CJCP Practice Exam

Which of the following is required in the medical record? A. The patient's race and ethnicity B. The patient's religious affiliation C. The patient's advance directives

A. The patient's race and ethnicity RC.02.01.01, EPs 4, 28; PC 02.02.03, EP 9; RI.01.01.01, EP 9

Openings in 2-hour fire-rated walls are required to be fire rated for how long? A. 2 hours B. 1.5 hours C. 2.5 hours

B. 1.5 hours LS.02.01.10, EP 4

For hospitals not using TJC for deemed status purposes, the hospital seeking JC accreditation for the first time must meet the parameters for the minimum number of patients, which is A. 10 patient served, with 5 active at the time of survey B. 10 patients served, with 1 active at the time of survey C. 30 patients served, representing records equal to 10% of the average daily census

B. 10 patients served, with 1 active at the time of survey ACC chapter, "Eligibility Requirements for Initial Surveys" section

The hospital selects one high-risk process and conducts a proactive risk assessment at least every A. 12 months B. 18 months C. 24 months

B. 18 months LD.04.04.05, EP 10

For hospitals that use JC accreditation for deemed status purposes, a preanesthesia evaluation is completed and documented by an individual qualified to administer anesthesia within A. 24 hours prior to surgery or a procedure requiring anesthesia services B. 48 hours prior to surgery or a procedure requiring anesthesia services C. 48 hours after registration or admission to the hospital

B. 48 hours prior to surgery or a procedure requiring anesthesia services PC.03.01.03, EP 18

Psychiatric treatment plan must be written and include

- A substantiated diagnosis - Short-term and long-range goals - Specific treatment modalities used - Responsibilities of each member of the treatment team - Adequate documentation to justify the diagnosis and the treatment and rehab activities - The treatment received by the patient must be documented in such a way to assure that ALL ACTIVE THERAPEUTIC EFFORTS ARE INCLUDED

Types of second generation tracers

- Cleaning, disinfection and sterilization (CDS) - Patient flow across the care continuum - Contracted services - Diagnostic imaging - Ongoing professional practice evaluation (OPPE)/focused professional practice evaluation (FPPE)

Psychiatric evaluation components must include

- Medical history - Record of mental status - Note the onset of illness and the circumstances leading to admission - Describe attitudes and behavior - Estimate intellectual functioning, memory functioning, and orientation - Include an inventory of he patient's assets in descriptive, not interpretative, fashion

The three topics evaluated with system tracers

1. Data Management 2. Infection Control 3. Medication Management

Second generation tracer

A deep and detailed exploration of a particular area, process, or subject

Immediate Threat to Health or Safety (Medicare Condition-level deficiency)

A threat that represents immediate risk and has or may potentially have serious adverse effects on the health or safety of the patient, resident or individual served. Results in a Preliminary Denial of Accreditation = no clarifications

Hospitals are required to retain tissue records on storage temperatures, outdated procedures, manuals, and publications for a minimum of A. 10 years B. 6 years C. 7 years

A. 10 years

If corridors are 6 feet wide or more, for certain objects to project into the corridor, they must be no more than A. 36 inches wide and cannot project more than 6 inches into the corridor. B. 36 inches wide and cannot project more than 8 inches into the corridor. C. 48 inches wide and cannot project more than 6 inches into the corridor.

A. 36 inches wide and cannot project more than 6 inches into the corridor. LS.02.01.20, EP 12

The frequency of generator emergency power testing is A. 4 hours every 36 months B. 4 hours every 48 months C. 4 hours every 24 months

A. 4 hours every 36 months

The hospital sets incremental influenza vaccination goals, consistent with achieving the A. 90% rate established in the national influenza initiatives for 2020 B. 95% rate established in the national influenza initiatives for 2020 C. 90% rate established in the national influenza initiatives for 2015

A. 90% rate established in the national influenza initiatives for 2020 IC.02.04.01, EP 5

When demonstrating an Evidence of Standards Compliance (ESC), which of the following percentages over 4 months would determine a hospital's EP compliance score? A. 90% through 100% of the sample size is in compliance = score 2 B. 85% through 89% of the sample size is in compliance = score 1 C. Less than 85% of the sample size is in compliance = score 0

A. 90% through 100% of the sample size is in compliance = score 2 ACC chapter, "Corrective ESC" section, "Sample Sizes" subsection

During a survey, the surveyor may determine that which of he following exhibits compliance with patients' right to effective communication? A. A Tagalog-speaking patient is provided with an interpreter to help in reviewing the consent-to-treat form B. A deaf patient is given verbal information on visitation rights by a speaker mouthing the words clearly and carefully C. A college-educated patient is given a copy of the pharmaceutical insert as medication teaching instruction

A. A Tagalog-speaking patient is provided with an interpreter to help in reviewing the consent-to-treat form RI.01.01.01, EP 5; RI.01.01.03, EP 1

Which of the following correctly states the required time frame specified in the standard for assessing and reassessing a patient and his or her condition? A. A nutritional screening (when warranted by the patient's needs or condition) is completed within 24 hours after Inpatient admission B. a nutritional plan is developed within 72 hours after inpatient admission C. Initial patient assessments must be completed within 24 hours of admission, in accordance with law and regulation

A. A nutritional screening (when warranted by the patient's needs or condition) is completed within 24 hours after Inpatient admission

Which of the following statements about Accreditation Participation Requirements (APRs) is correct? A. APRs state the requirements for participation in the accreditation process and for maintaining an accreditation award. B. APRs are classified as scoring category A or C. C. When a hospital does not comply with any APR, the hospital will be assigned a Preliminary Denial of Accreditation decision.

A. APRs state the requirements for participation in the accreditation process and for maintaining an accreditation award. APR chapter, Overview

Which of the following is a true statement about alcohol-based hand hygiene products? A. Alcohol type, concentration of alcohol, and contact time affect the efficacy of alcohol-based hand hygiene products B. a Small volume of alcohol application to the hands is as effective as hand washing with plain soap and water C. Wet hands do not affect the efficacy of alcohol-based hand products

A. Alcohol type, concentration of alcohol, and contact time affect the efficacy of alcohol-based hand hygiene products

For evaluation purposes, TJC recognizes that exact time frames for equipment and facility/utility testing may be impossible to meet and therefore allows which of the following time frames? A. Annually/every 12 months/once a year/every year = 1 year from the date of the last event, plus or minus 30 days B. Every 6 months = 6 months from the date of the last event, plus or minus 15 days C. Quarterly = 4 times a year, once in each quarter, plus or minus 30 days

A. Annually/every 12 months/once a year/every year = 1 year from the date of the last event, plus or minus 30 days EC chapter, "Other issues for Consideration" section - Q6 months = date of last event +/- 20 days - Quarterly = every three months, +/- 10 days

When is a hospital required to report to its tissue supplier a posttransplant infection or other adverse event related to the use of tissue? A. As soon as the hospital becomes aware of the infection or event B. After the hospital identifies and informs tissue recipients of its infection risk C. Before the final disposition of the tissue

A. As soon as the hospital becomes aware of the infection or event TS.03.03.01, EPs 3, 5

When anesthesia is administered at hospitals that do not use JC accreditation for deemed status purposes, at what point(s) should a patient be assessed? A. Before initiating the operative or other high-risk procedure, with a reevaluation immediately before the administration of deep sedation or anesthesia B. Before initiating the operative or other high-risk procedure, with an initial evaluation within 48 hours prior to surgery C. within 72 hours prior to surgery

A. Before initiating the operative or other high-risk procedure, with a reevaluation immediately before eh administration of deep sedation or anesthesia PC.03.01.03, EPs 1, 8

Hospitals are required to identify risks for acquiring and transmitting infections based on which the following? A. Geographic location, community, and population served; the care, treatment, and services the hospital provides; and the analysis of surveillance activities and other infection control data B. Geographic location, community and population serviced; the care, treatment, and services the hospital provides; and established goals for minimizing the possibility of transmitting infections C. The care, treatment, and services the hospital provides; findings from the evaluation of effectiveness of the hospital's infection prevention and control plan; and other infection control data

A. Geographic location, community, and population served; the care, treatment, and services the hospital provides; and the analysis of surveillance activities and other infection control data IC.01.03.01, EPs 1-3

Which of the following statements on accreditation decisions is correct? A. If the hospital uses Joint Commission accreditation for deemed status purposes, the results of the extension survey will immediately affect the accreditation status of the hospital. B. If the hospital does not use accreditation for deemed status, the survey findings from an extension survey generally will not be reflected in the accreditation decision of the hospital for 6 months. C. If the hospital uses Joint Commission accreditation for deemed status purposes, the results of the extension survey will not be reflected in the accreditation decision of the hospital for 12 months.

