Certified Medical Director (CMD) — Questions and Answers

Question 1: Which level of care in long-term care primarily provides assistance with activities of daily living (ADLs) without requiring skilled nursing services?

Inpatient rehabilitation facility (IRF)
Intermediate care facility (ICF) / Assisted living (Correct answer)
Skilled nursing facility (SNF)
Long-term acute care hospital (LTACH)

Correct answer: Intermediate care facility (ICF) / Assisted living

Intermediate care facilities and assisted living communities provide custodial care and ADL support for individuals who do not require skilled nursing or rehabilitation services.

Question 2: A medical director is asked to evaluate a proposed incentive compensation plan for employed physicians. Which element is most essential to ensure compliance with Anti-Kickback Statute safe harbors?

Bonuses tied to referral volume to affiliated services
Productivity targets linked to specialist referral rates
Compensation set in advance and not based on the value of referrals (Correct answer)
Annual compensation reviews conducted by the medical director alone

Correct answer: Compensation set in advance and not based on the value of referrals

Anti-Kickback safe harbors for employment require that compensation be set in advance at fair market value and not reflect the volume or value of referrals.

Question 3: When evaluating a staff education program's effectiveness for a quality improvement goal, the MOST rigorous measure is:

Staff satisfaction scores on post-session surveys
Change in the targeted clinical outcome or process measure post-training (Correct answer)
Number of staff who attended the training session
Amount of money spent on training materials

Correct answer: Change in the targeted clinical outcome or process measure post-training

Measuring change in the targeted clinical outcome or process is the most meaningful indicator that training produced real improvement.

Question 4: Which quality improvement model uses Plan-Do-Study-Act cycles for iterative change?

Lean Value Stream Mapping
Root Cause Analysis
Six Sigma DMAIC
Model for Improvement (IHI) (Correct answer)

Correct answer: Model for Improvement (IHI)

The Institute for Healthcare Improvement's Model for Improvement uses PDSA cycles to test and implement changes incrementally.

Question 5: A medical director at a post-acute facility is concerned about rising overhead costs being allocated to clinical departments. Which costing method allocates costs based on the actual resources consumed by each service?

Step-down cost allocation
Activity-based costing (ABC) (Correct answer)
Standard cost accounting
Direct cost allocation

Correct answer: Activity-based costing (ABC)

Activity-based costing allocates overhead based on the actual activities (and their cost drivers) that consume resources.

Question 6: When communicating with a resident who has hearing loss, which accommodation is MOST important to implement first?

Speak louder and more slowly without other modifications
Write all communications exclusively and avoid verbal interaction
Confirm the resident's preferred communication method and use assistive devices as needed (Correct answer)
Schedule a speech-language pathology consult before any discussion occurs

Correct answer: Confirm the resident's preferred communication method and use assistive devices as needed

Confirming the resident's preferred method respects individual needs; some residents prefer lip reading, hearing aids, or written communication.

Question 7: Which document legally authorizes a designated person to make healthcare decisions for an incapacitated long-term care resident?

Durable power of attorney for healthcare (Correct answer)
Living will
DNR order
Advance beneficiary notice

Correct answer: Durable power of attorney for healthcare

A durable power of attorney for healthcare designates a surrogate decision-maker when the resident loses capacity.

Question 8: Which leadership style is MOST associated with empowering long-term care staff to identify and solve quality problems themselves?

Autocratic leadership
Transactional leadership
Laissez-faire leadership
Transformational leadership (Correct answer)

Correct answer: Transformational leadership

Transformational leaders inspire and empower staff to take ownership of quality improvement and innovation.

Question 9: A CMD is reviewing antibiotic prescribing patterns and finds broad-spectrum antibiotics are being used empirically for asymptomatic bacteriuria. What framework should guide the corrective intervention?

Immediate restriction of broad-spectrum antibiotic formulary access
Mandatory urine culture protocols for all residents
Infection control committee escalation
Antimicrobial stewardship program principles and McGeer criteria (Correct answer)

Correct answer: Antimicrobial stewardship program principles and McGeer criteria

Antimicrobial stewardship programs using McGeer criteria help distinguish true UTI from asymptomatic bacteriuria, reducing unnecessary antibiotic use.

Question 10: What is the role of financial forecasting in healthcare management?

It eliminates the need for budgeting.
It is irrelevant for healthcare management.
It focuses solely on reducing staff.
It helps predict future financial needs and plan accordingly (Correct answer)

Correct answer: It helps predict future financial needs and plan accordingly

Financial forecasting in healthcare management involves predicting future financial needs and trends based on historical data and anticipated changes. This allows organizations to proactively plan for upcoming investments, potential challenges, and resource allocation, such as staffing or equipment purchases. Accurate forecasting is essential for strategic decision-making, ensuring the organization can meet future demands and maintain financial health.

Question 11: Which type of advance directive specifically designates another person to make healthcare decisions on behalf of a patient who loses decision-making capacity?

Do-not-resuscitate order
Durable power of attorney for healthcare (Correct answer)
Living will
POLST form

Correct answer: Durable power of attorney for healthcare

A durable power of attorney for healthcare (healthcare proxy) legally designates an agent to make medical decisions when the patient cannot.

Question 12: How should CMD professionals measure success in industry trends & emerging technologies?

Using defined metrics, benchmarks, and regular evaluation against established goals (Correct answer)
Success measurement is not applicable
Through subjective self-assessment only
By comparing only to minimum requirements

Correct answer: Using defined metrics, benchmarks, and regular evaluation against established goals

Success in industry trends & emerging technologies is measured through defined metrics and benchmarks, with regular evaluation against established professional goals.

Question 13: A hospital system is implementing a Clinical Integration Network (CIN). What is the primary purpose of this structure?

To replace the existing hospital medical staff bylaws
To eliminate fee-for-service reimbursement immediately
To consolidate all physician practices under a single employment contract
To enable independent physicians to coordinate care and negotiate jointly with payers based on quality and efficiency (Correct answer)

Correct answer: To enable independent physicians to coordinate care and negotiate jointly with payers based on quality and efficiency

A CIN allows independent physicians to clinically integrate care delivery and, if they meet FTC standards, to jointly negotiate value-based contracts with payers.

