CPHQ Regulatory and Accreditation 2

Question 1

Which CMS Conditions of Participation requirement mandates that hospitals have a governing body ultimately responsible for the conduct of the hospital?

Accepted Answer

Governing body standard

Answer

The CMS Conditions of Participation Governing Body standard holds the governing board ultimately responsible for the hospital's operations and quality of care.

Question 2

A hospital is preparing for a CMS validation survey following a complaint. What should staff understand about this type of survey?

Accepted Answer

It may be unannounced and triggered by a complaint or accreditation deficiency

Answer

CMS validation surveys can be unannounced and are often triggered by complaints or when an accreditation organization finds deficiencies.

Question 3

Under HIPAA's Minimum Necessary Standard, which scenario is compliant?

Accepted Answer

A billing clerk accesses only the diagnosis codes and procedure codes needed to process a claim

Answer

The Minimum Necessary Standard requires that access to PHI be limited to the least amount needed to accomplish the intended purpose.

Question 4

The Joint Commission's National Patient Safety Goal NPSG.15.01.01 addresses which of the following?

Accepted Answer

Suicide risk reduction in healthcare settings

Answer

NPSG.15.01.01 requires organizations to identify patients at risk for suicide and implement risk reduction strategies.

Question 5

Which accreditation standard requires organizations to define the scope of performance improvement activities and include all hospital departments?

Accepted Answer

Leadership standard on quality improvement planning

Answer

The Joint Commission Leadership standard requires that the organization's PI plan define scope and encompass all departments and services.

CPHQ - Certified Professional in Healthcare Quality Practice Test

CPHQ - Certified Professional in Healthcare Quality Practice Test

CPHQ Regulatory and Accreditation 2