Discuss Any Revisions to Masking Policies With Your Staff, IC Experts

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By A.J. Plunkett

The CDC recently revised its guidance on COVID-19 universal masking, but consult with your staff and infection control experts before making changes to your organization policies.

The guidance from CDC and CMS has been revised several times over the last few months, including the final days in September. (Find the revised CDC guidance here and the revised CMS memo here.)

It’s been a challenge keeping up with the CDC changes, especially those revisions that then link to other changing guidance, noted Kurt Patton, MS, RPh, pharmacist, founder of Patton Healthcare Consulting, and former director of accreditation services for The Joint Commission.

On September 23, the CDC updated its infection control guidance for healthcare personnel (HCP), linking the relaxing of mask requirements to rates of COVID-19 community transmission.

“I think each hospital has to look at this and discuss with their workforce and physicians what they want to do,” said Patton. “It appears that most counties are low transmission rates at this time. If the workforce is exhausted from mask wearing, take advantage of the flexibility. If the workforce is angry about 2 years of deaths and their own personal risk, stay masked.”

Ivan W. Gowe, MS, MLS (ASCP)CM, CIC, an infection preventionist at Pardee Hospital in Hendersonville, North Carolina, said his organization was following the guidance update from their accreditation organization, DNV Healthcare, issued on September 29 and based on the revised CDC guidance.

According to Gowe, the following applies to all staff, regardless of vaccination status:

When a hospital’s county has a high transmission level and high community level:

  • Masking required in all areas

When a hospital’s county has a high transmission level and low or medium community level:

  • Masking required in all areas where staff can encounter patients

When a hospital’s county does NOT have a high community level:

  • Masking is only required in all areas where staff can encounter patients unless the following are present, which would then require that individual to mask everywhere:

Suspected or confirmed COVID-19 or other respiratory infection (e.g., those with runny nose, cough, sneeze); or

Higher-risk exposure with someone with COVID-19 within 10 days after their exposure; or

Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 outbreak; universal use of source control could be discontinued as a mitigation measure once no new cases have been identified for 14 days; or

Have otherwise had source control recommended by public health authorities.

When hospital’s county does NOT have a high transmission level:

  • Masking is not required anywhere, unless:

Suspected or confirmed COVID-19 or other respiratory infection (e.g., those with runny nose, cough, sneeze); or

Higher-risk exposure with someone with COVID-19 within 10 days after their exposure; or

Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 outbreak; universal use of source control could be discontinued as a mitigation measure once no new cases have been identified for 14 days; or

Have otherwise had source control recommended by public health authorities.

Other CDC and CMS guidance:

The CDC’s revised guidance continues to recommend universal source control, for individuals in healthcare settings who:

  • “Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); or
  • Had close contact (patients and visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection, for 10 days after their exposure; or
  • Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 out-break; universal use of source control could be discontinued as a mitigation measure once no new cases have been identified for 14 days; or
  • Have otherwise had source control recommended by public health authorities.”

In addition, on September 26, CMS updated its QSO-21-08-NLTC memo to say, “COVID-19 Focused Infection Control Survey Tool for Acute and Continuing Care Providers and Suppliers,” to reflect that the focused survey tool was no longer going to be used.

A new note on the memo states:“This CMS memo supersedes several previously issued COVID-19 IPC guidance memos as noted here, including: QSO-20-13-Hospitals-CAHs REVISED, QSO-20-15 Hospital/CAH/EMTALA REVISED, QSO-20-16-Hospice, QSO-20-18-HHA, QSO-20-19- ESRD – REVISED, QSO-20-22- ASC, CORF, CMHC, OPT, RHC/FQHCs, QSO-20-23- ICF/IID & PRTF, QSO-20-36-ESRD.”

DNV guidance on QSO memo

According to the DNV advisory:

CMS is returning to “the existing standard survey processes and state agencies and accreditation organizations will continue to assess infection prevention and control by focusing on the regulatory requirements. Surveyors will no longer use the special FIC survey and tool on a national or case by case basis. Facilities should no longer use the tool for voluntary self-assessment of their ability to meet infection prevention and control priorities. CMS continues to encourage facilities to carefully review the Centers for Disease Control and Prevention (CDC) guidelines as there have been changes to the recommendations since the original tool and update were released.”

As for visitation restrictions: “CMS determined that continued federal guidance on visitation restrictions for hospitals was no longer necessary as of the memo update on February 4, 2022. Facilities should continue to review their own infection prevention and control policies and practices to prevent the spread of infectious disease and illness, including COVID-19, consistent with national standards of practice.”

The DNV advisory continued that, “per the QSO memo: Facilities should continue to adhere to basic infection prevention and control principles for COVID-19 that are consistent with national standards of practice.”

DNV also notes that the QSO memo states: “We continue to expect healthcare staff and surveyors (AOs, contractors, Federal, State, and Local partners) to comply with basic infection prevention and control practices such as hand hygiene, and the use of other personal protective equipment, as appropriate for the situation (i.e., standard, contact, airborne, etc.).”

A.J. Plunkett is editor of Inside Accreditation & Quality, an HCPro publication.