HACP QUESTIONS WITH CORRECT
ANSWERS , GRADED A+
Certification bbProcess bb- bbAnswer bbHospitals bbhave bbsome bboptions bbwhen bbit
bbcomes bbto bbMedicare bbcertification: bb
• bbA bbhospital bbcan bbbe bbdirectly bbcertified bbby bbMedicare bb
• bbA bbhospital bbcan bbbe bbaccredited bbby bba bbdeemed-status bbprovider bb
• bbA bbhospital bbcan bbforgo bbMedicare bbcertification bbentirely
Certification bbProcess bb- bbAnswer bbROLE bbOF bbTHE bbSTATE bbENFORCEMENT
bbAGENCY bb
With bbover bb4000 bbhospitals bbacross bbthe bbUnited bbStates, bbCMS bbdoes bbnot bbhave
bbthe bbmanpower bbto bbconduct bbon-site bbsurveys. bbTherefore, bbCMS bbhas bbceded
bbsurvey bbactivities bbto bbeach bbState. bbThe bbState bbEnforcement bbAgency bb(SA) bbis
bbusually bbthe bbDepartment bbof bbHealth bbor bbsimilar bbbody. bbThe bbSA bbis
bbresponsible bbfor: bb
• bbInvestigating bbcomplaints bbabout bbhospitals bband bballeged bbviolations bbof bbpatient
bbrights bbor bbother bbCoP' bb
• bbConducting bbfull bbvalidation bbsurveys bbof bba bbhospital's bbcompliance bbto bbthe
bbCoP'. bb
• bbIssuing bbreports bbof bbfindings bband bbmonitoring bbcorrective bbaction bbplans bb
• bbRecommending bbto bbCMS bbpotential bbtermination bbof bba bbhospital's bbability bbto
bbparticipate bbin bbMedicare bbpayment bbprograms
Certification bbProcess bb- bbAnswer bbMEDICARE bbCERTIFICATION bbNUMBER bb
Each bbhospital bbis bbassigned bba bbunique bbcertification bbnumber bbcalled bba bbCCN.
bbThis bbnumber bbis bbused bbby bbthe bbhospital bbfor bbany bbservice bbunder bbwhich
bbMedicare bbis bbbilled. bbCMS bbwill bbassess bba bbhospital's bbcompliance bbwith bbthe
bbCoP bbfor bball bbservices, bbareas bband bblocations bbin bbwhich bbthe bbhospital
bbreceives bbreimbursement bbfor bbpatient bbcare bbservices bbbilled bbunder bbits bbCCN.
Certification bbProcess bb- bbAnswer bbCOMPOSITION bbOF bbTHE bbSURVEY bbTEAM bb
The bbState bbEnforcement bbAgency bbdecides bbthe bbcomposition bband bbsize bbof bba
bbsurvey bbteam. bbIn bbgeneral, bba bbsurvey bbteam bbfor bba bbfull bbsurvey bbof bba bbmid-
size bbhospital bbwould bbinclude bbtwo-four bbsurveyors bbwho bbwill bbbe bbat bbthe bbfacility
bbfor bb3 bbor bbmore bbdays. bbEach bbhospital bbsurvey bbteam bbwill bbinclude bbat bbleast
bbone bbRN bbwith bbhospital bbsurvey bbexperience, bbas bbwell bbas bbother bbsurveyors
bbwho bbhave bbthe bbexpertise bbneeded bbto bbdetermine bbwhether bbthe bbfacility bbis bbin
bbcompliance. bbSurvey bbteam bbsize bband bbcomposition bbare bbnormally bbbased bbon
bbthe bbfollowing bbfactors: bb
,• bbSize bbof bbthe bbfacility bbto bbbe bbsurveyed, bbbased bbon bbaverage bbdaily bbcensus; bb
• bbComplexity bbof bbservices bboffered, bbincluding bboutpatient bbservices; bb
• bbType bbof bbsurvey bbto bbbe bbconducted; bb
• bbWhether bbthe bbfacility bbhas bbspecial bbcare bbunits bbor bboff-site bbclinics bbor
bblocations; bb
• bbWhether bbthe bbfacility bbhas bba bbhistorical bbpattern bbof bbserious bbdeficiencies bbor
bbcomplaints; bband bb
• bbWhether bbnew bbsurveyors bbare bbto bbaccompany bba bbteam bbas bbpart bbof bbtheir
bbtraining
Certification bbProcess bb- bbAnswer bbAll bbhospital bbsurveys bbare bbunannounced.
bbHospitals bbare bbnot bbprovided bbwith bbadvance bbnotice bbof bbthe bbsurvey.
