At the end of February, CANA hosted our annual Cremation Symposium in Las Vegas. That’s right, we encouraged people to travel to meet up with more than one hundred people and network in a popular tourist destination — it was a different time. Unsurprisingly, the topic of discussion on the floor was the coronavirus pandemic, or the spread of COVID-19. Fortunately, the US Center for Disease Control (CDC) has released guidelines with information on handling infected, or potentially infected, cases at your funeral home, crematory, prep room, etc. These preventative measures align with current best practices in the prep room or crematory (i.e. wear universal PPE, limit exposure to the disease, and clean all surfaces carefully) that protect you from everything from the common cold to tuberculosis. Current estimates suggest that more than 500,000 people will die from COVID-19 in the US by the end of February, an average of more than 10% more deaths than previous years (CANA released a special report on states' deaths and cremation rates). But your cases are not the only potential source of infection in your businesses. Of those that contract COVID-19, 80% are estimated to be mild which means they are more likely to transmit the disease. Experts are warning that rest of 2020 will be difficult depending on our response, and likely to continue until there is a readily available and adopted vaccine. With state and local governments setting the current restrictions and guidance, current and accurate information is important to track. Consider designating one staff member in your office as point person to monitor reports and updates from the CDC and your local jurisdictions, at least daily, to make sure your business is operating with the best information. As this post is updated, newest content will appear in gold to highlight latest information. So what do you need to know to prepare your business when an outbreak hits? make a business planSince "workers performing mortuary services, including funeral homes, crematoriums, and cemetery workers" have been officially listed as Essential Critical Infrastructure Workers, it is even more important to make sure your business is prepared for this challenge. Inform, educate, and train your staff of the CDC recommendations. Now that this post is getting so long, we've added a Table of Contents linking to information below: As a reminder, if there are federal and local orders/laws in conflict, follow the most restrictive to ensure that you comply with both, and ask for additional guidance and support as needed. Some resources to consider are: your state governor, local mayor, local health agency, as well as the Disaster Mortuary Operational Response Teams (D-MORT), Emergency Management Agencies (EMA) or Community Emergency Response Team (CERT) plus the Council of State and Territorial Epidemiologists (CSTE) and the National Association of County and City Health Officials (NACCHO). Be sure to check with health and government authorities any time you have questions to ensure safety and compliance for you, your staff, and your business. If you are designated an essential worker in an area under an enforced lockdown, consider carrying staff identification, state professional license, or some other information that demonstrates your status for ease of movement. CARING FOR THE DECEASED For any staff who handle the dead, the National Association of Funeral Directors (NFDA) and the Funeral Service Association of Canada (FSAC/ASFC) have useful resources for embalming, prep room, and removal staff in accordance with CDC guidelines (including specific guidelines for funeral homes) and OSHA guidance which clearly state recommendations for Personal Protective Equipment (PPE), transporting the deceased, and cleaning surfaces. Many authorities believe that cases and deaths are under-reported, so anyone coming in contact with the deceased should operate assuming that the case is positive. A new study finds that the novel coronavirus remains viable long after the death of the host, continuing to replicate for more than 35 hours afterward. Thus "we recommend all work on corpses be conducted according to guidelines recently published by the World Health Organization, especially in the framework of widespread death in pandemics." In the case of embalming, funeral homes are encouraged to follow families wishes assuming that the firm and embalmer have access to PPE and the time to embalm safely. Remember, as important as it is to wear PPE when handling the deceased, it is also important to follow the recommended sequence for putting on and removing the equipment. Cremation is a sure way to destroy any contagion on a deceased body, which is why it's preferred for Creutzfeldt-Jakob Disease and Ebola, but the WHO has stated that "people who have died from COVID-19 can be buried or cremated. Confirm national and local requirements that may dictate the handling and disposition of the remains." The CDC has not released definitive information on how long the coronavirus lives in a deceased body, but they do say that "there is currently no known risk associated with being in the same room at a funeral or visitation service with the body of someone who died of COVID-19." As always, families should do what's right for them, which can include caring for the deceased themselves. They can have funerals and burials as long as they follow their state and local mandates regarding the number of people and social distancing guidelines. OPERATING THE CREMATORY Most guidelines that have been released do not specifically mention the crematory or operator. The following assumes that the crematory operator does not come into direct contact with the deceased, rather handles the container. If the operator in your business handles the deceased, see above. CANA recommends the following:
Generally, viruses are killed above 200 degrees Fahrenheit, so the cremation process kills the coronavirus in fewer than three minutes. There is no concern about virus exiting the building via emissions through the stack or remaining in cremated remains, however the operator should wear PPE to ensure transmission from operator to urn does not occur. When releasing cremated remains to the family, limit the size of groups to ten or fewer, but also consider bringing the urn and paperwork to the client waiting in the car. Try to minimize physical paperwork with electronic documents and signatures, or providing gloves, to cut back on touching paper. Similarly, keeping clearly marked sanitized and used pens to take and return for cleaning will cut back on multiple use. In this pandemic situation, some crematories are concerned about regulations which limit the cremations a business can perform. CANA is supporting state associations who are working with these regulators to address these permits in the hardest hit areas. BUSINESS SUPPORT With the Families First Coronavirus Response Act (FFCRA), passed March 18 and effective April 1 through December 31, 2020, businesses have new requirements for managing staff. All employers with 500 or fewer employees must provide paid Family Medical Leave Act (FMLA) leave and paid sick leave – this is new for those who manage companies with fewer than 50 employees who were previously exempt from such requirements. The Department of Labor, Wage and Hour Division has required posters and useful information to communicate with your staff. Once the FFCRA-mandated leave expires on December 31, 2020, employers with 500 or less employees are no longer compelled to provide emergency paid sick leave (EPSL) or expanded FMLA (EFMLA) to eligible employees. Instead, a covered employer may voluntarily continue to provide EPSL or EFMLA leave and receive the tax credit. The tax credit availability for those employers that choose to continue to provide FFCRA leaves is now set to expire on March 31, 2021. As an employer who was previously exempt, this could be overwhelming, so it’s important to open lines of communication with your staff and establish a clear chain of command to address rapidly developing information. Don’t assume that all staff will immediately take advantage of these benefits and leave the business in a time of crises. Provide guidance and support in addition to addressing their concerns about what to do if they or a family member get sick. Don’t be afraid of questions or to admit that you don’t know. Importantly, communicate often to make sure staff are okay and keep lines of communication open. The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed March 27 and retroactively effective to February 15, 2020, offers financial assistance to small businesses and large corporations alike. The US Senate Committee on Small Business & Entrepreneurship has provided the Small Business Owner’s Guide to the CARES Act resource. If your business is having financial difficulty, you can apply for relief through the Payment Protection Program (PPP) with the US Small Business Administration (SBA) and your current bank. Alternately, you can seek support from the Employee Retention Credit (ERC), however a business cannot receive both the PPP and the ERC. To better understand how both resources effect your business, CANA recommends contacting services who manage and administer your payroll, business insurance, health insurance, preneed providers, and bank. These are groups carefully monitoring how these regulations and opportunities impact your work in your area, and know your business best. For those in need of extra staff support, state associations in hard-hit areas and the NFDA have organized volunteer programs to help. Reach out to these associations with your need or availability. SERVING THE LIVING But don’t forget that the living are actually your primary audience, and the ones your staff come into contact with every day. The CDC has special recommendations for the workplace in “Guidance for Businesses and Workplaces to Plan, Prepare, and Respond.” Many of the roles at a funeral home, like funeral directors, embalmers, crematory operators, don’t do the kind of jobs that let you work from home. We cannot access the prep room from our living room, or arrange with families from our beds. So encouraging proactive measures to keep employees well, then being flexible when people are ill, is key to keeping your staff and the community safe in any outbreak. By now, everyone knows the top four guidelines on personal safety:
When making arrangements or directing a funeral, these measures are important. The CDC provides guidance on the risk of different types of funeral services to help families make the right decision for themselves. Included in the list of protective steps, the CDC now recommends, and many states mandate, "covering your mouth and nose with a cloth face cover when around others." With the spread of new, aggressive variants, the CDC also recommends some masks be doubled for extra protection. As of January 20, 2021, masking, social distancing, and other precautions are required on federal land including Veterans Cemeteries. Of course, the most vulnerable populations are typically older generations and those with pre-existing conditions (including smokers). If a staff member is concerned that they have been exposed, the CDC has issued guidelines for Safety Practices for Critical Workers which include frequent temperature