Compliance and Accreditation Flashcards
6 cards from real CHSP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Compliance and Accreditation flashcards as text
Which federal agency is primarily responsible for enforcing workplace safety standards in healthcare facilities?
Answer: OSHA
OSHA (Occupational Safety and Health Administration) is the federal agency that sets and enforces workplace safety standards, including those applicable to healthcare facilities.
What is the primary purpose of a Statement of Conditions (SOC) in healthcare facility compliance?
Answer: To outline a plan for resolving Life Safety Code deficiencies
A Statement of Conditions documents existing Life Safety Code deficiencies and the facility plan to resolve them, serving as a compliance tool during accreditation surveys.
During a Joint Commission survey, which approach is used to evaluate patient care processes?
Answer: Tracer methodology
The Joint Commission uses tracer methodology, which follows the experience of care for individual patients through the organization to assess compliance with standards.
Which document must a healthcare facility maintain to demonstrate compliance with CMS Conditions of Participation?
Answer: Quality Assessment and Performance Improvement (QAPI) program documentation
CMS requires healthcare facilities to maintain a QAPI program with documentation showing ongoing efforts to improve patient care quality and safety.
What is the recommended frequency for conducting an Environment of Care (EOC) risk assessment?
Answer: At least annually
Environment of Care risk assessments should be conducted at least annually to identify and address potential hazards in the healthcare facility.
Which NFPA standard is commonly referred to as the Life Safety Code?
Answer: NFPA 101
NFPA 101 is the Life Safety Code, which addresses construction, protection, and occupancy features to minimize danger from fire, smoke, and panic in buildings.