Infection prevention and control for COVID-19: Interim guidance for home care settings
*this document was last updated on April 24, 2020. Please refer back for future updates.
This document provides guidance specific to the COVID-19 pandemic for home care providers.
Individuals responsible for policy development, implementation and oversight of infection prevention and control measures specific to home care services should be familiar with relevant infection prevention and control (IPC) background documents on Routine Practices and Additional Precautions and occupational health and safety legislation. The term "staff" is intended to include anyone who provides formal medical or personal care in the home. The term "client" is intended to refer to patients who are receiving home care services.
Important measures to prevent introduction and spread of COVID-19 in and between client homes:
- Staff must follow current infection prevention and control guidelines for use of personal protective equipment (PPE) while in the home
- All staff must be trained in putting on a mask outside of each client's home and wearing a mask at all times for the duration of their visit in the home and discarding it afterward, and in properly assessing the need for additional PPE, putting it on, wearing and removing it to minimize contamination of themselves and the immediate environment
- Use of eye protection by staff (e.g., a face shield) for duration of their visit in the client's home should be strongly considered
- All staff must use Droplet and Contact Precautions, in addition to Routine Practices, for all client contact and care, when the client (or someone in their home) is suspected or confirmed to be infected with COVID-19
In December 2019, a cluster of cases of pneumonia of unknown origin was reported from Wuhan, Hubei Province in China. On January 10, 2020, a novel coronavirus, that causes a disease now referred to as COVID-19 was identified as the cause of this cluster of pneumonia cases. A pandemic was declared on March 11, 2020.
For current information, organizations providing home care services should refer to the Public Health Agency of Canada Coronavirus Disease (COVID-19): Outbreak Update and to local, provincial or territorial public health authorities.
Over the last few months, our understanding of COVID-19 has rapidly expanded. Person-to-person transmission is increasing in Canadian communities. COVID-19 is most commonly spread from an infected person through respiratory droplets generated through cough or sneezing, close personal contact such as touching or shaking hands, or touching something with the virus on it and then touching one's mouth, nose or eyes before washing one's hands. COVID-19 can also be spread through the air during aerosol-generating medical procedures (AGMPs).
There is evidence of unrecognized asymptomatic, pre-symptomatic or pauci-symptomatic transmission of this virus. Both staff and clients in home care settings may have COVID-19 infection without symptoms, or with undetected mild or atypical symptoms at the time of visits.
The Public Health Agency of Canada (PHAC) develops evidence-informed infection prevention and control guidelines and recommendations to complement provincial and territorial public health efforts in monitoring, preventing, and controlling healthcare-associated infections.
The purpose of this document, Infection Prevention and Control for COVID-19: Interim Guidance for Home Care Settings, is to provide interim guidance to home care organizations and staff, to prevent the transmission of COVID-19 in home care settings.
Home care organizations provide comprehensive services to clients in their homes and communities and therefore play a key role in preventing unnecessary hospital and long-term care admissions. Home care is used to describe formal medical or personal care delivered in the home. This includes but is not limited to care delivered by nurses, physiotherapists, occupational therapists, respiratory therapists, and personal support workers.
This interim guidance is based upon Canadian guidance developed for previous coronavirus outbreaks, experience with COVID-19 in other countries, as well as interim guidance from other Canadian and international bodies. It has been informed by technical advice provided by members of the PHAC National Advisory Committee on Infection Prevention and Control (NAC-IPC).
Infection prevention and control strategies to prevent or limit transmission of COVID-19 in the home care setting are similar to those used for the IPC management of other acute respiratory infections and include:
- Prompt identification of all persons with signs and symptoms of COVID-19
- Signs and symptoms may include:
- Fever (temperature of 38.0°C or greater), OR
- Any new or worsening respiratory symptoms (cough, shortness of breath, runny nose or sneezing, nasal congestion, hoarse voice, sore throat or difficulty swallowing), OR
- Any new onset atypical symptoms including but not limited to chills, muscle aches, diarrhea, malaise, or headache
- Signs and symptoms may include:
- Institution of IPC measures to prevent infections (e.g., Routine Practices including hand hygiene, point-of-care risk assessment (PCRA), and implementation of Droplet and Contact Precautions, and use of an N95 respirator for AGMPs)
- For more information, staff can refer to PHAC's guidelines on Routine Practices and Additional Precautions for Preventing the Transmission of Infection in Healthcare Settings
This guidance has been developed for Canadian home care organizations and staff and may differ from guidance developed by other countries. It should be read in conjunction with the relevant provincial, territorial and local legislation, regulations, and policies.
This guidance is informed by currently available scientific evidence and expert opinion and is subject to change as new information becomes available.
Infection prevention and control preparedness
Organizations providing home care must ensure that:
- They maintain awareness of data on the local and regional spread of COVID-19
- They have capacity to call and pre-screen clients prior to scheduled visits
- Staff conducting telephone screening are provided with appropriate guidance on how to screen for signs and symptoms of COVID-19
- Staff receive ongoing training and monitoring of compliance with conducting PCRAs, Routine Practices, including hand hygiene, and implementation of Additional Precautions, including Droplet and Contact Precautions
- A home safety risk assessment is completed for each client to determine whether the client environment is suitable for home care services
- Policies and procedures are in place to prevent the introduction and spread of COVID-19 between client homes, and that these are informed by regional and/or provincial/territorial directives or recommendations. This includes policies and procedures pertaining to:
- Communication with staff and clients on COVID-19 updates
- Active self-screening of staff for exposures or signs or symptoms of COVID-19
- Conducting telephone client (and household member) screening for signs and symptoms of COVID-19 prior to visits
- The need for PCRAs to be conducted by all staff prior to any interactions with a client or household member; Routine Practices, including hand hygiene, applied in the care of all clients; and when and in what circumstances to implement Additional Precautions (e.g., Droplet and Contact Precautions)
- How to manage client or unprotected staff exposures, signs and symptoms, or confirmed COVID-19
- Monitoring and evaluation of IPC practices and outcomes (e.g., hand hygiene compliance)
- Staff expected to participate in or be exposed to AGMPs must be fit-tested for an N95 respirator and be monitored for proper wearing, performing a seal check each time the mask is applied, and removal of N95 respirators according to the home care program's respiratory protection program
- Workflow practices to mitigate the risk of breaches in IPC (e.g., advance preparation of supplies needed for hygiene practices, to avoid risk of contaminating items)
- Limiting equipment brought into the home to that which is essential, minimizing contamination, and proper cleaning and disinfection
- Environmental cleaning, laundry, and waste management
- Proper storage of PPE (e.g., staff should bring adequate PPE with them to each visit, PPE should not be stored in a client's home, and a plastic-lined waste receptacle should be placed at the door exiting the home for disposal)
- Proper cleaning and disinfection of any reusable PPE
- Staff and clients are provided with information about COVID-19, how the virus causes infection, and how to protect themselves and others, including:
- The importance of hand hygiene and how to wash hands and how to use alcohol-based hand rub (ABHR)
- Instructions on respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow followed by performing hand hygiene)
- Instructions on how and where to dispose of used supplies
- Training on how to properly put on and take off PPE to avoid self-contamination
- Clients/household members and staff (when part of care plan) are directed to resources on environmental cleaning and disinfection.
- Staff have necessary PPE available to them at the point of care for all home care visits
- There is regular assessment to determine stock of necessary PPE (e.g. gloves, gowns, masks, face, or eye protection) and other necessary supplies including ABHR
- There is coordinated procurement of supplies with provincial or territorial buying groups to maximize access
- Staff ill, or with an exposure to someone with confirmed COVID-19, as defined by occupational health or their local public health department, or those otherwise determined to require self-isolation according to public health directives, must follow the policies of jurisdictional public health authorities to determine restrictions and when they can return to work
- All staff should ensure that:
- They adhere to organizational IPC policies and procedures and jurisdictional public health guidance
- Once daily, they self-monitor and immediately report any new signs or symptoms to the home care organization management
- Prior to working every shift, they report to the home care organization management if they have had potential unprotected exposure to a case of COVID-19
- They are knowledgeable about:
- How to conduct a PCRA prior to all interactions to determine what IPC measures are needed to protect clients and themselves from infection
- Routine Practices and Additional Precautions
- The use and limitations of the specific PPE available for their use
- Provincial/territorial online assessment/telephone tools (where offered) to facilitate and triage COVID-19 testing
- Where to get tested if they become symptomatic or if requested by local public health authorities or the home care organization
- They understand and participate in programs to conserve PPE
Home safety risk assessment
A trained staff member should conduct a home safety risk assessment to verify that the environment is suitable for providing the necessary level of care in the home. Assessment should verify:
- Whether the client and household members are capable of adhering to the recommended precautions such as hand hygiene, respiratory hygiene, environmental cleaning and limitations on movement within the home
- Household members maintain a physical distance of 2 metres from staff during the visit
- Safety concerns are addressed such as fire hazards and risk for accidental ingestion associated with ABHR
- The client has a means through which to communicate with their primary healthcare provider should their condition worsen
Screening and management
Home care organizations must ensure that there are processes in place to conduct active screening of staff and clients for symptoms or signs of COVID-19.
