1 Access to Medical Facilities.... . >>>JACQUIE: Good afternoon, everyone. Welcome to today's webcast, access to medical facilities, with Mark Derry, president of Eastlake Derry and Associates. This webcast is stay -- tailored to architects, engineers, directors of plant operations, ADA coordinators and anyone else concerned with ADA accessibility and ensuring the best quality of care, customer service and independence as well as family members with disabilities. This webcast is going to present an overview of common issues with accessibility at medical facilities, including barriers in older hospital building and errors in construction that are most commonly documented. You can read more about Mark Derry on our webcast page but I'm going to get to the webcast before much longer. This webcast is sponsored by NIDRR, who funds your host for today's program, the DBTAC southwest ADA center. I am Jacquie Brennan and with DBTAC southwest ADA center. I'll be assisting with today's presentation. For those of you listening to the webcast today, to submit your questions click on the e-mail button on your screen or e-mail them directly to swbtac@ilru.org. If you have any technical difficulties today please feel 2 free to call at 713-520-0232. Thank you for joining us today. Now I'll turn it over to the presenter. >>>MARK: Thank you for that great intro. I'm Mark Derry. I'm president and CEO of Eastlake, Derry and Associates. I'm an ADA consultant and travel around the country doing trainings and working with facilities and architects to ensure that good access is being provided at their facilities that they own or are building. One of the facility types that I spend a lot of time with are hospitals and medical care facilities. There are several of us in the country that do this -- a lot of us that do this type of business and give advice on accessibility in the ADA and those of that do this usually fall into a niche of one sort or another. Mine has ended up being medical care facilities and universities, both of which are facilities that provide us with a lot to look at regarding accessibility and a lot of different opportunities to think of new and interesting ideas for removing barriers on older facilities, as well as coming up with new ideas and better ways and more efficient ways of making sure that our accessibility is good on those new construction sites. And I'll talk about that quite a bit as we get towards the end of our session today. I want to talk a little bit about the laws up front 3 in the first piece of this presentation. We're going to take time in between several sections for questions and answers so that you all can e-mail in your questions and I can try to answer them today while we're together. For those of you who have questions beyond the scope of this call or would like to ask a question that comes to you after the presentation, feel free to send that question to info@eastlakederry.com. Eastlake -- one word. D E R R Y. You can always get the best place for technical assistance nationally -- your DBTACs centers. No matter where I go or who I'm working with, they are the top information provider that I give out as a resource in my travels, both working with facility folks and in teaching. We will also talk about -- their universal number is 800-949-4232. At the end of my session I'll talk about getting a hold of the department of justice as well as the access board who I will be referencing throughout our conversation today. So why should businesses be proactive about complying with the ADA? Well, it's the law. More than 1100 new lawsuits were filed under title 3 since 2005. Once a lawsuit is filed, the remedies required to settle the matter may be more onerous and attorney's fees can come into play and so it can be very expensive. It's 4 also good business. Over a 5th of the population has a disability now. Right now. And that number is increasing with the aging of the baby boomers. Everyone enjoys telling me how my generation, the baby boomer generation, is going to be the largest group of old folks there ever was. I'm so tired of hearing that, but with age, comes the occurrence of disability more often, and so in the future we're going to see a increase in the need for accessibility in everything we do. So this isn't going away. It's just picking up steam and getting more and more important as every year goes by. How do ADA lawsuits and government investigations typically start? Well, unhappy patients and members of the public can file suits directly. Profession plaintiffs out there can sue your business for quick monetary settlement, which is happening quite frequently in states like Florida and California. And the department of justice receives a complaint and starts investigating or initiates its own investigation as part of an initiative is another way complaints can be brought. The tends in the DOJ settlements and concept agreements are -- consent agreements are kind of important because in the early settlements -- I look at these all the time. Settlements tend to create precedents and we'll talk about equipment in this 5 session and how you can't point to a specific measurement or entry in our ADA accessibility guidelines for something like an exam table because it's not part of the fixed structure. But in precedent-setting cases, as we've always been taught, if you don't have something specifically explained in (indiscernible) and you're looking to provide good accessibility, take what you know about accessibility as far as transfer heights, reach of range issues, and apply them to that item that you're trying to make accessible. And the DOJ has done that in precedent-setting cases so that now there isn't some expectation out there that our equipment in our facilities will be accessible as well. So I'm going to share some resources with you during the session on how to read up on precedent-setting cases as well through DOJ. Early settlements were mostly over the lack of effective communication for persons with hearing or cognitive disabilities. The lack of sign language interpreter policy, lack of TTYs, the lack of accessible exam tables and transfer devices has been coming up through cases that the department of justice write settlement consent agreements on. One I'm going to talk about quite a bit more later is the Washington hospital center that the department of justice had a settlement 6 with and that has issues, not just regarding the physical barriers again but like access -- lack of accessible patient rooms but also equipment, policies, and training. So let's look at accessibility under the ADA in this first part of our session so that we can get kind of a quick coverage of the law and the requirements and spend our other couple of sessions talking about the nuts and bolts of accessibility. Accessibility under the ADA falls under several titles. There's five. The ones that will apply mostly to our work in medical care facilities will be titles 1, 2, 3. Title 1 affects employment and while we're only required to have an accessible route to and through our work areas, we may get a call as a director of planning when a person asks for a reasonable accommodation under title 1 employment under ADA. And so there may be circumstances where we need to look at accessibility for particular workstations , for instance, if we're a facility guy. And that would be based on a title 1 reasonable accommodation request. But the share of our time is facility folks, will be spent on physical barriers and communications barriers that