CHFM Compliance and Regulatory Standards 2 — Questions and Answers
Question 1: Under CMS Conditions of Participation, how frequently must a hospital conduct a fire drill in each smoke compartment?
- Monthly
- Quarterly (Correct answer)
- Semi-annually
- Annually
Correct answer: Quarterly
CMS requires hospitals to conduct fire drills at least quarterly in each smoke compartment on each shift.
Question 2: Which NFPA standard specifically governs the installation of fire alarm systems in healthcare facilities?
- NFPA 13
- NFPA 25
- NFPA 72 (Correct answer)
- NFPA 101
Correct answer: NFPA 72
NFPA 72, the National Fire Alarm and Signaling Code, governs fire alarm system installation and inspection.
Question 3: 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?
- 24 hours
- 48 hours
- 72 hours (Correct answer)
- 7 days
Correct answer: 72 hours
NFPA 110 requires that an emergency generator that fails a test be repaired and restored within 72 hours.
Question 4: Which agency enforces the Americans with Disabilities Act (ADA) accessibility standards in healthcare facility construction?
- The Joint Commission
- OSHA
- Department of Justice (Correct answer)
- CMS
Correct answer: Department of Justice
The Department of Justice (DOJ) enforces ADA Title III requirements for public accommodations, including healthcare facilities.
Question 5: Under OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030), how often must an employer offer hepatitis B vaccination to at-risk employees?
- Upon hire only (Correct answer)
- Upon hire and annually
- Upon hire and after needlestick exposure
- Annually and after exposure
Correct answer: Upon hire only
OSHA requires employers to offer hepatitis B vaccination to at-risk employees at the time of initial employment (upon hire).
Question 6: 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?
- Plan of Correction (Correct answer)
- Statement of Deficiency
- Waiver Request
- Equivalency Report
Correct answer: Plan of Correction
A Plan of Correction (PoC) is the formal document submitted to CMS describing how and when deficiencies will be corrected.
Question 7: Which ASHRAE standard addresses ventilation requirements for healthcare facilities including minimum air changes per hour for operating rooms?
- ASHRAE 55
- ASHRAE 62.1
- ASHRAE 90.1
- ASHRAE 170 (Correct answer)
Correct answer: ASHRAE 170
ASHRAE Standard 170, Ventilation of Health Care Facilities, sets minimum ventilation requirements including air changes per hour for clinical spaces.
CHFM Compliance and Regulatory Standards 2
Under CMS Conditions of Participation, how frequently must a hospital conduct a fire drill in each smoke compartment?