CHSP Compliance and Accreditation 5 — Questions and Answers
Question 1: A healthcare organization receives a CMS Statement of Deficiencies (Form CMS-2567). What must the organization submit in response?
- A corrective action plan called a Plan of Correction (PoC) (Correct answer)
- An appeal to the HHS Secretary within 10 days
- A written admission of liability
- A request for immediate dismissal of findings
Correct 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.
Question 2: Which TJC National Patient Safety Goal (NPSG) directly addresses the safe use of clinical alarm systems in hospitals?
- NPSG.01.01.01
- NPSG.06.01.01 (Correct answer)
- NPSG.03.06.01
- NPSG.15.01.01
Correct 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.
Question 3: 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?
- 7 days
- 10 days (Correct answer)
- 30 days
- 60 days
Correct 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.
Question 4: 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?
- Interim Life Safety Measures (ILSM) (Correct answer)
- Statement of Conditions (SOC) waiver
- Time-Limited Variance (TLV)
- Equivalency Demonstration Report (EDR)
Correct 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.
Question 5: Which element is NOT typically included in a healthcare organization's written compliance program as recommended by the OIG?
- Designation of a compliance officer
- Written policies and procedures
- Employee disciplinary guidelines
- A mandatory arbitration clause for all disputes (Correct answer)
Correct 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.
Question 6: When The Joint Commission issues a 'Requirement for Improvement' (RFI) following a survey, the accredited organization must submit evidence of standards compliance within:
- 10 days
- 30 days
- 45 days (Correct answer)
- 60 days
Correct 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.
Question 7: 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?
- Only failures lasting longer than 4 hours
- All utility system failures that affect patient care (Correct answer)
- Only scheduled maintenance shutdowns
- Failures reported to CMS only
Correct 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.
CHSP Compliance and Accreditation 5
A healthcare organization receives a CMS Statement of Deficiencies (Form CMS-2567).
What must the organization submit in response?