CMS Hospital CoPs and State Licensure Regulation Updates for Acute and Critical Access Hospitals

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Date:3/17/2020
Start Time:12:00 AM
End Time:12:00 AM
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Understanding Federal and State Hospital Regulations 101


In light of recent public health guidance related to large, in-person events and hospital restrictions on staff travel, the MHA Health Institute has decided to cancel in-person attendance at CMS Hospital CoPs and State Licensure Regulation Updates for Acute and Critical Access Hospitals.

Because the information provided at this seminar is vital to hospital operations, we will record presentations and will make those recordings available to those who are registered. If access to the presentations is not desired, contact MHI to cancel registration.

After the recordings are available, registrants will have the opportunity to participate in a live Q&A webinar. Additional details will be shared as they are available.

The hotel has been notified, and all hotel reservations associated with this event have been canceled.

Thank you for your patience and partnership as we respond to this critical situation for hospitals and communities.


This educational activity is provided by MHA Health Institute.
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Supported by Missouri Organization of Nurse Leaders.
 



Preconference — Understanding Federal and State Hospital Regulations 101

Preconference Audience

directors of compliance, directors of risk management, directors of accreditation, directors of nursing and directors of quality


Preconference Purpose

This preconference session provides the audience with an overview of the regulatory and survey environment for state hospital licensure and CMS certification. The session will provide an overview of the survey process, considerations in writing a plan of correction, as well as regulatory and survey resources available to hospitals.

Preconference Learning Objectives

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

  • discuss how to navigate through the CMS 2567 form
  • identify the required components of a corrective action plan


Preconference Agenda

4:30 p.m. — Welcome and Overview
Sarah M. Willson, MBA, BSN, CHPCA
Vice President of Clinical and Regulatory Affairs
Missouri Hospital Association
Jefferson City

4:45 p.m. — Federal Hospital Regulations
Sarah M. Willson, MBA, BSN, CHPCA

5:15 p.m. — State Hospital Regulations
Jane Drummond, J.D.
General Counsel and Vice President of Legal Affairs
Missouri Hospital Association
Jefferson City

5:45 p.m. — Break

6 p.m. — Overview of Survey Process and the CMS 2567
Lynn Rasnick, MSN, BSN, RNC
Administrator and Manager of Risk & Regulatory Compliance
Parkland Health Center Bonne Terre
Bonne Terre, Mo.

Lisa Riggs, MSN, APRN-BC, CCRN-K
Director of Regulatory Readiness
Saint Luke’s Health System
Kansas City, Mo.

Sarah M. Willson, MBA, BSN, CHPCA

Sarah Yelton, R.N., CPHQ, HACP, LSSGB
Quality Resource Analyst
Saint Luke’s Hospital of Kansas City
Kansas City, Mo.

7 p.m. — Navigating Resources
Sarah M. Willson, MBA, BSN, CHPCA

7:30 p.m. — Adjournment


CMS Hospital CoPs and State Licensure Regulation Updates for Acute and CAH

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. Faculty will discuss case examples of the top CoPs 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:

  • discuss the top survey findings and specific aspects that are not met, as well as how these can be addressed
  • review recent changes in CMS and state regulations
  • discuss the current update for construction
  • discuss the current updates for life safety codes
  • discuss the 2020 changes in the federal and state regulations


Conference Agenda

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
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altoona, Iowa

10 a.m. — Break

10:15 a.m. — CMS and CoPs Regulations (continued)
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

1 p.m. — CMS and CoPs Regulations (continued)
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

2:30 p.m. — Break

2:45 p.m. — CMS and CoPs Regulations (continued)
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

4 p.m. — Adjournment

Conference Agenda

8 a.m. — CMS and CoPs Regulations (continued)
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

9:45 a.m. Break

10 a.m. — Life Safety Code
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

11 a.m. — Construction Updates
Carrie Brixey
Architect
Missouri Department of Health and Senior Services
Jefferson City

David East
Mechanical Engineer
Missouri Department of Health and Senior Services
Jefferson City

Noon — Special Message from Bureau Chief Richard Grindstaff

1 p.m. — CMS COPs Regulations (continued)
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

2:30 p.m. — Break

2:45 p.m. — CMS and CoPs Regulations (continued)
Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC

4 p.m. — Adjournment

Faculty

Carrie Brixey received her Bachelor of Architecture at the University of Arkansas-Fayetteville. After gaining practical experience working in various cities and states as both an intern and a licensed professional, she found a home with the Missouri Department of Health and Senior Services. She enjoys reviewing the health care facilities, particularly working with the designers and facilities.

