ADA Compliant sinks in Exam Rooms

During a tenant improvement to a new doctor's office in an existing building, the question of sink accessibility came up. The Bldg Dept. told me at least one Exam Room (and sink) must be fully ADA compliant. I had originally designed all Exam Rooms with ADA compliant sinks, but the client wanted prefab cabinets with sinks in them which were not compliant. They argued that the sinks were only for the Doctor's and staff, and since they didn't have any wheelchair bound employees, that the sinks in cabinets were fine. (Again, these sinks do not have knee space clearance). The same discussion came up regarding the Break Room sink and the Lab sink. Common sense would say to make these fixtures all accessible, but I would like the code reference that requires it.

CBC Sect. 1105B.3.2.4 states that all such offices be made accessible. This sends me to 1109B.8 which states that "...all such offices or suites shall be made accessible...". This is the closest wording I have found which indicates all clinic-level exam rooms are to be accessible. Is there an exact reference?

Thanks for your input.
Original Post
Ed:

I'm sure that JamesNew simply left out the quotation marks as he was quoting his bigoted client who apparently has no intention of ever hiring an employee who "rides" in a wheelchair.

JamesNew:

The best you can do for now is to try and hang your hat on 1115B.4.7. Even though it is in the Bathing and Toilet Facilities (Sanitary Facilities) section, I have to think that this section was meant to cover all sinks.

DSA had proposed for the 2007 CBC pulling and relocating the requirements for sinks from Sec. 1115B - Bathing and Toilet Facilities (Sanitary Facilities) to a more appropriate location within Sec. 1117B - Other Building Components. I don't know why this didn't happen. Does anyone know what happened witht this?
the sink in the exam room is an exclusive-use employee work station, thus is not required to be accessible (except in the case of a disabled employee that may require a special accommodation)...

note also that in the event the empolyer hires a disabled employee that may have a unique requirement, an appropriately-modified employee-use lavatory may not necessarily comply with 'standard' accessible lavatory design dimensions/clearances, etc. (i.e. an employee with a severe back problem, who wears a brace and cannot bend, so needs a higher sink)

the lavatory in the common-use accessible bathroom is for use of the invited public (patients, family, vendors, etc.)

hil
SBS,

Certainly you jest.

> I'm sure that JamesNew simply left out the quotation marks as he was quoting his bigoted client who apparently has no intention of ever hiring an employee who "rides" in a wheelchair.

Why would I feel justified in doing the same thing just because an idiot referred to an African American by the "N" word? Quoted or not, it's at the very least insensitive, at most, telling. I thought we're supposed to be professionals? Mad
ADAguy...
Always appreciate your input, so am curious...

This same question came up only last week.

Someone I consider very knowledgeable on the fine points as well as evolving language and upcoming clarifications was emphatic that such items are work stations, not public facilities, and as such do not have to comply.

Is there something specific in code or intepretive published material that is on point? If so, I'd be interested, and would like to follow up with same person to see what he says.

hil
This should be the definitive answer. State law is pasted below with my italics for applicable language, sinks in doctor's offices must be accessible as the sink is a sanitary facility.
19955.5. All passenger vehicle service stations, shopping centers,
offices of physicians and surgeons, and office buildings constructed
in this state with private funds shall adhere to the provisions of
Chapter 7 (commencing with Section 4450) of Division 5 of Title 1 of
the Government Code. As used in this section, "office building"
means a structure wherein commercial activity or service is performed
or a profession is practiced, or wherein any combination thereof is
performed or practiced in all or the majority of the building or
structure.
When sanitary facilities are made available for the public,
clients, or employees in these stations, centers, or buildings, they
shall be made available for persons with disabilities.
Any new requirements imposed by the amendments to this section by
Chapter 931 of the Statutes of 1973 shall only apply to those
stations, centers, or office buildings constructed on or after
September 30, 1973. Any other new requirements imposed by amendments
to this section by Chapter 995 of the Statutes of 1974 shall only
apply to those offices or office buildings constructed on or after
January 1, 1975.
Hope this helps
Jim Fruit
Curious Hil please follow the cookies:

if a medical office is a "B" occupancy
Then, Section 1105B.3.2.4 applies,

Then, per 1105B.3.2.4, Section 1109B applies

if Section 1109B appplies

Then 1109B.6 Diagnostic and treatment areas applies, requiring at least one dressing room, sanitary facility, etc. (sink) for each unit or suite shall be made accessible and per 1109B.8 Offices or Suites shall be made accessible, subject to other provisions of these regulations.
Jim, the point made to me in discussion recently was that the sink in question is not a "sanitary facility", it is a work station. Semantics are critical.

