2025 Accreditation & Regulatory Summit

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The regulatory environment is in a period of uncertainty. Get first-hand knowledge on the latest in the CMS certification arena. This opening address will cover current and likely future actions from CMS and their impact on accrediting organizations and hospitals. To be forewarned is to be forearmed!

This presentation is for CIHQ accredited organizations. Get the latest information on changes to standards, survey procedures, and the top condition-level deficiencies levied over the past 12 months. This will also be your opportunity to seek interpretation of standards and get your questions answered.

Patient-reported outcome measures (PROMs) are questionnaires measuring the patients' views of their health status. Patient-reported experience measures (PREMs) are questionnaires measuring the patients' perceptions of their experience while receiving care. This presentation will assist hospitals in implementing strategies to integrate these measure into care practices to improve patient outcomes.

By October we will have been 10 months into the Trump administration. The pace of change and the overall upheaval of the federal government has been striking. This presentation will discuss the political landscape of the healthcare industry. From DOGE to executive orders to new leadership at HHS, you’ll be better prepared to handle the challenges now and into the future.

Eliminating prior authorization, getting paid on time and at 100% of what you agreed to may seem far-fetched but it's happening more than you'd think. Direct contracting with employers and their representatives is proving to be advantageous for all stakeholders and a way forward for improving access and a better experience for patients. In this presentation, we will learn what direct contracting is and what it isn't. We will also come to understand how this model benefits hospitals and employers.

This session highlights sterile compounding accreditation compliance strategies. The presenter will include information about the latest NIOSH and USP <795>, <797>, and <800> survey process(es) and include tips for how to always be prepared. The presentation focuses on understanding critical standards, ensuring adequate documentation, and developing an organized approach to achieve compliance.

This presentation will examine current trends in dialysis regulatory standards and their implications for healthcare providers. Topics include the CMS End Stage Kidney Disease Regulatory Update, review of the top 10 deficiencies that occur during a survey, and strategies to improve patient safety and minimize risk.

This session will explore how automation can streamline compliance workflows, reduce regulatory risks, and support hospitals’ quality improvement efforts. Attendees will learn how to identify improved process opportunities, select the right tools, and overcome implementation barriers.

This presentation will discuss how hospitals need to respond in the event of an infectious disease outbreak in their facility. The goal is to educate attendees on critical steps to help maintain control and navigate through stressful events associated with an infectious disease outbreak.

While there is no chapter entitled “Human Resources”, requirements for an effective staff training and development program are embedded throughout the Medicare Conditions of Participation. This presentation will address expectations of both CMS and accrediting organizations in designing and implementing compliant human resource processes.

Hospitals often use mock surveys to prepare for the real thing. This presentation will cover the implementation of a multi-disciplinary robust mock survey process and management of a large survey across multiple hospitals. Effective communication before, during and after the survey will be a highlight.

This presentation will cover the regulatory basis for what needs to be reported for the IRF QRP (existing and new/modified measures), as well as how it should be reported accurately and completely. This involves a wide variety of access to internal data and external systems, including governmental systems. How to report measures and what should be reported is a complicated issue involving education from a variety of different regulatory sources, including CMS, CDC, and QIES. This presentation will also include the policy landscape around the future of the IRF QRP program.

Hospitals must comply with the NFPA 101 Life Safety Code 2012 edition. The code is highly complex and references multiple other NFPA codes. How do you make sense of it all? This presentation will cover the basic structure of the Life Safety Code and how to identify and implement interim life safety measures (ILSM) when deficiencies are identified.

Have you noticed? The hospital industry is undergoing a building boom! New construction, renovation, remodeling; it seems all of us are involved in some construction activity. This presentation will cover the requirements for performing construction risk assessments – both from a building and infection control perspective. You’ll learn about the most common citations during a survey and how to prevent them.

2025 ushered in a plethora of uncertainties for laboratories and hospitals. A well-documented shortage of healthcare professionals, apprehension about funding cuts, and regulatory changes have made 2025 a year to adapt to change. This presentation will share actionable information on two movements that are gaining traction in the healthcare industry: Clinical Lab 2.0 and the Workforce Action Alliance.

This presentation will focus on what happens when healthcare facilities do not keep up with required preventative maintenance on medical equipment, as well as address the importance of completing and documenting all preventative maintenance activities. The presentation will also cover the most frequently cited areas of non-compliance.

Regular, focused life safety rounds are essential to ensuring compliance with NFPA 101, the Life Safety Code. Hear from a prominent pediatric hospital on how they implemented a multi-disciplinary in-house life safety rounding program and review their top findings from 2024. From developing protocols and checklists to fostering a culture of continuous improvement, participants will gain actionable strategies to enhance life safety practices within their healthcare institutions.