Question 14: When a surrogate decision-maker demands treatment the resident's advance directive explicitly refuses, the Medical Director should:

Defer entirely to the nursing staff's judgment
Follow the surrogate's instructions to avoid conflict
Honor the advance directive as it reflects the resident's prior autonomous wishes (Correct answer)
Seek a court order before making any decision

Correct answer: Honor the advance directive as it reflects the resident's prior autonomous wishes

A valid advance directive reflects the resident's own autonomous choices and takes precedence over surrogate preferences.

Question 15: What is a key principle of industry trends & emerging technologies in Certified Medical Director practice?

Avoiding all standardized approaches
Applying structured methodologies based on evidence and best practices (Correct answer)
Relying solely on personal experience
Minimizing documentation requirements

Correct answer: Applying structured methodologies based on evidence and best practices

Industry Trends & Emerging Technologies in Certified Medical Director practice requires applying structured, evidence-based methodologies while adapting to specific professional contexts.

Question 16: Why is cost control essential in healthcare financial management?

It focuses on cutting costs at the expense of quality care.
It ensures efficient use of resources and maintains financial health (Correct answer)
It has no impact on the quality of care.
It helps reduce the number of services offered.

Correct answer: It ensures efficient use of resources and maintains financial health

Cost control is essential in healthcare financial management because it ensures the efficient use of limited resources without compromising the quality of patient care. By identifying and eliminating inefficiencies, negotiating better prices, and streamlining operations, healthcare organizations can maintain financial health. This allows them to continue providing necessary services and invest in improvements, ultimately benefiting patients.

Question 17: A Medical Director learns that a resident signed a DNR order but the family is now requesting full resuscitation at the time of a cardiac event. What is the correct response?

Allow nursing staff to decide in the moment based on clinical judgment
Honor the family's request since they are present and the resident cannot speak for themselves
Suspend the DNR order pending an emergency ethics consultation
Follow the resident's documented DNR order, which reflects their autonomous decision while competent (Correct answer)

Correct answer: Follow the resident's documented DNR order, which reflects their autonomous decision while competent

A validly executed DNR order reflects the competent resident's autonomous wishes and must be honored; family preferences do not override a resident's own directive.

Question 18: Which scenario BEST demonstrates the principle of active listening in a care conference?

Reflecting back what the family has said and asking clarifying questions before responding (Correct answer)
Interrupting the family to correct inaccurate statements immediately
Nodding continuously regardless of whether you understand what is being said
Taking detailed notes while simultaneously answering phone messages

Correct answer: Reflecting back what the family has said and asking clarifying questions before responding

Reflecting and clarifying before responding confirms understanding, validates the speaker, and ensures that responses address the actual concern rather than assumptions.

Question 19: The Social Determinants of Health (SDOH) data standard Z-codes in ICD-10-CM are increasingly relevant to long-term care technology because:

Z-codes trigger automatic Medicaid eligibility determinations within the EHR
EHR systems that capture Z-codes enable risk stratification and referral workflows targeting food insecurity, housing instability, and social isolation (Correct answer)
Z-codes replace clinical diagnosis codes for residents with no active medical conditions
CMS requires Z-code documentation for all Medicare Part A SNF claims effective 2024

Correct answer: EHR systems that capture Z-codes enable risk stratification and referral workflows targeting food insecurity, housing instability, and social isolation

Structured SDOH documentation using Z-codes within EHR workflows enables population health platforms to identify and address non-clinical barriers that drive adverse outcomes.

Question 20: When implementing industry trends & emerging technologies practices, what should CMD professionals prioritize?

Personal preferences and comfort level
Speed of implementation above all else
Cost reduction as the sole objective
Alignment with professional standards, stakeholder needs, and organizational goals (Correct answer)

Correct answer: Alignment with professional standards, stakeholder needs, and organizational goals

Effective implementation of industry trends & emerging technologies requires balancing professional standards, stakeholder needs, and organizational objectives for optimal results.

Question 21: A Medical Director is evaluating a new resident with multiple comorbidities for fall risk. Which validated tool is MOST appropriate for quantifying fall risk in a long-term care setting?

Braden Scale
Morse Fall Scale (Correct answer)
APACHE II score
Glasgow Coma Scale

Correct answer: Morse Fall Scale

The Morse Fall Scale is a validated, widely used instrument specifically designed to assess fall risk in clinical and long-term care settings.

Question 22: The ethical duty of non-maleficence requires a Medical Director to:

Always follow the wishes of the resident's family
Distribute resources equally among all residents
Maximize benefit to the greatest number of residents
Avoid causing unnecessary harm through actions or omissions (Correct answer)

Correct answer: Avoid causing unnecessary harm through actions or omissions

Non-maleficence is the obligation to refrain from actions or omissions that cause unnecessary harm to residents.

Question 23: Which emerging care model leverages real-time location system (RTLS) technology most directly to improve safety in memory care units?

Medication dispensing automation triggered by resident proximity
Wander management systems that alert staff when residents approach exit zones (Correct answer)
Automated bed-exit alarms linked to EMR fall documentation
Electronic prior authorization for antipsychotic medications

Correct answer: Wander management systems that alert staff when residents approach exit zones

RTLS-based wander management tracks resident location in real time and triggers alerts before elopement occurs, directly improving safety in dementia units.

Question 24: A Medical Director wants to improve staff recognition of early sepsis in nursing home residents. Which training approach aligns BEST with adult learning principles?

Conducting a simulation-based workshop using realistic case scenarios (Correct answer)
Distributing a lengthy policy document on sepsis criteria
Requiring staff to independently read a journal article on sepsis
Posting a laminated chart of sepsis signs in the break room only

Correct answer: Conducting a simulation-based workshop using realistic case scenarios

Simulation-based training with realistic scenarios engages adult learners actively and improves retention and clinical application.

Question 25: Which federal regulation requires nursing facilities to have a written infection control program that includes surveillance, prevention, and control of infections?

29 CFR 1910.1030
42 CFR Part 483.10
42 CFR Part 483.80 (Correct answer)
42 CFR Part 483.25

Correct answer: 42 CFR Part 483.80

42 CFR Part 483.80 mandates that long-term care facilities maintain an infection prevention and control program with designated oversight.

Question 26: A facility is experiencing repeated C. difficile outbreaks. Which action by the CMD would MOST directly address the root cause?

Lead a root cause analysis examining antibiotic prescribing patterns and contact precaution adherence (Correct answer)
Mandate ribotyping of all C. difficile isolates
Increase environmental cleaning frequency in resident rooms
Transfer all positive residents to acute care facilities

Correct answer: Lead a root cause analysis examining antibiotic prescribing patterns and contact precaution adherence

Root cause analysis targeting antibiotic stewardship and infection control precautions addresses the primary modifiable drivers of C. difficile transmission in LTC.