Certification bbProcess bb- bbAnswer bbSURVEY bbACTIVITIES bb
Arrival bbby bbthe bbSurvey bbTeam bb
The bbentire bbsurvey bbteam bbshould bbenter bbthe bbhospital bbtogether. bbUpon bbarrival,
bbsurveyors bbshould bbpresent bbtheir bbidentification. bbThe bbteam bbcoordinator bbshould
bbannounce bbto bbthe bbAdministrator, bbor bbwhoever bbis bbin bbcharge, bbthat bba bbsurvey
bbis bbbeing bbconducted. bbIf bbthe bbAdministrator bb(or bbperson bbin bbcharge) bbis bbnot
bbonsite bbor bbavailable bb(e.g., bbif bbthe bbsurvey bbbegins bboutside bbnormal bbdaytime
bbMonday-Friday bbworking bbhours), bbthey bbwill bbask bbthat bbthe bbAdministrator bbbe
bbnotified bbthat bba bbsurvey bbis bbbeing bbconducted. bbThe bbsurvey bbwill bbnot bbbe
bbdelayed bbbecause bbthe bbAdministrator bbor bbother bbhospital bbstaff bbis/are bbnot bbon
bbsite bbor bbavailable.
Certification bbProcess bb- bbAnswer bbSurvey bbSchedule bb
Unlike bbthe bbdeemed-status bbagencies, bbCMS bbdoes bbnot bbprovide bba bbtemplate bbor
bblikely bbsurvey bbschedule bbto bbhospitals. bbThe bbTeam bbCoordinator bbworks bbwith
bbthe bbother bbsurveyors bbto bbdetermine bbwhere bband bbwhen bbvarious bbactivities bbwill
bbtake bbplace. bbThere bbis bbno bbset bbagenda bbor bbschedule bbof bbactivities. bbThe
bbamount bbof bbtime bbspent bbin bban bbarea bband bbthe bbspecific bbactivities bbthat bboccur
bbin bban bbarea bbare bbleft bbto bbthe bbsurveyor's bbdiscretion.
Certification bbProcess bb- bbAnswer bbThe bbnumber bbof bbpatient bbrecords bbreviewed bbis
bbbased bbon bbthe bbfacility's bbaverage bbdaily bbcensus. bbThe bbsample bbshould bbbe bbat
bbleast bb10 bbpercent bbof bbthe bbaverage bbdaily bbcensus, bbbut bbnot bbfewer bbthan bb30
bbinpatient bbrecords.
Certification bbProcess bb- bbAnswer bbThe bbnumber bbof bbpatient bbrecords bbreviewed bbis
bbbased bbon bbthe bbfacility's bbaverage bbdaily bbcensus. bbThe bbsample bbshould bbbe bbat
bbleast bb10 bbpercent bbof bbthe bbaverage bbdaily bbcensus, bbbut bbnot bbfewer bbthan bb30
bbinpatient bbrecords.
Certification bbProcess bb- bbAnswer bbOn bbany bbMedicare bbhospital bbsurvey,
bbcontracted bbpatient bbcare bbactivities bbor bbpatient bbservices bb(such bbas bbdietary
bbservices, bbtreatment bbservices, bbdiagnostic bbservices, bbetc.) bblocated bbon bbhospital
, bbcampuses bbor bbhospital bbprovider bbbased bblocations bbwill bbbe bbsurveyed bbas bbpart
bbof bbthe bbhospital bbfor bbcompliance bbwith bbthe bbconditions bbof bbparticipation.
Certification bbProcess bb- bbAnswer bbA bbdeficiency bbat bbthe bbCondition bblevel bbmay
bbbe bbdue bbto bbnoncompliance bbwith bbrequirements bbin bba bbsingle bbstandard bbor
bbseveral bbstandards bbwithin bbthe bbcondition bbor bbwith bbrequirements bbof
bbnoncompliance bbwith bba bbsingle bbpart bb(tag) bbrepresenting bba bbsevere bbor bbcritical
bbhealth bbor bbsafety bbbreach. bbEven bba bbseemingly bbsmall bbbreach bbin bbcritical
bbactions bbor bbat bbcritical bbtimes bbcan bbkill bbor bbseverely bbinjure bba bbpatient, bband
bbrepresents bba bbcritical bbor bbsevere bbhealth bbor bbsafety bbthreat.
Certification bbProcess bb- bbAnswer bbTHE bbCMS bbPLAN bbOF bbCORRECTION bb
Following bbthe bbsurvey bba bbstatement bbof bbdeficiencies bb(Form bbCMS-2567) bbwill
bbbe bbmailed bbwithin bb10 bbworking bbdays bbto bbthe bbhospital. bbForm bbCMS-2567 bbis
bbthe bbdocument bbdisclosed bbto bbthe bbpublic bbabout bbthe bbhospital's bbdeficiencies
bband bbwhat bbis bbbeing bbdone bbto bbremedy bbthem.
Certification bbProcess bb- bbAnswer bbThe bbhospital bbis bbrequired bbto bbsubmit bba
bbwritten bbplan bbof bbcorrection bbto bbthe bbsurvey bbagency bbwithin bb10 bbcalendar
bbdays bbfollowing bbreceipt bbof bbthe bbwritten bbstatement bbof bbdeficiencies. bbThe bbplan
bbof bbcorrection bbis bbsubmitted bbon bbthe bbForm bbCMS-2567. bbThe bbrequired
bbcharacteristics bbof bba bbplan bbof bbcorrection bbinclude: bb
• bbCorrective bbaction bbto bbbe bbtaken bbfor bbeach bbindividual bbaffected bbby bbthe
bbdeficient bbpractice, bbincluding bbany bbsystem bbchanges bbthat bbmust bbbe bbmade; bb
• bbThe bbposition bbof bbthe bbperson bbwho bbwill bbmonitor bbthe bbcorrective bbaction bband
bbthe bbfrequency bbof bbmonitoring; bb
• bbDates bbeach bbcorrective bbaction bbwill bbbe bbcompleted; bb
• bbThe bbadministrator bbor bbappropriate bbindividual bbmust bbsign bband bbdate bbthe
bbForm bbCMS-2567 bbbefore bbreturning bbit bbto bbthe bbsurvey bbagency; bband bb
• bbThe bbsubmitted bbplan bbof bbcorrection bbmust bbmeet bbthe bbapproval bbof bbthe bbState
bbagency, bbor bbin bbsome bbcases bbthe bbCMS bbRegional bbOffice bbfor bbit bbto bbbe
bbacceptable.
Condition bbof bbParticipation: bbGovernance bb- bbAnswer bbIf bba bbhospital bbsystem bbhas
bbchosen bbto bbhave bbone bbbody bbact bbas bbthe bbgoverning bbbody bbfor bbmultiple
bbseparately bbcertified bbhospitals, bbthis bbdoes bbnot bbalter bbthe bbfact bbthat bbeach
bbhospital bbmust bbseparately bbdemonstrate bbcompliance bbwith bbthe bbCoPs. bbEach
bbseparately bbcertified bbhospital bbmust bbbe bbseparately bband bbindependently
bbassessed bbfor bbits bbcompliance bbwith bbthe bbCoPs, bbthrough bbeither bbState bbSurvey
bbAgency bbor bbapproved bbnational bbaccreditation bbprogram bbsurveys. bbThere bbis bbno
bbsurvey bbof bba bbhospital bb"system," bbsince bbthe bbMedicare bbagreement bband bbits
bbterms bbare bbspecific bbto bbeach bbcertified bbhospital.
Condition bbof bbParticipation: bbGovernance bb- bbAnswer bbThe bbgoverning bbbody bbmust
bbtake bbactions bbthrough bbthe bbhospital's bbQAPI bbprogram bbto: bb
ANSWERS , GRADED A+
Certification bbProcess bb- bbAnswer bbHospitals bbhave bbsome bboptions bbwhen bbit
bbcomes bbto bbMedicare bbcertification: bb
• bbA bbhospital bbcan bbbe bbdirectly bbcertified bbby bbMedicare bb
• bbA bbhospital bbcan bbbe bbaccredited bbby bba bbdeemed-status bbprovider bb
• bbA bbhospital bbcan bbforgo bbMedicare bbcertification bbentirely
Certification bbProcess bb- bbAnswer bbROLE bbOF bbTHE bbSTATE bbENFORCEMENT
bbAGENCY bb
With bbover bb4000 bbhospitals bbacross bbthe bbUnited bbStates, bbCMS bbdoes bbnot bbhave
bbthe bbmanpower bbto bbconduct bbon-site bbsurveys. bbTherefore, bbCMS bbhas bbceded
bbsurvey bbactivities bbto bbeach bbState. bbThe bbState bbEnforcement bbAgency bb(SA) bbis
bbusually bbthe bbDepartment bbof bbHealth bbor bbsimilar bbbody. bbThe bbSA bbis
bbresponsible bbfor: bb
• bbInvestigating bbcomplaints bbabout bbhospitals bband bballeged bbviolations bbof bbpatient
bbrights bbor bbother bbCoP' bb
• bbConducting bbfull bbvalidation bbsurveys bbof bba bbhospital's bbcompliance bbto bbthe
bbCoP'. bb
• bbIssuing bbreports bbof bbfindings bband bbmonitoring bbcorrective bbaction bbplans bb
• bbRecommending bbto bbCMS bbpotential bbtermination bbof bba bbhospital's bbability bbto
bbparticipate bbin bbMedicare bbpayment bbprograms
Certification bbProcess bb- bbAnswer bbMEDICARE bbCERTIFICATION bbNUMBER bb
Each bbhospital bbis bbassigned bba bbunique bbcertification bbnumber bbcalled bba bbCCN.
bbThis bbnumber bbis bbused bbby bbthe bbhospital bbfor bbany bbservice bbunder bbwhich
bbMedicare bbis bbbilled. bbCMS bbwill bbassess bba bbhospital's bbcompliance bbwith bbthe
bbCoP bbfor bball bbservices, bbareas bband bblocations bbin bbwhich bbthe bbhospital
bbreceives bbreimbursement bbfor bbpatient bbcare bbservices bbbilled bbunder bbits bbCCN.
Certification bbProcess bb- bbAnswer bbCOMPOSITION bbOF bbTHE bbSURVEY bbTEAM bb
The bbState bbEnforcement bbAgency bbdecides bbthe bbcomposition bband bbsize bbof bba
bbsurvey bbteam. bbIn bbgeneral, bba bbsurvey bbteam bbfor bba bbfull bbsurvey bbof bba bbmid-
size bbhospital bbwould bbinclude bbtwo-four bbsurveyors bbwho bbwill bbbe bbat bbthe bbfacility
bbfor bb3 bbor bbmore bbdays. bbEach bbhospital bbsurvey bbteam bbwill bbinclude bbat bbleast
bbone bbRN bbwith bbhospital bbsurvey bbexperience, bbas bbwell bbas bbother bbsurveyors
bbwho bbhave bbthe bbexpertise bbneeded bbto bbdetermine bbwhether bbthe bbfacility bbis bbin
bbcompliance. bbSurvey bbteam bbsize bband bbcomposition bbare bbnormally bbbased bbon
bbthe bbfollowing bbfactors: bb
,• bbSize bbof bbthe bbfacility bbto bbbe bbsurveyed, bbbased bbon bbaverage bbdaily bbcensus; bb
• bbComplexity bbof bbservices bboffered, bbincluding bboutpatient bbservices; bb
• bbType bbof bbsurvey bbto bbbe bbconducted; bb
• bbWhether bbthe bbfacility bbhas bbspecial bbcare bbunits bbor bboff-site bbclinics bbor
bblocations; bb
• bbWhether bbthe bbfacility bbhas bba bbhistorical bbpattern bbof bbserious bbdeficiencies bbor
bbcomplaints; bband bb
• bbWhether bbnew bbsurveyors bbare bbto bbaccompany bba bbteam bbas bbpart bbof bbtheir
bbtraining
Certification bbProcess bb- bbAnswer bbAll bbhospital bbsurveys bbare bbunannounced.
bbHospitals bbare bbnot bbprovided bbwith bbadvance bbnotice bbof bbthe bbsurvey.
