2025 Accreditation & Regulatory Summit

Are You Gambling with Compliance

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Featured Topics

Speaker: Richard Curtis, RN, MS, HACP-CMS

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!

Speaker: Jennifer Crook, RN, CPHRM, HACP-CMS, HACP-PE

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.

Speaker: Gina Miller, MSN, RN, HACP

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.

Speaker: Jennifer Vavrinchik

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.

Speaker: William Kinch, MBA, HACP-PE

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.

Speaker: Nancy Stratton

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.

Speaker: Michael Jones BA, HACP-PE

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.

Speaker: Lara Burnside

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.

Speaker: Richard Gallaher

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.

Speaker: Helen McKnight, PharmD, MBA, BCSCP

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.

Speaker: Alison Hollender

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.

Speaker: Carrie Levake, RN, BSN, HACP-CMS

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.

Speaker: Richard Curtis, RN, MS, HACP-CMS

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.

Speaker: Laura Rhoads MBA, CPHQ, HACP

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.

Speaker: Taylor Vaughn

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.

Speaker: Richard Curtis, RN, MS, HACP-CMS

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.

Speaker: Paula Barnes, MBA, BSN, RN, HACP

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.

Speaker: Jerry Shafran

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.

Speaker: Jody Randall MSN, RN, CIC, HACP-CMS

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.

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!

Speaker: David Balat

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.

Speaker: Brian Betner

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.

Speaker: Mary Ellen DeBardeleben MBA, MPH, CJCP

Speaker: Elisabeth Plush

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.

Speaker: Brad Neider

“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.

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