CHSP Compliance and Accreditation 4 — Questions and Answers
Question 1: Under CMS Conditions of Participation, how frequently must a hospital conduct a full-scale emergency preparedness exercise?
- Annually (Correct answer)
- Every two years
- Every three years
- Monthly
Correct answer: Annually
CMS requires hospitals to conduct a full-scale community-based or facility-based emergency preparedness exercise at least annually.
Question 2: Which accreditation standard requires hospitals to perform a proactive risk assessment, such as a Failure Mode and Effects Analysis (FMEA), at least annually?
- The Joint Commission NPSG.01.01.01
- The Joint Commission Leadership standard LD.04.04.05 (Correct answer)
- DNV-GL Standard MM.1
- HFAP Standard 16.00.I
Correct 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.
Question 3: 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?
- Environment of Care (EC) (Correct answer)
- National Patient Safety Goals (NPSG)
- Provision of Care (PC)
- Leadership (LD)
Correct answer: Environment of Care (EC)
The Environment of Care chapter governs physical environment safety, including ligature-risk assessments in behavioral health settings.
Question 4: Which federal law establishes the foundation for workplace safety compliance programs in U.S. healthcare settings?
- HIPAA
- The Occupational Safety and Health Act of 1970 (Correct answer)
- The Employee Retirement Income Security Act
- The Americans with Disabilities Act
Correct 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.
Question 5: During a TJC survey, surveyors use the 'tracer methodology' primarily to:
- Review only paper-based medical records
- Follow a patient's care experience across departments to evaluate system integration (Correct answer)
- Audit financial billing records for compliance
- Inspect only the physical environment of the facility
Correct 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.
Question 6: A hospital's infection control compliance program is primarily measured against which set of CMS standards?
- Conditions of Participation §482.42 (Correct answer)
- EMTALA regulations §489.24
- HIPAA Privacy Rule §164.530
- Stark Law §411.357
Correct 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.
Question 7: Which accreditation organization uses the 'NIAHO' standards and employs a continuous survey process instead of triennial surveys?
- The Joint Commission
- HFAP (Healthcare Facilities Accreditation Program)
- DNV GL – Healthcare (Correct answer)
- CIHQ (Center for Improvement in Healthcare Quality)
Correct answer: DNV GL – Healthcare
DNV GL – Healthcare uses NIAHO standards and conducts annual surveys, integrating ISO 9001 quality management with CMS CoP compliance.
CHSP Compliance and Accreditation 4
Under CMS Conditions of Participation, how frequently must a hospital conduct a full-scale emergency preparedness exercise?