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
A healthcare organization receives a CMS Statement of Deficiencies (Form CMS-2567). What must the organization submit in response?
Answer: A corrective action plan called a Plan of Correction (PoC)
Organizations cited on Form CMS-2567 must submit a Plan of Correction (PoC) outlining how each deficiency will be addressed and by what date.
Which TJC National Patient Safety Goal (NPSG) directly addresses the safe use of clinical alarm systems in hospitals?
Answer: NPSG.06.01.01
NPSG.06.01.01 requires hospitals to improve the safety of clinical alarm systems by establishing policies to manage alarm fatigue.
Under OSHA's Bloodborne Pathogens Standard (29 CFR 1910.1030), employers must offer the hepatitis B vaccine to at-risk employees within how many days of initial assignment?
Answer: 10 days
OSHA's BBP standard requires that hepatitis B vaccination be offered to occupationally exposed employees within 10 working days of initial assignment.
A hospital safety officer discovers that life safety code (LSC) deficiencies cannot be immediately corrected. What TJC mechanism allows continued operation while fixes are underway?
Answer: Interim Life Safety Measures (ILSM)
Interim Life Safety Measures (ILSMs) are temporary compensatory actions required when LSC deficiencies create increased life safety risk during remediation.
Which element is NOT typically included in a healthcare organization's written compliance program as recommended by the OIG?
Answer: A mandatory arbitration clause for all disputes
OIG compliance program guidance includes a compliance officer, written policies, training, auditing, and disciplinary standards — not mandatory arbitration clauses.
When The Joint Commission issues a 'Requirement for Improvement' (RFI) following a survey, the accredited organization must submit evidence of standards compliance within:
Answer: 45 days
Organizations receiving an RFI from TJC must submit an Evidence of Standards Compliance (ESC) with a Measure of Success within 45 days.
A hospital's environment of care committee is reviewing its utility management plan. Under TJC standards, which utility failure scenario requires a written response protocol?
Answer: All utility system failures that affect patient care
TJC EC.02.05.07 requires written response protocols for failures of all utility systems that could affect patient care, regardless of duration.