ASHE Regulatory Compliance & Safety Standards 3 — Questions and Answers
Question 1: Under TJC Environment of Care (EC) standards, how often must hospitals conduct a proactive risk assessment of high-risk processes?
- Every 5 years
- Annually
- At least once every 3 years (Correct answer)
- Only when a sentinel event occurs
Correct answer: At least once every 3 years
The Joint Commission's Leadership standard requires a proactive risk assessment of high-risk processes at least every three years or when significant changes occur.
Question 2: NFPA 72 governs which system type in healthcare facilities?
- Medical gas systems
- Fire alarm and signaling systems (Correct answer)
- Electrical distribution systems
- HVAC control systems
Correct answer: Fire alarm and signaling systems
NFPA 72 is the National Fire Alarm and Signaling Code, covering design, installation, testing, and maintenance of fire alarm systems.
Question 3: The RACE acronym used in healthcare fire response training stands for:
- Remove, Activate, Confine, Extinguish/Evacuate
- Report, Assess, Control, Evacuate
- Rescue, Alarm, Contain, Extinguish (Correct answer)
- Relocate, Alert, Close, Exit
Correct answer: Rescue, Alarm, Contain, Extinguish
RACE stands for Rescue (patients in immediate danger), Alarm (activate pull station), Contain (close doors), Extinguish or Evacuate — the standard hospital fire response sequence.
Question 4: Which ASHRAE standard specifically addresses ventilation in health care facilities including pressure relationships and air change rates?
- ASHRAE 62.1
- ASHRAE 90.1
- ASHRAE 170 (Correct answer)
- ASHRAE 55
Correct answer: ASHRAE 170
ASHRAE Standard 170, Ventilation of Health Care Facilities, specifies minimum ventilation rates, pressure relationships, filtration, and humidity requirements for healthcare spaces.
Question 5: A hospital's Category 1 electrical system (per NFPA 99) must have an alternate power source capable of restoring power within how many seconds?
- 30 seconds
- 10 seconds (Correct answer)
- 60 seconds
- 5 seconds
Correct answer: 10 seconds
NFPA 99 requires the Essential Electrical System for Category 1 spaces to restore power within 10 seconds of normal power failure.
Question 6: Under CMS Conditions of Participation, a hospital experiencing a utility system outage that affects patient care must notify CMS within:
- 72 hours (Correct answer)
- 24 hours
- 48 hours
- Immediately upon restoration
Correct answer: 72 hours
CMS requires hospitals to report certain adverse events — including serious utility failures — within 72 hours through their State Survey Agency.
Question 7: What is the primary purpose of a Healthcare Failure Mode and Effect Analysis (HFMEA)?
- To document past incidents for insurance purposes
- To proactively identify and mitigate risks before harm occurs (Correct answer)
- To assign liability after a patient safety event
- To schedule preventive maintenance for medical equipment
Correct answer: To proactively identify and mitigate risks before harm occurs
HFMEA is a prospective, proactive risk assessment tool used to identify potential failure points in healthcare processes before they cause patient harm.
ASHE Regulatory Compliance & Safety Standards 3
Under TJC Environment of Care (EC) standards, how often must hospitals conduct a proactive risk assessment of high-risk processes?