are covered under title 2 for State and local government programs and services, if we're a State hospital or government-owned hospital. And title 3 for public 7 accommodations if we're a privately owned hospital. It would be covered under title 3. Under those titles -- in title 3, we are responsible -- as soon as the ADA came around -- now we're 18 years into the law passed in 1990 which said that existing structures needed to look at what we call "readily achievable barrier removable." Readily achievable is a huge gray area we're supposed to make a call on as for as what our family as our building can afford. This needs to be taken into account, including who owns this, parent hospital company or medical care company. It depends on the big picture as far as how much we can afford to remove barriers and what's readily achievable, according to our budget, disruption of services, and other matters we take into account as we look at readily-achievable barrier removal. Then in new construction and alterations, once we're touching something we need to make it right. New construction after 1992 was supposed to meet accessibility requirements. And alterations, after that date, also are supposed to meet and come as close to new construction standards as possible. The alteration uses the ADAG as that golden ring but there may be a issue with a footprint on a restroom because we have a pipe chase in the way or some other issue that may be an 8 issue to us providing perfect accessibility under an alteration. An addition is like new construction -- it's got to be right. Alterations, both under ADA and building code, we have what we call the 20% travel rule. And if you're a title 3 public accommodation hospital or medical care facility and you do an alteration to the facility and it's what we call a primary function area, you're supposed to look at what barriers you have along the path of travel to that primary function area that you can remove in the process of that construction project. And so the threshold that both building codes and ADA have named as the disproportionate number is 20% of the project costs as far as how much we need to put towards removing those barriers along that path of travel. And they can include your parking, accessible route into your facility leading to that primary function area, as well as other issues along the route like restrooms, drinking fountains, and pay phones. So the 20% rule can get fairly involved and I highly recommend talking to a ADA consultant as you're planning projects. Plan review -- I'll repeat probably several times -- is a great idea. If you're doing design of medical facilities and don't have somebody on staff 9 who's a specialist of accessibility, I highly recommend sending your design and plan documents, construction documents, for plan review prior to construction. So to what extent must a commercial facility or public accommodation comply with the American disability accessibility guidelines? Built for January 26, '93 facilities must remove barriers, alterations to facilities must comply with ADAG to the maximum extent feasible and commercial facilities built after January 26 -- goes '92 to '93 depending on when you filed your permit and occupancy, must comply with ADAG -- it's a very rare, nonoccurring event usually. If it's new construction it ought to be right. Both under the ADA and whatever your current building code is in your state. Many states have adopted the international building code and the accessibility requirements in the A N S I A 117.1 -- the A N S I accessibility standard referenced in the building code has requirements that mirror the requirements under ADA. We're currently working under current ADA standard, CFR -- 28 CFR part 36, as it was produced when the ADA was passed and revised in '94. We have a revised ADA -- what's now called the ADA/ABA accessibility guidelines -- Americans with disabilities act and architectural barriers act accessibility guidelines. ADA applying to the 10 facilities I talked to -- under the titles, state and local governments, and public accommodations, and also the architectural barriers act which applies to federal facilities. That new guideline was published by the access board in 2004 but hasn't finished going through the adoption process by the department of justice, who enforces all of this, and for our hospitals -- and we're still waiting for that standard to be approved or adopted by department of justice. And the running joke with folks in my trainings is when you ask when it's going to come out, the general answer is in the spring because we've been hearing in the spring for -- since about 1998 now. We really do look forward to possibly having it in the spring this time. It has gone much farther through the rule-making process and we'll see how that goes. But the new revised ADAG from 2004 very much mirrors what you'll find under building code in the ANSI 117 document. That's under what we call harmonization of the codes -- there's been an effort to make accessibility standards we're trying to follow, to make sure our environments all look the same. When we're looking at hospitals, under ADA, we're looking at three modes of accessibility really. Not only the physical access, which on general used hospitals includes 10% of the patient rooms and 11 bathrooms must be accessible. Hospital and rehab facilities specializing in treatments that affect mobility require 100% of the patient rooms and bathrooms to be accessible. This is on new construction, now. And long-term care facilities, like nursing homes, 50% of the patient rooms and bathrooms must be accessible. Then all of your public areas, of course, must be accessible in new construction. And so it also includes under the ADA and applying the ADA to the health care environment, reasonable modifications and policies, practices, and procedures. So you'd be looking at things -- I'll talk more about those in a little bit as we talk about setting up things -- but modifications in policies, practices, and procedures are things that health care providers do to make reasonable modifications for allowing disabled individuals to enjoy the goods and services offered by the business unless it -- they can demonstrate it would fundamentally offer its program or create undue burden. Service animal policies we need to have in place. Modifying your no animals in the hospital to allow service animals is a modification in policies and procedures. Evacuation plans need to be in place, and the third prong of that is having policies in place for auxiliary aids and services so to provide effective 12 communication to customers with disabilities. So with that, I'm about 20 minutes into it but I've gotten a good chunk of the law passed us. In the next section I want to start diving into actual accessibility and access at our medical facilities. But I wanted to make the point this is something we all need to do. If you're not doing it already you're late. And we need to talk about procedures for setting up good ADA policies towards the end of this training. Do we have in calls -- or any questions so far, Jacquie? >>JACQUIE: We have one and may be something you're going to yet cover so I can hold it if that's the case. Do you have any suggestion to applying to officials who say the historical integrity of the building would be affected by cutting a ramp -- >>>MARK: Yes. That question comes up pretty often on our older facilities, especially the historic ones. We don't want to do something to affect the historic significance