Study Guide 22 Flashcards
- A facility is or is not required to safeguard medical records from loss, destruction, or
unauthorized use? - Is 2. Is not
1
the facility must have what type of agreement with one or more hospitals approved for
participation under the Medicare and Medicaid program?
1. Health Care Partnership Agreement
2. Cooperative Agreement
3. Transfer agreement
4. Healthcare Stipulation Agreement
3
What type of agreement must provide for the transfer of residents from the facility to the hospital,
and ensure of timely admission to the hospital when transfer is medically appropriate?
1. Health Care Partnership Agreement
2. Cooperative Agreement
3. Transfer agreement
4. Healthcare Stipulation Agreement
3
Is a facility considered to have a transfer agreement in effect if the facility has attempted in good
faith to enter into an agreement with a hospital sufficiently close to the facility to make transfer
feasible?
1. Yes 2. No
1
The administrator must submit to the State Survey Agency, the ombudsman, the residents and
their legal representatives written notification of an impending closure of the facility within how many
days?
1. 10
2. 30
3. 60
4. 90
3
A facility that is closing may or may not admit new residents to the facility on or after the date on
which such written notification is submitted.
1. May 2. May not
2
True or False - A facility that is closing must have a closure plan approved by the State for the
transfer and relocation of all residents by a date after closure of the facility.
1. True 2. False
2
True or False - In a facility closure, residents must be transferred to the most appropriate facility
or other setting in terms of quality, services, and location, and must take into consideration their
individual needs, choices, and best interests?
1. True 2. False
1
A facility is or is not required to have a policy that requires the administrator provide residents
notice of a closure?
1. Is 2. Is not
1
A facility may or may not ask a resident to sign a binding arbitration agreement?
1. May 2. May not
1
A facility is or is not required to inform a resident they can refuse to sign a binding arbitration
agreement?
1. Is 2. Is not
1
True or False - The facility must explain the arbitration agreement to the resident in a form and
language they understand.
1. True 2. False
1
True or False - Residents must sign an acknowledgement that they understand the terms of an
arbitration agreement.
1. True 2. False
1
True or False - An arbitration agreement must provide for the selection of an arbitrator by the
facility?
1. True 2. False
2
True or False - The arbitration agreement must provide for the selection of a venue that is
convenient to both parties?
1. True 2. False
1
The arbitration agreement must allow the resident the right to rescind the agreement within
_____ calendar days of signing it.
1. 10
2. 20
3. 30
4. 45 calendar days
3
True or False -The arbitration agreement must explicitly state that the resident is required to sign
an agreement as a requirement to continue to receive care at, the facility.
1. True 2. False
2
The arbitration agreement may or may not prohibit the resident from communicating with
federal, state, or local officials about the arbitration agreement.
1. May 2. May not
2
When the facility and a resident resolve a dispute through arbitration, a copy of the signed
arbitration agreement and the arbitrator’s final decision must be retained by the facility for
________ years after the resolution of that dispute and be available for inspection upon request
by CMS.
1. 2 years
2. 3 years
3. 5 years
4. 7 years
3
True or False - If hospice care is furnished in a nursing facility through a hospice agreement,
the facility must ensure that hospice services meet professional standards and principles.
1. True
2. False
1
True or False - The facility must determine the services the nursing facility will continue to
provide, based on each resident’s hospice plan of care.
1. True 2. False
2
The facility must notify the hospice provider if there is a significant change in the hospice
resident’s physical, mental, social, or emotional status within what time-frame?
1. Immediately
2. 24 hours
3. 48 hours
4. 7 days in writing
1
How soon must the facility notify the hospice provider of any clinical complications that suggest
a need to alter the plan of care.
1. Immediately
2. 24 hours
3. 48 hours
4. 7 days in writing
1
How soon must the facility notify the hospice provider if the resident must be transferred from
facility for any condition or of the resident’s death.
1. Immediately
2. 24 hours
3. 48 hours
4. 7 days in writing
1
Which of the following is responsible to determine the appropriate course of hospice care,
including the determination to change the level of services provided?
1. The Nursing facility
2. The hospice provider
3. The Medical Director
4. The state Ombudsman
2
True or False - An agreement between the hospice provider and a nursing facility must state the
facility’s responsibility to furnish 24-hour room and board, nursing services and coordinate care
with the hospice representative.
1. True 2. False
1
True or False - A hospice agreement must specify the hospice provider’s responsibilities to
provide medical direction and management of the hospice patient and the nursing care, spiritual
and dietary counseling, and bereavement and social services?
