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

Supported by Missouri Organization of Nurse Leaders

Dates & Location

Wednesday, March 20, and Thursday, March 21

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

Register on or before Wednesday, March 6.

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 thanks to a generous 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 on Dec. 17.

Hotel Reservation

Online hotel registration:
Hotel cutoff date: Tuesday, Feb. 26
Group code: CACCACA (King) or CACCACB (Double Queen)
Request MHA Health Institute room rate:

  • king deluxe $119 + tax
  • double queen (two queen beds) $119 + 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.

CMS gives accrediting organizations the authority to deem hospitals in compliance with the Medicare CoPs. Det Norske Veritas (DNV GL Healthcare) is such an accrediting organization. Representatives of DNV will present their experiences surveying hospitals in the four states comprising CMS’ Region 7, which includes Missouri. They will present their insights on the top conditions and standards that cause problems for hospitals and suggestions to mitigate the risk of being found out of compliance.

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 CoPs and state licensure citations in Missouri and how to write an acceptable plan of correction, as well as how to handle problems with surveyors and disagreements about survey findings.

Learning Objectives

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

  • describe the CoPs requirements that are more problematic or challenging for hospitals in CMS’ Region 7
  • discuss the top survey findings and specific aspects that are not met as well as how these can be addressed
  • review upcoming changes in CMS and state regulations
  • discuss the perspective on the accreditation landscape and what is on the horizon
  • differentiate the DNV survey process from other accrediting organizations


Wednesday, March 20

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

8:45 a.m. — CMS’ and CoPs Regulations
Patrick Horine, MHA
DNV GL Healthcare
Milford, Ohio

Caroline Skrzypczak
Area Sales Manager - South
DNV GL Healthcare
Houston, Texas 

10 a.m. — Break

10:15 a.m. — CMS’ and CoPs Regulations (continued)
Patrick Horine, MHA
Caroline Skrzypczak

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

1 p.m. — CMS’ and CoPs Regulations (continued)
Patrick Horine, MHA
Caroline Skrzypczak

2:30 p.m. — Break

2:45 p.m. — CMS’ and CoPs Regulations (continued)
Patrick Horine, MHA
Caroline Skrzypczak

4 p.m. — Adjournment

Thursday, March 21

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

8 a.m. — CMS’ and CoPs Regulations (continued)
Patrick Horine, MHA
Caroline Skrzypczak

9:30 a.m. — Break

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

11 a.m. — Adjournment


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 Missouri.

Patrick Horine serves as the president of DNV GL Healthcare USA, Inc. He is responsible for the North American health care business of DNV GL, which includes a growing portfolio of standards-driven accreditation and certification services. DNV GL National Integrated Accreditation of Healthcare Organizations (NIAHO®) has attracted more than 500 hospitals, and is recognized for its unique design, which integrates Medicare compliance with the ISO 9001 Quality Management System.

Caroline Skrzypczak resides in Houston, Texas, and has been with DNV GL since 2018. She is an area sales manager and is responsible for 10 states (including Missouri) in the southern U.S. She supports hospitals in becoming accredited and certified. Skrzypczak holds a bachelor’s degree from Texas A&M University.

Sarah Willson has been in health care for more than 20 years. She has a bachelor’s degree in nursing from the University of Missouri Sinclair School of Nursing in Columbia, Mo. She has a Master of Business Administration Healthcare from William Woods University in Fulton, Mo. Willson’s background includes varied areas of clinical practice and more than 15 years of health care leadership and operational design experience. 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.

ACHE — MHA Health Institute is authorized to award 8.5 hours of pre-approved ACHE Qualified Education credit for this program toward advancement, or recertification, in the American College of Healthcare Executives. Participants in this program who wish to have the continuing education hours applied toward ACHE Qualified Education credit must self-report their participation. To self-report, participants must log into their MyACHE account and select ACHE Qualified Education Credit.

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 17, 2019. 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

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
 Patrick Horine, MHA  Nothing to disclose
 Caroline Skrzypczak  Nothing to disclose
 Richard Grindstaff, R.N.  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

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 MHI at 573/893-3700 before the meeting dates.