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How to create and implement a mandatory face mask policy at your medical office  

What began as a CDC guideline is evolving into a legal duty with more than 20 states and countless municipalities across the country adopting laws requiring individuals to wear masks or face coverings in enclosed indoor public spaces, including medical offices. As a result, medical offices must adopt and enforce mandatory mask policies at their facilities. While mask requirements vary slightly by jurisdiction, here are the 10 basic elements they should include.

Defining our terms

 This analysis is about non-medical face masks that people at medium at low risk levels are required to wear, as opposed to N95 particulate respirators and more elaborate respiratory equipment, eye and face shields other personal protection equipment (PPE) required for personnel at high risk of infection.

  1. Policy statement

Start by stating that office entrants must wear a proper mask or face covering and that failure to comply will be grounds for denial of entrance or immediate removal and, if the violator is an employee, discipline up to and including termination (Policy, Sec. 1).

  1. Statement of purpose

Indicate that the purpose of this policy is to prevent COVID-19 infection and ensure compliance with regulatory requirements and public health guidelines (Policy, Sec. 2).

  1. Definition of “mask”

Include a specific definition of what constitutes a mask, namely, a non-medical face mask, bandana or other covering that:

  • Goes over the nose and mouth;
  • Ties around the ears or back of the head;
  • Fits snugly against the sides of the face and;
  • Is secured under the chin.

Just as importantly, clarify what a mask does not include, namely, the N95 type filtered medical mask required by healthcare workers nor a face shield that protects only the wearer (Policy, Sec. 3).

  1. Whom the policy covers

Explain that the mandatory mask policy covers not just employees but all facility entrants, including patients, couriers, contract workers, health professionals, vendors, visitors and guests, unless an exemption applies (Policy, Sec. 4).

  1. Where the policy applies & doesn’t apply

Clarify that the policy covers not just all indoor spaces but also outdoor work areas where proper social distancing can’t be maintained, as well as in company vehicles. Also list exceptions where people don’t have to wear a mask, which may differ by jurisdiction but typically includes:

  • Work or time spent alone in a personal office or workspace;
  • Walking, exercising or other outdoor activity where individuals are at least six feet apart;
  • Driving a single-occupancy vehicle;
  • Telework; or
  • Other operations, conditions or situations where people are alone in a personal room or space or assembled but still maintain the required social distancing boundaries (Policy, Sec. 4).
  1. Masks don’t replace required PPE

Clarify that wearing a mask in no way relieves employees of their duty to use the job-specific PPE required by your office’s safe work procedures and OSHA policies (Policy, Sec. 5).

  1. Exemptions

Establish legitimate exemptions where wearing a mask could actually endanger the user, such as when:

  • A medical professional has advised that wearing a mask may pose a health risk or impair the user’s breathing;
  • Wearing a mask would create a health or safety risk to the wearer under federal, state or local regulations or guidelines;
  • The user can’t put on or take off the mask without assistance;
  • The user is deaf or hard of hearing and relies on facial and mouth movements to communicate; or
  • The user is under 2-years-old (Policy, Sec. 5).
  1. Accommodations

In addition to health and safety exemptions, the Americans with Disabilities and other federal and state antidiscrimination laws require you to make reasonable accommodations for disabilities, religious beliefs and other protected characteristics to the point of undue hardship (Policy, Sec. 6).

  1. Employer responsibilities

List the roles and responsibilities of different stakeholders under the Policy, starting with office management as employer. Under OSHA laws, employers must supply required PPE at their own expense, except for personal items like safety boots. While it’s unclear which side of the line COVID-19 masks fall, best practice seems to dictate that employers furnish the masks but allow employees to pay for and use their own masks instead. Other employer responsibilities include ensuring signs are posted, proper disposal or cleaning is arranged and training is provided (Policy, Sec. 7.1).

  1. Other roles & responsibilities

Other roles and responsibilities to address:

  • Department heads should assess and identify mask supply needs, ensure signs are posted and rules are followed in their work area (Policy, Sec. 7.1);
  • In addition to carrying out the responsibilities exercised by department heads at smaller facilities without departments, supervisor should also deliver the necessary mask training and instruction and enforce the mask rules (Policy, Sec. 7.3); and
  • Employees should be responsible for properly using and either disposing of or laundering/storing their masks, depending on what kind of masks you use (Policy, Sec. 7.4).











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