AI_3000.07_Animals_in_the_Medical_Center.pdf

Walter Reed National Military Medical Center

ADMINISTRATIVE

INSTRUCTION

NUMBER 3000.07

January 29, 2018

D000

SUBJECT: Animals in the Medical Center

References: See Enclosure 1

1. PURPOSE. This Administrative Instruction (AI), based on the authority of references (a) through (c), and in accordance with (IAW) the guidance of references (d) through (ab), establishes Walter Reed National Military Medical Center (WRNMMC) policy to provide procedures for the introduction of animals, either visiting or remaining, onboard WRNMMC.

This AI incorporates and cancels NATNAVMEDCENINST 6800.1A, “Pets Onboard the National Naval Medical Center (NNMC) Complex,” October 8, 2008 (Reference (ac)) and NATNAVMEDCENINST 6800.1A, “Pet Therapy Program,” December 2, 2010 (Reference (ad)).

2. APPLICABILITY. This AI applies to:

a. All of WRNMMC and its associated clinics, which include Tri-Service Dental Clinics.

This consists of assigned or attached personnel, Service members, federal civilians, contractors, and others assigned temporary or permanent duties to WRNMMC or its clinics.

b. Those WRNMMC and associated clinics using contract staff, whom also must comply with this AI, must ensure that copies are maintained in the clinic area and all other applicable AIs. Inclusion of contractor applicability also requires that the statement of work outlines this compliance and a statement on where they can be found in the clinic area.

3. POLICY. It is WRNMMC policy, IAW references (h), (j), (m), and (p), to recognize the important and therapeutic role that appropriately authorized and trained dogs provide in the healing process of patient care, and to accommodate visits of authorized dogs within WRNMMC facilities. This policy implements hospital policy IAW reference (f) (Naval Support Activity Bethesda Instruction 10570.1B). While an individual may possess and/or use other animals as service animals, at present WRNMMC’s policy is to only recognize and allow for service dogs to be present within WRNMMC facilities, per reference (f). Should Naval Support Activity Bethesda (NSA-B) change its policies and procedures to accommodate other service animals, such as miniature horses, WRNMMC leadership will consider if a change in this policy is warranted, taking into consideration the factors outlined in section 35.136(i) of reference (h).

This policy does not cover or address military working dogs that are part of the Department of

WRNMMC-AI 3000.07

Defense (DoD) military working dog program (see DoD Directive 5200.31E), authorized civilian law enforcement working dogs, or dogs that may be involved in research activities (see DoD Instruction 3216.01). Also, animals needed for law enforcement purposes (such as those used by NSA-B Security) are permitted in WRNMMC facilities.

4. RESPONSIBILITIES. See Enclosure 2

5. PROCEDURES. See Enclosure 3 through 12

6. RELEASABILITY. Not cleared for public release. This AI is available to users with Common Access Card authorization on the WRNMMC Intranet site at:

https://www.wrnmmc.intranet.capmed.mil/DocumentCenter/WRBINST

7. EFFECTIVE DATE. This AI:

a. Is effective upon signature; and

b. Will expire effective 10 years from the publication date if it hasn’t been reissued or cancelled before this date IAW DoD Instruction 5025.01 (Reference (d)).

JOHN R. ROTRUCK

Captain, Medical Corps U.S. Navy Chief of Staff

Enclosures

1. References

2. Responsibilities

3. Procedures Concerning Service Dogs

4. Service Dog Waiver Form

5. Animal Assisted Therapy (AAT) Dogs

6. WRNMMC Facility Dog Handler Application

7. WRNMMC Facility Dog Handler Sample Appointment Letter

8. WRNMMC Facility Dog Handler Training Record

9. Animal Assisted Activity (AAA) Dogs

10. Personal Pet Visits

11. Palliative Personal Pet Visit Request Memorandum

12. WRNMMC Gift Fund Eligible List of WRNMMC Facility Dog Goods and Services Glossary https://www.wrnmmc.intranet.capmed.mil/DocumentCenter/WRBINST

3 ENCLOSURE 1

ENCLOSURE 1

REFERENCES

(a) Deputy Secretary of Defense Action Memorandum, "Implementation of Military Health System Governance Reform," March 11, 2013

(b) DoD Directive 5136.13, "Defense Health Agency (DHA)," September 30, 2013

(c) National Capital Region (NCR) Medical Directorate Concept of Operations, September 10,

(d) DoD Instruction 5025.01, “DoD Issuance Program,” June 6, 2014

(e) Technical Med 4, DOD Human-Animal Bond Principles and Guidelines, August 3, 2015

(f) NSABETHINST 10570.1C, “Animals Onboard Naval Support Activity Bethesda,”

November 28, 2017

(g) DoD Instruction 1300.27, “Guidance on the Use of Service Dogs by Service Members,”

January 7, 2016

(h) Title 28, Code of Federal Regulations (CFR)

(i) Title 38, CFR

(j) WRNMMC Red Cross Program for Assistance Dogs and Animal Visitation Program

Handbook

(k) “Memorandum of Understanding between the Department of Justice and the Department of

Defense: Status of Certain American Red Cross Volunteers,” retrieved from http://www.militaryonesource.mil/12038/MOS/MWR/PR000613-09REDXMOU.pdf

(l) Section 504 of the Rehabilitation Act, 29 USC 794

(m) Americans with Disabilities Act (ADA), 42 USC 12101-12213

(n) Title 40, United States Code

(o) Title 42 United States Code §§ 12101 et seq.

(p) Department of Justice, Disability Rights Section Guidance and Frequently Asked Questions on the ADA

(q) “Support Animals in the MTF,” by CAPT Luke Spencer, The Air Force Medical Law

Quarterly, Summer 2016

(r) OTSG/MEDCOM Policy Memo 14-051, “Updated Guidance on the Use of Animals in the

Healthcare Setting (Service Animals, Animal Assisted Therapies, and Animal Assisted Activities), June 23, 2014

(s) DoD Instruction 1000.15, “Procedures and Support for Non-Federal Entities Authorized to Operate on DoD Installations,” October 24, 2008

(t) “Focus on Service Dogs,” by Lt Christine Supervielle, Naval Hospital Camp Pendleton, available at http://navymedicine.navylive.dodlive.mil/archives/5769

(u) WRNMMC Department of Rehabilitation Therapeutic Service Dog Training Program

(v) American Kennel Club (AKC) Evaluator’s Guide

(w) Canine Good Citizen (CGC) Program

(x) 673d Medical Group Operating Instruction 44-167, “Hospital Animal Assisted

Activities/Pet Therapy,” March 4, 2016

(y) 60th Medical Group Instruction 44-80, “Canine-Assisted Therapy (CAT) Program,”

January 31, 2012

(z) 88th Medical Group Instruction 44-168, “Animal-Assisted Activities/Therapy Program,”

October 30, 2015 http://www.militaryonesource.mil/12038/MOS/MWR/PR000613-09REDXMOU.pdf http://navymedicine.navylive.dodlive.mil/archives/5769

(aa) DODI 1300.24, “Recovery Coordination Program (RCP),” dated December 1, 2009

(ab) ADA National Network, “Service Animals and Emotional Support Animals,” 2014

(ac) NATNAVMEDCENINST 10570.1A CH-1, “Pets Onboard the National Naval Medical

Center (NNMC) Complex,” October 8, 2008 (hereby cancelled)

(ad) NATNAVMEDCENINST 6800.1A, “Pet Therapy Program,” December 2, 2010 (hereby cancelled)

5 Enclosure 2

ENCLOSURE 2

RESPONSIBILITIES

1. WRNMMC DIRECTOR. The Director will:

a. Approve AAT, AAA, and all other animals in the hospital programs at WRNMMC.

b. Ensure there are proper processes and procedures in place to allow for appropriately trained and certified dogs to be permitted in authorized parts of the hospital.

c. Ensure the health and safety of patients, staff, visiting dogs, and dog handlers.

d. Grants exceptions to this policy, as needed. An example would be granting access to WRNMMC facilities for those individuals involved in training service dogs in an accredited program.WRNMMC Director may grant an exception to policy to accommodate an emotional support dog on WRNMMC property that is prescribed within the calendar year by an appropriately licensed mental health provider. If such an exception for the emotional support dog is given, that exception would only apply for WRNMMC properties and only for a set period of time. Per reference (f), the NSA-B Commanding Officer would be the individual who coordinates any exceptions to policy requests for NSA-B property. Concerning emotional support dogs, see further details in Enclosure 3, paragraph 1f(3).

2. WRNMMC CHIEF OF STAFF (COS). The COS will oversee this policy.

3. WRNMMC DIRECTOR FOR SPECIAL ASSISTANTS. The WRNMMC Director for Special Assistants will provide day-to-day direction for this policy.

4. WRNMMC DIRECTORATES, DEPARTMENT CHIEFS, AND SERVICE CHIEFS. The WRNMMC Directorates, Department Chiefs, and Service Chiefs will work with Patient Relations and individuals in other appropriate offices to monitor dog access to WRNMMC facilities and notify patients and visitors of this policy.

5. WRNMMC AMERICAN RED CROSS (ARC) STATION MANAGER. The WRNMMC Red Cross Station Manager will:

a. Oversee the ARC Animal Visitation Program (reference (j)) at WRNMMC. Dogs in this program are predominantly used as part of Animal-Assisted Activities (AAA).

b. Ensure that only appropriately qualified individuals serve as Red Cross volunteer dog handlers for the WRNMMC ARC Animal Visitation Program, IAW reference (j).

6 Enclosure 2

c. Ensure that only appropriately qualified and certified dogs provide services as part of the WRNMMC ARC Animal Visitation Program, IAW reference (j).

6. WRNMMC FACILITY DOG PROGRAM DIRECTOR. The WRNMMC Facility Dog Program Director will:

a. Oversee and manage the WRNMMC Facility Dog Program.

b. Dogs in this program are used as part of AAT as well as AAA.

7. WRNMMC FACILITY DOG TRAINING COORDINATOR. The WRNMMC Facility Dog Training Coordinator will:

a. Ensure that only appropriately qualified individuals handle the WRNMMC Facility Dogs.

b. Be in charge of and responsible for the day to day operations of the WRNMMC Facility Dog Program.

c. Ensure that only appropriately qualified and certified dogs provide services as part of the WRNMMC Facility Dog Program.

8. WRNMMC FACILITY DOG MANAGER. The WRNMMC Facility Dog Manager will:

a. Be in charge of and responsible for the administrative records for the WRNMMC Facility Dog Program.

9. WRNMMC AND NATIONAL INTREPID CENTER OF EXCELLENCE SERVICE

CHIEFS FOR OCCUPATIONAL THERAPY. The Chiefs of Occupational Therapy will:

a. Manage and oversee the WRNMMC service dog in training program as part of AAT, per reference (u).

10. WRNMMC STAFF. The WRNMMC staff will:

a. Communicate with any AAA/AAT handler about patients who should not be visited by a dog. Examples of this type of patient would be those who are or who are suspected of becoming violent, who are emotionally unpredictable, who are allergic to dogs, which are afraid of dogs, who are in isolation (contact precaution) rooms, and or who are on one of these areas: pre/post-operative recovery, and sterile areas.

b. Engage in proper hand hygiene whenever around any dog in the facility.

