Regulatory and Accreditation Flashcards
7 cards from real CPHQ 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 and Accreditation flashcards as text
A critical access hospital (CAH) must be located how many miles from the nearest hospital (or more in mountainous terrain) to qualify for that designation?
Answer: 25 miles (35 in mountainous terrain)
Under CMS rules, a CAH must be located more than 35 miles from another hospital, or more than 15 miles in areas with mountainous terrain or only secondary roads.
Under the Joint Commission's accreditation process, a 'Requirement for Improvement' (RFI) differs from a 'Requirement for Immediate Threat to Life' in that an RFI:
Answer: Requires resolution within 45–60 days via an Evidence of Standards Compliance submission
An RFI requires the organization to submit Evidence of Standards Compliance (ESC) within 45–60 days demonstrating how the finding was corrected.
Which regulatory body oversees the safety and effectiveness of medical devices used in healthcare facilities and has authority to issue recalls?
Answer: Food and Drug Administration (FDA)
The FDA regulates medical devices under the Federal Food, Drug, and Cosmetic Act and has authority to order recalls and mandate device reporting.
A hospital's compliance officer discovers that a physician has a financial relationship with a laboratory to which the physician refers patients. This arrangement may violate:
Answer: The Stark Law (Physician Self-Referral Law)
The Stark Law (42 U.S.C. § 1395nn) prohibits physicians from referring Medicare/Medicaid patients to entities with which they have a financial relationship unless an exception applies.
NCQA accreditation standards differ most significantly from Joint Commission hospital standards in that NCQA primarily focuses on:
Answer: Health plan and managed care organization performance
NCQA (National Committee for Quality Assurance) primarily accredits health plans, medical groups, and managed care organizations, not hospitals.
Which document must a hospital maintain to demonstrate compliance with The Joint Commission's Life Safety chapter requirements related to building construction type and occupancy?
Answer: Statement of Conditions (SOC)
The Statement of Conditions (SOC) is the document hospitals complete to demonstrate compliance with NFPA 101 Life Safety Code requirements.
A quality professional is auditing nursing home compliance with federal regulations. The primary federal regulatory framework governing nursing facility requirements is found in:
Answer: Title XIX of the Social Security Act and 42 CFR Part 483
Nursing facility requirements are governed primarily by Title XIX (Medicaid) of the Social Security Act and implemented through 42 CFR Part 483 Requirements for States and Long Term Care Facilities.