1. business and industrial
2. business operations
3. business plans

SETI Agenda – Monday, April 13, 2015 (Day 1)
7:30 AM
Registration
30 min
Fitzgerald Ballroom
8:00 AM
Welcome & Introduction
Thomas E. Hamilton – Director, Survey & Certification Group
Renard Murray – Acting Consortium Administrator for Quality Improvement and Survey & Certification Operations
Kathryn McCanna – President, Association of Health Facilities Survey Agencies
15 min
8:15 AM
Overview and Objectives
Anita Segar – Director, Survey & Certification Training
5 min
8:20 AM
Keynote Speaker – Plenary Training 1
Rear Admiral Nicole Lurie, MD, MSPH - Assistant Secretary for Preparedness and Response (ASPR)
70 min
9:30 AM
State of the Survey
Thomas E. Hamilton – Director, Survey & Certification Group
30 min
10:00 AM
Driving Quality through Value-Based Purchasing – A Companion to Survey & Certification –
Plenary Training 2
Jean Moody-Williams – Deputy Director, Center for Clinical Standards and Quality
30 min
10:30 AM
Break
15 min
10:45 AM
Breakout Training
90 min
Duncan (2nd Floor)
John Owens (2nd Floor)
Fitzgerald Ballroom
DACS (1A)
Small Hospitals and Critical
Access Hospital (CAH) Inpatient
Services
How Much Is Enough for CAHs &
Small Hospitals?
• Revised CAH Guidance
• Why we don’t define what it
means for a hospital to be “primarily
engaged” in providing inpatient
services?
DCCP (1B)
Division of Continuing Care Providers Efficiency and Effectiveness
Initiatives
DCCP has four focused survey processes in various stages of development
which will decrease overall onsite survey time while increasing the productivity of the actual onsite survey time. In addition, DCCP has converted
all their basic training courses to a web-based format and has completed
evaluations as to the effectiveness of this format.
DNH (1C)
Update on Focused Surveys
Status, findings, and next steps
for each focused survey type
Presenters: Marilyn Dahl, Kianna
Banks
Presenters: Peter Ajuonoma, Don Howard, Melissa Rice, Patricia Sevast,
Annette Snyder
Presenters: Evan Shulman, Alice
Bonner, Michele Laughman,
Shelly Ray, Marianne Culihan,
Cathleen Lawrence
12:15 PM
Lunch
75 min
1:30 PM
Breakout Training
90 min
3:00 PM
Duncan (2nd Floor)
John Owens (2nd Floor)
Fitzgerald Ballroom
DACS (2A)
Key Changes in Critical Access
Hospital Regulations and
Guidance
• What’s changed?
• Key differences from hospital
requirements
DCCP (2B)
Certification Communication
This presentation will discuss
proposed changes in the State
Operations Manual (SOM) regarding
procedures, tools, and timelines for
communication between Survey
& Certification and the Medicare
Administrative Contractors (MAC)
referencing both the SOM and the
Program Integrity Manual.
DNH (2C)
§483.13 Resident Behavior and Facility Practices/Case Law
Relating to Abuse and Neglect/Elder Justice Act–Reporting
Reasonable Suspicion in a Long-Term Care Facility
• Description of Departmental Appeals Board (DAB) cases related to this
issue
• Survey & Certification guidance related to abuse, neglect and misappropriation
• Reporting requirements in Elder Justice Act
Presenters: Kianna Banks, Anita
Moore
Presenters: Peggye Wilkerson,
Frank Whelan
Presenters: Nadine Renbarger, Jennifer Jaffe, Karen Tritz
Break
15 min
Duncan (2nd Floor)
John Owens (2nd Floor)
Fitzgerald Ballroom
Fitzgerald Ballroom
3:15 PM
Division Meetings
Dallas
ARA: Gerardo Ortiz
Division Meetings
Western
ARA: Steve Chickering
Division Meetings
Midwest
ARA: Nadine Renbarger
Division Meetings
Northeast
ARA: William Roberson
4:45 PM
Adjournment
90 min
SETI Agenda – Tuesday, April 14, 2014 (Day 2)
Fitzgerald Ballroom
8:00 AM
CMS Awards
15 min
8:15 AM
Complaint Investigation Planning for States – Plenary Training 3
Sharon Lash, Jan Tarantino, Kathryn McCanna
60 min
9:15 AM
Survey & Certification Group Infection Prevention and Control Update – Plenary Training 4
Dan Schwartz, MD, MBA – Medical Director, Survey & Certification Group
Karen Hoffmann, RN, BSN, MS FSHEA – Infection Preventionist, Infection Control Consultant, Survey & Certification Group
45 min
10:00 AM
Break
15 min
10:15 AM
Regional Healthcare Ecosystem Analyst (RHEA) – Plenary Training 5
Bruce Y. Lee, MD, MBA – Director of Operations Research at the Johns Hopkins Bloomberg School of Public Health
60 min
11:15 AM
Carbapenem-Resistant Enterobacteriaceae (CRE) – Plenary Training 6
Shari Ling, MD – Deputy Chief Medical Officer, CMS
30 min
11:45 AM
Lunch
75 min
1:00 PM
Breakout Training
90 min
Duncan (2nd Floor)
John Owens (2nd Floor)
Fitzgerald Ballroom B & C
Fitzgerald Ballroom A
DACS (3A)
Shared Electronic Health Records
(EHR)
• Recognize permitted disclosures of
protected health information under
the Health Information Portability
and Accountability Act (HIPAA).