Question 27: In the context of CMD practice, 'therapeutic privilege' refers to the controversial practice of:

Withholding information from a patient believed to cause harm by knowing it (Correct answer)
Granting family members access to restricted clinical areas
Prescribing controlled substances without DEA registration
Allowing only privileged physicians to perform certain procedures

Correct answer: Withholding information from a patient believed to cause harm by knowing it

Therapeutic privilege involves withholding information from a patient on the grounds that disclosure would harm them, which is largely rejected in modern medical ethics.

Question 28: A Medical Director at a long-term care facility wants to reduce the risk of delirium in post-surgical residents. Which multicomponent intervention program has the strongest evidence base?

Continuous physical restraint to prevent falls during confusion episodes
Routine use of benzodiazepines for nighttime sedation
Immediate transfer to inpatient psychiatric care upon delirium onset
The Hospital Elder Life Program (HELP) or equivalent non-pharmacological delirium prevention protocols (Correct answer)

Correct answer: The Hospital Elder Life Program (HELP) or equivalent non-pharmacological delirium prevention protocols

The Hospital Elder Life Program (HELP) uses non-pharmacological interventions—including reorientation, mobility, sleep hygiene, and nutrition—and has the strongest evidence for delirium prevention in older adults.

Question 29: A Medical Director discovers that a physician on staff is consistently failing to complete H&P examinations within 72 hours of admission. The MOST appropriate initial step is to:

Counsel the physician and document the discussion (Correct answer)
Report the physician directly to the state medical board
File a grievance with the facility administrator only
Terminate the physician's medical staff privileges immediately

Correct answer: Counsel the physician and document the discussion

The Medical Director's supervisory role requires addressing performance issues through direct counseling and documentation before escalating to formal disciplinary action.

Question 30: The Medical Director's role in staff competency validation MOST often involves:

Conducting bedside skills checks for all nursing aides annually
Approving continuing education budgets for staff
Administering written licensing exams to nursing staff
Participating in policy development and reviewing clinical protocols staff must follow (Correct answer)

Correct answer: Participating in policy development and reviewing clinical protocols staff must follow

Medical Directors contribute to workforce competency by developing and reviewing the clinical policies and protocols that define staff performance expectations.

Question 31: The purpose of structured peer review in a long-term care medical staff is PRIMARILY to:

Improve physician performance and ensure quality of care through collegial feedback (Correct answer)
Provide documentation for malpractice litigation
Punish physicians who make clinical errors
Satisfy administrative requirements without clinical impact

Correct answer: Improve physician performance and ensure quality of care through collegial feedback

Peer review is a collegial quality improvement process intended to identify and address performance opportunities.

Question 32: The 'just culture' model in healthcare workforce management emphasizes:

Differentiating between human error, at-risk behavior, and reckless conduct (Correct answer)
Zero tolerance for any error regardless of context
Eliminating incident reporting to avoid liability
Assigning blame to the individual closest to the error

Correct answer: Differentiating between human error, at-risk behavior, and reckless conduct

Just culture distinguishes error types to promote fair accountability and learning without punishing honest mistakes.

Question 33: A nursing facility resident asks that their HIV status not be disclosed to their adult children. The Medical Director is ethically obligated to:

Maintain confidentiality unless there is an overriding legal duty to warn (Correct answer)
Disclose to immediate family members for their protection
Notify the state health department immediately
Post the information in the medical record only visible to physicians

Correct answer: Maintain confidentiality unless there is an overriding legal duty to warn

Confidentiality of HIV status must be maintained unless a specific legal exception such as a duty-to-warn applies.

Question 34: A CMD observes that a nurse practitioner working in the facility is practicing beyond her state-defined scope by independently ordering controlled substances without physician co-signature. The CMD should:

Report only if a resident is harmed
Immediately address the scope-of-practice violation and correct prescribing practices per state law and facility policy (Correct answer)
Transfer prescriptive authority entirely to the NP to reduce physician workload
Allow the practice if no harm has occurred to date

Correct answer: Immediately address the scope-of-practice violation and correct prescribing practices per state law and facility policy

Scope-of-practice violations for controlled substances carry legal and regulatory risk; the CMD must correct the practice immediately regardless of whether harm has occurred.

Question 35: When a nursing facility experiences high staff turnover, the Medical Director's MOST effective contribution is to:

Collaborate with administration on root-cause analysis and retention strategies (Correct answer)
Reduce the number of medical orders to lower staff workload
Delegate all oversight to the Director of Nursing
Personally perform all clinical assessments to cover gaps

Correct answer: Collaborate with administration on root-cause analysis and retention strategies

Collaborating on root-cause analysis addresses systemic turnover drivers and supports sustainable workforce retention.

Question 36: A Medical Director is reviewing a proposal for a 'hospital-at-home' program partnering with the SNF. Under CMS's Acute Hospital Care at Home waiver, what is the SNF Medical Director's most critical oversight role?

Taking over as the attending of record for all hospital-at-home patients residing in the community
Approving all diagnostic imaging orders placed by the hospital-at-home program physician
Certifying that the SNF will absorb all financial risk for hospital-at-home episodes
Ensuring clear clinical criteria and communication protocols exist for determining when a patient requires transfer to acute care (Correct answer)

Correct answer: Ensuring clear clinical criteria and communication protocols exist for determining when a patient requires transfer to acute care

The Medical Director must ensure robust clinical escalation criteria and communication pathways exist to safely identify when hospital-at-home patients need rapid transfer to higher-acuity settings.

Question 37: A CMD is developing a delirium identification and management protocol. Which tool is MOST validated for delirium screening in long-term care residents?

Montreal Cognitive Assessment (MoCA)
Clock Drawing Test
Mini-Mental State Examination (MMSE)
Confusion Assessment Method (CAM) (Correct answer)

Correct answer: Confusion Assessment Method (CAM)

The Confusion Assessment Method (CAM) is the most widely validated and used tool for detecting delirium across care settings including long-term care.

Question 38: Under Medicare regulations, what is the minimum required frequency for physician visits to nursing facility residents during long-term care stays?

