providing access by removing barriers is not readily achievable, the law requires public accommodations to provide readily achievable alternatives to barrier removal.  For example, if an automobile dealer cannot eliminate barriers to the showroom, sales negotiations could be conducted at another location or at the customer's home.

Surcharges

Public accommodations may not assess any surcharges on individuals with disabilities for auxiliary aids and services, barrier removal, or alternative measures taken in lieu of barrier removal.

Alterations of existing facilities.

Title III requires that physical alterations to public accommodations undertaken after January 26, 1992, be readily accessible to and usable by people with disabilities to the maximum extent feasible.  The term "alterations" refers to changes a business is undertaking for its own purposes, such as renovation, and does not refer to steps a business takes to comply with the ADA's requirements for barrier removal.  Alterations that affect or could affect usability are required to be accessible.

When alterations are made to "primary function areas"-work areas and areas used by the public-alterations must also be made to provide an accessible path of travel to the altered areas.  "Path of travel" means access to rest rooms, telephones, and drinking fountains serving the area.  The cost of providing an accessible path of travel need not exceed 20 percent of the total cost of
the original alterations.

New construction

All newly constructed facilities must be readily accessible to and usable by people with disabilities if a completed application for a building permit or permit extension was filed after January 25, 1992, and the facility is occupied after January 26, 1993.

The technical standards for accessible new construction and alterations are set out in the ADAAG.

What do these requirements of the ADA mean to you?

Congress and DOJ recognize that businesses not only are unique but also have different financial and other resources.  Although most public accommodations will have to do something to comply with the ADA, the law allows businesses to determine on a case-by-case bases what steps must be taken to comply.

Here are a few simple steps that DOJ recommends for getting started:

  • Contact organizations of or for people with disabilities in your community to help identify physical barriers to your facility or your goods or services and to familiarize you with various kinds of auxiliary aids and services that can help you communicate effectively with your customers or clients. 
  • Make a list of architectural, policy, and communication barriers. 
  • In consultation with organizations of or for people with disabilities, set priorities for removing architectural barriers, changing any discriminatory policies, and providing effective      communication.
  • Develop an implementation plan designed to achieve compliance with the ADA.  Such a plan, if appropriately designed and diligently executed, could serve as evidence of a good faith effort to comply.
Tax incentives

Congress also has amended the Internal Revenue Code to include tax incentives for businesses that incur expenses in removing barriers or increasing accessibility for people with disabilities.  The "Tax Deduction to Remove Architectural and Transportation Barriers to People with Disabilities and Elderly Individuals" (Title 26, Internal Revenue Code, Section 190) allows a deduction for "qualified architectural and transportation barrier removal expenses" not to exceed $15,000 for any taxable year.  The "Disabled Access Tax Credit" (Title 26, Internal Revenue Code, Section 44) is available to eligible small businesses with 30 or fewer employees or $1 million or less in gross annual receipts.  This provision allows a tax credit of 50 percent of eligible access expenditures tat exceed $250 but do not exceed $10,250 made for the purpose of complying with the ADA during the tax year.

For more information on these tax provisions, contact the Internal Revenue Service, Office of the Chief Counsel, PO BOX 7604, Ben Franklin Station, Washington, DC 20044, (202) 62203110 (voice only).

Please note that this Guide provides only an overview of the ADA.  There may be other requirements that are not discussed here but that do apply to your business.  Detailed information about a business' obligations with respect to employment are not covered, and requirements for new construction and alterations of existing facilities are discussed only briefly.

The following section answers some common questions about compliance with the public accommodations section of the ADA raised by health care providers.

OUTPATIENT MEDICAL and HEALTH CARE FACILITIES

Q.   Are outpatient medical and health care facilities considered to be places of public accommodation?

A.   Yes, privately operated medical and health care facilities are covered by Title III. Examples of such facilities are the offices of private doctors, dentists, optometrists, opticians, chiropractors, psychiatrists, psychologists and other therapists, acupuncturists, and nutritionists; clinics; family planning facilities; occupational and physical therapy facilities; laboratories and radiology facilities; and day care surgery centers located in facilities separate from hospitals.  The public accommodation provisions of the Americans with Disabilities Act (ADA)also apply to the offices of private medical and health care providers located in private homes.  This publication addresses all of these types of facilities. Private hospitals and other in-patient facilities, which are also public accommodations under Title III of the ADA, are not addressed here.
 

Q.   Are there other federal laws protecting the civil rights of people with disabilities that medical and health care facilities should know about?