Home care organizations should liaise with jurisdictional public health authorities to determine the most rapid way to have COVID-19 testing of staff completed and reported, and for guidance on the indications for COVID-19 testing of clients and where this should be conducted.
Staff screening must include self-assessment for exposures, signs and symptoms of COVID-19 and a daily temperature check.
- If a staff member develops signs or symptoms of COVID-19 at work they should immediately perform hand hygiene, ensure that they do not remove their mask, inform their supervisor, avoid further client contact and leave as soon as it is safe to do so
- Staff experiencing any signs or symptoms (including mild respiratory symptoms) must be tested for COVID-19 and excluded from work, and advised to follow local public health guidance with regard to testing and further management
Home care organizations should work with public health authorities to manage and monitor exposed staff.
Home care organizations should ensure that there is a process in place for screening all clients and their household members by calling prior to every visit. This should include asking whether the client or any other member in the home has signs or symptoms of COVID-19 or is under investigation or confirmed to have COVID-19.
- Clients or household members with signs or symptoms of COVID-19 should be advised to self-isolate and contact their primary care provider or refer to local public health for further guidance
- Those experiencing more severe symptoms should be referred to emergent care
Client care and infection control measures
Point-of-care risk assessment (PCRA)
Prior to any client interaction, all staff have a responsibility to assess the infectious risks posed to themselves, the client, and any others from a client, situation or procedure.
- The PCRA is a routine practice that should be applied by all staff before every clinical encounter regardless of COVID-19 status and is based on the staff professional judgment (i.e. knowledge, skills, reasoning and education) made regarding the likelihood of exposing themselves and/or others to infectious agents, for a specific interaction, a specific task, with a specific client, and in a specific environment, under available conditions
- The PCRA helps staff to select the appropriate actions and/or PPE to minimize the risk of exposure to known and unknown infections
Staff are required to perform hand hygiene:
- On entry to and exit from the client's home
- Before and after contact with a client, regardless of whether gloves are worn
- After removing gloves
- Before and after contact with the client's environment (e.g., medical equipment, bed, table, door handle) regardless of whether gloves are worn
- Any other time hands are potentially contaminated (e.g., after handling blood, body fluids, bedpans, urinals, or wound dressings)
- Before preparing or administering all medications or food
- Before performing aseptic procedures
- Before putting on PPE and during removal of PPE according to organizational procedure for putting on or removing PPE
- After other personal hygiene practices (e.g. blowing nose, using toilet facilities, using tissues, etc.)
Clients should be trained to perform hand hygiene and be assisted with this if they are physically or cognitively unable. Clients should perform hand hygiene:
- Upon entering or leaving their home
- Prior to eating, oral care, or handling of medications
- After personal hygiene practices or use of toileting facilities
- Any other time hands are potentially contaminated (e.g. after handling wound dressings or bodily fluids, etc.)
Hands may be cleaned using ABHR containing 60-90% alcohol or soap and water. Washing with soap and water is preferable if hands are visibly soiled, or when caring for clients with Clostridioides difficile infection.
Routine Practices apply to all staff, at all times when providing home care and include but are not limited to:
- Conducting a PCRA
- Hand hygiene
- Appropriate use of PPE
- Adhering to respiratory hygiene (i.e., covering a cough with a tissue or coughing into elbow followed by performing hand hygiene)
Masking/eye protection for all staff providing care in the home for duration of visits
Given community spread of COVID-19 within Canada and evidence that transmission may occur from those who have few or no symptoms, masking for the full duration of visits for all home care staff is recommended. The rationale for full-visit masking of staff is to reduce the risk of transmitting COVID-19 infection from staff to clients or other household members, at a time when no signs or symptoms of illness are recognized, but the virus can be transmitted. Use of eye protection (e.g., a face shield) for duration of visits should be strongly considered in order to protect staff from COVID-19 transmission occurring in the community.
Staff should refer to local, provincial, or territorial guidance and facility policies on specific recommendations for use of masks, eye protection, and other PPE, and PPE conservation strategies.
When masks and face shields are applied for the full duration of visits, home care staff must:
- Perform hand hygiene before they put on their mask and face shield when they enter the home, before and after removal, and prior to putting on a new mask or face shield
- Wear a mask securely over their mouth and nose and adjust the nose piece to fit snugly
- Not touch the front of mask or face shield while wearing it or removing it (and immediately perform hand hygiene if this occurs)
- NOT dangle the mask under their chin, around their neck, off the ear, under the nose or place on top of head
- Remove masks just prior to leaving the home, while in an area where client or other household members are not present and discard in a waste receptacle followed by hand hygiene
- Remove full face shields just prior to leaving the home, while in an area where client or other household members are not present and dispose of or reprocess as per the home care organization's infection prevention and control guidance
- If masks with attached visors are used these should be removed and discarded in a waste receptacle
- Perform hand hygiene during and after PPE removal and between client encounters
It is a foundational concept in IPC practice, that masks should not be re-worn. However, in the context of the COVID-19 pandemic and PPE shortages, home care organizations and staff should follow jurisdictional guidance with regard to mask use, reuse, and reprocessing.
If re-use of masks is recommended, staff must remove their mask by the ear loops or elastics taking care not to touch front of mask, and carefully store the mask in a clean dry area and in accordance with organizational and jurisdictional public health guidance, taking care to avoid contamination of the inner surface of the mask, and perform hand hygiene before and after mask removal and before putting it on again.
Masks should be disposed of and replaced when they become damaged, wet, damp, or soiled (from the wearer's breathing or external splash), or when they come in direct contact with a client.
Staff should be informed of how to access additional masks as needed.
Droplet and Contact Precautions
Droplet and Contact Precautions should be implemented for all clients diagnosed with or presenting with new signs or symptoms of possible COVID-19
- Signs or symptoms may include:
- Fever (temperature of 38.0°C or greater), OR
- Gloves, long-sleeved cuffed gown (covering front of body from neck to mid-thigh), mask and face or eye protection should be worn upon entering the client's home or when within 2 metres of the client on Droplet and Contact Precautions. Examples of face or eye protection (in addition to mask) include full face shield, mask with attached visor, non-vented safety glasses or goggles (regular eyeglasses are not sufficient)
- PPE should be removed in the correct order and discarded into a waste receptacle when exiting the client's home
- Full face shields should be removed (disposed of or reprocessed as per the home care organization's IPC guidance) *If masks with attached visors are used these should be removed and discarded
- Hand hygiene should occur according to best practices for putting on or removing PPE
Aerosol-generating medical procedures (AGMPs)
An AGMP is any procedure conducted on a patient that can induce production of aerosols of various sizes, including droplet nuclei. AGMPs are rarely performed in home care settings.
Follow provincial or territorial guidance for procedures that require the use of an N95 respirator in addition to Droplet and Contact Precautions. This guidance may vary among provinces and territories.
Handling of client care equipment and laundry
Single-use disposable equipment and supplies should be used whenever possible, and discarded into a waste receptacle after each use. All reusable equipment (e.g. blood pressure monitor, thermometer) and supplies, along with toys, electronics, games, etc. should whenever possible be dedicated for use by one client and stored at their home.
Only essential equipment should be brought into the home. When it is necessary to bring equipment into the home, a disposable barrier will be utilized (i.e., a plastic bag) to prevent placing equipment directly onto surfaces in the home. This equipment may be kept in a plastic bag and hung from a hook while not in use.