1. True 2. False
1
True or False - Each nursing facility providing hospice care under a written agreement may but
is not required to include both the hospice resident’s plan of care and detail the services to be
provided to the hospice patient.
1. True 2. False
2
A hospice agreement must state that the nursing facility must report all alleged violations of
mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown
source, and misappropriation of patient property by hospice personnel, to the hospice administrator
how soon after the nursing facility becomes aware of the alleged violation?
1. Immediately
2. 24 hours
3. 48 hours
4. 7 days in writing
1
True or False - The hospice provider must provide bereavement services to nursing facility staff
related to grieving for hospice patients.
1. True 2. False
1
he nursing facility is or is not required to designate a member of the facility’s interdisciplinary
team to work with hospice representatives to coordinate resident care.
1. Is 2. Is not
1
True or False - A nursing facility must communicate with the hospice medical director, the
attending physician, and other practitioners to coordinate the medical care provided to a hospice
resident.
1. True 2. False
1
The hospice provider must provide which of the following to the nursing facility?
1. The most recent hospice plan of care specific to each patient.
2. Hospice election form.
3. Physician certification and re-certification of the terminal illness specific to each patient.
4. All of the above
4
True or False - A qualified social worker is an individual with a minimum of a bachelor’s degree
in social work or in sociology, gerontology, special education, rehabilitation counseling, and
psychology.
1. True 2. False
1
A qualified social worker is also an individual with a minimum of how many years of supervised
social work experience in a health care setting working directly with individuals.
1. 1 year
2. 2 years
3. 5 years
4. 7 years
1
True or False - A facility may but is not required to report daily staffing information about direct
care staff, and whether those individuals are an employee of the facility, or is through an agency.
1. True 2. False
2
A facility must submit direct care staffing information to the CMS no less than how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
4
Each facility must develop and maintain an emergency preparedness plan that must be
reviewed and updated at how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
True or False - The facility emergency preparedness plan must include a facility-based and
community-based risk assessment, an all-hazards approach, and must include a missing resident
search plan.
1. True 2. False
1
True or False - The facility emergency preparedness plan must assess the resident population,
including, but not limited to, persons at-risk, the type of services the facility has the ability to provide
in an emergency, and continuity of operations, including delegations of authority and succession
plans.
1. True 2. False
1
True or False - The facility emergency preparedness plan must Include a process for
cooperation and collaboration with local, tribal, regional, state, or federal emergency preparedness
officials to secure an integrated response during a disaster or emergency situation.
1. True 2. False
1
True or False - The facility emergency preparedness plan must implement emergency
preparedness policies and procedures, based on the emergency plan risk assessment.
1. True 2. False
1
The facility emergency preparedness plan and policies must be reviewed and updated how
often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
The facility emergency preparedness plan must provide for the subsistence needs for staff and
residents during an emergency and must include fall of the following except:
1. Food
2. Water
3. Medical
4. Outside catering services
5. Pharmaceutical supplies
4
rue or False - The facility emergency preparedness plan must provide for alternate sources of
energy (electrical generator) to maintain safe food and atmospheric temperatures.
1. True 2. False
1
The facility emergency preparedness plan must also provide for alternate sources of energy
(electrical generator) to maintain which of the following?
1. Emergency lighting
2. Fire detection.
3. Fire extinguishing
4. Alarm systems
5. Sewage and waste disposal
6. All of the above
6
True or False - The facility emergency preparedness plan may but is not required to track the
location of on-duty staff and sheltered residents during and after an emergency.
1. True 2. False
2
The facility emergency preparedness plan must detail the evacuation plan to provide for which
of the following?
1. Medical care 2. Food 3. Treatment 4. Transportation 5. Communication 6. All of the above
6
True or False - The facility emergency preparedness plan must include the means to shelter in
place residents, staff, and volunteers who remain in the nursing facility.
1. True 2. False
1
True or False - The facility emergency preparedness plan must include a system of medical
documentation that preserves resident information, protects confidentiality of resident information,
and secures and maintains the availability of records.
1. True 2. False
1
True or False - The facility emergency preparedness plan must include the use of volunteers in
an emergency or other emergency staffing to address surge needs during an emergency (increased
staffing needs).
1. True 2. False
1
True or False - The facility emergency preparedness plan must include arrangements with other
nursing facilities and other providers to receive residents in the event of an emergency.
1. True 2. False
1
The nursing facility emergency preparedness communication plan must be reviewed and
updated at least how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
The facility emergency preparedness plan must include the names and contact information for
the which of the following?
1. Staff.
2. Entities providing services under arrangement.
3. Residents’ physicians.
4. Other LTC facilities.
5. The State Licensing and Certification Agency.
6. The state Ombudsman
7. Other sources of assistance.
8. All of the above.
8
True or False - The facility emergency preparedness plan must detail an emergency
preparedness training and testing program that is based on the emergency plan risk assessment
policies and procedures.
1. True 2. False
1
The facility emergency preparedness training and testing program must also be reviewed and
updated at least how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
True or False - The facility must provide initial training in emergency preparedness policies and
procedures to all new and existing staff, and agency staff and volunteers.
1. True 2. False
1
The facility must conduct exercises to test the emergency plan at least how often?
1. Once per year 2. Twice per year 3. Three times a year 4. Quarterly
2
True or False - Emergency facility exercises must include announced and scheduled staff drills.
1. True 2. False
2
Each nursing home must have a community based full scale emergency drill how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
5
True or False - If a community-based emergency exercise is not accessible, the facility may
conduct an individual, facility-based functional exercise.
1. True 2. False
1
If the facility experiences an actual natural or man-made emergency that requires activation of
the emergency plan, the facility is or is not exempt from conducting its next required full-scale
community-based or individual, facility-based functional exercise following the onset of the
emergency event.
1. Is 2. Is not
1
A facility can or cannot be required to conduct a second full-scale exercise that is community-
based or an individual, facility-based functional exercise, or a mock disaster drill.
1. Can 2. Cannot
1
A tabletop exercise of a disaster drill must contain which of the following elements?
1. A facilitator and group discussion using a narrated, clinically-relevant emergency scenario
2. A set of problem statements, directed messages, or prepared questions designed to
challenge an
emergency plan.
3. A post-disaster analysis of the response to the drill
4. All of the above
4
True or False - The facility must document all drills, tabletop exercises, and emergency events,
and revise the emergency plan, as needed.
1. True 2. False
1
The facility must implement emergency and standby power systems based on which of the
following?
1. OSHA audit
2. The facility emergency plan
3. Facility wide audit
4. All of the above
2
The emergency generator must be located in accordance with the location requirements found
in the Health Care Facilities Code NFPA ____
1. NFPA 99
2. NFPA101
3. NFPA110
4. NFPA113
1
The emergency generator must be located in accordance with the location requirements found in
Life Safety Code NFPA _____.
1. NFPA 99
2. NFPA101
3. NFPA110
4. NFPA113
2
The facility must implement the emergency power system inspection, testing, and maintenance
requirements per the Health Care Facilities Code NFPA ____.
1. NFPA 99
2. NFPA101
3. NFPA110
4. NFPA113
3
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 journaling
4. Post budget journal
2
True or False - The Facility must maintain an onsite fuel source to power emergency
generators and a plan to keep emergency power systems operational during the emergency, unless
it evacuates.
1. True 2. False
1
Which of the following is correct about the PBJ?
1. Each facility is required to acquire software that captures real time payroll information
regarding nurse staffing hours
2. This information must be collected and transmitted to the CMS quarterly.
3. The CMS can use this data to verify minimum staffing hours
4. All of the above
4
Each facility must implement an effective, comprehensive QAPI program that focuses on which
of the following:
1. State surveys and quality of care audits
2. Casper QI reports
3. Indicators of the outcomes of care and resident quality of life.
4. Facility wide assessment and focused audits
3
True or False - Each facility must maintain documentation and demonstrate evidence of an
ongoing QAPI program through systematic identification, reporting, investigation, analysis, and
prevention of adverse events.
1. True 2. False
1
What does QAPI stand for?
1. Quality Assurance and Performance Improvement
2. Quarterly Assurance and Performance Improvement
3. Quality Assurance and Performance Implementation
4. Quarterly Assurance and Performance Implementation
1
The facility QAPI program must have documentation and evidence of its ongoing QAPI program’s
implementation and the facility’s compliance, and must present that evidence upon request to which of the
following?
1. State surveyors
2. The CMS
3. State and federal officials
4. All of the above
4
Which of the following are the five elements of QAPI?
1. Design and Scope
2. Governance and Leadership
3. Feedback, Data Systems and Monitoring
4. Performance Improvement Projects (PIPs)
5. Systematic Analysis and Systemic Action
6. All of the above
6
What is a PIP under the QAPI program which focuses on a particular problem area?
1. A Performance Implementation Program
2. A Performance Improvement Project
3. A Project Improvement Program
4. A Performance Investigation Program
2
The facility QAPI program must be comprehensive and address the full range of care and
services provided by the facility and include which of the following?