ADAguy, likewise, you have inserted the word 'sink' but the foundational question is whether this is a sanitary facility (meaning a toilet/washroom for common use) or if it is a work station for the sole use of the physician or other employee.

The argument made to me recently (and which after reflection I think is correct) was that just like the cabinets that hold drugs, the special disposal unit for contaminated items, and other features of an exam room, the sink is NOT there for the use of the patient, and is there ONLY for use of the employee. There is no requirement for a sink or any other sanitary facility to be placed IN the exam room for use of a patient (therefore the sink could even be inside a piece of cabinetwork with a closed door in front of it). There is also the related issue of exam room sinks that have foot pedal controls commonly found in medical facilities, necessary to proper functionality. If such a sink was NOT allowed in the exam room in question, the empolyee would no longer be able to properly perform his/her work properly.

I do not think this is quite as slam dunk as suggested. I do not hear anything that convinces me this sink is NOT an employee work station as such is defined. Why do you think this is NOT an employee work station?

hil
hil,

Understood you wish to parse sentences and use semantics. I have worked this issue extensively, see DRA v. Sutter Health. The CA courts consider (at least within this settlement agreement) that "office" exam room "sinks" must be accessible as they are sanitary facilities and not "specifically designed medical equipment" limited to the select group of physicians and medical employees use.

The lab sink may be a "specifically designed medical equipment", if not and it is available as a sanitary facility, make it accessible.

Break rooms must be accessible, the break room sink is a generic sink and cannot be argued otherwise to get out of accessible design.

It is time to get away from being "minimum" and consider that what you can "sell" to the "authority having jurisdiction" will not serve your client well when taken to legal task. Take a "reasonable person" approach to providing disabled access with job scoping accurately/comprehensively done and you will have a defensible position.

Awaiting my ration

Jim Fruit
jim...

I have no disagreement that 'better' is 'better'... and that exceeding the minimum requirement is a laudable objective.

When discussing here, the objective is first to determine what is and is not 'required' by law (and in that I include Federal law), so that one can determine the baseline minimum above which one can rise. As regular readers here may know I often 'dig' at this while also believing in and encouraging more universal solutions.

The reason I raise the question is that the individual I discussed this with recently has extensive litigation experience and stated he has prevailed in past on this same issue, with an argument that is opposite to what you indicate.

There are a number of lines of reasoning that need to be considered when deciding if and when to exceed the 'requirement'. One of these (as it relates to the exam room sink) is that while making the sink 'lower' is an advantage to wheelchair users, it is a disadvantage to those not in wheelchairs or of tall stature, potentially resulting in back injuries to employees forced to use it. If this were not the case, then the logical action would be to make every sink lower. But because lower sinks are not 'better' for everyone, doing so would be, in essence, a type of reverse discrimination for everyone not in a wheelchair (except perhaps for children and short adults).

Then you have the secondary question of functionality relating to foot pedal operation. If the sink is not a work station, and must be lowered, and also cannot have foot pedals, then an entirely different type of operational hardware must be employed by which the water flow can be controlled in a 'handless' fashion (by staff), at the appropriate height and reach ranges, and of a type than can be operated by disabled individuals (not just the wheelchair user).

That is why the question of whether this is a work station or not becomes key. If it is, functionally, a work station and not for patient use, and there are no functionally disabled or wheelchair users on staff, the "reasonable person" approach you suggest would actually be to not lower the sink.

I am not familiar with DRA v. Sutter, so would have to look this up to see the actual language. Is that an Appeal or Supreme Court decision that is current case law? If you have a link or more specific information the case, it would be helpful.

Thanks,
hil
OK, so just for fun I looked up the case (DRA v. Sutter) on the DRA web site, and read all of the linked/published materials outlining the settlement:

This was a trial pre-settlement between consenting parties, not a published decision... so this case does not have any import as regards setting precedent (case law). The reasons for settlement were stated to be avoidance of a trial (among others) at which the merits of the allegations would have been ascertained/adjudicated.

The defendant admitted no liability and no specific non-compliant features were agreed.

The outcome involves hiring a consultant to review facilities (Sally Swanson's firm). Until the survey is done, there is no way to know what interpretation she might apply as regards this specific item, and if there is a dispute over her interpretation, the issues will be further batted around.

The list of specific portions of facilities to be reviewed includes exam rooms and restrooms serving exam rooms. There is no mention (in the settlement exhibits) specifically regarding sinks "in" exam rooms, as opposed to restrooms serving exam rooms.)

Although Plaintiff may have claimed in the Complaint materials that sinks in exam rooms should be made accessible, there is nothing in the published materials suggesting that this was the case, or that this was verified or agreed. There is no discussion in the Settlement materials regarding whether physician-use sinks in exam rooms were claimed deficient, or whether they are considered work stations.

Based on this, I don't understand the foundation for the earlier very positive statements made indicating that the outcome of the case was that the exam room sinks are not work stations, and therefore do not comply with requirements.

hil
A word on settlements;
No one stipulates they are responsible in any manner for the case merit arguments.
No one claims they are guilty.
The parties agree to settle without further trial proceedings, typically due to economics such as it is more cost effective to correct the situation than pay additional attorney fees for protracted litigation. (yes plumbers and thier materials are less expensive than trial lawyers)

Unfortunately Jurgen is no longer with the firm. He will require a considerable recovery time and may not return to the working world. The agreements for applicable standards when I do these reviews is taken directly from the codes, I.E. ADA and CA CH11B do not apply to specifically designed medical equipment. When judging a "sink" in an exam room, there has to be a specific medical design and use for the fixture that distinguishes the sink from a customary use sanitary facility. The state law (see prior post) requires accessibility for employees as well. The Plaintiff Attorney involved argued these points during evidentiary hearings and prevailed. If there are other design considerations they must be considered from the Client's need point of view. It is a valid point to bring up taller persons and persons with trouble stooping and bending, this concept is used for drinking fountains such as the "hi-lo" units we see installed in the recent past.

So do exam rooms in medical offices require accessibility?, yes. Are the sinks in medical office exam rooms considered employee work stations?, yes. Do you need to consider other design factors?, yes. It is now the Architect's charge to satisfy the design constraints and convince the Client the solution is optimal.

This is clear as mud unless you can clearly identify specific medical procedures that preclude the medical office exam room sink from being used in a general manner as a sanitary facility (hand washing by anyone or otherwise having someone's limbs into the sink for general cleaning).

Awaiting my ration.

Jim Fruit
Jim,

What are sinks in doctor's offices? Sanitary facilities.

Work stations? What work do doctors do at the sink that required their years of study?

I think a sink is a sink. I won't let my doctor touch me until I see him wash his hands in the sanitary facility. Then he starts working.

Still waiting for my ration? I'm not going to warn you anymore. I'll smack you on the nose with a shoe if you try to take my scat away again. Cool
Jim, you almost had me, in that you agreed the exam room must be accessible and the sink is a work station... until you said:

quote:
This is clear as mud unless you can clearly identify specific medical procedures that preclude the medical office exam room sink from being used in a general manner as a sanitary facility (hand washing by anyone or otherwise having someone's limbs into the sink for general cleaning).


I do not agree with your "preclude" concept (which I do not believe is articulated in the law). This standard does not apply to any other work stations, and there is no reason it would apply to sinks in exam rooms. The test is whether the sink's primary functional purpose (the reason it exists in the room in the first place) is for the use of the employee (in this case the physician), and if there are other appropriate and accessible sinks made available for patients elsewhere (attached or not). It would be an 'impossible' standard to state that any work station must be accessible unless its functional purpose "precludes" others from using it if they attempt to do so (i.e. without permission of the employer).

hil
Using your "logic" Hil, it is for more likely for a doctor to use and in-room sink to not only wash his hands but to use it to clean a patients hands or to direct the patient to take a pill after the doctor has left the room, using the faucet and cup at the sink, or, as in some cases, there is a drinking fountain at the sink.

As previously stated, at least 1 must be accessible, but more is preferred (though not mandated).

Why, is the owner fighting this? Is he buying closeouts?
I'm not convinced that the exam room sink meets the criteria for a work station. Let's take a look at a typical visit to the doctor's office: a nurse comes in and takes your vitals; then a medical assistant comes in and does some additional poking and prodding; finally the doctor arrives and does their examination. I know when I visit the doctor's office I want to be darn sure that everyone who lays a hand on me has thoroughly washed it first. And like Ed, I want to see it happen. Just my humble opinion here - sanitary facility.
SBS...

sounds to me like you just described a work station installed specifically for use by staff in connection with performing required work functions...

foundationally, since those who actually practice medicine, and their staffs, are the ones who need to state whether the sinks are work stations, as they are the only ones really qualified to make that determination... since there is NO mandate to provide sinks in exam rooms for patients, and these sinks exist initially ONLY because they are necessary to the work of the staff, I fail to understand how these could be classified as anything other than work stations...

perhaps the original poster and his client can chime in on the 'purpose' of the sinks (i.e. why the designer planned them into the project in the first place)...