of the structure. However, the law does say we have to apply accessibility if it's it at all possible without affecting the historic significance of that structure. We're going to narrow it down to what gives that building historic 13 significance and we're not going to touch that but still need to look at how we can provide accessibility through an alternate route and various ways of providing access without touching that piece. The building is still covered. Lot of people think just because it's on the national register of historic places that somehow exempts them from the accessibility requirements of the ADA. It doesn't. We need to look at how we can best provide accessibility. I would seek the services of people with disabilities or a accessibility consultant or some place like a center for independent living in your local area for advice and ideas on how best to accomplish that. Other questions? I'll keep moving -- >>>JACQUIE: Let me see. Yeah. That's it for now. >>>MARK: Okay. So the elements of a accessible compliance program, as I finish up the law part of this, is talking to your in-house council or hiring an attorney experienced with ADA requirements to help design a compliance program if you haven't already. Designate one responsibility person or department to respond to complaints. Commit resources to conduct an audit of ADA compliance or get training and advice and do the compliance audit yourself at your facility as the 14 facility director with help from the outside. And have written ADA policies covering the three major areas of compliance that I mentioned -- the physical access, the reasonable modifications and policies, practices, and procedures, and the provision of auxiliary aids and services -- and have that -- the ADA policies already done before you need them. Have an interpreter policy before someone comes in and needs an interpreter. Have a service animal policy before somebody comes in with a service animal. Because if you have the policy set in place, everything will go 200% smoother when your customer shows up for services at your facility. So I would get all relevant departments involved in the process and familiar with basic ADA requirements, and put in place a review process for changes that may affect accessibility. Somebody does a small construction project on site and it affects accessibility, we need to deal with that in the scope of the project. Include a ADA training module in all employee training to educate the work force. Send out the ADA message in different and multiple channels of education. For instance, in your trainings, news letters to reenforce all this. Incorporate ADA compliance in your existing internal audit functions. 15 So where do we go to look at what accessibility is? We can talk about the standards and as I do I want to relate to you some of the things that I've been seeing and some of the ways we've provided solutions for the barriers and I'll share that with you as I go through this, talking a bit about barriers. But where does this come from? The accessibility standard that we use, which starts with the ADA accessibility guidelines or ADAG. When it's adopted in the law by the agency enforcing the law, like department of justice, then it becomes our accessibility standard. Same as in building code more or less -- same kind of idea where you've got your local authority having jurisdiction, adopting your local building code and the standards it references. Most states will reference the ANSI documents or the ADAG documents referenced in ADA. Those are the two main accessibility standards. Some states have their own requirements thrown in with the general requirements you'll see common to these accessibility standards so you need to make sure you check state by state, just like anything else you're going to do in a project to make sure what your building code is in your state. It also affects you on things like parking. You may have a local ordnance or mote vehicle law. That's not going to be something that's a requirement in ADA or 16 necessarily in building code but it is required by the local authority, the motor vehicle authorities in order for them to write tickets. So if it's missing we're not going to get effective enforcement. Asking local what the parking requirement is a good example to make sure you're addressing everything correctly. Accessibility under the ADA starts with the ADAG and that's produced by an entity whose original name was the United States architectural and transportation barriers compliance board -- USATBCB. None of us had enough time to say that over again and again. It became the access board and now it's known as the United States access board. So the access board develops and maintains the accessibility guidelines for the environment under the ADA as well as architectural barriers act. Then -- that covers under -- covers ADA and ABA and your local building code official of course is your local authority regarding your local building code. The new ADAG that I referred to briefly before, the one that is coming out in the spring hopefully, was published in 2004 in DOJ's proposed rule. They refer to it as ADAG 2004, and that, as I said, is still waiting for adoption by DOJ. It has been adopted by the Department of Transportation, DOT, as their new 17 enforceable standard but we're waiting on department of justice. However, when I'm looking at my standards for accessibility, I look at all the standards for accessibility to make sure I'm looking at everything that's applicable to my local facility that I'm working on. I'll look at the current ADAG and the ADAG 2004 to see what's new, what's coming. I'll also look at the local building code and check out ANSI and see what the requirements are in ANSI. That way I'm checking to make sure I'm using what's called the most stringent requirement among the various codes. Now, the ADAG 2004 and the ANSI documents look so much alike, the number system is very similar. If you're looking up something in ANSI you're going to be looking it up under the same basic section numbers within the ADAG 2004. In fact, the easiest way for you to do this as a professional who's doing plans or checking out codes in your local area is to go www.access-board.gov. And when you click on the accessibility standards links on their website you can click on a document called the "comparison" which actually is a document you do not want to down load. It's about 500 pages. It will wear out a printer cartridge but it's great to have on your desk top because it has three columns -- one column shows the 18 current ADAG requirement, then the ANSI, then the ADAG 2004 requirements. You can look at all three on the comparison document by going to the access board website and bookmarking that link. I highly recommend doing that. >>>JACQUIE: Assuming that in the spring they will go ahead and, you know, finally bless the -- for projects underway right now -- let's say construction isn't complete or hasn't started yet but will start before the spring, will they need to follow the add da bag (phonetic) at that point or how will that work? >>>MARK: It depends on how it shapes out with the rule making with the DOJ. That's one of the calls they're having to make in the rule-making process that we're waiting to see. When is the effective date of the new ADAG? I will tell you, in my experience, the new ADAG is not as onerous as some people might make it out to be. There are ranges that make it easier for folks to be accessible where we had absolute numbers in the current ADAG as an example -- 18-inch toilet center line is a requirement. That's an absolute number. 