7 Enclosure 2

c. Coordinate, as needed, on palliative pet visits.

d. Inform patients and visitors of this policy.

e. Complete requisite paperwork and notify individuals should a patient, visitor, or staff member be bitten or injured by any dog in the hospital:

(1) Notify the attending provider.

(2) Notify Public Health (Preventive Medicine), complete the DD Form 2341, Report of Animal Bite—Potential Rabies Exposure. The DD Form 2341 requires a sequence number, and Public Health should maintain the log.

(3) Complete a patient safety report. Patient Safety, the Risk Manager, and the Legal Office should be informed.

f. Contact NSA-B Security if there is any animal found running loose in or on WRNMMC properties (for instance, a stray) for pick up, per reference (f).

g. Work with Patient Relations with issues concerning dogs on WRNMMC properties and whether they meet criteria for access.

11. ALL AAA/AAT HANDLERS. AAA Handlers—as part of the American Red Cross Program will:

a. Complete all required training for themselves and their animals. This includes orientation.

b. Maintain required health standards for their dogs.

c. Provide written proof that the dog(s) they are handling is/are covered with liability insurance. The handler is responsible in a court of competent jurisdiction for misconduct by either themselves or their dog that results in illness or injury to a patient, visitor, staff member, or other dog. The handler will also agree to sever WRNMMC from any joint liability and to indemnify and hold harmless WRNMMC, the Department of Defense, and the United States with respect to claims for damages arising from the participation of the handler and or dog in the animal assisted activity dog therapy program. ARC Handlers must also provide ARC any changes to the insurance coverage.

d. Provide certification that the dog is free from disease and internal/external parasites before they can enter the hospital or hospital-associated buildings.

e. Ensure that they and the dog are feeling well for a full 24 hours before visiting at the hospital.

f. Clean up and remove any animal waste.

8 Enclosure 2

g. Immediately remove any dog if the patient responds negatively.

h. Ensure that the AAA/AAT dog remains in control and is housebroken.

i. Engage in proper hand hygiene.

j. For any government employee, properly account for the time that she/he is away from primary duties to serve as the handler.

k. Follow the provisions in this instruction concerning the handling of an AAA/AAT dog.

l. Comply with any specific requirements of the program for which they belong. For instance, ARC handlers will follow the terms and conditions as required by the ARC. The WRNMMC ARC Office has separate procedures for an ARC handler to report an injury.

10. SERVICE DOG OWNERS/HANDLERS. Service dog owners/handlers will:

a. Be responsible for their service dog.

b. Clean up and remove service dog waste.

c. Ensure that the service dog remains in control and is housebroken.

d. Follow the provisions in this instruction for handling a service dog and any Service-specific requirements they have for acquiring and using them.

11. HOUSEKEEPING. Housekeeping staff will assist, as needed, with removal of any dog waste (stool emesis, etc.) in the area.

12. INFECTION CONTROL. Infection Control will work closely with hospital staff (including ARC volunteers) to ensure adherence to the training guidelines that maintain proper infection control procedures.

13. PATIENT RELATIONS DEPARTMENT. The Patient Relations Department will liaise with appropriate hospital staff to address issues concerning dogs in the facility. This includes facilitating notice to patients and visitors about the policy and whether their dog meets acceptable criteria for their access on WRNMMC properties.

9 Enclosure 3

ENCLOSURE 3

PROCEDURES CONCERNING SERVICE DOGS

1. General provisions.

a. As a federal facility, the Rehabilitation Act, reference (l), applies to WRNMMC and its facilities. However, that law incorporates provisions, concerning service dogs and accommodations of them, from reference (m), the Americans with Disabilities Act (ADA).

Courts analyze alleged violations of the Rehabilitation Act with the ADA, and reference (g) specifically mentions the ADA. For a service animal to operate or be utilized at WRNMMC, it must be independently certified to ensure consistency. Certification must come from an organization accredited by Assistance Dogs International (ADI) or the International Guide Dog Federation (IGDF). If a service dog is not certified by ADI or IGDF, the WRNMMC Director has discretion to grant a waiver. An individual with a dog that is not ADI or IGDF certified must request a waiver in writing (waiver form and procedures – see enclosure 4) Waivers are granted on a case by case basis. Therefore, for purposes of this policy, and unless otherwise modified by higher headquarters authority and/or mission requirements, WRNMMC will follow reference (l) as well as the Department of Veterans Affairs (VA) provisions concerning access to WRNMMC property.

b. As outlined below, the definition of a service dog, by regulation, varies depending on whether the service dog handler is a Recovering Service Member (RSM) or not.

c. RSMs.

(1) Per reference (g), WRNMMC staff, including those in primary care, care management teams, and in the Occupational Therapy Department, assist RSMs in the determination that they have a medical condition that requires the services of a dog for Activities of Daily Living (ADL). The purpose of a service member acquiring a service dog is to assist the service member with public access or the activities of daily living while he or she remains on active duty or while transitioning. The service member’s chain of command must approve the assignment of the service dog.

(2) Once a determination has been made that the RSM is entitled to the use of a service dog, is appropriately counseled, and has an approved service dog, WRNMMC will grant the RSM, and the service dog, facility access and accommodation to the greatest extent possible commensurate with health and safety, per reference (g). Paragraph (5) below outlines the conditions under which a service dog will be denied access to WRNMMC property or removed from WRNMMC property.

