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May 18, 2021


8:00am - 12:30pm




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

Dates and Times

Tuesday, May 18, from 8 a.m. to 12:30 p.m.
Wednesday, May 19, from 8 a.m. to 12:30 p.m.


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. Staying up to date 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 compliance and how to avoid them. Discussions also will explore the risks of compliance during construction, touching on contaminant avoidance and common pitfalls we have seen since the beginning of COVID-19.

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:

  • gain insight into recent changes in CMS and state regulations
  • describe recent changes in CMS regulations and how the surveyors will survey for these changes
  • discuss the top-cited deficiencies in Missouri
  • discuss the risks of compliance during construction-related activities
  • discuss the differences between the 2021 edition of NFPA 101 – Life Safety Code with the widely used 2012 edition

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

AXIS Medical Education
MHA Health Institute


General Information


Register on or before Thursday, May 13, to ensure delivery of instructional materials.


This virtual event series is eligible for use of the MHA Health Institute coupon. Note: Coupons were mailed to MHA-member hospital CEOs in December 2020.

This virtual event also is being offered at a reduced registration fee to MHA-member hospitals thanks to a generous contribution from the MHA Management Services Corporation.

Sponsored by:

Additional sponsorship opportunities are available.

Contact An Expert

Daphney Partridge

Daphney Partridge

Vice President of Education
Kita Kay

Rita Kay

Manager of Educational Programs
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