A.   Yes.  Section 504 of the 1973 Rehabilitation Act, which applies to recipients of federal financial assistance, may apply to medical and health care facilities.  The ADA does not supersede Section 504.  Facilities that have been subject to Section504 must still comply with that law; these facilities may also be subject to additional requirements under the ADA.
 

Q.   Are outpatient medical and health care facilities required to have TDDs (Telecommunications Devices for the Deaf?)

A.   No.  For making calls to and receiving calls from customers with hearing or speech impairments who use TDDs, retail stores will be able to rely on the relay systems that telephone companies must establish by July 26, 1993.  Operators employed by relay systems will relay communications between TDD-users and people using conventional telephones.  Only those businesses that allow customers to make outgoing calls on more than an incidental convenience basis must provide TDDs.

Health care facilities can ensure effective communication by training staff who answer the telephone to anticipate incoming calls through the relay services. Handling these calls may take longer because an operator at the relay system will be receiving typed communications from the caller and will also be using the relay system equipment to type communications from the health care facility staff person to the caller.  Training should be undertaken as soon as possible because at least 40 states already offer some type of relay service. 

For your information, however, a TDD is relatively inexpensive, usually costing about $275 and would be a welcome service for customers with hearing or speech impairments.  If you have a TDD, be sure to list your telephone number followed by "Voice/TDD" in any publications or advertisements to signify that customers can communicate with you by voice or TDD.
 

Q.   Are health care facilities that offer parking required to provide accessible parking spaces for people with mobility impairments?  If such parking is required, how many spaces must be provided? 

A.   Yes.  If an health care facility owns and operates the parking lot, it must provide accessible parking if it is readily achievable to do so.  If a health care facility is tenant, responsibility for providing accessible parking rests with both the landlord and the tenant.  These responsibilities may be allocated between the landlord and tenant in the lease or other contract. 

The spaces must comply with the dimensions specified in the ADAAG if it is readily achievable to meet those standards.  The ADAAG also specifies a formula for determining the number of accessible spaces which must be followed if it is readily achievable to do so.  If it is not readily achievable to comply with the ADAAG standards for the number and dimensions of accessible spaces, a retail store must provide as many spaces as readily achievable and of readily achievable dimensions.

If it is not readily achievable to provide any accessible spaces, a health care facility must provide readily achievable alternatives to barrier removal.  For example, health care facilities could consider providing valet parking as an alternative method of providing access.
 

Q.   Are health care facilities required to remove barriers posed by sidewalk curbs?

A.   Curb cuts (also known as curb ramps) enable people who use wheelchairs or other mobility devices to have ready access to health care facilities.  If the only parking available is on a city street and the facility does not have ownership or control of the sidewalk, the municipality, not the health care facility, is responsible for providing curb ramps.  If a health care facility owns or controls the sidewalk, it must provide curb ramps if readily achievable.  If a health care facility is a tenant, responsibility for providing curb ramps rests with both the landlord and the tenant. These responsibilities may be allocated between the landlord and tenant in the lease or other contract.

The ADAAG establishes standards for construction of curb ramps that must be followed if readily achievable.
 

Q.   Must all entrances to existing health care facilities be accessible?

A.   No, but one entrance, preferably the main entrance, must be accessible, making it possible for people with disabilities to "get through the door."  In multi-use facilities, a sufficient number of entrances must be accessible if readily achievable so that people with disabilities can reach all services offered at a particular facility.  For most health care facilities that have steps, ramping one step or even several steps will be readily achievable.

Installation of a permanent ramp, rather than a portable one, is required unless such installation is not readily achievable.  If a public accommodation cannot meet the ADAAG technical requirements for ramps because of space or other limitations, it can deviate slightly from these specifications as long as the ramp is still safe.

If a permanent ramp cannot be installed, a portable ramp must be used if readily achievable.  Portable, i.e., moveable, ramps also must be safe.  Most portable ramps are relatively inexpensive to purchase or construct.

A health care facility using a portable ramp should install a doorbell or intercom(with an appropriate sign) to summon an employee to bring the ramp to the door if readily achievable.  If the accessible entrance is one other than the main entrance, a sign at the main entrance should indicate where the accessible entrance is located.

If none of these access options is readily achievable, health care facilities must provide service through readily achievable alternative methods.  For example, doctor could examine a patient at no additional charge at a hospital where the doctor has privileges or at the patient's home.
 

