Self Evaluation Plan and Transition Plan: Part 6 - Entity Self-Evaluation
Information presented herein can also be found at Corada and the New England Action Guide.
Facility Self-Evaluation
This is the sixth article in a series about Self Evaluation Plan and Transition Plan (SEPTP). Previous parts of this series covered the history of SEPTP, identified who is in charge of the SEPTP at an entity, sent out a public notice, discussed training options for those involved with the SEPTP, and covered grievance procedures regarding compliance with the Americans with Disabilities Act (ADA). Now it is time to evaluate the entity with Part 6 - Entity Self-Evaluation.
The ADA regulations [ref. U.S. DOJ, 28 CFR Part 35, Subpart A, 35.105 and 35.150(a) and (d)] require state and local governments and agencies/entities to conduct a self-evaluation of their programs and services to identify barriers to access. The entity self-evaluation is a comprehensive review of all programs, activities, services, and facilities operated by the entity. One of the fundamental reasons for performing the self-evaluation is to identify potential problems before they occur, so that discrimination complaints won’t be necessary. By identifying the facilities, policies, programs, services, and activities that do not comply, the entity can take action to remove those barriers to ensure that the entity is not discriminating against individuals with disabilities.
SEPTPs are living documents/plans that require periodic updating. It is recommended that the SEPTP be audited every three (3) years, or whenever a significant change is adopted for the ADA or when the entity undergoes changes such as building renovations/modifications/additions, program revisions or additions, or mergers/acquisitions with other entities.
For instance, Title II and III regulations and ADA Standards were changed in 2010 to include recreation areas from play areas to swimming pools, residential facilities, event ticketing policies, policies concerning other-power-driven mobility devices, miniature horses as service animals and specifications for video-remote-interpreting.
The ADA addresses two types of accessibility, facility accessibility and program accessibility. Facility accessibility requires that a building or structure be physically accessible. Individuals with disabilities cannot be provided access to programs, services, and activities if a building is inaccessible. Program accessibility includes facility accessibility, but also means that a person with a qualified disability receives the same benefits from a program or service and has an equal opportunity to participate as any other participant. The ADA requires all Title II programs, but not all Title II buildings, to be accessible.
Facility audits need to be performed only in those areas open to the public for SEPTP projects, along with employee common-use areas. Other areas within entity-owned facilities that are not accessible to the public must also be accessible for employees with disabilities as a requirement of ADA Title I. Accessibility in employee work areas should be assessed on a case-by-case basis based on the needs of the individual and nature of their disability. The entity should be committed to ensuring that all workspaces are accessible pursuant to the requirements of each job and making the necessary modifications and reasonable accommodations when needed for a disabled employee to perform essential job functions. Entity pedestrian facilities within the public entity right-of-way (ROW) should be included.
Furthermore, since information technology barely existed when the ADA was passed in 1990 and updated in 2010, and most entities now have a website that needs to be accessible to people with disabilities, websites need to be evaluated frequently to maintain compliance with accessibility requirements.
Functionality of elements within accessible facilities is an issue that is easily overlooked. Implementation regulation 28 CFR Part 35.133, Maintenance of Accessible Features, states, “A public entity shall maintain in operable working condition those features of facilities and equipment that are required to be readily accessible to and usable by persons with disabilities by the Act or this part.” In other words, if an element is accessible, it also has to work properly. For example, if a door to a restroom does not open fully because of binding in the automatic closer, the door is not in fully operable working condition and should be repaired or replaced. This is true for private entities also. See CFR Part 36.211.
So as part of this process it is important to determine which standards will be used to evaluate the facilities. Options include the following:
1991 ADA Standards
2010 ADA Standards
Architectural Barriers Act (ABA) for federal facilities
Section 504 - Rehabilitation Act
Fair Housing Act (FHA) for multi-family housing
State and/or local government accessibility standards (if more stringent than the ADA Standards)
Public Right of Way Guidelines
Shared Use Paths
After conducting a self-evaluation, an entity can develop a transition plan for structural changes and/or action plan for non-structural changes. Those plans will be discussed in later parts of this series.
The entity should work with the entity’s departments and agencies to modify policies and procedures, as applicable.
Identify Departments and Programs
One way to make sure that the self-evaluation is comprehensive is to identify all of the public entity’s facilities, programs, services, and activities. For example, a city or town may have twenty or more departments. A state or county will probably have more agencies, offices and departments. Public and private entities can vary significantly.
Within each department there may be many facilities, programs, services, and activities. A Council on Aging, for example, might provide meal programs, transportation programs, health services, recreational activities, and referral services. A state judiciary will have many courts or court buildings and might provide other services such as mediation, divorce education, legal training and a court newsletter.
The self-evaluation can be done in at least four ways:
By the ADA Coordinator
By the ADA Coordinator and an ADA team
By the ADA Coordinator and ADA liaisons for each department and agency
By an outside consultant in collaboration with the ADA Coordinator
The size of the entity and the budget will probably determine how the self-evaluation is conducted. The self-evaluation should cover general nondiscrimination provisions, communications, program and facility accessibility and web accessibility. Entities with a large number of facilities can use the following guide to determine where to start.
Facilities with the highest user count.
Facilities more likely to be used by seniors or disabled individuals.
Facilities where complaints have been registered regarding accessibility.
Facilities with unique services and/or programs.
Facilities with access to public transportation.
To conduct a self-evaluation:
Identify all facilities, programs, activities, and services and their locations.
Determine whether employees and officials are familiar with the public entity’s ADA obligations, including barrier removal and the requirement to make reasonable modifications to policies, practices and procedures.
Determine whether employees and officials know how to arrange for auxiliary aids and services, such as sign language interpreters, material in Braille and assistive listening systems; to ensure that communication with people with disabilities is as effective as others.
The focus of this employee/official review can begin with distribution of a questionnaire to each department, followed by interviews or other data gathering if needed to better understand the responses or the operation of each department. Key items reviewed within each department included ADA-specific training of employees, past interaction and accommodation of persons with disabilities, review of publications produced by each department, and staff suggestions to help them accommodate persons with disabilities.
Review service, activity and program’s policies and procedures to determine whether they ensure an equal opportunity for people with disabilities to participate and benefit.
Survey facilities and determine whether there are physical barriers to access programs. If non-structural changes, such as moving programs, should be made, include them in the action plan. If structural changes are needed, include them in the transition plan.
Entities are not required to take actions that would result in undue financial and administrative burdens. However, they are required to make reasonable modifications to policies, practices, and procedures where necessary to avoid discrimination, unless they can demonstrate that doing so would fundamentally alter the nature of the service, program, or activity being provided.
Self-evaluation forms should be completed as the self-evaluation progresses. These self-evaluation forms should include fillable PDF, Word and/or text for Brailling.
Report writing formats can be challenging. The SEPTP should be prepared using existing software resources used by the entity, if possible. If the entity does not have existing software resources, common word processing software like Microsoft Word can be used for narrative based reports like introductory information, executive summaries, assumptions, etc. Barrier items should be reported on tabular software such as spread sheets or internet based data bases. Spread sheet software such as Microsoft SharePoint, Google Sheets, and Airtable will work for small organizations and when edits are allowed only by the owner. For larger organizations or where multiple participants are allowed to edit, live internet-based databases are recommended for data entry and edits.
For existing entities that are auditing an existing SEPTP, after the self-evaluation it is important to update the SEPTP to include any new barriers, obtain funding to remove the barriers, and assign responsibility for the barrier removal. This is important any and every time programs are moved or added to existing inaccessible facilities or to areas within facilities.
Throughout the process, the Consultant will develop and maintain a schedule detailing proposed meetings and frequency to provide the Consultant sufficient guidance, opportunity to gather information and ideas, and to provide updates on findings, progress, and plan development for future steps.
SUMMARY: The entity self-evaluation is a comprehensive review of all programs, activities, services, and facilities operated by the public entity. SEPTPs are living documents/plans that require periodic updating. The next article in this series is Part 7 - Transition Plan.
If you need help building a new SEPTP or auditing your existing SEPTP, please call Richard Acree at 615-752-0060, or email inspections4ada@gmail.com. For additional information please see SEPTP.
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