Each year CMS publishes changes to the Prospective Payment System (PPS) for hospitals. Failure to comply with these requirements can affect your hospital’s reimbursement from Medicare. This presentation will provide an overview of the PPS regulations and key areas of compliance.

Hospitals participating in the Inpatient Quality Reporting Program (IQR) must attest to meeting the requirements of certain structural measures annually. The “Hospital Commitment to Health Equity” is an attestation-based structural measure that acknowledges a hospital’s commitment to health equity. This presentation will cover the specific requirements under this structural measure and strategies for compliance.

The US Health Insurance Portability and Accountability Act (HIPAA), enacted in 1996, was established to safeguard patient privacy and secure health information. HIPAA sets strict standards for managing, transmitting, and storing protected health information. This presentation will cover the latest changes to HIPAA and the impact on hospitals.

This presentation is for organizations accredited by the other three deeming authorities. You’ll get the latest information on changes to standards, policies, and survey process for each agency.

The legal front of the healthcare industry has been active like never before. Changes in law and regulations have hospitals scrambling to make sense of it all. This session will update you on current and future legal issues affecting hospitals so that you can prepare for the impact.

“Laughter is the Best Medicine”—is funny! The healthcare humor will tickle your funny bone and have you laughing. “The Healthy Humorist®” has been known to skewer such topics as healthcare lingo, diet plans, pharmaceutical ads, medical marijuana and scrubs. Not just your standard comedy show, though, the program is uplifting, too. You may find yourself committing to lightening up and laughing more, or to adopting a new healthy habit.

Back by popular demand! Join your colleagues for an hour of fun and test your knowledge of accreditation standards. You’ll form into teams and compete against each other. They’ll be prizes for the winners, but be careful, this year the team with the worse score is going to jail!

This presentation will cover the regulatory basis for what needs to be reported for the IRF QRP (existing and new/modified measures), as well as how it should be reported accurately and completely. This involves a wide variety of access to internal data and external systems, including governmental systems. How to report measures and what should be reported is a complicated issue involving education from a variety of different regulatory sources, including CMS, CDC, and QIES. This presentation will also include the policy landscape around the future of the IRF QRP program.

Topic: Accreditation & Certification – State of the Union
Topic: Human Resources – The Unwritten COP
Topic: CIHQ Accreditation Program Update

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, critical access, and psychiatric hospitals.

In addition, Rick has overseen the management of Accreditation Resource Services (ARS) – the consulting arm of CIHQ with over 450 clients nationwide.

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.

Lara Burnside has spent the last 30 years creating workplaces that honor and value every person – whether they are a patient, employee or clinician.

Lara has built human resources and patient experience departments from the ground up – achieving multiple recognitions including the Malcom Baldrige Quality Award, one of the highest national honors.

Lara is the Co-Founder of CSE Leadership, a global consulting and coaching practice focused on equipping leaders and clinicians with powerful tools to improve the patient care experience.

By tapping into clients’ passion and purpose, she achieved top quartile performance and beyond in more than 200 hospitals across the United States.

Beckers Healthcare has recognized Lara three times as one of the nation’s leading CXO’s.

Brian Betner is an attorney and consultant with Hall Render, a national law firm focused on the needs of the health care industry. His practice is devoted to providing advice and counsel to leadership of health systems, hospitals, medical staffs, and physician groups with an emphasis on governance, medical staff operations, clinical integration, quality, and compliance-related matters.

Brian previously served for several years as Vice Chair for the Medical Staff, Credentialing, and Peer Review Practice Group of the American Health Law Association.

He regularly contributes to industry standard setting initiatives having recently authored a federal physician wellness law, and also speaks and publishes often on issues related to our ever-changing health care industry and its impact on hospitals, medical staff, physicians, and other providers.

David Balat is the founder of Healthcare Finance Specialists and has broad experience across the healthcare spectrum with special expertise in health care finance. He is a former seasoned hospital executive with over 20 years of healthcare industry leadership and executive management experience.

David has been invited to testify before the U.S. House Committee on Oversight and Reform in Washington, D.C., and before various House committees in the Texas State Legislature.

He is a published author and op-ed columnist in Newsweek, U.S. News & World Report, Real Clear Politics, and other news outlets.

He is also an active speaker and commentator on matters of health policy, health care finance, and health care reform.

Helen E. McKnight is the Director of Accreditation and Medication Safety for Cardinal Health. She joined Cardinal Health in 2022. Her 30-year healthcare career includes practicing pharmacy in Florida, New York, and Alabama.

Dr. McKnight was the first Alabama pharmacist to pass the Board of Pharmacy Specialties-Compounded Sterile Preparations exam. She was a member of the American Society of Health-System Pharmacists (ASHP) Leading Edge and the ASHP Foundation’s Pharmacy Leadership Academy programs.