A. If the hospital uses Joint Commission accreditation for deemed status purposes, the results of the extension survey will immediately affect the accreditation status of the hospital. ACC chapter, "Extension Surveys" section

Buildings are considered new health care occupancies if final plans for new construction, additions, renovations, or changes in occupancy were approved by the local authority having jurisdiction after A. March 1, 2003 B. March 1, 2005 C. March 1, 2001

A. March 1, 2003 LS chapter, "Abount This Chapter" section

Who is responsible for privileging volunteer licensed independent practitioners during an emergency? A. Medical staff B Chief medical officer C. Human Resources leadership

A. Medical staff EM.02.02.13, EPs 2, 4, 6

Leaders evaluate the performance expectations of contracted services using which of the following principles? A. Methods to evaluate contractor performance may include the review of incident reports, audits of documentation, and review of reports from the contractual entity B. Contracted services are monitored annually by evaluating these services in relations to the hospital's expectations C. Steps to improve contracted services that do not meet expectations including increasing the monitoring of the contracted services, providing consultation or training to the contractor, and renegotiating the contract terms up to but excluding the termination of the contract

A. Methods to evaluate contractor performance may include the review of incident reports, audits of documentation, and review of reports from the contractual entity LD chapter, Introduction to Oversight of Care, Treatment, and Services Provided Through Contractual Agreement, Standard LD.04.03.09; LD.04.03.09, EPs 6, 7

Which of the following are required under the Performance Improvement standard for collecting data to monitor performance? A. Patient perception of the safety and quality of care, treatment, or services; the use of blood and blood components; and the results of resuscitation B. significant adverse drug reactions, significant medication errors, and staff suggestions for improving patient safety C. staff opinions and needs, all reported and confirmed transfusion reactions, and the use of blood and blood components

A. Patient perception of the safety and quality of care, treatment, or services; the use of blood and blood components; and the results of resuscitation PI.01.01.01, EPs 7, 8, 11, 14-16, 30

The surveyor(s) will use which of the following criteria to select initial individual tracers? A. Patients whose tracers would allow for the evaluation of identified program specific risk areas/categories (such as elements of performance [EPs] identified with risk icons) B. Patients who receive all of their care, treatment, and services in a single department or unit C. Units or programs that were not included in previous surveys

A. Patients whose tracers would allow for the evaluation of identified program specific risk areas/categories (such as elements of performance [EPs] identified with risk icons) ACC chapter, "Individual Tracer Activity" section

Which of the following meets the competency requirement for waived testing using at least two methods per person per test? A. Periodic observation of routine work by the supervisor or qualified designee and performance of a test on a blind specimen B. Use of a written test specific to the test assessed and performance of a test C. Performance of a test and monitoring of each user's quality control performance

A. Periodic observation of routine work by the supervisor or qualified designee and performance of a test on a blind specimen WT.03.01.01, EP 5

Which of the following is an activity regulated by the Clinical Laboratory Improvement Amendments of 1988 (CLIA '88)? A. Staff members use instruments owned by staff members, owned by the organization, or owned by the patient in performing waived laboratory tests B. A staff member provides only instruction to a patient on how to perform whole blood glucose testing on a home device C. A patient performs a test on himself or herself

A. Staff members use instruments owned by staff members, owned by the organization, or owned by the patient in performing waived laboratory tests WT chapter, "About This Chapter" section

The organized medical staff must be structured using which of the following guiding principles? A. The organized medical staff is responsible for structuring itself to provide a uniform standard of quality patient care, treatment, and services. B. The organized medical staff is accountable to the Medical Staff Executive Committee. C. Applicants for privileges must be members of the medical staff.

A. The organized medical staff is responsible for structuring itself to provide a uniform standard of quality patient care, treatment, and services. MS chapter, "Organized Medical Staff Structure" section

Which of the following is true regarding the elements of performance (EPs) and requirements shown in the tables included in the "Early Survey Policy Option" (ESP) chapter of the Comprehensive Accreditation Manual for Hospitals? A. They are applicable to a first survey B.They are applicable to a second survey C. They are applicable to either a first or second survey, at the discretion of the surveyor

A. They are applicable for a first survey

The hospital staff orientation includes the following documentation prior t patient care A. Unit-specific orientation, specific job responsibilities, and sensitivity to cultural diversity B. General orientation, sensitivity to cultural diversity, and a welcome meeting to the specific unit C. Sensitivity to cultural diversity, department job responsibilities, and unit-specific orientation

A. Unit-specific orientation, specific job responsibilities, and sensitivity to cultural diversity HR.01.04.01, EPs 3-6

Under what conditions may a hospital keep concentrated electrolytes in patient care areas? A. When patient safety necessitates their immediate use and precautions are used to prevent inadvertent administration B. When storage within patient care areas has been approved by a registered pharmacist, in accordance with law and regulation C. When the electrolytes are labeled individually with a visible fluorescent warning label that states "MUST BE DILUTED"

A. When patient safety necessitates their immediate use and precautions are used to prevent inadvertent administration MM.03.01.01, EP 2

If self-administration of medications is allowed, the hospital is required to have which of the following? A. Written processes that address training, supervision, and documentation to guide the safe and accurate self-administration of medications or the administration of medications by a family member B. A written policy on self-administration of medications available in the predominant language(s) of the patient population C. A list of criteria for determining that the patient or family member who administers the medication is competent at medication administration before being allowed to administered medications

A. Written processes that address training, supervision, and documentation to guide the safe and accurate self-administration of medications or the administration of medications by a family member MM.06.01.03, EPs 1, 7

Sterilization of reusable instruments and devices requires that A. a chemical indicator is placed correctly in the instrument packs in every load B. a biological indicator is used at least daily for each sterilizer and with every load containing implantable items C. for dynamic air removal-type sterilizers, a Bowie-Dick test is performed with every load when the sterilizer is used to verify efficacy of air removal

A. a chemical indicator is placed correctly in the instrument packs in every load IC.02.02.01, EP 2; AAMI ST-79

A hospital's scope of services document is A. a document that is approved by the governing body that defines the care, treatment, and services provided at the organization B. a document that is approved by the senior leaders that defines the care, treatment, and services provided by the organization C. a legal document that is approved by the legal counsel that states the legal and operational authority for the hospital

A. a document that is approved by the governing body that defines the care, treatment, and services provided at the organization LD.01.03.01, EP 3

An organization may request to alter an already scheduled survey date or delay an unannounced survey if A. an internal disaster has flooded one nursing unit. B. the organization is involved in a major strike. C. on the day(s) of the survey, the organization is celebrating after its move to a new building.

A. an internal disaster has flooded one nursing unit. ACC chapter, "Survey Postponement Policy" section

The Standards Applicability Grid and services provided by the hospital are used to determine A. applicability of standards. B. applicability of criticality. C. surveyor days.

A. applicability of standards. SAG chapter, HIM chapter, "Understanding the Icons Used in this Manual" section; ACC chapter, "Accuracy of the Application Information" and "During the Survey" sections

Any hospital may apply for Joint Commission accreditation if it: A. assesses and improves the quality of its care, treatment, and/or services and provides services addressed in Joint Commission standards. B. will use Joint Commission accreditation for deemed status purposes. C. is either in the United States or its territories or outside the United State but within a privately owned hospital that provides care, treatment, and/or services to patients who are U.S. citizens.

A. assesses and improves the quality of its care, treatment, and/or services and provides services addressed in Joint Commission standards. ACC Chapter, "General Eligibility Requirements" section

Exit corridors must be A. at least 8 feet wide in new construction B. at least 8 feet wide in existing buildings C. more than 8 feet wide in existing buildings

A. at least 8 feet wide in new construction LS.02.01.20, EP 11

Biological indicators should be done A. at least weekly, every day before use, and with every implant load B. every day of use, with every implant load, and at least weekly C. after installation, relocation, malfunction, or major repair and with every implant load

A. at least weekly, every day before use, and with every implant load EC.02.04.03, EP 5; AAMI ST-79

A preprocedure process to verify the correct procedure, for the correct patient, at the correct site occurs A. at the time(s) the hospital decides this information should be collected B. at the time the patient is registered at the hospital and at the time of preadmission assessment C. at the time of admission to the hospital, so it is not necessary to repeat it before the patient enters the procedure room

A. at the time(s) the hospital decides this information should be collected NPSG chapter, Rationale for UP.01.01.01

Outside exit stairs must A. be separated from the interior of the building by the same fire rating required for the exit stairs B. be constructed to extend vertically from the ground to a point greater than 15' above the top landing C. be constructed to extend less than 10' horizontally to protect from flame spread

A. be separated from the interior of the building by the same fire rating required for the exit stairs LS.02.01.20, EP 4

Stairs and ramps serving as egress are required to be equipped with handrails on A. both sides in new construction B. at least one side in new construction C. both sides in existing buildings

A. both sides in new construction LS.02.01.20, EP 7

Cleaning and performance low-level disinfection of medical equipment, devices, and supplies applies to items such as A. clinicians' stethoscopes and hospital glucose meters B. patient's own blood glucose meters and equipment used in isolation C. equipment used in isolation and clinicians' stethoscopes

A. clinicians' stethoscopes and hospital glucose meters IC.02.02.01, EP 1

If conflicts regarding the medical staff bylaws, rules and regulations, or policies arise between the governing body and the organized medical staff, the organization implements its A. conflict management process B. fair hearing and appeal process C. grievance process

A. conflict management process MS.01.01.01, EP 10; LD.02.04.01, EPs 1-5

The topics evaluated with system tracers are A. data use, infection control, and medication management. B. data use, leadership, and infection control. C. data use, leadership, and medication management.

