HACP EXAM 2026 QUESTIONS AND
ANSWERS GUARANTEED PASS
⩥ Certification Process. 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'.
• 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. 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. 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;
• 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. Answer: All hospital surveys are unannounced.
Hospitals are not provided with advance notice of the survey.
⩥ Certification Process. 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 be delayed
because the Administrator or other hospital staff is/are not on site or
available.
⩥ Certification Process. 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. 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. 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. 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 hospital provider based locations will be surveyed as part of
the hospital for compliance with the conditions of participation.
⩥ Certification Process. Answer: A deficiency at the Condition level
may be due to noncompliance with requirements in a single standard or
several standards within the condition or with requirements of
noncompliance with a single part (tag) representing a severe or critical
health or safety breach. Even a seemingly small breach in critical actions
or at critical times can kill or severely injure a patient, and represents a
critical or severe health or safety threat.
⩥ Certification Process. Answer: THE CMS PLAN OF CORRECTION
Following the survey a statement of deficiencies (Form CMS-2567) will
be mailed within 10 working days to the hospital. Form CMS-2567 is
the document disclosed to the public about the hospital's deficiencies
and what is being done to remedy them.
⩥ Certification Process. Answer: The hospital is required to submit a
written plan of correction to the survey agency within 10 calendar days
following receipt of the written statement of deficiencies. The plan of
ANSWERS GUARANTEED PASS
⩥ Certification Process. 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'.
• 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. 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. 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;
• 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. Answer: All hospital surveys are unannounced.
Hospitals are not provided with advance notice of the survey.
⩥ Certification Process. 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 be delayed
because the Administrator or other hospital staff is/are not on site or
available.
⩥ Certification Process. 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. 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. 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. 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 hospital provider based locations will be surveyed as part of
the hospital for compliance with the conditions of participation.
⩥ Certification Process. Answer: A deficiency at the Condition level
may be due to noncompliance with requirements in a single standard or
several standards within the condition or with requirements of
noncompliance with a single part (tag) representing a severe or critical
health or safety breach. Even a seemingly small breach in critical actions
or at critical times can kill or severely injure a patient, and represents a
critical or severe health or safety threat.
⩥ Certification Process. Answer: THE CMS PLAN OF CORRECTION
Following the survey a statement of deficiencies (Form CMS-2567) will
be mailed within 10 working days to the hospital. Form CMS-2567 is
the document disclosed to the public about the hospital's deficiencies
and what is being done to remedy them.
⩥ Certification Process. Answer: The hospital is required to submit a
written plan of correction to the survey agency within 10 calendar days
following receipt of the written statement of deficiencies. The plan of