Certification bbProcess bb- bbAnswer bbSURVEY bbACTIVITIES bb
Arrival bbby bbthe bbSurvey bbTeam bb
The bbentire bbsurvey bbteam bbshould bbenter bbthe bbhospital bbtogether. bbUpon bbarrival,
bbsurveyors bbshould bbpresent bbtheir bbidentification. bbThe bbteam bbcoordinator bbshould
bbannounce bbto bbthe bbAdministrator, bbor bbwhoever bbis bbin bbcharge, bbthat bba bbsurvey
bbis bbbeing bbconducted. bbIf bbthe bbAdministrator bb(or bbperson bbin bbcharge) bbis bbnot
bbonsite bbor bbavailable bb(e.g., bbif bbthe bbsurvey bbbegins bboutside bbnormal bbdaytime
bbMonday-Friday bbworking bbhours), bbthey bbwill bbask bbthat bbthe bbAdministrator bbbe
bbnotified bbthat bba bbsurvey bbis bbbeing bbconducted. bbThe bbsurvey bbwill bbnot bbbe
bbdelayed bbbecause bbthe bbAdministrator bbor bbother bbhospital bbstaff bbis/are bbnot bbon
bbsite bbor bbavailable.
Certification bbProcess bb- bbAnswer bbSurvey bbSchedule bb
Unlike bbthe bbdeemed-status bbagencies, bbCMS bbdoes bbnot bbprovide bba bbtemplate bbor
bblikely bbsurvey bbschedule bbto bbhospitals. bbThe bbTeam bbCoordinator bbworks bbwith
bbthe bbother bbsurveyors bbto bbdetermine bbwhere bband bbwhen bbvarious bbactivities bbwill
bbtake bbplace. bbThere bbis bbno bbset bbagenda bbor bbschedule bbof bbactivities. bbThe
bbamount bbof bbtime bbspent bbin bban bbarea bband bbthe bbspecific bbactivities bbthat bboccur
bbin bban bbarea bbare bbleft bbto bbthe bbsurveyor's bbdiscretion.
Certification bbProcess bb- bbAnswer bbThe bbnumber bbof bbpatient bbrecords bbreviewed bbis
bbbased bbon bbthe bbfacility's bbaverage bbdaily bbcensus. bbThe bbsample bbshould bbbe bbat
bbleast bb10 bbpercent bbof bbthe bbaverage bbdaily bbcensus, bbbut bbnot bbfewer bbthan bb30
bbinpatient bbrecords.
Certification bbProcess bb- bbAnswer bbThe bbnumber bbof bbpatient bbrecords bbreviewed bbis
bbbased bbon bbthe bbfacility's bbaverage bbdaily bbcensus. bbThe bbsample bbshould bbbe bbat
bbleast bb10 bbpercent bbof bbthe bbaverage bbdaily bbcensus, bbbut bbnot bbfewer bbthan bb30
bbinpatient bbrecords.
Certification bbProcess bb- bbAnswer bbOn bbany bbMedicare bbhospital bbsurvey,
bbcontracted bbpatient bbcare bbactivities bbor bbpatient bbservices bb(such bbas bbdietary
bbservices, bbtreatment bbservices, bbdiagnostic bbservices, bbetc.) bblocated bbon bbhospital
, bbcampuses bbor bbhospital bbprovider bbbased bblocations bbwill bbbe bbsurveyed bbas bbpart
bbof bbthe bbhospital bbfor bbcompliance bbwith bbthe bbconditions bbof bbparticipation.
