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Service Animals: Access to Dental Facilities

Dentistry Today — Tue, 01 Aug 2006 00:00:00 +0000

A person walks into your dental office with a dog on a leash. The person appears to be totally normal, and the dog is not wearing any identification markings. The person walks to the front desk, signs in, and takes a seat in the reception room to await dental treatment. What would you do? How would you approach this person? What are you required to do legally?
The Americans with Disabilities Act (ADA) has a variety of important definitions and laws regarding what you may and may not do and say.1 Letís explore these terms and prepare to aid the disabled patient in a calm, caring, and legal manner.

Illustration by Cheryl Gloss

First, according to the ADA, a service animal is ìany guide dog, signal dog, or other animal individually trained to provide assistance to an individual with a disability. If they meet this definition, animals are considered service animals under the ADA regardless of whether they have been licensed or certified by a state or local government.î2 Types of service animals include dogs, miniature horses, and other animals, the most common being the service dog. The animals are trained for many different types of disabilities. Service dogs are used for some people who are blind, use wheelchairs (or need stability when walking), suffer from seizures, are deaf (or hard of hearing), or who have other disabilities as qualified by the Americans with Disabilities Act.2 All service animals, regardless of the type of service or ownerís age, have full access and privileges to enter any place a normal person would be permitted to enter. Businesses may not charge for the service animal or increase prices or fees due to the animalís presence.
According to federal law, service animals are not considered pets. They are not subject to any rule that normally applies to pets. Service animals are allowed to work without a leash (even where leash laws exist) if their service task requires that they are not leashed to complete that task. For example, opening a door for a person in a wheelchair is not usually possible with a leash on the animal.
Second, only certain people are protected by the ADA law and allowed to use service animals in public places. Only a person who is legally defined as disabled is allowed special access privileges under the ADA law. A disabled person is defined as follows: “with respect to an individual, a physical or mental impairment that substantially limits one or more of the major life activities of such individual; a record of such an impairment; or being regarded as having such an impairment. ‘Major life activities’ is normally defined as: functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.” This disability may or may not be visible to anyone. That is, the person may not look handicapped.
Therefore, for a person to be protected under the ADA, the person must be legally disabled, and the service animal must be specifically trained to aid that individual. To determine if the person and animal qualifies, you may ask only the following questions:

• Are you disabled?

• Is that a service animal?

You may not ask the nature of the disability, degree of disability, or ask for identification or certification of the person or service animal. You can refuse entry or ask the animal to be removed only for a limited number of reasons:

• The person says he or she is not disabled.

• The person says the animal is not a service animal.

• The animal shows aggression toward the owner or another human.

• The presence of the service animal will result in a fundamental alteration to the nature of the business.

Therapy animals are not legally defined by federal law, but some states have laws defining therapy animals. They provide people with contact to animals but are not limited to working with people who have disabilities. They are usually the personal pets of their handlers and work with their handlers to provide services to others. Federal laws have no provisions for people to be accompanied by therapy animals in places of public accommodation that have “no pets” policies. Therapy animals usually are not service animals.
Other important details regarding service animals:

• You are not required to provide special accommodations for the animal.

• The owner (or someone who the owner has made arrangements with) must ensure the animal urinates and defecates in the appropriate places, and any waste is disposed of in a proper manner.

• You must provide corridors, seating areas, doorways, and other public or patient access areas wide enough for a wheelchair to maneuver easily.

• There is appropriate etiquette regarding how to treat a person with a service animal. You and your staff should be familiar with these rules and encourage compliance with others in the area.
Service animal etiquette:

• Always speak to the person.

• Do not pet a service dog. The service dog/animal might be distracted from its work.

• Do not offer food or treats to a service dog.

• Do not harass or startle a service animal.

• Do not bark and/or whistle at the service dog.

• Do not ask questions about the personís disability. Some people may feel uncomfortable discussing their disability or their service animal.

• If you are afraid of dogs/ animals, then remove yourself and go to another area.

