CPHQ Regulatory and Accreditation 4

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?

Accepted Answer

25 miles (35 in mountainous terrain)

Answer

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:

Accepted Answer

Requires resolution within 45–60 days via an Evidence of Standards Compliance submission

Answer

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?

Accepted Answer

Food and Drug Administration (FDA)

Answer

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:

Accepted Answer

The Stark Law (Physician Self-Referral Law)

Answer

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:

Accepted Answer

Health plan and managed care organization performance

Answer

NCQA (National Committee for Quality Assurance) primarily accredits health plans, medical groups, and managed care organizations, not hospitals.

CPHQ - Certified Professional in Healthcare Quality Practice Test

CPHQ - Certified Professional in Healthcare Quality Practice Test

CPHQ Regulatory and Accreditation 4