KAISER PERMANENTE MEDICAL CENTER
SAMPLE MEDICAL CENTER POLICY AND PROCEDURE
SUBJECT: PATIENT CARE
TITLE: PET PROGRAM/ANIMAL VISITATION AND ADA SERVICE ANIMALS
1. PURPOSE:
1.1 To provide guidelines for the visitation of service animals specially trained assistance
animals or pets to the Medical Center.
1.2 Pet Program is designed to help the patient adjust to the stress of hospitalization by
providing a familiar non-threatening focus of attention in the hospital environment.
1.3 To ensure that Medical Center facilities and services are fully accessible to
individuals with disabilities in compliance with the Americans With Disabilities Act of
1990 (“ADA”) and Section 504 of the Rehabilitation Act (“Section 504”) and other
applicable federal and state laws.
2. DEFINITIONS:
2.1 Assistance Animals: Blind, deaf, and disabled persons and his/her specially trained
assistance dog will be admitted to the medical facility or clinics in accordance with the
American Disabilities Act. A licensed person or certified agency specially trains these
assistance dogs to ensure their temperament and predictability around humans and other
animals. Examples of assistance animals include:
2.1.1 Guide dog: Trained for blind or visually impaired person.
2.1.2 Signal dog: Trained to alert a hearing-impaired person.
2.1.3 Service dog: Trained to do work or perform tasks for the benefit of an individual
with a disability.
2.2 Pet Program: A visitation by a family pet or other animal deemed by the primary
health care provider to be psychologically or physiologically therapeutic for the patient
(e.g., long-term and terminally ill patients) will be at the discretion of the physician in
consultation with the Infection Control Nurse as applicable. Examples of therapy pets
include:
2.2.1 Family Pet
2.2.2 Hospital Approved Organizations (i.e., TDI - Therapy Dogs International, INC.)
2.2.3 Canine Companions for Independence
3. POLICY: ADA SERVICE ANIMALS
3.1 The presence of a certified guide dog, service dog, or signal dog will be permitted
throughout the medical center campus without a physician's order in accordance to the
American Disabilities Act of 1990 ("ADA") and Section 504 of the Rehabilitation Act
("Section 504") and other applicable federal and state laws and regulations that prohibit
discrimination on the basis of disability.
3.2 Providers must make reasonable modifications in their policies, practices and
procedures when necessary to provide accommodation to members, patients and family
members with disabilities. Generally, this includes modifying any no-pets policy to
permit use of a service animal by an individual with a disability.
3.3 An individual who uses an animal for assistance with hearing, seeing, mobility or
emotional support may have that animal accompany them into a health care setting
3.4 Service animals must be permitted to accompany the individual with a disability to all
areas of the facility where members and patients are normally allowed to go, except
where the animal could pose a direct threat to the health or safety of the individual or
others (see restrictions below) or it would result in fundamental alteration in the nature of
the services, facilities, privileges or accommodations offered or provided.
3.5 An individual with a service animal may not be segregated from other members.
3.6 Evidence of current vaccinations such as rabies may be requested.
3.7 Restrictions on Service Animals
3.7.1 A person with a disability cannot be asked to remove his service animal
from the premises unless:
3.7.1.1 The nature of the services, facilities, privileges or accommodations
provided or offered would be fundamentally altered, or if
3.7.1.2 The safe operation of the medical center would be jeopardized, or
the animal poses a direct threat to the health or safety of the individual or others.
3.7.2 Service animals must be allowed to stay with the member/patient during
inpatient services unless a medical justification showing that the presence or use
of a service animal would pose a health risk in certain parts of the institution can
serve as the basis for the exclusion of a service animal from the areas of the
institution directly involved. For example, a service animal could be excluded if
its presence would pose a health risk or fundamentally alter the nature of the
services provided or offered.
3.7.2.1 A service animal may be excluded from:
3.7.2.1.1 All operating rooms
3.7.2.1.2 Outpatient surgery and special procedure rooms and other
areas where a sterile field is present; and
3.7.2.1.3 Clean and sterile supply areas, and medication storage
areas, since these areas are not places of public accommodation
and/or an animal’s presence in these areas would inherently pose a
direct threat to health or safety thereby interfering with the safe
operation of the medical center and/or constitute a fundamental
alteration of the services provided.
