Acute Care Hospitals — CMS’ Hospital CoP and State Licensure Regulations

Contact Our Team

Seminar

Date:3/22/2017
Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional:
Additional Information
Description:

Provided by MHA Center for Education
 

Supported by Missouri Organization of Nurse Leaders
 


Dates & Location

Wednesday, March 22, and Thursday, March 23, 2017

Add to Calendar

Camden on the Lake
2359 Bittersweet Rd.
Lake Ozark, Mo.
573/365-5620

Register on or before Wednesday, March 15.

MHA-member — $375
Nonmember — $475

Registration includes continental breakfast, lunch, refreshments and program materials. This seminar is being offered at a reduced registration fee to MHA-member hospitals because of a contribution from MHA Management Services Corporation.


Hotel Reservation

Request MHA Center for Education room rate:

  • king deluxe $123 + tax
  • one bedroom king grand suite $153 + tax
  • one bedroom executive grand suite $173 + tax

Group code: MHAC0317
Hotel cut-off date: Tuesday, Feb. 21


Audience

CEOs; CNOs; COOs; CFOs; chief medical officers; physicians; nurse executives, nurses and nurse managers; risk managers; patient safety officers; health care attorneys; compliance officers; directors and managers of pharmacy, quality, accreditation, health information management, medical records, social work, dietary, radiology, emergency department, outpatient, surgical services, laboratory, infection control, safety and security, and facility management; TJC coordinators; policy and procedure committee members; ethics committee members; any staff responsible for ensuring compliance with CMS CoPs.


Purpose

Every hospital that accepts payment for Medicare and Medicaid patients must comply with the Centers for Medicare & Medicaid Services’ Conditions of Participation and the Missouri hospital licensure statutes and regulations. CMS’ CoPs and interpretive guidelines for hospitals provide surveyors with a tool to assess a hospital’s compliance with applicable federal regulations. Understanding the CoPs will allow a hospital to maintain a constant level of survey readiness.

Participants will gain an understanding of the survey process, and additional state and federal requirements for distinct part units. Participants also will hear from a surveyor’s perspective on what constitutes a standard, condition or immediate jeopardy level citation, and how to avoid an immediate jeopardy citation. Faculty will discuss actual case examples of the top CoP and state licensure citations in Missouri, how to write an acceptable plan of correction, as well as how to handle problems with surveyors and disagreements about survey findings. Representatives from CMS and the state will present and be available for questions.


Learning Objectives

Upon completion of this program, participants will be able to:

  • describe the CMS' CoP survey
  • describe the standards that health care organizations must meet to achieve compliance
  • discuss the importance of the physical environment to the patient care experience
  • discuss the clinical laboratory improvement amendments
  • discuss the survey process and different aspects of the regulatory system
  • identify how to have open communication during the survey process and beyond
  • recognize how to work through survey issues with the Missouri state agency and CMS

Agenda

Wednesday, March 22

8 a.m. — Registration/Continental Breakfast

8:30 a.m. — Welcoming and Overview
Sarah M. Willson, MBA, BSN, CHPCA
Vice President of Clinical and Regulatory Affairs
Missouri Hospital Association
Jefferson City

8:40 a.m. — Preparing for an On-site Review of CMS’ CoP
Michele Kala, M.S., R.N.
Nurse Surveyor
Carol Roesch, MBA, BSN, R.N.
Nurse Surveyor
Healthcare Facilities Accreditation Program
Chicago

10 a.m. — Break

10:15 a.m. — Preparing for an On-site Review of CMS' CoP (continued)
Michele Kala, M.S., R.N.
Carol Roesch, MBA, BSN, R.N.

11:45 a.m. — Lunch (provided)

12:30 p.m. — Preparing for an On-site Review of CMS' CoP (continued)
Michele Kala, M.S., R.N.
Carol Roesch, MBA, BSN, R.N.

2:15 p.m. — Break

2:30 p.m. — Preparing for an On-site Review of CMS' CoP (continued)
Michele Kala, M.S., R.N.
Carol Roesch, MBA, BSN, R.N.

4:30 p.m. — Adjournment

Thursday, March 23

7:30 a.m. — Registration/Continental Breakfast

8 a.m. — Preparing for an On-site Review of CMS' CoP (continued)
Michele Kala, M.S., R.N.
Carol Roesch, MBA, BSN, R.N.