A. data use, infection control, and medication management ACC chapter, "System Tracer Activity" section

Under the National Patient Safety Goal for maintaining and communicating accurate medication information, medication reconciliation includes A. identifying and resolving discrepancies and providing information about medications upon discharge B. providing information on medications to be taken at the end of the encounter and forwarding a medication list to the primary care provider at discharge C. obtaining a medication history, identifying and resolving discrepancies, getting clarification of the correct dosage, and obtaining information during transitions of care

A. identifying and resolving discrepancies and providing information about medications upon discharge Rationale for NPSG.03.06.01

According to Life Safety (LS) requirements, the number of smoke compartments may vary, depending on existing or new construction, in which of the following ways? A. In new buildings, at least two smoke compartments are provided for every story with patient sleeping or treatment rooms, for nonsleeping stories that have an occupant capacity of 50 or more people, and on usable but unoccupied stories B. In existing buildings, at least two smoke compartments are provided for every story that has more than 50 patients in sleeping rooms C. In new buildings, at least two smoke compartments are provided for every story with more than 30 patients in sleeping or treatment rooms and for nonsleeping stories that have an occupant capacity of 50 or more people

A. in new buildings, at least two smoke compartments are provided for every story with patient sleeping or treatment rooms, for nonsleeping stories that have an occupant capacity of 50 or more people, and on usable but unoccupied stories LS.02.01.30, EPs 14, 15

Periodic risk assessments for multi-drug-resistant organism acquisition and transmission must be conducted A. in time frames defined by the hospital B. whenever there is an outbreak C. at least annually

A. in time frames defined by the hospital NPSG.07.03.01, EP 1

Possible abuse and neglect cases are reported A. internally in the hospital and externally to agencies in accordance with law and regulation B. externally to agencies, in accordance with law and regulation C. to security in the hospital and externally to the local police department

A. internally in the hospital and externally to agencies in accordance with law and regulation PC.01.02.09, EPs 6, 7

Surveyors will assess the hospital's compliance with sentinel event-related standards by A. interviewing leadership and staff about related expectations and responsibilities B. determining whether or not events are sentinel events C. inquiring about sentinel events that have been reported to TJC

A. interviewing leadership and staff about related expectations and responsibilities SE chapter, XII. Survey Process

For hospitals that use JC accreditation for deemed status purposes, the requirements regarding restraints for violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff members, or others stipulates that the one-hour face-to-face assessment A. must be performed within one hour of restraint application by the licensed independent practitioner or a trained nurse B. includes a debriefing session that must take place within one hour after the conclusion of restraint use C. can be performed via a telemedicine link to fulfill the in-person evaluation with the LIP

A. must be performed within one hour of restraint application by the LIP or a trained nurse PC.03.05.11, EPs 1, 2

To minimize the effects of fire, smoke, and heat, undercuts on doors required to be fire rated must be A. no larger than 3/4 inch B. 1/2 inch C. at least 1/8 inch

A. no larger than 3/4 inch LS.02.01.10, EP 5

The final time-out for a surgical or other invasive procedure must A. occur immediately before the start of the procedure and may be performed before or after draping the patient, as long as it involves the immediate members of the procedure team B. have all components documented in the medical record for each patient, including the components and the correct patient, site, and procedure C. confirm the correct site by using consent, imaging, or site marking

A. occur immediately before the start of the procedure and may be performed before or after draping the patient, as long as it involves the immediate members of the procedure team UP.01.03.01, EPs 1, 2, 4

For hospitals that use Joint Commission accreditation for deemed status purposes, which of the following is a requirement for pharmacy staffing? A. The hospital has at least one fulltime pharmacist on staff to supervise and coordinate all the activities of the pharmacy department or pharmacy services. B. A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department or pharmacy services. C. The supervising pharmacist holds a PharmD or RPh degree.

B. A full-time, part-time, or consulting pharmacist develops, supervises, and coordinates all the activities of the pharmacy department or pharmacy services. HR.01.01.01, EP 28

The medical staff makes the decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) according to which of the following objective, evidence-based processes? A. Completed applications for privileges are acted on within the time period specified in the medical staff policies and procedures. B. In instances in which there is doubt about an applicant's ability to perform privileges requested, an evaluation by an external and internal source may be requested by the organized medical staff. C. Medical staff membership is recommended and granted by the medical staff.

B. In instances in which there is doubt about an applicant's ability to perform privileges requested, an evaluation by an external and internal source may be requested by the organized medical staff. MS.06.01.05, EPs 6, 11; MS.07.01.01, EP 5

When an organization chooses to be surveyed under the Early Survey Policy, TJC conducts a. on-site surveys if (1) the hospital is licensed or has a provisional license, according to applicable law and regulation; (2) the building in which the services will be offered or from which the services will be coordinated is identified, constructed, and equipped to support such services; (3) the hospital has identified the date it will begin operations; and (4) it has identified its CEO or administrator, its director of clinical or medical services, and its nurse executive, if applicable B. two on-site surveys, both of which will be announced; the first survey can be conducted as early as two months before the organization begins its operations, provided that the organization meets certain criteria C. on-site surveys if (1) the hospital is licensed or has a provisional license, according to applicable law and regulation; (2) the building in which the services will be offered or from which the services will be coordinate is identified, constructed, and equipped to support such services; and (3) the hospital has identified its CEO or administrator, its director of clinical or medical services, and its nurse executive if applicable

A. on-site surveys if (1) the hospital is licensed or has a provisional license, according to applicable law and regulation; (2) the building in which the services will be offered or from which the services will be coordinated is identified, constructed, and equipped to support such services; (3) the hospital has identified the date it will begin operations; and (4) it has identified its CEO or administrator, its director of clinical or medical services, and its nurse executive, if applicable ACC chapter, "Early Survey Policy" section

The signature stamp or method of electronic authentication may be used by A. only the individual identified by it B. the individual identified by it or his or her authorized proxy, such as a physician assistant or nurse practitioner who works with a particular physician C. the authorized individual ho introduces the entry into the medical record through transcription or dictation

A. only the individual identified by it RC.01.02.01, EP 5

A request to postpone a survey may be granted if A. patients are being moved to a new building on the day of survey B. senior administration are on a retreat or are out of state C. a natural disaster has occurred in the past 24 hours

A. patients are being moved to a new building on the day of survey

For psychiatric hospitals that use JC accreditation for deemed status, the written plan of care must A. provide documentation that demonstrates all active therapeutic efforts are included B. include a substantial diagnosis that is different from the initial diagnosis C. be based on a patient's long-term goals rather than short-term goals

A. provide documentation that demonstrates all active therapeutic efforts are included

According to "Information Management" (IM) chapter requirements, the hospital's list of prohibited abbreviations, acronyms, symbols, and dose designations must include which of the following? A. qd, MS, u B. IU, Q.O.D., cc C. U, cc, MSO4

A. qd, MS, u IM.02.02.01, EP 3

The governing body provides for internal structures and resources, including staff members, that support safety and quality through A. selection of the chief executive responsible for managing the hospital B. identification of a nurse leader at the executive level who participates in decision making C. provision for the recruitment and retention of staff members

A. selection of the chief executive responsible for managing the hospital LD.01.03.01, EPs 4, 5; LD.01.04.01, EPs 2, 5

Two or more organizations that share a single Centers for Medicare & Medicaid Services Certification Number (CCN) must be A. surveyed together and accredited as a single organization B. accredited as a single organization and may be surveyed separately C. surveyed together but accredited separately

A. surveyed together and accredited as a single organization ACC chapter, "Concurrent Survey Option" section

The accreditation effective date for an organization that undergoes an initial survey is A. the date on which an acceptable Evidence of Standards Compliance (ESC) was submitted, if the organization has a Requirement for Improvement (RFI). B. the day after the date on which an acceptable ESC was submitted, if the organization has an RFI. C. the day after the last day of the survey, if the organization has an RFI.

A. the date on which an acceptable Evidence of Standards Compliance (ESC) was submitted, if the organization has a Requirement for Improvement (RFI). ACC chapter, "Initial Surveys" section

The hospital's plan for managing interruptions to electronic information processes is tested for effectiveness according to time frames defined by A. the hospital B. The Joint Commission C. The National Incident Management System (NIMS)

A. the hospital IM.01.01.03, EP 5

Individual tracers focus on A. the hospital's system of providing care, treatment, or services to patients B. assessing whether patients are receiving the correct medications based on clinical assessments C. clinical documentation supporting billing practices

A. the hospital's system of providing care, treatment, or services to patients ACC chapter, "Tracer Methodology" section

The frequency for data collection is identified by A. the leaders B. priorities of the medical staff C. the governing board and the medical staff

A. the leaders PI.01.01.01, EP 2

Which of the following aspects of the process for ongoing professional practice evaluation (OPPE) must be documented in writing? A. the process that facilitates the evaluation of each practitioner's ongoing professional practice B. the process for collecting certain types of data during the OPPE C. The process for determining whether to continue, limit, or revoke any existing privileges

A. the process that facilitates the evaluation of each practitioner's ongoing professional practice MS.08.01.03, EPs 1-3

The hospital measures its medical record delinquency rate at regular intervals, but no less than every A. three months B. six months C. 60 days

A. three months RC.01.04.01, EP3

Indwelling urinary catheters must be inserted according o evidence-based guidelines that address A. using aseptic techniques and limiting catheter duration B. the use of aseptic techniques and intermittent catheterizations C. limiting the use of urinary catheters but when necessary using silver-impregnated Foleys

A. using aseptic techniques and limiting catheter duration NPSG.07.06.01, EP 1

Psychiatric progress note timeframes

At least weekly for the first 2 months and then once a month thereafter

Which of the following bases are used in determining whether a hospital may have more than one organized medical staff? A. A hospital with a single governing body that has multiple inpatient care sites, each of which serves two or more geographically similar patient populations, may have a separate organized medical staff at each site. B. A hospital with a single governing body that has multiple inpatient care sites, each of which serves two or more geographically distinct patient populations, may have a separate organized medical staff at each site. C. Each medical staff may have its own guiding principles that are appropriate for the patient population and are fully integrated into the individual medical staff's structure.

B. A hospital with a single governing body that has multiple inpatient care sites, each of which serves two or more geographically distinct patient populations, may have a separate organized medical staff at each site. MS chapter, Overview

Which is true of the Basic Building Information (BBI form when a hospital has multiple sites? A. One BBI must be prepared for the hospital B. A single BBI may cover multiple buildings, if the buildings are physically connected C. The hospital may prepare a separate BBI for each building, if the buildings are not connected

B. A single BBI may cover multiple buildings, if the buildings are physically connected

When using abbreviations in an order, a preprinted form, or medication-related documentation, you may use a trailing zero only in which of the following circumstances? A. It is never acceptable to use a trailing zero. B. A trailing zero may be used only when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. C. A trailing zero may be used only when included in the organization's standardized list of dose designations, terminology, and other symbols.