3.7.2.2 In addition, a service animal is more likely to be excluded from:
3.7.2.2.1 Inpatient and outpatient oncology units, rooms where protective
isolation is in force, infusion centers, and isolation/infectious disease areas
where a potential exposure threat to neutropenic or severely
immunocompromised patients (including the owner of the animal) exists;
and
3.7.2.2.2 Any other area containing equipment critical for life support and
that have “restricted access” to the general public due to infection-control
measures in place. General infection-control measures that may dictate
such limited access include:
3.7.2.2.2.1 Where the area is required to meet environmental
criteria to minimize the risk of disease transmission;
3.7.2.2.2.2 Where strict attention to hand hygiene and absence of
dermatologic conditions are required; and.
3.7.2.2.2.3 Where barrier protective measures, e.g. use of gloves
and wearing of gowns and masks, are indicated for all patients and
visitors in the affected space
3.7.3 A member or patient may be separated from their service animal for short
periods of time, if it is necessary to provide a service, i.e. Aqua PT, Audiology
testing, or other procedures where there is limited space. The separation should
not be any longer than it takes to provide the service.
3.7.4 Care and Supervision of Service Animals
3.7.4.1 Care and supervision of a service animal are the responsibility of
the member and/or guardian.
3.7.4.2 Kaiser Permanente staff is at no time required to supervise or care
for the service animal. Therefore, a member or patient would need to make
their own arrangements to have someone feed, water and/or walk the
animal throughout the hospital stay/visit.
4. POLICY: PET THERAPY PETS
4.1 The decision to allow an animal/pet visitation into patient care areas within the
medical center will be considered on a case by case basis in consultation between hospital
nursing and infection control.
4.2 The visit should be coordinated through the patient’s nurse, who will take the proper
steps outlined in this policy. For a first time pet visitation into a patient care area, the
coordinating nurse should inform the owner/handler of the general requirements for
domestic animals at the medical center and remind the owner/handler to keep the animal
on leash at all times.
4.3 The animal’s behavior must not interrupt activities of patient care. Special attention
should be taken in controlling the animal during activation of alarms (i.e. fire, codes,
monitors).
4.4 All pet therapy visits are to be time limited on length of the visit (usually 15-20
minutes).
4.5 Patients having a domestic animal visit in their room must be in a private room.
4.6 The nursing staff will coordinate and supervise the visit (i.e., Pet Therapy Program) to
assure that all volunteers and animals are in compliance with departmental policies and
procedures.
4.6.1 All visits to the clinics will be coordinated through the various Clinic
Directors..
4.7 All visiting pets must provide proof of current vaccinations from their veterinarian
and must be a Pet Therapy Program volunteer or family member/designee (for household
pets).
4.7.1 Pet Therapy Program animals must submit proof of vaccinations from their
veterinarian to the Volunteer Coordinator on an annual basis.
4.7.2 Household pets will need to submit proof of vaccinations and a copy will
need to be placed into the patient's chart.
4.8 Volunteer Coordinator must maintain a file on each animal enrolled in the Pet
Therapy Program. Each file must include updated proof of vaccinations, associated
volunteer contact information, any submitted complaints, and any other pertinent
information relating to the animal or associated volunteer.
4.9 Animal handlers are to remain in constant attendance with the animal during the visit
to the medical center. (The Pet Therapy volunteer must remain with their animals at all
times. Until further notice, dogs are the only pets to be included in the Pet Therapy
Program.)
5. PROCEDURES:
5.1 All visits by pets other than ADA service animals will be coordinated with hospital
personnel.
5.2 Hand hygiene is the most important activity in preventing the spread of infection in
the health care setting. Persons having direct contract with the animal, it’s equipment, or
other items with which it has been in contact should wash their hands with soap and
water if visibly soiled or use of waterless alcohol degermer if hands are not visibly soiled.
5.3 An extra sheet should be placed on the bed as a barrier and removed immediately
after the animal has completed the visit. 5.4 Patients will change their hospital gown if
they have held an animal.
5.5 Supplies and equipment for immediate clean-up of animal waste must be readily
available during each animal visit. Animal waste will be cleaned up by the Pet Therapy
Program volunteer, family member, or caretaker of the pet. Clean up procedures should
be performed by using appropriate personal protective equipment (PPE). Gloves are the
minimum protection. The spill should be removed with paper towels, which should be
placed in a plastic bag in the trash container, by the animal handler. After removal of the
organic debris, the area of the spill should be cleaned with a facility approved disinfectant
by Environmental Services.
5.6 Staff, patients, and volunteers will wash hands as necessary.
5.7 All patient wounds will be covered when animals are in attendance.
5.8 Hospital personnel will immediately report any incident resulting from the pet
visitation to the supervisor/manager and complete a Responsible Reporting Form (RRF).
5.9 Supervisor/manager receiving any incident report related to Pet Therapy program
must notify the Volunteer Coordinator. All unusual occurrence reports (RRF) must be
forwarded to the Quality Department.