Weekly for the first month, then monthly thereafter
Every 30 days for all residents indefinitely
Monthly for the first year, then quarterly thereafter
Every 30 days for the first 90 days, then every 60 days thereafter (Correct answer)

Correct answer: Every 30 days for the first 90 days, then every 60 days thereafter

Medicare regulations require physician visits every 30 days for the first 90 days of a nursing facility stay, then at least every 60 days thereafter, though more frequent visits may be clinically indicated.

Question 39: When a family demands aggressive life-sustaining treatment that the care team believes is medically futile, the Medical Director should FIRST:

Discharge the resident to a hospital
Issue a unilateral DNR order
Convene an ethics committee consultation (Correct answer)
Immediately comply with all family demands

Correct answer: Convene an ethics committee consultation

Ethics committee consultation provides a structured, neutral forum to address conflicts over medically futile treatment.

Question 40: During a care conference, a resident's surrogate decision-maker requests CPR despite the resident's documented DNR. The CMD should:

Revoke the DNR to comply with surrogate wishes
Explain that the resident's own advance directive takes precedence over surrogate preferences (Correct answer)
Perform CPR if the surrogate insists at the time of arrest
Transfer the resident to a facility willing to honor the surrogate's request

Correct answer: Explain that the resident's own advance directive takes precedence over surrogate preferences

A competently executed advance directive reflecting the resident's own wishes legally and ethically supersedes surrogate preferences under U.S. law.

Question 41: A Medical Director is developing a training program to reduce catheter-associated urinary tract infections (CAUTI). The FIRST step should be:

Assessing current staff knowledge and identifying specific practice gaps (Correct answer)
Mandating that all catheters be removed facility-wide
Ordering new catheter supplies immediately
Reporting the facility to CMS for the high CAUTI rate

Correct answer: Assessing current staff knowledge and identifying specific practice gaps

Assessing knowledge and practice gaps provides the baseline needed to design a targeted and effective training intervention.

Question 42: Under OBRA regulations, a long-term care facility must inform residents of their right to formulate advance directives. This requirement reflects which ethical principle?

Autonomy (Correct answer)
Justice
Fidelity
Non-maleficence

Correct answer: Autonomy

Mandating advance directive counseling upholds autonomy by ensuring residents can direct their future care.

Question 43: A Medical Director notices that medication error rates increase on night shifts. The BEST systemic response is to:

Transfer all complex medication residents to day shift
Suspend the night shift nurses pending investigation
Require all night shift staff to retake their licensing exams
Analyze shift-specific contributing factors and target training accordingly (Correct answer)

Correct answer: Analyze shift-specific contributing factors and target training accordingly

Analyzing shift-specific factors targets root causes and allows training interventions to be tailored to the actual problem.

Question 44: A long-term care facility tracks fall rates monthly. The control chart shows a data point 3 standard deviations above the mean. This indicates:

Measurement error only
Common cause variation
Normal seasonal variation
Special cause variation (Correct answer)

Correct answer: Special cause variation

A data point beyond 3 standard deviations on a control chart signals special cause variation, suggesting an assignable, non-random factor requiring investigation.

Question 45: Which competency framework is MOST commonly used to guide Medical Director professional development in the United States?

JCAHO Leadership Standards
ACGME Milestones
AMDA CMD Competency Framework (Correct answer)
NCQA HEDIS Measures

Correct answer: AMDA CMD Competency Framework

AMDA – The Society for Post-Acute and Long-Term Care Medicine developed the CMD competency framework for Medical Director professional development.

Question 46: A SNF Medical Director reviews a vendor's AI-assisted wound assessment tool that claims 95% accuracy. What additional information is most important before recommending adoption?

Whether the tool received FDA 510(k) clearance for a different indication
The number of patents filed by the developer
The vendor's annual revenue and market share
The demographic and wound-type composition of the validation dataset (Correct answer)

Correct answer: The demographic and wound-type composition of the validation dataset

A 95% accuracy claim is meaningless without knowing if the validation population matches your residents; performance may differ substantially across skin tones and wound types.

Question 47: The concept of 'double effect' in medical ethics is most relevant when:

A treatment benefits two patients simultaneously
A facility operates two separate care units
Pain management may hasten death as an unintended side effect (Correct answer)
Two physicians disagree on a treatment plan

Correct answer: Pain management may hasten death as an unintended side effect

The doctrine of double effect justifies an action with both good and unintended harmful effects, such as high-dose opioids for comfort care.

Question 48: A resident with intact decision-making capacity refuses a recommended antibiotic. The Medical Director's ethically correct action is to:

Consult with the family to override the refusal
Transfer the resident to a hospital immediately
Administer the antibiotic anyway to prevent harm
Document the refusal and respect the resident's decision (Correct answer)

Correct answer: Document the refusal and respect the resident's decision

Respecting autonomy means a competent resident's informed refusal must be honored and documented.

Question 49: A CMD implements a new wound care protocol and uses a run chart to track healing rates. Run charts are primarily used to:

Calculate odds ratios for risk factors
Determine sample size requirements
Display process performance over time (Correct answer)
Test for statistical significance between groups

Correct answer: Display process performance over time

Run charts plot data points sequentially over time to identify trends, shifts, or patterns in a process, supporting ongoing quality monitoring.

Question 50: When a Medical Director identifies a pattern of substandard physician performance in a facility, the most appropriate action under peer review principles is to:

Report the physician directly to the state medical board without internal review
Inform all residents and families about the performance concerns
Immediately terminate the physician's admitting privileges
Initiate a confidential peer review process through the facility's medical staff structure (Correct answer)

Correct answer: Initiate a confidential peer review process through the facility's medical staff structure

Peer review through the medical staff structure provides due process protections and a structured method for addressing performance concerns.

Question 51: When onboarding a new attending physician to a nursing facility, the Medical Director should PRIORITIZE:

Orienting the physician to facility-specific policies, culture, and resident population needs (Correct answer)
Reviewing the physician's personal financial disclosures
Assigning the physician the most complex cases immediately to test competence
Delegating all orientation tasks to the admissions coordinator

Correct answer: Orienting the physician to facility-specific policies, culture, and resident population needs

Facility-specific orientation ensures the new physician understands policies, culture, and population needs critical for safe, effective care.

Question 52: Electronic medication administration records (eMAR) with barcode scanning reduce which specific type of medication error most effectively?

Wrong patient and wrong medication administration errors at the point of care (Correct answer)
Pharmacy compounding errors for high-alert medications
Drug-drug interaction errors not flagged during order entry
Prescribing errors originating from physician order entry

Correct answer: Wrong patient and wrong medication administration errors at the point of care

Barcode-enabled eMAR catches wrong-patient and wrong-drug errors at the bedside by verifying the five rights electronically at the moment of administration.

