CHFM Compliance and Regulatory Standards 5 — Questions and Answers
Question 1: Under OSHA's Respiratory Protection Standard (29 CFR 1910.134), before an employee can wear a tight-fitting respirator, the employer must ensure which of the following?
- Annual fit test only
- Medical evaluation only
- Medical evaluation, fit test, and training (Correct answer)
- Training and fit test only
Correct answer: Medical evaluation, fit test, and training
OSHA requires medical evaluation, fit testing, and training before an employee uses a tight-fitting respirator.
Question 2: A hospital undergoes a triennial survey by The Joint Commission. During the survey, a Pattern of Failure (PoF) is cited. What does this designation mean?
- A single critical finding requiring immediate correction
- Multiple findings of the same standard across different areas (Correct answer)
- A finding that poses immediate threat to life
- A finding cited in two consecutive surveys
Correct answer: Multiple findings of the same standard across different areas
A Pattern of Failure (PoF) means the same or similar deficiency was found in multiple locations, units, or instances during the survey.
Question 3: The FGI Guidelines for Design and Construction of Hospitals are referenced by which regulatory authority to establish minimum space requirements?
- OSHA
- CMS
- State licensing agencies (Correct answer)
- EPA
Correct answer: State licensing agencies
Most state health facility licensing agencies adopt the FGI Guidelines as the minimum design and construction standard for healthcare facility planning.
Question 4: Under NFPA 25 (Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems), wet-pipe sprinkler systems must be hydrostatically tested at what pressure?
- 100 psi for 2 hours
- 150 psi for 2 hours
- 200 psi for 2 hours (Correct answer)
- 250 psi for 2 hours
Correct answer: 200 psi for 2 hours
NFPA 25 requires hydrostatic testing of existing wet-pipe sprinkler systems at 200 psi for 2 hours when the system is modified or shows signs of damage.
Question 5: A healthcare facility manager receives a Notice of Proposed Rulemaking (NPRM) from CMS. What is the appropriate initial action?
- Immediately implement the proposed changes
- Submit formal public comments during the comment period (Correct answer)
- Contact The Joint Commission for guidance
- File for a waiver from the proposed rule
Correct answer: Submit formal public comments during the comment period
An NPRM invites public comment before a rule is finalized; the facility should review and submit comments during the designated comment period.
Question 6: Under CMS requirements for Critical Access Hospitals (CAHs), what is the maximum number of inpatient beds allowed?
- 15
- 25 (Correct answer)
- 35
- 50
Correct answer: 25
CMS designates Critical Access Hospitals as rural hospitals with no more than 25 inpatient beds, with an average stay of 96 hours or less.
Question 7: Which accreditation organization uses the ISO 9001 quality management system integrated with its hospital accreditation standards?
- The Joint Commission
- HFAP
- DNV GL Healthcare (Correct answer)
- CIHQ
Correct answer: DNV GL Healthcare
DNV GL Healthcare integrates ISO 9001 quality management system requirements into its NIAHO hospital accreditation standards.
CHFM Compliance and Regulatory Standards 5
Under OSHA's Respiratory Protection Standard (29 CFR 1910.134), before an employee can wear a tight-fitting respirator, the employer must ensure which of the following?