ADAguy, I think it is worthwhile to dig into this not because of this specific owner's situation, but because there is a need for clarity on what is and is not required, so that we can all use this analysis going forward.

hil
Break Room sinks must be accessible. That is clear. Lab sinks, where patients don't specifically go, are not as clear. (I have shown both Break Room sinks and Lab sinks to be accessible, incidently).

The issue of Exam sinks came up after I had shown accessible wall hung ADA compliant sinks in all exam rooms. The client wished to have specifically designed cabinetry by Midmark installed instead. Midmark does 90% of the pre-fab medical cabs in the US apparently. This cabinet certainly does create a "work station" in my mind because the cabinet is tailored to the doctor's and staff's needs, but there is no reason to think that a patient, as I have on occaision, would not use the sink to wash their hands. I always feel a little sneaky about it, as though if the Doctor walked in, they might feel I am getting too comfortable with "their" equipment or facility. I CERTAINLY would not open the drawers of their sink cabinet. This would be crossing some unspoken line. Am I allowed to use their sink? That depends on the doctor, but I can't see them refusing my use of it. For that reason, I made them all accessible initially. I still don't know what Midmark's opinion is or whether they offer ADA cabs/sinks. This has been asked of the client repeatedly, and perhaps I will need to ask this of Midmark directly.

Since the sink is primarily for the doctor and staff, perhaps a side approach exam sink for occaissional patient use is acceptable? Hil, I appreciate your approach. I am sure there are those on this forum that will never be reasonable or compromising about such things.
The below are comments from Midmark folks. Chew this up for awhile:


No problem we can accommodate ADA height for that room. We do offer ADA height cabinets and sink units so we can do this area. I think that having one room would be a good idea here.

With the ADA units we drop them down to the lower height and we raise the kickplates to 8" high from 4.5" high. This is so that a wheelchair can go by without the providers feet hitting the cabinet.

I have been able to gather much information on this topic from the various projects I have done for Sutter, CHW, UC Davis, UCSF, Palo Alto Medical Foundation and Adventist Health. For cabinetry you are usually faced with some ADA requirements and they fall into two separate realms. Cabinetry that is public property and cabinetry that is private property.


Public property:

This would be anything that is built to be used by patients or visitors of the facility. Any areas that they will have access to. For cabinetry it may be a shelve to hang clothes, a reception desk to fill out papers, a bathroom cabinet etc. This would be required to fit the ADA height in all areas.


Private property:

This is an area such as an exam cabinet, lab cabinet, MA station, Nursing Station, Break Room, Utility room, storage room etc. These are cabinets that patient should not be accessing (you would not want a patient in any of these rooms accessing your supplies). There are still some ADA requirements here in case you were ever to staff a physician or an employee in a wheelchair. We have found that all of the most recent projects with large facilities have chosen to go 10% or less of the cabinetry at this height, many of them not even doing any private property areas at ADA height. When applicable it may only be a sink that is lowered.


The problem is an ergonomic one as your staff currently is not in wheelchairs so you would be compromising their backs by having them bend down lower to access ADA tables. Most of our clients note that our cabinetry is modular and if they ever hire someone in a wheelchair they can easily pull the cabinet out and replace it with an ADA height sink cabinet. The easiest way to find out and what I recommend is to call up your local inspector and ask them these questions before the decision is made. They should be happy to assist here.
Ditto!

This is why we identify and discuss "issues" so that they don't elevate to "problems" ( a negative conotation that infers willingness to "sue" virsus "issue" which implies a willingness to identify and seek out a resolution so that it doesn't elevate to the fiscal benefit of a "few".

Hil has seen far too many "P's" in his years. I bet he could write a really good book with examples of issues that elevated to P's but could have been resolved well before that point. This has been Ed's contention all along.