B. A trailing zero may be used only when required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report the size of lesions, or catheter/tube sizes. IM.02.02.01, EP 3, Note 1

Which of the following are voluntary processes the hospital may undergo in order to receive monies from Medicare or Medicaid? A. Certification and state licensure B. Accreditation and certification C. State licensure and accreditation

B. Accreditation and certification

Patient care impact icons indicate the immediacy of risk to the quality of care and patient safety. Which of the following statements about these icons is correct? A. An icon indicates situations that could indirectly impact patients by creating an immediate risk to safety or quality of care, treatment, and services B. An icon identifies issues that, when found out of compliance, indicate a situation exists that could pose a significant threat to patient safety or quality of care C. An icon is used to record patient risk situations at an Accreditation Participation Requirement (APR) if identified by a surveyor, whether on site or after returning to TJC

B. An icon identifies issues that, when found out of compliance, indicate a situation exists that could pose a significant threat to patient safety or quality of care HM chapter, "Understanding the Icons Used in This Manual" section

When nonpharmacist health care professionals are allowed by law or regulation to obtain medications after the pharmacy is closed, which of the following quality control procedures is appropriate? A. The individual removing the medication from floor stock records the medication on a log sheet B. An independent second check by another individual occurs prior to administration of the medication C. The pharmacist stocks the medication and therefore is aware of the medications being dispensed

B. An independent second check by another individual occurs prior to administration of the medication MM.05.01.13, EP 5

Which of the following is true about competency assessments and performance evaluations? A. Competency assessments and performance evaluations are required to be performed at least every three years and must be performed at the same time B. Competency assessments focus on specific knowledge, skill, and ability and are required at least once every three years C. Performance evaluations are required annually and focus on the staff member's competence, as well as include other expectations for that staff member

B. Competency assessments focus on specific knowledge, skill, and ability and are required at least once every three years HR.01.06.01; HR.01.07.01

Which of the following is the nurse executive required to coordinate? A. The credentialing and privileging of nursing staff B. Development of hospitalwide plans to provide nursing care, treatment, and services C. Programs to recognize nursing staff for exceptional performance

B. Development of hospitalwide plans to provide nursing care, treatment, and services NR.02.01.01

Quantitative test result reports in the medical record for waived testing are accompanied by reference intervals (normal values) specific to the test method used and the population served. Which of the following is true? A. Documented semiquantitative results, such as urine macroscopic and urine dipsticks, are required B. If the reference intervals are not documented on the same page as and adjacent to the waived test result, the result must have a notation directing the reader to the location C. A check mark or an X is sufficient to document a positive or negative test result

B. If the reference intervals are not documented on the same page as and adjacent to the waived test result, the result must have a notation directing the reader to the location WT.05.01.01, EP 3

The hospital's written infection prevention and control goals include which of the following? A. Integrating all hospital components, limiting unprotected exposure to pathogens, and improving compliance with hand hygiene B. Improving compliance with hand hygiene, limiting the transmission of infections associated with procedures, and addressing the hospital's prioritized risks C. Addressing the hospital's prioritized risks; identifying methods for reporting infection surveillance and control information to external organizations; and limiting the transmission of infections associated with the use of medical equipment, devices, and supplies

B. Improving compliance with hand hygiene, limiting the transmission of infections associated with procedures, and addressing the hospital's prioritized risks IC.01.04.01, EPs 1-5; IC.01.05.01, EPs 6, 8

Joint Commission standards require hospitals to maintain a list of look-alike/ sound-alike medications. A common error with look-alike/sound-alike medications involves which of the following? A. The wrong medication listed on the medication administration record (MAR) B. Medical staff confusion about medications on the hospital's formulary C. Confusion about appropriate dosages based on patient age

C. Confusion about appropriate dosages based on patient age MM.01.02.01, EP 2

Where would you find tables that list the selected elements of performance (EPs) and requirements that are applicable to a first survey when a hospital has chosen the Early Survey Policy Option? A. On the JC website, under the "Early Survey Option" tab B. In the "Early Survey Policy Option" (ESP) chapter of the Comprehensive Accreditation Manual for Hospitals (CAMH) C. Under the "Early Survey Policy" section head in the chapter "The Accreditation Process" (ACC) of the CAMH

B. In the "Early Survey Policy Option" (ESP) chapter of the Comprehensive Accreditation Manual for Hospitals (CAMH) ESP chapter

Which of the following reflects how accredited hospitals must formally select and notify TJC of their chosen core measure set(s) and/or non-core measures and he associated listed vendor? A. If the hospital can identify only one core measure set related to its patient population, it must collect data on all the applicable measures in that core measure set, along with nine non-core measures B. In the event that the hospital cannot identify six sets of measures from the current complement of core measure sets, then the hospital must make its best effort to select all those measure sets that address the patient populations served and services provided by the hospital in order to meet ORYX performance measure reporting requirements C. If the hospital serves patient populations with conditions that correspond with only two core measure sets, the hospital must collect data on all of the applicable measures in the two core measure sets, along with six non-core measures

B. In the event that the hospital cannot identify six sets of measures from the current complement of core measure sets, then the hospital must make its best effort to select all those measure sets that address the patient populations served and services provided by the hospital in order to meet ORYX performance measure reporting requirements PM chapter, "Current Requirements for Hospitals" section

Which of the following is true regarding informed consent? A. It is a document signed by the patient to authorize care, treatment, and services. B. It is a process that, through application of a written policy, considers patient needs and preferences, compliance with law and regulation and patient education. C. It is not a risk area that is required to be addressed during the Intracycle Monitoring process through the Focused Standards Assessment (FSA)

B. It is a process that, through application of a written policy, considers patient needs and preferences, compliance with law and regulation and patient education RI.01.03.01, EPs 1-5

What is the relationship between the Conditions of Participation for the Medicare program and JC standards and elements of performance (EPs)? A. The COP for hospitals exceed JC standards and EPs B. JC standards and EPs meet or exceed the COPs for hospitals C. The two are exactly the same

B. Joint Commission standards and EPs meet or exceed the Conditions of Participation for hospitals AXA, first page

To whom are hospitals required to communicate responsibilities for preventing and controlling infection? A. Medical staff and the individual(s) the hospital has identified as responsible for the infection prevention and control program B. Licensed independent practitioners, staff, visitors, patients and families C. Leaders, LIPs, and staff

B. LIPs, staff, visitors, patients, and families IC.02.01.01, EP 7

According to Joint Commission standards, who should review and consider clinical practice guidelines when designing or improving processes? A. leaders B. Leaders and the organized medical staff C. An interdisciplinary team of clinicians representing multiple hospital departments

B. Leaders and the organized medical staff LD.04.04.07, EPs 4, 5

In which of the following options are all the examples listed required by JC standards to be included on the hospital's list of prohibited abbreviations? A. U, u; ICU; IU B. MSO4, MS, MgSO4 C. Q.D., QD, QID, q.d., qid, qod

B. MSO4, MS, MgSO4

Appropriate fall risk management must include which of the following assessments? A. Patients are assessed for their risk for falls based on changes to their condition, and interventions to reduce falls are based on the setting and population B. Patients are assessed for their risk for falls based on the setting and patient population, and interventions to reduce falls are based on the patient's assessed risk C. Patients are assessed for their risk for falls based on the setting and patient population, and interventions to reduce falls are based on the setting

B. Patients are assessed for their risk for falls based on the setting and patient population, and interventions to reduce falls are based on the patient's assessed risk PC.01.02.08, EPs 1, 2

A surveyor looks for which of the following during a hazardous materials and waste tracer? A. Inventory of hazardous materials and waste, labels of hazardous waste for the volume of the container, and actions taken to minimize the risks associated with selecting and using hazardous energy sources B. Permits, licenses, and manifests; monitoring results for gases and vapors; and procedures to respond to spills C. Actions to minimize or eliminate identified safety and security risks in the physical environment and the use of precautions and personal protective equipment

B. Permits, licenses, and manifests; monitoring results for gases and vapors; and procedures to respond to spills EC.02.02.01, EPs 3, 4 7, 10-12

Which of the following is not a service listed in the "Standards Applicability Grid" (SAG) chapter? A. Long Term Acute Care B. Primary Care Medical Home C. Surgical Specialty

B. Primary Care Medical Home SAG chapter, first page -Primary Care Medical Home is an optional certification program

The hospital conducts fire drills at which of the following intervals? A. Quarterly on shifts between 6:00 AM and 9:00 PM, all announced B. Quarterly on all shifts, with at least 50% unannounced C. Quarterly on all shifts, unannounced

B. Quarterly on all shifts, with at least 50% unannounced EC.02.03.03, EPs 1, 3, 4

The Joint Commission uses which of the following analytic methods in the ORYX initiative? A.. Run and control chart analysis B. Target and control chart analysis C. Pareto and run chart analysis

B. Target and control chart analysis

Psychiatric hospitals that JC accreditation for deemed status purposes must A. provide a psychiatric evaluation for each patient within 72 hours of admission B. record an individual comprehensive treatment plan with weekly progress notes for the first two months and at least a month thereafter C. ensure the availability of a registered professional nurse for a minimum of 18 hours per day

B. record an individual comprehensive treatment plan with weekly progress notes for the first two months and at least a month thereafter "Appendix B: Special Conditions of Participation for Psychiatric Hospitals" (AXB), 482.61(b)(1); 482.61(d), "Standard: Recording Progress"; 482.62(d)(2)

Which of the following comply with either the current CDC hand hygiene guidelines or the current WHO hand hygiene guidelines? A. CDC and WHO hand hygiene guidelines prohibit artificial nails or extenders for indirect care providers B. The CDC guidelines state that health care personnel should not wear artificial nails and should keep natural nails less than 1/4" long I they care for patients at high risk of acquiring infections C. WHO hand hygiene guidelines allow each organization to choose its own approach, according to the level of recommendation

B. The CDC guidelines state that health care personnel should not wear artificial nails and should keep natural nails less than 1/4" long I they care for patients at high risk of acquiring infections NPSG.07.01.01