1. Quality of life
2. Resident choice
3. Quality indicators shown to be predictive of desired outcomes for residents
4. All of the above
4
The QAPI program must include which of the following?
1. Written policies and procedures
2. Data collection
3. Monitoring
4. Adverse event monitoring
5. All of the above
5
True or False - QAPI policies and procedures must detail how feedback from staff and residents
will be used to identify high risk problems?
1. True 2. False
1
True or False - The facility QAPI program must detail the adverse event monitoring system to
identify, report, track, investigate, analyze and use data and information relating to adverse events
in the facility.
1. True 2. False
1
The facility must set priorities for its QAPI performance improvement activities that focus on
high-risk, high-volume, or problem-prone areas that include which of the following except?
1. Health outcomes
2, Resident autonomy
3. Staff retention
4. Resident choice,
5. Quality of care
3
The quality assessment and assurance committee must meet how often?
1. Daily 2. Weekly 3. Monthly 4 Quarterly 5. Annually
4
Which facility program must track medical errors and adverse resident events, and analyze their
causes?
1. The QAPI program
2. The Infection Control Program
3. The Compliance and Ethics Program
4. The Guardian Angel Program
1
True or False - Performance Improvement projects for the QAPI program must include at least
an annual project that focuses on high risk or problem-prone areas identified through the data
collection and analysis.
1. True 2. False
1
Which of the following has full legal authority and responsibility for operation of the facility and
is responsible and accountable for an ongoing QAPI program?
1. Administrator
2. DON
3. Governing body
4. Medical director
5. State ombudsman
3
True or False - The QAPI program must be sustained during changes in leadership and
staffing, and be sufficiently staffed, equipped and have technical training to effectively function.
1. True 2. False
1
The clear expectations of the QAPI program are set around which of the following?
1. Safety
2. Quality
3. Rights
4. Choice
5. Respect
6. All of the above
6
A facility must maintain a quality assessment and assurance committee consisting at a
minimum all of the following except?
1. The director of nursing services.
2. The long term care ombudsman.
3. The Medical Director.
4. The infection preventionist.
5. At least three other members of the facility’s staff, at least one of whom must be the
administrator, owner, a board member or other individual in a leadership role
2
True or False - The facility administrator may be a member of the Quality Assessment and
Assurance Committee?
1. True 2. False
1
The quality assessment and assurance committee reports to which of the following regarding
the committee’s activities and the QAPI program?
1. Administrator
2. DON
3. Governing body
4. Medical director
5. State ombudsman
3
Which facility program must develop and implement plans of action to correct identified quality
deficiencies?
1. Infection control and prevention program
2. Compliance and ethics Program
3. QAPI program
4. Quality Assessment and Assurance Committee
4
Which facility program regularly reviews and analyzes data collected under the QAPI program
and then act on the data to make improvements?
1. Infection control and prevention program
2. Compliance and ethics Program
3. QAPI program
4. Quality Assessment and Assurance Committee
4
The data collected by the quality assurance committee is or is not required to be disclosed to
the State if requested?
1. May 2. Is not
2
Good faith attempts by the quality assurance committee to identify and correct quality
deficiencies may or may not be used as a basis for sanctions.
1. May 2. May not
2
Which facility program must establish and maintain a safe, sanitary, and comfortable
environment and to help prevent the development and transmission of communicable diseases and
infections.
1. Infection control and prevention program
2. Compliance and ethics Program
3. QAPI program
4. Quality Assessment and Assurance Committee
1
Which facility program must prevent, identify, report, investigate, and control infections and
communicable diseases for all residents, staff, volunteers, visitors, and others.
1. Infection control and prevention program
2. Compliance and ethics Program
3. QAPI program
4. Quality Assessment and Assurance Committee
1
Which of the following is not true about the infection control and prevention program.
1. The facility must designate one or more individuals as the infection preventionist (IP)
2. The infection preventionist is responsible for the facility’s IPCP.
3. The infection preventionist must have primary professional training in nursing, medical
technology, microbiology, epidemiology, or other related field.
4. The infection preventionist must be qualified by education, training, experience or
certification.
5. The infection preventionist must work full time at the facility.
5
After two 90-day benefit periods, a physician will need to meet with the patient and recertify
that the terminal illness is still accurate to extend the hospice benefits for another ___ days.
1. 30
2. 45
3. 60
4. 90
5. 120
3
True or False - There is a limit on how many times a patient can be re-certified to receive
hospice benefits.
1. True
2. False
2
