CPHQ Regulatory and Accreditation 5 — Questions and Answers
Question 1: The False Claims Act (FCA) allows private citizens to file lawsuits on behalf of the government against entities that commit fraud. These individuals are called:
- Compliance officers
- Qui tam relators (Correct answer)
- Beneficiary advocates
- Whistleblower liaisons
Correct answer: Qui tam relators
Under the False Claims Act, private citizens who file fraud lawsuits on behalf of the government are called qui tam relators and may receive a portion of recovered funds.
Question 2: When a healthcare organization identifies a sentinel event, The Joint Commission requires submission of which analysis within 45 days?
- Failure Mode and Effects Analysis (FMEA)
- Root Cause Analysis (RCA) and action plan (Correct answer)
- Plan of Correction
- Corrective Action Report to CMS
Correct answer: Root Cause Analysis (RCA) and action plan
The Joint Commission requires an accredited organization to submit a thorough root cause analysis and improvement action plan within 45 days of identifying a sentinel event.
Question 3: Under CMS Hospital Conditions of Participation, which standard requires hospitals to have a process for credentialing and privileging practitioners?
- Nursing Services CoP
- Medical Staff CoP (§482.22) (Correct answer)
- Governing Body CoP
- Patient Rights CoP
Correct answer: Medical Staff CoP (§482.22)
The Medical Staff CoP (§482.22) requires hospitals to have a well-organized medical staff with bylaws governing credentialing, privileging, and peer review.
Question 4: A hospital receives a 'Immediate Jeopardy' (IJ) citation during a survey. The organization must respond by:
- Submitting a written plan within 60 days
- Removing the IJ by implementing acceptable corrective actions before the surveyor leaves or within a short timeframe (Correct answer)
- Voluntarily withdrawing from accreditation
- Reporting the finding to the state legislature
Correct answer: Removing the IJ by implementing acceptable corrective actions before the surveyor leaves or within a short timeframe
An Immediate Jeopardy finding requires the organization to implement corrective actions acceptable to the surveyor, often before the survey team departs, to remove the immediate threat.
Question 5: Which federal agency administers the Medicare and Medicaid programs and sets Conditions of Participation for healthcare facilities?
- Agency for Healthcare Research and Quality (AHRQ)
- Centers for Medicare and Medicaid Services (CMS) (Correct answer)
- Health Resources and Services Administration (HRSA)
- Centers for Disease Control and Prevention (CDC)
Correct answer: Centers for Medicare and Medicaid Services (CMS)
CMS, within the Department of Health and Human Services, administers Medicare and Medicaid and establishes the Conditions of Participation that facilities must meet.
Question 6: A quality professional is reviewing the organization's compliance with CLIA (Clinical Laboratory Improvement Amendments). CLIA regulations are designed to ensure quality in:
- Radiology imaging and interpretation
- Human laboratory testing on patient specimens (Correct answer)
- Pharmacy compounding practices
- Surgical equipment sterilization
Correct answer: Human laboratory testing on patient specimens
CLIA establishes quality standards for all laboratory testing performed on human specimens to ensure accurate, reliable, and timely patient test results.
Question 7: The concept of 'deemed status' for accreditation organizations means that:
- All state licenses are automatically granted upon accreditation
- Accreditation by an approved organization is accepted as meeting CMS Conditions of Participation (Correct answer)
- The organization is exempt from all federal inspections permanently
- The governing board is approved by CMS directly
Correct answer: Accreditation by an approved organization is accepted as meeting CMS Conditions of Participation
Deemed status means CMS has determined that an accreditation organization's standards are equivalent to or stricter than Medicare CoPs, so accredited facilities are 'deemed' compliant.
CPHQ Regulatory and Accreditation 5
The False Claims Act (FCA) allows private citizens to file lawsuits on behalf of the government against entities that commit fraud.
These individuals are called: