Are hospitals with religious affiliations subject to the ADA?
Yes and No. Religious organizations or entities controlled by religious organizations are exempt from Title III (public accommodations) of the ADA. However, if a facility has 25 or more employees (15 or more exmployees as of July 26, 1994), it is subject to the employment obligations under Title I of the ADA.
Additionally, if a hospital with religious affiliations receives Medicare (Part A) funding, it is still obligated under Section 504 of the Rehabilitation Act of 1973 to make its services accessible to persons with disabilities. Section 504 prohibits discrimination against persons with disabilities by entities receiving federal financial assistance.

A private medical practice leases space from a landlord. Who is responsible for making the facility accessible under Title III of the ADA?
Both the landlord and the clinic are responsible for complying with Title III requirements. It is allowable for both parties to allocate responsibility in the lease agreement regarding ADA compliance. However, this agreement is effective only between the two parties and in no way diminishes the responsibility of both parties for complying with Title III of the ADA.

Who is responsible for providing auxiliary aids and services, if needed, to ensure effective communication between a patient and the physician?
It is the responsibility of the physician to communicate effectively with patients who have hearing, speech, or visual impairments unless an "undue burden", meaning significant difficulty or expense, or a fundamental alteration in the nature of the physician's services would result.
If the patient has a hearing impairment and the message which needs to be conveyed between the physician and the patient is straight forward (e.g. prescribing an X-ray or a blood test), an appropriate way of communicating may simply be hand written notes between the physician and the patient. If the communication is more complex, such as describing a complicated medical procedure, and if the patient usually communicates using sign language, the physician is required to provide a qualified sign language interpreter, upon request, as long as doing so does not cause an undue burden on his or her operating costs. The physician may not pass on the costs of hiring the interpreter directly to the patient with the hearing impairment, but can spread the costs to all patients like any other overhead cost.
If the patient has a speech impairment, the physician may be able to communicate effectively by simply allotting sufficient time to allow the patient to express his or her self or by utilizing the patient's communication board.

If an individual who is deaf arrives for a medical appointment with a sign language interpreter (and assuming no prior arrangement has been made), who is responsible for the cost of paying for the interpreter's services - the physician or the patient?
The physician is not responsible for paying the interpreter for his or her services if, as in this case, the patient simply shows up with the interpreter without making prior arrangements with the physician. A physician must be given adequate time to find a qualified interpreter if, in fact, one is needed.
If the physician is in a private practive (covered under Title III), he or she has the final decision on how best to communicate with the patient who is hearing or speech impaired. Even if the patient requests a qualified sign language interpreter this may not always be warranted. However, the physician is obligated to communicate with the patient effectively. If the information to be communicated is straight foward, such as prescribing an X-ray or a blood test, the physician may be able to communicate with the patient by using pen and paper (assuming the patient is able to read and comprehend script). if, on the other hand, a more complicated procedure needs to be described, such as heart bypass surgery, the services of a qualified sign language interpreter may be required. In either case, the physician has the right to be given adequate time to obtain interpreter service.
If the physician is covered under Title II (e.g. the physician works at a county owned by hospital), he or she must honor the patient's preference for communicating unless he or she can demonstrate that another equally effective means of communicating is available, or if the choice for communicating would fundamentally alter the nature of the physician's service, or if an undue financial or administrative burden would result.

Which set of design standards does our hospital have to comply with - ADAAG or UFAS? What are the determining factors?
Public hospitals (those facilities covered under Title II of the ADA) may choose between using the Americans with Disabilities Act Accessibility Guidelines (ADAAG) or the Uniform Federal Accessibility Standards (UFAS) for new construction and alterations. Private hospitals (those facilities covered under Title III of the ADA) do not have this choice and must comply with ADAAG for new construction and alterations.
Most hospitals have been subject to UFAS under Section 504 of the Rehabilitation Act since 1973. (Section 504 prohibits any program receiving federal funds from discriminating against individuals with disabilities.) UFAS is the design standard referenced in most Section 504 regulations and since many hospitals receive some form of federal funds such as Medicare, they have been obligated, when making alterations to existing facilities or constructing new facilities, to make their facilities accessible using UFAS as their guideline.
A public facility cannot alternate between UFAS and ADAAG. If it chooses to follow UFAS for one floor of a new building, it cannot switch to ADAAG for the next floor. Likewise, it cannot follow UFAS for one alteration project in a building and then follow ADAAG for another alteration project in the same building.

