The devil is in the details: more than a decade later, the ADA is still a tricky law to follow.
It's been more than a dozen years since the Americans with Disabilities Act became law, guaranteeing those with a variety of handicaps the right to work and access to public buildings. While the landmark civil rights legislation has had a profound impact in many ways, its myriad rules and standards still pose a problem for all institutions, including long term care facilities.
Cynthia Leibrock--a Livermore, Colo., interior designer who now specializes in universal design and aging, and the author of Design Details for Health (John Wiley & Sons)--says she's still never found a nursing home that is ADA compliant.
But that doesn't meant that Leibrock finds problems in the form of steep stair-cases and inaccessible bathrooms. The problems for most facilities are usually in the smaller issues that muddy the ideal of being fully compliant with the ADA.
"People don't get the nuances of the ADA," says Leibrock. "They get the basics right, but they miss the details."
It's those details that Leibrock closely examines when she surveys a nursing home. When she does, she can be sure that she'll literally find "hundreds of violations"--even in facilities built since the ADA became law.
"Not many [of the violations] are life-threatening," she says. "They are smaller matters."
A typical example, Leibrock said, is a Dutch door. Many facilities use these divided doorways to give residents a view of a room or hall without fully opening the door. But ADA restrictions say that any object that is lower than 80 inches above the floor and higher than 27 inches can't protrude more than three inches. The top half of the dutch door is therefore non-compliant.
But "even the smaller details can disable someone," says Leibrock. The height requirements are to protect blind people who use a cane to sweep the landscape in front of them: They would have no way of knowing that the top half of the Dutch door would open in their path.
States of inconsistency
Perhaps the biggest obstacle to a facility being 100 percent compliant with the ADA is the lack of consistency in regulations and restrictions from state to state. Federal ADA standards and state building codes differ, and state building codes aren't uniform from place to place.
Jim Terry, a Birmingham, Ala., architect and chief executive officer of Evan Terry Associates, RC., routinely hears the complaint from clients who operate facilities throughout the United States. "They tell us it would be great if there were one national standard so they could have a national model to duplicate."
But, says Terry, "that's not possible. Something that one state requires, another won't allow."
One state, for instance, requires a bathroom grab bar to be 33 inches off the floor. Another mandates a height of between 34 inches and 36 inches. Even toilet paper holders defy uniformity: In California and many other states, the holder must be 7 inches to 9 inches in front of the water closet. The ADA regulations say the holder may not be more than 36 inches from the rear wall. "So, in a 30-inch water closet," says Terry, "the holder would be too close for the state standard."
States are making an effort to align their accessibility standards to at least be compatible with, the ADA standards, says Terry. And, a revised set of combined ADA/ABA (Architectural Buildings Act) regulations now open to comment may help down the road. But it's unlikely that all the involved parties will ever get together on a single code.
"There's so much politics involved," says Terry. "These issues are emotional and critically important to people. Advocates have worked hard to win battles, and they don't want to give them up to harmonize with standards won by other people with different agendas.
"Everyone's pulling for their own needs on different sides of each issue," Terry continues, and there may be or four sides to the issue. Politics don't even land in the same place twice. We don't wind up with the same sorts of compromises."
Courts of enforcement
The result is that litigation has become the chief enforcer of the ADA. "There are lots of advocacy groups out there," says Terry, "and they're saying people aren't doing anything until we sue them. So we're going to file as many suits as possible.
"These groups' members are saying the law's been in place a long time now. It's time for these places to be compliant."
Terry believes most lawsuits could be stopped through preventive work. "Ninety-nine percent of the companies that call us have a lawsuit because they had a problem with patient care. After that, the plaintiffs began looking for everything they could find."
Leibrock and Terry advocate hiring ADA specialists to survey a facility and identify non-compliance issues. Services vary: Terry's architectural firm performs five types, ranging from a "high-speed walkthrough" to a "standard barrier survey." Costs increase with thoroughness, says Terry. The simple walkthrough costs as little as $2,000, but may identify only 25 percent of the issues noted in the most detailed survey. The barrier survey--which also prioritizes problems and suggests solutions--can run between 25 and 40 cents per square foot.
For all its complexities, the ADA "has done a lot of good," says Leibrock. "The United States is the most accessible nation in the world." Still, she believes the law could be improved. "There are many problems that actually work against older people."
Leibrock cites Japanese research that led to the development of angled bathtub grab bars. These bars don't demand the same upper-body strength as the horizontal bars mandated by the ADA, making them more appropriate for older, weaker residents. But in some places, the angled bars aren't compatible with what's required by the ADA and state codes.
"You can claim [the modified bars] are a conditional equivalent to what's required," says Leibrock. "The law allows that. But no one will sign off on it--no state inspector and no one in the federal government.
"In the future," says Leibrock, "the regulations should be based on performance specifications. We need to stop giving lip service to the idea of meeting people's needs and really design an environment that allows people to do things for themselves."
THE ACT ITSELF
The AMERICANS WITH DISABILITIES ACT of 1990
One Hundred First Congress of the United States of America at the second session
Begun and held at the City of Washington on Tuesday, the twenty-third day of January, one thousand nine hundred and ninety.
To established a clear and comprehensive prohibition of discrimination on the basis of disability.
(b) Purpose.--It is the purpose of this Act--
(1) to provide a clear and comprehensive national mandate for the elimination of discrimination against individuals with disabilities;
(2) to provide clear, strong. Consistent, enforceable standards addressing discrimination against individuals with disabilities;
(3) to ensure that the Federal Government plays a central role in enforcing the standards established in this Act on behalf of individuals with disabilities; and
(4) to invoke the sweep of congressional authority, including the power to enforce the fourteenth amendment and to regulate commerce, in order to address the major areas of discrimination faced day-to-day by people with disabilities.
RELATED ARTICLE: Sweating the small (and not so small) stuff.
Long term are facilities typically provide good patient care, but they fall down in providing good visitor care, according to Jim Terry, an Alabama architect specializing in accessibility and ADA issues.
The places that are good at it are making accommodations for visitors as well as patients, according to Terry. They know that the people who are deciding where to place a spouse or family member may need some type of accommodations themselves. "Their first impression is going to be, 'Hey, I got a parking spot,'" Terry says. "You can let them decide whether to go or not, rather them shooing them out of your building."
Terry tells building managers to "look out year window and see if your handicapped places are full most of the time. If they are, you need more spots."
Other building Suggests looking at:
* Water fountains. Some low for people in wheelchairs, others high for people who have trouble bending
* Furniture. Firm raised (18-20 inches) seats, with armrests that extend to the chair's edge.
* Signage. Visual impairments make low-contrast, high-glare and warm colors hard to read.
* Bathrooms. "The ADA doesn't require grab bars in every room, but the more you have, the better," says Terry.
* Easy-to-operate hardware. Try to operate any hardware with your fingers taped together or your hand balled into a fist. That's why levers are better than knobs.
* Door forces. Non-fire rated doors shouldn't require more than five pounds of force.
* Floor surfaces. Walk the route from the parking lot to the rooms. Pay close attention to thresholds and to transitions between different flooring types.
* Curb ramps. Keep the slope gentle and never paint them (the paint is slippery). If they aren't right, says Terry, "rip 'em out. It's cheaper to rip out 100 ramps than it is to defend one lawsuit." "None of these are really expensive," says Terry, "and they serve a huge portion of the population. They also say a lot about your care of people who need these accommodations. They pay off in goodwill, new business and references."