HACP Study Guide Exam 2026 Questions
and Answers
The SA is responsible for: - Correct answer-1. Investigating complaints
2. Conducting validation surveys
3. Issuing reports of findings and monitoring CAPs
4. Recommending to CMS termination of payment
Survey team size is based off of: - Correct answer-1. Average daily census
2. Complexity of services offered
3. Type of survey
4. Special units and/or offsite locations
5. Historical pattern of deficiencies
6. Surveyors-in-training
Does CMS provide survey template or schedule? - Correct answer-No. Deemed
status agencies do though.
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,# of medical records reviewed by CMS during survey - Correct answer-No fewer
than 30 unless it's a smaller hospital in which case, it is 20.
Condition-Level Finding - Correct answer-1. Noncompliance with single standard
or several standards within the condition
2. Noncompliance with a single part representing a severe or critical health or
safety breach
When is final report sent? - Correct answer-Within 10 working days
When is hospital response (written plan of correction) to final report due? - Correct
answer-Within 10 calendar days
Plan of correction must include: - Correct answer-1. Corrective action for each
deficiency
2. Position of person who will monitor CAP
3. Dates of anticipated completion
4. Administrator signature (for CMS surveys only)
5. Must meet approval of SA (for CMS surveys only)
Can you have one governing body for multiple separately certified hospitals? -
Correct answer-Yes, as long as it doesn't conflict with state law. Each hospital will
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, continue to have its own survey (demonstrate compliance independently of the
others).
Responsibilities for Contracted Services (GB and Hospital) - Correct answer-GB:
1) Assess services furnished under contract, 2) ID quality & performance problems
and respond, 3) monitor CAPs
Hospital: Maintain list of contracted services, including scope and nature of
services provided
Emergency Medical Treatment & Labor Act (EMTALA) - Correct answer-For
facilities without emergency services, the medical staff must develop policies &
procedures for appraisal of emergencies, initial treatment (stabilization), and
referral. Facility maintains responsibility for the patient until properly transferred.
Hospital cannot rely on 9-1-1- to substitute emergency response.
Requirements for Informing Patients of their Rights - Correct answer-1. Must be
done in advance of furnishing or discontinuing patient care whenever possible
2. Must be provided in a language or manner the patient (or representative) can
understand
Important Message from Medicare Requirements (IM) - Correct answer-(For
Medicare Patients)
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and Answers
The SA is responsible for: - Correct answer-1. Investigating complaints
2. Conducting validation surveys
3. Issuing reports of findings and monitoring CAPs
4. Recommending to CMS termination of payment
Survey team size is based off of: - Correct answer-1. Average daily census
2. Complexity of services offered
3. Type of survey
4. Special units and/or offsite locations
5. Historical pattern of deficiencies
6. Surveyors-in-training
Does CMS provide survey template or schedule? - Correct answer-No. Deemed
status agencies do though.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,# of medical records reviewed by CMS during survey - Correct answer-No fewer
than 30 unless it's a smaller hospital in which case, it is 20.
Condition-Level Finding - Correct answer-1. Noncompliance with single standard
or several standards within the condition
2. Noncompliance with a single part representing a severe or critical health or
safety breach
When is final report sent? - Correct answer-Within 10 working days
When is hospital response (written plan of correction) to final report due? - Correct
answer-Within 10 calendar days
Plan of correction must include: - Correct answer-1. Corrective action for each
deficiency
2. Position of person who will monitor CAP
3. Dates of anticipated completion
4. Administrator signature (for CMS surveys only)
5. Must meet approval of SA (for CMS surveys only)
Can you have one governing body for multiple separately certified hospitals? -
Correct answer-Yes, as long as it doesn't conflict with state law. Each hospital will
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
, continue to have its own survey (demonstrate compliance independently of the
others).
Responsibilities for Contracted Services (GB and Hospital) - Correct answer-GB:
1) Assess services furnished under contract, 2) ID quality & performance problems
and respond, 3) monitor CAPs
Hospital: Maintain list of contracted services, including scope and nature of
services provided
Emergency Medical Treatment & Labor Act (EMTALA) - Correct answer-For
facilities without emergency services, the medical staff must develop policies &
procedures for appraisal of emergencies, initial treatment (stabilization), and
referral. Facility maintains responsibility for the patient until properly transferred.
Hospital cannot rely on 9-1-1- to substitute emergency response.
Requirements for Informing Patients of their Rights - Correct answer-1. Must be
done in advance of furnishing or discontinuing patient care whenever possible
2. Must be provided in a language or manner the patient (or representative) can
understand
Important Message from Medicare Requirements (IM) - Correct answer-(For
Medicare Patients)
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
