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 the Emergency Preparedness Rule (42 CFR Part 483.73), a Medical Director's primary role during emergency planning is to:
Answer: Ensure that medical care policies address continuity of care during emergencies
The Medical Director ensures that the facility's emergency plan includes provisions for maintaining resident medical care and medication management during crises.
Which statistical tool is most useful for identifying whether a variation in a quality measure represents a special cause versus common cause variation?
Answer: Statistical process control (SPC) chart
Statistical process control charts display data over time with control limits that help distinguish random (common cause) from systematic (special cause) variation.
A resident's family files a complaint with the state ombudsman regarding the frequency of physician visits. As Medical Director, you should first:
Answer: Review the resident's medical record to assess whether visit frequency was clinically appropriate
A thorough medical record review allows the Medical Director to assess whether the visit frequency met clinical need and regulatory requirements before responding.
The INTERACT (Interventions to Reduce Acute Care Transfers) quality improvement program is designed to:
Answer: Reduce unnecessary emergency department transfers by improving early recognition and management of clinical changes
INTERACT provides tools for early identification and management of acute changes in condition to reduce avoidable hospital transfers.
When a facility is placed on the Special Focus Facility (SFF) list by CMS, it means the facility:
Answer: Has a history of serious quality problems and receives more frequent surveys
Special Focus Facility designation means the facility has persistent, serious quality problems and is subject to enhanced survey frequency and scrutiny.
The primary purpose of a facility's infection control risk assessment (ICRA) is to:
Answer: Identify facility-specific infection risks and prioritize prevention strategies
An ICRA helps facilities systematically identify their unique infection risks and allocate prevention resources appropriately.
A Medical Director notices that a particular attending physician's residents have a hospital readmission rate significantly higher than facility average. The best approach is to:
Answer: Approach the physician collegially with data and discuss potential contributing factors
A collegial, data-driven conversation with the physician is the appropriate first step, allowing for exploration of contributing clinical and systemic factors.