[HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
**Question 1.** Which organization is granted deeming authority to conduct CMS surveys on
behalf of the federal government?
A) American Hospital Association (AHA)
B) The Joint Commission (TJC)
C) National Institutes of Health (NIH)
D) Centers for Disease Control and Prevention (CDC)
Answer: B
Explanation: The Joint Commission is one of the recognized accrediting organizations that
receive deeming authority from CMS to perform surveys that satisfy Medicare certification
requirements.
**Question 2.** A state survey agency conducts a validation survey. What is the primary
purpose of this survey?
A) To assess a new hospital’s eligibility for Medicare participation
B) To verify that an accrediting organization continues to meet CMS standards
C) To investigate a complaint of patient abuse
D) To review the hospital’s financial statements
Answer: B
Explanation: Validation surveys are performed by state agencies to ensure that the accrediting
organization’s survey process remains consistent with CMS Conditions of Participation.
**Question 3.** During a complaint investigation, which document is most critical for
establishing the factual basis of the alleged violation?
A) The hospital’s marketing brochure
B) The patient’s signed consent form
C) The surveyor’s interpretive guidelines worksheet
D) The physician’s residency contract
, [HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
Answer: C
Explanation: Surveyors use interpretive guidelines to document observations and fact‑finding
during complaint investigations, providing the evidentiary basis for any compliance
determination.
**Question 4.** Which of the following is NOT a required element of the patient’s right to
informed consent under the CoPs?
A) Disclosure of the nature of the proposed treatment
B) Explanation of alternatives, including no treatment
C) Provision of a written consent form for every procedure
D) Discussion of material risks associated with the treatment
Answer: C
Explanation: While documentation of consent is required, a written form is not mandated for
every procedure; verbal consent may be sufficient when appropriate.
**Question 5.** Under the CMS patient‑rights regulations, a patient may request a grievance
for which of the following reasons?
A) Preference for a specific hospital cafeteria menu item
B) Dissatisfaction with the hospital’s parking fees
C) Alleged violation of privacy rights under HIPAA
D) Desire to change the hospital’s color scheme
Answer: C
Explanation: Grievances must address concerns related to patient rights, including privacy
violations, quality of care, and discrimination.
**Question 6.** Which of the following statements about the use of restraints and seclusion is
correct?
A) PRN (as needed) orders for restraints are permissible if documented.
, [HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
B) Physical restraints may be used without a physician’s order in emergencies.
C) Restraints must be ordered by a qualified health professional and reviewed regularly.
D) Seclusion is allowed for patients who are merely agitated but not dangerous.
Answer: C
Explanation: CMS requires that restraints and seclusion be ordered by a qualified professional,
with ongoing assessment and documentation; PRN orders are prohibited.
**Question 7.** Who holds ultimate accountability for the quality of care provided by the
medical staff according to the CoPs?
A) The chief financial officer (CFO)
B) The governing body of the hospital
C) The head of housekeeping
D) The external accrediting organization
Answer: B
Explanation: The governing body is responsible for overseeing the medical staff’s credentialing,
privileging, and overall quality of care.
**Question 8.** Which of the following is a required component of a hospital’s nursing staffing
plan?
A) Minimum of three nurses per patient regardless of acuity
B) Staffing ratios based on patient acuity and unit needs
C) Rotation of nurses every 30 minutes to reduce fatigue
D) Mandatory overtime for all nurses during flu season
Answer: B
Explanation: CMS requires that nursing staff levels be appropriate to patient acuity and unit
requirements, not a fixed ratio for all patients.
, [HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
**Question 9.** Under USP 797, which of the following is essential for the preparation of sterile
compounded medications?
A) Use of a laminar flow hood with a minimum ISO Class 5 environment
B) Preparation in a standard patient care room
C) Allowing staff to wear regular street clothing
D) No requirement for personnel competency assessment
Answer: A
Explanation: USP 797 mandates sterile compounding in a controlled environment, typically an
ISO Class 5 (or equivalent) laminar flow hood, to ensure product sterility.
**Question 10.** In an emergency, which professional is NOT required to review medication
orders before administration?
A) Pharmacist
B) Attending physician
C) Registered nurse
D) Hospital administrator
Answer: D
Explanation: In emergencies, the pharmacist may be unavailable, and the order can be
administered based on the physician’s order and nursing assessment; administrators are not
involved in order review.
**Question 11.** The pre‑operative History & Physical (H&P) must be completed within what
timeframe of patient admission?
A) 12 hours
B) 24 hours
C) 48 hours
D) 72 hours
Services CMS Certification Review Guide
**Question 1.** Which organization is granted deeming authority to conduct CMS surveys on
behalf of the federal government?
A) American Hospital Association (AHA)
B) The Joint Commission (TJC)
C) National Institutes of Health (NIH)
D) Centers for Disease Control and Prevention (CDC)
Answer: B
Explanation: The Joint Commission is one of the recognized accrediting organizations that
receive deeming authority from CMS to perform surveys that satisfy Medicare certification
requirements.
**Question 2.** A state survey agency conducts a validation survey. What is the primary
purpose of this survey?
A) To assess a new hospital’s eligibility for Medicare participation
B) To verify that an accrediting organization continues to meet CMS standards
C) To investigate a complaint of patient abuse
D) To review the hospital’s financial statements
Answer: B
Explanation: Validation surveys are performed by state agencies to ensure that the accrediting
organization’s survey process remains consistent with CMS Conditions of Participation.
**Question 3.** During a complaint investigation, which document is most critical for
establishing the factual basis of the alleged violation?
A) The hospital’s marketing brochure
B) The patient’s signed consent form
C) The surveyor’s interpretive guidelines worksheet
D) The physician’s residency contract
, [HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
Answer: C
Explanation: Surveyors use interpretive guidelines to document observations and fact‑finding
during complaint investigations, providing the evidentiary basis for any compliance
determination.
**Question 4.** Which of the following is NOT a required element of the patient’s right to
informed consent under the CoPs?
A) Disclosure of the nature of the proposed treatment
B) Explanation of alternatives, including no treatment
C) Provision of a written consent form for every procedure
D) Discussion of material risks associated with the treatment
Answer: C
Explanation: While documentation of consent is required, a written form is not mandated for
every procedure; verbal consent may be sufficient when appropriate.
**Question 5.** Under the CMS patient‑rights regulations, a patient may request a grievance
for which of the following reasons?
A) Preference for a specific hospital cafeteria menu item
B) Dissatisfaction with the hospital’s parking fees
C) Alleged violation of privacy rights under HIPAA
D) Desire to change the hospital’s color scheme
Answer: C
Explanation: Grievances must address concerns related to patient rights, including privacy
violations, quality of care, and discrimination.
**Question 6.** Which of the following statements about the use of restraints and seclusion is
correct?
A) PRN (as needed) orders for restraints are permissible if documented.
, [HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
B) Physical restraints may be used without a physician’s order in emergencies.
C) Restraints must be ordered by a qualified health professional and reviewed regularly.
D) Seclusion is allowed for patients who are merely agitated but not dangerous.
Answer: C
Explanation: CMS requires that restraints and seclusion be ordered by a qualified professional,
with ongoing assessment and documentation; PRN orders are prohibited.
**Question 7.** Who holds ultimate accountability for the quality of care provided by the
medical staff according to the CoPs?
A) The chief financial officer (CFO)
B) The governing body of the hospital
C) The head of housekeeping
D) The external accrediting organization
Answer: B
Explanation: The governing body is responsible for overseeing the medical staff’s credentialing,
privileging, and overall quality of care.
**Question 8.** Which of the following is a required component of a hospital’s nursing staffing
plan?
A) Minimum of three nurses per patient regardless of acuity
B) Staffing ratios based on patient acuity and unit needs
C) Rotation of nurses every 30 minutes to reduce fatigue
D) Mandatory overtime for all nurses during flu season
Answer: B
Explanation: CMS requires that nursing staff levels be appropriate to patient acuity and unit
requirements, not a fixed ratio for all patients.
, [HACPCMS] HACP Center for Medicare And Medicaid
Services CMS Certification Review Guide
**Question 9.** Under USP 797, which of the following is essential for the preparation of sterile
compounded medications?
A) Use of a laminar flow hood with a minimum ISO Class 5 environment
B) Preparation in a standard patient care room
C) Allowing staff to wear regular street clothing
D) No requirement for personnel competency assessment
Answer: A
Explanation: USP 797 mandates sterile compounding in a controlled environment, typically an
ISO Class 5 (or equivalent) laminar flow hood, to ensure product sterility.
**Question 10.** In an emergency, which professional is NOT required to review medication
orders before administration?
A) Pharmacist
B) Attending physician
C) Registered nurse
D) Hospital administrator
Answer: D
Explanation: In emergencies, the pharmacist may be unavailable, and the order can be
administered based on the physician’s order and nursing assessment; administrators are not
involved in order review.
**Question 11.** The pre‑operative History & Physical (H&P) must be completed within what
timeframe of patient admission?
A) 12 hours
B) 24 hours
C) 48 hours
D) 72 hours
