Regulatory and Accreditation Flashcards
7 cards from real CPHQ practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory and Accreditation flashcards as text
Which CMS Conditions of Participation requirement mandates that hospitals have a governing body ultimately responsible for the conduct of the hospital?
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.
A hospital is preparing for a CMS validation survey following a complaint. What should staff understand about this type of survey?
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.
Under HIPAA's Minimum Necessary Standard, which scenario is compliant?
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.
The Joint Commission's National Patient Safety Goal NPSG.15.01.01 addresses which of the following?
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.
Which accreditation standard requires organizations to define the scope of performance improvement activities and include all hospital departments?
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.
A state health department conducts a licensure survey and finds a deficiency. The facility must submit which document to remain licensed?
Answer: Plan of Correction (PoC)
A Plan of Correction is the formal response submitted to regulatory bodies detailing how identified deficiencies will be remediated.
Which federal law established the conditions under which individuals can inspect and amend their own health records?
Answer: HIPAA Privacy Rule
The HIPAA Privacy Rule grants individuals the right to access, inspect, and request amendments to their own protected health information.