• Discuss sharing of EHRs permitted
under HIPAA and does not violate
the Condition of Participation (CoP)
or Condition for Coverage (CfC) for
medical record requirements.
DCCP (3B)
Intermediate Care Facilities for
Individuals with Intellectual
Disabilities Quality Assurance
Project
DCCP completed QA reviews for two
ICF/IID W-tags in 2014 and plans
to complete additional reviews in
2015. The results of these reviews
have identified a need for increased
surveyor interview skills and
improved documentation of findings
with a clear need for more thorough
in-house review before release of the
Form CMS-2567.
DNH (3C)
Nursing Home Facility Closure—
Survey Process and Enforcement
Requirements
• Overview of facility closure
regulations
• What’s required?
• Who does what in facility closure
process, role of Medicaid agency and
state licensure?
DACS (3D)
Determining Independent
Compliance of Co-located
Hospitals
• What do State Survey Agencies (SA) need to know about
Medicare hospital payment
classifications?
• How is independent compliance evaluated?
Presenters: Erin McCoy, Marilyn Dahl
Presenters: Melissa Rice, Sandra
Phelps
Presenters: Peggi Leoni, Ginger Odle,
Michael Cook
Presenters: David Eddinger,
Lisa Marunycz
2:30 PM
Break
15 min
2:45 PM
Breakout Training
90 min
Duncan (2nd Floor)
John Owens (2nd Floor)
Fitzgerald Ballroom B & C
Fitzgerald Ballroom A
DACS (4A)
Hospital, Ambulatory Surgical
Center, Rural Health Clinic, and
Federally Qualified Health Center
Update
• Patient Safety Initiative
• Complaint investigations
• Fiscal Year 2016 Ambulatory Surgical Center (ASC) infection control
worksheet plans
• Recent regulatory changes and
updates to interpretive guidelines
• Compounded preparations
DCCP (4B)
Flying Forward: Managers and
the New End Stage Renal Disease
(ESRD) Core Survey Process
The purpose of this Quality Assurance Efficiency and Effectiveness
(QAEE) Initiative is to increase the
efficiency of the traditional ESRD
survey process while maintaining a
highly-effective survey process.
DNH (4C)
Long Term Care Efficiency and
Effectiveness
• Addressing Long Term Care (LTC)
complaint workload
• Nursing Home Survey Evaluation
Summary
DCCP (4D)
Community Mental Health
Centers (CMHCs)
Effective October, 2015 State
Survey Agencies began survey
of CMHCs. This presentation
will discuss the cut-over process
as well as frequently asked
State Agency questions and
issues concerning the survey
and certification of the provider
type.
Presenters: Mary Ellen Palowitch, Erin
McCoy, Shonte Carter, Anita Moore
Presenters: Judith Kari, Joseph
Messana, MD
Presenters: Kathryn McCanna,
Laura Hudspeth, Karen Tritz, George
Banville
Presenter: Don Howard
Duncan (2nd Floor)
Fitzgerald
4:15 PM
AHFSA Leadership Meeting
CMS & Regional Office Leadership Meeting
5:15 PM
Adjournment
60 min
SETI Agenda – Wednesday, April 15, 2014 (Day 3)
8:00 AM
Registration Area
Fitzgerald Ballroom
Morning Networking
(SA Directors late breakfast networking opportunity)
Combined CMS/AHFSA Leaders’ Meeting –
“Leadership Issues Meeting”
75 min
Fitzgerald Ballroom
9:15 AM
Best Practices for State Agency Directors: Doing More with Less – Plenary Training 7
Dorya Huser Robinson, Michael Cook
60 min
10:15 AM
Break
15 min
10:30 AM
CMS Updates & Awards
Updates – Question and Answer Session
120 min
Karen Tritz – Director, Division of Nursing Homes
Sarah Bennett – Division of Clinical Laboratory Services
Marilyn Dahl – Director, Division of Acute Care Services
Peggye Wilkerson – Deputy Director, Division of Continuing Care Providers
Thomas E. Hamilton – Director, Survey & Certification Group
Anita Segar – Director, Survey & Certification Training
12:30 PM
Adjournment