Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19)

Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19)

This interim guidance is based on what is currently known about coronavirus disease 2019 (COVID-19). The Centers for Disease Control and Prevention (CDC) will update this interim guidance as needed and as additional information becomes available.

Summary of Recent Changes

A revision was made on 10/31/2020 to reflect the following:

  • Facility Ventilation Considerations
  • Long-term planning for COVID-19 infection control and prevention

People experiencing homelessness are at risk for infection during community spread of COVID-19. This interim guidance is intended to support response planning by emergency management officials, public health authorities, and homeless service providers, including overnight emergency shelters, day shelters, and meal service providers.

COVID-19 is caused by a new coronavirus. We are learning about how it spreads, how severe it is, and other features of the disease. Transmission of COVID-19 in your community could cause illness among people experiencing homelessness, contribute to an increase in emergency shelter usage, and/or lead to illness and absenteeism among homeless service provider staff.

Early and sustained action to slow the spread of COVID-19 will keep staff and volunteers healthy, and help your organization maintain normal operations.

Community coalition-based COVID-19 prevention and response

Planning and response to COVID-19 transmission among people experiencing homelessness requires a “whole community”external icon approach, which means that you are involving partners in the development of your response planning, and that everyone’s roles and responsibilities are clear. Table 1 outlines some of the activities and key partners to consider for a whole-community approach.

Table 1: Using a community-wide approach to prepare for COVID-19 among people experiencing homelessness

table 1
Connect to community-wide planning

Connect with key partners to make sure that you can all easily communicate with each other while preparing for and responding to cases. A community coalition focused on COVID-19 planning and response should include:

  • Local and state health departments
  • Homeless service providers and Continuum of Care leadership
  • Emergency management
  • Law enforcement
  • Healthcare providers
  • Housing authorities
  • Local government leadership
  • Other support services like outreach, case management, and behavioral health support
Identify additional sites and resources
Continuing homeless services during community spread of COVID-19 is critical, and homeless shelters should not close or exclude people who are having symptoms or test positive for COVID-19 without a plan for where these clients can safely access services and stay.
Decisions about whether clients with mild illness due to suspected or confirmed COVID-19 should remain in a shelter, or be directed to alternative housing sites, should be made in coordination with local health authorities. Community coalitions should identify additional temporary housing and shelter sites that are able to provide appropriate services, supplies, and staffing.Ideally, these additional sites should include:
  • Overflow sites to accommodate shelter decompression (to reduce crowding) and higher shelter demands
  • Isolation sites for people who are confirmed to be positive for COVID-19
  • Quarantine sites for people who are waiting to be tested, or who know that they were exposed to COVID-19
  • Protective housing for people who are at increased risk of severe COVID-19

Depending on resources and staff availability, non-group housing options (such as hotels/motels) that have individual rooms should be considered for the overflow, quarantine, and protective housing sites. In addition, plan for how to connect clients to housing opportunities after they have completed their stay in these temporary sites.

Communication

  • Stay updated on the local level of transmission of COVID-19 through your local and state health departments.
  • Communicate clearly with staff and clients.
    • Use health messages and materials developed by credible public health sources, such as your local and state public health departments or the Centers for Disease Control and Prevention (CDC).
    • Post signs at entrances and in strategic places providing instruction on hand washing and coughpdf icon[1 page] etiquette, use of masks, and social distancing.
    • Provide educational materials about COVID-19 for non-English speakers or hearing impaired, as needed.
    • Keep staff and clients up-to-date on changes in facility procedures.
    • Ensure communication with clients and key partners about changes in program policies and/or changes in physical location.
  • Identify platforms for communications such as a hotline, automated text messaging, or a website to help disseminate information to those inside and outside your organization. Learn more about communicating to workers in a crisisexternal icon.
  • Identify and address potential language, cultural, and disability barriers associated with communicating COVID-19 information to workers, volunteers, and those you serve. Learn more about reaching people of diverse languages and cultures.

