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2023 Accreditation &
Regulatory Summit
Today's Challenges / Tomorrow's Opportunities
September 26-28, 2023
Marriott Convention Center
Allen, TX
2023 HACP Preparatory
Course & National
September 25-26, 2023
Marriott Convention Center
Allen, TX
CIHQ Webinars
Condition of Participation
for Utilization Review
April 13, 2023
NFPA 101 Life Safety Code
The Basics
May 19, 2023
Accreditation & Regulatory Journal

2023 Accreditation & Regulatory Summit

Today’s Challenges / Tomorrow’s Opportunities
Today’s Challenges / Tomorrow’s Opportunities

Featured Speakers & Topics

Get first-hand knowledge on the latest in the accreditation and certification arena. This opening address will cover initiatives from CMS and their impact on accrediting organizations and hospitals. The presentation will also cover the latest annual report to Congress, return of the validation survey process, and much more!
If you're new to regulatory compliance or simply want to “freshen up”, then this workshop is tailor made for you. We’ll cover the role of CMS and accrediting agencies, an overview of the Medicare Conditions of Participations, how surveys are performed, and how deficiencies are identified.
Sometimes bad things happen to good hospitals. Immediate jeopardy (IJ) is the most serious deficiency that CMS issues. It’s rare, but if it does occur, how a hospital responds is absolutely critical. This workshop will help us understand the most common causes for an IJ, requirements for immediate abatement, and how to avoid termination from Medicare!
Electronic medical records (EHR’) have transformed how we deliver and document healthcare. The rewards have been great, but EHR’ have created new challenges from a regulatory standpoint. This workshop will cover what is best about EHR’ and focus on the design and functional limitations that have proven problematic during surveys.
Even the best survey can be derailed simply because line staff and physicians didn’t know how to interact with surveyors appropriately and effectively. This workshop will cover the practical do’s and don’ts in working with surveyors. We can take these learnings back to our hospital and use them to train our staff and physicians!
Richard Curtis, RN, MS, HACP-CMS
» Topic: Accreditation – State of the Union
» Topic: CMS Survey & Certification Process – The Basics
» Topic: Immediate Jeopardy – Identification & Response
» Topic: Electronic Medical Records – Praise & Pillory
» Topic: How to Interact with Surveyors – Tips for Success
Richard (Rick) Curtis is the Chief Executive Officer for CIHQ. Rick is nationally recognized as an expert on standards and the CMS Certification & Survey Process. As CEO, Rick successfully guided CIHQ in becoming the nation’s 4th CMS approved deeming authority for acute care hospitals.
Rick is a regular speaker at numerous state and national conferences on the CMS survey process.
Rick is nationally certified in healthcare accreditation, and serves as Chair of the Board of Examiners for the Healthcare Accreditation Certification Program (HACP). Rick has a degree in Nursing from the University of Hawaii, with a Master’s Degree in Health Services Administration.

Did you know that negligent credentialing or privileging can literally bring a hospital to its knees! This workshop will address regulatory requirements surrounding appointment, credentialing, privileging, and appraisal of the medical staff. As importantly, we’ll learn where the risks are and how to protect your hospital and its medical staff.
The survey is over, the hospital has received its report, and now the “fun” begins – its time to write a plan of correction (POC). Writing an acceptable POC is a critical part of being accredited. It’s not easy and failure to do so could put your hospital’s accreditation at-risk. This workshop will help us understand how to write a complete, acceptable, - and most importantly - achievable POC.
Traci Curtis, BA, RCP, HACP-CMS
» Topic: Medical Staff Credentialing, Privileging, & More
» Topic: How to Write a Plan of Correction
Traci Curtis is the Executive Director of Survey Operations for CIHQ. Traci has more than 32 years of experience in healthcare including regulatory compliance and survey preparation.
Traci has held clinical as well as executive management positions at the corporate and facility level in Respiratory Services, Regulatory Compliance, Quality, Risk, Infection Control and Education.
Traci joined CIHQ in 2007 as a Generalist Lead Surveyor and in 2011 was promoted to her executive level position. Currently she oversees the accreditation division for hospitals, freestanding emergency centers, urgent care centers and congregate living health facilities, as well as business development and marketing.