David East received his Bachelor of Science in mechanical engineering from University of Missouri — Columbia. He has been working for the Missouri Department of Health for 13 years.

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 largely has 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 Gov. Matt Blunt. Drummond later served in that same capacity in the governor’s office. In 2007, Gov. 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 reentered 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.

Richard Grindstaff has been working for Missouri Department of Health 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.

Lynn Rasnick has been in health care for 38 years and a nurse for 32 years. Her background includes maternal-child nursing such as labor and delivery, neonatal intensive care/neonatal transport, pediatric emergency department, nursing management, travel nursing, quality management, performance improvement engineer/project management, Lean Six Sigma Black Belt, and director of maternal/child nursing for a large home care agency serving the east coast of south Florida. She is the administrator of Parkland Health Center Bonne Terre, which is a three-bed critical access hospital and has oversight for risk management, patient safety, compliance/privacy liaison and regulatory compliance for Parkland Health Center Farmington, which is a 130-bed acute care hospital. Rasnick's survey background includes The Joint Commission, CMS, HFAP (AOA), Missouri Department of Health, OSHA, American Academy of Sleep Medicine, as well as disease-specific certification such as TJC Stroke certification, Missouri Time Critical Diagnosis for stroke and STEMI, and other various hospital survey processes. She currently isenrolled to complete her master's in nursing with an emphasis in health care policy.

Lisa Riggs is the director of regulatory readiness at Saint Luke's Health System, in Kansas City, Mo. In her role, she supports the quality teams at each of the Saint Luke's entities to continuously be ready for regulatory surveys and oversight. She is a consultant to senior leadership regarding state, TJC and CMS regulatory updates and interpretation. Riggs’ background is critical care nursing. She has worked in multiple roles, primarily in nursing and quality, serving as the director of quality at Saint Luke's Hospital prior to her current role in regulatory readiness. Riggs has a Lean Six Sigma Black Belt, and she is a member of the American Association of Critical Care Nurses, American Nurses Association, American College of Cardiology and Society of Critical Care Medicine.

Nancy Ruzicka is a recognized expert on state and federal rules, regulations and interpretative guidelines for hospitals, critical access hospitals, rural health clinics and other Medicare-certified entities. She previously worked as a director of integrity & compliance and privacy official at Mercy Medical Center in Des Moines, and as director of regulatory compliance at UnityPoint Health in West Des Moines. She also has more than 20 years of experience with the Iowa Department of Inspections and Appeals, which is the Medicare state survey agency in Iowa. She also was a practicing pharmacist for 35 years. Ruzicka holds master's degrees in health law and business administration and a bachelor's degree in pharmacy, all from Drake University in Des Moines. She is certified in health care compliance and maintains her Iowa pharmacy license.

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.

Sarah Yelton has been a registered nurse for more than 40 years and has served in a variety of bedside and administrative positions. She is a Certified Professional in Healthcare Quality, Healthcare Accreditation Certified Professional and a Lean Six Sigma Green Belt. While working for 11 years as the quality director for the CMS contractor End Stage Renal Disease Network 12, Yelton reviewed all of the ESRD CMS/State Conditions for Participation survey reports conducted in Iowa, Missouri, Kansas and Nebraska, and mentored units as they formulated their corrective action plans. She accompanied CMS surveyors as they conducted particularly difficult ESRD surveys. Yelton is a former quality examiner for the Excellence in Missouri Foundation. Since joining Saint Luke’s Hospital in 2010, she has coordinated and participated in more than 70 CMS, TJC, OSHA and other oversight agency surveys.