(3) For RSMs, a service dog is one obtained from an accredited service dog organization, approved by the Department of Veterans Affairs (VA) or other governmental approval agency, and that is individually trained to do work or perform tasks for the benefit of an individual with a disability. The dog is trained to respond to a verbal command, hand gestures, or condition of the

10 Enclosure 3

RSM. (Section 17.148 of reference (i) outlines the types of service dogs the VA will recognize for the purpose of paying benefits.)

d. Other patients or visitors at WRNMMC who need service dogs but are not RSMs.

(1) For their purposes, WRNMMC will follow the ADA’s definition of a service dog, which is a dog that has been individually trained to do work or perform tasks for an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability. The task(s) performed by the dog must be directly related to the person's disability.

The dog must be trained to take a specific action when needed to assist the person with a disability. For example, a person with diabetes may have a dog that is trained to alert him/her when their blood sugar reaches high or low levels. A person with depression may have a dog that is trained to remind him/her to take their medication. Or, a person who has epilepsy may have a dog that is trained to detect the onset of a seizure and then help the person remain safe during the seizure.

(2) These individuals will also be given facility access and accommodation to the greatest extent possible commensurate with health and safety. Paragraph (5) below outlines the conditions in which a service dog will be denied access to WRNMMC property or removed from WRNMMC property.

e. Should a service dog be required, as part of a “reasonable accommodation” for a member of WRNMMC’s workforce, under the ADA, the Rehabilitation Act, or the Equal Employment Opportunity Act, those accommodations will be negotiated and annotated in writing as part of the individual’s employment and personnel file, and managed by the individual’s workplace supervisor. The ADA definition of service dog will apply.

f. Dogs that do not meet the definition of a “service dog” yet remain in the possession of an individual are defined as “companion animals” or “pets” for purposes of this instruction.

(1) “Companion animals” or “pets” are not service dogs, and are not authorized in WRNMMC unless somehow meeting requirements for another cadre of dog in this instruction.

(2) The provision of emotional support, wellbeing, comfort, companionship, or crime deterrence will not qualify a dog as a service dog.

(3) The WRNMMC Director may, but is not required to, grant an exception to policy to accommodate an emotional support dog within WRNMMC properties that is prescribed within the calendar year by an appropriately licensed mental health provider. If that exception is given, the owner of the dog must have the exception to policy with them at all times and WRNMMC staff may request documentation for the patient in this case. At no time will MTF operations be disrupted, nor will the emotional support dog’s presence compromise patient care, patient safety, or infection prevention and control procedures.

g. Service dogs in training. Both the National Intrepid Center of Excellence (NICoE) and the WRNMMC Occupational Therapy Department run a program in which, as part of therapy, 11 Enclosure 3 certain patients help train service dogs, reference (u) provides amplifying guidance.

Additionally, the WRNMMC Director has discretion to grant trainers with service dogs in training access to WRNMMC facilities, provided that the training is occurring under the auspices of an accredited program. Otherwise, service dogs in training are not considered service dogs.

h. Should someone (a member of the WRNMMC workforce, patient, visitor, etc.) be allergic to any service dog, care will be taken to make reasonable accommodations for that other person.

For instance, one may be moved to a different location within a room or a different room in WRNMMC, with the minimal amount of disruption to normal operations.

2. Responsibilities of all service dog owners/handlers including RSMs, patients, visitors, or staff members.

a. Consistent with section 35.136 of reference (h) and section 1.218 of reference (i), service dog owners/handlers must ensure their dog wears a harness, leash, or other tether, unless the handler is unable, because of a disability, to use a harness/leash/tether or the use of the harness/leash/tether would interfere with the service dog’s safe and effective performance of work or tasks. If that is the case, the service dog must be under the handler’s complete control through voice, signals, or other effective means. Per section 3103 of reference (n), service dogs are not permitted to run free or roam in a building or on the property. Service dogs on WRNMMC are subject to the same terms, conditions, and regulations as generally govern admission of the public to the property, consistent with section 1.218 of reference (i).

b. Service dogs shall not be left unattended in any WRNMMC facility.

c. Service dogs must be under the direct supervision and control of the service dog owner/handler at all times while at WRNMMC. Per the ADA, “under control” also means that a service dog should not be allowed to bark repeatedly in a quiet place at WRNMMC. However, if a dog barks just once, or barks because someone has provoked it, this would not mean that the dog is out of control.

d. A treating provider must document, as part of a treatment plan, the need to allow a service dog to remain overnight or in an acute inpatient area for a shorter duration. The service dog remaining during an in-patient stay must be required as an integral part of the treatment provided during the in-patient period. If this occurs, the service dog handler or an alternate handler (and not a member of WRNMMC’s workforce or volunteer) must be responsible for control of the service dog and the care of the service dog, at all times. The patient is responsible for arranging for the service dog’s care; in accordance with the service dog care plan, while the patient is admitted as an in-patient, or if emergency treatment is needed. Should something arise and the patient is not able to make these arrangements, WRNMMC staff can attempt to assist with making arrangements or executing the care plan by contacting any alternate handlers the patient had previously identified (if known) or the WRNMMC ARC office (301-295-1538 during normal business hours). However, there is no guarantee that the ARC office can/will provide or arrange such care. Local emergency veterinarians or animal clinics may need to be called to make arrangements, which is consistent with VA policy and the ADA. Before WRNMMC staff makes arrangements, the patient must be given the opportunity and attempt to execute the care

12 Enclosure 3 plan for the service dog. Nonetheless, WRNMMC will not assume responsibility for the care of the service dog.

e. Service dog owners/handlers are solely responsible for providing care (including veterinary care) and stewardship for their service dogs, to include feeding, watering, exercise, toileting, and waste removal. Service dogs must be housebroken and must be trained to eliminate its waste in an outdoor area. The handler/owner of such a dog is responsible for proper disposal of all of the service dog’s waste in a trash receptacle outside the facility.

f. A service dog may not be excluded based on assumptions or stereotypes about the animal's breed or how the animal might behave. However, no service dog will create a nuisance or otherwise jeopardize the health, safety, comfort, treatment or wellbeing of patients, staff, visitors, or other service or facility dogs. NSA-B security may be contacted to assist.