Supplies

Have supplies on hand for staff, volunteers, and those you serve, such as:

  • Soap
  • Alcohol-based hand sanitizers that contain at least 60% alcohol
  • Tissues
  • Trash baskets
  • Masks
  • Cleaning supplies
  • Personal protective equipment (PPE), as needed by staff (see below)

Staff considerations

  • Provide training and educational materials related to COVID-19 for staff and volunteers.
  • Minimize the number of staff members who have face-to-face interactions with clients with respiratory symptoms.
  • Develop and use contingency plans for increased absenteeism caused by employee illness or by illness in employees’ family members. These plans might include extending hours, cross-training current employees, or hiring temporary employees.
  • Staff and volunteers who are at increased risk for severe illness from COVID-19 should not be designated as caregivers for sick clients who are staying in the shelter. Identify flexible job duties for these increased risk staff and volunteers so they can continue working while minimizing direct contact with clients.
  • Put in place plans on how to maintain social distancing (remaining at least 6 feet apart) between all clients and staff while still providing necessary services.
  • All staff should wear a mask for source control (when someone wears a mask over their mouth and nose to contain respiratory droplets), consistent with the guidance for the general public. See below for information on laundering washable masks.
  • Staff who do not interact closely (e.g., within 6 feet) with sick clients and do not clean client environments do not need to wear personal protective equipment (PPE).
  • Staff should avoid handling client belongings. If staff are handling client belongings, they should use disposable gloves, if available. Make sure to train any staff using gloves to ensure proper use and ensure they perform hand hygiene before and after use. If gloves are unavailable, staff should perform hand hygiene immediately after handling client belongings.
  • Staff who are checking client temperatures should use a system that creates a physical barrier between the client and the screener as described here.
    • Screeners should stand behind a physical barrier, such as a glass or plastic window or partition that can protect the staff member’s face from respiratory droplets that may be produced if the client sneezes, coughs, or talks.
    • If social distancing or barrier/partition controls cannot be put in place during screening, PPE (i.e., facemask, eye protection [goggles or disposable face shield that fully covers the front and sides of the face], and a single pair of disposable gloves)  can be used when within 6 feet of a client.
    • However, given PPE shortages, training requirements, and because PPE alone is less effective than a barrier, try to use a barrier whenever you can.
  • For situations where staff are providing medical care to clients with suspected or confirmed COVID-19 and close contact (within 6 feet) cannot be avoided, staff should at a minimum, wear eye protection (goggles or face shield), an N95 or higher level respirator (or a facemask if respirators are not available or staff are not fit tested), disposable gown, and disposable gloves. Cloth face coverings are not PPE and should not be used when a respirator or facemask is indicated. If staff have direct contact with the client, they should also wear gloves. Infection control guidelines for healthcare providers are outlined here.
  • Staff should launder work uniforms or clothes after use using the warmest appropriate water setting for the items and dry items completely.
  • Provide resources for stress and coping to staff. Learn more about mental health and coping during COVID-19.

Facility layout considerations

  • Use physical barriers to protect staff who will have interactions with clients with unknown infection status (e.g., check-in staff). For example, install a sneeze guard at the check-in desk or place an additional table between staff and clients to increase the distance between them to at least 6 feet.
  • In meal service areas, create at least 6 feet of space between seats, and/or allow either for food to be delivered to clients or for clients to take food away.
  • In general sleeping areas (for those who are not experiencing respiratory symptoms), try to make sure client’s faces are at least 6 feet apart.
    • Align mats/beds so clients sleep head-to-toe.
  • For clients with mild respiratory symptoms consistent with COVID-19:
    • Prioritize these clients for individual rooms.
    • If individual rooms are not available, consider using a large, well-ventilated room.
    • Keep mats/beds at least 6 feet apart.
    • Use temporary barriers between mats/beds, such as curtains.
    • Align mats/beds so clients sleep head-to-toe.
    • If possible, designate a separate bathroom for these clients.
    • If areas where these clients can stay are not available in the facility, facilitate transfer to a quarantine site.
  • For clients with confirmed COVID-19, regardless of symptoms:
    • Prioritize these clients for individual rooms.
    • If more than one person has tested positive, these clients can stay in the same area.
    • Designate a separate bathroom for these clients.
    • Follow CDC recommendations for how to prevent further spread in your facility.
    • If areas where these clients can stay are not available in the facility, assist with transfer to an isolation site.

