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This document provides personal protective equipment (PPE) and cloth face covering guidance specific for behavioral health clinicians and clients during the outbreak of coronavirus disease 2019 (COVID-19). The following recommendations are based on CDC guidance for healthcare settings (updated 4/13/20) and include information on the Local Health Officer Directive on face coverings.


PPE For behavioral health providers

Behavioral health providers should consider the following recommendations when planning their PPE use.

  • Wear a medical facemask at all times while in the agency, clinic, or facility.
    • Use a facemask instead of a cloth face covering, when available.
    • Prioritize facemasks for providers if there are anticipated shortages, then clients with symptoms of COVID-19, if supply allows.

  • Use a medical facemask before entry into care areas (clinic, therapy, or group rooms and client rooms) and shared spaces (e.g. milieu).
    • To avoid risking self-contamination, consider continuing to wear a facemask (extended use) instead of intermittently switching back to their cloth face covering. The medical facemask should be removed and discarded if soiled, damaged, or hard to breathe through.
    • Take care not to touch your medical facemask. Wash your hands before and after adjusting or touching a medical facemask.
    • Leave the client care area if you need to remove your medical facemask.
    • Disposable medical facemasks should be removed and discarded after exiting the care area and closing the door unless implementing extended use or reuse.

  • To reduce risk of medical facemasks being used as ligatures, use masks with elastic ear loops instead of ties or dispose of face masks with ties in a secure location not accessible by clients.

Providers should consider the following recommendations before using a cloth face covering:

  • Cloth face coverings are not considered PPE and should NOT be worn instead of a medical facemask if more protection beyond preventing infected individuals from spreading disease is required (for example as a barrier to blood, fecal matter, or other bodily fluids)

  • Wear a cloth face covering for parts of the day when not engaged in direct client care activities (e.g. clerical work) and switch to a medical facemask when PPE is required.
    • Change cloth face coverings if soiled, damp, or hard to breathe through.
    • Wash hands immediately before and after any contact with the cloth face covering.

  • After removing a medical face mask at the end of a shift, put on a cloth face covering when leaving the facility.

  • If medical masks are not available, cloth face coverings should be used in combination with a face shield that covers the entire front and sides of the face, extending to the chin or below.
Facilities should provide guidance and training about when, how, and where cloth face coverings can be used (e.g., frequency of laundering, guidance on when to replace, circumstances when they can be worn in the facility, importance of proper hand washing). For more information on face coverings and the Local Health Officer Directive, visit www.kingcounty.gov/masks.
  • Put on clean, non-sterile gloves upon entry into a client care area or shared area.
  • Change gloves if they become torn or heavily contaminated.
  • Remove and discard gloves when leaving the care area, and immediately perform hand hygiene (hand washing).
  • Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the client care area or shared area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection.
  • Remove eye protection before leaving the care area or shared area.
  • Reusable eye protection (e.g., goggles) must be cleaned and disinfected according to manufacturer's reprocessing instructions prior to re-use. Disposable eye protection should be discarded after use unless following protocols for extended use or reuse.
  • Put on a clean isolation gown upon entry into the client care area or shared area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use.

  • If there are shortages of gowns, they should be prioritized for:
    • aerosol generating procedures
    • care activities where splashes and sprays are anticipated
    • high-contact client care activities that provide opportunities for transfer of pathogens to the hands and clothing of a provider. Examples include:
      • de-escalation, especially if client is spitting or thrashing
      • restraining a client
      • giving injections
      • assisting clients with CPAPs
      • dressing
      • bathing/showering
      • providing hygiene
      • changing linens
      • changing briefs or assisting with toileting
      • device care or use
      • wound care

Please refer to CDC guidance on Strategies for Optimizing the Supply of Isolation Gowns for appropriate strategies depending on your organization's supply of isolation gowns.

For providers on a Code Gray (de-escalation) team, we recommend you consider wearing full PPE (masks, gloves, eye protection and gowns) at all times in client areas to be prepared for situations where you will be in close contact with clients and/or have additional staff help with de-escalation from a distance of more than 6ft while directly involved staff don PPE.