Q.   How does a health care facility know if the doorway for the accessible entrance is wide enough for customers who use wheelchairs or other mobility devices?

A.   The ADAAG standard states that a minimum of 32 inches of clear opening measured between the face of the door and the opposite stop when the door is opened 90 degrees is required to provide access to customers who use wheelchairs or other mobility devices.  Offset hinges can increase the amount of clear space by several inches.

Automatic or push button doors are the best for providing access.  Whether installing them is readily achievable or not depends on the circumstances of the individual retail store.
Another measure that makes doors easier to use, not only for customers who use mobility devices but also for those who have conditions that limit their manual dexterity, is to install lever or U-shaped handles.  Some retrofit levers cost less than $10 and can improve access significantly.

Adjusting door closures or springs and oiling hinges are also inexpensive steps that make it easier to open doors and prevent them from closing too quickly. Widening doors, installing accessible door handles, and making door adjustments are examples of modifications that will be readily achievable for most businesses.
 

Q.   Are the offices of health care providers located in private homes required to make their facilities accessible to patients who use wheelchairs or other mobility devices?

A.   All areas of the home used by clients or patients are places of public accommodation under the ADA.  Therefore, health care providers must remove barriers to access in those areas if it is readily achievable to do so.  As with other public accommodations, barriers at the entrance to the home office, as well as barriers to approaches, rest rooms, and hallways, must be removed if readily achievable.

If it is not readily achievable to remove architectural barriers, medical and health care providers must take readily achievable alternative measures such as providing services at other locations or at the home of the patient or client.
 

Q.   Can a health care facility deny service to a person with a disability because
his or her disability or behavior resulting from the disability may be disturbing to other customers?

A.   No.  The ADA specifically prohibits this type of discrimination against people with disabilities.
 

Q.   Must health care facilities allow service animals, including guide dogs, to accompany customers with disabilities into their places of business?

A.   Yes, except in the rare circumstances that the presence of an animal would compromise health and/or safety standards, such as in an operating room.
 

Q.   Are health care facilities allowed to ask patients or clients with disabilities about their medical history or whether they have certain conditions or diseases?

A.   Medical and health care facilities may only ask questions that are necessary forth treatment and care of patients.  Such questions must have a legitimate medical purpose.  Facilities may not ask such questions as a method of eliminating patients or clients from services to which they are entitled.  Nor can such questions be asked because of fear, myths, or stereo-types about certain conditions or diseases.
 

Q.   Can health care facilities refer a patient or client with a disability to another practitioner solely because the other practitioner is familiar with the patient's type of disability?

A.   Medical or health care facilities that routinely make referrals may refer an individual with a disability to another facility for service only if the patient seeks or requires treatment or services outside the referring facility's area of specialization.  For example, a clinic specializing exclusively in drug rehabilitation could refuse to treat a person who is not a drug addict but could not refuse to treat a person who is a drug addict simply because the patient tests positive for HIV.  Conversely, a clinic that specializes in the treatment of individuals with HIV could refuse to treat an individual who does not have HIV, but it cannot refuse to treat a person for HIV infection simply because that person is also a drug addict.

Facilities that are not accepting any new patients may refer new patients to another facility.
 

Q    How can a health care facility determine whether its premises are accessible to people who use wheelchairs or other mobility devices?  What steps must they take to provide access?

A.   These are some common sense approaches medical and health care facilities can use to determine whether their premises are accessible.
After determining whether "getting through the door" is possible, facilities should determine whether aisles between office furniture and equipment are wide enough for a person using a wheelchair o other mobility device to pass.  Examination, treatment, and dressing room doorways must also be wide enough for individuals using wheelchairs or other mobility devices.  (See earlier question for information about doorway widths.)
Widening doors and rearranging furniture and storage items are examples of methods to provide access that will be readily achievable for most health care facilities.

Registration and patient interview areas with built-in counters should be evaluated to determine whether individuals using wheelchairs can use them.  If readily achievable, accessible counters (28 t0 34 inches high with knee spaces at least 27inches high, 30 inches wide, and 19 inches deep) must be made available.  If it is not readily achievable to provide accessible counters, then readily achievable alternative measures must be taken to provide access, such as providing a table or clipboard which patients and clients can use while filling out forms.

Facilities should also evaluate whether there are level changes between treatment and service areas.  For most health care facilities, providing a ramp for one or even several steps is a readily achievable measure to provide access.  If it is not readily achievable to install a permanent ramp, then a facility must use a portable ramp if it is safe and readily achievable.
 

Q.   Must health care facilities provide accessible rest rooms?  How can restrooms be made accessible?

A.   Rest rooms are an integral part of a health care facility's services.  Therefore, these facilities must take all readily achievable measures to remove barriers to and in rest rooms.
Certain relatively simple steps can increase access and usability.  Widening entry and stall doors; moving obstacles such as vending machines; rearranging toilet partitions to increase maneuverability for patients and clients using wheelchairs; installing a raised toilet seat; installing grab bars near the toilet; repositioning paper towel dispensers; installing lever handles on at least one sink; and installing insulation material around exposed lavatory pipes to prevent wheelchair users from burning their legs while sitting at the sink are examples of readily achievable measures for most health care facilities.

If a health care facility provides more than one rest room and not all are accessible, a sign should indicate where the accessible rest room(s) is (are)located.

Simple symbols indicating which facilities are for men or women are easier for some people with cognitive impairments (such as mental retardation) to understand than words or other images.  Raised letters and Braille differentiating men's and women's rest rooms are important for people who are blind, and large, high-contrast signs help people with limited vision.  Health care facilities must take all of these measures if readily achievable.
 

Q.   Are health care facilities with offices on both the ground floor and another floor reached only by stairs required to install an elevator?

A.   Although installing an elevator will not be readily achievable for most facilities, some means of providing access to floors above or below the ground level may be required.  If there are only several steps to reach the additional levels, a ramp is required if it is readily achievable to install one.  If there are many steps, installation of a wheelchair lift, which is much less expensive than an elevator, is required if readily achievable.  Other alternatives include using an alternative route that is accessible, such as a service entrance.

When it is not readily achievable to provide some type of access to the other level(s), medical and health care facilities must take other readily achievable steps to provide services to people with disabilities.  For example, they may be able to provide services at alternative locations such as a colleague's office on the ground-floor, the home of the patient or client, or another suitable location.
 

Q.   For health care facilities that have elevators, what is required to make them accessible?

A.   If readily achievable, facilities must install raised letters and Braille on the control panels and outside the doors for blind patients.

Placing a large, high-contrast sign with raised marking indicating the floor number opposite the elevator door helps orient people with limited vision.

If elevator controls are mounted out of reach of people who use wheelchairs and it is not readily achievable to lower them, installing a stick or pointer near the control panel will help some patients and clients operate the elevator independently.  Door timers must also be adjusted so the doors do not close too quickly.
 

Q.   What assistance must health care facilities provide for patients and clients who use wheelchairs or other mobility devices to ensure equal and effective treatment and services?

A.   Individuals with mobility impairments often find it difficult or impossible to use certain standard equipment found in medical and health care facilities.  For example, people who are not ambulatory cannot use standard-height examining tables.

Therefore, health care providers cannot conduct certain examinations that require patients to lie prone or supine unless the individual is lifted onto the table. Such measures can be unsafe, embarrassing, and undignified for many patients. Although people who use wheelchairs or other mobility devices are most often affected by this particular barrier to treatment, older patients and others who are semi-ambulatory also can experience difficulty.

An adjustable-height examining table is an ideal solution if it is readily achievable to obtain one.  Such tables can be lowered to the height of a wheelchair seat, thus enabling some patients who use wheelchairs to move independently or with minimum assistance from their wheelchairs to the table and back again.  The adjustable feature also allows medical or health care personnel to elevate the table to a comfortable height to conduct an examination.

If it is not readily achievable to obtain such a table, facilities must obtain if readily achievable, an inexpensive, padded table the height of a wheelchair seat for use by patients who cannot use the conventional tables.  This type of low table can also be used for some examinations of and consultations with patients who do not have disabilities.  A group of physicians could purchase such a table and make arrangements to share its use.

If neither of these options is readily achievable, then medical and health care facilities must provide assistance to help patients onto the high tables, including lifting them if necessary.  Such measure must be undertaken in safe manner to avoid injury to both the health care personnel and the patient and to preserve the dignity of the patient as much as possible.

Similarly, health care facilities must provide such assistance to patients with mobility impairments who are having radiology exams or other tests conducted on surfaces that cannot be adjusted for height or that are inaccessible in some other way.

In all of these situations, medical and health care personnel should follow the instructions and preferences of the patient with regard to lifting or providing other assistance.

Modifications to the manner in which certain examinations are conducted are also required.  For example, some X-ray equipment used to take mammograms is built so the patient must stand to have the X-ray taken.  Other mammogram equipment requires the patient to sit on a wheeled stool with a swivel seat.  In both situations, a woman with a disability that prevents her from standing or sitting safely on such a stool would not be able to undergo the X-ray examination.

Replacing the stool with a stable chair or allowing the patient to undergo the examination from her wheelchair are appropriate methods of providing access. Medical and health care facilities must provide assistance to undress and dress as needed or requested by patients with disabilities unless doing so fundamentally alters the services provided.

If they have a blanket policy prohibiting individuals other than patients in examination or treatment facilities, medical and health care facilities must modify the policy to allow a family member, friend, or personal care assistant to accompany a patient or client when necessary during the examination or treatment.
 

Q.   What access problems do patients with mobility impairments encounter at dentists' offices?

A.   Some patients who use wheelchairs either cannot independently transfer into the dentists' chair or must remain in their wheelchairs because of their disabilities. For a patient who does not have to remain in his or her wheelchair and wishes to transfer to the dentists' chair, dental staff must provide assistance in transferring unless doing so would fundamentally alter the service provided.

Staff should follow the instructions and preferences of the patient with regard to lifting or providing other assistance.  Cushions or pillows may be necessary tenable a patient to sit comfortably in the dentists' chair for the examination or treatment.

Some procedures do not require the patient to transfer from the wheelchair.  In these cases dentists should allow the patient to remain in the wheelchair if he or she wishes.  Dentists must take steps, however, to ensure that the patient is made as comfortable as possible.  If a patient can be treated only while seated in his or her wheelchair, dental staff must take whatever steps are necessary to conduct the examination and provide treatment unless doing so would fundamentally alter the nature of the treatment provided.
 

Q.   How can health care facilities provide effective communication with patients who are blind or who have limited vision?

A.   Patients and clients with vision impairments may need orientation to locate the examination or treatment room within the medical or health care facility.  It is customary to offer to orient a person with a vision impairment to his or her surroundings.  If he or she accepts the offer of assistance, the staff person should offer his or her arm to the patient or client and guide the person to the appropriate area, alerting him or her to obstacles along the way.

Printed material and information used by the health care facility such as consent-to-treatment and insurance forms must be accessible to people with vision impairments.  Information about the condition for which the individual is seeking treatment, instructions that must be followed before certain tests, and release-of-information forms must also be made available in an accessible format.

This Guide provides general information to promote voluntary compliance with the Americans with Disabilities Act of 1990 (ADA).  It was prepared under a grant from the U.S. Department of Justice.  While the Office on the Americans with Disabilities Act has reviewed its contents, any opinions or interpretations in this document are those of the Council of Better Business Bureaus' Foundation and the Disability Rights Education and Defense Fund and do not necessarily reflect the views of the Department of Justice.  The ADA itself and the Department's ADA regulations should be consulted for further, more specific guidance.

This Guide is available in alternative formats.  For more information contact:

Council of Better Business Bureaus' Foundation
4200 Wilson Boulevard
Arlington, VA  22203
(703) 247-3656

RESOURCE LIST

U.S. Department of Justice
Office on ADA
P.O. Box 66738
Washington, DC  20035-9998
(202) 514-0301 Voice
(202) 514-0307 Voice
(202) 514-0383 TDD

Architectural and Transportation Barriers Compliance Board
1331 F. Street, NW, Suite 1000
Washington, DC  20004-1111
(800) 872-2253 Voice/TDD
(202) 272-5434 Voice/TDD

Equal Employment Opportunity Commission
Office of Legal Counsel, ADA Services
1801 L. Street, NW
Washington, DC  20507
(202) 663-4503 Voice
(800) 669-3362 Voice
(202) 663-7026 TDD

Job Accommodation Network
West Virginia University
809 Allen Hall
Morgantown, WV  26506-6123
(800) 526-7234 Voice/TDD
(800) ADA-WORK

National Institute on Disability and Rehabilitation Research: 
Disability and Business Technical Assistance Centers
(800) 949-4ADA

The President's Committee on Employment of People with Disabilities
1331 Fth Street, NW, Suite 300
Washington, DC  20004-1107
(202) 376-6200 Voice
(202) 376-6205 TDD

Disability Rights Education and Defense Fund
1633 Q Street, NW, Suite 220
Washington, DC  20009
(202) 986-0375 Voice/TDD

2212 Sixth Street
Berkeley, CA  94710
(510) 644-2555 Voice
(510) 644-2626 TDD
(800) 466-4232 Hotline