3. To the extent permitted by law, service dog owners/handlers are responsible for any damages or injuries caused by their service dogs. Should a service dog cause an injury, WRNMMC staff will request that the service dog handler/patient provide information related to the service dog’s health records (particularly proof of current rabies vaccination), consistent with VA policy.

4. General infection control considerations. Dogs can transmit infectious diseases to humans, and likewise, humans can transmit infectious diseases to animals. Dogs can become transient vectors or carriers of potential human pathogens and could be responsible for cross-infection.

Proper infection prevention procedures are warranted at all times to minimize the risk of transmission between humans and dogs.

a. Every effort should be made to limit any dogs from licking patients, particularly wounds, or medical devices. Service dogs should not be engaging in this behavior.

b. As a general rule, service dogs should not be on patient beds, hospital furniture or wheelchairs. If the patient requests the service dog to be on their bed, a barrier (sheet) may be placed on the bed for the animal to lie on beside the patient. The sheet will be discarded into the hospital laundry after each patient use.

c. Patients and staff should not have any contact with dog waste unless required for their duties consistent with this instruction. .

d. Any area contaminated by dog urine, feces, emesis, or blood, must be cleaned using appropriate personal protective equipment (gloves) and a hospital approved disinfectant. Should this occur, service dog owners/handlers must alert the nearest WRNMMC staff member for assistance in contacting Housekeeping.

e. Scrupulous hand hygiene by patients, family, and staff should take place before and after contact with any service dog.

13 Enclosure 3

f. Dogs should appear healthy, clean, well-groomed, and be odor free.

5. Limitations on the access of service dogs. Consistent with section 35.136 of reference (h) and section 1.218 of reference (i), a service dog will be denied access to WRNMMC property or an individual may be asked to remove a service dog from WRNMMC property if one or more of the conditions below occur. NSA-B Security may be contacted to assist. Per section 35.136 of reference (h) and section 1.218 of reference (i), if a service animal needs to be properly excluded, WRNMMC staff will give the individual with a disability the opportunity to participate in the service, program, or activity at WRNMMC without having the service dog on the premises.

a. The service dog is not under the control of the owner/handler or an alternate handler and the animal’s handler or alternate handler does not take effective action to control the service dog.

b. The dog is not housebroken. The dog must be trained to eliminate its waste in an outdoor area.

c. The animal otherwise poses a risk to the health or safety of people or other dogs in the hospital. This assessment will be made on an individual basis and based on, to the extent possible, objective criteria, to include, but not limited to:

(1) External signs of aggression from the service dog, such as growling, biting, snapping, or baring its teeth and or lunging;

(2) External signs of parasites or other external signs of disease or bad health.

d. The service dog goes into an area restricted from access by the service dog. These “off-limit” areas are designed to ensure patient care, patient safety, or infection control standards are not compromised. These areas include but are not limited to:

(1) Operating rooms and surgical suites.

(2) Areas where invasive procedures are being performed.

(3) Acute inpatient hospital setting where the presence of the service dog is not part of the documented treatment plan.

(4) Decontamination, sterile processing, and sterile storage areas.

(5) Food preparation areas. However, they are allowed in public food service areas.

(6) Any area where an individual must wear personal protective clothing or must take barrier protective measures to enter. A service dog may be able to go in the emergency room or an examination room if the person with the disability (handler) or an alternate handler is able to control the service dog (on a harness/leash/tether/use of voice or other control) and the service

14 Enclosure 3 dog’s presence would not compromise patient care, patient safety, or infection prevention and control procedures, which is consistent with the VA’s policy.

6. Individuals concerned about dogs, including whether the dog appears to be an emotional support dog rather than a service dog, should contact the Patient Relations Office. Personnel in that office, will, as needed, coordinate action with appropriate WRNMMC staff, to include service chiefs, department chiefs, directorates, etc.

7. Consistent with section 1.218 of reference (i) and reference (p), an individual with a disability must not be asked what their disability is, cannot be asked for medical documentation of their disability, and must not be required to provide documentation, such as proof that a dog has been certified, trained, or licensed as a service dog to gain access to WRNMMC property when accompanied by the service dog. However, an individual may be asked:

a. Is the dog required because of a disability?

b. What work or task the dog has been trained to perform?

8. When it is not obvious that a dog is a service dog, WRNMMC adopts the way the VA makes this determination, and that is to ask a person the above two questions. Whether the dog is a service dog will be determined based on the person’s answers to these questions. If someone presents proof of a dog’s “accreditation”, training is not an automatic way to gain access.

Consistent with the VA’s policy, a dog need not be trained by an “accredited” organization in order to be a service dog that may access WRNMMC property.

9. Should a person with a service dog need to ride in a WRNMMC ambulance, WRNMMC will attempt to accommodate the service dog. However, if the space in the ambulance is crowded and the dog's presence would interfere with the emergency medical staff's ability to treat the patient, staff will make other temporary arrangements to care for the service dog until the service dog care plan can be initiated.

