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.

On April 13, 2020, CDC recommended implementing source control (use of masks) for all patients, visitors and staff entering or residing in a healthcare facility to prevent dispersal of respiratory droplets from known, asymptomatic and pre-symptomatic people with COVID. The Joint Commission subsequently issued a statement in support of this CDC recommendation. 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. The organization must have a process to determine if the patient is capable of wearing a face covering, or mask, based on clinical assessment. One example of appropriate implementation might be that if a patient 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 patient would be required to wear a face mask to protect themselves and the patient from possible exposure when the patient is not given a mask. 

Organizations that use Joint Commission accreditation for deemed status purposes should monitor the CMS website as waivers are being approved frequently and may include state-specific waivers. Click here to access the CMS website for COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers.

Additional Resources:
COVID-19 Resources
Last updated on September 10, 2020
Manual: Critical Access Hospital
Chapter: Infection Prevention and Control IC

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