Question 53: A long-term care network is implementing a care transitions technology platform to reduce 30-day readmissions. Which feature is most evidence-supported for reducing readmissions?

Electronic admission notifications sent to the receiving hospital only
Automated post-discharge follow-up calls and medication reconciliation alerts within 48–72 hours of discharge (Correct answer)
Real-time insurance eligibility verification at the time of discharge
Automated scheduling of SNF readmission appointments for all discharged residents

Correct answer: Automated post-discharge follow-up calls and medication reconciliation alerts within 48–72 hours of discharge

Timely post-discharge follow-up with medication reconciliation within 48–72 hours is the intervention with the strongest evidence for reducing 30-day readmissions.

Question 54: A medical director reviews a trend showing increased urinary tract infection (UTI) rates in a skilled nursing facility. Which intervention is most aligned with antimicrobial stewardship principles?

Increase the frequency of routine urinalysis screening for all residents
Restrict antibiotic use to physicians only, removing NP/PA prescribing authority
Implement culture-directed antibiotic therapy and reduce empiric broad-spectrum antibiotic use (Correct answer)
Prescribe prophylactic antibiotics for all catheterized residents

Correct answer: Implement culture-directed antibiotic therapy and reduce empiric broad-spectrum antibiotic use

Antimicrobial stewardship programs promote culture-directed, targeted antibiotic therapy and discourage empiric broad-spectrum use to reduce resistance, C. difficile rates, and adverse effects.

Question 55: In long-term care, the principle of justice as it applies to resource allocation MOST closely means:

The wealthiest residents receive priority for scarce services
All residents receive identical treatments regardless of need
Justice only applies to legal disputes, not clinical decisions
Resources are distributed fairly based on clinical need and established criteria (Correct answer)

Correct answer: Resources are distributed fairly based on clinical need and established criteria

Justice in healthcare requires equitable distribution of resources according to need and transparent criteria.

Question 56: A resident's family demands that the attending physician prescribe antibiotics for a likely viral upper respiratory infection. The Medical Director is consulted after the attending refuses. The MOST appropriate Medical Director response is to:

Prescribe the antibiotics to satisfy the family and avoid conflict
Support the attending physician's evidence-based decision and help communicate it to the family (Correct answer)
Report the attending to the medical staff committee for refusing family requests
Refer the family to a different facility if they are dissatisfied

Correct answer: Support the attending physician's evidence-based decision and help communicate it to the family

The Medical Director should reinforce evidence-based, appropriate prescribing practices and help communicate clinical reasoning to families, supporting antibiotic stewardship.

Question 57: How does industry trends & emerging technologies contribute to professional excellence in CMD certification?

It benefits organizations but not individual practitioners
It has no measurable impact on practice
It only matters during certification exams
It enhances competency, improves outcomes, and supports continuous professional growth (Correct answer)

Correct answer: It enhances competency, improves outcomes, and supports continuous professional growth

Industry Trends & Emerging Technologies is integral to CMD professional excellence, directly enhancing competency and driving measurable improvement in practice outcomes.

Question 58: The interRAI suite of assessment instruments, increasingly integrated into EHR platforms, is best described as:

A proprietary CMS-mandated MDS replacement scheduled for 2027 implementation
A standardized, internationally validated set of comprehensive geriatric assessment tools used across care settings (Correct answer)
A Medicare Advantage plan quality measurement framework
A clinical decision support algorithm exclusive to acute care hospitals

Correct answer: A standardized, internationally validated set of comprehensive geriatric assessment tools used across care settings

interRAI instruments are standardized assessments validated across 35+ countries that provide comprehensive functional, cognitive, and clinical profiles across post-acute and long-term care settings.

Question 59: A resident with COPD is prescribed supplemental oxygen at 2 L/min. Family requests increasing it to 4 L/min because 'more is better.' The CMD should:

Reduce oxygen to 1 L/min as a compromise
Order a pulmonology consult before any discussion
Explain that high-flow oxygen may suppress hypoxic drive in COPD and is not indicated (Correct answer)
Increase oxygen to satisfy family and reduce conflict

Correct answer: Explain that high-flow oxygen may suppress hypoxic drive in COPD and is not indicated

In COPD patients, excessive supplemental oxygen can suppress the hypoxic respiratory drive and worsen hypercapnia, making education on targeted saturation goals essential.

Question 60: Which of the following MOST accurately describes the Medical Director's role in the facility's QAPI (Quality Assurance and Performance Improvement) program under CMS regulations?

Delegate all QAPI participation to designees without attending meetings
Serve as an active participant providing clinical leadership and guidance (Correct answer)
Chair the QAPI committee and have final approval authority over all decisions
Review QAPI data only if a survey deficiency is cited

Correct answer: Serve as an active participant providing clinical leadership and guidance

CMS requires the Medical Director to actively participate in QAPI, providing clinical expertise and leadership, though they do not need to serve as committee chair.

Question 61: Under federal regulations, a Medical Director in a skilled nursing facility is primarily responsible for staff physicians in which capacity?

Managing payroll and benefits for clinical staff
Coordinating medical care and overseeing the medical care policies (Correct answer)
Conducting annual performance appraisals for all nurses
Approving all staff hires and terminations

Correct answer: Coordinating medical care and overseeing the medical care policies

Federal regulations require the Medical Director to coordinate medical care and oversee compliance with medical care policies.

Question 62: A skilled nursing facility is developing a pandemic preparedness plan. Which element is MOST critical for the Medical Director to include in the risk mitigation component?

Outsourcing infection control to the local hospital system
A plan to suspend all admissions indefinitely
Cohorting protocols, PPE stockpile thresholds, and staff illness surveillance triggers (Correct answer)
Elimination of all communal dining and activities permanently

Correct answer: Cohorting protocols, PPE stockpile thresholds, and staff illness surveillance triggers

Effective pandemic risk mitigation requires cohorting strategies, defined PPE thresholds, and staff surveillance systems to detect and contain transmission early.

Question 63: A Medical Director is asked to certify a resident as unable to make decisions solely to allow a family-preferred treatment. This action would violate which principle?

Justice
Beneficence
Fidelity and honesty (Correct answer)
Non-maleficence

Correct answer: Fidelity and honesty

Falsely certifying incapacity violates the duty of fidelity and professional honesty owed to the resident.

