CPHQ Regulatory and Accreditation 2 — Questions and Answers
Question 1: Which CMS Conditions of Participation requirement mandates that hospitals have a governing body ultimately responsible for the conduct of the hospital?
- Medical staff bylaws
- Governing body standard (Correct answer)
- Administrative policy
- Quality management plan
Correct answer: Governing body standard
The CMS Conditions of Participation Governing Body standard holds the governing board ultimately responsible for the hospital's operations and quality of care.
Question 2: A hospital is preparing for a CMS validation survey following a complaint. What should staff understand about this type of survey?
- It is always announced 30 days in advance
- It may be unannounced and triggered by a complaint or accreditation deficiency (Correct answer)
- It focuses only on medication safety
- It replaces the routine accreditation survey
Correct answer: It may be unannounced and triggered by a complaint or accreditation deficiency
CMS validation surveys can be unannounced and are often triggered by complaints or when an accreditation organization finds deficiencies.
Question 3: Under HIPAA's Minimum Necessary Standard, which scenario is compliant?
- A nurse shares the full medical record with a billing clerk for a routine claim
- A billing clerk accesses only the diagnosis codes and procedure codes needed to process a claim (Correct answer)
- A receptionist views patient psychiatric notes out of personal curiosity
- An IT technician downloads all patient records to troubleshoot a printer
Correct answer: A billing clerk accesses only the diagnosis codes and procedure codes needed to process a claim
The Minimum Necessary Standard requires that access to PHI be limited to the least amount needed to accomplish the intended purpose.
Question 4: The Joint Commission's National Patient Safety Goal NPSG.15.01.01 addresses which of the following?
- Hand hygiene compliance
- Suicide risk reduction in healthcare settings (Correct answer)
- Medication reconciliation at discharge
- Prevention of central line-associated infections
Correct answer: Suicide risk reduction in healthcare settings
NPSG.15.01.01 requires organizations to identify patients at risk for suicide and implement risk reduction strategies.
Question 5: Which accreditation standard requires organizations to define the scope of performance improvement activities and include all hospital departments?
- Environment of Care standard
- Leadership standard on quality improvement planning (Correct answer)
- Human Resources standard
- Infection Control standard
Correct answer: Leadership standard on quality improvement planning
The Joint Commission Leadership standard requires that the organization's PI plan define scope and encompass all departments and services.
Question 6: A state health department conducts a licensure survey and finds a deficiency. The facility must submit which document to remain licensed?
- Root cause analysis only
- Plan of Correction (PoC) (Correct answer)
- Sentinel event report
- OSHA 300 log
Correct answer: Plan of Correction (PoC)
A Plan of Correction is the formal response submitted to regulatory bodies detailing how identified deficiencies will be remediated.
Question 7: Which federal law established the conditions under which individuals can inspect and amend their own health records?
- The Affordable Care Act
- HIPAA Privacy Rule (Correct answer)
- EMTALA
- The Hill-Burton Act
Correct answer: HIPAA Privacy Rule
The HIPAA Privacy Rule grants individuals the right to access, inspect, and request amendments to their own protected health information.
CPHQ Regulatory and Accreditation 2
Which CMS Conditions of Participation requirement mandates that hospitals have a governing body ultimately responsible for the conduct of the hospital?