18 inches on center. I laugh with some of my students sometimes because we say absolute numbers are very difficult in construction. Construction you'll have things a quarter inch off. It is not an exact science. We'd like it to 19 be but that's not the way it is. If you've got an absolute number, you're really going to take a chance of being technically noncompliant a lot more often than if it is like in the ANSI where it's a range of 16 to 18 inches. Now you'll be able to hit it, the range is much easier to use in construction than an absolute number. So -- but getting back to your question, if they approve it in the spring, chances are you're not going to be required to go back and, if there's things that are different or have to be immediately upgraded. However, the argument and conversation that's going on right now is where do the readily achievable terms fall into place there. If you've built it under the current ADAG should you be upgrading? For instance, there's a vertical bar required on a side wall of a restroom. It's not in current ADAG. When the new one comes out do we need to add the vertical bar to our projects? Under building code it's a requirement so I'm recommending people include it on new construction projects but we'll have to see what DOJ tells us about the extent to which we have to go back and look at projects that were built under a current, good accessibility standard, being the ADAG and now we have the 2004. So it's a long answer, but basically we need to see -- DOJ is the one that write it is rules for how all of this is applied. And 20 that's where we're going to get guidance on this. >>>JACQUIE: Thanks. >>>MARK: Sure. The -- I mentioned earlier that the numbering system is very similar to what you'll find in ANSI on the ADAG 2004. The changes that are included in it I'll explain a little bit. Medical care and long-term care facility requirements remain basically the same as far as 10% accessible patient rooms in general, hospitals 50% and long term and 100% in facilities specializing in treatment of conditions that affect mobility. There is a new exception for toilet rooms in critical care or intensive care patient rooms because it's such a high level of assistance in that area. The new ADAG also looks like ANSI in that it lowers the number of allowed spaces. When you're looking at accessible parking doesn't lower the number of spaces. Reduces number of accessible spaces that trigger additional van space. One of every eight to one of every six spaces needs to be a van space with that wide, 8-foot access aisle so folks can use a transfer device and have room to get off it. That scoping is increased from what we've got in current ADAG -- currents 1 to 8 and 1 to 6 is the requirement under many building codes and we'll see if that is how it stays hen the DOJ -- 21 when the DOJ adopts it. I believe it will be. The other big difference in the document is space in toilet rooms -- at the toilet current ADAG has allowed the sink to encroach the moving space. And in the new ADAG it looks like new building code in that you have to have that 60 inch box at the toilet of clear floor space and the lavatory can no longer encroach in that 60 inches of space. The maneuvering space for the lavatory can but the -- no other fixtures than grab bars and stuff are allowed to be in the toilet fixture space, that dotted line you see in the requirements for maneuvering space. That's huge for architects and planners. The -- make sure you're laying out toilet rooms -- if they're single use make sure you have the side transfer space next to the toilet. All the years we had lavatories hugging that toilet at 36 inches off the side wall of the toilet precluding anyone from wheeling in and transferring over to the toilet. Now with the building code and revised ADAG we have the space that has to be in there in a public toilet. The grab bars I mentioned -- the change in the grab bars in that there's an additional requirement for a 18 inch vertical grab bar above your side wall grab bar, next to a toilet. And that, again, is already required under ANSI and international building code and it's 22 coming in the ADAG 2004. Why is that important that I mentioned that so we don't forget it? Well, for those of us who have ever done a restroom and forgot to do a grab bar -- that's not me. I never forget but some of my customers do and when they do we're taking the whole wall apart because they've forgotten the blocking that has to go in the framing for the grab bars. If we haven't done the blocking in the wall for the new vertical grab bar, then we're tearing into the wall to retro fit the blocking and grab bars required by new code. So it's important we look at these issues on our plan review before it becomes an issue in construction and somebody's writing us up for it. And we have to retro fit which is three times as expensive as doing it right right off the bat. Another thing that is new that we're seeing is -- and is in an issue we're seeing -- is toilet paper dispensers. We can't get the guy who changes the toilet paper to change the toilet paper on time so instead of firing that person or giving them a corrective action plan we decided we're going to buy giant toilet paper dispensers that never run out. The problem is if you mount them under the grab bar where they've historically gone, now the bottom of the dispenser is almost on the floor trying to reach it and doesn't meet the minimum 23 distance above the floor it's supposed to be. New ADAG is allowing us to install those dispensers above the side wall grab bar but it's a narrow range you get to install it in so you have to watch it because it has to be at least 12 inches above that side wall grab bar so your arm isn't hitting it if you're using the side wall grab bar to transfer. But the opening of the dispenser where the toilet paper comes out can't be any higher than 48 inches for our reach ranges. And so it's a very small space. It's 12 inches above the grab bar, which is 33 to 36. And then 48 Max to the bottom of that dispenser. So it's pretty precise where it has to go. There isn't a lot of leeway there which is usually a problem in construction. For urinals we have guidance on what a elongated urinal is. For years people have asked what that was. There wasn't a minimum depth specified. Now it is given to us as 13-1/2 inches minimum in the ADAG 2004. There's also clarity given in the other thing on the urinals we're running into in our surveys, the urine -- the accessible urinal is supposed to be mounted no higher than 17 inches above the floor and the flush is not supposed to be higher than 44 inches. The quick fix on the flush is installing an autoflush, and then my facility guys tell me it's okay if you're doing a hard 24 wired unit but if not you better plan on batteries every so often which is a maintenance issue we try to stay away from. But that is an answer. The (indiscernible) urinal is supposed to be 17. It's supposed to be in an alcove. This is one we're seeing all the time. The urinal will be mounted in an alcove that's only 30 inches wide but it's over 2 feet deep. ADAG says where it's more than 24 inches it needs to have 36 inches width for your approach. You can move partition walls in that scenario to make it a wider approach to the urinal or one of the tricks we've used is to rebuild the wall that the urinal sits on and bring it out. If it was easier to move walls