Study Guide 21 Flashcards
True or False - The infection preventionist must have specialized training in infection prevention and
control.
1. True 2. False
1
The infection preventionist is or is not required to be a member of the quality assessment and assurance
committee and report to the committee the findings of the IPCP on a regular basis.
1. Is 2. Is not
1
Residents must be offered the influenza immunization in which months each year?
1. February 1 to April 30
2. November 1 to march 31
3. October 1 through March 31
4. September 1 to February 28
3
True or False - Each resident must receive the influenza immunization to remain in the facility
1. True 2. False
2
True or False - The infection preventionist must be qualified by education, training, experience and
certification.
1. True 2 False
1
True or False - The resident’s medical record must indicate that the resident was provided education
regarding the influenza immunization and if they received the immunization or refused due to medical
contraindications or refusal.
1. True 2. False
1
True or False - A nursing facility must have policies and procedures to ensure that when the
COVID-19 vaccine is available to the facility, each resident and staff member is offered the vaccine,
unless the immunization is medically contraindicated or the resident or staff member has already been
immunized.
1. True 2. False
1
True of False - Before offering the COVID-19 vaccine, staff and residents must be provided with
education regarding the benefits and risks and potential side effects associated with the vaccine.
1. True 2. False
1
True of False - Where the COVID-19 vaccination requires multiple doses, the resident or staff
member must be provided information on any changes in the benefits, risks and potential side effects
of the COVID-19 vaccine, before requesting consent for administration.
1. True 2. False
1
True of False - The resident’s medical record does not need to document if a resident received the
vaccine or did not receive the COVID-19 vaccine due to medical contraindications or refusal.
1. True 2. False
2
The facility will conduct a review of the facility Infection Prevention and Control Program how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
The CMS COVID report must include which of the following?
1. Suspected and confirmed COVID-19 infections among residents and staff, including residents
previously treated for COVID-19
2. Total deaths and COVID-19 deaths among residents and staff
3. Personal protective equipment and hand hygiene supplies in the facility
4. Ventilator capacity and supplies in the facility
5. Resident beds and census
6. Access to COVID-19 testing while the resident is in the facility
7. Staffing shortages
8. All of the above
8
True of False - The CMS COVID 19 Report must detail the COVID-19 vaccine status of residents and
staff, including , the number of residents and staff vaccinated, and how many doses of COVID-19
were administered.
1. True 2. False
1
True of False - The CMS COVID Report must detail the therapeutics administered to residents for
treatment of COVID-19.
1. True 2. False
1
Must provide the required COVID 19 reporting information to the CDC how often?
1. Daily 2. Weekly 3. Monthly 4. Quarterly 5. Annually
2
A facility must Inform residents and their families by 5 p.m. on ______________ following the
occurrence of either a) a single confirmed infection of COVID-19, or b) three or more residents or staff
with new-onset of respiratory symptoms occurring within 72 hours of each other.
1. The next calendar day
2. The next 2 calendar days
3. The next 3 calendar days
4. The next 5 calendar days
1
COVID 19 reporting information submitted to the CDC and CMS may or may not include personally
identifiable information?
1. May 2. May not
2
True or False - Must report to the CDC and the CMS actions taken by the facility to
prevent or reduce the risk of COVID 19 transmission, including if normal operations will be\
altered.
1. True 2. False
1
Must report to the CDC and the CMS the cumulative updates for residents and their families
regarding COVID 19 at least ____ or by 5 p.m. the next calendar day following the subsequent
occurrence of either.
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
2
Must inform residents and their family each time a confirmed infection of COVID-19 is identified, or
whenever 3 or more residents or staff report a new onset of respiratory symptoms that occur within
____ hours of each other.
1. 24 2. 36 3. 72 4. 96
3
True or False - The facility must test residents and staff for COVID 19, and identify all individuals
diagnosed with COVID 19 or symptoms consistent with COVID-19.
1. True 2. False
1
True or False - Must detail the response time for COVID 19 test results and other factors to help
identify and prevent the transmission of COVID-19.
1. True 2. False
1
True or False - Must document COVID 19 testing that was completed and the results of each staff
test.
