Approximately how many pages of regulations do hospitals have to assure?
a) 10,000
b) 25,000
c) 75,000
d) more than 100,000
d) more than 100,000 (it's about 128,000)
100
Is State Licensure of a hospital mandatory or volunteer?
mandatory
100
Joint Commission is:
a) announced and every 2 years
b) announced and every 3 years
c) unannounced and every 2 years
d) unannounced and every 3 years
Unannounced and every 3 years
100
How often does JCAHO require that staff be trained on restraint use?
a) annually
b) when hired and on the employee's anniversary date
c) this is not a JCAHO requirement
d) every 2 years
annually
100
What is UP?
Universal Protocol
200
How much money is budgeted for CMS in the United States?
a) 500 billion
b) 750 billion
c) 1 trillion
d) 100 trillion
1 trillion
200
Is JCAHO Accreditation mandatory or volunteer?
volunteer
200
What is MEC?
Medical Executive Committee
200
Which of the following are a part of our "Hospital property"?
-parking lot
-sidewalks
-driveway
-the access road in front of the hospital
All of the above IF it is within 250 feet of the hospital
200
What is EBP?
Evidence Based Practice
300
Some hospitals are randomly chosen to participate in a CMS Survey AFTER a JCAHO survey. How many days out can they come?
a) 30
b) 60
c) 90
d) 120
60 days!
300
If we have breached EMTALA, we have how long to self report?
-24 hours
-72 hours
- 7 days
-1 month
72 hours
300
Give an example of both high level disinfection and low level disinfection.
Sterile Processing and Scopes
Cleaning between patient uses
300
Medication prep must be how far from the sink?
(splashing)
3 feet
300
What is AONE?
American Organization of Nurse Executives
400
How many days (max) for Federal onsite investigation for EMATLA, Death associated with restraints, Fires resulting in death or injury.
a) 7,5,5
b) 5,5,2
c) 7,7,7
d) 5,5,5
5,5,2
400
What is PSQ?
Patient Safety Quality
400
Name ONE of the top three most frequently cited standards from Medicare CoP?
Restraint or Seclusion (Patient rights)
RN Supervision of Nursing Care (Nursing services)
Patient Rights: Care in a Safe Setting (Patient rights)
400
Who or what has "overall accountability" for the function of SJ -LSL?
a) Lisle (President)
b) Candace (Regional VP)
c) The Board at LSL
d) the President of MEC
The Board
400
Which of the following is the most frequently cited on a CMS VALIDATION Survey?
a) Infection Control
b) Nursing Services
c) Physical Environment
d) Patient Rights
a) Infection Control 7
b) Nursing Services 5
c) Physical Environment 30
d) Patient Rights 4
500
What is SSE?
Serious Safety Event
500
What is CJR?
Comprehensive Care for Joint Replacement
500
There are 3 levels of citation for a CMS survey. Name two.
HINT- they are all bad.
Condition Level
Standard Level
Immediate Jeopardy
500
What is ANCC?
American Nurses Credentialing Center
500
There are 3 Components that MUST EXIST for Immediate Jeopardy. Name one.