readings, mask wearing, and frequent disinfecting of work spaces. The CDC and Environmental Protection Agency (EPA) have released joint guidance on appropriate disinfectants and cleaners. Shared work spaces include break rooms, vehicles, and any shared equipment. The CDC has developed a toolkit with language and posters you can use to communicate with your staff. And don't forget your four-legged co-workers. Some animals have tested positive for the coronavirus, though it's unclear whether the virus can spread from pets to humans. To protect your pets, service animals, and your community, the CDC recommends limiting their interactions as well. COVID-19 FUNERAL ASSISTANCE Starting Monday, April 12, 2021, the Federal Emergency Management Agency (FEMA) will accept applications for financial assistance to families who have lost loved ones to COVID-19 since January 20, 2020. Families must meet the eligibility requirements and must have appropriate documentation to make a claim. Some of this documentation comes from the funeral home, crematory, cemetery, or supplier that served them, so be prepared for requests for duplicate invoices, death certificates, and other support from your families. This program is a fantastic resource to US citizens and other qualified residents who were faced with the unexpected expense of the death of a loved one. You may choose to be proactive and reach out to the families you have served since January 20, 2020 to offer help in determining eligibility or offer receipts and paperwork. The FEMA COVID-19 Funeral Assistance webpage provides detailed instructions, FAQ, and requirements to help in addition to guidance on spotting fraudulent scams claiming to offer assistance. For those families who delayed services or interments, it is advisable they make those plans and purchases prior to submitting their application, since they are eligible for one reimbursement only. This is the largest scale death benefit program FEMA has administered so patience and persistence will be helpful. FEMA will release more information in the coming days and weeks and CANA will report to you as the details become available. MANAGING STAFF In the event that someone does get sick, encourage them to stay home. This is a difficult argument to make with the existing workforce shortage on top of a potentially growing caseload, because these jobs rely on you being in person to serve your families. But with the COVID-19 pandemics, you cannot serve your community while being sick yourself. Sick employees need to stay home to recuperate and be well, but also to prevent the spread of disease in the community. As the disease continues to spread, you may encounter employee shortages from illness, school closures, and caring for loved ones. Your business must have a plan for what you will do if you have too few staff. Death Care Services are deemed as a low risk sector, and typically exempt from reporting to OSHA, the Bureau of Labor Statistics (BLS), or state agency incidents of illness, however CANA Member Regulatory Support Services recommends making a record of all work-related illnesses and injuries and placing that record in the affected employee’s file. For confirmed cases of COVID-19 or an employee that shows symptoms of COVID-19, this would include the employer’s directive to an ill employee that he or she does not return to work until cleared to do so by health care professional. The challenge with COVID-19, or any infectious disease for that matter, is knowing with absolute certainty that an illness is a result of exposure in the workplace. Especially with the high communicability of the coronavirus, sources of exposure outside the workplace must be considered when assessing whether to report any fatality or hospitalization of an employee as a result of contracting COVID-19. However, some states are presuming that any essential worker who contracts the disease to have become infected at work thus making them eligible for worker compensation. Check your state's department of labor for any specific requirements. The federal, state, and local health authorities have recommendations on reducing spread in the workplace including isolation and quarantine periods. In some cases, this could mean a note from a doctor about when it's safe for an infected employee to return to work. Plus, recommendations vary between health agencies with frequent changes. Stay informed on these protocols and update policies. Then, once expectations are set, you need to follow them while maintaining privacy. Remember that it can be obvious who is sick when they need shifts covered, but you can never explicitly confirm a diagnosis of an employee. If you have concerns that staff may take advantage of policies, reach out to a labor attorney to discuss options and risks. Staff morale suffers when colleagues become ill or need to quarantine: fear for their colleague's and their own health, resentment of working to cover extra shifts, stress and exhaustion from a long pandemic, and more. Team-building is never more important than in a crisis. Like the military, we're not protecting ourselves for us, but also for the person working beside you, and the people at home. Whatever you can do to build team cohesion will benefit everyone in the short- and long-term. A Note about Vaccines: The federal government can mandate vaccination, but is unlikely to do so. Individual states/provinces are allowed to mandate vaccination, especially for specific licenses, but this will be determined on their own timelines and dependent on availability of the vaccine. It's currently unknown if employers can require staff be vaccinated, but it's unlikely, particularly