Compliance and Regulatory Standards Flashcards

Under CMS Conditions of Participation, how frequently must a hospital conduct a fire drill in each smoke compartment?

Answer: Quarterly

CMS requires hospitals to conduct fire drills at least quarterly in each smoke compartment on each shift.

Which NFPA standard specifically governs the installation of fire alarm systems in healthcare facilities?

Answer: NFPA 72

NFPA 72, the National Fire Alarm and Signaling Code, governs fire alarm system installation and inspection.

A healthcare facility's generator fails to start during a monthly test. Under NFPA 110, what is the maximum allowable time to restore the generator to full operational status?

Answer: 72 hours

NFPA 110 requires that an emergency generator that fails a test be repaired and restored within 72 hours.

Which agency enforces the Americans with Disabilities Act (ADA) accessibility standards in healthcare facility construction?

Answer: Department of Justice

The Department of Justice (DOJ) enforces ADA Title III requirements for public accommodations, including healthcare facilities.

Under OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030), how often must an employer offer hepatitis B vaccination to at-risk employees?

Answer: Upon hire only

OSHA requires employers to offer hepatitis B vaccination to at-risk employees at the time of initial employment (upon hire).

A hospital is cited for a deficiency under the Life Safety Code during a CMS survey. What document must the facility submit to CMS outlining corrective actions?

Answer: Plan of Correction

A Plan of Correction (PoC) is the formal document submitted to CMS describing how and when deficiencies will be corrected.

Which ASHRAE standard addresses ventilation requirements for healthcare facilities including minimum air changes per hour for operating rooms?

Answer: ASHRAE 170

ASHRAE Standard 170, Ventilation of Health Care Facilities, sets minimum ventilation requirements including air changes per hour for clinical spaces.