2023 CMS CoPs Updates — Seven-Part Virtual Series

Friday, March 31
Patient Rights Update and Overview 

Session Overview
Hospitals and critical access hospitals must comply with the Centers for Medicare & Medicaid Services Conditions of Participation. Based on CMS, DNV and The Joint Commission, Patient Rights is the second most-cited condition-level deficiency. Within that condition, most noncompliances come from the regulations governing lack of safe environment, abuse, restraints and seclusion. This is a new CoP for CAHs, effective Jan. 1, 2023.

Objectives

• • describe the CMS requirements for providing care in a safe environment for all patients, specifically patients who are suicidal or in need of behavioral health services
  • discuss the CMS adoption of the TJC Suicide Panel recommendations of the comprehensive ligature risk interpretative guidelines
  • explain CMS definitions of abuse, restraints and seclusion
  • describe abuse investigation requirements
  • explain restraint death reporting requirements

Nancy Ruzicka
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altonna, Iowa

Friday, April 7
Infection Prevention and Antibiotic Stewardship

Session Overview
This program will cover the CMS infection control standards and antibiotic stewardship program for both hospitals and CAHs. The new CMS interpretative guidelines will be discussed, as well as common deficiencies in infection control and tips to ensure compliance.

Objectives

• • describe new CMS infection control CoPs regulations and interpretative guidelines
  • describe new CMS requirements for the antibiotic stewardship program
  • identify examples of commonly cited infection control issues

Nancy Ruzicka
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altonna, Iowa

Friday, April 14
Nursing Services

Session Overview
This session will provide an overview of the CMS regulations governing the provision of nursing services in hospitals and CAHs. Discussions will include the interpretative guidelines and the most-cited Missouri deficiencies.

Objectives

• • describe minimum nurse staffing requirements
  • explain basic nursing care plans
  • describe essential parts of medication orders
  • explain appropriate medication administration timing

Nancy Ruzicka
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altonna, Iowa

Friday, April 21
Construction Updates and Life Safety Codes

Session Overview
Staying current on codes in the health care industry can be overwhelming, especially throughout this past year. This session will provide attendees with insights on the most common areas of incompliance and how to avoid them.

Objectives

• • understand how life safety surveys identify top code compliance concerns
  • outline how to remain code compliant through the transition away from CMS 1135 waivers
  • explore risks of compliance during construction-related activities

Mark Chrisman, PE, Ph.D.
Health Sector Executive I Principal
Henderson Engineers
Lenexa, Kan.

Samuel Beckman
Principal/Architect
ACI Boland Architects
Kansas City, Mo.

Friday, April 28
Governing Body

Session Overview
Throughout the last several years, there has been increasing scrutiny by regulators and accrediting organizations on the hospital’s governing body’s role in compliance with CoPs. This presentation will examine the regulatory requirements for hospital boards and describe situations where the governing body have been cited.

Objectives

• • describe governing board responsibilities and specific responsibilities for patient rights, quality improvement and medical staff credentialing
  • describe minimum requirements for medical staff bylaws, rules and regulations, and governing body oversight
  • explain the differences in medical staff credentialing regulations for telemedicine providers and on-site providers
  • describe hospital responsibilities for credentialing nonphysician staff in the hospital

Nancy Ruzicka
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altonna, Iowa

Friday, May 5
Emergency Preparedness ABCs

Session Overview
Are you ready for the next temporary loss of power? Does your hospital staff know how to handle loss of access to the EHR system? How do you deal with workplace violence issues? Learn about the CMS emergency preparedness rule, identify potential gaps in compliance and discover how those gaps can be closed.

Objectives

• • explain CMS expectations of the types of emergencies to be covered in your plan
  • describe training and testing requirements
  • describe the minimum required topics for policies and procedures

Nancy Ruzicka
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altonna, Iowa

Friday, May 12
Most Frequently Cited Deficiencies in Hospitals and Critical Access Hospitals

Session Overview
All hospitals and CAHs participating in the Medicare program are required to comply with CMS CoPs. There are deficiencies that are commonly cited throughout the nation during standard surveys and complaint investigations. This presentation identifies the top-cited regulations, explains the regulations and why they are found noncompliant.