1. True 2. False
1
True or False - Must document on the resident record that testing was offered, completed, and the
results of each test.
1. True 2. False
1
When an individual is identified with COVID-19 symptoms or who tests positive, the facility is or is not
required to take action to prevent the transmission of COVID-19.
1. Is 2. Is not
1
Which of the following is not true?
1. The facility must have procedures to address residents and staff who refuse COVID 19 testing or
who are unable to be tested.
2. The facility must develop and implement policies and procedures to ensure that all staff are fully
vaccinated for COVID-19.
3. Staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary
vaccination series for COVID-19.
4. The COVID 19 policies and procedures apply to staff who exclusively work outside the
facility or only do telehealth and have no contact with other staff or residents.
4
True or False - Completion of a primary vaccination series for COVID-19 is defined as the
administration of a single-dose vaccine, or all required doses of a multi-dose vaccine.
1. True 2. False
1
True or False - The facility COVID 19 policies and procedures must apply to all facility staff and
licensed practitioners, who provide any treatment or other services for residents.
1. True 2. False
1
True or False - Must track that all staff have received either a single-dose COVID-19 vaccine, or the
first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to providing care
to residents.
1. True 2. False
1
COVID 19 policies and procedures are or are not required to track staff who have had booster shots
or are exempted from the vaccine or delayed due to medical or clinical reasons.
1. Are 2. Are not
1
Staff can or cannot request an exemption from the staff COVID-19 vaccination requirement?
1. Can 2. Cannot
1
Any documentation which confirms a recognized clinical contraindication to a COVID-19 vaccination
and supports a staff request for medical exemption, must be signed and dated by whom?
1. Administrator.
2. Medical Director
3. Licensed practitioner.
4. Director of Nursing.
3
True or False - It is only recommended that a facility have contingency plans for staff who are not fully
vaccinated for COVID-19.
1. True 2. False
2
Each facility must have a compliance and ethics program to prevent and detect which of the following?
1. Criminal violations.
2. Civil violations.
3. Administrative violations.
4. All of the above.
4
True or False - The compliance and ethics program must have high-level personnel with substantial
control over the organization or who have a substantial role in making policies.
1. True 2. False
1
True or False - For purposes of the compliance and ethics program , the term “0perating organization”
means the individual or entity that operates a facility.
1. True 2. False
1
True or False - The facility compliance and ethics program must have policies and standards to
reduce the prospect of criminal, civil, and administrative violations, and promote quality of care.
1. True 2. False
1
True or False - Each facility must appoint a compliance and ethics program contact person to whom
individuals may report suspected violations, as well as an alternate method of reporting suspected
violations anonymously without fear of retribution.
1. True 2. False
1
The facility compliance and ethics program is or is not required to have policies that detail disciplinary
standards and consequences for committing violations that apply to all employees, volunteers, and
others?
1. Is 2. Is not
1
True or False - The facility compliance and ethics program requires assignment of specific individuals
within the high-level personnel of the operating organization with overall responsibility to oversee
compliance with the program’s standards, policies, and procedures.
1. True 2. False
1
The facility compliance and ethics program high level personnel includes which of the following?
1. The chief executive officer (CEO)
2. Members of the board of directors
3. Directors of major divisions in the operating organization
4. All of the above
5. Just 1 and 2
4
True or False - A facility must not delegate substantial discretionary authority to individuals who the
operating organization knows or should know have a propensity to engage in criminal, civil, and
administrative violations.
1. True 2. False
1
True or False - The facility must effectively communicate the standards, policies, and procedures of
the compliance and ethics program to the staff, volunteers, agency personnel and contractors which
includes mandatory training and orientation sessions.
1. True 2. False
1
True or False - The facility compliance and ethics program does not need to have auditing and
monitoring systems to detect criminal, civil, and administrative violations.
1. True 2. False
2
The facility compliance and ethics program is or is not required to have a reporting system where
anyone can report violations anonymously without fear of retribution, and a process to ensure
confidentiality of any reported data.
1. Is 2. Is not
1
The facility compliance and ethics program is or is not required to have consistent enforcement of
standards, policies, and procedures through appropriate disciplinary mechanisms, including the
requirement to specifically discipline individuals who fail to detect and report a violation to the
compliance and ethics program contact person.