Question 64: A Medical Director discovers a physician colleague has been prescribing controlled substances inappropriately for nursing home residents. The first required step is to:

Contact the DEA directly without notifying administration
Ignore it if no immediate harm is evident
Personally confront the colleague publicly
Report findings to the facility administrator and follow facility policy (Correct answer)

Correct answer: Report findings to the facility administrator and follow facility policy

Medical Directors have a duty to report colleague misconduct through established facility and professional channels.

Question 65: Under AMDA guidelines, how frequently must the Medical Director conduct a formal review of the facility's quality assessment and assurance (QAA) committee activities?

Annually
Semi-annually
Quarterly (Correct answer)
Monthly

Correct answer: Quarterly

CMS regulations require QAA committees, of which the Medical Director is a required member, to meet at least quarterly to review and address quality deficiencies.

Question 66: Which ethical principle requires a Medical Director to act in the best interest of residents even when their preferences conflict with family wishes?

Justice
Non-maleficence
Beneficence (Correct answer)
Autonomy

Correct answer: Beneficence

Beneficence obligates the Medical Director to prioritize the resident's well-being above competing interests.

Question 67: Under the Americans with Disabilities Act (ADA), a medical director's facility must provide reasonable accommodations for staff with disabilities. Which scenario requires accommodation?

A physician requesting exemption from all overnight call permanently
A nurse requesting a higher salary due to a disability
A staff member requesting a private office for personal comfort
A medical assistant with a documented back injury requesting ergonomic equipment to perform essential job functions (Correct answer)

Correct answer: A medical assistant with a documented back injury requesting ergonomic equipment to perform essential job functions

The ADA requires reasonable accommodations that allow employees with documented disabilities to perform essential job functions, such as ergonomic equipment for a back injury.

Question 68: Under the CMS Interoperability and Patient Access Final Rule, what obligation does a SNF's EHR vendor have regarding patient data access?

Offer interoperability only between facilities within the same health system
Submit all resident records to a central CMS data repository monthly
Provide patients with access to their health data through standardized FHIR-based APIs without special effort (Correct answer)
Restrict patient data access to protect proprietary clinical protocols

Correct answer: Provide patients with access to their health data through standardized FHIR-based APIs without special effort

The 2020 CMS Interoperability Rule requires certified EHR systems to implement HL7 FHIR R4 APIs enabling patients to access their data through third-party apps.

Question 69: A resident requests that their diagnosis not be shared with their adult children. Which principle guides the Medical Director's response?

Resident autonomy and confidentiality must be respected unless the resident lacks capacity (Correct answer)
The Medical Director should consult with the ethics committee before responding
Disclosure to family is required when the condition is serious
Family must always be informed to ensure care continuity

Correct answer: Resident autonomy and confidentiality must be respected unless the resident lacks capacity

Competent residents have the right to control their health information; confidentiality must be maintained unless the resident consents to disclosure.

Question 70: A Medical Director wants to benchmark facility performance against national standards. Which data source is most appropriate for post-acute care quality metrics?

Minimum Data Set (MDS) quality measures reported on Care Compare (Correct answer)
Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Agency for Toxic Substances Disease Registry data
National Health Interview Survey

Correct answer: Minimum Data Set (MDS) quality measures reported on Care Compare

MDS-derived quality measures published on CMS Care Compare provide standardized, publicly reported benchmarks for nursing facility performance nationally.

Question 71: Which of the following best describes the role of the medical director in a nursing facility's Quality Assessment and Assurance (QAA) committee?

Delegate all QAA responsibilities to the director of nursing
Chair or actively participate in identifying, evaluating, and correcting quality deficiencies (Correct answer)
Serve as a non-voting consultant only
Attend only when a citation has been issued by a state surveyor

Correct answer: Chair or actively participate in identifying, evaluating, and correcting quality deficiencies

Federal regulations require the medical director to actively participate in the QAA committee, which is charged with identifying and correcting quality deficiencies.

Question 72: When obtaining informed consent for a clinical procedure on a nursing facility resident, which element is MOST critical?

Getting written consent from the attending physician
Documenting that the administrator approved the procedure
Obtaining the signature of the next of kin
Ensuring the resident understands risks, benefits, and alternatives (Correct answer)

Correct answer: Ensuring the resident understands risks, benefits, and alternatives

Valid informed consent requires that the resident comprehends material information including risks, benefits, and alternatives.

Question 73: A physician on staff consistently uses dismissive language when speaking to residents about treatment options. As Medical Director, what is the most appropriate intervention?

Ask nursing staff to mediate the communication issues directly
Immediately suspend the physician's privileges pending investigation
Wait until the annual performance review to address the behavior
Privately counsel the physician, provide specific feedback, and set clear expectations (Correct answer)

Correct answer: Privately counsel the physician, provide specific feedback, and set clear expectations

Private, specific counseling with clear expectations is the appropriate first intervention that preserves dignity while addressing the behavior directly.

Question 74: A Medical Director wants to use remote patient monitoring (RPM) for residents with chronic heart failure. Which metric, when tracked via wearable sensor, most reliably predicts imminent decompensation?

Blood pressure taken at morning care
Resting heart rate alone
Daily weight trend combined with symptom scoring (Correct answer)
Oxygen saturation measured once weekly

Correct answer: Daily weight trend combined with symptom scoring

Daily weight gain of ≥2 lbs combined with dyspnea or edema symptoms is the most validated early warning signal for heart failure decompensation.

Question 75: Which ethical framework evaluates the morality of an action solely based on its outcomes or consequences?

Deontology
Virtue ethics
Utilitarianism (Correct answer)
Principlism

Correct answer: Utilitarianism

Utilitarianism judges actions by whether they produce the greatest good for the greatest number.

Question 76: A Medical Director is asked to comment on implementing a robotics-assisted medication dispensing system. The primary patient safety advantage of such systems over manual dispensing is:

Reduction of dispensing errors through barcode verification and closed-loop medication reconciliation (Correct answer)
Faster dispensing speed enabling nurses to spend more time on clinical tasks only
Elimination of the pharmacist's role in the medication management process
Automatic prior authorization submission to Medicare Part D plans

Correct answer: Reduction of dispensing errors through barcode verification and closed-loop medication reconciliation

Automated dispensing systems with barcode verification create a closed-loop process that catches the majority of dispensing errors before medications reach residents.