Certification bbProcess bb- bbAnswer bbA bbdeficiency bbat bbthe bbCondition bblevel bbmay
bbbe bbdue bbto bbnoncompliance bbwith bbrequirements bbin bba bbsingle bbstandard bbor
bbseveral bbstandards bbwithin bbthe bbcondition bbor bbwith bbrequirements bbof
bbnoncompliance bbwith bba bbsingle bbpart bb(tag) bbrepresenting bba bbsevere bbor bbcritical
bbhealth bbor bbsafety bbbreach. bbEven bba bbseemingly bbsmall bbbreach bbin bbcritical
bbactions bbor bbat bbcritical bbtimes bbcan bbkill bbor bbseverely bbinjure bba bbpatient, bband
bbrepresents bba bbcritical bbor bbsevere bbhealth bbor bbsafety bbthreat.
Certification bbProcess bb- bbAnswer bbTHE bbCMS bbPLAN bbOF bbCORRECTION bb
Following bbthe bbsurvey bba bbstatement bbof bbdeficiencies bb(Form bbCMS-2567) bbwill
bbbe bbmailed bbwithin bb10 bbworking bbdays bbto bbthe bbhospital. bbForm bbCMS-2567 bbis
bbthe bbdocument bbdisclosed bbto bbthe bbpublic bbabout bbthe bbhospital's bbdeficiencies
bband bbwhat bbis bbbeing bbdone bbto bbremedy bbthem.
Certification bbProcess bb- bbAnswer bbThe bbhospital bbis bbrequired bbto bbsubmit bba
bbwritten bbplan bbof bbcorrection bbto bbthe bbsurvey bbagency bbwithin bb10 bbcalendar
bbdays bbfollowing bbreceipt bbof bbthe bbwritten bbstatement bbof bbdeficiencies. bbThe bbplan
bbof bbcorrection bbis bbsubmitted bbon bbthe bbForm bbCMS-2567. bbThe bbrequired
bbcharacteristics bbof bba bbplan bbof bbcorrection bbinclude: bb
• bbCorrective bbaction bbto bbbe bbtaken bbfor bbeach bbindividual bbaffected bbby bbthe
bbdeficient bbpractice, bbincluding bbany bbsystem bbchanges bbthat bbmust bbbe bbmade; bb
• bbThe bbposition bbof bbthe bbperson bbwho bbwill bbmonitor bbthe bbcorrective bbaction bband
bbthe bbfrequency bbof bbmonitoring; bb
• bbDates bbeach bbcorrective bbaction bbwill bbbe bbcompleted; bb
• bbThe bbadministrator bbor bbappropriate bbindividual bbmust bbsign bband bbdate bbthe
bbForm bbCMS-2567 bbbefore bbreturning bbit bbto bbthe bbsurvey bbagency; bband bb
• bbThe bbsubmitted bbplan bbof bbcorrection bbmust bbmeet bbthe bbapproval bbof bbthe bbState
bbagency, bbor bbin bbsome bbcases bbthe bbCMS bbRegional bbOffice bbfor bbit bbto bbbe
bbacceptable.
Condition bbof bbParticipation: bbGovernance bb- bbAnswer bbIf bba bbhospital bbsystem bbhas
bbchosen bbto bbhave bbone bbbody bbact bbas bbthe bbgoverning bbbody bbfor bbmultiple
bbseparately bbcertified bbhospitals, bbthis bbdoes bbnot bbalter bbthe bbfact bbthat bbeach
bbhospital bbmust bbseparately bbdemonstrate bbcompliance bbwith bbthe bbCoPs. bbEach
bbseparately bbcertified bbhospital bbmust bbbe bbseparately bband bbindependently
bbassessed bbfor bbits bbcompliance bbwith bbthe bbCoPs, bbthrough bbeither bbState bbSurvey
bbAgency bbor bbapproved bbnational bbaccreditation bbprogram bbsurveys. bbThere bbis bbno
bbsurvey bbof bba bbhospital bb"system," bbsince bbthe bbMedicare bbagreement bband bbits
bbterms bbare bbspecific bbto bbeach bbcertified bbhospital.
Condition bbof bbParticipation: bbGovernance bb- bbAnswer bbThe bbgoverning bbbody bbmust
bbtake bbactions bbthrough bbthe bbhospital's bbQAPI bbprogram bbto: bb
