Nurse Executive Test Regulatory Frameworks & Compliance 2 — Questions and Answers
Question 1: A hospital is found to have a pattern of failing to report adverse events to The Joint Commission. Which regulatory consequence is MOST likely to result?
- Immediate loss of Medicare/Medicaid certification
- Conditional accreditation status with a follow-up survey (Correct answer)
- Automatic state license revocation
- Mandatory closure pending federal investigation
Correct answer: Conditional accreditation status with a follow-up survey
TJC typically places organizations with serious compliance gaps on conditional accreditation, requiring a follow-up survey to verify corrective action.
Question 2: Under the Emergency Medical Treatment and Labor Act (EMTALA), which situation would constitute a violation?
- Transferring a stable patient to a facility with a higher level of care at the patient's written request
- Refusing to perform a medical screening exam until insurance eligibility is confirmed (Correct answer)
- Documenting the medical screening exam findings before the patient is seen by a physician
- Offering a patient in active labor the option to transfer after risks and benefits are explained
Correct answer: Refusing to perform a medical screening exam until insurance eligibility is confirmed
EMTALA prohibits conditioning a medical screening examination on insurance verification or ability to pay.
Question 3: A nurse executive is reviewing a new state regulation requiring nurse-to-patient staffing ratios. This type of mandate is best classified under which regulatory category?
- Federal administrative law
- State statutory law (Correct answer)
- Voluntary accreditation standard
- Federal constitutional law
Correct answer: State statutory law
State-mandated staffing ratios are enacted through state legislatures as statutory law and enforced by state boards of nursing or health departments.
Question 4: Which federal agency is primarily responsible for enforcing the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule?
- Centers for Medicare & Medicaid Services (CMS)
- Office for Civil Rights (OCR) within HHS (Correct answer)
- Agency for Healthcare Research and Quality (AHRQ)
- Centers for Disease Control and Prevention (CDC)
Correct answer: Office for Civil Rights (OCR) within HHS
The HHS Office for Civil Rights (OCR) is the primary enforcement agency for HIPAA Privacy and Security Rules.
Question 5: A nurse executive discovers that a staff nurse has been accessing patient records of celebrities without a treatment relationship. Under HIPAA, what is the FIRST action the nurse executive should take?
- Terminate the nurse immediately to prevent further breaches
- Conduct a risk assessment to determine breach notification requirements (Correct answer)
- Report the violation directly to the Office for Civil Rights
- Notify affected patients before completing an internal investigation
Correct answer: Conduct a risk assessment to determine breach notification requirements
HIPAA's Breach Notification Rule requires a risk assessment to determine the probability that PHI was compromised before notification decisions are made.
Question 6: The Conditions of Participation (CoPs) for hospitals are significant because they:
- Are voluntary standards that hospitals choose to adopt for quality improvement
- Determine eligibility to receive Medicare and Medicaid reimbursement (Correct answer)
- Apply only to critical access hospitals in rural areas
- Are enforced exclusively by The Joint Commission on behalf of CMS
Correct answer: Determine eligibility to receive Medicare and Medicaid reimbursement
CMS Conditions of Participation are federal requirements that hospitals must meet to participate in and receive payments from Medicare and Medicaid programs.
Question 7: A nurse executive is developing a compliance plan following a self-disclosure of billing irregularities to the OIG. Which element is considered foundational to an effective healthcare compliance program according to OIG guidance?
- Outsourcing all compliance functions to a third-party auditing firm
- Designating a compliance officer with direct reporting to the governing body (Correct answer)
- Implementing a zero-tolerance policy that automatically terminates any employee involved in a violation
- Restricting compliance training to management and billing department staff only
Correct answer: Designating a compliance officer with direct reporting to the governing body
OIG guidance identifies designating a compliance officer with authority and direct access to the governing board as a cornerstone of an effective compliance program.
Nurse Executive Test Regulatory Frameworks & Compliance 2
A hospital is found to have a pattern of failing to report adverse events to The Joint Commission.
Which regulatory consequence is MOST likely to result?