• Do not try to separate the handler from his or her service animal.

Note: Most states have additional regulations as well as penalties for noncompliance.

DENTAL OFFICES AS PUBLIC ACCOMMODATION

Although most dental offices are privately owned and operated, they are still required to comply with the ADA regulations and provide access to disabled people using service animals.
“The Americans with Disabilities Act defines a dental office as a public accommodation. Therefore, dental offices cannot discriminate against individuals with disabilities such as blindness or hearing loss who utilize the services of a dog or other trained service animal.”3
“Hospitals, medical or dental offices, and other healthcare provider sites, as places of public accommodation, must permit the use of a service animal by an individual with a disability. Like other places of public accommodation, they may enforce “no pets” policies in certain areas (such as operating rooms) if they can show that permitting service animals in would result in a fundamental alteration or safety hazard to those areas. For example, if appropriate medical personnel can show that the presence or use of a service animal would pose a significant health risk in certain designated areas of a hospital, then service animals may legally be excluded in those areas (Americans with Disabilities Act Title III Technical Assistance Manual, 4.2300).”4

References

1. Americans with Disabilities Act: Part 36, Section 104, 302(c). Available at: http://www.usdoj.gov/crt/ada/reg3a.html#Anchor-36104. Accessed on July 11, 2006.

2. Americans with Disabilities Act: questions and answers. Question #2. Available at: http://www.usdoj.gov/crt/ada/qasrvc.htm. Accessed on July 11, 2006.

3. Americans with Disabilities Act: questions & answers. J Am Dent Assoc. 1992;123(suppl):1-12.

4. Delta Society. Access Denied ñ Now What? Available at: http://www.deltasociety.org/ServiceAccessDenied.htm. Accessed on June 8, 2006.

Ms. Henson is the president of Cornerstone Dental Academy, where she authored the curriculum and oversees the education of dental auxiliaries and continuing education of dental auxiliaries, hygienists, and dentists. She travels as a speaker and consultant and presents a variety of seminars and clinical programs. In 2005, Ms. Henson received the Woman of Distinction award from Success in the City for her passion, ethics, and commitment to dental education. Ms. Henson is a registered dental assistant, a 2006 member of The Speaking Consulting Network, a national, state, and local member of the American Dental Assistants Association, an approved provider for the AGD through the PACE program, certified in nitrous oxide monitoring, and a BLS CPR instructor. She can be reached at (281) 855-4370, cornerstone@dcn2.net, or by visiting cornerstoneden-talacademy.com.

Eight Steps to HIPAA Privacy Compliance

Dentistry Today — Sat, 01 Mar 2003 00:00:00 +0000

Step aside OSHA, CDC, EPA, FDA, and BDE. The federal law for the Health Insurance Portability and Accountability Act, known as HIPAA, has provided us yet another acronym to add to our bowl of alphabet soup. While this one has more letters than the rest, it could have more ambiguity than all others combined!

The primary objective of the HIPAA law (which was enacted back in 1996) was to provide United States citizens better access to health insurance. To that end, it assures portability when employees switch employers. Likewise, it attempts to control healthcare fraud and abuse. Bottom line, the law claims to theoretically reduce administrative costs while controlling the privacy of electronic health information.

That said, you may be questioning how this law can possibly affect your professionally run dental office, which does not share patient information openly with others. As with most government related laws, HIPAA does not discriminate (or favor anyone for that matter). In fact, as healthcare providers, everyone gets the same recognition and automatic acceptance into their private club of compliance, unless your office does not submit or receive electronic transactions. In other words, if you do not transfer information via electronic media (dial-up Internet, magnetic tape or disks, a clearinghouse, or through a vendor of practice management software or billing service), you do not have to comply. However, you must keep in mind that offices that retrieve patient benefit information over a company’s Web site or transmit patient benefit information (even on paper, via fax) are considered a covered entity!

If you currently do not submit patient information electronically, but plan to do so in the future, smart money says to do it now, while the information is easy to access and educational resources are more readily available to coach you through the process.