For hospitals that use Joint Commission accreditation for deemed status purposes, who should ensure that hospitalwide quality assessment and performance improvement and training programs address problems identified by the individual responsible for infection prevention and control? A. The infection preventionist B. The chief executive officer, medical staff, and nurse executive C. Leaders and the governing board

B. The chief executive officer, medical staff, and nurse executive LD.01.02.01, EP 4

Which of the following is not an acceptable identified under the requirement that two patient identifiers be used when administering medications, blood, or blood components? A. The patient's name B. The patient's room number C. The patient's telephone number

B. The patient's room number NPSG.01.01.01, EP 1

Which of the following is required for means of egress? A. Side-hinged or pivot doors must not swing in the direction of egress where occupancy is 50 or more B. Walls containing horizontal exits must be fire rated for 2 or more hours, and doors within a required means of egress shall not be locked from the egress side C. Walls containing horizontal exits must be fire rated for 1 or more hours and must extend from uppermost slab to lowest slab

B. Walls containing horizontal exits must be fire rated for 2 or more hours, and doors within a required means of egress shall not be locked from the egress side LS.02.01.20, EPs 1-3

If The Joint Commission becomes aware of a sentinel event that meets the criteria of the Sentinel Event Policy, A. the hospital is expected to prepare a comprehensive systematic analysis and action plan and submit them to The Joint Commission within 30 calendar days of the event. B. a hospital's accreditation decision may be impacted if it fails to submit a comprehensive systematic analysis within an additional 45 days following its due date. C. the hospital's response will be due in 15 business days.

B. a hospital's accreditation decision may be impacted if it fails to submit a comprehensive systematic analysis within an additional 45 days following its due date. SE chapter, "Required Response to a Sentinel Event" section

The (D) icon associated with the National Patient Safety Goal that requires written information to be provided to the patient (or family, as needed) on the medications that the patient should be taking wen he or she is discharged from the hospital or at the end of an outpatient encounter (for example, name, dose, route, frequency, purpose) would indicate that A. a medication reconciliation form would need to be in the medical record B. a written policy or guideline for a medication reconciliation would include that the patient will be given written information on his/her medications C. a medication reconciliation form or list would be given to the patient

B. a written policy or guideline for medication reconciliation would include that the patient will be given written information on his or her medications NPSG.03.06.01, EP 4

Organizational integration exists if there is A. shared governance or portrayal to the public that the component is part of the organization B. budgetary control directly or ultimately by the governing body or shared governance C. budgetary control directly or ultimately by the governing body, or there is a common organized medical staff

B. budgetary control directly or ultimately by the governing body or shared governance ACC chapter, "Organizational and Functional Integration" section

When preparing the list of high-alert and hazardous medications, the hospital A. is required to use the lists of hazardous medications from the National Institute for Occupational Safety and Health (NIOSH) B. considers its unique utilization patterns of medications and its own internal data about medication errors and sentinel events C. is required to include medications that are new to the market or new to the hospital that are high-alert or hazardous medications

B. considers its unique utilization patterns of medications and its own internal data about medication errors and sentinel events MM.01.01.03

Basic Building Information (BBI) is updated in the electronic Statement of Conditions (SOC) A. every three years B. continually C. annually

B. continually Introduction to Standard LS.01.01.01

The hospital has access to the Focused Standards Assessment (FSA) tool A. only at the time of application. B. continuously. C. at one-year intervals after the hospital's last full survey, with the exception of the year of the triennial survey.

B. continuously ACC chapter, "Focused Standards Assessment (FSA)" section

When temporary privileges are granted to meet an important care need, the organized medical staff verifies A. education and current licensure B. current licensure and current competence C. current licensure and a complete application

B. current licensure and current competence MS.06.01.13, EPs1-3

When should the hospital begin the discharge planning process for a particular patient? A. at least 24 hours period to discharge B. early in the patient's episode of care, treatment or services C. after completion of all ordered diagnostic testing

B. early in the patient's episode of care, treatment or services PC.04.01.03, EP 1

Who is responsible for managing risk in the physical environment? A. only staff members who know how to identify and minimize risks are responsible for safety B. everyone who works in the organization is responsible for safety C. ultimately the leadership team is responsible for safety

B. everyone who works in the organization is responsible for safety Rationale for EC.03.01.01

Hospitals must use each core measure set and/or non-core measure set for at least how many quarters before replacing it? A. for at least four quarters over the two most recent 12-month reporting periods B. for at least four consecutive quarters C. for at least six consecutive quarters

B. for at least four consecutive quarters APR.04.01.01, EP 18

At the time of credentialing, the hospital verifies A. from the primary source whenever feasible, the applicant's current licensure at the time of initial granting, renewal, and revision of privileges and at eh time of license expiration, as well as the applicant's relevant training and current competence B. from the primary source whenever feasible, or from a credentials verification organization (CVO) I writing, the applicant's current licensure at the time of initial granting, renewal, and revision of privileges and at the time of license expiration, as well as the applicant's relevant training and current competence C. from the primary source whenever feasible, or from a CVO, the applicant's current licensure at the time of initial granting, renewal, and revision of privileges and at the time of license expiration, as well as the applicant's relevant training and current competence

B. from the primary source whenever feasible, or from a credentials verification organization (CVO) I writing, the applicant's current licensure at the time of initial granting, renewal, and revision of privileges and at the time of license expiration, as well as the applicant's relevant training and current competence MS.06.01.03, EP 6

The essential strategies to prevent the spread of health care-associated infections (HAIs) are A. hand hygiene, contact precautions, and cleaning from clean to dirty. B. hand hygiene, contact precautions, and cleaning and disinfecting patient care equipment. C. hand hygiene, contact precautions, and regular assessment of the infection control program.

B. hand hygiene, contact precautions, and cleaning and disinfecting patient care equipment. NPSG.07.03.01, Rationale and Note

The requirement of reducing the likelihood of patient harm associated with the use of anticoagulation therapy applies to A. routine situations in which short-term prophylactic anticoagulation is used for venous thromboembolism prevention B. hospitals that provide anticoagulation therapy and/or long-term anticoagulation prophylaxis C. routine situations in which short-term prophylactic anticoagulation is used for venous thromboembolism prevention and anticoagulation therapy and/or long-term anticoagulation orphylaxis

B. hospitals that provide anticoagulation therapy and/or long-term anticoagulation prophylaxis NPSG.03.05.01, Note

A pharmacist reviews the appropriateness of all medication orders except A. when medications are dispensed or removed from floor stock or from an automated storage and distribution device B. in emergency room settings when the LIP orders medications and the LIP is available to provide immediate intervention should a patient experience an ADR C. in the hospital's radiology service, when, through protocol or policy, the role of the LIP is defined in terms of timely intervention in the event of a patient emergency

B. in emergency room settings with the LIP orders medications and the LIP is available to provide immediate intervention should a patient experience an ADR

Regarding patient rights, the hospital must A. provide a written copy of patient rights at every visit B. inform patients of their rights C. offer a copy of the patients' rights at the time of registration

B. inform patients of their rights

To eliminate transfusion errors related to patient misidentification, when using a two-person verification process for administering blood or a blood product, the first person must be a qualified transfusionist, and the second person A. must be qualified to participate in the process, as defined by The Joint Commission. B. may be the charge nurse on the nursing unit. C. must be a registered nurse.

B. may be the charge nurse on the nursing unit. NPSG.01.03.01, EPs 2, 3

Existing storage rooms for combustible materials larger than 50 square feet that do not have fire-rated walls with 3/4-hour fire-rated doors A. may have doors held open by an automatic release device, be resistant to passage of smoke, and have a positive latch on doors B. must be sprinklered, be resistant to passage of smoke, and have a self-closing or automatic-closing device on doors C. may be sprinklered, have self-closure on doors, and are resistant to passage of smoke

B. must be sprinklered, be resistant to passage of smoke, and have a self-closing or automatic-closing device on doors LS.02.01.30, EP 2

When submitting a clarifying Evidence of Standards Compliance (ESC), if your hospital selects records as part of its sample, the record should be from a period of A. no more than 30 days before the last day of the survey B. no more than 30 days before the first day of the survey C. no more than 45 days before the first day of the survey

B. no more than 30 days before the first day of the survey ACC chapter, "Standards Clarification" section

An OPO is an A. on-site process observation B. organ procurement organization C. orientation privacy option

B. organ procurement organization TS.01.01.01, EPs 1, 2

Every JC accreditation standards chapter includes A. overview, introduction, standards, an elements of performance (EPs) B. overview, outline, standards, and EPs C. overview, rationale, standards and EPs

B. overview, outline, standards and EPs HM chapter, "Requirements for Accreditation" section

The Statement of Conditions™ (SOC™) is a management process to continually identify, assess, and resolve Life Safety Code® deficiencies. When the hospital A. plans resolution of deficiencies through a Plan for Improvement (PFI), the hospital monitors the PFI on a monthly basis for 4 months. B. plans to resolve deficiencies through a PFI, the hospital must consider and document interim life safety measures (ILSM) and correct the PFI within the time frame accepted by The Joint Commission. C. addresses resolution of deficiencies, the hospital resolves deficiencies immediately through the maintenance work order system and resolves deficiencies within 30 days.