since the experimental COVID-19 vaccines are initially approved for emergency, not widespread, use. If you are considering requiring staff get the vaccine, contact a labor attorney to discuss feasibility and risk-benefit analysis. VACCINE AVAILABILITY At the end of 2020, vaccines to protect people against the novel coronavirus began to receive authorizations by governments around the world. The rollout and availability of the vaccines has left many confused on who is eligible, how to get vaccinated, and where to get the shot. Your state and local associations are great resources for information on when funeral home, cemetery, and crematory employees (licensees and also those who coordinate the proper recovery, handling, identification, transportation, tracking, storage, and disposal of human remains) are eligible to get vaccinated. In many cases, vaccinations are distributed by county governments under direction from state governments. The federal government has designated all mortuary staff as essential workers as part of the critical infrastructure of public health. For US practitioners, one CANA member shared this list of Statewide Vaccination Plans with details on vaccination phases and registration enrollment websites for each state. This list provides links to state's government websites to see the latest information. Your state and local associations are additional great resources since they have connections to state and local governments to learn the latest information and advocate on your behalf. Unfortunately, CANA Members report that staff have been turned away from vaccination centers, despite being eligible. In some cases, one facility will refuse but another will administer the shot. In one area, we learned that mortuary workers are eligible, but were instructed to register as another licensee since "funeral director" was left off the list. In addition to registering for the vaccination, bringing your government-issued identification and health insurance card, CANA also recommends bringing proof of employment at a death care facility. Let us know about your perspective on the vaccination process and experience in our pulse poll. If you and your colleagues have questions about the vaccines themselves, you can read more about the program, the testing, and possible side effects on the CDC's website. CANA Members who have received the vaccine, report typical vaccination side effects like soreness in the arm and fatigue. Remember: when you and your team have all been vaccinated, PPE is still an important part of keeping your loved ones and your entire community safe. Current vaccines require two doses given several weeks apart to reach full protection, and neither dose is immediately effective but require time to build up in your system. After which, the CDC has stated that the long-term efficacy of the vaccine is still unknown and that the vaccinated or "naturally immune" from previous infections may still carry live virus. Not to mention that standard PPE will always be recommended for backroom positions handling the dead. Please continue to wear PPE. DIRECTING THE FUNERAL And don’t forget that you also host community events and services with their own considerations. The CDC has special, updated guidelines for “Mass Gatherings or Large Community Events” to help you plan and host safe services. Primarily, they recommend having posters and signs in addition to supplies on hand to keep everyone healthy, namely hand sanitizer, soap, tissues, and face coverings. Keep surfaces like door handles and light switches clean, and remember to talk to your community volunteers about being safe, too. The CDC even has a toolkit with posters and language you can use to communicate safe practices to your attendees. Enforcing best practices can be challenging with frequently changing information and fear of the unknown. Set a policy to protect your staff and visitors that includes your federal, state/provincial, and local requirements for safety of gatherings. Then, since there is nothing worse than having something in writing that sounds great but is not followed in practice, you must implement the plan, communicate it, train staff on it, and enforce it. Once you've set a standard, you don’t want to have to play funeral cop — but you also don’t want to let expectations slip. But scenarios are never simple—you can be reasonable and sensitive to the situation. Visitors are not employees, so you don’t have the same ability to enforce rules, but posting signs and agreements prove to the government agency(ies) that you are encouraging compliance, along with your documented protocols for family interactions. Consider investing in conflict resolution and de-escalation training for staff to make these conversations easier. Depending on your location, you have state and local restrictions, and your business can be held legally responsible for violations, not the individual or family who is violating the order. But more than legal repercussions, ask yourself: Do I want to be in the news for hosting a superspreader event? Given how readily this virus spreads, it can happen too easily and then you're facing two crises—the increased calls from the pandemic and a public relations battle. Consider your community's trust and develop policies to comply. With increasing emphasis on mitigating the spread of COVID-19, in areas with active outbreaks, the CDC recommends community-based interventions including "event cancellations, social distancing, and creating employee plans to work remotely," careful planning and communications with your families is important. Social distancing, in particular, runs counter to the spirit of