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

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

This educational activity is jointly provided by AXIS Medical Education and MHA Health Institute.
AxisLogo_4ColorProcess MHA Health Institute Logo

Sponsored by Missouri Organization of Nurse Leaders

Dates & Location

Wednesday, March 21, and Thursday, March 22

Courtyard by Marriott
3301 LeMone Industrial Blvd.
Columbia, Mo.

Register on or before Wednesday, March 7.

MHA member — $375
Nonmember — $475

The registration fee 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 the MHA Management Services Corporation. This seminar also is eligible for use of the MHA Health Institute coupon. Coupons were mailed to MHA-member hospital CEOs in mid-December.

Hotel Reservation

Online hotel registration:
Hotel cutoff date: Wednesday, Feb. 28
Group code: CMSCMSA (King) or CMSCMSB (Double Queen)
Request MHA Health Institute room rate:

  • king deluxe $119 + tax
  • double queen (two queen beds) $119 + tax
  • one bedroom executive grand suite $173 + tax


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.


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.

Learning Objectives

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

  • review the final conditions of participation for emergency preparedness that were implemented Nov. 15, 2017
  • provide current awareness and findings of conducted CMS surveys that included these CoPs
  • 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


Wednesday, March 21

8 a.m. — Registration/Continental Breakfast

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

8:40 a.m. — CoPs for Emergency Preparedness: Summary and Available Resources
Jackie Gatz, MPA, CHEP
Vice President of Grant Management and Safety
Missouri Hospital Association
Jefferson City

9:40 a.m. — Break

9:55 a.m. — Decreasing Regulatory Burden in Hospitals: Big Changes in 2018 Panel Presentation
Jane C. Drummond, J.D.
General Counsel and Vice President of Legal Affairs
Missouri Hospital Association
Jefferson City

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

Jim Mikes, Sc.D., MPH
Vice President for Rural Advocacy and Regulation
Missouri Hospital Association
Jefferson City

Sarah M. Willson, MBA, BSN, CHPCA

10:55 a.m. — Regulatory Updates Part I
Richard Grindstaff, R.N.

11:55 a.m. — Lunch (provided) and Networking

1 p.m. — State Survey Update
Richard Grindstaff, R.N.

2:30 p.m. — Break

2:45 p.m. — Regulatory Updates Part II
Richard Grindstaff, R.N.

4 p.m. — Adjournment

Thursday, March 22

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

8 a.m. — Regulatory Updates Part III
Richard Grindstaff, R.N.

9:30 a.m. — Break

9:45 a.m. — Regulatory Updates Part III (continued)
Richard Grindstaff, R.N.

11 a.m. — Adjournment


Jane Drummond joined MHA in 2014 as the General Counsel and Vice President of Legal Affairs. Drummond provides a full range of legal support to MHA, its related organizations and boards. Her duties include health care compliance, corporate advice and judicial advocacy. Drummond also serves as liaison to a variety of legal professional groups involved in health care law and policy.

Drummond graduated from the University of Missouri School of Law in 2001. Since then, she has largely worked in the public policy arena, while gaining additional experience in private practice. She began her legal career as a health and employment law associate at Husch and Eppenberger (now Husch Blackwell). Based on her health law experience, she was appointed to the position of General Counsel for the Missouri Department of Health and Senior Services under Governor Matt Blunt. Drummond later served in that same capacity in the governor’s office. In 2007, Governor Blunt appointed her to serve as the director of DHSS, a cabinet-level position which she held through the end of the Blunt administration.

Drummond re-entered private practice in 2009, joining the Jefferson City firm of Schreimann, Rackers, Francka & Blunt. While there, she focused on employment-related services and litigation, largely for public entities.

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 has been working for DHSS for more than 12 years. He started his nursing career in acute care, which included emergency room, ICU and psychiatry. 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.

Jim Mikes is responsible for supporting Missouri’s critical access and rural hospitals located outside of the state’s eight major metropolitan areas with research and advocacy related to policy, operations and regulation. Mikes also serves as MHA’s resource for its post-acute care members. Mikes received a bachelor's of health science in respiratory therapy from the University of Missouri-Columbia, a master's of public health from St. Louis University and a doctorate of science from Tulane University in New Orleans.

Sarah Willson has been in health care over 20 years.  She has a Bachelor’s degree in Nursing from University of Missouri Sinclair School of Nursing in Columbia, Missouri.  She has a Master’s degree in Business Administration Healthcare from William Woods University in Fulton, Missouri. Willson’s background includes varied areas of clinical practice and over 15 years of health care leadership and operational design experience and she is certified in Hospice and Palliative Medicine.  She is a member of the American College of Healthcare Executives.

Continuing Education

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

Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and the MHA Health Institute. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation
AXIS Medical Education designates this continuing nursing education activity for 8.5 contact hours.
Learners are advised that accredited status does not imply endorsement by the provider or ANCC of any commercial products displayed in conjunction with an activity.

MCLE — The Missouri Bar has approved the program for 10.2 MCLE credit hours.

All Other Participants — A certificate of attendance for 8.5 clock hours will be provided.

Requirements for Credit:

  • Attend/participate in the educational activity and review all course materials.
  • Complete the CE Declaration form online by 11:59 pm ET Friday, April 6, 2018. Instructions will be provided. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation.
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.

AXIS Contact Information
For information about the accreditation of this program please contact AXIS at 954/281-7524 or

Disclosure of Conflicts of Interest
AXIS Medical Education requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by AXIS for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

 Name of Faculty or Presenter  Reported Financial Relationship
 Jane C. Drummond, J.D.  Nothing to disclose
 Jackie Gatz, MPA, CHEP  Nothing to disclose
 Richard Grindstaff, R.N.  Nothing to disclose
 Jim Mikes, Sc.D., MPH  Nothing to disclose
 Sarah M. Willson, MBA, BSN, CHPCA
 Nothing to disclose

The planners and managers reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

 Name of Planner/Manager  Reported Financial Relationship
 Rita F. Kay  Nothing to disclose
 Dee Morgillo, M.Ed., CHCP  Nothing to disclose
 Holly M. Hampe, D.Sc., R.N., MHA, MRM  Nothing to disclose
 Sarah M. Willson, MBA, BSN, CHPCA  Nothing to disclose
 Ronald Viggiani, M.D.  Nothing to disclose

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Americans With Disabilities Act
In compliance with the Americans With Disabilities Act, we will make every reasonable effort to accommodate your request. For any special requests, please contact the MHA Health Institute at 573/893-3700 before the meeting dates.