9:15 a.m. — Break

9:30 a.m. — New CoPs for Emergency Preparedness: Summary and Available Resources
Jackie Gatz, MPA
Vice President of Grant Management and Safety
Missouri Hospital Association
Jefferson City

9:45 a.m. — State Survey Update
Richard Grindstaff, R.N.
Chief, Bureau of Hospital Standards
Missouri DHSS’ Bureau of Hospital Standards
Jefferson City

10:15 a.m. — CMS Update
Julie Metz, BSN, R.N.
Nurse Consultant
Centers for Medicare & Medicaid Services
Midwest Consortium Division of Survey, Certification & Enforcement
Kansas City, Mo.

Captain Victoria Vachon, MBA/MSN, R.N., NE-BC
Non Long Term Care Branch Manager, Region VII
Centers for Medicare & Medicaid Services
Midwest Division of Survey & Certification
Kansas City, Mo.

11:30 a.m. — Adjournment

Faculty

Michele Kala, M.S., R.N.
Nurse Surveyor
Healthcare Facilities Accreditation Program
Chicago

Michele Kala is a nurse surveyor who has more than 40 years of experience in clinical and administrative health care. She has worked for the Healthcare Facilities Accreditation Program for more than nine years, four of which were as manager of accreditation services. HFAP, the nation’s oldest hospital accreditation organization, has been authorized by CMS to accredit health care facilities for compliance with CMS standards since the beginning of Medicare in 1965.

Kala has been trained as an HFAP nurse surveyor under the following accreditation manuals: Accreditation Standards for Acute Care Facilities, Accreditation Standards for Ambulatory Surgical Centers, Accreditation Standards for Critical Access Facilities and Accreditation Standards for Ambulatory Care Facilities. Additionally, she currently provides HFAP central office support in the review of standards and other accreditation-related functions.

Jackie Gatz, MPA
Vice President of Grant Management and Safety
Missouri Hospital Association
Jefferson City

Jackie Gatz is responsible for the oversight and strategic operations of a subcontract for the federal Hospital Preparedness Program. She leads several initiatives to increase hospital surge capacity while developing a sustainable program to ensure continuity of safe and quality health care. This includes, but is not limited to, providing technical assistance to Missouri hospitals and facilitating the development and operation of five nonurban health care coalitions — regional collaboratives for emergency preparedness and response coordination. Gatz serves on the executive committee for the American Hospital Association’s Emergency Readiness Group.

Richard Grindstaff, R.N.
Chief, Bureau of Hospital Standards
Missouri DHSS’ Bureau of Hospital Standards
Jefferson City

Richard Grindstaff has been working for DHSS for more than 12 years. He started his nursing career in acute care which included emergency room, ICU and psychiatrics. Grindstaff was a long-term care surveyor for more than 12 years. In 2016, he was promoted to Chief of the Bureau of Hospital Standards, overseeing regulations and licensure of all hospitals in the state of Missouri.

Carol Roesch, MBA, BSN, R.N.
Nurse Surveyor
Healthcare Facilities Accreditation Program
Chicago

Carol Roesch has more than 37 years of experience as a registered nurse in both clinical and administrative positions. She has more than five years of experience as a nurse surveyor working with the Healthcare Facilities Accreditation Program. Roesch has been trained as a HFAP surveyor under the following accreditation manuals: Accreditation Standards for Acute Care Facilities, Accreditation Standards for Critical Access Facilities and the Accreditation Standards for Ambulatory Surgery Centers. In addition, she has been trained as a HFAP certification reviewer under the Certification Standards for Primary Stroke Certification.


Continuing Education

Participants must attend the program in its entirety and complete an evaluation form to receive a certificate of attendance and continuing education contact hours.

Registered NursesThe following nursing contact hours will be awarded until Friday, March 31:
6.5 contact hours for Wednesday, March 22
2.25 contact hours for Thursday, March 23

The MHA Center for Education is an approved provider of continuing nursing education by the Midwest Multistate Division, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

Midwest Multistate Division approval as a provider is awarded to the MHA Center for Education in recognition of its ability to provide quality educational activities. Approved provider status does not include approval or endorsement of any commercial products at this educational activity. All planners, content experts and presenters participating in continuing education activities provided by the MHA Center for Education must adhere to a fair, unbiased and evidence-based approach to presenting content and must declare any relationships with commercial organizations.

All Other Participants — A certificate of attendance for 10 clock hours will be awarded.