HACP Exam 2026 Questions and Answers
Certification Process - Correct answer-Hospitals have some options when it comes
to Medicare certification:
• A hospital can be directly certified by Medicare
• A hospital can be accredited by a deemed-status provider
• A hospital can forgo Medicare certification entirely
Certification Process - Correct answer-ROLE OF THE STATE ENFORCEMENT
AGENCY
With over 4000 hospitals across the United States, CMS does not have the
manpower to conduct on-site surveys. Therefore, CMS has ceded survey activities
to each State. The State Enforcement Agency (SA) is usually the Department of
Health or similar body. The SA is responsible for:
• Investigating complaints about hospitals and alleged violations of patient rights or
other CoP'
• Conducting full validation surveys of a hospital's compliance to the CoP'.
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,• Issuing reports of findings and monitoring corrective action plans
• Recommending to CMS potential termination of a hospital's ability to participate
in Medicare payment programs
Certification Process - Correct answer-MEDICARE CERTIFICATION NUMBER
Each hospital is assigned a unique certification number called a CCN. This number
is used by the hospital for any service under which Medicare is billed. CMS will
assess a hospital's compliance with the CoP for all services, areas and locations in
which the hospital receives reimbursement for patient care services billed under its
CCN.
Certification Process - Correct answer-COMPOSITION OF THE SURVEY TEAM
The State Enforcement Agency decides the composition and size of a survey team.
In general, a survey team for a full survey of a mid-size hospital would include
two-four surveyors who will be at the facility for 3 or more days. Each hospital
survey team will include at least one RN with hospital survey experience, as well
as other surveyors who have the expertise needed to determine whether the facility
is in compliance. Survey team size and composition are normally based on the
following factors:
• Size of the facility to be surveyed, based on average daily census;
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,• Complexity of services offered, including outpatient services;
• Type of survey to be conducted;
• Whether the facility has special care units or off-site clinics or locations;
• Whether the facility has a historical pattern of serious deficiencies or complaints;
and
• Whether new surveyors are to accompany a team as part of their training
Certification Process - Correct answer-All hospital surveys are unannounced.
Hospitals are not provided with advance notice of the survey.
Certification Process - Correct answer-SURVEY ACTIVITIES
Arrival by the Survey Team
The entire survey team should enter the hospital together. Upon arrival, surveyors
should present their identification. The team coordinator should announce to the
Administrator, or whoever is in charge, that a survey is being conducted. If the
Administrator (or person in charge) is not onsite or available (e.g., if the survey
begins outside normal daytime Monday-Friday working hours), they will ask that
the Administrator be notified that a survey is being conducted. The survey will not
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, be delayed because the Administrator or other hospital staff is/are not on site or
available.
Certification Process - Correct answer-Survey Schedule
Unlike the deemed-status agencies, CMS does not provide a template or likely
survey schedule to hospitals. The Team Coordinator works with the other
surveyors to determine where and when various activities will take place. There is
no set agenda or schedule of activities. The amount of time spent in an area and the
specific activities that occur in an area are left to the surveyor's discretion.
Certification Process - Correct answer-The number of patient records reviewed is
based on the facility's average daily census. The sample should be at least 10
percent of the average daily census, but not fewer than 30 inpatient records.
Certification Process - Correct answer-The number of patient records reviewed is
based on the facility's average daily census. The sample should be at least 10
percent of the average daily census, but not fewer than 30 inpatient records.
Certification Process - Correct answer-On any Medicare hospital survey,
contracted patient care activities or patient services (such as dietary services,
treatment services, diagnostic services, etc.) located on hospital campuses or
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
Certification Process - Correct answer-Hospitals have some options when it comes
to Medicare certification:
• A hospital can be directly certified by Medicare
• A hospital can be accredited by a deemed-status provider
• A hospital can forgo Medicare certification entirely
Certification Process - Correct answer-ROLE OF THE STATE ENFORCEMENT
AGENCY
With over 4000 hospitals across the United States, CMS does not have the
manpower to conduct on-site surveys. Therefore, CMS has ceded survey activities
to each State. The State Enforcement Agency (SA) is usually the Department of
Health or similar body. The SA is responsible for:
• Investigating complaints about hospitals and alleged violations of patient rights or
other CoP'
• Conducting full validation surveys of a hospital's compliance to the CoP'.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,• Issuing reports of findings and monitoring corrective action plans
• Recommending to CMS potential termination of a hospital's ability to participate
in Medicare payment programs
Certification Process - Correct answer-MEDICARE CERTIFICATION NUMBER
Each hospital is assigned a unique certification number called a CCN. This number
is used by the hospital for any service under which Medicare is billed. CMS will
assess a hospital's compliance with the CoP for all services, areas and locations in
which the hospital receives reimbursement for patient care services billed under its
CCN.
Certification Process - Correct answer-COMPOSITION OF THE SURVEY TEAM
The State Enforcement Agency decides the composition and size of a survey team.
In general, a survey team for a full survey of a mid-size hospital would include
two-four surveyors who will be at the facility for 3 or more days. Each hospital
survey team will include at least one RN with hospital survey experience, as well
as other surveyors who have the expertise needed to determine whether the facility
is in compliance. Survey team size and composition are normally based on the
following factors:
• Size of the facility to be surveyed, based on average daily census;
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
,• Complexity of services offered, including outpatient services;
• Type of survey to be conducted;
• Whether the facility has special care units or off-site clinics or locations;
• Whether the facility has a historical pattern of serious deficiencies or complaints;
and
• Whether new surveyors are to accompany a team as part of their training
Certification Process - Correct answer-All hospital surveys are unannounced.
Hospitals are not provided with advance notice of the survey.
Certification Process - Correct answer-SURVEY ACTIVITIES
Arrival by the Survey Team
The entire survey team should enter the hospital together. Upon arrival, surveyors
should present their identification. The team coordinator should announce to the
Administrator, or whoever is in charge, that a survey is being conducted. If the
Administrator (or person in charge) is not onsite or available (e.g., if the survey
begins outside normal daytime Monday-Friday working hours), they will ask that
the Administrator be notified that a survey is being conducted. The survey will not
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
, be delayed because the Administrator or other hospital staff is/are not on site or
available.
Certification Process - Correct answer-Survey Schedule
Unlike the deemed-status agencies, CMS does not provide a template or likely
survey schedule to hospitals. The Team Coordinator works with the other
surveyors to determine where and when various activities will take place. There is
no set agenda or schedule of activities. The amount of time spent in an area and the
specific activities that occur in an area are left to the surveyor's discretion.
Certification Process - Correct answer-The number of patient records reviewed is
based on the facility's average daily census. The sample should be at least 10
percent of the average daily census, but not fewer than 30 inpatient records.
Certification Process - Correct answer-The number of patient records reviewed is
based on the facility's average daily census. The sample should be at least 10
percent of the average daily census, but not fewer than 30 inpatient records.
Certification Process - Correct answer-On any Medicare hospital survey,
contracted patient care activities or patient services (such as dietary services,
treatment services, diagnostic services, etc.) located on hospital campuses or
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
