What’s Trending in Missouri Conditions of Participation Citations in Acute Care Hospitals and How to Avoid

Audience

CEOs; COOs; CFOs; chief nursing officers; 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; and any staff responsible for ensuring compliance with CMS Conditions of Participation

Overview

Hospitals face common challenges, including compliance with federal regulation and accreditation standards. There are several cited deficiencies, which are common to many organizations, including infection prevention, patient rights and provision of nursing services, to name a few. This session will focus on the most problematic deficiencies and the expectations for compliance standards. Recent changes in interpretative guidelines also will be discussed.

Objectives

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

• • describe the most frequently cited deficiencies
  • explain how compliance is assessed for each area of common deficiencies
  • describe recent changes in CMS surveyor guidance and expectations

Speaker

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 and 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.