B. plans to resolve deficiencies through a PFI, the hospital must consider and document interim life safety measures (ILSM) and correct the PFI within the time frame accepted by The Joint Commission. LS.01.01.01, EP 3

To help a patient determine whether to participate in research, investigation, or clinical trials, the hospital provides the patient information on A. potential benefits, costs, discomforts, and side effects B. potential benefits risks, discomforts, and side effects C. potential benefits, risks, discomforts, and costs

B. potential benefits, risks, discomforts, and side effects RI.01.03.05, EP 2

Under Human Resources (HR) standards, the hospital provides orientation to external law enforcement and security personnel on which of the following? A. Correct procedures for responding to hazardous materials and waste spills or exposure B. How to report safety concerns to The Joint Commission C. Distinctions between administrative and clinical seclusion and restraint

C. Distinctions between administrative and clinical seclusion and restraint

The "Environment of Care" (EC) chapter addresses the standards for A. safety and security, medical equipment, emergency management, hazardous materials and waste, and utilities. B. safety and security, medical equipment, hazardous materials and waste, fire safety, and utilities. C. safety and security, utilities, medical equipment, emergency management, hazardous materials and waste, and fire safety.

B. safety and security, medical equipment, hazardous materials and waste, fire safety, and utilities. EC chapter, "About This Chapter" section (EM is covered in a separate chapter)

Low-level disinfection is sufficient for such medical equipment, devices, and supplies as A. flexible endoscopes B. stethoscopes and blood glucose meters C. implants and surgical instruments

B. stethoscopes and blood glucose meters IC.02.02.01, EPs 1, 2

The documentation icon D indicates A. that paper documentation is essential only at the time of survey. B. that written documentation is required. C. documentation in the medical record.

B. that written documentation is required. HIM chapter, "Understanding the Icons Used in the Manual" section

When the organization identifies undesirable patterns, trends, or variations in its performance related to the safety or quality of care, its analysis of possible causes includes A. the most likely days on which errors are occurring B. the adequacy of staffing, including nurse staffing C. the use of run and control charts

B. the adequacy of staffing, including nurse staffing

The organized medical staff is accountable to A. the medical executive committee B. the governing body C. no one but itself; it is self-governing

B. the governing body

One of the conditions that allows a deemed-status hospital with swing beds to transfer or discharge residents without being cited for noncompliance is A. the resident has not paid for his or her stay B. the health or safety of individuals in the facility is endangered C. the resident leaves against medical advice without signing a form acknowledging this action

B. the health or safety of individuals in the facility is endangered PC.04.01.07, EP 1

During disasters, the hospital may grant disaster privileges to volunteer licensed independent practitioners as long as A. there is medical staff executive oversight, primary source verification occurs within 48 hours, and the decision to continue disaster privileges is made after 72 hours. B. the hospital obtains two forms of identification, performs primary source verification within 72 hours, and makes the decision to continue disaster privileges within 72 hours. C. the hospital obtains two forms of identification, one being a valid government-issued photo identification; there is medical staff executive oversight; and primary source verification occurs as soon as possible.

B. the hospital obtains two forms of identification, performs primary source verification within 72 hours, and makes the decision to continue disaster privileges within 72 hours. EM.02.02.13, EPs 5-8

Which of the following best describes hospital leadership structure? A. individual leaders participate in more than one group but each has one defined role B. the leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities C. leadership groups in every hospital include at least governance, management, and medical staff members and clinical staff members

B. the leadership group is composed of individuals in senior positions with clearly defined, unique responsibilities Introduction to Leadership Structure, Standards LD.01.01.01 - LD.01.07.01

The written procedure for reporting of critical results or tests must include A. the definition of stat critical results and tests B. the person who must report the critical results of the test C. the acceptable length of time between the order of the test and reporting of critical results of tests and diagnostic procedures

B. the person who must report the critical results of the test NPSG.02.03.01, EP 1

TJC requires that the hospital's written procedure for managing the critical results of tests and diagnostic procedures include which of the following? A. a written list of all critical stat test results B. the person who must report the critical results of the tests C. the acceptable length of time between the order of the test or diagnostic procedure and the reporting of critical results

B. the person who must report the critical results of the tests NPSG.02.03.01, EP 1

Labeling medications or solutions is necessary when A. two or more solutions are on or off the sterile field B. the are transferring from the original packaging to another container C. they are immediately administered

B. they are transferring from the original packaging to another container NPSG.0.04.01, EPs 1, 2

An operationally integrated service, program, or related entity that delivers care, treatment, or services is eligible for survey with the organization applying for survey if there are at least A. four out of the eight functional integration characteristics B. three out of the eight functional integration characteristics C. five out of the seven functional integration characteristics

B. three out of the eight functional integration characteristics

Privileges for licensed independent practitioners are granted for a period not to exceed A. three years B. two years C. one year

B. two years MS.06.01.07, EP 9

Random Validation of Evidence of Standards Compliance surveys occur A. unannounced within 30 days of the end of the triennial survey. B. unannounced after the Evidence of Standards Compliance (ESC) has been accepted. C. unannounced after the ESC and Measure of Success (MOS) have been accepted.

B. unannounced after the Evidence of Standards Compliance (ESC) has been accepted. ACC chapter, "Random Validation of Evidence of Standards Compliance" section

Before use or administration of a medication brought into the hospital by a patient, his or her family, or a licensed independent practitioner, the hospital identifies the medication and A. informs the prescriber B. visually evaluates the medication's integrity. C. places any medication in excess of the dose to be administered into a locked medication storage container or room.

B. visually evaluates the medication's integrity. MM.03.01.05, EP 2

The organization meets the requirements regarding the time frame for a medical history and physical examination if the medical history and physical examination are completed: A. within 24 hours before registration or admission but prior to surgery or a procedure requiring anesthesia. B. within 24 hours after registration or admission and before surgery or a procedure requiring anesthesia services. C. 60 days before registration or admission, and then an update is completed within 24 hours prior to registration or admission.

B. within 24 hours after registration or admission and before surgery or a procedure requiring anesthesia services. PC.01.02.03, EPs 4, 5

Conflicts of interest can occur in many circumstances and may involve professional or business relationships; therefore, the governing body, senior managers, and leaders of the organized medical staff A. work together to define in writing conflicts of interest involving leaders that could affect safety and quality of care, treatment, and services. B. work together to define in writing conflicts of interest involving leaders that could affect safety and quality of care, treatment, and services and develop a written policy that defines how conflicts of interest involving leaders will be addressed. C. work together to define in writing conflicts of interest involving leaders that could affect safety and quality of care, treatment, and services and develop a process that defines how conflicts of interest involving leaders will be addressed.

B. work together to define in writing conflicts of interest involving leaders that could affect safety and quality of care, treatment, and services and develop a written policy that defines how conflicts of interest involving leaders will be addressed. LD.02.02.01, EPs 1, 2

Temporary privileges for applicants for new privileges are granted for no more than A. 45 days B. 90 days C. 120 days

C. 120 days

An organization seeking reaccreditation can undergo an unannounced survey within which time frame? A. 18-24 months B. 12-36 months C. 18-36 months

C. 18-36 months ACC chapter, "Unannounced Surveys" section

An organization must keep a soiled linen or trash receptacle in a room protected as a hazardous area if the receptacle is larger than which of the following? A. 8 gallons B. 16 gallons C. 32 gallons

C. 32 gallons LS.02.01.70, EP 2; LS.03.01.70, EP 2

In assessing whether the hospital maintains a safe, functional environment, which of the following would be of greatest concern to a surveyor examining a patient room? A. A dimmer switch B. A locked cabinet C. A "nasty" smell

C. A "nasty" smell EC.02.06.01, EPs 11, 20, 23

The "Required Written Documentation" (RWD) chapter of the Comprehensive Accreditation Manual for Hospitals provides which of the following? A. The names and formats of specific written documents required by TJC B. A grid showing which required written documentation must be on paper and which may be electronic C. A list of elements of performance (EPs) that require written documentation

C. A list of elements of performance (EPs) that require written documentation RWD chapter, first page

In what type of document is a hospital required to define the nurse executive's authority and responsibility? A. The hospital's written standards of nursing practice B. The hospital's written nursing policies and procedures C. A written contract, written agreement, letter, memorandum, job or position description, or other document

C. A written contract, written agreement, letter, memorandum, job or position description, or other document NR.01.01.01, EP 5; NR.02.02.01, EPs 1, 3

The hospital evaluates the effectiveness of emergency management planning by which of the following? A. Annual review of its risks, hazards, and potential emergencies, as defined in its hazard vulnerability analysis (HVA); periodic review of the objectives and scope of its Emergency Operations Plan (EOP); and periodic review of inventory B. Annual review of its risks, hazards, and potential emergencies, as defined in its HVA; periodic review of the objectives and scope of its EOP; and annual review of inventory C. Annual review of its risks, hazards, and potential emergencies, as defined in its HVA; annual review of the objectives and scope of its EOP; and annual review of inventory

C. Annual review of its risks, hazards, and potential emergencies, as defined in its HVA; annual review of the objectives and scope of its EOP; and annual review of inventory EM.03.01.01, EPs 1-3

For hospitals that use JC accreditation for deemed status purposes, the hospital rains staff members on the use of restraint and seclusion and assesses their competence at which of the following intervals? A. Before participating in the use of restraint and seclusion and annually thereafter B. At orientation, before participating in the use of restraint and seclusion, and annually thereafter C. At orientation, before participating in the use of restraint and seclusion, and periodically thereafter

C. At orientation, before participating in the use of restraint and seclusion, and periodically thereafter PC.03.05.17, EP 2

Scoring categories indicate the level of performance of the element of performance (EP), such as which of the following? A. Category A indicates structural requirements, such as a building component. B. Category C EPs are frequency-based requirements and are scored based on the number of times a hospital is found not to be compliant, such as a National Patient Safety Goal. C. Category A indicates policies, plans, or programs that are either present or not.

