2025 OAHE Fall Conference Agenda

Navigating CMS and AO Surveys: Best Practices for Compliance and Preparation

Session Abstract

On-site tri-annual surveys conducted by CMS and Accreditation Organizations are critical assessments that evaluate healthcare facilities' adherence to regulatory standards and quality measures. This presentation will equip participants with essential best practices for effectively preparing for and navigating these surveys, ensuring smooth, successful outcomes, and ongoing compliance with CMS Conditions of Participation and Accreditation Organization standards.

The session will focus on understanding the survey process, from pre-survey preparations to post-survey follow-up. Attendees will gain insights into common surveyor expectations, the critical areas of focus during the survey, and the importance of readily organizing documentation. Additionally, the presentation will address the significance of staff training, proactive risk management, and ensuring that all policies, procedures, and practices align with regulatory requirements.

A key focus will also be handling the new CMS concurrent validation process. This emerging practice allows real-time compliance validation during the survey process and requires healthcare facilities to be well-prepared for simultaneous documentation review and feedback. Participants will learn strategies for handling this concurrent validation, ensuring that all necessary data and evidence are readily available and that any issues identified during the survey can be promptly addressed to avoid findings or delays in certification.

Proper etiquette for surveyor scribes and escorts will also be highlighted. Attendees will learn the roles and responsibilities of scribes, who document the surveyor's findings, and escorts, who accompany surveyors throughout the facility. Key topics will include maintaining professionalism, respecting confidentiality, facilitating smooth communication, and fostering a collaborative and transparent environment with the surveyors.

Practical strategies for fostering a survey-ready culture within the facility will be covered, emphasizing continuous improvement, mock surveys, and real-time issue resolution. Participants will also learn how to respond to survey findings, develop corrective action plans, and maintain ongoing compliance to avoid penalties or negative survey outcomes.

By the end of the session, attendees will have a comprehensive understanding of the survey process, the best practices required to manage the CMS or Accreditation Organization tri-annual survey confidently and effectively, the proper etiquette for interacting with surveyors, and how to handle the CMS concurrent validation process, ultimately contributing to improved healthcare quality, safety, and compliance.

Speaker:  Michael Jones, CHSP, CHCM, HACP-PE, HACP-IC, HACP-CMS - Principal Consultant, Covenant Rock Consulting

Mike has over 19 years of experience and expertise in Environment of Care, Life Safety, and Emergency Management and is well-versed in CMS, Joint Commission, DNV, CIHQ, AAAHC, NFPA, OSHA, EPA, and DOT codes and standards.

He has served in multiple leadership roles throughout his career. Working in a variety of Hospitals and associated offsite Emergency Departments, Ambulatory Surgical Centers, and Clinics, he conducted internal accreditation audits for Life Safety, Environment of Care, and Emergency Management, provided direction & assistance to all levels of leadership in the development & application of life safety, employee safety, environmental protection, and emergency management programs, and developed and implemented standardized Life Safety policies, procedures and permit forms for multiple Acute Care Hospitals.

His current certifications include Certified Healthcare Safety Professional (CHSP), Certified Hazard Control Manager (CHCM), Certified Six Sigma Green Belt (CSSGB), Healthcare Accreditation Certification Program (HACP) – CMS, Infection Control, and Physical Environment, HVAC Fire and Life Safety Inspections Certification, Certified OSHA 30, Incident Safety Officer Certification, Incident Command System for High Rise Operations (NFA) Certification, FEMA MGT-457, NIMS 100, 200, 700, 800, SFFMA Firefighter 1, Emergency Medical Technician (2002-2014), Department of Transportation Training for Regulated Medical Waste and Hazardous Waste, Hazardous Materials (CFR 40).

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Normalizing Conversations about Mental Health & Wellness of a Healthcare Facility Manager and a Healthcare Construction Contractor (Panel Discussion)

Abstract

The term mental has historically carried a negative stigma, but in today’s society, open conversations about mental health are increasingly normalized and essential—especially in high-pressure industries. This presentation explores the evolving dialogue around mental health through the lens of healthcare facility management and construction. With soaring inflation, prolonged supply chain disruptions, a shrinking skilled labor pool, and relentless expectations to achieve more with less, professionals in these roles face unprecedented stress. Through an open and candid discussion, a Healthcare Facility Manager and a Healthcare Construction Contractor will share real-world mental health challenges they encounter daily. Attendees will gain practical insights and coping strategies aimed at fostering resilience and promoting mental wellness in the face of professional adversity.

Speaker #1 - Ruben Garcia

Speaker Experience

Ruben Garcia is a Life Safety and Physical Environment consultant who has been very active in the industry for over 15 years. He is a national speaker and has presented at the NFPA Conference and multiple healthcare facility state chapter conferences.

