Animal-Assisted Therapy

Section 250.890  Animal-Assisted Therapy a)         Animal-assisted therapy programs may be established in hospitals if the boarding and grooming location of the animals is separate and distinct from patient care units and the presence of the animals is part of a special program established in accordance with this Section. b)         The hospital's Medical Staff and Infection Control Committee shall approve an animal-assisted therapy program prior to operation of the program. c)         The Infection Control Committee and Medical Staff shall develop written policies and procedures for operation of the animal-assisted therapy program, including, but not limited to, the following.  All policies and procedures shall be developed in accordance with the Guidelines of the Centers for Disease Control and Prevention titled "Guidelines for Environmental Infection Control in Health-Care Facilities:  Recommendations – Animals in Health Care Facilities" (see Section 250.160). 1)         Designation of a department within the hospital that will be responsible for operation and establishment of the animal-assisted therapy program (e.g., Volunteer Services). 2)         Development of written goals and objectives for the program. 3)         Policies governing sanitation, infection control and care and grooming of animals, including veterinary care. 4)         Certification and training requirements for animals, animal handlers and hospital staff. 5)         Policies for patient screening and assessment for participation in animal-assisted therapy. 6)         Policies governing areas in the hospital where animals are permitted and prohibited, including whether therapy will be held in a public area of the hospital or in the patients' rooms. 7)         Policies for determining the length of therapy sessions. 8)         Policies governing the types of animals that will be permitted to participate in the program. 9)         Policies governing patient safety and incidents of biting, scratching or other behavior, and including reporting requirements and patient care. 10)         Policies governing patient consent requirements for participation in the program, for both adult and child patients. d)         Records shall be kept for each patient who participates in the program and shall be available for review by Department staff. e)         All animal-assisted therapy sessions shall be prescheduled and approved in advance by the patient's physician and hospital staff who are responsible for the program. f)         If a therapy animal is to be boarded overnight in the hospital, the hospital shall establish, in addition to the infection control requirements of this Section, policies governing the location in the hospital where the animal will board.  A hospital staff member who has had training for this responsibility shall be responsible for the care and management of the animal during the time that the animal is boarding. g)         Therapy animals shall be accompanied at all times that the animal is in the hospital by a volunteer or staff member who is familiar with and capable of controlling the animal's behavior. h)         The animal-assisted therapy program shall be evaluated annually in a written report to the Infection Control Committee.