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 between 100,000 to 150,000 people will die from COVID-19 in the US. 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 the next two months, in particular, will be difficult depending on our response. 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 Plan
Since "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:
- Caring for the Deceased
- Operating the Crematory
- Business Support
- Serving the Living
- Managing Staff
- Directing the Funeral
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) 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. 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. 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:
- accept only cases in leak-proof, sturdy cremation containers per CANA Crematory Operations best practices
- the use of Standard Precautions should ensure safest possible work conditions. This includes PPE, as mentioned above, which is in short supply so follow optimize your use per CDC guidelines.
- clean all shared tools, equipment, and surfaces frequently - e.g. the cremation container, door or loader, refrigerator, door handles and light switches
- maintain social distancing between co-workers and other people who may enter the crematory
- Limit witnessed cremations to ten or fewer people total, including the funeral director and operator or other staff present.
Generally, viruses are killed above 200 degrees Fahrenheit, so the cremation process kills coronavirus. 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 size of groups to ten or fewer, but also consider bringing the urn and paperwork to the client in his or her 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.
With the Families First Coronavirus Response Act (FFCRA), passed March 18 and effective April 1, 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.
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 and availability.
Serving the Living
But don’t forget that the living are actually your primary audience, and the ones your staff come in to contact with every day. The CDC has more resources than just postmortem handling, and have special recommendations for the workplace in “Interim Guidance for Businesses and Employers to Plan 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:
- Wash your hands often, for at least 20 seconds.
Are you sick of singing the A, B, C’s while washing your hands? The good news is some other popular songs have 20-second choruses, including Landslide by Fleetwood Mac, Raspberry Beret by Prince, Jolene by Dolly Parton, Fever by Peggy Lee, Africa by Toto, Mr. Brightside by The Killers, and Truth Hurts by Lizzo. Mix it up and keep scrubbing.
- Avoid touching your eyes, nose, mouth, and ears.
- Cough and sneeze into a disposable tissue and discard it.
- Maintain at least six-feet (2-metres) around others, particularly sick persons.
When making arrangements or directing a funeral, these measures are important. The CDC now recommends "covering your mouth and nose with a cloth face cover when around others." 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. Shared work spaces include break rooms, vehicles, and any shared equipment.
And don't forget your four-legged staff. Some animals have tested positive for coronavirus, though it's unclear whether the virus can spread from pets to humans. To protect your pets and your community, the CDC recommends limiting their interactions as well.
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.
Unless asked in writing to do so by OSHA, the Bureau of Labor Statistics (BLS), or a state agency operating under the authority of OSHA or the BLS, Death Care Services are deemed as a low risk sector, 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 medical 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.
Directing the Funeral
And don’t forget that you also host community events with their own considerations. The CDC has special guidelines for “Mass Gatherings or Large Community Events” to help you plan and host safe services. Primarily, they recommend having supplies on hand to keep everyone healthy, namely hand sanitizer, soap, and tissues. Keep surfaces like door handles and light switches clean, and remember to talk to your community volunteers about being safe, too.
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.
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. New 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
Social media is flooded with images of empty store shelves, 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 information about Healthcare Supply of Personal Protective Equipment 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:
- All N95s in existing stock and those being manufactured now are sent to the Federal Emergency Management Agency (FEMA)
FEMA allocates supplies to each state’s Emergency Operations Center (EOC) based on need
Each EOC manages requests from entities within its respective state — including death care professionals
To place a request for N95s, you’ll need to contact your state’s EOC.
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.
Keep Calm and Wash Your Hands
Situations 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.
For the next few weeks, CANA Members are invited to join us for weekly 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)
Barbara Kemmis is Executive Director of the Cremation Association of North America.