1. Is 2. Is not
1
True or False - After a violation is detected, the operating organization must ensure that all
reasonable steps are taken to respond to the violation and to prevent and detect criminal, civil, and
administrative violations under the Act.
1. True 2. False
1
An organizations with five or more facilities must include annual mandatory training in the compliance
and ethics program how often?
1. Weekly
2. Monthly
3. Quarterly
4. Annually
4
True or False - The operating organization must designate a central compliance officer for the
compliance and ethics program, and have designated liaisons in the facility.
1. True 2. False
1
This compliance officer for the compliance and ethics program must report directly to the governing
body and can or cannot be subordinate to the general counsel, chief financial officer or chief operating
officer.
1. Can 2. Cannot
2
The facility compliance and ethics program must be reviewed how often?
1. Weekly
2. Monthly
3. Quarterly
4. Annually
4
Each facility must meet the requirements of the Life Safety Code NFPA ____.
1. 99
2. 100
3. 101
4. 205
3
True or False - Facility corridor doors and doors to rooms containing flammable or combustible
materials must have positive latching hardware.
1. True 2. False
1
True or False - Roller latches are not prohibited on facility doors.
1. True 2. False
2
True or False - Fire safety codes that are an unreasonable financial hardship for a facility may be
waived if it does not affect the health and safety of residents.
1. True 2. False
True or False - A long-term care facility may install alcohol-based hand rub dispensers if the
dispensers are installed to prevent inappropriate access to the dispenser.
1. True 2. False
1
True or False - Each facility must install battery-operated single station smoke alarms in resident
sleeping rooms and common areas and inspect, test, maintain, and replace the batteries that conform
to the manufacturer’s recommendations and that verifies correct operation of the smoke alarms.
1. True 2. False
1
Battery operated smoke detectors are or are not needed in a facility that has system-based smoke
detectors in patient rooms and common areas that are installed, tested, and maintained in accordance
with NFPA 72.
1. Are 2. Are not
1
True or False - Battery operated smoke detectors are needed in a facility that is fully sprinklered in
accordance with NFPA 13 - Standard for the Installation of Sprinkler Systems.
1. True 2. False
2
True or False - A long term care facility must install an approved, supervised automatic sprinkler
system in accordance with the 1999 edition of NFPA 13, Standard for the Installation of Sprinkler
Systems.
1. True 2. False
1
When a sprinkler system is shut down for more than __ hours, the facility must evacuate the building
or that portion affected by the system outage, and establish a fire watch until the sprinkler system is
back in service.
1. 4 hours
2. 6 hours
3. 8 hours
4. 10 hours
4
True or False - An emergency electrical power system must supply power adequate to power at least
lighting all entrances and exits, the fire detection, alarm, and extinguishing systems, and life support
systems in the event the normal electrical supply is interrupted.
1. True 2. False
1
When life support systems are used, a nursing facility is or is not required to have emergency
electrical power with an emergency generator (as defined in NFPA 99, Health Care Facilities) located
on the premises.
1. Is 2. Is not
1
True or False - A facility is not required to conduct regular inspection of all bed frames, mattresses,
and bed rails, to identify areas of possible entrapment.
1. True 2. False
2
True or False - When bed rails and mattresses are used and purchased separately from the bed
frame, the facility must ensure that the bed rails, mattress, and bed frame are compatible.
1. True 2. False
1
Bedrooms must accommodate no more then how many residents?
1. 2
2. 4
3. 6
4. 8
2
True or False - After November 28, 2016, in new construction bedrooms must accommodate no
more than two residents.
1. True 2. False
1
Semi private bedrooms must measure at least ___ square feet per resident in multiple resident
bedrooms.
1. 60 2. 80 3. 100 4. 160
2
A private room must have at least ____ square feet in single resident rooms.
1. 60 2. 80 3. 100 4. 160
3
Resident bedrooms are or are not required to have direct access to an exit corridor.
1. Are 2. Are not
1
True or False - Each resident room must be equipped with or located near a toilet and bathing
facilities.