Non-compliance to the NFPA life safety code is one of the most common deficiencies cited during surveys. What happens if your hospital can’t correct the issue(s) in a timely manner? This workshop offers a detailed understanding of the need for interim life safety measures, as well as how to submit waivers and equivalencies to CMS.
For far too many hospitals, emergency preparedness is an afterthought – until disaster strikes! Based on actual incidents, this workshop will identify “real world” issues that hospitals have faced and how our hospitals can be better prepared. Learn from others who have lived through disasters – what works and what doesn’t.
William Kinch, MBA, HACP-PE
» Topic: NFPA LSC – ILSM, Waivers, & Equivalencies
» Topic: Top Issues in Emergency Preparedness
William (Billy) Kinch is a senior facilities specialist surveyor with CIHQ specializing in environmental health and safety. Billy is responsible for standards development and interpretation for the physical environment and emergency preparedness standards for CIHQ. Billy is a regular speaker as part of CIHQ’ monthly webinars and also speaks at State and National conferences.
Billy also acts as the content expert in developing the HACP-PE certification exam.
Billy received his Master Degree in Business Administration from Phoenix University and is a certified healthcare accreditation specialist specializing in the care environment (HACP-PE).

Back by popular demand, this workshop provides a step-by-step roadmap to preparing for and managing a survey. We’ll cover time-tested strategies for document preparation, staff training, survey logistics, and more. We’ll walk away with key tools and techniques to help our hospitals have a successful survey experience.
Gina Miller, MSN, RN, HACP-CMS
» Topic: Basics of Survey Preparation
Gina Miller is a Generalist Surveyor for CIHQ/ARS. Gina has more than 37 years of experience in healthcare including regulatory compliance and survey preparation. Gina’s has held clinical as well as executive management positions in Nursing, Case Management, Quality and Regulatory Compliance.
Gina joined CIHQ in 2017 as a Generalist Surveyor and became a Lead Surveyor in 2018.
Gina received her BSN from Alderson-Broaddus University and MSN from Western Governor’s University. She is nationally certified in healthcare accreditation (HACP).

An opioid epidemic is sweeping the nation! Its effects are being felt throughout the healthcare industry. The need for an effective opioid stewardship program couldn’t be greater. This workshop will not only provide the regulatory framework for opioid stewardship but will also review evidence-based best practices that we can implement in our hospitals.
Paula Barnes, MBA, BSN, RN, HACP-CMS
» Topic: Opioid Stewardship – A Quality of Care Imperative
Paula Barnes is a Generalist Surveyor for CIHQ/ARS. Paula has 26 years of experience in healthcare including regulatory compliance and survey preparation.
Paula’s clinical background is in nursing with a focus on emergency and intensive care medicine. She has held clinical as well as executive management positions in Nursing, Quality and Regulatory Compliance. Paula joined CIHQ in 2019 as a Generalist Surveyor.
Paula received her BSN from East Carolina University MBA from the University of Phoenix. She is nationally certified in healthcare accreditation (HACP).

It’s horrible to even contemplate, yet hospitals must face the reality that active shooter incidents are on the rise. It’s a risk we must do our best to prepare for. This workshop is designed to cover the basics of an evidence-based active shooter management plan. We’ll learn how best to prepare our hospitals, and – heaven forbid – to respond!
Russ Cole, CFM, HACP-PE
» Topic: Active Shooter – Preparing for the Unthinkable
Russ is a facilities specialist surveyor for CIHQ. Russ has more than 38 years of experience in fire and life safety, facility engineering, and emergency preparedness.
Russ has held executive management positions in both city and countywide fire protections districts as an emergency preparedness Incident Command Team member at both a state and national level.
Russ joined CIHQ in 2011 as a Facility Specialist Surveyor. Russell received his Associates degree in Fire Technology from Oxnard College in Oxnard, California. He has also been an instructor in fire technology at Oxnard Community College in Oxnard, California.

Compounding medications is a high-risk process! CMS, accrediting organizations, and state boards of pharmacy aggressively assess a hospital’s compliance to USP-797 / 800 standards. This workshop will help us understand the basics of sterile compounding requirements, the most common deficiencies cited, and how to prepare your pharmacy for survey.
Michael J. Freudiger, PharmD, APh, BCPS, BCSCP
» Topic: Sterile Compounding USP 797 / 800
Michael is clinical pharmacist, advanced practice pharmacist (APh), and Compounding and Regulatory Compliance Supervisor at Valley Children’s Healthcare and Saint Agnes Medical Center in California, USA. He is board-certified as a pharmacotherapy specialist and is a board-certified sterile compounding pharmacist.
Michael earned his PharmD from the University of the Pacific and completed a PGY1 Pharmacy Practice Residency at the Department of Veterans Affairs Healthcare System in Loma Linda, California, USA. He holds an adjunct faculty position at multiple pharmacy schools and guest faculty positions for delivering compounding education.