Reusable client care equipment (e.g., BP monitor, stethoscope) should be cleaned first and then disinfected after each use, with a hospital grade disinfectant (e.g., disinfectant wipes) according to manufacturer's instructions and organizational protocols for cleaning and disinfection of reusable equipment.
Linen, towels, and clothing should be dedicated for use by one client. Machine wash all laundry at 60-90°C using regular laundry detergent and dry thoroughly.
Environmental cleaning and disinfection
The client, other individuals living in the home, and the home care support worker should be informed on environmental cleaning practices. Surfaces that are frequently touched (e.g., bedside tables, bedframes, and door handles) should be cleaned and disinfected daily.
For high-touch surfaces such as door handles, toys, and phones, it is recommended to use either:
- Regular household cleaners, or
- In the event that regular household cleaners are not available, use a diluted bleach solution to disinfect the environment
- Clean surfaces initially and disinfect with diluted bleach prepared according to the instructions on the label or in a ratio of 1 teaspoon (5 mL) per cup (250 mL) or 4 teaspoons (20 mL) per litre (1000 mL) assuming bleach is 5 % sodium hypochlorite, to give a 0.1 % sodium hypochlorite solution. (Health Canada's Hard-surface disinfectants and hand sanitizers for COVID-19).
Particular attention should be paid to cleaning and disinfecting the bathroom and toilet surfaces and the client care area. Any surfaces that become contaminated with respiratory secretions or other body fluids should be cleaned and disinfected as soon as possible. The virus that causes COVID-19 may be shed in stool; therefore, it is important to ensure that bathrooms are thoroughly disinfected.
Client and household member education
Clients and household members should be directed to appropriate national, provincial, territorial, or local COVID-19 resources pertaining to:
- The importance of hand hygiene and how to wash hands and how to use ABHR
- Instructions on respiratory hygiene (i.e., covering their cough with a tissue or coughing into their elbow followed by performing hand hygiene)
- How to safely and effectively care for a client with suspected or confirmed COVID-19 to prevent the infection from spreading to household contacts
- Instructions on how and where to dispose of used supplies
- The importance of not sharing personal hygiene items such as soap, cream or lotion, toothpaste, toothbrush, razor (or electric shaver), towel, skin, nail and other oral care items, including with family members.
Handling lab specimens
All specimens collected for laboratory investigations should be regarded as potentially infectious. Clinical specimens should be collected and transported in accordance with organizational policies and procedures. For additional information on biosafety procedures when handling samples from residents under investigation for COVID-19, refer to the PHAC's biosafety advisory.
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The National Advisory Committee on Infection Prevention and Control (NAC-IPC) is an external advisory body that provides subject matter expertise and advice to the Public Health Agency of Canada on the prevention and control of infectious diseases in Canadian healthcare settings.
This guideline was prepared by: Dr. Cheryl Volling, Anna Bottiglia, Dr. Marina Salvadori, Dr. James Brooks, & Dr. Marianna Ofner.
NAC-IPC members: Dr. Joanne Embree, (Chair), Dr. Jennie Johnstone (Vice-Chair), Ms. Molly Blake, Ms. Josiane Charest, Dr. Maureen Cividino, Ms. Nan Cleator, Ms. Jennifer Happe, Dr. Susy Hota, Ms. Anne Masters-Boyne, Dr. Matthew Muller, Ms. Patsy Rawding, Ms. Suzanne Rhodenizer Rose, Dr. Patrice Savard, Dr. Stephanie Smith, Dr. Nisha Thampi.
PHAC Healthcare-Associated Infections Prevention and Control Section: Dr. James Brooks (Director), Ms. Kathy Dunn (Manager), Ms. Katherine Defalco, Ms. Toju Ogunremi, Ms. Adina Popalyar, Ms. Anna Bottiglia, Ms. Sabrina Chung, Dr. Kahina Abdesselam, Mr. Steven Ettles, and Mr. John McMeekin.
The authors gratefully acknowledge the contributions of: Ka Wai Leung, Tara Leah Donovan, Victoria Power, Allyson Hankins, Joanne Archer, Josianne Charest, Nan Cleator and Darlene Campbell, scientific writer.
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