Facility ventilation considerations

  • Ensure ventilation systems operate properly and per established local/national codes. Increase the indoor delivery of outdoor air as much as possible. Do not open windows and doors if doing so poses a safety or health risk (e.g., risk of falling, triggering asthma symptoms) to clients, staff, volunteers, or visitors using the facility.
  • Consider taking steps to improve ventilation in the building, in consultation with an HVAC professional, based on local environmental conditions (temperature/humidity) and ongoing community transmission in the area. Identifying the best steps for your specific facility will depend on a number of factors including but not limited to layout, number of occupants, environmental factors, and available resources. Potential steps include:
    • Increase the percentage of outdoor air (e.g., using economizer modes of HVAC operations) potentially as high as 100% (first verify compatibility with HVAC system capabilities for both temperature and humidity control as well as compatibility with outdoor/indoor air quality considerations).
    • Increase total airflow supply to occupied spaces, if possible.
    • Disable demand-control ventilation (DCV) controls that reduce air supply based on temperature or occupancy.
    • Consider using natural ventilation (i.e., opening windows if possible and safe to do so) to increase outdoor air dilution of indoor air when environmental conditions and building requirements allow. If temperatures outside make it difficult to leave multiple windows open, consider safely securing window fans or box fans (sealing the perimeter around the box fan) to blow air out of selected windows. The resulting make-up air will come into the building via multiple leak points and blend with indoor air as opposed to a single unconditioned incoming air stream.
    • Improve central air filtration:
      • Increase air filtrationexternal icon to as high as possible without significantly diminishing design airflow.
      • Inspect filter housing and racks to ensure appropriate filter fit and check for ways to minimize filter bypass.
    • Consider running the HVAC system at maximum outside airflow for 2 hours before and after occupied times.
    • Generate clean-to-less-clean air movementspdf iconexternal icon by re-evaluating the positioning of supply and exhaust air diffusers and/or dampers and adjusting zone supply and exhaust flow rates to establish observable pressure differentials. Have staff work in “clean” ventilation zones that do not include higher-risk areas such as visitor reception or exercise facilities (if open). Careful placement of window exhaust fans can also assist in establishing directional airflow.
  • Consider using portable high-efficiency particulate air (HEPA) fan/filtration systems to help enhance air cleaningpdf iconexternal icon (especially in higher-risk areas). HEPA systems not only capture and remove potentially infectious particles in the air but their clean air discharge is just as beneficial as fresh outdoor air when it comes to diluting contaminants.
  • Ensure exhaust fans in kitchens and restroom facilities are functional and operating at full capacity when the building is occupied. Consider running exhaust fans for several hours before and after occupied times when possible.
  • Consider using ultraviolet germicidal irradiation (UVGI)pdf iconexternal icon as a supplemental technique to inactivate potential airborne virus in the upper-room air of common occupied spaces. Seek consultation with a reputable UVGI manufacturer or an experienced UVGI system designer prior to installing and operating UVGI systems.
  • Collaborate with the health department and other community partners to identify resources for improving ventilation and air quality. Some potential sources include Emergency Solutions Grants Programexternal icon, Emergency Solutions Grants Program COVID-19external icon, Community Development Block Grant COVID-19external icon , Coronavirus Relief Fundexternal icon.

For more information about ventilation considerations for buildings, see COVID-19 Employer Information for Office Buildings.