Better, attention to detail and the law would be a start

Need an editor Hil?
Excellent discussion so far, but I'm throwing in my 2 cents with hil. All the reasons have already been stated. I just want to expand on the current reality that the majority of code enforcement officials only consider wheelchair acess, and ignore other disabilities. Making everything wheelchair accessible can be discriminatory to those who have difficulty bending or stooping, short-statured individuals, certain types of mobility device users, etc. That's why the work station provision of 1123B.2 makes perfect sense. Just because something isn't wheelchair-accessible, doesn't mean it isn't "compliant". I have spoken to many plan-check professionals who have said they feel guilty if they don't make everything wheelchair-accessible; they end up requiring employee counter areas to be lowered and end up creating ergonomic problems unnecessarily and hardship for employees with back problems or other disabilities. I can't count how many times I have seen a builder have to buy specialized equipment for an employee-only work station because of lowered counter heights that were never necessary. If a particular employee needed an accommodation in the future it would have been required under Title I of the ADA, and then it would be specific for the needs of the individual's particular disability. Something to think about.
Michael,

One cent change back.

> the majority of code enforcement officials only consider wheelchair acess, and ignore other disabilities.

Are you on something? You live in the Thousand Oaks area and you can honestly make this claim?

Let us, the disabled be in charge of disabled access and we'll created access for everyone. Those non-disabled people doing the job now don't have any idea how to create meaningful access and obviously are unable to read and understand what they read.

Both you and hil live in an area where there is virtually no compliant access mandated by any code officials. Weren't the present circumstances created by not having anyone that understands the laws and making them comply? Don't blame the wheelers for the deficiencies of access to other disabilities, place the blame where it belongs. It's not either or. Making things wheelchair accessible is good for everyone. Making it accessible for everyone else is not the problem. Having the proper people in the mix is the only fix. As yet, it's never been tried.

We have more books on access than ever before yet we still have virtually no compliant application and no one in charge applying what those books say.

Before trying to change the laws you don't like (wheelchair access) why don't we first try implementing them and see what happens? In case you don't understand what equal access means, everything should be wheelchair accessible.

Let me offer you some help:

Equal access for wheelers is mandated. That's what equal access means. Accommodations are special treatment for individuals who need special treatment to do the job. If every employer was allowed to only make their workplace accessible "IF" a gimp is hired, we'd probably see about 70% unemployment for the disabled population. Opps! That is our unemployment rate because the employer wouldn't have to spend the money on making their facilities accessible to us. I'm sorry you still can't see the difference.

Like hil, you'd apparently be much happier if we were still out of sight, in institutions and out of your hair. Mad Cool
michael...
i appreciate your comments and perspective...
by the way i attended one of your recent seminars and wanted to thank you for your time and effort...


ed...

apparently you have not carefully read the thread, as your comments are not on point to what both I and Michael were discussing...

the question posed is whether a sink in an exam room is a 'work station' because its primary purpose (and the only purpose for which it is installed in the room initially) is for the use of the physician...

so far i've not heard anything in this thread that convinces me the sink must be considered a feature intended to be made accessible to patients...

your separate 'lecture' about general problems with accessibility are simply not relevant to the question on the table...

respectfully,
hil
Using this line of discussion, the patient after wiping themselves with a product handed to them by staff, uses the sink to wash their hands, face or arms, before re-dressing and leaving the Exam Room.
I use the sinks all the time to wash before leaving a place full af nasties.



quote:
Originally posted by ADAguy:
Using your "logic" Hil, it is for more likely for a doctor to use and in-room sink to not only wash his hands but to use it to clean a patients hands or to direct the patient to take a pill after the doctor has left the room, using the faucet and cup at the sink, or, as in some cases, there is a drinking fountain at the sink.

As previously stated, at least 1 must be accessible, but more is preferred (though not mandated).

Why, is the owner fighting this? Is he buying closeouts?
Here we go again
So do exam rooms in medical offices require accessibility?, yes. Are the sinks in medical office exam rooms considered employee work stations?, yes. Do you need to consider other design factors?, yes. It is now the Architect's charge to satisfy the design constraints and convince the Client the solution is optimal.
For direction, see OSHPD published documents on their web site, CAN 11-B. CAN is an acronym for "code application notes", these are their policy notes that are used for plan reviews. Their take on the issue is that exam room sinks are general use for staff AND patients and require accessibility unless there is a specific medical procedure that precludes disabled access. They use the example of a sink specifically used to wash "endoscopes" that necessitates a deep tub.
(the endo part of scope is what the device is used for)
Ideally the architect should design for persons other than wheelchair users, this requires the building Owner to agree to multiple fixtures in an exam room.
Anyone ever hear of "universal design", might be a good idea to use the concepts more for solving design issues for everyone.
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