AHCA/NCAL Quality & Regulatory Workshop

AHCA/NCAL Quality & Regulatory Workshop

February 27 & 28, 2020 

Ala Moana Hotel (Garden Lanai Room)

Registration and Continental Breakfast opens at 7:30 am; Workshop is from 8:30 am – 4:00 pm

OverviewAgendaContinuing Education CreditsRegistrationFees/PaymentHotel Information and Parking


The Healthcare Association of Hawaii (HAH) is pleased to welcome the American Health Care Association’s (AHCA’s) Quality Team to Honolulu!  We begin this workshop with a focus on quality and regulatory changes for nursing facilities, updates on the Patient-Driven Payment Model (PDPM), Phase III Requirements of Participation (ROP), and survey trends.

For the second day of the workshop, we invite our ALF and ARCH members to join us as the AHCA team delves into Quality Strategies, utilizing LTC Trend Tracker and data to improve performance, Infection Prevention and Control, and creating a safe environment for staff and residents.

Learning Objectives:

Attendees of this workshop will:

  1. Describe the Quality Strategy and implementation of core practices into every day care processes
  2. Examine the Phase III Requirements of Participation and the impact on long-term care facilities
  3. Identify survey trends and solutions to combat the common F-Tag citations
  4. Explain the Hawaii Medicaid VBP program and how to succeed
  5. List the functional outcomes and how to make improvements under PDPM
  6. Implement processes to get to the root cause of infection prevention and control
  7. Identify steps to create an environment of safety for staff and residents
  8. Designate strategies to combat the workforce shortage and explore effective solutions



David Gifford, MD, MPH
Senior Vice President of Quality & Regulatory Affairs
American Health Care Association

David Gifford, MD, MPH, is the Senior Vice President of Quality and Regulatory Affairs at the American Health Care Association, the largest association in the country representing long term and post-acute care facilities. He helped create the department which assists providers in their quality improvement efforts and works with Administration officials on regulations and policies impacting the profession. Dr. Gifford also serves on the Board of the Advancing Excellence in America’s Nursing Homes campaign and the Baldridge Foundation Board.

He is a former Director of the Rhode Island State Department of Health, where he received the National Governor’s award for Distinguished Service Award for State Officials and was a semi-finalist for the Harvard Kennedy School of Government Innovations in Government award for work on the nursing home survey process.

Prior to that he served as Chief Medical Officer for Quality Partners of Rhode Island where he directed CMS’ national nursing home-based quality improvement effort. He received his medical degree from Case Western Reserve University and conducted his geriatric fellowship at UCLA where he also earned his Master’s in Public Health in Epidemiology.


Holly Harmon, RN, BSN, MBA, LNHA, FACHCA
Vice President, Quality, Regulatory & Clinical Services American Health Care Association

Holly Harmon, RN, MBA, LNHA, FACHCA brings both passion and a wealth of practical, real-world, clinical and operational experience to her role as Vice President, Quality, Regulatory & Clinical Services at AHCA. Her extensive service in a wide array of settings including post-acute care, long term care, residential care, assisted living, independent living, a psychiatric hospital and occupational health have provided her with insights, knowledge, skills and innovative ideas which she exuberantly shares with others.

In addition to her vast clinical experience, Ms. Harmon has put her dynamic energy into leading the statewide Maine Culture Change Coalition/LANE as President, the Maine Partnership to Improve Dementia Care in Nursing Homes as Co-Chair, Vice-President of American College of Health Care Administrators, Maine Chapter and the Maine LANE Co-Convener for the national Advancing Excellence in America’s Nursing Homes Campaign. She also served as the Director of Quality Improvement & Regulatory Affairs at the Maine Health Care Association.

She puts her boundless energy and warm and energetic personality into training, education and presenting both, nationally and locally. She has made simplifying the complex world of long term and post-acute care policy and practice an art.


Pamela Truscott, MSN, RN, DNS-CT, QCP
Senior Manager, Clinical and Regulatory Services
American Health Care Association

Pamela Truscott, MSN, RN, DNS-CT, QCP is the Senior Manager, Clinical and Regulatory Services with the American Health Care Association (AHCA).  She joined the AHCA family in June 2019 and has been actively involved with a variety of education, tools and resources such as: trauma-informed care, behavioral health, functional outcomes improvement, and infection prevention and control.  Prior to joining AHCA, Pam worked for the Nebraska Health Care Association as the Vice President of Professional Development for seven years.  She is an active member in the American Nurses Association as well as the American Association of Post-Acute Care Nurses.  Pam has over 20 years of long-term care experience and shares a passion for growing education and cultivating new leaders in long-term care.

