ADA Requirements for Medical Offices

The Department of Justice guide on medical care access says private hospitals and medical offices are covered by Title III of the ADA as places of public accommodation, and offices run by state and local governments are covered by Title II. Section 504 of the Rehabilitation Act covers any of these that receive federal financial assistance, which the guide says can include Medicare and Medicaid reimbursements. The Title III regulations list the professional office of a health care provider by name.

According to that guide, these laws require medical care providers to give people with disabilities full and equal access to their services and facilities, along with reasonable modifications to policies, practices and procedures, unless a modification would fundamentally alter the nature of the services.

This guide covers the physical space. It is a starting point, not a compliance review. State and local accessibility codes can also apply, so check them with your architect.

Both are. The Title III regulations at 28 CFR 36.201(b) say that the landlord who owns the building and the tenant who owns or operates the place of public accommodation are both subject to the requirements, and that allocation of responsibility as between the parties may be determined by lease or other contract.

The Department of Justice guide answers the question directly for tenants: if you lease your medical office, you are responsible, and tenants and landlords are equally responsible. The lease may specify that the landlord handles some or all of the accessibility requirements. The guide adds that the tenant is frequently made responsible for the space it uses and controls, such as exam rooms and reception, while the landlord handles common space, such as toilet rooms used by more than one tenant.

A lease clause decides who pays and who does the work between landlord and tenant. Read it with that limit in mind, and ask your attorney what it does and does not do if a patient brings a complaint.

The rule that applies depends on what you are doing to the space, which is why it matters whether you are taking a suite as it stands or building it out.

• New construction and alterations. The ADA sets requirements for both, found for private entities in 28 CFR Part 36, Subpart D, using the 2010 ADA Standards for Accessible Design. The Department of Justice guide says new and altered exam rooms must meet the Standards.
• Path of travel. Under 28 CFR 36.403, an alteration affecting an area that contains a primary function must, to the maximum extent feasible, make the path of travel to that area, and the restrooms, telephones and drinking fountains serving it, accessible, unless the cost and scope are disproportionate to the overall alteration. A clinical build-out can therefore raise questions about space outside your suite.
• Existing facilities. Under Title III, barriers must be removed where removal is readily achievable, meaning easily accomplishable and able to be carried out without much difficulty or expense. If removal is not readily achievable, the services are to be made available through alternative methods, if those are readily achievable.

Buildings put up before the ADA took effect are not excused. The guide says all buildings, including those built earlier, are subject to the requirements for existing facilities.

The Department of Justice guide describes an accessible exam room as having an accessible route to and through the room, an entry door with adequate clear width, maneuvering clearance and accessible hardware, appropriate accessible exam equipment properly placed, and enough clear floor space inside the room for side transfers and lift equipment. It gives a minimum clear door opening of 32 inches with the door opened to 90 degrees, and notes that these rooms may need additional floor space.

Not every room has to be built this way. The guide says the number needed depends on the size of the practice, the patient population and other factors: one may be enough in a small practice, and a large clinic will likely need more. It also says that examining a patient in a wheelchair because the patient cannot get onto the table is generally not acceptable, and points to tables that adjust down to wheelchair level, approximately 17 to 19 inches from the floor.

Equipment has its own rule for federally funded programs. The HHS Section 504 regulation at 45 CFR Part 84, Subpart J, covers medical diagnostic equipment, naming physicians' offices and clinics among its settings. Subject to the limits in the rule, it calls for at least 10 percent of units of each type of equipment in use, and no fewer than one, to meet the accessibility standards, or 20 percent in programs specializing in conditions that affect mobility. It also calls for at least one accessible exam table and one accessible scale within two years after July 8, 2024, a date that has now passed, for recipients that use them. Ask counsel whether the rule applies to your practice, and check the current text, because these rules can change.

ADA questions are cheapest to answer during the search, while you can still walk away or trade for a landlord commitment. Have a qualified accessibility consultant or your architect review the space and the plans, and use the answers in the lease negotiation.

• ✓Is there an accessible route from parking and the public sidewalk to our suite door?
• ✓Are building entrances, elevators and common toilet rooms accessible, and who will fix them if they are not?
• ✓Will our planned alterations trigger path-of-travel work outside the suite, and who pays for it?
• ✓How many accessible exam rooms does our practice need given its size and patient population?
• ✓Do the room dimensions allow side transfers and lift equipment, and will we have a table that lowers to wheelchair level?
• ✓Does the lease make the landlord responsible for accessibility in common areas and building systems?
• ✓Does the lease make us responsible for anything outside the space we control?
• ✓If we inherit a prior tenant's build-out, has anyone confirmed it meets the Standards that applied?

TAG represents tenants and buyers, not landlords, so it can put these items into the letter of intent and press for a clear division of responsibility. The technical review belongs to a qualified consultant, and the legal review to your attorney.

The Department of Justice guide says that, subject to IRS rules, federal tax credits and deductions are available to private businesses to offset expenses incurred to comply with the ADA, and it points to IRS Form 8826 for the Disabled Access Credit. Eligibility and limits are set by the IRS and can change, so ask your CPA before counting on either.