C. Category A indicates policies, plans, or programs that are either present or not. HM chapter, "Understanding the Icons Used in the Manual" section

Which of the following information cannot be publicly disclosed? A. Date of a hospital's most recent full on-site survey B. List of a hospital's previous accreditation decisions for the past seven years C. Comprehensive systematic analyses in response to sentinel events

C. Comprehensive systematic analyses in response to sentinel events. ACC chapter, "Publicly Available Accreditation and Certification Information" section and "Confidential Information" section

According to the National Patient Safety Goal regarding the hospital's identification of safety risks inherent in its patient population, which of the following is not an action required to identify patients at risk for suicide? A. Addressing the patient's immediate safety needs and most appropriate setting for treatment B. Conducting a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide C. Conducting a medical history and physical examination within 24 hours after registration or inpatient admission

C. Conducting a medical history and physical examination within 24 hours after registration or inpatient admission NPSG.15.01.01, EPs 1, 2

Which of the following requirements is accurate? A. The travel distance from any point to a fire extinguisher is 100' for less B. Class J-type portable fire extinguishers are located within 30' of grease-producing cooking devices C. Eighteen inches or more of open space is maintained below the sprinkler deflector to the top of storage

C. Eighteen inches or more of open space is maintained below the sprinkler deflector to the top of storage LS.02.01.35, EPs 6, 8, 9

Which of the following is a requirement to maintain the integrity of the means of egress? A. a dead-end corridor may be used for storage as long as there is at least 25 square feet of storage, suites of patient sleeping rooms are limited to 5,000 square feet, and suites used for other purposes are limited to 10,000 square feet B. The corridor width is not obstructed by wall projections greater than 6" C. In new buildings, exit corridors are at least 8 feet wide; in existing buildings, exit corridors are at least 4 feet wide

C. In new buildings, exit corridors are at least 8 feet wide; in existing buildings, exit corridors are at least 4 feet wide

When generator emergency power testing is being done, which of the following is also required? A. Interim measures during the testing B. Interim measures during the testing and retesting after repairs C. Interim measures if a required test fails

C. Interim measures if a required test fails EC.02.05.07, EPs 5-10

Which of the following would be an acceptable process to comply with the requirement that before use or administration of a medication brought into the hospital by a patient, his or her family, or a LIP, the hospital identifies the medication and visually evaluates the medication's integrity? A. Medications are sent to teh pharmacy for review and then are returned to the nursing unit for administration. Nursing documents that this process has occurred on the medication order for the patient to take his or her own medication B. A pharmacy staff member visually inspects the medication for particulates or discoloration and then adds a code/symbol in the medical record to indicate that it has been verified and is acceptable as labeled for safe administration C. Medications are sent to the pharmacy, and the pharmacist adds a code/symbol on the medication container to indicate that it has been verified and is acceptable as labeled for safe administration

C. Medications are sent to the pharmacy, and the pharmacist adds a code/symbol on the medication container to indicate that it has been verified and is acceptable as labeled for safe administration

The hospital's written process for accepting a patient is required to include all except which of the following? A. Criteria for determining the patient's eligibility for care, treatment, and services B. Procedures for accepting referrals C. Procedures for discharging patients

C. Procedures for discharging patients PC.01.01.01, EPs 2, 3

The medical record must contain a concise discharge summary that includes which of the following? A. Patient demographic information; reason for hospitalization; procedures performed; care, treatment, and services provided; patient's condition and disposition at discharge, information provided to the patient and family, provisions for follow-up care; name and contact information for the patient's primary care physician B. Patient demographic information; reason for hospitalization; procedures performed; care, treatment, and services provided; patient's condition and disposition at discharge; information provided to the patient and family; provisions for follow-up care C. Reason for hospitalization; procedures performed; care treatment, and services provided; patient's condition and disposition at discharge; information provided to the patient and family; provisions for follow-up care

C. Reasons for hospitalization; procedures performed; care, treatment, and services provided; patient's condition and disposition at discharge; information provided to the patient and family; provisions for follow-up care RC.02.04.01, EP 3

Which of the following information is publicly disclosable by TJC? A. All sentinel event information B. Comprehensive systematic analyses C. Services included within the scope of an organization's accreditation decision

C. Services included within the scope of an organization's accreditation decision ACC, QR, and SE chapters

Which of the following is not required as part of annual training for technologists who perform diagnostic computed tomography (CT) examinations? A. Radiation dose optimization techniques addressed in Image Gently and Image wisely campaigns B. Safe procedures for operation of the types of CT equipment used C. Techniques for CT systems used for therapeutic radiation treatment planning or delivery

C. Techniques for CT systems used for therapeutic radiation treatment planning or delivery HR.01.05.03, EP 14

The "Leadership" (LD) chapter is divided ino four sections: "Leadership Structure," "Leadership Relationships,", "Hospital Culture and System Performance Expectations," and "Operations." Standards pertaining to leadership structure convey some basics precepts about leadership's role and responsibilities. Which statement below does not accurately portray the role and responsibility of leadership? A. The governance or governing body has the ultimate authority and responsibility for establishing policy and maintaining safety and quality of care, treatment, or services. These responsibilities of the governing body are defined in writing. B. Senior managers (including the CEO and nurse executive) and leaders of the organized medical staff work with the governing body to define their shared and unique responsibilities and accountabilities. The organized medical staff is accountable to the governing body. C. The CEO, who is selected by the organized medical staff, manages the hospital and identifies a nurse leader at the executive level.

C. The CEO, who is selected by the organized medical staff, manages the hospital and identifies a nurse leader a the executive level LD.01.01.01; LD.01.07.01; GL, governance

As hospitals collect data to monitor their performance for all significant discrepancies between preoperative and postoperative diagnoses, which of the following describes the monitoring requirement? A. The hospital is required to review every surgical record to collect these data B. Record review through the ongoing professional performance evaluations is sufficient as the source of the data required to be collected C. The determination of data sources is based on the identified risk assessments regarding these discrepancies as well as organizational policies and procedures and law and regulation

C. The determination of data sources is based on the identified risk assessments regarding these discrepancies as well as organizational policies and procedures and law and regulation PI.01.01.01, EP 5

Which of the following is true regarding end-of-life care, treatment, and services? A. Staff members and licensed independent practitioners may proceed with care, treatment, and services unless they become aware that the patient has an advance directive. B. The hospital is required to honor all advance directives. C. The existence or lack of an advance directive does not determine the patient's right to access care, treatment, and services.

C. The existence or lack of an advance directive does not determine the patient's right to access care, treatment, and services. RI.01.05..01, EPs 8, 11, 17

How does the hospital coordinate the patient's care, treatment, and services? A. The hospital has a written process to receive or share patient information when the patient is referred to other internal or external providers of care, treatment, and services B. The hospital's written policy for handoff communication provides for the opportunity for discussion between the giver and receiver of patient information C. The hospital coordinates care, treatment, and services within a time frame that meets the patient's needs

C. The hospital coordinates care, treatment, and services within a time frame that meets the patient's needs PC.02.02.01, EPs 1, 2

Which of the following statements best describes second generation tracers? A. A detailed exploration of credentialing and privileging is performed as a second generation tracer during triennial surveys B. Contracted services, diagnostic imaging, and restraint use are common second generation tracers that take a deep and detailed look at these specific high-risk processes C. The surveyor will look at several processes at a system level when conducting a second generation tracer on clinical/health information

C. The surveyor will look at several processes at a system level when conducting a second generation tracer on clinical/health information ACC chapter, "Tracer Methodology" section Second generation tracers take a deep and detailed look at a high-risk area, risk, or process at a system level (cleaning/disinfection/sterilization, patient flow, contracted services, diagnostic imaging, OPPE and FPPE, therapeutic radiation, clinical/health information)

To what extent is the hospital required to involve the patient's family in decisions about the patient's care, treatment, and services? A. To the extent authorized by the licensed independent practitioner responsible for managing the patient's care, treatment, and services in the hospital, in accordance with law and regulation B. To the extent authorized by the patient's own physician, who must be promptly notified of the patient's admission to the hospital C. To the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation

C. To the extent permitted by the patient or surrogate decision-maker, in accordance with law and regulation RI.01.02.01, EPs 1-8

Which of the following practices to prevent central line-associated bloodstream infections (CLABSIs) is correct? A. Evaluate central venous catheters daily and remove them when no longer needed B. Do not use femoral vein catheters for pediatric patients, unless other sites are unavailable C. Use a catheter checklist and a standardized protocol for central venous catheter insertion

C. Use a catheter checklist and a standardized protocol for central venous catheter insertion NPSG.07.04.01, EPs 6, 8, 13

JC standards require medications to be administered A. 30 minutes before or after the scheduled administration time B. within 60 minutes of the scheduled administration time C. according to what has been determined as the proper time

C. according to what has been determined as the proper time MM.06.01.01, EP 7

The mission, vision, and goals of the hospital A. are created by the governing body B. are created by the governing body and senior managers C. are created by the governing body, senior managers, and leaders of the organized medical staff

C. are created by the governing body, senior managers, and leaders of the organized medical staff LD.02.01.01

Noncompliance with patient's rights may be found during survey if patients A. are allowed to view their medical records B. request to have their medical records amended, and the hospital complies C. are not allowed to know wh as obtained information about their heath information

C. are not allowed to know who has obtained information about their health information RI.01.01.01, EP 10

During the on-site survey, the surveyor will evaluate the hospital's compliance and performance regarding applicable standards, National Patient Safety Goals (NPSGs), and Accreditation Participation Requirements (APRs) and may A. search for or investigate sentinel events B. review an actual comprehensive systematic analysis C. assess a hospital's processes for responding to sentinel events

C. assess a hospitals' processes for responding to sentinel events SE chapter, XII. Survey Process

The "Patient Safety Systems" (PS) chapter does not A. explain how hospitals can evaluate the status and progress of their patient safety systems B. discuss how hospitals can develop into learning organizations C. contain any new standards or requirements

C. contain any new standards or requirements PS chapter, "What Does This Chapter Contain?" section

The time frame for completion of the medical record is A. defined by the hospital B. within 30 days after the patient's discharge C. defined by the hospital and does not exceed 30 days after the patient's discharge

C. defined by the hospital and does not exceed 30 days after the patient's discharge

The retention time for the original or legally reproduced medical record is A. six years, in accordance with law and regulation B. seven years, in accordance with law and regulation C. determined by its use and hospital policy, in accordance with law and regulation

C. determined by its use and hospital policy, in accordance with law and regulation RC.01.05.01, EP 1

Medical record entries can be authenticated through A. electronic signatures or written signatures or initials B. written signatures or initials, rubber-stamp signatures, or computer key C. electronic signatures, written signatures or initials, rubber-stamp signatures, or computer key

C. electronic signatures, written signatures or initials, rubber-stamp signatures, or computer key

To evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks, environmental rounds are required A. every month in patient and nonpatient care areas. B. at least every size months in nonpatient care areas. C. every six months in patient care areas and at least annually in nonpatient care areas.