The FDA has strict requirements governing failures of medical devices and removing of implants. Failure to report device failures or manage implant removal appropriately can result in financial penalties as well a potential loss of revenue. This workshop will cover the basic regulations, how to minimize risk, and maximize reward.
» Topic: Medical Device Failures & Implants
Alan is the Chief Sales Officer for SpendMend. He has over 30 years of healthcare experience in clinical social work, bedside nursing, and hospital administration. Alan is a Fellow in the American College of HealthCare Executives and a HealthCare Accreditation Certified Professional. He is a serial entrepreneur and patent holder. He has developed several healthcare software solutions including TrackCore Tissue and Implant Tracking solution, Turnover Tracker and collaborated with SpendMend’s Audit and IT teams to create the Explanted Medical Device Warranty Credit Tracking solution.

Always remember – CMS certifies individual hospitals, not health systems. So how do you “systemize” hospitals and still comply with Medicare? This workshop will answer that question. We’ll learn how to manage hot button issues such as governance, system policies, performance data, staffing and more.
Patricia Cook, R.Ph., B.S., HACP-CMS
» Topic: Integrated Health Systems – Challenges with the COP’
Pat is a Senior Consultant and Head of Consulting Services at Courtemanche & Associates. Working in collaboration with the C&A Leaders, Pat manages Courtemanche & Associate’s business development initiatives and oversees the clinical delivery of services and support. With her extensive healthcare experience, Pat serves as a knowledgeable resource to new and existing clients, helping to guide them through their accreditation and regulatory needs.
Pat is a graduate of St. John’s University, Queens New York where she earned her bachelor’s degree in Pharmaceutical Sciences. She also holds the following certifications: Six Sigma Green Belt, Certified Healthcare Accreditation Professional (HACP), and is a Master Trainer in TeamSTEPPS.

An effective rounding program can serve as an early warning system to potential issues during a survey. This workshop will provide practical strategies for our hospitals to develop a comprehensive and resource efficient rounding program that will leave us survey ready!
Chris Dube, BBA, MBA
» Topic: Rounding as a Survey Management Tool
Chris is a senior healthcare executive who has spent 20+ years in the healthcare industry as a provider and working with technology to help hospitals and healthcare facilities improve patient safety and experience. Chris has worked for Sentact for the past 9 years, serving as the company’s COO from 2014-2017 and the President from 2017 – on. During this time, Chris has worked with top hospitals around the country such as Common Spirit and New York Presbyterian to assist in the delivery of high-quality care and offering solutions that create real value.

Often referred to as “that other set of regulations”, non-compliance to requirements under the PPS can have a significant adverse impact on the financial health of a hospital and medical professionals. This workshop will provide an overview of the PPS and identify the most common areas of non-compliance.
Sarah Hauch, RN, BSN
» Topic: Basics of the Prospective Payment System
Sarah is the PPS Coordinator with Corewell Health South's Watervliet Inpatient Rehabilitation facility. As a PPS Coordinator, she collaborates with a multidisciplinary team of healthcare professionals to ensure that all aspects of CMS guidelines are met through proper documentation throughout the patient stay.
Since 2017, she has held multiple roles as a Registered Nurse in Inpatient Rehabilitation, Emergency Medicine, Urgent Care, and as a House Supervisor. She currently is part of the Shared Governance Committee with Corewell Health South's Professional Development team to promote healthy and successful change within the acute care setting.

At the end of the day, ensuring regulatory compliance comes down to individual accountability. So how does a hospital establish and maintain a culture of accountability? This workshop has the answer. We’ll learn about the attributes of successful organizations and practical strategies to begin the journey to accountability in our hospitals.
Alan Coppock, M.Ed., MBA, FACHE
» Topic: Fostering Accountability Throughout Your Organization
Alan is the Chief Executive Officer and Founder of Adminologybay, a healthcare consulting firm that specializes in identifying the innovative “game changers” and bringing their solutions to the C-Suite Executives who need them, serving to strengthen sustainability for US Hospitals.
Alan is adept in helping a team understand the basis of Hospital Operations is the simple working equation: Revenue - Margin = Expense. He helps organizations identify the right structures that allow them to manage to their Daily Operational targets and then train the care teams and supervisors how to manage to their available resources.