Dr. McKnight holds a Doctor of Pharmacy from the University of Florida and completed her pharmacy practice residency at the University of Maryland Medical System. She received an MBA from New England College in New Hampshire.

Jennifer Vavrinchik has dedicated her entire career in nephrology nursing. Jennifer’s career includes clinical and operational leadership in both incenter and outpatient dialysis settings.

She began her career in dialysis as a Patient Care Technician while attending nursing school and has been an advanced practitioner since 1992.

In 2018, she co-founded National Dialysis Accreditation Commission, an accreditation organization specializing in outpatient dialysis facilities and serves as the Chief Operating Officer.

Jerry Shafran is the Chief Executive Officer for YouCompli which was founded in 2016. Having sold a business that revolutionized how insurance companies manage compliance, Jerry was inspired to bring that same expertise to the healthcare field.

Jerry launches, manages, and sells software and content solutions that simplify complex work.

His innovations enable professionals to focus on their core business priorities. Jerry has over 30 years of experience in the technology and healthcare industries.

Jody Randall is the CEO and founder of HCE Global, an international healthcare consulting firm dedicated to driving excellence in healthcare delivery, compliance, and organizational performance.

Jody has over 30 years of diverse nursing experience specializing in biochemical dependency, cardiology, medical-surgical, labor and delivery, and surgical services. Healthcare leadership roles included Infection Prevention, Quality and Risk Management. Jody is Board Certified in Infection Prevention and Control (CIC), and is a Healthcare Accreditation Certified Professional (HACP-CMS).

Laura Rhoads has a BS in Biochemistry from Trinity University and an MBA with a concentration in Health Care Administration from Boston University. She first obtained her CPHQ (Certified Professional in Healthcare Quality) in 2003 and her HACP (Healthcare Accreditation Certification Program) in 2014.

Laura currently is the Manager of Regulatory Compliance for Memorial Hermann Health System where she manages the mock survey process and actual survey process guiding teams to continual compliance with federal, state, and accreditor-specific requirements.

Mary Ellen DeBardeleben is the National Director of Quality at Encompass Health and has worked at the company since July, 2008. As the National Director of Quality, Mary Ellen works to identify, recommend, and implement improvements in Encompass Health’s capacity for establishing and using performance metrics to improve patient outcomes, regulatory compliance, and patient experience. Mary Ellen received her BS in Neuroscience from Vanderbilt University in Nashville, TN and her MBA and MPH in Health Care Organization and Policy at the University of Alabama at Birmingham.

Elisabeth Plush is the Director of Government Relations for Encompass Health and has been with the company for 6 years. She has knowledge and expertise in healthcare policy and regulatory issues and is responsible for lobbying Congress on legislative matters impacting inpatient rehabilitation providers. Prior to joining Encompass Health she worked on pharmaceutical policy and managed care issues. She attended Drexel University in Philadelphia for her undergraduate work and has an MPH from the University at Buffalo.

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).

Michael Jones is a Facility Specialist for CIHQ/ARS. Michael has more than 18 years of experience specializing in healthcare facilities operations.

Michael’s background includes Emergency Medical Services. He has held positions in Facilities Engineering, Construction, Grounds, Security, and Clinical Engineering Environmental Services.

Michael joined CIHQ in 2024 as a Facility Specialist Surveyor. He participates in the research and development of policies, tools and forms provided to clients via the ARS Resource Library.

Michael received his bachelor’s degree in Leadership, Education and Communications from Texas A&M University in College Station, Texas. He currently holds certifications for the HACP in Physical Environment, Infection Control, and CMS.

Nancy Stratton joined COLA as it's first Chief Executive Officer in the Company’s history to have worked as a medical laboratory technologist early in her career. With her commitment to expand its mission to serve more laboratories, COLA received approval to accredit laboratories performing tests in the specialty of pathology, including the subspecialties of histopathology, oral pathology and cytology.

Before moving into the CEO position for the division, Nancy held various management positions in which she guided her team to new levels of excellence in quality management, customer service, human resources, risk management, and regulatory and medical legal compliance.

With over 17 years of leadership experience, including a significant tenure as Director of Plant Operations at St. Tammany Health System, Richard Gallaher has a proven track record of overseeing the maintenance, life safety, and grounds departments of a large healthcare system.

Richard currently serves as an Adjunct Instructor for Northshore Technical Community College and President/CEO at Healthcare Maintenance Solutions, LLC. Richard provides valuable insights and training to healthcare organizations in compliance with regulatory standards.

Taylor Vaughn is a Facility Manager at Children’s Health in Dallas, Texas. In this role, she assumes responsibility for ensuring systemwide compliance with facilities-related regulatory compliance.

