CHC Standards, Policies, and Procedures 2 — Questions and Answers
Question 1: Which element is MOST critical when drafting a healthcare compliance policy to ensure enforceability?
- Clear, unambiguous language with defined scope and applicability (Correct answer)
- Use of technical legal jargon to demonstrate authority
- Lengthy preambles explaining historical context
- References to competitor organization policies
Correct answer: Clear, unambiguous language with defined scope and applicability
Enforceable policies require clear language, a defined scope, and explicit applicability so staff know exactly what is required of them.
Question 2: Under the OIG's Seven Elements of an Effective Compliance Program, policies and procedures should be reviewed at minimum:
- Every five years
- Annually or when significant regulatory changes occur (Correct answer)
- Only when a violation is discovered
- Every ten years unless laws change
Correct answer: Annually or when significant regulatory changes occur
The OIG recommends policies be reviewed at least annually and updated promptly when laws, regulations, or organizational operations change.
Question 3: A hospital policy states that all vendor gifts must be reported if they exceed $25. An employee receives a $30 gift card and does not report it. This is BEST described as:
- A regulatory violation requiring immediate federal reporting
- A policy non-compliance issue subject to internal disciplinary action (Correct answer)
- An ethics violation only, with no compliance implications
- A minor oversight with no corrective action needed
Correct answer: A policy non-compliance issue subject to internal disciplinary action
Failure to follow an internal policy threshold triggers internal disciplinary processes rather than automatic federal reporting.
Question 4: The Anti-Kickback Statute (AKS) safe harbor for personal services requires that arrangements be:
- Verbal agreements documented within 90 days
- Set in advance in a written agreement specifying aggregate compensation (Correct answer)
- Approved by the OIG on a case-by-case basis
- Limited to services provided by licensed physicians only
Correct answer: Set in advance in a written agreement specifying aggregate compensation
The AKS personal services safe harbor requires a written agreement signed in advance that specifies aggregate compensation and the services to be provided.
Question 5: A procedure document should differ from a policy document in that a procedure document primarily:
- Articulates the organization's values and mission
- Provides step-by-step instructions for completing a specific task (Correct answer)
- Describes the legal rationale for compliance requirements
- Sets high-level expectations without operational detail
Correct answer: Provides step-by-step instructions for completing a specific task
Procedures operationalize policies by providing detailed, sequential steps employees follow to accomplish a specific task.
Question 6: Which standard is considered the benchmark for healthcare privacy and security policies in the United States?
- The Joint Commission's Comprehensive Accreditation Manual
- HIPAA's Privacy and Security Rules (Correct answer)
- The Sarbanes-Oxley Act
- ISO 27001 Information Security Standard
Correct answer: HIPAA's Privacy and Security Rules
HIPAA's Privacy and Security Rules establish the federal baseline requirements for protecting patient health information that healthcare organizations must embed in their policies.
Question 7: When a new federal regulation is issued, the compliance department's FIRST step regarding existing policies should be to:
- Immediately suspend all affected operations pending policy updates
- Conduct a gap analysis between current policies and the new regulation (Correct answer)
- Notify the board of directors and await their instructions
- Outsource policy revision to external legal counsel only
Correct answer: Conduct a gap analysis between current policies and the new regulation
A gap analysis identifies where existing policies fall short of new regulatory requirements, enabling targeted and efficient updates.
CHC Standards, Policies, and Procedures 2
Which element is MOST critical when drafting a healthcare compliance policy to ensure enforceability?