Did you know that your accrediting agency is required to report potential Medicare fraud and abuse to the Office of the Inspector General (OIG)? These types of issues often result in sanctions and heavy financial penalties. This presentation will help us understand the most common types of fraud and abuse, as well as how respond to them.
Linda Moore, Senior Vice President & General Counsel - CHC
» Topic: Medicare Fraud & Abuse – What You Need to Know
Linda is responsible for oversight and guidance of all legal matters affecting facilities and organizations of CHC and its affiliates. Linda’s extensive healthcare regulatory and legal experience comes from more than 17 years’ experience with healthcare Systems.
Linda has a Bachelor of Business Administration from Southern Methodist University, Dallas, TX, and her Juris Doctor from Texas A&M University School of Law, Ft. Worth, TX (formerly known as Texas Wesleyan University School of Law). She is a member of the American Health Law Association and the Texas Bar Association.
Did you know that your accrediting agency is required to report potential Medicare fraud and abuse to the Office of the Inspector General (OIG)? These types of issues often result in sanctions and heavy financial penalties. This presentation will help us understand the most common types of fraud and abuse, as well as how respond to them.
Amy Brown, Vice President Risk Management and Chief Compliance Officer – CHC
Amy oversees all risk management programs for CHC. Amy is also responsible for the development, implementation and oversight of the Compliance Program for CHC. Amy has a Bachelor of Journalism with a concentration in Public Relations from the University of Texas, Austin. She also earned a Master of Arts degree in Public Administration and Health Care Policy from the University of Houston. She holds a Certification in Professional Healthcare Risk Management (CPHRM), Certification in Healthcare Compliance (CHC), and Certification in Healthcare Privacy Compliance (CHPC).

The Interoperability and Patient Access rule by CMS (CMS-9115-F) promises to put patients first, giving them access to their health information when they need it most and in a way they can best use it. This workshop provides an overview of this rule, the regulatory requirements for hospitals, and effective strategies to build a compliant program.
Cindy Campbell, MHA Healthcare Informatics, BSN, RN
» Topic: Medicare Interoperability Requirements
Cindy is a nationally recognized thought-leader and management consultant to the continuum of healthcare at home. Cindy holds a Master of Health Administration with specialty in Healthcare Informatics, and a Bachelor of Science in Nursing.
Cindy and her team help agencies leverage strategic thought and operational efficiency into organizational, work-process and clinical model design for Home Health, Hospice, Palliative Care and Private Duty organizations throughout the United States. Cindy has served as a Board Member of the National Association for Homecare & Hospice, Chair of the Pediatric Homecare & Hospice Association of America, and member of the Executive Committee of the American Telemedicine Association’s Homecare and Remote Monitoring Special Interest Group.

The incidence of legionella and other opportunistic water-borne pathogens in our nation’s hospitals is on the rise. Both CMS and accrediting organizations expect hospitals to have a plan in place to prevent and respond to infection risks in our water supply. This workshop will help us perform an assessment to identify risks in our water supply and implement a compliant management program.
John Kalns, Ph.D.
» Topic: Water-Borne Pathogen Management Program
John is the Vice President, Chief Scientific Officer, and Founder of Hyperion Biotechnology, Inc. The company specializes in Legionella water testing and waterborne pathogen management. John developed the program and the environmental microbiology laboratory that maintains CDC ELITE and environmental testing (EMLAP) accreditations. John received his BS in Chemistry from the University of Michigan (at Ann Arbor) and his Ph.D. in Pharmaceutics from Oregon State University. He also oversees Hyperion’s CLIA certified laboratory and has expertise in clinical reference testing and human performance testing. John has co-authored multiple academic and research articles on biomarkers in physical fatigue and holds several patents in this field.

We talk a lot about accreditation surveys. But what happens when the FDA, DEA, State Board, OIG, or OSHA walk in our doors? This workshop provides keen insight into how these entities conduct surveys and how our hospitals can best be prepared. There is an old saying: “to be forewarned is to be forearmed.”
Christie Hutchinson, RN, BSN, MBA, CPEN, CPHQ, CPHRM, HACP-CMS
» Topic: Hospital Investigations – It’s Not Just Accreditation
Christie is the CEO of QCC Healthcare Consultants where she works with healthcare organizations to improve their compliance, quality, and operational efficiencies. As a healthcare risk manager, Christie is instrumental in identifying successes and areas of opportunities for her clients, assisting them in achieving the highest level of quality care for their patients.
Christie is the founder and president of the Texas Healthcare Advisory Council serving healthcare professionals in the DFW area. She also serves on the North Texas Association for Healthcare Quality (NTAHQ) Board.

