Compliance Standards

POLICY: Appropriate Use of Facial Coverings for Infection Control

  1. Policy Statement: It is the policy of the facility to maintain and attain best practices in the prevention and spread of infection. The facility follows all recommendations from CMS, CDC and state and local regulatory agencies.

Source control refers to use of respirators or well-fitting face masks or surgical grade masks to cover a person’s mouth and nose to prevent spread of respiratory secretions when they are breathing, talking, sneezing, or coughing.

Source control options for HCP include:

  • A NIOSH-approved particulate respirator with N95 filters or higher.
  • KN95
  • Surgical grade masks
    • The facility uses masks for source control as per CDC, CMS, and State guidelines. When the facility is free from a COVID outbreak masks are not required for COVID-19 source control unless otherwise posted for required appropriate isolation/treatment or procedure.
    • If the facility does not require masking for source control, it should allow individuals to use a mask or respirator based on personal preference, informed by their perceived level of risk for infection based on their recent activities (e.g., attending crowded indoor gatherings with poor ventilation) and their potential for developing severe disease if they are exposed.

Source control options for residents/visitors – surgical grade masks unless otherwise indicated.

Definitions (59AER23-1)

  1. Common Area – refers to areas where patients are not treated, diagnosed, or examined.
  2. Employee – refers to any person under employment or contact of a health care setting, including health care practitioner, administrative staff, maintenance staff, aides, contractors, students, and volunteers.
  3. Healthcare setting – refers to any place where health care practitioners and/or health care providers practice their profession or provide services.
  4. Patient – refers to person receiving services from a health care professional.
  5. Sterile areas – refers to locations where surgery is conducted or where procedures that require aseptic techniques are performed.
  6. Sterile procedure – refers to aseptic procedures with the goal of minimizing the risk of microbial contamination to reduce the rate of invasive or surgical site infection.
  7. Visitor – refers to any person in a health care setting who is not an employee or patient of the health care setting.

59AER23-2 Standards for the Appropriate Use of Facial Coverings for Infection Control

(1) Health care practitioners and health care providers may choose to require a patient to wear a facial covering only when the patient is in a common area of the health care setting and is exhibiting signs or symptoms of or has a diagnosed infectious disease that can be spread through droplet or airborne transmission.

(2) Health care practitioners and health care providers may choose to require or encourage a visitor to wear a facial covering only when the visitor is:

(a) Exhibiting signs or symptoms of or has a diagnosed infectious disease that can be spread through droplet or airborne transmission,

(b) In sterile areas of the health care setting or an area where sterile procedures are being performed,

(c) In an in-patient or clinical room with a patient who is exhibiting signs or symptoms of or has a diagnosed infectious disease that can be spread through droplet or airborne transmission, or

(d) Visiting a patient whose treating health care practitioner has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase risk of transmission of an infection from employees without signs or symptoms of infection to a patient and whose treating practitioner has determined that the use of facial coverings is necessary for the patient’s safety.

(3) Opt-Out Requirements are as follows if a health care practitioners and health care providers who choose to require a facial covering for any patient may opting-out of wearing a facial covering:

(a) Education is provided to the resident regarding the risks and benefits to    themselves or others.

(b) The resident refuses to wear the facial covering as per practitioner order and resides in a room alone so the resident can opt-out of the requirement.

(c) If arrangements can be made to accommodate a room without a roommate. The residents agree to stay in their assigned room when not masked. The resident can opt-out of the requirement.

(d) The safety of the other residents and/or staff are not affected by the Resident’s decision not to wear facial covering.

(e) Every effort will be made to accommodate the residents’ wishes as per their right to make informed decisions as- long- as it does not affect the safety and well-being of other residents or staff.

(3). Staff exhibiting signs and symptoms of respiratory illness will immediately report to a supervisor and follow COVID-19 testing policies. If staff test negative for COVID-19 and continue with allergy type symptoms remaining afebrile, runny nose, cough, scratchy throat, staff will be encouraged or required to wear source control until symptoms have resolved.

Responsibility: The Administrator is responsible for ensuring staff adhere to the guidelines.

References:

https://ahca.myflorida.com/health-care-policy-and-oversight/bureau-of-health-facility-regulation/rulemaking?utm_source=iContact&utm_medium=email&utm_campaign=hqa-alert&utm_content=RuleNotice_07.07.2023_59AER23-1%2659AER23-2