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On Infection Prevention & Control

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Face Covers for Individuals Served at Behavioral Health Care Organizations


Robert Campbell, PharmD, director, Clinical Standards Interpretation for Hospital/Ambulatory Programs

Editor’s Note: This blog post is part of The Joint Commission’s daily communication on issues relevant to organizations managing the COVID-19 pandemic. The full list of FAQs is available here.

Can individuals served at behavioral health care organizations be given a face covering or face mask to wear for source control?

Any examples are for illustrative purposes only.

The Joint Commission does not determine which items are prohibited from a behavioral health care setting. Items that are prohibited from use in an organization, due to the risk of harm to self or others, should be determined by the organization. 

Source control involves having people wear a cloth face covering or facemask over their mouth and nose to contain their respiratory secretions and thus reduce the dispersion of droplets from an infected individual.

On April 13, the Centers for Disease Control & Prevention (CDC) recommended implementing source control (use of masks) for all patients, visitors and staff entering or residing in a health care facility to prevent dispersal of respiratory droplets from known, asymptomatic and pre-symptomatic people with COVID-19. The Joint Commission subsequently issued a statement in support of this CDC recommendation. Compliance with the recommendation should be based upon an organization’s assessment, policies/procedures, individual care plans, and applicable state rules or regulations.

When evaluating the updated CDC recommendations for an individual with behavioral health needs, it is important to complete an assessment of the impact that wearing a face covering or mask would have on the safety of the individual served, staff and visitors. 

The expectation is for organizations to complete a clinical risk assessment of the individual served for possible self-harm or harm to others. An organization must have a process to determine if the individual is capable of wearing a face covering or mask, based on clinical assessment. One example of appropriate implementation might be that if an individual served is in close observation because of risk of suicide or is unable to wear a mask because of respiratory compromise – people within 6 feet of the individual would be required to wear a face mask to protect themselves and the individual from possible exposure. 

Organizations that use Joint Commission accreditation for deemed status purposes should monitor the Centers for Medicare and Medicaid Services (CMS) website as waivers are being approved frequently and may include state-specific waivers.  

Additional Resources:
COVID-19 Resources
COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers 

Robert Campbell, PharmD, is director, Clinical Standards Interpretation Hospital/Ambulatory Programs and director, Medication Management. Prior to these roles, he served as the pharmacist for Clinical Standards Interpretation in the Division of Healthcare Improvement at The Joint Commission. Campbell also surveys as a field representative for The Joint Commission in the Hospital Accreditation and Critical Access Hospital Accreditation Programs and is a reviewer in the Medication Compounding Certification Program. Prior to joining The Joint Commission, Campbell worked in health care organizations and held leadership positions with oversight responsibilities for performance improvement, accreditation readiness, risk management, infection control and medical staff services, as well as inpatient and outpatient pharmacy services.