CHSP Regulatory Compliance & Standards 5 — Questions and Answers
Question 1: A hospital receives a citation for a 'repeat violation' from OSHA. Compared to an 'other-than-serious violation,' the penalty for a repeat violation can be up to how many times higher?
- 2 times
- 5 times
- 10 times (Correct answer)
- 20 times
Correct answer: 10 times
OSHA can assess penalties for repeat violations up to 10 times the penalty for an 'other-than-serious' or 'serious' violation, reflecting the increased risk from ongoing non-compliance.
Question 2: The Sentinel Event Policy of The Joint Commission requires organizations to conduct a root cause analysis (RCA) and submit an action plan within how many days of a sentinel event?
- 30 days
- 45 days
- 60 days (Correct answer)
- 90 days
Correct answer: 60 days
TJC's Sentinel Event Policy requires organizations to submit a thorough and credible RCA and action plan within 45 calendar days of the event or of becoming aware of it.
Question 3: Under the Americans with Disabilities Act (ADA), healthcare facilities are required to provide accessible routes to all areas of the facility because they are classified as:
- Federal facilities
- Public accommodations (Correct answer)
- Educational institutions
- Government contractors
Correct answer: Public accommodations
Hospitals and medical offices are classified as public accommodations under ADA Title III, which requires them to remove barriers to access for individuals with disabilities.
Question 4: Which standard specifically addresses ventilation requirements for airborne infection isolation (AII) rooms in healthcare facilities?
- ASHRAE Standard 55
- ASHRAE Standard 62.1
- ASHRAE Standard 170 (Correct answer)
- ASHRAE Standard 90.1
Correct answer: ASHRAE Standard 170
ASHRAE Standard 170 (Ventilation of Health Care Facilities) specifies ventilation requirements for AII rooms, including negative pressure and minimum air change rates.
Question 5: A healthcare facility's hazardous materials management program must address OSHA's requirement to maintain Safety Data Sheets (SDS) that are:
- Accessible only to safety officers during business hours
- Readily accessible to employees during each work shift (Correct answer)
- Stored in a central locked cabinet for security
- Available only in the safety officer's office
Correct answer: Readily accessible to employees during each work shift
OSHA's HazCom Standard requires that SDS be readily accessible to employees during their work shift, which may include electronic access as long as it is always available.
Question 6: Under NFPA 101, a healthcare occupancy is required to have a corridor width of at least how many inches to facilitate patient evacuation?
- 36 inches
- 44 inches
- 60 inches (Correct answer)
- 96 inches
Correct answer: 60 inches
NFPA 101 requires corridors in healthcare occupancies to be at least 8 feet (96 inches) wide in areas used by patients, but the minimum for non-patient areas is 44 inches; however, for patient use areas, the 96-inch (8-foot) standard applies to facilitate bed/gurney evacuation.
Question 7: Which regulation requires healthcare facilities to develop and implement an Emergency Operations Plan (EOP) that addresses six critical areas including communication and resources?
- OSHA 29 CFR 1910.38
- CMS Conditions of Participation 482.41(a)
- CMS Emergency Preparedness Rule (42 CFR Part 482.15) (Correct answer)
- NFPA 99 Chapter 12
Correct answer: CMS Emergency Preparedness Rule (42 CFR Part 482.15)
The CMS Emergency Preparedness Rule (42 CFR Part 482.15) requires hospitals to develop a comprehensive EOP addressing communication, resources and assets, safety and security, staff roles, utilities, and patient clinical needs.
CHSP Regulatory Compliance & Standards 5
A hospital receives a citation for a 'repeat violation' from OSHA.
Compared to an 'other-than-serious violation,' the penalty for a repeat violation can be up to how many times higher?