Additionally, Taylor is an esteemed Subject Matter Expert and Content Writer at Legacy FM, where she contributes her expertise to the development of tailored training materials for healthcare systems.

Taylor is also a Senior Consultant with Covenant Rock Consulting, providing guidance on Life Safety and Environment of Care Management. Taylor is the current President-Elect for the Texas Association of Healthcare Facilities Management (TAHFM).

Jennifer Crook is a Generalist Surveyor for CIHQ/ARS. Jennifer has more than 20 years of experience in healthcare including regulatory compliance and survey preparation.

Jennifer’s clinical background is in critical care with a focus in emergency medicine, intensive care, interventional radiology and cardiac catheterization laboratory. She has held both clinical and executive management level positions in Quality, Risk, Education, Infection Control and Regulatory Compliance.

Jennifer joined CIHQ in 2024 as a Generalist Surveyor. Her role also includes participation in the research and development of documents and alerts that are provided via Accreditation Resource Services (ARS).

Jennifer received a nursing degree from Marymount University in Arlington, Virginia. She is nationally certified in healthcare accreditation (HACP) for both CMS and PE.

Gina Miller is a Generalist Surveyor for CIHQ/ARS. Gina has more than 40 years of experience in healthcare including regulatory compliance and survey preparation. Gina’s clinical background is in nursing with a focus on emergency medicine. She has held clinical as well as executive management positions in Nursing, Case Management, Quality and Regulatory Compliance.

Prior to joining CIHQ, Gina served as the Director of Quality & Outcomes Management at Pomerene Hospital providing oversight of regulatory compliance, quality, infection prevention and medical staff.

Gina joined CIHQ in 2017 as a Generalist Surveyor and became a Lead Surveyor in 2018. She participates in the research and development of documents and alerts that are provided via Accreditation Resource Services (ARS).

Gina received her BSN from Alderson-Broaddus University and MSN from Western Governor’s University. She is nationally certified in healthcare accreditation (HACP).

Carrie Levake is a Generalist Surveyor for CIHQ/ARS. Carrie has more than 28 years of experience in healthcare including regulatory compliance and survey preparation.

Carrie’s clinical background is in nursing with a focus in acute care, internal medicine, and emergency medicine.

She has held both clinical and executive management level positions in Quality, Patient Advocacy, Infection Control, Laboratory and Regulatory Compliance. Prior to joining CIHQ in 2024 as a Generalist Surveyor, Carrie served as a State Health Surveyor providing oversight of state and federal regulatory compliance across multiple healthcare facilities.

Carrie received her nursing degree from the University of Wisconsin-Madison in Madison, Wisconsin. She is nationally certified in healthcare accreditation (HACP-CMS).

Paula Barnes is a Generalist Surveyor for CIHQ/ARS. Paula has 29 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.

Prior to joining CIHQ, Paula served as a Corporate Regulatory Compliance & Accreditation Specialist providing regulatory consultation services for a large healthcare system in Eastern NC.

Paula joined CIHQ in 2019 as a Generalist Surveyor. She participated in the development and maintenance of resource documents provided by Accreditation Resource Services (ARS).

Paula received her BSN from East Carolina University and her MBA from the University of Phoenix. She is nationally certified in healthcare accreditation (HACP) for both CMS and IC.

Before pursuing a law career, Alison Hollender worked at Cook Children’s Healthcare System and earned a Master’s in Healthcare Administration. Both experiences gave her an inside view of healthcare organizations.

Today, Alison provides counsel on licensure and certification of healthcare facilities, regulatory compliance and operations, Medicare and Medicaid reimbursement, and corporate healthcare transactions.

She represents individual healthcare professionals, hospitals and health systems, and ambulatory surgical centers. Alison regularly helps clients license and accredit new facilities, relocate, undergo mergers and changes of ownership, and navigate transactions in compliance with healthcare regulations.

If he’s not already, Brad Nieder, MD, CSP*, will soon be on your list of favorite doctors. He’s also a funny motivational keynote speaker and master of ceremonies. Yes, Dr. Brad–“The Healthy Humorist®”–is unlike any other doctor you’ve encountered.

Dr. Brad has been a professional keynote speaker for nearly 20 years. He earned the Certified Speaking Professional (CSP) designation in 2011 and is simply one of the best conference speakers and clean comedians in the meetings industry today.

Described as “Jerry Seinfeld with an ‘MD,’” the funny doctor was infected with the comedy bug while watching Johnny Carson’s “Tonight Show” monologues from the foot of his parents’ bed.

He was a founding member of an improvisational troupe (The Simps) while an undergraduate student at Stanford University. He also performed clean standup comedy throughout Denver while he was in medical school at the University of Colorado.

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