Hospital staff don’t always understand the Medicare conditions of participation (CoPs) and that even accredited hospitals, such as Joint Commission on Accreditation of Healthcare Organization (JCAHO) or Det Norske Veritas (DNV) hospitals, must comply with Medicare CoPs in order to receive Medicare funding. There are commonly cited deficiencies throughout the nation during standard surveys and complaint investigations. This presentation will identify the top-cited regulations and why the regulations are found to be out of compliance.

• Describe and discuss why an accredited hospital must comply with CMS regulations.
• Explain the implications of a condition level deficiency.
• Describe the most commonly cited deficiencies.
• Explain the regulation and the related interpretative guidelines for each deficiency.

This program is intended for general acute hospitals including JCAHO and DNV accredited hospitals, non-accredited hospitals and CAHs including staff such as CEOs, CMOs, CNPs, nurses, case management staff, discharge planning staff quality improvement staff, JCAHO/DNV liaison staff and others responsible for ensuring compliance with the regulations.

Nancy Ruzicka is a recognized expert on state and federal rules, regulations and interpretative guidelines who has presented at many organizations and educational events. She previously worked as director of integrity and compliance and privacy official at Mercy Medical Center-Des Moines, director of regulatory compliance at UnityPoint Health, Des Moines and has more than 20 years of experience with the Iowa Department of Inspections and Appeals. Ruzicka holds master’s degrees in health law and business administration and a bachelor’s degree in pharmacy, all from Drake University. She is certified in health care compliance and maintains her Iowa pharmacy license.