15 Enclosure 4

ENCLOSURE 4

WRNMMC SERVICE DOG ACCESS WAIVER FORM

Patient Name:

Date and Time of Visitation:

Work Performed by Dog:

Occupational Therapy staff concerns with visit: Yes No

If “Yes”, list concerns: __________________________________________________________

Breed: Name of Dog:

Certifying Agency:

I verify that my dog‘s health and shot records are up to date.

Patient Printed Name: Signature and Date:

Occupational Therapy Staff Printed Name: Signature and Date:

Coordinator Printed Name: Signature and Date:

The coordinator is the Service Dog Coordinator overseeing the waiver process. Typically, this individual is the Occupational Therapy Service Chief or his designee. Once completed, the form then goes into the Service Dog Coordinator files and a copy is to be carried by the patient at all times. All Service Dogs Access Waivers will be conducted in accordance with WRNMMC-AI 3000.04, “Animals in the Medical Center.”

16 Enclosure 5

ENCLOSURE 5

AAT DOGS

1. Background: Prior to the integration of the National Naval Medical Center (NNMC) and Walter Reed Army Medical Center (WRAMC) and the renaming of the facility to WRNMMC, two AAT programs existed. At WRAMC, it was a program to engage, as part of therapy, the training of service dogs and some AAA activities. At NNMC, the program was entitled “Pet Therapy Program,” (reference (ad) hereby cancelled). The dogs used at NNMC were considered “facility” dogs, and they engaged in AAA, and, at times, AAT.

2. Per reference (f), NSA-B retains authority over installation access, control, and domiciling for any dog participating in AAT. Dogs participating in AAT at WRNMMC will only be as part of a WRNMMC Director or Director’s designee approved program; the WRNMMC director retains the right to refuse or limit any such program. The Facility Dog Program Training Coordinator manages facility dog visits, trains the handlers, and sends facility dog and handler teams to specific approved locations on the day of the visit; this individual assigns their duties. The WRNMMC Facility Dog Manager maintains records on the WRNMMC facility dogs.

Individuals wishing to bring a dog into WRNMMC to engage in AAT or AAA will need to speak with the ARC Station Manager and ARC Animal Visitation Program Coordinator.

WRNMMC leadership is the approval authority for the use of facility dogs at WRNMMC and the addition of any other dogs to the WRNMMC Facility Dog program, AAA, or AAT activity.

3. Consistent with section 1.218 of reference (i), AAT is designed to be a goal-directed clinical intervention that incorporates the use of a dog into a patient’s treatment regimen. Any AAT dog present at WRNMMC must facilitate achievement of patient-specific treatment goals as documented in the patient’s treatment plan. The AAT dog is an integral part of a treatment process designed to improve physical, social, emotional, and cognitive function. The interventional goals are designed, documented, and tracked by a health care professional and are tailored to each patient’s individual needs. Upon completion of a “therapy session,” a member of the WRNMMC (to include NICoE) workforce or volunteer retains the AAT dog rather than the patient. Examples of AAT include, but are not limited to, a patient with balance dysfunction using a trained dog wearing a rigid-handled harness to assist with gait, or a patient performing service dog training to cope with post-traumatic stress.

4. To be eligible for AAT at WRNMMC, the AAT intervention must be documented in the patient’s health record. An AAT session may be terminated, if in clinical judgment, the therapy session is not in the best interest of the patient, WRNMMC, or the dog. This policy applies to all AAT programs.

17 Enclosure 5

5. Consistent with section 1.218 of reference (i), dogs participating in AAT may be permitted to be present at WRNMMC and at ceremonial events when their presence would not compromise patient care, patient safety, or infection control standards.

6. Owners/handlers will not leave dogs who are participating in AAT unattended or off leash in any WRNMMC facility.

7. While inside a WRNMMC facility, dogs participating in AAT must be held on a leash with six feet maximum length but held close to the handler as not to impede movement by other staff, patients, or visitors or harness and under the direct control of the owner/handler at all times.

Anyone has authority to require an owner/handler to remove a misbehaving AAT dog (barking, growling, lunging, begging for food, uncontrollable by the handler, etc.) from the local area. If necessary, personnel should contact Patient Relations or NSA-B Security for support in this matter.

8. If, at any time, someone observes a dog who is participating in AAT to appear sick, infected or demonstrate a change in temperament, that individual should contact WRNMMC staff, who will assist in the matter (i.e., informing the owner/handler that the dog must be removed from the premises).

9. Dogs participating in AAT must be housebroken and must be trained to eliminate its waste in an outdoor area. The handler/owner of such a dog is responsible for proper disposal of all of the animal’s waste in a trash receptacle outside the facility.

10. Health and temperament requirements for dogs participating in AAT.

a. All dogs participating in AAT must have an American Kennel Club Canine Good Citizen (Temperament Testing) certificate. They must have a trained primary owner/handler. See Enclosures (6), (7), and (8) for documents for trained, authorized, and approved WRNMMC Facility Dog Handlers. WRNMMC Facility Dog Handlers must complete the WRNMMC Facility Dog Handler Training and they are assigned their activities by the WRNMMC Facility Dog Program Training Coordinator. Personnel from other commands are welcome to participate as WRNMMC Facility Dog Handlers in the WRNMMC Facility Dog Program subject to review and approval by the WRNMMC Facility Dog Program Director, the WRNMMC Facility Dog Training Coordinator, and their command. The AAT dog’s owner/handler must maintain and provide documentation of the dog’s temperament, health, and welfare standards to the WRNMMC ARC or Facility Dog Program Coordinator. The ARC coordinator, for the ARC dogs, and the WRNMMC Facility Dog Manager, for the WRNMMC Facility dogs, will maintain a copy of these records. WRNMMC and the dog organization may request copies of the health records of these dogs from the WRNMMC staff that care for them. Should the coordinator have