Do we have to provide accessible signage in our facility? If our facility already has signage, do we have to replace it with signs meeting ADAAG specifications?
Health care providers are not required to buy new accessible signage to post in places where they do not currently use signs. The ADA is not a mandate to provide signs. The ADA is a mandate to ensure that certain signs already in place can be read by a broader number of people.
Private hospitals (those covered by Title III) are required to replace existing signs that pose barriers to people with visual impairments to the extent that it is "readily achievable" to do so (easy to accomplish without much difficulty or expense). They should follow the standards for accessible signage that are set out in the Americans with Disabilities Act Accessibility Guidelines (ADAAG) for new construction and alterations. ADAAG requires that signs have good light/dark contrast in order to be easily read. Overhead signs are required to have large type in order to be easily read. Where pictograms are used (for example, stick figures to identify men's or women's restrooms), they must be accompanied by the appropriate words ("men" or "women"). In addition, where signs are used to designate permanent rooms and spaces (restrooms, exit doors, and room numbers), tactile signage (signs containing both raised and brailled characters) is required and should be posted in a uniform location beside the door or doorway. Tactile signage is also required on elevator control panels to distinguish all control buttons as well as on elevator door jambs, used to indicate what floor you are on. In an existing facility, it is permitted to spread out over several years' time the task of complying with these accessible signage requirements if, for a particular facility, it is not readily achievable to accomplish the task in a single year.
Public hospitals (those covered by Title II) are required to replace existing signage to the extent that doing so does not pose an undue or financial or administrative burden. Public hospitals may follow either the signage requirements of ADAAG or the signage requirements of UFAS, which are very similar to those of ADAAG.

Our clinic is located at the top of a hill and there are no accessible path of travel leading to it. Do we have to tear everything up and start over?
No. The ADA is not a mandate to rebuild America. Private businesses are required to only do what is "readily achievable" (easy to accomplish without much difficulty or expense) when it comes to retrofitting an existing facility in order to make it accessible.
If parking is provided and if the path of travel leading from the parking area to the building is too steep, the clinic must make accessible parking available closer to the clinic if it is readily achievable to do so. If not, the clinic must still provide an alternative method of parking, such as valet parking, when it is readily achievable to do so.

If we remodel the second floor of a private medical building that is not currently serviced by an elevator, do we still have to make the second floor accessible?
Yes. Even though the second floor is not serviced by an elevator, this does not diminish your responsibility under Title III of the ADA to make the remodeled space accessible. There are many different types of disabilities and just because an individual who uses a wheelchair may not be able to access the second floor, this does not hold true for individuals with other types of disabilities. Also keep in mind that individuals with mobility impairments who are able to walk short distances or who use other mobility devices may well be able to get to the second floor. The obligation to comply with the accessibility standards in the space that is being remodeled remains firm, even where there is no elevator to serve the area.
Furthermore, depending upon the overall cost of the renovation, there may be an obligation to install a platform lift or take other measures to make it easier for individuals with disabilities to access the second floor.
Title III states that whenever an alteration is made to an area where major activities take place, the facility is required to make that area accessible, and is also required to provide an accessible path of travel from the entrance to the altered area. This overall cost for providing this accessible path of travel does not have to exceed 20 percent of the original alteration costs. For example, if a facility was to spend $100,000 renovating the second floor of this medical building, it is obligated to pay an additional $20,000 if necessary to make the path of travel from the building's entrance to the second floor accessible. The path of travel requirement covers such things as sidewalks, lobbies, and corridors; ramps, stairs, lifts, and elevators; and the restrooms, telephones, and drinking fountains servicing the altered area.

The only way for us to make our patient rooms accessible is for us to remove one of the beds in our semi-private rooms. We are a private hospital and we cannot afford to lose this revenue. What can we do?
For some hospitals, the loss of a single bed could cost the hospital upwards of $100,000 per year in revenue. The loss of revenue is one factor that can be considered under Title III when making the "readily achievable" determination. In some cases it may not be readily achievable for the hospital to lose beds. In such a case the hospital remains obligated to find other readily achievable ways to make their services available to individuals with disabilities who cannot use the patient rooms independently.

