Mask use recommendations continue to change as the pandemic unfolds. The Centers for Disease Control and Prevention (CDC) guidance on mask use for the general public differs from the guidance specific to healthcare personnel (HCP). In addition to mask use recommendation variance in and out of the healthcare setting, the CDC guidelines may conflict with state and local mask ordinances. Mask use also can be a controversial subject in healthcare settings when patients and healthcare workers demand mask exceptions. However, healthcare employers and administrators are responsible for ensuring the safety of patients, staff, and the public. This can be a difficult feat which requires simultaneously balancing adherence to national public health authority guidance, federal law, and varying local and state ordinances related to mask use. Well-communicated and understood mask wearing policies in healthcare settings can reduce confusion and conflict.
Federal Face Mask Guidance
It is imperative for HCP to keep abreast of CDC updates to the mask recommendations for themselves, patients, and visitors as outlined in the Interim-Infection Prevention and Control Recommendations. The recommendations included in the guidance are dependent upon the level of SARS-CoV-2 transmission in your community: [1,2]
- Counties with substantial to high community transmission:
- Source control is recommended for everyone in a healthcare setting-regardless of vaccination status
- Counties with low to moderate community transmission can consider the following allowances for fully vaccinated individuals who do not have suspected or confirmed COVID-19 or other respiratory infection, have not had close contact or a high risk exposure with someone with COVID-19 in the last 10 days, are not moderately to severely immunocompromised, or had source control recommended by public health authorities:
- Fully vaccinated HCP may choose not to wear a mask when in well-defined areas that are restricted from patient access, such as staff meeting rooms or staff kitchens
- During indoor visitation, if the patient and their visitors are fully vaccinated, they may choose not to wear a mask during the visit if in a single-person room, in a multi-person room when roommates are not present, or in designated visitation areas when others are not present. Visitors must wear a mask when around other residents or HCP, regardless of vaccination status.
- During outdoor visitation, patients and visitors generally do not need to wear a mask
- Fully vaccinated nursing home residents may consider not wearing a mask when in communal areas of the facility, but should consider wearing a mask if at increased risk for severe disease
Mask use should be incorporated into your existing infection control policies and procedures as an element of Standard Precautions during the COVID-19 pandemic. Keeping these policies and procedures up-to-date and educating HCP on guidelines is important as they will be answering questions and directing patients according to these guidelines.
The Occupational Safety and Health Administration (OSHA) requires that employers provide a safe and healthful workplace that is free from serious recognized harms, and that both employers and employees comply with OSHA standards. Additionally, OSHA offers detailed guidance for employers to protect their workers who are unvaccinated or otherwise at-risk, or fully vaccinated but located in areas with substantial to high community transmission. This includes providing workers with face coverings, surgical masks, or respirators as appropriate per CDC recommendations and applicable OSHA standards.
Ensuring your infection control policies and procedures are updated to include the mask-wearing requirements for patients, visitors and staff in accordance with CDC guidance and applicable OSHA standards can ensure a safe work environment and facilitate documentation of compliance.
Employees who believe employers are not following CDC guidelines in order to protect them from contracting COVID-19, have a right to file a complaint and are protected from retaliation as a result of voicing their health or safety concerns.[5,6] This scenario, among others, is specifically addressed on OSHA’s COVID-19 FAQ page under the topic of Worker Protection Concerns.
Employees may insist on wearing more than the recommended personal protective equipment (PPE). It is important for workers to feel safe and supported. If employees are providing their own protective equipment, the employer is responsible to ensure its adequacy. For example, N95 masks require yearly fit testing to properly ensure employees are protected.
Employees who understand the hazards of the work environment are more likely to be compliant with the practice’s infection control policy. Provide basic infection control education per OSHA guidelines on PPE, including how to properly wear masks. Additional training may assist employees to become compliant with minimum standards.
CDC: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Recommendations for all HCP, patients, and visitors while in a healthcare setting
CDC: Use Masks to Slow the Spread of COVID-19
Recommendations for the general public
CDC: COVID Data Tracker: COVID-19 Integrated County View
County view of key data for monitoring the COVID-19 pandemic, including level of community transmission and case counts
OSHA: Protecting Workers: Guidance on Mitigating and Preventing the Spread of COVID-19 in the Workplace
Guidance for employers and workers on lessening the spread of COVID-19 in the workplace
OSHA: COVID-19 Frequently Asked Questions (Cloth Face Coverings)
Summary of key differences between cloth face masks, surgical masks, and respirators as well as answers to common mask questions for settings not covered by the Healthcare ETS
Local and State Face Mask Ordinances
Throughout the COVID-19 Pandemic, every state in the U.S. has addressed masks and made recommendations for the public to some degree. These recommendations are expected to continue to evolve over time and may offer vague exceptions for patients with medical conditions, which may not be tailored to the medical setting. It is important that you be aware of your local and state mask requirements and that you follow your internal policies and procedures based upon health authority guidance.
