CMD Regulatory Compliance & Quality Improvement 3 — Questions and Answers
Question 1: The Five-Star Quality Rating System published on Nursing Home Care Compare includes which three domains?
- Staffing, physician visits, and resident satisfaction
- Health inspections, staffing, and quality measures (Correct answer)
- Financial performance, staffing, and incident reports
- Infection rates, medication errors, and fall rates
Correct answer: Health inspections, staffing, and quality measures
CMS's Five-Star system rates facilities on health inspection results, staffing levels, and clinical quality measures.
Question 2: Under OBRA 87, which of the following is a core Medical Director responsibility?
- Performing monthly H&Ps for all residents
- Implementation and coordination of resident care policies (Correct answer)
- Personally supervising all medication administration
- Chairing the infection control committee
Correct answer: Implementation and coordination of resident care policies
OBRA 87 designates the Medical Director as responsible for implementation and coordination of resident care policies and the overall medical care program.
Question 3: A 'never event' in a long-term care setting most accurately refers to:
- Any adverse event that was not anticipated in the care plan
- A serious, largely preventable patient safety incident that should never occur (Correct answer)
- An incident that was never reported to state authorities
- A medication error that never caused patient harm
Correct answer: A serious, largely preventable patient safety incident that should never occur
Never events are serious, largely preventable patient safety incidents whose occurrence signals fundamental systems failures.
Question 4: 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
- Initiate a confidential peer review process through the facility's medical staff structure (Correct answer)
- Immediately terminate the physician's admitting privileges
- Inform all residents and families about the performance concerns
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 5: MDS (Minimum Data Set) 3.0 quality measures are important to a Medical Director because they:
- Determine individual physician reimbursement rates
- Provide standardized clinical outcome data used for quality monitoring and public reporting (Correct answer)
- Replace the need for internal chart audits
- Are required only for Medicare-certified facilities with more than 100 beds
Correct answer: Provide standardized clinical outcome data used for quality monitoring and public reporting
MDS 3.0 quality measures generate standardized, federally reported clinical outcomes used by facilities, surveyors, and consumers.
Question 6: The concept of 'safe harbor' in quality improvement programs primarily protects:
- Residents who file complaints against physicians
- Information generated in peer review or QI processes from discovery in litigation (Correct answer)
- Medical Directors from personal liability for all adverse events
- Facilities from CMS survey penalties during active QI projects
Correct answer: Information generated in peer review or QI processes from discovery in litigation
Safe harbor provisions in most states protect peer review and quality improvement deliberations from being used as evidence in civil lawsuits.
Question 7: A facility's antibiotic stewardship program should primarily aim to reduce which risk?
- Pharmacy costs only
- Antimicrobial resistance and Clostridioides difficile infections (Correct answer)
- Physician prescribing documentation errors
- Resident refusal of prescribed medications
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.
CMD Regulatory Compliance & Quality Improvement 3
The Five-Star Quality Rating System published on Nursing Home Care Compare includes which three domains?