Facility procedure considerations

  • Plan to maintain regular operations to the extent possible.
  • Limit visitors who are not clients, staff, or volunteers.
  • Do not require a negative COVID-19 viral test for entry to a homeless services site unless otherwise directed by local or state health authorities.
  • Identify clients who could be at increased risk for complications from COVID-19, or from other chronic or acute illnesses, and encourage them to take extra precautions.
  • Arrange for continuity of and surge support for mental health, substance use treatment services, and general medical care.
  • Identify a designated medical facility to refer clients who might have COVID-19.
  • Keep in mind that clients and staff might be infected without showing symptoms.
    • Create a way to make physical distancing between clients and staff easier, such as staggering meal services or having maximum occupancy limits for common rooms and bathrooms.
    • All clients should wear masks any time they are not in their room or on their bed/mat (in shared sleeping areas). Masks should not be placed on young children under age 2, anyone who has trouble breathing, or is unconscious, incapacitated or otherwise unable to remove the mask without assistance.
  • Regularly assess clients and staff for symptoms.
    • Clients who have symptoms may or may not have COVID-19. Make sure they have a place they can safely stay within the shelter or at an alternate site in coordination with local health authorities.
    • An on-site nurse or other clinical staff can help with clinical assessments.
    • Provide anyone who presents with symptoms with a mask.
    • Facilitate access to non-urgent medical care as needed.
    • Use standard facility procedures to determine whether a client needs immediate medical attention. Emergency signs include:
      • Trouble breathing
      • Persistent pain or pressure in the chest
      • New confusion or inability to arouse
      • Bluish lips or face
    • Notify the designated medical facility and personnel to transfer clients that the client might have COVID-19.
  • Prepare healthcare clinic staff to care for patients with COVID-19, if your facility provides healthcare services, and make sure your facility has supply of personal protective equipmentpdf icon[1 page].
  • Provide links to respite (temporary) care for clients who were hospitalized with COVID-19 but have been discharged.
    • Some of these clients will still require isolation to prevent transmission.
    • Some of these clients will no longer require isolation and can use normal facility resources.
  • Make sure bathrooms and other sinks are consistently stocked with soap and drying materials for handwashing. Provide alcohol-based hand sanitizers that contain at least 60% alcohol at key points within the facility, including registration desks, entrances/exits, and eating areas.
  • Washable masks used by clients and staff should be laundered regularly. Disposable masks should not be laundered. Staff involved in laundering masks should do the following:
    • Masks should be collected in a sealable container (like a trash bag).
    • Staff should wear disposable gloves and a face mask. Use of a disposable gown is also recommended, if available.
    • Gloves should be properly removed and disposed of after laundering washable masks; clean hands immediately after removal of gloves by washing hands with soap and water for at least 20 seconds or using an alcohol-based hand sanitizer with at least 60% alcohol if soap and water are not available.
  • Clean and disinfect frequently touched surfaces at least daily and shared objects between use using an EPA- registered disinfectantexternal icon.
Considerations for creating a long-term strategy

Implementation of the public health prevention measures described in this guidance should continue if:

  • a case of COVID-19 has been identified in the facility,
  • COVID-19 cases have been identified in people experiencing homelessness in the community, or
  • there continues to be community spread of COVID-19

Even if no cases of COVID-19 have been identified in your locality for the past 14 days, continue to maintain the following key components of a sustainable approach to prevention and response:

  1. Monitor COVID-19 activity in your area. For the latest updates on local transmission of the virus that causes COVID-19, communicate regularly with your state, tribal, localexternal icon, or territorial health departments.
  2. Create flexible quarantine and isolation locations that are scalable in case the number of COVID-19 cases in the facility or community increases.
  3. Have a plan in place to reduce the number of people staying in the shelter and quickly increase cleaning and disinfection frequency in response to an identified case in the facility or a rise of transmission in the community.
  4. Keep a minimum set of infection prevention and control procedures in place at all times, including the following:

COVID-19 Readiness Resources