HACP COMPREHENSIVE EXAM 2026
QUESTIONS WITH SOLUTIONS
GUARANTEED PASS
⩥ How are certification of hospital compliance with CoP accomplished?
Answer: Observations, interviews, and document/record reviews.
⩥ What does a hospital survey asses? Answer: Asses compliance with
Federal health, safety, and quality standards that will assure that the
patient receives safe, quality care and services.
⩥ How many deemed-status agencies are there? Answer: 4
⩥ What are the 4 deemed-status agencies? Answer: (1) The Center for
Improvement in Healthcare Quality (CIHQ)
(2) The Joint Commission
(3) DNV Inc.
(4) American Osteopathic Association's HFAP Program
⩥ What section of the Social Security Act permits hospitals "accredited"
by an approved national accreditation organization to be exempt from
routine surveys by CMS to determine compliance with Medicare CoP?
Answer: Section 1865(b)(1)
,⩥ Is accreditation by a deemed-status agency required for Medicare
certification? Answer: No, it is voluntary
⩥ Before permitting deemed status, section 1865(b)(2) of SSA requires
that CMS consider the agencies: Answer: (1) Requirements for
accreditation
(2) Survey procedures
(3) Ability to provide adequate resources for conducting required
surveys
(4) ability to supply information for use in enforcement activities
(5) monitoring procedures for hospitals found out of compliance with
the conditions or requirements and ability to provide CMS with the
necessary data for validation
⩥ What is the maximum term of approval for deemed-status agencies?
Answer: 6 years
⩥ Are deemed-status agencies required to re-apply to CMS for
continued authority to accredit hospitals as a deemed provider? Answer:
Yes
⩥ What are some of the options that hospitals have when it comes to
Medicare certification? Answer: (1) directly certified by Medicare
(2) accredited by a deemed-status provider
, (3) forgo Medicare certification entirely
⩥ CMS has ceded survey activities to who? Answer: Each state through
'State Enforcement Agencies' e.g. Department of Health
⩥ What are State Enforcement Agencies (SA) responsible for? Answer:
(1) Investigating Complaints
(2) Full validation Surveys (CoP compliance)
(3) Issuing Report Findings and monitoring corrective action plans
(4) Recommending to CMS termination of hospital Medicare
participation
⩥ What is CCN? Answer: CMS Certification Number (hospital assigned
certificate number)
⩥ All Hospital Surveys are Unannounced Answer: True
⩥ How is the number of patient records to be reviewed determined?
Answer: Based on facilities average daily census (sample at least 10% of
the average daily census, not fewer than 30 inpatient records
⩥ A deficiency at the condition level maybe due to non-compliance with
requirements in a single standard or several standards within the
condition or with requirements of non-compliance with the single part
QUESTIONS WITH SOLUTIONS
GUARANTEED PASS
⩥ How are certification of hospital compliance with CoP accomplished?
Answer: Observations, interviews, and document/record reviews.
⩥ What does a hospital survey asses? Answer: Asses compliance with
Federal health, safety, and quality standards that will assure that the
patient receives safe, quality care and services.
⩥ How many deemed-status agencies are there? Answer: 4
⩥ What are the 4 deemed-status agencies? Answer: (1) The Center for
Improvement in Healthcare Quality (CIHQ)
(2) The Joint Commission
(3) DNV Inc.
(4) American Osteopathic Association's HFAP Program
⩥ What section of the Social Security Act permits hospitals "accredited"
by an approved national accreditation organization to be exempt from
routine surveys by CMS to determine compliance with Medicare CoP?
Answer: Section 1865(b)(1)
,⩥ Is accreditation by a deemed-status agency required for Medicare
certification? Answer: No, it is voluntary
⩥ Before permitting deemed status, section 1865(b)(2) of SSA requires
that CMS consider the agencies: Answer: (1) Requirements for
accreditation
(2) Survey procedures
(3) Ability to provide adequate resources for conducting required
surveys
(4) ability to supply information for use in enforcement activities
(5) monitoring procedures for hospitals found out of compliance with
the conditions or requirements and ability to provide CMS with the
necessary data for validation
⩥ What is the maximum term of approval for deemed-status agencies?
Answer: 6 years
⩥ Are deemed-status agencies required to re-apply to CMS for
continued authority to accredit hospitals as a deemed provider? Answer:
Yes
⩥ What are some of the options that hospitals have when it comes to
Medicare certification? Answer: (1) directly certified by Medicare
(2) accredited by a deemed-status provider
, (3) forgo Medicare certification entirely
⩥ CMS has ceded survey activities to who? Answer: Each state through
'State Enforcement Agencies' e.g. Department of Health
⩥ What are State Enforcement Agencies (SA) responsible for? Answer:
(1) Investigating Complaints
(2) Full validation Surveys (CoP compliance)
(3) Issuing Report Findings and monitoring corrective action plans
(4) Recommending to CMS termination of hospital Medicare
participation
⩥ What is CCN? Answer: CMS Certification Number (hospital assigned
certificate number)
⩥ All Hospital Surveys are Unannounced Answer: True
⩥ How is the number of patient records to be reviewed determined?
Answer: Based on facilities average daily census (sample at least 10% of
the average daily census, not fewer than 30 inpatient records
⩥ A deficiency at the condition level maybe due to non-compliance with
requirements in a single standard or several standards within the
condition or with requirements of non-compliance with the single part
