Regulatory Compliance & Quality Improvement Flashcards
7 cards from real CMD practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory Compliance & Quality Improvement flashcards as text
Under CMS Conditions of Participation, which of the following best describes the Medical Director's primary responsibility regarding quality assessment and performance improvement (QAPI)?
Answer: Ensuring the facility maintains an ongoing, comprehensive QAPI program
CMS CoPs require the Medical Director to ensure the facility maintains a comprehensive, data-driven QAPI program addressing all care domains.
A long-term care facility receives a deficiency citation for F-tag F758 (unnecessary antipsychotic medications). As Medical Director, what is the most appropriate first step?
Answer: Conduct a root cause analysis and develop a corrective action plan
A root cause analysis followed by a corrective action plan is the evidence-based first step in responding to a regulatory deficiency citation.
Which federal regulation specifically governs the frequency of Medical Director visits to skilled nursing facilities?
Answer: There is no federally mandated minimum visit frequency
Federal regulations do not specify a minimum visit frequency; the Medical Director must visit as often as necessary to fulfill their responsibilities.
The PDSA (Plan-Do-Study-Act) cycle is used in quality improvement primarily to:
Answer: Test changes on a small scale before broad implementation
PDSA cycles allow facilities to test small-scale interventions, study results, and refine approaches before facility-wide rollout.
Under HIPAA, a Medical Director reviewing aggregate quality data to identify trends in falls rates:
Answer: Is performing a permitted use under the healthcare operations provision
HIPAA permits use of protected health information for healthcare operations, including quality assessment and improvement activities.
A state surveyor cites a facility for not having physician orders reviewed within the required timeframe. The Medical Director should:
Answer: Accept joint accountability and work with medical staff to improve order review processes
The Medical Director is accountable for the overall medical care program, including physician practice patterns, and must take leadership to correct systemic deficiencies.
Which quality indicator would be most appropriate for a Medical Director to track when monitoring the effectiveness of a new pressure ulcer prevention protocol?
Answer: Prevalence and incidence rates of facility-acquired pressure injuries
Pressure injury prevalence and incidence rates are the direct outcome measures that reflect the effectiveness of a prevention protocol.