Objectives

• • describe and discuss why an accredited hospital must comply with CMS regulations
  • explain the implications of a condition-level deficiency
  • describe the most frequently cited deficiencies
  • explain the regulation and related interpretative guidelines for each deficiency

Nancy Ruzicka
Health Care Consultant
Ruzicka Healthcare Consulting LLC
Altonna, Iowa

Sam Beckman is principal and leader of the Healthcare Studio at ACI Boland with 20 years of health care design experience. During the past 15 years, he has been the architect for seven new community hospitals, and hundreds of health care remodels and facility additions. He is actively involved in health care projects throughout the Midwest, each with its own unique challenges regarding compliance with life safety codes and facility space planning. He strives to have a positive impact on clients and the communities they serve by sharing research, best practices and creativity.

A graduate of the University of Missouri, he worked for a contractor early in his career to gain hands-on experience. This curiosity and thirst for creativity led him to pursue and complete a Master of Architecture from the University of Kansas. In addition to nearly two decades of experience, he is a registered architect and is NCARB certified.

Mark Chrisman joined Henderson Engineers as a fire protection engineer in 2004 and quickly began establishing client relationships that he continues to maintain today. Now a principal and Henderson’s health care practice director, he is responsible for coordinating the strategy for Henderson’s health care practice throughout the country. Throughout his career, he has designed health care environments for some of the biggest names in the industry, such as HCA Healthcare, AdventHealth and Ascension, but regardless of the project size, he uses his extensive technical expertise and immense knowledge of regulatory compliance requirements to help save clients’ money and time on projects.

Chrisman not only loves to learn, but he also naturally teaches those around him. He is known for his uncanny ability to recall specific codes off the top of his head, but don’t let the Ph.D. after his name fool you, he’s also as down-to-earth as they come.

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 — Des Moines; as director of regulatory compliance at UnityPoint Health, West Des Moines; and 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, located in Des Moines, Iowa. She is certified in health care compliance and maintains her Iowa pharmacy license.

Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and 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.

This activity was planned by and for the healthcare team, and learners will receive a maximum of 10.5 Interprofessional Continuing Education (IPCE) credit for learning and change.

Credit Designation

Nursing — AXIS Medical Education designates this continuing nursing education activity for a maximum of 10.5 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.

Healthcare Executives — 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 10.5 hours.

Quality Professionals —This program has been approved by the National Association for Healthcare Quality for a maximum of 10.5 CPHQ continuing education credits for this event.

Attorneys Only — The Missouri Bar approved 1.8 Missouri CLE hours for attending each live session.

Requirements for Credit:

• • Attend/participate in the educational activity and review all course materials.
  • Complete the CE Attestation/Evaluation form online by 11:59 pm ET on June 12, 2023. Instructions will be provided. If you do not complete the online evaluation by this date, you will not be able to get CE credit for this event.
  • 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 info@axismeded.org.

Disclosure of Conflicts of Interest

AXIS Medical Education requires faculty, instructors, authors, planners, directors, managers, reviewers and other individuals who are in a position to control the content of this activity to disclose all real or apparent conflicts of interest they may have with ineligible companies. An ineligible entity is any organization whose primary business is t producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients. All relevant conflicts of interest are identified and mitigated prior to initiation of the planning phase for an activity. 

AXIS has mitigated and disclosed to learners all relevant conflicts of interest disclosed by staff, planners, faculty/authors, peer reviewers, or others in control of content for this activity. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of a presentation or activity. Disclosure information for faculty, authors, course directors, planners, peer reviewers, and/or relevant staff is provided with this activity.

The faculty reported the following relevant financial relationships or relationships they have with ineligible companies of any amount during the past 24 months:

The following directors, planners, managers and reviewers reported no financial relationships they have with any ineligible company of any amount during the past 24 months:

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.

Please note that your registration request will be submitted to the organizer for approval. Upon approval, virtual instructional materials and access information will be sent to the email address indicated on the registration form.

If you have special needs addressed by the Americans With Disabilities Act, please contact the Missouri Hospital Association.

MHA Health Institute
P.O. Box 60
Jefferson City, MO 65102
Phone: 573-893-3700
Fax: 573-893-2809

For cancellations received in writing before the established deadline date, the registrant will receive a full refund — minus a $50* processing fee per registrant. After the deadline date, no refunds will be granted. Registrants not in attendance will be responsible for the full registration fee. Substitutions are encouraged. We reserve the right to cancel this program because of insufficient registration.

*Unless otherwise specified in the program details.