to build a new wall to hang the urinal on and bring it out so it's less than 24 inches deep on your approach, it can fix that scenario sometimes easier. So that's one of the things we've been doing on urinals. There are differences in updates in the AD AG 2004 include on lavatories the apron clearance of 29 inches that's been required has been removed. So we're -- like building code, we're looking at 27 inches at the front of that lavatory. The measurement I always make -- I always make sure I take is 8 inches under the front of the lavatory. You're supposed to have the 27 inches knee clearance under the bowl and that's left out of a 25 lot of architectural drawings and I ask folks to put that measurement in in plan reviews to make sure that the lavatory is mounted as it's supposed to be, no higher than 34 inches to the top of the lav but also at least 27 inches of knee space under the bowl of the lav. That's not including the overflow dip for the sink. You measure it on the sides, on the round part of the bowl. That's kind of important. We're running into that all the time. On shower compartments -- there's been a few facilities that I call alternate design on a shower set up that's been available to us in hotel facilities and the alternate shower set-up can be handy when you're trying to get a accessible shower with a bench and do a facility. In some scenarios we haven't been allowed to use that in a hospital and there has been better clarity in section 608 of the new ADAG on showers and that the alternate design is permitted in any facility now. There's also a couple things that will be new. Half inch Max allowed in roll in showers. This one I don't particularly like. But there's a higher curve allowed -- up to two inches -- on a transfer shower in an existing facility. And the catch to this is you can only do that where the floor slab is affected. If you're trying to install or transfer a shower and are 26 having to cut the floor slab in order to sink it down and it affects the structural significance you're allowed to have a two inch lip on that shower, which I don't necessarily like. Makes for a tough transfer. Somebody transferring into that transfer shower and they've moved over to the bench and now they're trying to lift their leg and drag it into that shower to complete the transfer, it's a lot enough tougher -- lot tougher getting their foot over. So I don't like that one that much. Speaking of showers, that's one issue we see in hospitals all the time. I've seen it recently on new construction projects that I did final walk-throughs on where accessible transfer showers in accessible patient rooms, locker rooms, and other areas where we have to provide accessibility the shower is not 36 by 36 absolute. They'll be 36 by 38 or 36 -- 37 by 39. And technically in the standards it's required to be 36 by 36 absolute . The reasoning behind that is it's a much safer shower if it's exactly 36 inches. The person transfers into the shower, and they're less likely to slide down off the bench onto the floor because they're more pinned into that 36-inch space than they would be in a larger roll-in shower. That's why we want that 36 inches absolute. The way it's been specked in the 27 standards that 36 is an absolute numbers and inspectors are writing them up. We've had facilities I've worked on that had several -- couple dozen showers that had to be fixed before we could open the doors of the hospital. And that was very expensive to do after construction was already done. So we need to make sure that our panel and tile-type showers are 36 by 36 absolute. Quickly, before I stop and see if there's additional questions, other things that we've seen -- that we see in ADAG 2004 that people need to know about is the reference on fire strobes, another absolute number we see in hospitals where the accessible fire strobes for the fire alarm on the wall, current ADAG requires them to be 80 inches absolute to the center of the lens, is where you measure it on the wall or six inches down from the ceiling, whichever is lower. These things are 80, 81, 82, 80-1/2 and they're getting written up all the time. In the ADAG 2004 they're referring to NFA codes -- national fire alarm codes, which says we have a range to install the strobe. It's better to have range numbers so that we can make sure we're not having to retro fit something that's one inch off in the construction process and in alarms it's huge because to relocate an alarm box -- a lot of people don't realize, those of us in the business do, that's 28 supposed to be an uninterpreted wire to that box. So to rerun it a couple inches in a building that's already built is a big job. That's one that we appreciate the range on. Again, 80 to 96 on fire strobes. Do we have any new questions in the queue? >>>JACQUIE: We do. A lot. For our captioner's sake, I'm going to ask you to slow down a little on your answers. This question follows up on the question we had earlier -- following up on buildings in the historical registry can medical facilities locate rehab services in a separate part of the facility and still use the historical area only for persons without disabilities? >>>MARK: Don't think so. Give me the question again. Still need to provide an accessible route to the area. Can't provide services to your -- you're discriminating if you provide services to all people except those with disabilities. >>>JACQUIE: Right. I think that's the right answer on that. That's essentially what it sounds like. >>>MARK: There isn't anything wrong with providing an alternate entrance and -- in a historic structure, this is -- and then folks with disabilities are able to take an interior route to that historic area and view everything everyone else is able to view. That 29 might be an alternate route that's accessible. That's the kind of thing I'm talking about, where if that main entrance is totally inaccessible, it's a nightmare to make accessible is on the register of historic facilities, because of that front entrance we don't necessarily want to change that and fool with the historic significance -- we get in touch with the folks at the historic preservation society. There's a process that's in the front of your ADAG in the rule that you follow for consulting with the right folks on historic places and doing what you can do without affecting the historic significance. It's under section 36.405, when you want to read up on it. >>>JACQUIE: Okay. Thanks. Another one -- when a hospital that is tax-assisted -- that is, receives state, federal, and local tax dollars for homestead -- builds a new building attached to the old buildings, are they supposed to produce a plan to eliminate barriers in the existing building? >>>MARK: Okay. On this facility, when they say tax-assisted, I'm a little bit confused. I suppose it's private. If they're paying taxes it's privately owned which would make it title 3 entity and they should have been looking at removing barriers all along in the 30 existing facility. In the alteration -- and I talked about this earlier, they need to make everything as accessible as they can following the new construction requirements as their golden ring. And they may need to look at -- if they're not doing a -- they're not necessarily doing an alteration to a primary function area in that old part of the building, which would trigger -- may trigger the 20% rule for a path of travel. But they should have been already looking at all the barriers in that existing structure long before now. >>>JACQUIE: Okay. And