Healthcare Codes and Compliance Flashcards
7 cards from real ASHE practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Healthcare Codes and Compliance flashcards as text
The Healthcare Facilities Accreditation Program (HFAP) is an alternative accreditor to The Joint Commission. Which federal agency grants HFAP deemed status for hospital accreditation?
Answer: CMS
CMS grants deemed status to accrediting organizations like HFAP, DNV GL, and TJC, allowing them to survey hospitals for Medicare/Medicaid COP compliance.
Under NFPA 101, a smoke compartment in a healthcare occupancy may not exceed what maximum area?
Answer: 22,500 sq ft
NFPA 101 limits smoke compartments in healthcare occupancies to a maximum of 22,500 square feet to contain smoke spread during a fire.
Which EPA regulation governs the management, manifesting, and disposal of hazardous pharmaceutical waste generated by healthcare facilities?
Answer: RCRA Subtitle C (40 CFR Parts 260–270)
RCRA Subtitle C governs hazardous waste from generation through disposal, including pharmaceutical waste classified as hazardous (P- and U-listed, characteristic wastes).
In healthcare construction, a Pre-Construction Risk Assessment (PCRA) differs from an ICRA in that it specifically evaluates risks to which group?
Answer: Patients, visitors, and staff from all project-related hazards including noise, vibration, and utility disruptions
The PCRA evaluates all construction-related hazards (noise, vibration, utility outages, wayfinding) that could impact patients, visitors, and staff—broader than the infection-focused ICRA.
Which standard requires healthcare facilities to test and maintain water systems to control Legionella and other waterborne pathogens through a Water Management Program?
Answer: ASHRAE 188
ASHRAE 188 (Legionellosis: Risk Management for Building Water Systems) establishes requirements for water management programs to prevent Legionella growth in building water systems.
Under CMS Conditions of Participation, hospitals must conduct a fire risk assessment and establish a written fire plan. Which element is specifically required to be addressed in the written fire safety plan?
Answer: Procedures for use of the fire alarm system, containment of fire, and evacuation
CMS CoPs require the written fire plan to cover alarm activation procedures, fire containment, evacuation routes, and staff responsibilities during a fire emergency.
A healthcare facility's maintenance staff discovers a transformer room door has been propped open, compromising a 2-hour fire-rated barrier. Under NFPA 101, what is the most appropriate immediate action?
Answer: Implement an ILSM including increased surveillance and close the door immediately
When a fire-rated barrier is compromised, the immediate response is to restore the barrier (close the door) and activate ILSMs such as increased fire watch until permanent repair is made.