18 Enclosure 5 questions about any of the required paperwork that is presented, the coordinator should call a military veterinarian, and the dog will not participate in the AAT until the issue is resolved.

b. Dogs participating in AAT must also receive yearly physical health examinations, and handlers must provide documentation. Their skin should be free from fleas, ticks, lice, mites, and dermatitis. Teeth and gums should be clean and healthy.

c. The owner/handler must provide verification that immunizations are current. These include the rabies vaccine and distemper combination vaccine. (The leptosprosis vaccine and Bordetella vaccine are recommended non-core vaccinations.) For dogs that cannot receive rabies and distemper combination vaccines due to health concerns (such as an adverse reaction or auto-immune disease), the owner would need to provide current evidence that a blood titer has been performed to verify that the dog has sufficient antibody present and are “immune.”

d. Fecal examination must be performed to demonstrate that the AAT dog is free from intestinal parasites. There should be negative fecal flotation and negative heartworm tests done within one year

e. All AAT dogs must be actively treated with a monthly, or equivalent, veterinarian-approved flea and tick preventative and a veterinarian-approved heartworm and intestinal parasite preventative. Owners/handlers should be prepared to provide evidence that the treatment is current.

f. Consistent with paragraph 1.218 of reference (i), proof of compliance with vaccinations, prophylactic parasite control medications, and regular health screening compliance must be documented and accessible to the area(s) where patients may participate in AAT.

g. Raw food diets are discouraged, given their potential of transmitting illnesses.

11. There may be some areas and or some patients who would not benefit from AAT. These include patients who:

a. Are, or are suspected to become, violent.

b. Are emotionally unpredictable.

c. Allergic to animals.

d. Afraid of animals.

e. In isolation (contact precaution) rooms.

f. Pre-post-operative recovery area and sterile areas of the hospital.

19 Enclosure 5

g. Whenever the patient responds negatively, the AAT dog should be removed, and the matter should be documented in the patient’s record.

12. Infection Control considerations. All dogs can transmit infectious diseases to humans, and likewise, humans can transmit infectious diseases to dogs. Dogs can become transient vectors or carriers of potential human pathogens and could be responsible for cross-infection. Proper infection prevention procedures are warranted at all times to minimize the risk of transmission between humans and dogs.

a. Every effort should be made to limit dogs from licking patients, particularly wounds, or medical devices.

b. As a general rule, dogs should not be on patient beds, hospital furniture or wheelchairs. If the patient requests the AAT dog to be on their bed, a barrier (sheet) may be placed on the bed for the animal to lie on beside the patient. The sheet will be discarded into the hospital laundry after each patient use.

c. Patients and staff should not have any contact with dog waste.

d. Any area contaminated by dog urine, feces, emesis, or blood, must be cleaned using appropriate personal protective equipment (gloves) and a hospital approved disinfectant.

Housekeeping can be contacted to assist as needed.

e. Scrupulous hand hygiene by patients, family, and staff should take place before and after contact with the AAT dogs.

f. AAT dogs should appear healthy, clean, well-groomed, and be odor free before visiting.

g. The same “off limits” areas that apply to service dogs apply to dogs participating in AAT.

13. Photographs with any dogs participating in AAT will be consistent with the hospital’s photography policy. This will entail getting permission from persons whose image is in the photograph.

20 Enclosure 6

ENCLOSURE 6

WRNMMC FACLITY DOG HANDLER APPLICATION

Applicant Name:

Rank/Rate:

Department/Service:

Email Contact Information:

Work Telephone Contact Information:

Cellular Telephone Contact Information:

Availability: __________________________________________________________

I verify that this applicant is available to support the WRNMMC Facility Dog Program as a collateral duty and has permission to participate in the program.

Signature (WRNMMC Service Chief or higher / CO or designee for non-WRNMMC commands) Date Printed Name

Training Coordinator Signature Date Printed Name

The training coordinator is the WRNMMC Facility Dog Training Coordinator, who is the person responsible for the day to day coordination of the WRNMMC Facility Dogs Handler Program.

Once completed, the form will be maintained in the WRNMMC Facility Dogs Program files.

All WRNMMC Facility Dog Handler activities will be conducted in accordance with WRNMMC-AI 3000.04, “Animals in the Medical Center.”

21 Enclosure 7

ENCLOSURE 7

WRNMMC FACLITY DOG HANDLER SAMPLE APPOINTMENT LETTER

Date:

From: Assistant Chief of Staff To: (Applicant)

Subj: APPOINTMENT AS WRNMMC FACILITY DOG HANDLER

1. Effective immediately, you are hereby appointed as a WRNMMC Facility Dog Handler.

2. This appointment is to be considered as a collateral duty and is not to interfere with your primary duties as assigned.

3. You will be governed in your collateral duty as a WRNMMC Facility Dog Handler by

WRNMMC-AI 3000.07.

4. This appointment remains in effect for the period of time that you are attached to Walter Reed National Military Medical Center, unless otherwise revoked.