TWO-ARMED HIPAA
Before you begin to try to understand how to achieve compliance, let us first identify the 2 arms of HIPAA regulation. There is a Transactions and Code Set Arm and the Privacy Standards.

The transaction and code set standards require health plan clearinghouses and healthcare providers to use HIPAA-compliant diagnosis and procedure codes for electronic transmission of medical procedures. The CDT codes are believed to provide greater accuracy, which will (theoretically) expedite EOB payments.

Dental procedures are to follow new CDT-4 codes, which took effect on Jan. 1, 2003. If you need a copy of the CDT-4 codes, they are available at ADA salable materials (800) 947-4746. The deadline for compliance was set for Oct. 16, 2002. However, dentists were given an opportunity to extend the deadline to Oct. 16, 2003, providing they filed an extension by Oct. 15, 2002.

The Privacy Sector of HIPAA will require dental practices to implement a plan that in essence protects patient confidentiality and prohibits the misuse of Protected Healthcare Information, known as PHI. The plan can be categorized into the following 8 action steps to simply the compliance process.

Step 1: Develop a Written Policy
Your written policy or plan should describe how you and your team will meet HIPAA compliance criteria and how PHI will be evaluated and monitored as it is obtained and provided by your office.

Step 2: Assign A Privacy Officer and Contact Person
Identify an individual who can be accountable for overseeing operations as your Privacy Officer. This individual should have a genuine interest in patient privacy. Of equal importance, they should be well organized, articulate, and willing to accept responsibility for supervision of compliance. The Privacy Officer would receive patient requests for obtaining access to their PHI or requesting an amendment to their PHI. The officer would be responsible for maintaining records for complaints and can act as (or appoint) a Contact Person to receive complaints. If the Privacy Officer shares the role of the Contact Person, then they must also be professionally mature and non-emotional. This is of particular importance when dealing with patient-related complaints.

Step 3: Team Training
Training is a very important aspect of HIPAA compliance. HIPAA requires that all employers and employees alike are provided training on HIPAA compliance by April 14, 2003, in Privacy Etiquette. If an employee violates compliance requirements, an incident report is to be filed, and disciplinary action should follow to ensure that the behavior is not repeated.

Step 4: Business Associate Safeguards
All business associates (BA) (a person or entity that performs or assists in the performance of a function or activity involving the use or disclosure of PHI, such as accountants, consultants, financial institutions, management consultants, advisors, computer software vendors, answering services, dental laboratories, and temporary employees) must provide healthcare providers safeguards that ensure PHI will not be abused or used for anything other than treatment payment or operational services (TPO). Employees and associates are not included, since they are members of your workforce.
This requirement can be met through a signed agreement with all BAs. Agreements must be signed by April 14, 2003. The agreement must stipulate that the BA is willing to “open the books” to Health and Human Services (HHS) if privacy has been suspected to be violated.

Step 5: Posting of HIPAA Privacy Policy
All healthcare providers must post their HIPAA Privacy Policy Notice in a conspicuous place for patient viewing.

Step 6: Patient Acknowledgement of Privacy Policy
HIPAA requires healthcare providers to obtain patient acknowledgement (acceptance is not required, only acknowledgement) of the healthcare provider’s privacy policy. This requirement can be met by having each patient simply acknowledge receiving a copy of the written privacy policy by signing off to that effect. If the patient refuses, a note must be made in the patient’s record to indicate the refusal.

Step 7: Self Audits
Periodically, healthcare providers need to perform self audits. If at any time the healthcare provider or representatives find any violations, they are to be mitigated as soon as possible to limit further harm to PHI.

Step 8: Authorization and Record Keeping Logs for Use of PHI for Other Than TPO
In the event that a healthcare provider intends to use PHI for anything other than TPO (Treatment, Payment or Operational Services), the healthcare provider is required to obtain patient authorization. In addition, the healthcare provider is also required to keep a log that discloses who used the information, how it was used, and why it was used. The log, along with authorizations, are to be kept on file for 6 years from the time of use and/or authorization.