C. every six months in patient care areas and at least annually in nonpatient care areas. EC.04.01.01, EPs 12, 13

A laboratory test result is used to assess a patient's condition or make a clinical decision, and test results A. may be quantitative or qualitative B. if instrument-based, are either semiquantitative or quantitative C. if more precise than a qualitative test but less precise than a quantitative test, are usually semiquantitative and scored on a graded scale

C. if more precise than a qualitative test but less precise than a quantitative test, are usually semiquantitative and scored on a graded scale WT chapter, Overview

For hospitals that use JC accreditation for deemed status purposes, orders for nonviolent or non-self-destructive restraints are renewed A. every 24 hours B. after every evaluation by a physician, clinical psychologist, or other authorized licensed independent practitioner primarily responsible for the patient's ongoing care C. in accordance with hospital policy

C. in accordance with hospital policy PC.03.05.05, EP 6

A sentinel event A. is a patient safety event not primarily related to the natural course of the patient's illness or underlying condition that is a result of an error and results in any of the following: death, permanent harm, or severe temporary harm B. is an event, incident, or condition that could have resulted or did result in harm to a patient C. is a patient safety event not primarily related to the natural course of the patient's illness or underlying condition that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm

C. is a patient safety event not primarily related to the natural course of the patient's illness or underlying condition that reaches a patient and results in any of the following: death, permanent harm, or severe temporary harm. SE chapter, I. Sentinel Events

The hospital must prevent transfusion errors by requiring A. verification of the correct patient using a two-person process when the order for the blood or blood product is confirmed. B. matching the patient to the order using a two-person verification process. C. matching the blood to the patient and the blood to the order using a one-person verification process accompanied by automatic identification technology.

C. matching the blood to the patient and the blood to the order using a one-person verification process accompanied by automatic identification technology. NPSG.01.03.01, EP 1

Focused professional practice evaluation (FPPE) A. requires a period of focused review for new privileges except when the practitioner is board certified B. must be defined in the medical staff bylaws C. may include a different duration of monitoring for different levels of practitioners

C. may include a different duration of monitoring for different levels of practitioners MS.08.01.01, EPs 1-4

The organized medical staff A. grants membership to the medical staff to all practitioners privileged B. defines medical staff membership criteria C. may privilege non-licensed independent practitioners through the medical staff process if the governing body approves doing so

C. may privilege non-licensed independent practitioners through the medical staff process if the governing body approves doing so MS chapter, overview

The four phases of emergency management are A. planning, mitigation, preparedness, and recovery B. mitigation, preparedness, planning, and response C. mitigation, preparedness, response, and recovery

C. mitigation, preparedness, response, and recovery EM chapter, "About This Chapter" planning is not one of the four phases

A fire watch is required when a fire alarm or sprinkler system is out of service in an occupied building for A. more than 6 hours in a 24-hour period B. more than 4 hours in a 12-hour period C. more than 4 hours in a 24 hour period

C. more than 4 hours in a 24-hour period LS.01.02.01, EP 1

After TJC has determined that a hospital has conducted an acceptable comprehensive systematic analysis and developed an acceptable action plan following a sentinel event, TJC may assign one or more Sentinel Event Measures of Success (SE MOS), which will be due A. in 45 days B. in 60 days C. on a mutually agreed-upon date

C. on a mutually agreed-upon date SE chapter, "Follow-up Activities" in III. Responding to Sentinel Events; IX. Sentinel Event Measures of Success (SE MOS)

Medication labels for individualized medications prepared for multiple patients also include the A. location where medication is to be delivered and the specific dose and time for administration B. patient name, directions for use, and the specific dose and time for administration C. patient name, location where medication is to be delivered, and directions for use

C. patient name, location where medication is to be delivered, and directions for use

The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery requires the hospital to have an alternative process for site marking for A. minimal-access procedures treating a unilateralized internal organ, whether percutaneous or through a natural orifice B. premature infants or elderly patients for whom the mark may cause a permanent tattoo C. patients who refuse site marking

C. patients who refuse site marking UP.01.02.01, EP 5

Staff members and LIPs are required to have annual education on at least A. restraint policy, prevention of surgical site infections, and role in the environment of care B. prevention of multidrug-resistant organisms (MDROs), restraint policy, and waived testing C. prevention of surgical site infections, MDROs, and central line-associated bloodstream infections (CLABSIs)

C. prevention of surgical site infections, MDROs, and central line-associated bloodstream infections (CLABSIs) NPSG.07.03.01, EP 2; NPSG07.04.01, EP 1; NPSG 07.05.01, EP 1; WT.03.01.01, EP 6 ;PC.03.02.01-PC.03.02.11; PC.03.03.01-PC.03.03.31; EC.03.01.0, EPs 1-3

The most correctly completed immediate postoperative note includes the name of the primary surgeon and his or her assistant(s), the procedure performed, and a description of A. procedure findings, any specimens removed, and postoperative diagnosis B. procedure findings, estimated blood loss, and postoperative diagnosis C. procedure findings, estimated blood loss, any specimens removed and postoperative diagnosis

C. procedure findings, estimated blood loss, any specimens removed and postoperative diagnosis RC.02.01.03, EP 7

The "Life Safety" (LS) chapter contains standards and elements of performance (EPs) on A. general life safety design and building construction, including means of egress and maintenance of free and unobstructed access to all exits in business occupancies B. fire alarm notification, including audible and coded alarms, and maintenance of fire safety equipment C. protection provided by door features, fire barriers, stairs and other vertical openings, corridors, smoke detectors, and building services such as elevators and chutes

C. protection provided by door features, fire barriers, stairs and other vertical openings, corridors, smoke detectors, and building services such as elevators and chutes LS chapter, "About This Chapter" section

As part of the ORYX requirements, hospitals are required to report on A. three of the six measure sets B. four of the six measure sets C. six measure sets

C. six measure sets

Organizations may receive an Accreditation with Follow-up Survey decision if any open, accepted Plan for Improvement (PFI) items in the Statement of Conditions (SOC) are not completed within A. one month of the projected completion date B. four months of the projected completion date C. six months of the projected completion date

C. six months of the projected completion date LS chapter, "Managing Compliance with the NFPA LSC" section; ACC Chapter, "The Accreditation Decision Process" section

In a hospital's decision process to renew existing privileges, the LIP applicant's physical ability to perform privileges requested by evaluated and documented by A. a currently licensed doctor of medicine or osteopathy B. having his or her health status confirmed by the director of a training program, the chief of services, or the chief of staff t another hospital at which the applicant holds privileges C. the applicant's statement that no health problems exist that could affect his or her practice

C. the applicant's statement that no health problems exist that could affect his or her practice MS.06.01.05, EPs 2, 6, Note

An operative or other high-risk procedure report is required to contain A. the name of the procedure performed, findings of the procedure, any estimated blood loss, and any specimen(s) removed B. the name(s) of the LIP(s) who performed the procedure, a description of the procedure, findings of the procedure, and the postoperative diagnosis C. the name(s) of the LIP(s) who performed the procedure and any assistant(s), the name and description of the procedure performed, findings of the procedure, any estimated blood loss, any specimen(s) removed, and the postoperative diagnosis

C. the name(s) of the LIP(s) who performed the procedure and any assistant(s), the name and description of the procedure performed, findings of the procedure, any estimated blood loss, any specimen(s) removed, and the postoperative diagnosis RC.02.01.03, EP 6

Central-line associated bloodstream infection (CLABSI) surveillance is required A. in high-risk areas, such as the neonatal intensive care unit (NICU) B. in medical/surgical intensive care units C. throughout the hospital

C. throughout the hospital NPSG.07.04.01, EP 13

The standardized process for anticoagulation management requires patient involvement and A. use of authoritative resources to manage potential food and drug interactions for patients receiving heparin. B. assessment of the patient's baseline coagulation status by identifying risk factors such as age, weight, bleeding tendency, and genetic factors. C. use of only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available.

C. use of only oral unit-dose products, prefilled syringes, or premixed infusion bags when these types of products are available. NPSG.03.05.01, EPs 1, 3, 4

The hospital determines the required items for the preprocedure process, and A. the documented standardized list must be used during the preprocedure verification process B. the documented standardized list must be included in the medical record C. use of the standardized list does not have to be documented in the medical record

C. use of the standardized list does not have to be documented in the medical record UP.01.01.01, EP 2

To allow an accredited hospital time to bring a newly acquired service, program, or site up to the accredited hospital's standard of performance, extension surveys are conducted A. within 6 months. B. within 6 to 9 months. C. within 6 to 12 months.

C. within 6 to 12 months. ACC chapter, "Extension Survey" section

Perinatal Care (PC) measure set

Hospitals with 300+ live births per year must include this measure set among its selection of six ORYX measure sets for which data must e collected and submitted to TJC

Standard that relates to patient flow

LD.04.03.11

Timeframe for completion of a psychiatric evaluation (psychiatric hospital only)

Within 60 hours of admission CMS - 482.61(b)(1)