1. True 2. False
1
True or False - For facilities that receive approval of construction or are newly certified after November
28, 2016, must have each resident room with its own bathroom equipped with at least a commode and
sink as opposed to just being located close to a bathroom.
1. True 2. False
1
True or False - A nursing facility must have procedures for dementia management and resident abuse
prevention?
1. True 2. False
True or False - Each facility must include mandatory training in the facility QAPI program that informs
staff of the purpose and goals of the QAPI program.
1. True 2. False
1
A facility must include in its infection prevention and control program mandatory training which of the
following?
1. Written standards
2. Policies
3. Procedures
4. All of the above
4
A facility compliance and ethics program must have training how often if the operating organization
operates five or more facilities?
1. Daily 2. Weekly 3. Monthly 4. Annually
4
True or False - The nursing facility nurse aide in-service program may but is not required to Include
dementia management and cognitive impairment training?
1. True 2. False
2
True or False - A facility must not use any individual as a paid feeding assistant unless they completed
a state-approved training program for feeding assistants.
1. True 2. False
1
True or False - A nursing facility may but is not required to provide behavioral health training to staff.
1. True 2. False
2
Each resident must receive necessary behavioral health care and services to attain or maintain the
highest practicable physical, mental, and psycho-social well-being, in accordance with which of the
following?
1. Their comprehensive assessment
2. Their care plan
3. Their MDS
4. All of the above
4
Behavioral health does or does not encompass a resident’s whole emotional and mental well-being,
including the prevention and treatment of mental and substance use disorders.
1. Does 2. Does not
1
Sufficient nursing staffing is based on which of the following?
1. The number of residents
2. Resident acuity
3. The diagnoses and medical condition of the resident’s in the facility
4. All of the above
4
True or False - Staff must be trained to care for residents with mental and psycho-social disorders,
trauma, post-traumatic stress disorder, and how to use non-pharmacological interventions, if
appropriate.
1. True 2. False
1
True or False - A resident who displays or is diagnosed with a mental disorder or psycho-social
adjustment difficulty, or has a history of trauma and/or post-traumatic stress disorder, must receive
appropriate treatment and services to correct the diagnosed problem.
1. True 2. False
1
If a resident develops a pattern of decreased social interaction, increased withdrawal, anger and
depression, and was not previously diagnosed with a mental disorder or psycho-social adjustment
disorder, would the facility be cited?
1. Yes, the facility would be cited.
2. No, the facility would not be cited.
1
What does PBJ stand for?
1. Payroll budget journal
2. Payroll based journal
3. Profit based journal
4. Post budget journal
2
The facility must submit its QAPI plan to the state survey agency how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
The infection preventionist is or is not required to be full-time in the facility.
1. Is 2 Is not
2
A state or federal surveyor would be disqualified from surveying a particular skilled nursing facility for a
conflict of interest if the the surveyor currently works, or, within the past ________, has worked as an
employee, as employment agency staff at the facility, or as an officer, consultant, or agent for the facility to
be surveyed.
1. 1
2. 2
3. 3
4. 4
5. 5
6. 6
2
True or False - A surveyor would be disqualified from surveying a nursing facility if they have a
financial interest or ownership interest in that nursing facility?
1. True 2. False
1
True or False - A surveyor would be disqualified from surveying a nursing facility if they have a
financial interest or ownership interest in that nursing facility limited to ownership of publicly traded stock in
a publicly traded company, such as a broad based mutual fund?
1. True 2. False
2
True or False - A surveyor would not be disqualified from surveying a nursing facility if they have an
immediate family member who has a relationship with a facility?
1. True 2. False
2
True or False - A surveyor would be disqualified from surveying a nursing facility if they have an
immediate family member who is a resident in the facility?
1. True 2. False
1
True or False - The time of day that surveyors begin a survey should extend beyond the business
hours of 8:00 a.m. to 6:00 p.m. during the week and should vary to include weekend days, Saturday, and
Sunday
1. True 2. False
1
At least ____ percent of standard health surveys must begin either on the weekend or in the
evening/early morning hours before 8:00 a.m. or after 6:00 p.m.
1. 5 percent
2. 10 percent
3. 15 percent
4. 20 percent
2
