Masks and facial coverings policy

Policy

This policy describes Ascension Florida & Gulf Coast standards and protocols for the appropriate use of masks/facial coverings at all healthcare locations.

To ensure the health and safety of our patients, employees, and visitors face masks will be required under special circumstances, such as when a patient, visitor, or employee is exhibiting signs or symptoms of or has a diagnosed infectious disease that can be spread through droplet or airborne transmission.

Scope

This policy applies to all patients, visitors, and employees. Facial covering and other PPE recommendations and/or requirements may be reviewed and reassessed with national and state standards, and state and federal laws, rules, requirements, and regulations in the event of a community outbreak. The standards and protocols in this policy will govern in the event that the hospital encourages or requires the use of facial coverings at any of its locations. Unless otherwise noted, all other hospital policies, procedures, and guidance that encourage or require the use of facial coverings are subject to the standards, protocols, and provisions herein. This policy does not apply to the use of personal protective equipment that are recommended and/or required for chemical or physical hazards. 

Definitions

Common area  

• “Common area” refers to areas in a health care setting where patients are not treated, diagnosed, or examined.

Locations

• A healthcare facility that is part of Ascension Florida and Gulf Coast. Such facilities include any owned or affiliated hospitals, campuses, facilities, premises, and locations.

Masks

• Any cloth or surgical face mask, a face shield, or any other facial covering that covers the mouth and nose that is compliant with hospital’s current masking guidelines.

Patients

• Any person receiving treatment, care, or other services from the healthcare locations.

Professional staff members

• Any person who is an appointee to the professional staff at any of the healthcare locations, including Allied Health Professionals, Medical Staff, Associate Staff, and any other person or provider with permanent or temporary privileges at any of the healthcare locations who provide care, treatment, or other services for the hospital and/or patients.

Team members

• Any person that is an Ascension Florida and Gulf Coast employee, volunteer, student, resident, independent contractor, vendor, member of the board of the hospital, or any other person who provides any care, treatment, or other services (including clinical staff and physicians) to the healthcare locations and/or patients.

Visitors

• Any person visiting any of the healthcare locations that is not a patient, team member, or professional staff member.

Masking protocols and procedure

Ascension Florida & Gulf Coast may ask or encourage patients, visitors, team members and professional staff members to wear a mask consistent with policies, procedures, and protocols, and state and federal laws, rules, requirements, and regulations. Mask and other PPE recommendations and/or requirements may be reviewed and reassessed with national and state standards, and state and federal laws, rules, requirements, and regulations in the event of a community outbreak.

1. Patients
   1. In the event that the healthcare location requires the use of masks, patients may be required to wear a mask in the common areas if the patient is exhibiting signs or symptoms of, or has a diagnosed, infectious disease that can be spread through droplet or airborne transmission.
2. Visitors
   1. In the event that the healthcare location requires the use of masks, visitors may be required to wear a mask if the visitor is:
      1. Exhibiting signs or symptoms of, or has a diagnosed, infectious disease that can be spread through droplet or airborne transmission;
      2. In any sterile area, including where surgeries or procedures that require aseptic techniques are performed;
      3. 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
      4. Visiting a patient:
         1.  whose treating health care provider has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase the risk of transmission of an infection to the patient from others without signs or symptoms of infection; and
         2. whose treating provider has determined that the use of a mask is necessary for the patient’s safety.
3. Team members and professional staff
   1. In the event that the healthcare location requires the use of masks, team members and professional staff members may be required to wear a mask consistent with policies, procedures, and protocols, and state and federal laws, rules, requirements, and regulations.
4. Generally
   1. Ascension Florida and Gulf Coast reserves the right to require the use of masks in other circumstances consistent with national and state standards, and state and federal laws, rules, requirements, and regulations.

Opt-out of masking procedures

In the event that Ascension Florida and Gulf Coast encourages or requires the use of masks at any of its locations, visitors, patients, team members and professional staff members may opt-out from wearing masks as follows:

1. If an alternative method of infection control is available, patients and visitors may opt-out of any existing mask requirements by notifying a provider, and such request will be reviewed by the Infection Prevention team.
2. Team members and professional staff members may opt out of any mask requirements by notifying the Employee Health department, and such request will be reviewed by the Infection Prevention team.

Exclusions from the opt-out procedures

In the event that the healthcare location requires the use of masks at any of its locations, the following opt-out exclusions shall apply:

1. If there are no alternative methods of infection control or infectious disease prevention, a patient may not opt-out of any mask requirements in the following circumstances:
   1. A patient has been diagnosed or is exhibiting signs or symptoms of an infectious disease that can be spread through droplet or airborne transmission;
   2. Opting-out has been identified by a provider as being medically or programmatically contraindicated for medical, safety or programmatic issues; or
   3. Opting-out would otherwise infringe on the rights and would risk the safety or health of other patients, individuals or staff/employees.
2. If there are no alternative methods of infection control or infectious disease prevention, a visitor may not opt-out of any mask requirements in the following circumstances:
   1. The visitor has been diagnosed or is exhibiting signs or symptoms of an infectious disease that can be spread through droplet or airborne transmission;
   2. Opting-out would otherwise infringe on the rights and would risk the safety or health of other patients, individuals, or staff/employees
3. A team member or professional staff member may not opt-out of any mask requirements if the team member or professional staff member is:
   1. Conducting a sterile procedure, including aseptic procedures or surgeries, that call for practices that minimize the risk of microbial contamination to reduce the rate of invasive or surgical site infection;
   2. Caring for a patient or being present while sterile procedures are being performed, including aseptic procedures or surgeries;
   3. Working in a sterile area, including where surgeries or procedures that require aseptic techniques are performed;
   4. With a patient who is on droplet or airborne isolation;
   5. Working with a patient whose treating health care provider has diagnosed the patient with or confirmed a condition affecting the immune system in a manner which is known to increase the risk of transmission of an infection to
      the patient from others without signs or symptoms of infection; and whose treating provider has determined that the use of a mask is necessary for the patient’s safety; or
   6. Engaging in potentially hazardous activities that require a mask to prevent infection, injury or harm in accordance with national, state, and industry standards, and state and federal laws, rules, requirements, and regulations.
4. Ascension Florida and Gulf Coast reserves the right to consider other exclusions from the opt-out provisions in order to comply with applicable state and federal laws, rules, requirements and regulations.

Communication/education

In the event that Ascension Florida and Gulf Coast requires the use of masks at any of its locations, they will communicate such requirements, and the standards and protocols herein will be made available to the affected persons.

Reference(s)

1. Fla. Stat. § 408.824
2. Fla. Stat. § 381.026
3. Fla. Admin. Code 59AER23-1
4. Fla. Admin. Code 59AER23-2