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Personal Protective Equipment – Use of Face Coverings on a Behavioral Health Patient for Source Control

Can behavioral health patients be given a face covering or 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 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.

The CDC recommends implementing source control (use of masks) in a healthcare facility to prevent dispersal of respiratory droplets from known, asymptomatic and pre-symptomatic people with COVID when community transmission levels are high. Compliance with this recommendation should be based upon the organization's assessment, policies/procedures, individual care plans, and applicable state rules or regulations.

When evaluating the updated CDC recommendations for a patient 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 a patient(s), staff and visitors. The expectation is for organizations to complete a clinical risk assessment of the individual for possible self-harm or harm to others if they will wear a mask. The organization must have a process to determine if the patient is capable of wearing a face covering, or mask, based on clinical assessment. 

 
Manual: Behavioral Health
Chapter: Infection Prevention and Control IC
Last reviewed by Standards Interpretation: December 22, 2021 Represents the most recent date that the FAQ was reviewed (e.g. annual review).
First published date: May 12, 2020 This Standards FAQ was first published on this date.
This page was last updated on May 16, 2023 with update notes of: Editorial changes only Types of changes and an explanation of change type: Editorial changes only: Format changes only. No changes to content. | Review only, FAQ is current: Periodic review completed, no changes to content. | Reflects new or updated requirements: Changes represent new or revised requirements.
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