Requests for Face Mask Exceptions and Refusals
Practices may encounter patients and HCP who refuse to wear face masks. This refusal may be based on a medical issue, disability, non-compliance, or a simple misunderstanding of the importance of continued mask use following vaccination. It is important to consider certain situations where it may not be feasible for patients or HCP to wear a mask and to be prepared for multiple scenarios. Practices should have policies and procedures in place to protect the safety of patients and HCP in these situations.
Face Mask Refusal Due to Medical Issues
Certain underlying health conditions may make mask use less feasible for patients and staff. Some patients may have anxiety or claustrophobia and feel as though they cannot breathe. Others may have underlying pulmonary conditions such as COPD or asthma and be concerned about mask effects on their oxygen levels. It is important to emphasize; however, the reality is that there are very few medical conditions that prohibit mask use. The CDC offers mask guidance for the general public, which outlines who should not wear a mask.
Acknowledging concerns, providing education, and suggesting adaptations or alternatives are ways to address many of the medical-related safety concerns posed by patients and HCP. The education process should include information on the purpose of wearing a mask, specifically it is designed to protect those around you by limiting droplets emitted through talking, sneezing, and coughing. Additionally, it is important for patients to understand that even in the absence of symptoms and following vaccination these droplets may be infectious.
Alternatives that cover both the nose and mouth should be considered in varying circumstances. The patient should be encouraged to try the mask or mask alternative or adaptation during the visit. Reassure the patient that it can be removed if they experience problems and reschedule the visit if needed. Additionally, oxygen level monitoring with pulse oximetry may be useful to ease anxiety related to hypoxia concerns.
It is important to note that while mask alternatives may be appropriate for some office staff and patients, HCP who are patient-facing are required to wear surgical masks or respirators and will not have the same ability to utilize mask alternatives. HCP should comply with the CDC’s mask recommendations for HCP as outlined in the Interim Infection Prevention and Control Recommendations.
Face Mask Refusal Due to Disability—Americans with Disabilities Act
It is important to understand the Americans with Disabilities Act (ADA) as it relates to mask exception requests by HCP or patients due to a disability. Your approach to these requests should be the same as your approach to any other ADA Employee Accommodation or Patient Modification request.
Title I of the ADA covers employment. Generally, after an employee informs an employer of a disability, a request can be made by the employee for a reasonable accommodation. The employer is not required to make the accommodation if it causes significant difficulty or expense to business operations or if it poses a significant risk to the health or safety of the individual or others. The U.S. Equal Employment Opportunity Commission (EEOC) enforces the laws that prohibit employee discrimination. Common questions about COVID-19 and the ADA are answered on the EEOC website, including how to handle employee accommodation requests related to modified protective gear in settings where PPE is required for infection control:
“An employer may require employees to wear protective gear (for example, masks and gloves) and observe infection control practices (for example, regular hand washing and social distancing protocols). However, where an employee with a disability needs a related reasonable accommodation under the ADA (e.g., non-latex gloves, modified face masks for interpreters or others who communicate with an employee who uses lip reading, or gowns designed for individuals who use wheelchairs), or a religious accommodation under Title VII (such as modified equipment due to religious garb), the employer should discuss the request and provide the modification or an alternative if feasible and not an undue hardship on the operation of the employer's business under the ADA or Title VII.” 
When asked for a reasonable accommodation by an employee, you can request documentation regarding the medical condition restricting the use of a facemask in order to determine if and what reasonable accommodation may be possible. If this documentation supports a medical reason or specifically includes a doctor’s order for a mask exception, reasonable accommodations may be reviewed with the employee and considered such as:
- Job duty modifications
- Work from home alternatives if essential job duties can be performed remotely
- Alternate face coverings depending on job duties and patient interaction
Employees who cannot wear masks and for whom no accommodation can be is found, may be placed on paid or unpaid leave until face coverings are no longer required or their medical condition resolves.
Patient and Visitor Disability
Title III of the ADA, which covers places of public accommodation including medical offices, limits the manner in which patients and visitors can be asked about their disabilities. You may be familiar with these limitations due to other scenarios, such as those related to service animals. In the case of service animals, a place of public accommodation should not ask about the nature of a person's disability but may ask if the animal is required because of a disability and what task the animal has been trained to perform. Consider taking the same approach when a patient or visitor refuses to wear a mask. Simply ask if the reason they are unable to wear a mask is due to a disability. If it is, then a reasonable modification should be reviewed and agreed upon such as:
- Allowing alternate face covering styles such as a scarf, bandana, or face shield
- Allowing patients to wait in their car until roomed so that the face covering can be worn for less time
- Depending on the specialty, allowing certain services to occur via drive through, such as vaccinations
- Rescheduling the appointment to a telemedicine visit
If no alternative is tolerable, rescheduling the visit to the end of the same or different day when no other patients are present and when a vaccinated healthcare team is available may safely accommodate the patient.
These solutions should be agreed upon before the patient presents to your practice. For existing patients, this impact may be minimal depending on your practice. New patients, however, may present with new mask-wearing challenges that require additional time for ADA compliance. Ensure both existing and new patients are informed of the mask requirement when they make appointments or when they are called to confirm the appointment. This allows for reasonable modifications to be discussed prior to their arrival.
Patients Who Refuse to Comply with Your Face Mask Policy
In addition to a certain percentage of the public that refuses to wear masks, vaccinated patients may also believe they should not be required to wear masks in a healthcare setting. Establishing clear expectations, including reviewing your face mask-use policies and procedures prior to patients arriving, is crucial. This gives patients the opportunity to understand your expectations and decide whether they wish to comply and keep their appointment, or not to comply and therefore postpone or cancel their appointment. This process actively involves the patient in the decision-making process and can remove the element of “abandonment” by establishing conditions for care rather than simply denying care. These same principles apply in the event patients fail to comply with mask-use policies and procedures upon arrival. When this is the case, consider offering them telehealth visits or asking them to leave the clinic. Remember to document these processes and patients’ responses thoroughly in the medical record.
Asking patients to wear masks is a reasonable way to provide a safe environment for staff, patients, and visitors. Individual rights protected by the ADA and other state and federal laws must be balanced with public health authority guidance to protect the health and safety of all during the COVID era.
Physicians Practice: Prepare for patients who refuse to wear a mask in your practice
Recommendations on how to best prepare for patients who refuse to comply with your mask-wearing policy
Florida Healthcare Law Firm: My patient won’t wear a mask: Now what?
Strategies for responding to patients who will not wear masks, including ethical considerations and patient termination
Patient Requests for Medical Exemptions for Face Mask Use
HCP are increasingly being asked to provide medical exemptions for mask use. Responding to these requests for accommodation can be challenging since some requests are due to intolerance and not due to disability. If asked to sign a mask waiver for an established patient, ensure that the disability or accommodation is legitimate. Patients with non-legitimate requests should be educated about the importance of masks to protect those around them, not simply to protect themselves. If you receive requests from patients for mask exemptions, consider the following:
- Evaluate all patient requests for medical exemptions.
- Use your medical expertise to determine if a patient requires an accommodation.
- Clearly communicate why the request was denied. Do not use medical jargon, which can confuse patients about why their request was denied.
- Document rationales when refusing a patient’s requests for exemptions.
Resources For Developing Mask Policies
NORCAL Group: Sample Mask Policy for Employees
NORCAL Group: Sample Mask Policy for Patients and Visitors
NORCAL Group: Mask Policy Recommendations
ADA: FAQS Regarding Face Mask Policies
Burton Blatt Institute and Southeast ADA Center: Fact Sheet Regarding Face Mask Policies
 CDC. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html. Updated February 2, 2022. Accessed February 10, 2022.
 CDC. Use Masks to Slow the Spread of COVID-19. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/masks.html. Updated August 12, 2021. Accessed February 10, 2022.
 OSHA. OSH Act of 1970: General Duty Claus. https://www.osha.gov/laws-regs/oshact/section5-duties Accessed February 10, 2022.
 OSHA. Protecting Workers: Guidance on Mitigating and Preventing the Spread of COVID-19 in the Workplace. https://www.osha.gov/coronavirus/safework. Updated August 13, 2021. Accessed February 10, 2022.
 OSHA. COVID-19 Frequently Asked Questions. Worker Protection Concerns. https://www.osha.gov/coronavirus/faqs#worker. Accessed February 10, 2022.
 29 CFR §1977.3. National Archives eCFR website. https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XVII/part-1977/subject-group-ECFR45d318d80906952/section-1977.3 Accessed February 10, 2022.
 29 CFR §1910.132(b). National Archives eCFR website. https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XVII/part-1910/subpart-I/section-1910.132 Accessed February 10, 2022.
 CDC. Your Guide to Masks. https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html. Updated January 21, 2022. Accessed February 10, 2022.
 U.S. Equal Employment Opportunity Commission. The ADA: Questions and Answers. https://www.eeoc.gov/laws/guidance/ada-questions-and-answers. Issued May 1, 2002. Accessed January 13, 2022.
 U.S. Equal Employment Opportunity Commission. What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws. https://www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-and-other-eeo-laws. (see section G.2.) Updated December 20, 2021. Accessed January 13, 2022.
 Wong M. ADA Implications: I Don’t Want to Wear a Mask…. Labor & Employment Law Update. https://laborandemploymentlawupdate.com/2020/05/08/ada-implications-i-dont-want-to-wear-a-mask/. Published May 8, 2020. Accessed January 13, 2022.
 28 CFR § 36.302(c)(6). National Archives eCFR website. https://www.ecfr.gov/current/title-28/chapter-I/part-36/subpart-C/section-36.302. Accessed February 8, 2022.
 Buppert C. Patients Who Refuse to Wear a Mask: Responses That Won't Get You Sued. Medscape website. https://www.medscape.com/viewarticle/933606. Published July 9, 2020. Accessed January 13, 2022.