Face covering directive

The Local Health Officer Directive strongly urges all King County residents to wear face coverings in most public spaces. To reduce spread of COVID-19 in behavioral health settings, facilities should implement the face covering directive recommending everyone entering an agency, clinic, or facility wear a cloth face covering (if able to) while in the building, regardless of symptoms. This Directive may provide some challenges to behavioral health settings and these facilities are encouraged to use their best clinical judgement when implementing the Directive.

If someone is unable to wear a cloth face covering for a variety of reasons, they are exempt from the Directive. Examples of exemptions are:

  • Children ages 2-12 should only wear a face covering if a parent or caregiver supervises
  • Anyone with a disability that makes it hard for them to wear or remove a face covering
  • Anyone who is deaf and moves their face and mouth to communicate
  • Anyone who has been advised by a medical or behavioral health professional to not wear a face covering because of personal health issues
  • Anyone who has trouble breathing, is unconscious, or unable to remove the face covering without help

This Directive strongly encourages King County residents to wear face coverings, but there are no penalties for those who fail to comply. For more information on the Directive, visit www.kingcounty.gov/masks.

The most important things for facilities to do to protect the health of their clients, employees, and the public is to continue practicing Public Health guidance focusing on maintaining physical distance between clients and providers, excellent hand hygiene, and frequent surface-cleaning.


PPE and face coverings for clients

Clients should wear a medical face mask or cloth face covering while in the agency, clinic, or facility, if tolerated and able. Cloth face coverings are not considered PPE but may help prevent infected individuals from spreading disease.

  • Offer clients a medical or cloth face covering on arrival to the facility, if not already wearing one.
  • Instruct clients that if they must touch or adjust their face covering, they should wash their hands (or use hand sanitizer) immediately before and after.  If clients are unable to follow these instructions, or wear the face covering properly over their nose and mouth, face coverings are not recommended.
  • Do not place face coverings on anyone who is:
    • Having trouble breathing
    • Unconscious, incapacitated or otherwise unable to remove the face covering without assistance
    • Significantly uncomfortable or anxious while wearing a face covering
  • There is a risk that clients may attempt to use a face covering as ligature. Staff should be aware of this risk and consider how to monitor and reduce risk, including using face covering with elastic ear loops instead of ties and disposing of face covering with ties in secure locations not accessible by clients.
  • Clients may remove their face covering when in individual rooms but should put them back on when others (e.g., provider, visitors) enter their room and when leaving their room, especially when visiting shared spaces (e.g. milieu). Efforts should be made to de-densify rooms, if possible, reducing the number of clients per room to one. If clients must share rooms, try to maintain 6 feet of distance between roommates and encourage clients to wear a face covering while in the room together, except when sleeping.
  • Screen for symptoms (e.g. fever, dry cough, shortness of breath, chills, myalgias, headache, sore throat, new loss of taste or smell).


PPE and face coverings for visitors

To the extent possible, we recommend facilities limit visitors. Visitors should wear a medical facemask or cloth face covering while in the agency, clinic, or facility.

  • Offer visitors a medical facemask or cloth face covering on arrival to the facility, if not already wearing one.
  • Instruct visitors that if they must touch or adjust their face covering they should wash their hands (or use hand sanitizer) immediately before and after.
  • Do not place face coverings on young children under age 2 years.

Screen visitors for symptoms (e.g. fever, dry cough, shortness of breath, chills, myalgias, headache, sore throat, new loss of taste or smell, or others). Invite symptomatic visitors to return after their symptoms have resolved. Offer alternative ways for visitors to interact with clients, such as video conferencing.


Face coverings during meals and breaks

Food and drink are often provided during behavioral health therapy and support group meetings. If snacks must be provided, encourage attendees to eat and drink at one consolidated time during the meeting while maintaining physical distance. Cloth face coverings may be removed during these breaks but encouraged the rest of the meeting.

Provide soap and water or hand sanitizer before and after meal breaks so that attendees can safely remove and don their face coverings before and after eating.


Additional resources for PPE planning and conservation strategies