Agenda for Thursday, February 27, 2020
(for SNF)
Time Topic Description
8:30 – 9:00 am Welcome and Goals for the Day
  • Welcome icebreaker
  • Review of agenda and goals
9:00 – 10:00 am Setting the Stage: Where we have come from, where we are now, where we are going
  • Overview of major quality and regulatory changes in long term care, current priorities, future goals
    • Including Hawaii Quality Initiatives, SNF QRP, SNF VBP, Five Star, Nursing Home Compare, PBJ, PDPM, Legislative activity, CMS Quality Strategy, Phase II to Phase III, status of proposed rule on Burden Reduction, Population Health initiatives)
  • Your struggles, surprises, and success stories from the past year
10:00 – 10:45 am PDPM Evaluation: Functional Outcomes
  • CMS interest in PDPM
  • National trends to date
  • Doing the Right Thing in the Right Way
  • Functional outcomes: Best practices for improvement & measurement
  • Care planning & supportive documentation
10:45 – 11:00 am Break
11:00  am – 12:00 pm How to Succeed under Hawaii Medicaid VBP
  • Overview of Program
  • Where to start and focus?
  • Using QAPI & Core Practices
  • Applying QAPI to rehospitalizations, pressure injury, LS CAUTI, LS AP use
12:00 – 1:00 pm Lunch
1:00 – 2:00 pm Phase III Requirements of Participation
  • Phase III ROPs
  • Interpretive Guidance
  • Operationalizing Phase III
2:00 – 3:00 pm Survey Trends & Solutions
  • Trends in deficiency citations and other themes across Phase 1-3 and new survey process
  • HI/Region/Nation: Top Tags
    • Explore what are the most pressing survey/ROP issues in HI currently
  • New AHCA tools and resources to help members with regulatory compliance
3:00 – 3:30 pm Wrap Up/Q&A
  • Recap key takeaways
  • Share “aha” moments
  • Reflect on actions for follow up
  • Q&A
3:30 pm Adjourn


Agenda for Friday, February 28, 2020
(for SNF, ALF and ARCH)
Time Topic  Description
8:30 – 8:45 am Welcome and Goals for the Day
  • Review of agenda and goals
  • Reflections/questions from Day 1
8:45 – 9:45 am Quality Strategy Part 1: Doing the Right Thing in the Right Way – Core Practices
  • Quality Strategy
  • Core Practices
  • Quality Initiative
  • Quality Awards
9:45 – 10:45 am Quality Strategy Part 2: Doing the Right Thing in the Right Way – Implementation of Core Practices
  • Art of Implementation
  • How To
  • Challenges and Success Stories
10:45 – 11:00 am Break
11:00 – 11:30 am LTC Trend Tracker:  Why Use it
  • Using data to inform practice
  • Learning from tracking & trending data over time
  • How to use LTC Trend Tracker data/reports
11:30 am – 12:00 pm Infection Prevention and Control: Getting to the Root Cause
  • Latest survey learnings
  • Common & emerging issues
  • Reliable solutions
  • Using QAPI approaches
12:00 – 1:00 pm Lunch
1:00 – 1:45 pm Creating a Safe Environment Part 1: Staff
  • Establishing a safe culture & environment
  • Healthcare worker assault
  • Getting to the root causes
1:45 – 2:30 pm Creating a Safe Environment Part 2: Residents
  • Establishing a safe culture & environment
  • Abuse & neglect prevention and investigation (including resident to resident)
  • Seeking to understand
2:30 – 3:00 pm Workforce Solution: Coaching Approach
  • PHI Coaching Approach
    • Key pointers
    • Story sharing
3:00 – 3:30 pm Wrap Up/Q&A
  • Recap key takeaways
  • Share “aha” moments
  • Reflect on actions for follow up
  • Q&A
3:30 pm Adjourn


This continuing nursing education activity was approved by Oregon Nurses Association, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation for up to 11.5 contact hours. Approval valid through 02/27/2022. OCEAN ID #2020-03.

This program is approved by the National Association of Social Workers – Hawai’i Chapter (Approval HI62792020-129) for up to 11.5 Social Work continuing education contact hours.

State licensure boards have final authority on the acceptance of individual courses.
There is no conflict of interest for any planner or presenter with this learning activity.

To receive a Certificate of Completion, each participant must pay the registration fee, sign-in each day and complete the evaluation at the end of the workshop.  The number of contact hours issued is commensurate with participation.  Contact Lori Henning at lhenning@hah.org for more information.

Registration for this event has closed.


Registration fee:

Registration is limited to HAH SNF, ALF and ARCH Members only.  The registration fee includes the workshop, access to workshop materials, continental breakfast, buffet lunch, and validated parking at the Ala Moana Hotel parking garage on February 27 & 28, 2019.

Registration Fee for SNF members (Feb. 27 & 28):  $269 per person
Registration Fee for ALF/ARCH Members (Feb. 28 only):  $139 per person
Click here to pay via credit card (see below for how to pay by check).
Make checks out to HHERF and mail to:

Healthcare Association of Hawaii
707 Richards Street, PH2
Honolulu, HI 96813

*Cancellations will be charged a processing fee.  Cancellations must be received 72 hours in advance (email lhenning@hah.org or call 808-521-8961).
**NO REFUNDS for non-attendance.

The AHCA/NCAL Quality & Regulatory Workshop will be held at the Ala Moana Hotel  (410 Atkinson Drive, Honolulu HI 96814) in the Garden Lanai Room.


Self-parking in the Ala Moana Hotel Garage will be validated.  Bring your parking stub to the workshop and we’ll validate it for you at Registration.  Valet parking is not covered and costs $25 per car.

Overnight Guests

The Ala Moana Hotel is offering a 12% discount off of the best available rate at the time of booking in the Kona and Waikiki Towers, City/Mountain view. As long as there are rooms available, a discounted rate will be offered off of the best available rate at the time of booking.

To get the discount, you may book and pay for your reservation(s) one  of two ways:

  1. Online at www.alamoanahotelhonolulu.com, using  Promo Code“AHCA2020”; or,
  2. By phone, calling the Reservations Department.  If calling-in a reservation, mention the Promo Code “AHCA2020”.

Ala Moana Hotel reservations can be reached at:
1-800-367-6025; or 955-4811 from Oahu

The discount “AHCA2020” is only valid for travel between February 25 – March 2, 2020, based upon availability at time of booking.

The promo code will expire on 3/2/20, OR, if there are no rooms available (meaning the hotel is sold out), whichever occurs first.