Compliance and Accreditation Flashcards
7 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 7 Compliance and Accreditation flashcards as text
Under CMS Conditions of Participation, how frequently must a hospital conduct a full-scale emergency preparedness exercise?
Answer: Annually
CMS requires hospitals to conduct a full-scale community-based or facility-based emergency preparedness exercise at least annually.
Which accreditation standard requires hospitals to perform a proactive risk assessment, such as a Failure Mode and Effects Analysis (FMEA), at least annually?
Answer: The Joint Commission Leadership standard LD.04.04.05
TJC Leadership standard LD.04.04.05 requires organizations to conduct at least one proactive risk assessment annually to identify and reduce risks.
A hospital is cited by The Joint Commission for failing to maintain ligature-risk assessments in behavioral health units. Which TJC chapter most directly governs this requirement?
Answer: Environment of Care (EC)
The Environment of Care chapter governs physical environment safety, including ligature-risk assessments in behavioral health settings.
Which federal law establishes the foundation for workplace safety compliance programs in U.S. healthcare settings?
Answer: The Occupational Safety and Health Act of 1970
The Occupational Safety and Health Act of 1970 created OSHA and established employers' general duty to provide a safe working environment.
During a TJC survey, surveyors use the 'tracer methodology' primarily to:
Answer: Follow a patient's care experience across departments to evaluate system integration
Tracer methodology follows a patient's journey through the facility to assess how standards are applied across departments and care transitions.
A hospital's infection control compliance program is primarily measured against which set of CMS standards?
Answer: Conditions of Participation §482.42
CMS CoP §482.42 specifically addresses infection control, requiring hospitals to maintain an active program to prevent, control, and investigate infections.
Which accreditation organization uses the 'NIAHO' standards and employs a continuous survey process instead of triennial surveys?
Answer: DNV GL – Healthcare
DNV GL – Healthcare uses NIAHO standards and conducts annual surveys, integrating ISO 9001 quality management with CMS CoP compliance.