Question 77: A facility's antibiotic stewardship program should primarily aim to reduce which risk?

Pharmacy costs only
Physician prescribing documentation errors
Resident refusal of prescribed medications
Antimicrobial resistance and Clostridioides difficile infections (Correct answer)

Correct answer: Antimicrobial resistance and Clostridioides difficile infections

Antibiotic stewardship programs target antimicrobial resistance and C. difficile infections, which are major patient safety threats in long-term care.

Question 78: A Medical Director is leading an interdisciplinary team to reduce the risk of sepsis-related mortality among nursing home residents. Which early identification strategy is MOST effective?

Ordering daily blood cultures for all residents over age 75
Training staff to recognize and respond to early sepsis warning signs using validated clinical triggers such as qSOFA (Correct answer)
Prescribing prophylactic broad-spectrum antibiotics to high-risk residents
Transferring all febrile residents immediately to the emergency department

Correct answer: Training staff to recognize and respond to early sepsis warning signs using validated clinical triggers such as qSOFA

Training staff to recognize early sepsis warning signs using tools like qSOFA enables timely clinical escalation and intervention before sepsis progresses to septic shock.

Question 79: Under the concept of 'just culture' in patient safety, how should a Medical Director respond when a nurse self-reports a near-miss medication error?

Initiate disciplinary action to deter future errors
Encourage transparent reporting, conduct system analysis, and protect the reporter from punitive action (Correct answer)
Report the nurse to the state nursing board immediately
Require the nurse to complete additional medication certification before returning to work

Correct answer: Encourage transparent reporting, conduct system analysis, and protect the reporter from punitive action

Just culture principles prioritize transparent reporting and systemic analysis over individual punishment, recognizing that most errors stem from system failures rather than individual negligence.

Question 80: Interprofessional education (IPE) in long-term care is MOST valuable because it:

Allows one discipline to supervise the licensing of another
Satisfies CMS survey requirements for staff training hours
Improves team communication and collaborative care delivery (Correct answer)
Replaces the need for discipline-specific continuing education

Correct answer: Improves team communication and collaborative care delivery

IPE improves collaborative practice and team communication, which directly reduces care errors in long-term care settings.

Question 81: An ethics consultation in a long-term care facility is BEST described as:

A structured process to assist in resolving value-laden clinical conflicts (Correct answer)
A punitive review triggered by staff complaints
A legal proceeding requiring documentation of all parties' testimony
A binding arbitration process that overrides physician orders

Correct answer: A structured process to assist in resolving value-laden clinical conflicts

Ethics consultations are advisory processes designed to help resolve conflicts involving values and ethical principles in patient care.

Question 82: Which U.S. federal law protects nursing home residents' right to be free from physical and chemical restraints used for discipline or staff convenience?

HIPAA
OBRA 1987 (Correct answer)
EMTALA
ADA

Correct answer: OBRA 1987

OBRA 1987 established resident rights including freedom from inappropriate restraint use in certified nursing facilities.

Question 83: An emerging application of blockchain technology in healthcare most relevant to a Medical Director managing care transitions is:

Mining cryptocurrency using idle EHR server processing capacity during off-hours
Creating an immutable, decentralized record of care events and medication history accessible across providers without a central repository (Correct answer)
Automating CMS billing submission through distributed ledger reimbursement protocols
Replacing HIPAA-compliant cloud storage with blockchain wallets for each resident

Correct answer: Creating an immutable, decentralized record of care events and medication history accessible across providers without a central repository

Blockchain's immutable distributed ledger enables verifiable, tamper-resistant care records accessible to multiple authorized providers without relying on a single controlling entity.

Question 84: A Medical Director is evaluating a voice-activated ambient clinical documentation tool that transcribes physician-patient conversations into structured notes. The primary regulatory concern is:

Stark Law restrictions on physician use of vendor-provided technology
FDA device classification as a Class III medical device requiring PMA
CMS prohibition on ambient documentation in Medicare-certified facilities
HIPAA compliance regarding patient consent for recording and data storage (Correct answer)

Correct answer: HIPAA compliance regarding patient consent for recording and data storage

Ambient documentation tools capture PHI through audio recording, requiring clear patient consent policies, business associate agreements, and secure data handling under HIPAA.

Question 85: Which federal requirement MOST directly governs minimum training hours for certified nursing assistants (CNAs) working in Medicare/Medicaid-certified facilities?

Fair Labor Standards Act
HIPAA Privacy Rule
Americans with Disabilities Act
OBRA 1987 (42 CFR 483.152) (Correct answer)

Correct answer: OBRA 1987 (42 CFR 483.152)

OBRA 1987, codified at 42 CFR 483.152, mandates at least 75 hours of CNA training with at least 16 hours of clinical instruction.

Question 86: A medical director wants to compare the facility's financial performance against similar organizations. Which data source is MOST appropriate for this benchmarking?

The facility's prior-year budget
Patient satisfaction survey scores
Internal general ledger reports only
Industry databases such as CMS cost reports or HFMA benchmarks (Correct answer)

Correct answer: Industry databases such as CMS cost reports or HFMA benchmarks

Industry databases and CMS cost reports provide standardized data enabling meaningful peer comparison for financial benchmarking.

Question 87: In the context of value-based care, what does a 'Total Cost of Care' (TCOC) model require of participating SNFs that traditional fee-for-service does not?

Accountability for the full episode spending across all care settings, not just services rendered within the facility (Correct answer)
Mandatory participation in Medicare Shared Savings ACOs
Elimination of all ancillary therapy services to reduce expenditures
Submission of monthly cost reports to CMS certified public accountants

Correct answer: Accountability for the full episode spending across all care settings, not just services rendered within the facility

TCOC models hold facilities accountable for beneficiary spending across the entire care continuum, incentivizing care coordination and appropriate utilization beyond facility walls.

Question 88: The OIG (Office of Inspector General) Compliance Program Guidance for nursing facilities recommends that compliance programs include which element?

Mandatory enrollment of all physicians in federal compliance training
Designation of a compliance officer and open lines for reporting concerns without retaliation (Correct answer)
Monthly external audits by independent federal contractors
Quarterly financial disclosures to CMS for all facilities

Correct answer: Designation of a compliance officer and open lines for reporting concerns without retaliation

OIG compliance program guidance emphasizes designating a compliance officer and establishing confidential reporting mechanisms with non-retaliation protections.