the funeral by discouraging gatherings of more than 10 people, encouraging vulnerable populations to stay away, and avoiding direct contact with others. Fortunately, you are professionals trained in talking to families with compassion and understanding. For ideas on making your communications meaningful, watch a free, on-demand webinar from Lacy Robinson with " Practical Ways to Serve Families During COVID-19." Now that federal guidelines from the White House have sunset, state governors' and state and local health authorities are determining how businesses and communities can operate — you can find this list of resources above. In some areas, any visitation or service has been prohibited. White House guidelines to reopen businesses and services is recommended in multiple phases to keep employees healthy, prevent spread, and moderate hospital cases and is helping states set their own reopening procedures. These recommendations will require your business to develop plans and policies to accommodate your families' preference for service while maintaining the health of your community. Guidance from the CDC for consumers is written to help you educate your families on ways to hold services safely and the importance of taking social distance guidelines safely. Ceremony expert Glenda Stansbury provided a free resource to help you and your families find creative solutions, such as livestreamed services, to protect your business and the communities you serve. Grief expert Dr. Alan Wolfelt shared his suggestions on holding some form of ceremony at the Center for Loss blog. Develop a plan with recommendations from the CDC including how to communicate with relevant parties. Mostly, be in touch with state and community partners to help respond to changing needs of your community. Working together facilitates communications, response planning, and organizing when the need arises. The Council of State and Territorial Epidemiologists (CSTE) has a list of who to contact at the state-level and the National Association of County and City Health Officials (NACCHO) is a good resource for local-level needs. These are great new additions to your connections with first responders, hospices, and other community leaders. KEEP SUPPLIES STOCKED PPE and other safety materials have been difficult to source, so it’s a good idea to take stock of the goods you use frequently and make sure you have supplies. For those that are concerned about PPE supplies, the CDC has recommendations for Optimizing the Supply of PPE and and OSHA has issued interim guidance which brings their enforcement more in line with CDC recommendations. The CDC has also provided a PPE Burn Rate Calculator to help facilities to plan and optimize the use of PPE. Also, reach out to suppliers, even those outside of mortuary supply, if your need is severe. As a final resort, reach out to your local health authority, coroner, or medical examiner to explain your need and ask for recommendations. One CANA Member suggested ordering smaller quantities to prevent large orders being flagged and redirected. CANA Member Bass-Mollett shared their hard work finding the answer on how to request N95 masks as it was explained to John Flowers, CEO of Bass-Mollett:
The National Institute for Occupational Safety and Health (NIOSH) has issued recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators which suggests that equipment be alternated and discarded when damaged or dirtied. Some recommendations suggest to avoid wearing cosmetics, which could dirty the mask and reduce its effectiveness faster. Review the OSHA Standards on N95 respirators to ensure safety for staff and compliance for the business. Complaints about lax compliance have risen against health care facilities recently with fines in the millions of dollars, so review your policies and make sure staff are following them before a complaint can be made against your business. keep calm and wash your handsSituations like this, in times of increased caseloads and illness, require flexibility, patience and planning which is why you need to have these discussions and plans now. Like the radiation case study in 2019, we want to help you plan, be safe, and prevent panic and misinformation. As information continues to change rapidly, the best resource for the most current information on your business operations is your local government and health authority. Predictions say that "prolonged or intermittent social distancing may be necessary into 2022." Preparing now for the virus's resurgence in the Fall and Winter means you can protect yourself and your business with proactive plans and preventative measures. Situations like this also require extra care for yourself and your colleagues. "Stress prevention and management is critical for responders to stay well and to continue to help in the situation." Use the support resources from the CDC available by both call and text, and work together to stay healthy. Jason Troyer, PhD., specializes in helping death care professionals serve their families better. He wrote a post for us about taking care of yourself in these ever-changing times. Additional resources unique to death care are available in his Finding Resilience program. Thank you for the work you do. resourcesFor the next few months, CANA Members are invited to join us for monthly Open Forums to discuss how they're handling their response to COVID-19 and supporting their community. Check your inbox for instructions to join, or contact Membership Manager Brie Bingham for more information. US CENTER FOR DISEASE CONTROL (CDC)
US OCCUPATIONAL SAFETY AND HEALTH ADMINISTRATION (OSHA)
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