CHFM Compliance and Regulatory Standards 3 — Questions and Answers
Question 1: Under The Joint Commission's Environment of Care (EC) standards, what is the required minimum number of Environment of Care Committee meetings per year?
- Four (Correct answer)
- Six
- Eight
- Twelve
Correct answer: Four
TJC requires the Environment of Care Committee to meet at least four times per year (quarterly) to review EOC management plans.
Question 2: HIPAA's Security Rule requires covered entities to conduct a risk analysis. Which type of safeguard category does risk analysis fall under?
- Physical safeguards
- Technical safeguards
- Administrative safeguards (Correct answer)
- Operational safeguards
Correct answer: Administrative safeguards
Risk analysis is an administrative safeguard requirement under the HIPAA Security Rule at 45 CFR § 164.308.
Question 3: A healthcare facility seeks a waiver from a specific NFPA 101 requirement from CMS. What must the facility demonstrate to obtain a CMS waiver?
- An equivalent level of safety exists (Correct answer)
- The requirement is cost-prohibitive
- State law conflicts with the requirement
- The building was constructed before the code's adoption
Correct answer: An equivalent level of safety exists
CMS grants waivers only when the facility demonstrates that an equivalent level of safety is maintained through alternative means.
Question 4: Under EPA's Resource Conservation and Recovery Act (RCRA), how are pharmaceutical wastes classified in a hospital setting?
- Municipal solid waste
- Infectious waste
- Hazardous waste if they exhibit hazardous characteristics (Correct answer)
- Universal waste only
Correct answer: Hazardous waste if they exhibit hazardous characteristics
Pharmaceutical wastes may be classified as RCRA hazardous waste if they exhibit characteristics such as toxicity, ignitability, or are listed hazardous wastes.
Question 5: Which CMS Conditions of Participation standard requires hospitals to have a written Emergency Operations Plan that is exercised twice per year?
- 482.13 - Patient Rights
- 482.41 - Physical Environment
- 482.15 - Emergency Preparedness (Correct answer)
- 482.42 - Infection Control
Correct answer: 482.15 - Emergency Preparedness
CMS CoP 482.15 (Emergency Preparedness) requires hospitals to develop, implement, and exercise an emergency preparedness program twice annually.
Question 6: Under NFPA 99, which risk category classification applies to spaces where failure of equipment is unlikely to cause injury to patients or staff?
- Category 1
- Category 2
- Category 3 (Correct answer)
- Category 4
Correct answer: Category 3
NFPA 99 Category 3 applies to spaces where failure of equipment is unlikely to cause injury; Category 1 is the highest risk level.
Question 7: The National Integrated Accreditation for Healthcare Organizations (NIAHO) is administered by which accrediting body?
- The Joint Commission
- DNV GL Healthcare (Correct answer)
- HFAP
- CIHQ
Correct answer: DNV GL Healthcare
DNV GL Healthcare administers the NIAHO accreditation program, which is a CMS-deemed accreditation alternative to TJC.
CHFM Compliance and Regulatory Standards 3
Under The Joint Commission's Environment of Care (EC) standards, what is the required minimum number of Environment of Care Committee meetings per year?