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Key Elements of Non-Compliance: F-Tag 880


Since the beginning of the COVID-19 Public Health Emergency (PHE), Covenant Health Network has remained vigilant in assessing the needs of our network members, residents, staff, and families. While our network has always focused on ensuring the Health, Safety and Regulatory Compliance of all, we like CMS, must continue to take a more targeted approach to Infection Prevention and Control. There are currently nine federal tags as it relates to Infection Prevention and Control Programming (IPCP). Please see select elements of non-compliance below for F-tag 880 IPCP.

F-tag 880: The facility failed to:

  • Establish and Maintain an Infection Prevention & Control Program (IPCP) that is designed to provide a Safe, Sanitary, & Comfortable Environment.

Prevent the Development and Transmission of Disease and Infections.

  • The IPCP must be reviewed at least annually and revised and/or updated as necessary.

  • The facility must Implement Systems for:

    • PREVENTION

    • IDENTIFICATION

    • REPORTING

    • INVESTIGATING

    • CONTROLLING

Infections & Communicable Diseases for: RESIDENTS, STAFF, VISITORS, VOLUNTEERS, AGENCY STAFF.

  • The IPCP must be based the “FACILITY ASSESSMENT” (see 483.70(e).

  • The IPCP Systems must follow Current National and Individual State Standards.

  • The facility must Develop and Implement current Written Infection Prevention and Control Standards, Policies, Procedures.

All written Policy and Procedures must be based on Current National and State Standards.


All Staff must Handle, Store, Process, and Transport Laundry to Prevent the spread of Infection.

The facility must maintain a System for Recording identified incidents and taking appropriate corrective actions.


Here’s hoping you and your family are healthy and Safe during these uncertain and unprecedented times,


If more information is needed, please do not hesitate to contact Trish Manchester at pmanchester@covenanthealthnetwork.org or call 603-287-0484.

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