DEBUNKING HIPAA MYTHS
Use common sense! HIPAA can only require that you use reasonable safeguards and good faith efforts to secure patient acknowledgement of receipt of your privacy notice.

HIPAA cannot enforce office design for soundproofing and/or chart lock-up or elimination. The law does suggest, however, that you should not leave charts out on display for patient access. Likewise, sign-in sheets are discouraged, and reminder cards must not detail diagnosis or PHI.

HOW DOES THE PRIVACY RULE BENEFIT PATIENTS?
The privacy rule enables patients to find out how their information may be used and what disclosures of their information have been made. Likewise, it calls upon healthcare professionals to use appropriate safeguards to protect healthcare information. In general, the privacy rule sets boundaries by limiting the release of information (to a reasonable minimum) for the specific purpose of the request.
The privacy rule also provides patients with the right to examine and obtain a copy of their own health records and request corrections.

HOW DOES THE PRIVACY RULE THREATEN HEALTHCARE PROVIDERS?
The privacy rule is enforced by Health and Human Services (HHS) Office of Civil Rights (OCR). The HHS can hold violators accountable, with civil (fines) and criminal (jail) penalties.

To avoid such penalties, you simply need to make a good faith effort and take reasonable steps to maintain patient privacy. This would include a good faith effort in creating written policies, posting written policies, and securing patient acknowledgement of receipt of your privacy policy before disclosure of PHI.

Likewise, employers and employees must be trained in privacy etiquette by April 14, 2003. To that end, the office must use common sense by talking quietly and/or using curtains or partitions (if necessary) to minimize the chance of inadvertent disclosures. Furthermore, minimum necessary standards must be followed (which means you cannot disclose anything other than the information that is needed to accomplish the intended purpose). Of course, if PHI is used for anything other than TPO, the patient must be informed, and prior consent must be obtained.

Training
Get your training program in order now! Train your team in HIPAA privacy and develop written privacy policies that describe how you and your team will handle PHI. Assign a Privacy Officer to ensure appropriate safeguards, audit transactions, and monitor patient related communications. Likewise, have the Privacy Officer act as a Contact Person for handling patient complaints. Be sure to post your Privacy Policy and obtain patient signature for acknowledgement of receipt of your Privacy Policy. Make sure all your business associates have signed a BA agreement by April 14, 2003, which stipulates that they are willing to comply with privacy of PHI. If you intend to use PHI for anything other than TPO, then be sure to get prior authorization from the patients also.

CONCLUSION
Government regulations affecting healthcare providers can admittedly add to the burden of managing a dental practice. However, in the case of HIPPA, aside from the inconvenience of posting notices and obtaining signed acknowledgements, those who are willing to employ reasonable safeguards and use good faith efforts to comply can only enhance their professionalism as it relates to patient privacy. Such compliance is an appropriate course of action for those who continue to support excellence in patient care.

*Privacy Policy Notices, Forms and Authorizations are available through ADA salable materials (800) 947-4746; and AADS (800) 927 6101.

Other Resources

•American Dental Association website: http://www.ada.org/goto/hipaa.
•AADS (charts and forms) website: http:www.aads.com.
•National Dental EDI Council website: http://www.ndedic.org/.
•US Department of Health and Human Services website: http://aspe.os.dhhs.gov/admnsimp/.

Ms. Simon is a certified management consultant, national speaker, published author, and president of Simon Says Solutions, which is a practice management firm based in Scottsdale, Ariz. As a member of the National Speakers Association and the Institute of Management Consultants USA, she has earned the mark of CMC, which represents evidence of her certification and the highest standards of consulting and adherence to the ethical canons of the profession. For over 2 decades, Ms. Simon has dedicated herself to coaching dental professionals in solution based practice management systems. She can be reached at (800) FON-TEAM, or e-mail risa@simonsayssolutions.com, or visit the Web site at www.simonsayssolutions.com.