Policy Lifts and Transfers
Contact Clinical Operations
Last Review 6/5/2025
Effective Date 6/5/2025
1. Purpose
To establish clear guidelines for the safe lifting, transferring, and repositioning of patients to prevent injury to both patients and healthcare staff. This policy aims to ensure that all lifts and transfers are conducted in accordance with best practice standards, prioritizing patient safety, dignity, and comfort.
2. Scope
This policy applies to all ASC team members.
3. Definitions
• Reasonable Accommodation: Modification of policies, practices, or procedures necessary to provide individuals with disabilities access to medical services, unless modification fundamentally alters the nature of services (28 C.F.R. § 36.302)
• Interactive Process: Collaborative dialogue between facility and patient to:
o Assess communication needs (i.e., is an interpreter required)
o Identify barriers to accessing services
o Discuss patient’s specific needs/preferences
o Determine appropriate accommodations
o Document assessment and decisions
• Individualized Assessment: Evaluation of:
o Patient’s specific transfer needs
o Available accommodation options
o Safety considerations
o Equipment requirements
o Staff training needs (Required under 28 C.F.R. § 36.302)
• Lift: The act of raising or moving a patient from one surface to another, using manual or mechanical assistance.
• Transfer: The movement of a patient from one location to another, typically from bed to chair, bed to stretcher, or wheelchair to toilet.
• Mechanical Lift: An assistive device used to move a patient with minimal physical strain on staff, such as a hydraulic or electric patient lift.
• Assistive Devices: Tools or equipment, including transfer belts, slide sheets, and mechanical lifts, designed to support patient transfers.
4. Policy
1. Non-Discrimination and Transfer Assistance
Our facility is committed to full compliance with Title III of the Americans with Disabilities Act (42 U.S.C. §§ 12181-12189) and 28 C.F.R. Part 36, ensuring that individuals with disabilities receive equal access to medical services, including necessary accommodations for lifts and transfers. We:
a) Conduct individualized assessments for patients requiring transfer assistance through an interactive dialogue and patient mobility assessment tool to determine appropriate accommodations including language accommodations.
i. If an interpreter is required, the facility must provide the interpreter. A family member can be used in the case of an emergency or if the patient consents/requests that a family member serves as the interpreter.
b) Consider multiple transfer assistance options including but not limited to:
• Mechanical lift devices
• Trained staff assistance
• Patient-preferred transfer methods
• Specialized medical equipment
b) Document all transfer assistance requests, assessments, and accommodation decisions
c) Procure necessary equipment or arrange appropriate assistance within 5 business days of determining accommodation needs
2. Transfer Assessment and Implementation
The Assessment process for accommodation is ongoing as the needs/condition of the patient may change. Patients should be reassessed daily or as their condition changes. When a patient requires transfer assistance:
a) Clinical staff will engage in an interactive process with the patient to:
• Discuss specific transfer needs
• Consider patient’s transfer preferences
• Evaluate available accommodation options
• Determine appropriate safety protocols
b) Transfer assistance will be provided without:
• Additional charges to the patient
• Requiring third-party caregivers
• Mandatory waivers
• Discrimination based on disability status
c) Any denial of requested transfer accommodation must:
• Be based on documented safety requirements
• Demonstrate fundamental alteration to services
• Include alternative accommodation options
• Provide appeal process information
5. Procedure
1. Initial Patient Assessment and Interactive Process
a) Upon scheduling or during pre-operative consultation, clinical staff will:
• Inquire if patient requires transfer assistance
• Document specific mobility needs and preferences
• Review available accommodation options
• Engage in interactive dialogue about transfer solutions
b) Assessment Documentation Requirements:
• Patient’s specific transfer needs
• Preferred transfer method(s)
• Results of interactive dialogue
• Accommodation determination
• Implementation plan
• Any safety considerations
2. Transfer Assistance Implementation
a) Prior to scheduled procedure, staff will:
• Confirm availability of required equipment/assistance
• Verify staff training for specific transfer needs
• Document accommodation plan in patient record
• Communicate plan to all relevant personnel
b) During transfer procedures:
• Minimum of two trained staff members present
• Use approved transfer equipment as documented
• Follow established safety protocols
• Monitor patient comfort and safety
• Document completion in medical record
3. Staff Training Requirements
a) All clinical staff must complete:
• Annual ADA compliance training
• Safe patient transfer techniques
• Equipment operation certification
• Disability sensitivity training
• Documentation requirements review
b) Training documentation must include:
• Date of completion
• Specific competencies achieved
• Equipment certifications
• Annual renewal dates
4. Equipment Management
a) Facility will maintain:
• Inventory of transfer equipment
• Regular maintenance schedule
• Equipment certification records
• Procurement process for additional needs
b) Equipment checks include:
• Daily operational verification
• Safety inspection documentation
• Maintenance records
• Cleaning/sanitization logs
5. Documentation and Review
a) Required documentation:
• Transfer assistance requests
• Interactive process notes
• Accommodation decisions
• Implementation details
• Any modification denials with justification
• Patient feedback
b) Regular policy review:
• Quarterly assessment of implementation
• Annual policy updates
• Staff feedback integration
• Patient outcome evaluation
6. Accommodation Denial Process
If requested accommodation cannot be provided:
• Document specific safety/medical justification
• Demonstrate fundamental alteration if applicable
• Offer alternative accommodation options
• Include appeal process information that includes:
• A written explanation outlining the specific safety or medical reasons for the denial.
• Alternative accommodation options.
• The patient’s right to submit an appeal to the designated Compliance Officer within five business days of receiving the denial notice.
• Process for the Compliance Officer review and response to the appeal within seven business days.
• Information that if unresolved, the case will be escalated to executive leadership for final review.
• Report to compliance officer for review at Compliane@panoramaeyecare.com.
7. Quality Assurance
Monitor and document:
• Accommodation request outcomes
• Patient satisfaction metrics
• Staff compliance with procedures
• Equipment utilization rates
• Any transfer-related incidents
• Resolution of complaints/appeals
6. Policy Information
Should you have questions regarding this policy, please contact Compliance@panoramaeyecare.com or Clinical Operations Leadership.
Employee Signature Date