The COVID pandemic opened the nation’s eyes to the benefits and importance of telehealth services. CMS and payor sources are increasingly seeing the benefits of telehealth. It’s quickly becoming a whole new world, rife with possibilities and pitfalls. This presentation will outline the possibilities of telehealth now and in the future.
Sarjoo Patel, MD
» Topic: Telehealth – The New Wild West
Dr. Patel believes everyone has a right to well-coordinated, high quality, sustainable healthcare, regardless of their location. With a background in hospital medicine and management information systems, his ongoing projects leverage technology and information to increase access to and quality of healthcare, while reducing the costs of and frequent barriers to healthcare delivery.
Dr. Patel founded Beam Healthcare, bringing specialty care to rural healthcare facilities and underserved communities. Beam Healthcare provides telemedicine programs including hospitalist, cardiology, pulmonology, infectious disease, and respiratory therapy services to rural and critical access hospitals.

Overwhelmed? Stressed out? If it seems like work has become just one moment of drudgery after another, you’re probably right. We can’t solve that problem completely, but at least we can leave the Summit laughing! Our closing presentation will tickle our funny bones and teach us how to use humor to be more successful in our jobs and in our lives.
David Glickman
» Topic: Less Stress... More Success!
What do you get when you cross a very funny comedian with an expert on healthcare? David Glickman. Since making the decision to leave the comedy club world behind, David has merged his comedic entertainment skills with his knowledge of healthcare to create a program that provides great value to some of America’s most prestigious healthcare organizations.
In 2016, David was awarded the Council of Peers Award for Excellence (CPAE) and inducted into the Speaker Hall of Fame. This is a lifetime award for speaking excellence and professionalism.

Non-compliance to regulations addressing high-level disinfection and sterilization almost always result in condition-level deficiencies. The bar is high, and the survey process is aggressive. This workshop will help us understand the standard of care, identify the most common areas of non-compliance, and develop appropriate compliance strategies.
Gregg Agoston, MBA, CCSVP
» Topic: Hot Buttons in Sterilization & Disinfection
Greg is a Vice President at SpecialtyCare. Over the past 20 years, he has worked in the medical device service industry. He has been a presenter at several IAHCSMM national and local meetings on topics related to Central Service/Sterile Processing (CS/SP).
Greg helped with the revision of Chapter 11, Complex Medical Devices, in the Central Service Technical Manual (8th Ed.) and contributed to the Endoscope Reprocessing Manual (1st Ed.). He is a Certified Central Service Vendor Partner (CCSVP) through IAHCSMM.

Hospital-at-home enables some patients who need acute-level care to receive care in their homes, rather than in a hospital. Learn how this new care model can address inpatient capacity issues and improve patient satisfaction in a way that maintains regulatory compliance. This will be the new paradigm. The future is here!
Heather Kelsey, MSN, RN
» Topic: Hospital at Home – The Future is Here
Heather is the Director of Virtual Care, Triage and Scheduling at Conduit Health Partners. In her role, Heather is responsible for strategic and operational leadership, day-to-day management, and oversight of Conduit Health Partners’ Nurse Triage, Virtual Care Center and Scheduling teams.
She also collaborates with other Conduit leaders to develop new strategic services and process improvement strategies. Heather has more than 20 years of clinical experience and has been a Director at Conduit for more than a year.

Malware, ransom attacks, data breaches – the threats to hospitals and healthcare systems are real and growing! This presentation underscores the importance of a vibrant and adaptive cybersecurity program. Get the latest information on the threats we face and how to protect our information systems.
Michael Chung, CISSP
» Topic: Cybersecurity – Threats & Mitigation Strategies
Michael is a Principal Cybersecurity Consultant with Convergint Technologies and is responsible for overseeing Convergint's Healthcare and Federal cybersecurity programs. Michael has over 15 years of experience in the cybersecurity space built upon helping organizations implement security controls and safeguards to improve their security posture.
Michael was the former cybersecurity advisor to the National Physical Security Director at Kaiser Permanente where he worked closely with National and Regional Leadership to ensure compliance with cybersecurity standards. Prior to that, he acted as a cybersecurity advisor to the Department of Energy Office of Intelligence and Counterintelligence and was the technical lead for their endpoint security.