Hospital Management
Grievances and Complaints: Ensuring Hospitals Compliance with the CMS CoPs, Joint Commission, DNV Standards and OCR
Hospitals that accept Medicare or Medicaid reimbursement must comply with the CMS Conditions of Participation. The CMS grievance requirements have been a frequent source of deficiency citations. The grievance standards for acute hospitals are in the patient rights section of the Conditions of Participation manual. Although there is no similar section for Critical Access Hospitals, and the requirements for a..
Implementing ISO 27799 - Information Security Management in Health Information
The session will begin with an overview of ISO 27799, its objectives, and its importance in the healthcare sector. Attendees will learn about aligning their existing security practices with ISO 27799 standards, thereby enhancing their overall information security posture. Emphasis will be placed on risk assessment, control measures, and continuous monitoring to identify and mitigate potential vulnerabilitie..
Stark After Tuomey, Intermountain Health, Akron General, Prime Healthcare and Kalispell Regional
The session will provide an overview of the physician anti-referral law (known as Stark II), and its available exceptions. It will also show how violation of Stark II can raise FCA concerns, and it will provide an assessment of enforcement activities, showing how participants may be at risk. In addition, the session will review recent cases and show how they potentially impact participants.Claims filed by h..
Sexual Harassment in the Age of Social Media - Investigation, Assessment and Prevention Strategies
Given the ease of receiving and viewing sexually explicit materials on cell phones, computers, and social media, employers, as well as employees, should be concerned about preventing sexual harassment in the workplace. This workshop will focus on the issue of sexual harassment and how to prevent it in the workplace. It will provide an overview of sexual harassment, sex discrimination, its definiti..
The CMS Hospital Infection Prevention and Control and Antibiotic Stewardship Program: CMS Compliance Requirements 2025
A hospital must have an active infection control program throughout the facility to track, prevent and control infectious diseases, including Healthcare Associated Infections, or HAIs. Additionally, the hospital must have a program for the optimization of antibiotic use through stewardship. This program will discuss the changes CMS made to the infection control standards in 2019, and the interpretive guidel..
Physician Employment Agreements: Problem Areas that can be Landmines
We will review the elements of the physician employment agreement that can cause the greatest problems, focusing on the pitfalls and the complications that can develop when the parties do not fully understand what is being agreed to. Such items as corporate practice, term and termination, termination for cause, duties of the physician, call, non-compete clauses, and compensation are all items that should be..
The Coherent Organization: Sustainable, Healthy, Compassionate, Effective
The Coherent Organization is based on a model for organizational performance developed by Bruce Cryer called Inner Quality Management. There are four tenets of IQM, outlined in Bruce’s book, From Chaos to Coherence.Internal Self-ManagementCoherent CommunicationBoosting Organizational ClimateStrategic Processes of RenewalBruce worked with corporations, government agencies, health systems, and academic instit..
Informed Consent Update: Maneuvering the Maze Towards Compliance
Centers for Medicare and Medicaid (CMS) and the accrediting organizations, such as The Joint Commission (TJC) and DNV have certain elements required for informed consent. This program will discuss the current CMS hospital Conditions of Participation (CoPs), including critical access hospitals, Joint Commission, and DNV Healthcare standards, on informed consent requirements. There are three different section..
The Disruptive Practitioner: A Danger to the Hospital's Operation
Most disciplinary policies are progressive. A progressive policy applies increasingly more severe sanctions to additional incidents of bad behavior. It is very important that the organized medical staff have a disruptive practitioner policy. This webinar will discuss the development of such a policy, including what it should include, and how it should be implemented. It is also important to understand what ..
Medical Staff and Telemedicine: Meeting CMS Conditions of Participation and the Joint Commission Standards
Any hospital that accepts Medicare and Medicaid payments must comply with the regulations known as Conditions of Participation. The Centers for Medicare and Medicaid Services (CMS) hospitalCoPs have sections on all aspects of patient care including medical staff and telemedicine. The medical staff section includes information on credentialing and privileging requirements, implementing Medical Staff (MS) byl..
Paying for Referrals: A Danger to Your Freedom
The session will provide an overview of the Anti-Kickback Statute (AKS) and review what it prohibits, as well as review the Statute’s available safe harbors. It will also show how violation of the AKS can raise FCA concerns, and it will provide an assessment of enforcement activities, showing how participants may be at risk. In addition, the session will review recent cases and show how they potentially imp..
Complying with OCR Section 1557: Discrimination, Interpreters, Required Signs,and More
This webinar will discuss a law that applies to all hospitals, including critical access hospitals, and other healthcare providers such as physician offices and nursing homes. The law addresses nondiscrimination, required signs and notices, interpreters, a civil rights law for healthcare providers and others and more under Section 1557 of the Affordable Care Act. It forbids discrimination based on sex, race..
The Federal Anti-Kickback Statute And Stark Law: What Physicians, Hospitals and Other Providers Need to Know
This webinar will focus on the Anti-Kickback Statute (AKS) and Stark Law (Stark), the federal anti-referral legislation, with an in-depth discussion of each and their relationship with the federal False Claims Act. It will also provide a review of enforcement priorities by the Office of the Inspector General (OIG) and Department of Justice (DOJ), as well as cases that are pertinent to these enforcement acti..
Nursing:CMS CoP Standards for Hospitals
Every hospital that accepts Medicare and Medicaid reimbursement must follow the CMS (Center for Medicare and Medicaid Services) Conditions of Participation (CoPs) and it must be followed for all patients. This program will cover the nursing services section in the hospital CoP manual. Facilities with Deemed Status accredited by the Joint Commission, Health Care Facility Accreditation Program, CIHQ, and DNV ..
How to Stay Compliant: A Deep Dive into Recent Anti-Kickback Statute Enforcement Actions
This webinar will provide an in-depth review of recent enforcement actions taken by the HHS OIG. We will also briefly review the Anti-Kickback Statute (“AKS”), discuss any new safe harbors, and OIG Advisory Opinions that have been issued. Areas Covered The AKS New Anti-Kickback Safe HarborsNew OIG Advisory OpinionsEnforcement Actions taken by OIGWho Should AttendHospital executives, particularly CEOs, COOs,..