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

Summary of Recent Changes

Key Points

• COVID-19 vaccines are safe and effective, and widely accessible in the United States.
• Everyone ages 5 years and older is recommended to be vaccinated against COVID-19 as soon as possible to keep from getting and spreading COVID-19.
• This guidance is intended for homeless service providers. The guidance outlines strategies that service providers can use to help maintain healthy environments and operations, lower the risk of COVID-19 spread in their programs, prepare for when someone is sick with COVID-19, and support coping and resilience.
• Consistent and layered use of prevention strategies can help reduce the spread of COVID-19, including among clients, staff, and their families.
  • Regardless of COVID-19 vaccination status, all clients, staff, and volunteers should continue wearing well-fitting masks or respirators and maintain physical distance in shelters.
• This CDC guidance is meant to supplement—not replace—any federal, state, local, territorial, or tribal health and safety laws, rules, and regulations with which homeless shelters must comply.

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 coronavirus. 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.

Vaccination is the leading prevention measure to keep clients, staff, and volunteers healthy and help your organization maintain normal operations. COVID-19 vaccines are safe and effective, widely available, and provided at no cost to people living in the United States. Learn more about the benefits of getting a COVID-19 vaccine. See Interim Guidance for Health Departments: COVID-19 Vaccination Implementation for People Experiencing Homelessness for more information.

At this time, people should continue to follow prevention measures in homeless shelters, such as physical distancing and wearing well-fitting masks or respirators, even if they are up to date on vaccination. The guidance that follows applies to people in shelter settings, regardless of vaccination or booster status.

Community-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 whole community approach to prepare for COVID-19 among people experiencing homelessness

Communication

• Stay updated on the local level of transmission of COVID-19 through your local and state health departments.
• Find out where COVID-19 vaccines are available for staff and clients.
• Communicate clearly with staff and clients.
  • Promote COVID-19 vaccination among 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, coughpdf icon etiquette, mask wearing, and physical distancing.
  • Provide educational materials about COVID-19 for non-English speakers or hearing impaired individuals, 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 clients. 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
• Hand sanitizers that contain at least 60% alcohol
• Tissues
• Trash baskets
• Masks or Respirators
• Cleaning supplies
• Personal protective equipment (PPE), as needed by staff (see below)

Considerations for Staff and Volunteers

• Encourage staff and volunteers to get vaccinated or boosted as soon as they can, and stay up to date on COVID-19 vaccinations.
• If staff and volunteers are not up to date on COVID-19 vaccination, minimize the amount of time they spend in face-to-face interactions with clients.
• Provide training and educational materials related to COVID-19 for staff and volunteers.
• Develop and use contingency plans for staffing disruptions caused by absenteeism due to employee illness, illness in employees’ family members, or possible post-vaccination side effects. These plans might include extending hours, cross-training current employees, or hiring temporary employees.
• Regardless of vaccination status, 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 staff and volunteers at increased risk so they can continue working while minimizing direct contact with clients.
• Put in place plans on how to maintain physical distancing (remaining at least 6 feet apart) between all clients and staff/volunteers, regardless of vaccination status, while still providing necessary services.
• All staff and volunteers should wear a well-fitting mask or respirator regardless of vaccination status. See below for information on laundering washable masks.
• Staff and volunteers who do not interact closely (within 6 feet) with sick clients and do not clean client environments do not need to wear personal protective equipment (PPE).
• Staff and volunteers should avoid handling client belongings, regardless of vaccination status. If staff or volunteers are handling client belongings, they should use disposable gloves, if available. Make sure to train any staff or volunteers 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 or volunteers who are checking client temperatures should use a system that creates a physical barrier between the client and the screener.
  • 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 physical distancing or barrier/partition controls cannot be put in place during screening, PPE (for example, respirator, 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 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 (KN95 respirators or surgical mask can be used if respirators are not available), disposable gown, and disposable gloves. Cloth masks 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.
• Following close contact to someone with COVID-19, staff at homeless shelters should quarantine away from the workplace for 10 days from the date of their last known close contact, regardless of their vaccination and booster status. Staff who have come into close contact with someone with COVID-19 should be tested at least 5 days after last known close contact, regardless of vaccination and booster status.
• All homeless shelter staff who have symptoms of COVID-19 or test positive for SARS-CoV-2, the virus that causes COVID-19, should isolate away from work for 10 days from the date symptoms began or the date of the positive test if they do not have symptoms, regardless of their vaccination and booster status.
• Staff may follow general population guidance to end isolation or quarantine in other community settings. For example, staff can follow general population guidance for activities other than returning to work, such as grocery shopping.
• During crisis situations (i.e., staffing shortages that threaten the continuity of essential operations), homeless service providers should consult their state, tribal, local, or territorial health department to consider options for shortening the duration of quarantine or isolation for staff.
  • Reducing quarantine or isolation duration may be recommended for groups at lower risk of infection first (e.g., those who are up to date on their COVID-19 vaccines).
• Maintaining appropriate staffing in homeless shelters is essential to providing a safe work environment for staff and clients. As the COVID-19 pandemic progresses, staffing shortages may occur due to ongoing exposures, illness, or the need to care for family members at home. Homeless shelters must be prepared for potential staffing shortages and have plans and processes in place to mitigate these shortages.
• 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 dining areas, create at least 6 feet of space between seats, and/or allow either for food to be delivered to client rooms or for clients to take food away. If eating throughout the facility (like on their cots), clients should still remain 6 feet apart from others.
  • Members of the same family, or parents with children, can sit closer than 6 feet together when dining in shared spaces but should remain 6 feet from other clients.
• 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.
  • Clients should isolate for 10 days from the date symptoms began or the date of the positive test if they do not have symptoms, regardless of their vaccination and booster status.
  • In some circumstances, such as severely constrained availability of isolation spaces, it might be necessary to decrease the duration of isolation.
  • Decisions to shorten isolation should be made in coordination with the state, local, territorial, or tribal health department. Clients may follow general population guidance to end isolation or quarantine in other community settings. For example, if a client is working in a setting other than the homeless service site (and it is not a high-risk congregate setting at higher risk for transmission), they may return to work in accordance with the general population guidance.

Facility ventilation considerations

• Ensure ventilation systems operate properly and provide acceptable indoor air quality for the current occupancy level for each space.
• 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 (such as risk of falling, triggering asthma symptoms) to clients, staff, volunteers, or visitors using the facility.
• 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 portable high-efficiency particulate air (HEPA) fan/filtration systems to help enhance air cleaningpdf iconexternal icon (especially in areas at higher risk for transmission, such as nurse offices or screening rooms). Generate clean-to-less-clean air movementspdf iconexternal icon by evaluating and repositioning exhaust fans. 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.
• 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.
• Consider using ultraviolet germicidal irradiation (UVGI) 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, and Coronavirus Relief Fundexternal icon.

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 or proof of COVID-19 vaccination for entry to a homeless services site unless otherwise directed by local or state health authorities.
• 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 to receive medical care.
• 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 well-fitting masks or respirators over their nose and mouth any time they are not in their room or on their bed/mat (in shared sleeping areas), regardless of vaccination status. Masks or respirators should not be placed on children under 2 years old, anyone who has trouble breathing, or is unconscious, incapacitated, or otherwise unable to remove the mask or respirator without assistance.
• Regularly assess clients and staff for symptoms regardless of vaccination status.
  • 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 until they are able to be tested for COVID-19.
  • An on-site nurse or other clinical staff can help with testing and clinical assessments.
  • Provide all clients and staff with a well-fitting mask or respirator, regardless of symptoms or vaccination status.
  • Facilitate access to testing and 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
    • Pale, gray, or blue-colored skin, lips, or nail beds, depending on skin tone
  • 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 an ample supply of personal protective equipmentpdf icon.
• 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 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 hand sanitizer with at least 60% alcohol if soap and water are not available.

When to Clean