Speaker Biography

Ruben Garcia is the Market Director of Facilities Management for CommonSpirit Health. He is also a life safety surveyor for AAAHC. He is a Certified Healthcare Facility Manager, Certified Healthcare Constructor, Certified Fire Protection Specialist, Certified Fire Inspector I, Certified Life Safety Healthcare Facility Manager, Certified Fire Door Inspector, and NICET Certified in Fire Alarms. 

Speaker #2 - Jesse Flores

Speaker Experience

Vice President of Business Development and Strategic Planning at Acme Architectural Hardware. I have been in the fire door and door hardware industry for over 20 years.

Biography

COO at Acme Architectural Hardware with over 20 years in the door and hardware industry. I aim to be an industry leader in developing the future of fire door compliance. I have successfully built the best fire door inspection and remediation team in Houston, TX. Inventor/Entrepreneur

Speaker #3 - Jacqueline Marroquin

Speaker Experience

Jacqueline has presented at the Annual TAHFM Conference in 2023 and 2024.

Biography

Jacqueline is currently the Facilities Director at Methodist Hospital Specialty and Transplant, a 384-licensed bed facility in San Antonio, TX. Her previous position as a Facilities Coordinator is what led her career into Facilities Management and provided her with multiple opportunities to gain ample knowledge of the FM world and gain the leadership skills needed to promote within her organization.

Jacqueline firmly believes that the key to successful leadership is influence, not authority. She believes in using your vision and values as a compass to help guide and maintain a sense of what is important as you steer toward your goals. Teamwork is a key aspect of her beliefs in the FM world. She strives to create a more supportive, positive culture that will create a climate of psychological safety, promoting a learning environment for all.

Jacqueline not only fosters a continuous learning culture, she leads by example. She obtained her CLSS-HC in April of 2022 and graduated with her Bachelor’s in Healthcare Administration in December of 2022. She is also enrolled at Texas A&M for her MBA and is actively working on obtaining her CHFM and PMP.

Being a part of TAHFM has provided Jacqueline with a plethora of educational opportunities, resources, and a network of friendships she has instilled in her career path, allowing opportunities for growth and mentorship.

Speaker #4 - Thomas Johnson

Biography

Thomas helps high-achieving leaders move from stress and uncertainty to clarity, execution, and sustained impact. His work integrates performance psychology, leadership strategy, and Acceptance and Commitment Therapy (ACT) principles, ensuring his clients develop the self-awareness, psychological flexibility, and leadership presence necessary for long-term success. His approach is direct and strategic—helping leaders make high-stakes decisions, manage team dynamics, and take decisive action despite fear, doubt, or external pressures.

With nearly a decade of experience as a facilitator, entrepreneur, and leadership partner, TJ has worked with founders, executives, Fortune 500 professionals, and elite athletes. His partnerships with high performers ensure they develop the clarity, systems, and execution strategies necessary to thrive in complex environments. His work is particularly impactful for CEOs, founders, and high-stakes decision-makers who need to balance growth, relationships, and execution while maintaining long-term sustainability.

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Contain the Chaos: Navigating Regulatory Standards and Life Safety

This course provides a comprehensive understanding of life safety, ICRA containment, passive smoke & fire  protection and disaster restoration, emphasizing inspection, repair, compliance, and emergency response. Participants will learn how to assess risks, implement mitigation strategies, and restore facilities impacted by fire, hazardous materials, and environmental hazards. The curriculum incorporates industry best practices, regulatory requirements, and hands-on applications to enhance safety, compliance, and operational resilience.

Learning Objectives:

• ICRA Containment: Prevents infection spread during healthcare construction by using dust control, airflow management, and temporary barriers to protect patients, staff, and visitors from healthcare-associated infections (HAIs).
• Identify and apply safe practices for Asbestos Abatement, including identification, removal, and disposal to protect occupant health.
• Review Regulatory Compliance & Industry Standards, including OSHA, NFPA, and EPA regulations governing facility management.
• Understand Emergency Response & Risk Mitigation by developing response plans and strategies for minimizing disruption and ensuring swift recovery.
• Recognize proper Firestop systems and products, their properties, and their role in achieving compliance.

Speaker:  Tim Proodian

Tim is a distinguished American Society of Healthcare Engineering (ASHE) speaker and subject matter expert focusing on healthcare smoke and fire barrier compliance.  Tim has been in the healthcare industry for over 25 years, working with hospitals across the southern part of the United States.  Tim also works with facilities to streamline their pre-construction risk assessments, Infection Control Risk Assessments. Assisting healthcare facilities with performance improvement to increase life safety accountability and compliance with new construction and existing facilities. He is heavily involved with CMS, Joint Commission, and DNV in finding life-safety solutions that keep the facilities compliant with current life-safety standards.

His primary responsibility is to assist hospitals in working on keeping their smoke & fire barriers compliant.  He provides onsite training and certifications for engineers and contractors who may work above the ceilings.  Tim is also involved with the architects, engineers, and general contractors in healthcare, providing AIA certification training with a focus on firestop design in healthcare environments.

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