Assistant Chief of Staff “By Direction” Signature Block

22 Enclosure 8

ENCLOSURE 8

WRNMMC FACLITY DOG HANDLER TRAINING RECORD

23 Enclosure 9

ENCLOSURE 9

AAA DOGS

1. Per reference (f), NSA-B retains authority over installation access, control, and domiciling for dogs participating in AAA. Dogs participating in AAA at WRNMMC will only be as part of a WRNMMC Director or Director’s designee approved program; the WRNMMC director retains the right to refuse or limit any such program. At WRNMMC, dogs who participate in AAA do so IAW the WRNMMC ARC Program or through the WRNMMC Facility Dog Program. The WRNMMC ARC Station Manager or ARC Animal Visitation Coordinator maintains records on the ARC dogs. The WRNMMC Facility Dog Manager maintains records on the WRNMMC Facility Dog Program dogs. Individuals wishing to bring a dog into WRNMMC to engage in AAT or AAA will need to speak with the ARC Station Manager and ARC Animal Visitation Program Coordinator. WRNMMC is the approval authority for the use of facility dogs at WRNMMC and the addition of any other dogs to the WRNMMC Facility Dog program, AAA, or AAT activity.

2. The goal of a visit by a dog participating in AAA is to enhance quality of life through direct contact and social interaction. AAA interventions are not necessarily tailored to individual patient needs or medical conditions. Medical documentation in the patient’s record pertaining to the visit is not required.

3. Consistent with section 1.218 of reference (i), dog participating in AAA may be permitted to be present at WRNMMC and at ceremonial events when their presence would not compromise patient care, patient safety, or infection control standards.

4. Owners/handlers will not leave dogs who are participating in AAA unattended or off leash in any WRNMMC facility.

5. While inside a WRNMMC facility, dogs participating in AAA must be held on a leash with six feet maximum length but held close to the handler as not to impede movement by other staff, patients, or visitors or harness and under the direct control of the owner/handler at all times.

Anyone has authority to require an owner/handler to remove a misbehaving AAA dog (barking, growling, lunging, begging for food, uncontrollable by the handler, etc.) from the local area. If necessary, personnel should contact Patient Relations or NSA-B Security for support in this matter.

6. If, at any time, anyone observes a dog who is participating in AAA to appear sick, infected or demonstrate a change in temperament, that individual should contact WRNMMC staff, who will

24 Enclosure 9 assist in the matter (i.e., informing the owner/handler that the dog must be removed from the premises).

7. Dogs participating in AAA must be housebroken and must be trained to eliminate its waste in an outdoor area. The handler/owner of such a dog is responsible for proper disposal of all of the animal’s waste in a trash receptacle outside the facility.

8. Health and temperament requirements for dogs participating in AAA.

a. All dogs participating in AAA must have an American Kennel Club Canine Good Citizen (Temperament Testing) certificate, American Kennel Club Therapy Dog certificate, or Therapy Dog International certificate. They must have a trained primary owner/handler, see Enclosures (6), (7), and (8) for documents for trained, authorized, and approved WRNMMC Facility Dog Handlers. WRNMMC Facility Dog Handlers must complete the WRNMMC Facility Dog Handler Training, and they are assigned their activities by the WRNMMC Facility Dog Program Training Coordinator. Personnel from other commands are welcome to participate as WRNMMC Facility Dog Handlers in the WRNMMC Facility Dog Program subject to review and approval by the WRNMMC Facility Dog Program Director, the WRNMMC Facility Dog Training Coordinator, and their command. The AAA dog’s owner/handler must maintain and provide documentation of the dog’s temperament, health, and welfare standards to the WRNMMC Red Cross or WRNMMC Facility Dog Program Coordinator. The ARC Dog Coordinator, for the ARC AAA dogs, and the WRNMMC Facility Dog Manager, for the WRNMMC Facility dogs, will maintain a copy of these records. Should the coordinator have questions about any of the required paperwork that is presented, the coordinator should call a military veterinarian and the dogs will not participate in any AAA activity until the issue is resolved.

b. Dogs participating in AAA must also receive yearly physical health examinations. Their skin should be free from fleas, ticks, lice, mites, and dermatitis. Teeth and gums should be clean and healthy.

c. The owner/handler must provide verification that immunizations are current. These include the rabies vaccine and distemper combination vaccine. (The leptosprosis vaccine and Bordetella vaccine are recommended non-core vaccinations.) For dogs that cannot receive rabies and distemper combination vaccines due to health concerns (such as an adverse reaction or auto-immune disease), the owner must provide current evidence that a blood titer has been performed to verity that the dog has sufficient antibody present and are “immune.”

d. Fecal examination must be performed to demonstrate that the AAA dog is free from intestinal parasites. There should be negative fecal flotation and negative heartworm tests done within one year

e. All AAA dogs must be actively treated with a monthly veterinarian-approved flea and tick preventative and a veterinarian-approved heartworm and intestinal parasite preventative.

Owners/handlers should be prepared to provide evidence that the treatment is current.

25 Enclosure 9

f. Consistent with paragraph 1.218 of reference (i), proof of compliance with vaccinations, prophylactic parasite control medications, and regular health screening compliance must be documented and accessible to the area(s) where patients may participate in AAA.

g. Raw food diets are discouraged, given their potential of transmitting illnesses from dogs to people.

9. There may be some areas and or some patients who would not benefit from AAA. These include patients who:

a. Are, or are suspected to become, violent.

b. Are emotionally unpredictable.

c. Allergic to animals.

d. Afraid of animals.

e. In isolation (contact precaution) rooms.

f. Pre-post-operative recovery, and sterile areas of the hospital.

g. Whenever the patient responds negatively, the AAA dog should be removed, and the matter needs to be documented in the patient’s record.

10. Infection Control considerations. All dogs can transmit infectious diseases to humans, and likewise, humans can transmit infectious diseases to dogs. Dogs can become transient vectors or carriers of potential human pathogens and could be responsible for cross-infection. Proper infection prevention procedures are warranted at all times to minimize the risk of transmission between humans and dogs.

a. Every effort should be made to limit dogs from licking patients, particularly wounds, or medical devices.

b. As a general rule, dogs should not be on patient…