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

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Seminar: Wednesday, March 18, and Thursday, March 19

Date:3/19/2020
Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional:
Additional Information
Description:

Understanding Federal and State Hospital Regulations 101

Preconference: Tuesday, March 17


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

Tuesday, March 17, through Thursday, March 19

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


Register on or before Monday, March 2.

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 webinar also is eligible for use of the MHA Health Institute coupon. Note: Coupons were mailed to MHA-member hospital CEOs in December 2019.

This seminar is eligible for discounted registration. When a hospital registers more than three individuals, each registration above three is reduced by $100 per person. The discount is not available for online registration. To qualify, please contact Rita Kay directly at 573-893-3700, ext. 1319, to register all attendees, and please have the following information available at the time of the call.

  • each attendee’s name, email address and job title
  • form of payment: credit card or check
  • MHI coupon number, if applicable (all coupon policies apply)

Refunds will be applied to reduced registrations first. As always, we encourage hospitals to send substitutions.


Hotel Reservation

Request MHA Health Institute room rate: $119 + tax
Group code: COPS0320
Hotel cutoff date: Monday, Feb. 17



Preconference — Understanding Federal and State Hospital Regulations 101

Tuesday, March 17

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 — Tuesday, March 17

4 p.m. — Registration

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

Wednesday, March 18, and Thursday, March 19

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 — Wednesday, March 18

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
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

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

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 — Thursday, March 19

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

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 — Lunch (provided) and 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.


Continuing Education

Contact Hours for nurses, certified professionals in health care quality and health care executives offered for Wednesday, March 18, and Thursday, March 19 only.

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
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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
Nursing — AXIS Medical Education designates this continuing nursing education activity for 12 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.

Quality Professionals — This program is pending approval by the National Association for Healthcare Quality (NAHQ) to provide CPHQ CE credit.

ACHE — ACHE Qualified Education credit must be related to healthcare management (i.e., it cannot be clinical, inspirational, or specific to the sponsoring organization). It can be earned through educational programs conducted or sponsored by any organization qualified to provide education programming in healthcare management. Programs may be sponsored by ACHE, chapters, or other qualified sources, whether the programming is face-to-face or distance offerings (webinars, online seminars, self-study courses, etc.). You will receive a certificate of completion for 12.0 hours.

All Other Participants — A certificate of attendance for 12 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 10. 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 atinfo@axismeded.org.

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
 Carrie Brixey  Nothing to disclose
 David East  Nothing to disclose
 Nancy Ruzicka, MBA, M.J., RPh., B.S., CHC  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


Disclaimer
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.