then, funny you mentioned the 20% rule because the next part -- she has four questions all dealing with this particular scenario. The next is -- are they required to apply 20% of additional funds based on the cost of the new construction to the path of travel or vertical accessibility in the old building? >>>MARK: Okay. The -- if they're a title 3 entity, they are not doing the 20% rule -- let's see. It was an alteration or addition? >>>JACQUIE: Looks like it's just a new building that is attached to an old building. >>>MARK: So the new building is not an alteration to a primary function area. It's new 31 construction, an addition. That's not going to trigger the 20% rule. If they do an alteration within the older facility to an area that exists for them to do business, which is your basic definition of the primary function area, then they're looking at the 20% rule. And I would advise on this question the questioner send us this question in full length so we can talk about it more at length. >>>JACQUIE: There's just one more part to that particular question -- is the hospital required to continue barrier removal in the old building until all barriers are removed? >>>MARK: Yeah. That's exactly the method they're supposed to be doing. That's the end of barrier removal. People ask all the time, when are we accessible? When you're accessible. If you are accessible under readily achievable barrier -- it means people can access your goods and services under priorities the department of justice -- DOJ gave us which I'll talk about in a minute -- then you're accessible. It's an on going obligation that the DOJ makes. You do what you can afford to do today. Then you have a good year and you can remove some more barriers. Once you're fully accessible, you're there. That's the golden deal. 32 >>>JACQUIE: Okay. The next question is, would a request from the local visually-impaired committee providing input on how to improve way-finding in a building that is still under construction to apply change in the floor or wall texture changes to alert them that they are coming to an intersection in the building -- would doing that create an unreasonable request or germ burden for the setting? She has a little more explanation -- no more question but for of an explanation of what she's talking about. The problem is way-finding at an intersection where there are no doors or major entrances where braille signage would be applied. The idea is when there is a change in the texture of the floor that would alert the visually-impaired person to look for a brailled or raised-text sign that provides what is on the connecting hallway -- for example, patient rooms. >>>MARK: Okay. There is no current requirement in the accessibility standards for what the person is talking about as far as wall texture as a way-finding piece. And it's -- if there is a -- I'm trying to say it's not a bad idea, nice thinking as far as good access and perhaps that's something that they would like to take locally to that facility if that's an 33 issue that's recurring. It's also a great suggestion perhaps to send in to the access board because they do listen to questions, suggestions, and things from the public, and they actually establish research committees based on things like that that people have asked about. And so while there isn't a requirement I can currently point to in the standards for that request to make the facility do it, or any facility, it is something she can advocate for locally and may be something she wants to suggest that could be considered in future recall making. >>>JACQUIE: Okay. I work at a VA hospital and am trying to get them to make their facilities, programs accessible. What law should I look at? As a federal agency do I have any additional responsibility? >>>MARK: They need to -- federally covered facility, they're going to be -- they would have in the old days referred to (indiscernible) probably and now they would be referring to the new ADAG because it's been adopted by DOD, I believe. I would have to check on who's in charge of VA and whose facility it falls under. But that's the accessibility standard they may want to use. If they're -- under -- for federal buildings there are a lot -- they're a lot farther along 34 in -- it's the ABA -- architectural act accessibility guidelines. I believe he or she can access the document either through the DBTACs or through the access board if there are copies in print still. Otherwise, they can access it on line. >>>JACQUIE: All right. I will let you get back as long as we have a few minutes at the end. >>>MARK: I'll leave time at the end. We're -- when we're looking at removing these barriers and looking at a program for removing barriers, how do we organize that program? The rule of thumb that I always pass along for barrier removal in facilities is that which has been provided to us by the department of justice, and those four priorities for access are, one, approach an entrance, which includes your arrival points -- do you have a passenger loading zone? If so, it needs to be accessible. Accessible parking -- are there -- is there accessible route from public streets and public transportation? And can I get in the door? Two on our priorities, is access to goods and services -- can I access the services that are being offered by that medical care facility? The third priority is access to restrooms. And the fourth priority is access to other features offered. Now, in the medical care facilities, we look at restrooms in two 35 different places. Under the second priority, access to goods and services, we look at our patient room count and see how many accessible patient rooms we have and when we're counting patient rooms, those bathrooms associated with the patient rooms have to be -- accessible patient rooms have to be accessible. Then all public restrooms are supposed to be accessible in new construction. In readily achievable barrier removal we look at the access to the restrooms and see what barriers we can remove. That may include removing barriers in a restroom when you have two restrooms in a corridor readily achievable may mean retrofitting one of the restrooms and posting a sign at the restroom just down the hall that isn't accessible yet that -- of where the location of that accessible restroom is until the facility can afford to do the other restroom. But that's the difference between -- one of the differences between new construction and readily-achievable barrier removal, is trying to make sure we remove barriers to access to our goods and services versus new construction where all the public restrooms have to be accessible. Some of the most common issues we see in hospitals is the accessible parking, missing access aisles, or the accessible parking has been located on an area where you have way more than 2% slope in the parking space or 36 access aisle. Those are supposed to be nice and flat, 2% Max in all directions. And speaking of the 2%, that's where we see this come up on accessible routes all the time -- on cross slope. On accessible route, you're not supposed to have anymore than 2% cross slope along a sidewalk leading up to a hospital, along any accessible route to the hospital, up ramps going along the property. Shouldn't have more than 2% cross slope. And even on the new construction projects we are having some -- having to re-do a lot of sidewalks when we do final inspections because our contractors are reading it at 2% Max and they're framing it and pouring it -- forming it and pouring it at 2% and -- one side or the other of the sidewalk settles and now we have more than 2%. So that's something we're having to pay some attention to and try to really stress with our contractors on our projects that that 2% -- you might want to try to lay it out at 1-1/2%. Civil engineers have been trained to get water away from the building because water will do more damage to a building than anything. But I've had to train a lot of my civil engineers to consider the envelope of that building, the accessible envelope to include that accessible route and accessible parking for that 2% Max because that's something we're missing all the time. And in final 37 inspections we're re-doing -- I had one facility where we re-did 100 feet of sidewalk. That's not something we want to do on new construction projects. So the slopes on walking surfaces are an issue that we're seeing all the time. Protruding objects along accessible routes. Anything that sticks out from a wall more than 4 inches and is above 27 inches or below 80 inches is what we call a protruding object. Examples of protruding objects in hospitals might be fire extinguishers. If you've got a fire extinguisher that's more than a five-pounder in a hallway and is in the middle of the hallway, chances are it sticks off the wall five, six inches. That would be considered a protruding object and should be relocated towards a corner of the corridor or in a fire extinguisher case so it's recessed into the wall. Other protruding Octobers we're seeing in hospitals all the time is signage, where folks have done a sign to mark a specific department or area and they've mounted it on the wall below 80 inches, sticking out off the wall more than 4 inches and that's a protruding object. Somebody who is using a cane whose disability is related to low visibility or blindness they're not going to see the sign and will run into it. Likewise with the fire extinguisher. The cane will not detect it above 27 inches and they'll run into it. 38 Another one in hospitals -- in our older facilities we have a lot of wall-mounted computers where nurses -- it's a nurses station and nurses are doing data entry and the shelf or computer table folds down from the wall. And either the box itself sticks out more than four inches when it's closed or when the shelf is folded down it sticks way out there and it's an accident waiting to happen. That is a protruding object. On our newer facilities we're going to mobile units and this isn't as much of an issue, but they're all over the place in our older facilities. So signage -- Oh, the other one that's huge in our hospitals is suggestion boxes. They're almost always protruding objects. Many time they're built by a well-intentioned director of facilities and he brings it and it's bound to get torn off the wall because it's a protruding object. Anything sticking off the wall that people aren't going to see or people can't see and are using a cane to navigate the environment, those would be protruding objects as well as liability problems so we want to reduce those. Big flat screens, information boards that are installed in hospitals -- not only to replace huge televisions in patient room that are protruding objects -- I can't tell you how many times I've walked into a patient room and banged my head on the TV -- now 39 we're replacing the big TVs up in the corner of the room or up higher than 80 inches. Many facilities are going to flat screen TVs. Just be careful with those that the TV still doesn't protrude off the wall in your accessible route more than four inches because sometimes they do if you use an adjustable bracket. But the big ones we're using are at the nurses stations, like at the ER departments where we've got a status board and we're using a flat screen LED and it's one of these giant things I wish I could watch a football game off and they stick way out off the wall. And we've had one unit be run into by a sited person who wasn't paying enough attention and the whole unit came down off the wall and hit the floor. Since then that customer started recesses those units into the wall or providing a fixed, cane detectable object beneath the unit so that if a person is using a cane they have some sort of object they detect with the cane that makes them go around the protruding object rather than running into it. Those are huge. If those out there have questions about those, don't hesitate to send them at info@eastlakederry.com. We also have helpful information on our website. The other thing at facilities that we have to make sure we're keeping up with is maintenance of accessible 40 features. The ADA actually says once you provide accessibility you have to make sure you're maintaining the accessible features. So when it snows you should be out there shovelling the accessible route. Just like all the other routes, you need to make sure you've maintained accessible routes. If an elevator goes down, you're allowed to have temporary interruptions but you should be having a call out to the elevator company and documents you're waiting on a part. It shouldn't be more than a reasonable amount of time either. Maintenance of accessible features is a requirement. One that I wanted to mention before that I forgot is an issue we're fighting all the time on site with the accessible routes are accessible curb ramps. Again, that -- accessible curb ramps, there is plenty of information and assistance on designing them on the access board website. It's www.access-board.gov. There will be a document available following this section that is archived that will have these references on it as well. On the curb ramps, big thing we're seeing is not holding the 2% cross slope maximum, going down the curb ramp, and also people building what we call conical curve ramps where it's tilted toward the street. As the person comes down the curb ramp, the cross slope they're hitting is trying to steer them into the street. So for 41 assistance on good curb ramp design I highly recommend going to access board website and looking at the public rights of way links on the website. There you will see several helpful documents, including a new alterations manual for the accessible public rights of way that you'll find very useful. Okay. Those are common errors that I'm seeing in hospitals all the time. I've got about five minutes before I take more questions at the end. I'm just flying through my notes here. Signage is huge. We're seeing issues with signage at almost every hospital we go to. There's a couple good sign companies out there that are national that are doing it right. Sometimes they forget a few raised Letter and braille signs to keep the costs down too. Architects are approving the graphics packages, so we -- this is another item that could be reviewed in an accessibility plans review. We're missing -- on room signage we're missing raised letters or braille. The signs are being produced with high gloss finish to them when we want a low gloss or matte or egg shell finish. Directional overhead signs hardly ever have big enough letters on them. Signage is a big issue and on hospitals we spend a lot of money on graphics packages. Signage is expensive. So if you have questions on 42 signage, please send them in. We'd love to address them as we've also started a sign company. So the signage is something we want to pay attention to. So where to begin? As I wrap up my last five minutes before we do more questions, appoint someone who is going to address ADA issues at your facilities -- where it be a ADA officer to be responsible for ADA compliance of the facility. Chances are it's going to fall on the director of plan operations. Everything else does. You're in charge of housekeeping and security. Now they're going to put you in charge of ADA. Somebody has to do it. We appreciate your efforts. We need to develop a patient complaint process at our facilities so we have a methodology to react to issues that are brought up to our attention. Get training for your ADA officer. Establish, for instance, an environment of care committee that includes clinical and nonclinical specialists and people with disabilities or their advocates to consider disability-related policy issues at least quarterly. And establish training for all employees involved in direct patient assistance and repeat that regularly so that they understand how best to work with people with disabilities. 