When remodeling a private facility, what is meant by an accessible path of travel and how much will it cost us?
Whenever an alteration is made to an area where major activity takes place (primary function area), Title III of the ADA requires the altered area be made accessible in accordance with the Americans with Disabilities Act Accessibility Guidelines (ADAAG) and the path of travel from the entrance to the altered area must also be made accessible. The overall cost for providing this accessible path of travel does not have to exceed 20 percent of the original alteration costs. However, the facility is obligated up to the 20 percent limit. The path of travel requirement covers such things as sidewalks, lobbies, and corridors; ramps, stairs, lifts, and elevators; and the restrooms, telephones, and drinking fountains servicing the altered area.
Providing an accessible path of travel is not required if alterations are made to mechanical rooms, employee lounges, supply storage rooms, janitorial closets, entrances, corridors, or bathrooms. Furthermore, providing an accessible path of travel is not required when altering items such as windows, door hardware, electrical outlets, and signs. Additionally, ADAAG states that whenever alterations are being made "solely to the electrical, mechanical, or plumbing system, or to hazardous material abatement, or automatic sprinkler retrofitting", the accessible path of travel requirement is not triggered.

Do we have to provide telecommunication devices for the deaf (TDD) in our emergency room, for our ambulance service, and for our billing office?
Under Title II of the ADA, any emergency service operated by a public entity must be directly accessible to individuals who have hearing or speech impairments. This includes ambulance, fire, police (including 911) and poison control. Title II also requires public health facilities operating an emergency room to provide accessible communications within that area.
Under Title III of the ADA, an ambulance service operated by a private hospital is not mandated to have a TDD. However, it has to do whatever it can to make its services accessible and may choose to purchase a TDD (given that the average cost of a TD is only $200 - $300). Similarly, an emergency room of a private hospital should be able to provide a TDD given the moderate cost of the device.
A hospital billing service does not have to provide direct access for individuals with speech or hearing impairments. A telephone relay system is required to be in service throughout the United States by July 26, 1993. This service will enable individuals with hearing and speech impairments to communicate with individuals who do not have access to TDD's by utilizing a third party to relay information between the two. This service will open up lines of communication for all TDD users and will aid businesses in complying with the ADA.

Is there any money available for our clinic to assist with compliance costs or the provision of auxiliary aids?
Under Section 190 of the Internal Revenue Code a business may deduct up to $15,000 for qualified architectural and transportation barrier removal. Consult the IRS or a tax lawyer for more information. You should also request a copy of the IRS publication #907 which explains tax benefits related to the ADA. Funding may also be available through your state and local governments. Contract your local department of commerce for further information.

Our hospital van is four years old and is used to pick up elderly disabled patients from outlying areas. The van is not accessible and we are worried that we are not in compliance with ADA. What should we do?
The ADA does not require a van to be retrofitted with a lift. However, the hospital mst provide equivalent transportation services for people with disabilities who are unable to use the hospital's van. When and if you purchase a new van and if it seats more than 16 people, you should ensure that it is accessible to individuals with disabilities unless you are providing equivalent transportation services.

We are a private hospital. What happens if someone files suit against us. Will we be taken straight to court or is there a process for resolving any dispute before the lawyers get involved?
An individual may file suit if he or she feels that he or she has been discriminated against. At the request of the plaintiff or the defendant, and if the court permits it, the Department of Justice can intervene in the civil action if it feels the case is of general importance. Use of alternative means of dispute resolution is completely voluntary and may be used as an alternative to litigation if all parties agree.
Every effort should be made by your hospital to come into compliance with Title III of the ADA. A full assessment of your physical plant, policies and procedures, and provision of auxiliary aids should be undertaken. Identified facility access problems should be addressed where readily achievable to do so. Auxiliary aids should be provided where appropriate. All decisions should be documented. Involve individuals with disabilities from the community whenever possible in your determinations. Good faith efforts to come into compliance with the ADA may help in the event of a suit.

Listed below are some sources of additional information about the ADA:

National Rehabilitation Hospital
ADA Health Care Facility Access Project
(202) 877-1974 or (202) 877-1975 (Voice)
(202) 726-3996 (TDD)

Department of Justice (DOJ)
(202) 514-0301 (Voice)
(202) 514-0383 (TDD)
(202) 514-6193 (On-line Modem)

Equal Employment Opportunity Commission (EEOC)
1-800-663-3362 (Voice)
1-800-800-3302 (TDD)

Architectural Transportation Barriers Compliance Board (ATBCB)
1-800-USA-ABLE (Voice/TDD)

This document provides general information to promote voluntary compliance with the Americans with Disabilities Act (DAD). It was prepared under a grant from the U.S. Department of Justice. While the Public Access Section of the Civil Rights Division has reviewed its contents, any opinions or interpretations in this document are those of the National Rehabilitation Hospital 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.