Maintaining Compliance: Renewals, Record Keeping, and Team Retention


Maintaining Compliance:
Renewals, Record Keeping,
and Team Retention

Health care administrators have a responsibility to ensure the safety, reliability, and accountability of AAI programs. This means that records must be kept of all AAI teams, documenting current handler information, therapy dog registration, health records of both human and dog, renewals, and any supplementary training or records of reinstatement. Maintaining appropriate documentation of AAI team compliance is needed for Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and other credentialing reviews as well as for examining any adverse events. During a recent JCAHO review at the authors’ facility, therapy dog team records were requested as part of the review and lauded by the review team for the documentation included (and recommended in this chapter).

If an AAI team’s registration with a therapy dog organization is expiring, or the AAI team is noncompliant with your AAI program/health care facility standards, options for renewal, reinstatement, or retirement should be presented to the handler.

Over time, health and compliance of an AAI team can change. For instance, while a dog may be very well behaved initially on a geriatric unit where wheelchairs are present, if the dog is at home and his tail is accidently rolled over by a wheelchair, he could develop a fear. This dog may react differently to wheelchairs from then on, and a subsequent evaluation could identify the behavior change. A dog’s health may change over time, and it is important to identify any new or progressing health concerns that may influence the dog’s behavior, negatively impact their well-being, or have an impact on the safety of others in the health care facility (such as in the event of infection).

5.1Records and Registration

Proof of compliance should be kept for each AAI team active in your facility, and at no time should an AAI team’s presence be permitted in your facility without proof of compliance with all standards for AAI teams outlined in your policies and procedures. A copy of records for each individual volunteering as an AAI team should be kept by your AAI program, and also by your office overseeing volunteers.

The following documentation should be obtained for each AAI team:

registration with approved therapy animal group (see Figure 9);

records of registration renewals and reevaluations,

records of subsequent shadowing and observations with the AAI program,

records of any adverse events and subsequent retraining, and

annual veterinary health verification including negative fecal test results and vaccination dates (see Figure 10).

An electronic database may be developed by your AAI program in order to organize and provide easy access to important team information and monitor compliance. Name, contact, registration status, dog breed and name, and important dates may be kept in a data program such as Microsoft Excel (see Figures 11 and 12).


Figure 12 Example of an AAI team compliance database with information on the fulfillment of requirements for therapy dog teams.

Informing AAI teams of these requirements in the AAI manual and providing appropriate forms for collection of the information facilitate compliance. The downloadable online manual template ( includes this information.

5.2Renewal, Reinstatement, and Retirement

After initially fulfilling the requirements to participate in AAI as a therapy dog team, renewals should be required for both dog and handler. As vaccinations and health testing expire, records for both humans (through the office overseeing human volunteers at your health care facility) and their dogs (through delivery of veterinary records to your AAI program) should be monitored on a regular basis for compliance with up-to-date documentation. Any AAI team not in compliance with all records should not be permitted to visit the health care facility until they provide this documentation to achieve compliance.

Renewal requirements for maintaining registration in external therapy animal organizations vary. While some organizations may require an evaluation of training and temperament to renew a registration, others only require a passive form of renewal (such as payment of annual dues). Health care administrators are strongly advised to select an organization requiring a reevaluation of therapy dog health, behavior, and temperament at least every other year.

It is also advisable that AAI programs institute their own process for evaluating AAI teams on a continuing basis to verify that they are still appropriate for visiting in the facility and complying with your policies and procedures. This may take the form of a shadowing requirement for all AAI teams to be conducted on a yearly basis. This procedure allows your AAI program to verify appropriateness for program participation as well as identify any changes in behavior and training that may need to be addressed. These shadowings may be conducted by AAI staff or by your more experienced AAI volunteers in a leadership role.

Your policies should clearly state that AAI teams that fail to renew their qualifications will be prohibited from entering your facility until reinstatement occurs. Reinstatement procedures may vary depending on the reason the team is no longer in compliance. For example, if a team fails to provide proof of vaccination by submitting a health verification form within one year of their last veterinary visit, the team may be asked not to visit until this record has been submitted. Failure to provide proof of reevaluation or renewal of therapy dog registration may follow the same reinstatement process.

Occasionally, a dog working as an AAI team may develop a behavioral issue. Factors such as maturing/aging, changes in diet, exercise, routine, or health, and adverse events or experiences can result in a change in a dog’s behavior. AAI teams should be encouraged to look out for behavioral changes, and self-report them when necessary. Examples of common behavioral issues are:

vocalizing excessively (barking, yelping, whining, or howling),

pulling on leash,

reacting adversely to other dogs,

reacting adversely to equipment or environmental stimuli, and

jumping (on people, or on objects).

Program staff may learn of a behavioral issue from a staff member, visitor, or in some cases, a patient. Program staff may also learn of a behavioral issue occurring at an offsite location. The following procedures can be helpful when responding to a potential behavioral issue.

First, contact the volunteer immediately, inform him or her of the issue raised, and temporarily suspend the team from entering the facility while the issue is being addressed. Second, the issue should be documented in the AAI team’s record, and the handler advised to seek outside training from a credentialed dog trainer or animal behaviorist. Third, for reinstatement, a letter from the trainer or animal behaviorist should be required, documenting training completion and attesting that the dog is appropriate to return to normal visitation in the facility. It is also advisable for the AAI team to be subsequently shadowed in the health care facility to make sure all dog behavior is appropriate. Please note, any behavioral issue in which the dog shows signs of aggression or territoriality should result in retirement of the dog from the AAI program, as this type of behavior could lead to an adverse event including a dog bite.

Over time, it is natural for teams to retire. Retirement is typically initiated by the handler due to changes such as aging of the dog, time constraints on the volunteer, or moving away from their current city. However, some handlers may not recognize signs indicating the dog is no longer appropriate for visiting. Signs that a dog may be ready to retire from therapy work include

slowing down (the dog is unable to keep up with owner at a normal pace, and seems lethargic on visits),

exhibiting health issues (common health problems associated with aging including arthritis/joint problems, mobility difficulties, decreasing vision, and hearing loss), and

declining attention and responsiveness.

It is important to be mindful of aging, and the annual AAI team shadowing provides an opportunity to assess fitness for continued therapy dog work.

Records for retiring AAI teams may be kept for a 12-month period in case any questions arise. Some type of recognition or celebration for retiring dogs can also be arranged to recognize the contributions the dogs and handlers have made to the AAI program and health care facility.

5.3AAI Team Retention and Celebration

AAI programs and the health care facilities in which they operate invest considerable time and resources bringing volunteers on board to visit with patients, families, and staff. Just like in the health care workforce, volunteer dissatisfaction can lead to less effective care and turnover. Since payment is not an incentive for work as an AAI team, keeping volunteers in any program can be challenging. Regular communication with teams is key to building and maintaining strong relationships with the facility and staff. Scheduling enjoyable events for the AAI teams, which may include their families, provides a way for them to come together and socialize, either with or without their dogs. Whether a picnic is planned for an outdoor park (see Figure 13) with dogs included, a service event in the community bringing the AAI teams together to represent the organization (see Figure 14), or a meeting in a facility conference room without dogs, such events provide an opportunity to show appreciation for teams, obtain feedback about the program, and provide program updates.

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Apr 23, 2020 | Posted by in GENERAL | Comments Off on Maintaining Compliance: Renewals, Record Keeping, and Team Retention

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