Nurse Executive Test Regulatory Frameworks & Compliance 5 — Questions and Answers
Question 1: A nurse executive is preparing for a deemed status survey. 'Deemed status' means the organization:
- Has received a temporary exemption from CMS survey requirements pending accreditation renewal
- Has been accredited by an approved accrediting organization, which substitutes for CMS direct surveys (Correct answer)
- Has been deemed noncompliant and placed on a CMS improvement plan
- Has voluntarily chosen CMS direct surveys over accreditation body oversight
Correct answer: Has been accredited by an approved accrediting organization, which substitutes for CMS direct surveys
Deemed status means an accredited organization is presumed to meet CMS Conditions of Participation because the accrediting body's standards have been approved as equivalent to CMS requirements.
Question 2: Under the Occupational Safety and Health Administration (OSHA) Bloodborne Pathogens Standard, employers must provide hepatitis B vaccinations to at-risk employees:
- Only if the employee requests the vaccination in writing within 10 days of hire
- At no cost to the employee, within 10 working days of initial assignment to at-risk duties (Correct answer)
- After the employee demonstrates immunity through post-exposure serology testing
- Annually, as part of the required exposure control plan update
Correct answer: At no cost to the employee, within 10 working days of initial assignment to at-risk duties
OSHA's Bloodborne Pathogens Standard requires employers to offer hepatitis B vaccination at no cost within 10 working days of initial assignment to tasks involving potential exposure.
Question 3: A nurse executive is notified of a large-scale HIPAA breach affecting more than 500 individuals in a state. Under the Breach Notification Rule, the covered entity must notify the Secretary of HHS:
- Within 60 days of discovery, by submitting a paper report to the regional OCR office
- Without unreasonable delay and no later than 60 days after discovery, via the HHS web portal (Correct answer)
- Within 30 days of discovery and simultaneously notify local law enforcement
- After notifying all affected individuals, with no specific federal deadline for HHS notification
Correct answer: Without unreasonable delay and no later than 60 days after discovery, via the HHS web portal
For breaches affecting 500 or more individuals, covered entities must notify HHS without unreasonable delay and within 60 days of discovery using the HHS breach reporting web tool.
Question 4: A nurse executive receives a federal subpoena for patient records as part of a fraud investigation. The MOST appropriate initial action is to:
- Immediately produce the records to avoid obstruction of justice charges
- Notify legal counsel and place a litigation hold on the relevant documents (Correct answer)
- Notify affected patients before releasing any records to federal investigators
- Redact all patient identifiers before providing records to comply with HIPAA
Correct answer: Notify legal counsel and place a litigation hold on the relevant documents
Upon receiving a subpoena, the organization should immediately notify legal counsel and implement a litigation hold to preserve relevant documents pending legal review.
Question 5: The Corporate Integrity Agreement (CIA) is a tool used by the OIG primarily to:
- Require immediate repayment of all federal funds received during a compliance violation period
- Allow providers to continue participating in federal programs under enhanced monitoring after a settlement (Correct answer)
- Mandate appointment of an independent board of directors to oversee hospital governance
- Suspend a hospital's accreditation pending the outcome of a fraud investigation
Correct answer: Allow providers to continue participating in federal programs under enhanced monitoring after a settlement
A CIA is negotiated as part of a civil fraud settlement, permitting the provider to maintain Medicare/Medicaid participation in exchange for implementing rigorous compliance obligations under OIG oversight.
Question 6: Which federal law prohibits employment discrimination against qualified individuals with disabilities and requires healthcare organizations to provide reasonable accommodations, applying to employers with 15 or more employees?
- The Rehabilitation Act of 1973
- The Americans with Disabilities Act (ADA) (Correct answer)
- The Family and Medical Leave Act (FMLA)
- Section 504 of the Workforce Innovation and Opportunity Act
Correct answer: The Americans with Disabilities Act (ADA)
The ADA prohibits disability-based employment discrimination and mandates reasonable accommodations for qualified employees with disabilities in organizations with 15 or more employees.
Question 7: A nurse executive is evaluating whether a new physician recruitment arrangement complies with the Stark Law. Which of the following IS a recognized exception to the Stark Law's referral prohibition?
- Any arrangement in which total physician compensation does not exceed $50,000 annually
- Bona fide employment relationships where compensation is consistent with fair market value and not based on referral volume (Correct answer)
- Informal verbal agreements between hospital administrators and physicians regarding on-call coverage
- Recruitment arrangements for physicians who agree to refer exclusively to the employing hospital
Correct answer: Bona fide employment relationships where compensation is consistent with fair market value and not based on referral volume
The bona fide employment exception permits hospitals to employ physicians and compensate them at fair market value without triggering the Stark Law's referral prohibition, provided compensation is not tied to referral volume.
Nurse Executive Test Regulatory Frameworks & Compliance 5
A nurse executive is preparing for a deemed status survey. 'Deemed status' means the organization: