CHFM Compliance and Regulatory Standards 3

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?

Accepted Answer

Four

Answer

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?

Accepted Answer

Administrative safeguards

Answer

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?

Accepted Answer

An equivalent level of safety exists

Answer

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?

Accepted Answer

Hazardous waste if they exhibit hazardous characteristics

Answer

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?

Accepted Answer

482.15 - Emergency Preparedness

Answer

CMS CoP 482.15 (Emergency Preparedness) requires hospitals to develop, implement, and exercise an emergency preparedness program twice annually.

CHFM - Certified Healthcare Facility Manager Practice Test

CHFM - Certified Healthcare Facility Manager Practice Test

CHFM Compliance and Regulatory Standards 3