What Do You Need To Know About Universal Masking?
Date: April 28, 2020
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Into Action Consulting, Inc. is constantly updating facilities on updated or new standards and accreditation requirements. What do you need to know about universal masking recommendations? Here is a recent information notice by the Centers for Disease Control. This will help clear up some information for you. As always, do not hesitate to reach out to us with any questions!


In an effort to slow the spread of COVID-19, the CDC has released a revision of their infection prevention and control recommendations related to COVID-19. As of April 13th, the CDC is recommending that all healthcare facilities implement source control for everyone entering their facility, regardless of symptoms. What does this mean? All staff, patients, and visitors are urged to wear a cloth face covering or face mask over their mouth and nose when they are at a facility.

The Joint Commission, in support with the CDC’s recommendation, believes universal masking is critical to protect staff and patients from being infected by asymptomatic and pre-symptomatic individuals. Universal masking procedures should be implemented in any community where COVID-19 is occurring. Below are key points and requirements regarding universal masking at your facility. 


Patients and Visitors: 

  • All patients and visitors should be instructed to wear a cloth mask when entering any facility. If they arrive without a cloth mask, one should be provided. If there is a sufficient supply of medical grade face masks, one may be provided instead of a cloth mask. 
  • Face masks and coverings should not be placed on anyone who has trouble breathing or is unable to remove the mask without assistance. 
  • Patients may remove their face coverings when in their rooms but should put them back on when they leave their rooms or if someone enters the room that is not wearing a face covering or mask. 
  • Facilities should consider switching patients with respiratory symptoms (ie, cough or sneeze), including patients with confirmed COVID-19, to a medical grade face mask.


  • Staff should wear at least a cloth face mask when leaving their homes, per CDC recommendations. 
  • When providing direct patient care, they should be wearing a medical grade face mask.
    The CDC does not consider cloth face coverings PPE, as their capability to protect staff is unknown.
  • Staff who do not provide direct patient care can wear a cloth face covering, in order to conserve supplies of medical grade face masks. 
  • Masks may be removed when social distancing of at least 6 feet is possible (i.e., entering a private office).
  • Scheduling and location for meals and breaks should ensure that at least 6 feet of distance can be maintained between staff. 


In addition to cloth face coverings and medical grade face masks, facilities should be practicing consistent hand hygiene. Hand washing and sanitizing is essential to maintaining staff safety, even if staff are wearing masks. If the facemask is touched, adjusted or removed, hand hygiene should be performed. Proper hand hygiene entails washing hands with soap and water or using an alcohol-based sanitizer. 


To assist with rapid implementation of these new procedures, The Joint Commission has provided signage that can be posted at the entrances of facilities and an infographic that explains the do’s and don’ts of wearing a face mask. The documents can be downloaded here


We know this update can seem overwhelming and stressful but we’re here to help! We have a staff of professionals ready to assist you through this process. Give us a call or email us with your contact information and someone will promptly set up a phone conversation or schedule an appointment to come out to your facility for a consultation.

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