CPHQ Regulatory and Accreditation 4 — Questions and Answers
Question 1: 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?
- 10 miles (15 in mountainous terrain)
- 25 miles (35 in mountainous terrain) (Correct answer)
- 35 miles (15 in mountainous terrain)
- 50 miles (75 in mountainous terrain)
Correct 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.
Question 2: 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:
- Requires resolution within 45–60 days via an Evidence of Standards Compliance submission (Correct answer)
- Triggers immediate survey withdrawal of accreditation
- Must be reported to CMS within 24 hours
- Requires a root cause analysis submission within 72 hours
Correct 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.
Question 3: Which regulatory body oversees the safety and effectiveness of medical devices used in healthcare facilities and has authority to issue recalls?
- Centers for Medicare and Medicaid Services (CMS)
- Food and Drug Administration (FDA) (Correct answer)
- The Joint Commission (TJC)
- Agency for Healthcare Research and Quality (AHRQ)
Correct 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.
Question 4: 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:
- EMTALA
- The Stark Law (Physician Self-Referral Law) (Correct answer)
- HIPAA Privacy Rule
- The False Claims Act only
Correct 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.
Question 5: NCQA accreditation standards differ most significantly from Joint Commission hospital standards in that NCQA primarily focuses on:
- Acute inpatient hospital care quality
- Health plan and managed care organization performance (Correct answer)
- Long-term care facility standards
- Ambulatory surgery center compliance
Correct 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.
Question 6: 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?
- Statement of Conditions (SOC) (Correct answer)
- Environment of Care Risk Assessment
- Infection Control Risk Assessment (ICRA)
- Utility Management Plan
Correct 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.
Question 7: A quality professional is auditing nursing home compliance with federal regulations. The primary federal regulatory framework governing nursing facility requirements is found in:
- Title XVIII of the Social Security Act
- Title XIX of the Social Security Act and 42 CFR Part 483 (Correct answer)
- The Hill-Burton Act
- OSHA 29 CFR 1910
Correct 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.
CPHQ Regulatory and Accreditation 4
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?