Question 89: Succession planning in a long-term care medical staff context MOST directly addresses:

Identifying and developing future medical leaders to ensure continuity (Correct answer)
Rotating staff between facilities on a fixed schedule
Selecting which residents will be transferred when census changes
Planning for CMS survey frequency and inspector assignments

Correct answer: Identifying and developing future medical leaders to ensure continuity

Succession planning prepares future medical leadership to maintain organizational continuity when current leaders depart.

Question 90: Under Medicare's Inpatient Prospective Payment System (IPPS), payments are primarily based on:

Actual costs incurred during the hospitalization
Diagnosis-Related Groups (DRGs) assigned at discharge (Correct answer)
Physician orders for specific procedures
The number of days the patient was hospitalized

Correct answer: Diagnosis-Related Groups (DRGs) assigned at discharge

IPPS assigns patients to DRGs at discharge, and Medicare pays a fixed rate per DRG regardless of actual resource use.

Question 91: The 'quadruple aim' framework, which expanded the triple aim, added which dimension most relevant to technology adoption decisions?

Integrating social determinants of health into clinical documentation
Reducing pharmaceutical costs through generic substitution mandates
Expanding telehealth access to rural Medicare Advantage populations
Improving the work life and well-being of healthcare providers and care teams (Correct answer)

Correct answer: Improving the work life and well-being of healthcare providers and care teams

The quadruple aim added clinician/care team well-being to the original triple aim of better outcomes, lower costs, and improved patient experience, recognizing burnout as a systems threat.

Question 92: Which financial statement most directly tells a medical director whether the organization can meet its short-term obligations to pay staff and suppliers?

Statement of changes in equity
Income statement (profit and loss)
Balance sheet's current ratio (current assets ÷ current liabilities) (Correct answer)
Capital expenditure budget

Correct answer: Balance sheet's current ratio (current assets ÷ current liabilities)

The current ratio derived from the balance sheet measures liquidity by comparing current assets to current liabilities, indicating ability to meet short-term financial obligations.

Question 93: A long-term care facility wants to reduce avoidable hospitalizations. Which evidence-based program is specifically designed to achieve this goal?

HEDIS reporting framework
INTERACT (Interventions to Reduce Acute Care Transfers) (Correct answer)
CAHPS survey administration
IHI Triple Aim initiative

Correct answer: INTERACT (Interventions to Reduce Acute Care Transfers)

INTERACT is a quality improvement program with tools and protocols designed to identify, evaluate, and manage acute changes in condition before they require hospitalization.

Question 94: A facility wants to implement a new pain assessment protocol for non-verbal residents. Which validated tool is MOST appropriate?

McGill Pain Questionnaire
Numeric Rating Scale (NRS)
Visual Analog Scale (VAS)
Pain Assessment in Advanced Dementia (PAINAD) (Correct answer)

Correct answer: Pain Assessment in Advanced Dementia (PAINAD)

PAINAD is validated specifically for non-verbal residents with advanced dementia, assessing breathing, vocalization, facial expression, body language, and consolability.

Question 95: Which type of in-service education has been shown MOST effective at changing clinical staff behavior in long-term care settings?

One-time online modules without follow-up
Annual mandatory lecture-style presentations
Repeated, case-based learning with direct observation and feedback (Correct answer)
Distributing written policy updates via email only

Correct answer: Repeated, case-based learning with direct observation and feedback

Repeated case-based learning with observation and feedback is more effective than passive instruction at producing durable behavior change.

Question 96: Which approach best demonstrates professional competency in CMD practice?

Relying solely on initial certification training
Avoiding challenging assignments
Following only personal preferences
Integrating education, experience, and evidence-based decision making (Correct answer)

Correct answer: Integrating education, experience, and evidence-based decision making

True competency in CMD practice comes from integrating formal education with practical experience and using evidence to guide decisions.

Question 97: Which metric is MOST useful for benchmarking a facility's pressure injury prevention program performance?

Prevalence rate of facility-acquired pressure injuries compared to national benchmarks (Correct answer)
Staff-to-resident ratio in the wound care unit
Total number of pressure injuries reported annually
Number of wound care specialist consultations per quarter

Correct answer: Prevalence rate of facility-acquired pressure injuries compared to national benchmarks

Facility-acquired pressure injury prevalence rates compared to national benchmarks provide actionable, risk-adjusted quality data for performance improvement.

Question 98: A resident with early-stage dementia expresses a wish to return home, but the care team believes this is unsafe. The Medical Director should:

Transfer care immediately to a geriatric psychiatrist
Dismiss the request because the resident has dementia
Simply document the request without further action
Perform a formal capacity assessment and involve the ethics committee if needed (Correct answer)

Correct answer: Perform a formal capacity assessment and involve the ethics committee if needed

A formal capacity assessment is required before overriding a resident's expressed preference, even with cognitive impairment.

Question 99: A newly hired charge nurse is observed using a restraint technique not consistent with facility policy. The Medical Director should FIRST:

File a complaint with the State Board of Nursing
Immediately terminate the nurse's employment
Notify the Director of Nursing so corrective training can be initiated (Correct answer)
Personally retrain the nurse at the bedside without documenting the incident

Correct answer: Notify the Director of Nursing so corrective training can be initiated

Notifying the Director of Nursing ensures the competency gap is addressed through proper supervisory and educational channels.

Question 100: Under AMDA guidelines, the Medical Director's role in responding to a sentinel event at the facility INCLUDES:

Participating in root-cause analysis and recommending system-level improvements (Correct answer)
Filing a personal malpractice claim against the facility
Limiting involvement to signing the required CMS forms only
Avoiding involvement to maintain objectivity

Correct answer: Participating in root-cause analysis and recommending system-level improvements

AMDA guidelines direct Medical Directors to actively participate in root-cause analysis and lead system-level improvements after sentinel events.

Certified Medical Director (CMD)

The CMD credential, awarded by the American Board of Post-Acute and Long-Term Care Medicine (ABPLM), recognizes physicians' dual clinical and managerial expertise in post-acute and long-term care settings, covering ethics, systems management, workforce development, and clinical care delivery.

100

Questions

120 min

Time Limit

70%

To Pass

Checking for saved progress...

Exam Rules

You can skip questions and return to them later
Flag questions for review before submitting
No feedback shown until you submit the entire exam
Unanswered questions count as wrong — answer everything
10 pretest questions are mixed in and don't affect your score
Timer auto-submits when time runs out
Your progress is auto-saved every 30 seconds