43 The review of policies for effective communication. There are two cases I wanted to mention before we're done that folks can go to for a wealth of information. There are two -- they're two I refer to all the time. One is the hospital -- the Washington hospital settlement agreement. It's on the department of justice website at ADA.gov. If you go to ADA.gov and click enforcement at the top and then click settlements and scroll down to November of 2005 you will see two settlements there in November of 2005 -- one is the Washington hospital settlement and the other is valley imaging partners. Those two settlement agreements are a wealth of information for precedents that have been set by the department of justice as they establish these settlement consent agreements with existing medical care facilities. The valley imaging partners set out -- I worked on that one and we developed a matrix for the department of justice for a group of imaging centers that listed all of our equipment and what lifting and transfer equipment we had available and established a transfer team that could be at any site within an agreed amount of time as our policy for equipment and transferring to imaging equipment. And so -- also in the Washington hospital agreement you'll see a lot of information as far as 44 accessible medical equipment, exam rooms, exam tables, and other issues we've been talking about today. So those two cases are key settlement agreements to folks who are listening to us today. Okay. Let's see how many questions we can fit in. >>>JACQUIE: Okay. The first one I want to mention is really a comment about the VA hospital question. And this is -- it just says that the VA has adopted IBC, although add da bag (phonetic) still apply. However, the VA has a more stringent supplement titled barrier free design guide. And it is available on the VA website. >>>MARK: Interesting. I'll go there and educate myself on that. I haven't done any VA facilities. I hadn't heard of them using IBC. But I'll look into it and appreciate the advice. >>>JACQUIE: Another question says I am really enjoying your webcast. Thank you so much for all the great information. I work for a large urban hospital, and I have been asked to review the facility, the programs, and services to assess their accessibility. I am starting from square one. >>>MARK: God bless you. >>>JACQUIE: The hospital has not really addressed disability in a significant way. 45 Can you recommend ways I can get better buy-in from top management? >>>MARK: Yes, I can. The person needs to get in touch with me, though, through info@eastlakederry.com because I can share a lot of advice and I'm happy to do that. I've mentored a lot of folks that have been put in that position of being the all ADA and access guru at their facility and walking into it brand new. So I'm happy to be of any assistance I can be on that one. >>>JACQUIE: At least they know -- >>>MARK: Thank you for the compliment. >>>JACQUIE: At least they know they are the ADA coordinator. I bet you have sometimes found, as I have, that when they send you to a person that is their ADA that person don't know they are that. >>>MARK: If you want to call, make sure you have a little extra time because they may put you on hold for half an hour while they appoint an ADA coordinator. >>>JACQUIE: I've received a request from an employee who is visually impaired requesting we make our website accessible. I'm new on this job and I'm not sure what I need to do. We get federal funding for research, if that matters. >>>MARK: They're more -- more than likely, 46 through their funding sources they're required to go with 508 -- the DBTAC -- 800-949-4232 can get you on the right track and can give you a wealth of advice on IT. And they can do it very well and send you in the right direction. >>>JACQUIE: Okay. And for right now at least, this is our last question and the timing on that will work out pretty well. I understand that new regulations have not been adopted yet, but can you tell me what I can expect in terms of differences in the standards that will be apply to medical facilities from what they are now? >>>MARK: Okay. And that's a great question. You will see a standard that is easier to meet because of the ranges that have been applied to many of the absolute measurements. I spoke to the toilet center line that was always a problem. Signage has always been required to be right at 60 inches on center on the latch side wall of the door, next to a door. And the signs are always an inch off or -- and it wasn't necessarily a barrier but it didn't meet code. Now there's a range of 48 to 60, so I recommend that people mount their signs at 60 to the top of the sign and you know you're always going to be within the range. Because they've changed the way you measure it. You measure it to the raised 47 letters or the braille now. And so there are ranges that have been applied to different things we look at in accessibility that make it easier to remove barriers and also in existing facilities and also make it easier for new construction projects to meet the accessibilities standards without having to do a lot of re-dos because they can come real close to what the measurement is and if it's got a range they're still okay. The side wall grab bar in a toilet room is supposed to be 42 inch grab bar and that has to be mounted at 12 off the back wall in order to stick out at 54 like it's supposed to. That one hasn't been addressed. Instead of specking out a 42 inch grab bar why don't you call for a 48 inch grab bar? Then our contractor can be off an inch and still be within the requirements. There's some when you come across them and something's happened -- give me an e-mail if you'd like and I'm glad to share as far as any fixes or experience that I have on the particular issues. But I really believe these new standards will be helpful because we're all going to be looking at similar measurements. >>>JACQUIE: Okay. I think we have all the questions done. So thanks so much, Mark. This was really an interesting one. I learned a whole lot today and I always enjoy webcasts when that happens. 48 >>>MARK: Thank you. >>>JACQUIE: The archives will be available tomorrow at ILRU.org. Also please don't forget to complete the evaluation on the webcast page. We're interested in receiving your feedback. Thanks to the National Institute on Rehabilitations -- NIDRR, our sponsor for today. We hope you'll join us for more webcasts after the holidays when the webcasts will resume. This webcast would not be possible without the efforts of our webcast team, Rob Dickehuth and Jennifer, our captioner for today. Thanks for joining us and have a dazzling day.