1. Which of the following is an activity likely to occur during a Joint Commission survey?

1. Competency assessment review
2. Review of survey planning documents
3. Building tour
4. Patient tracers
5. All of the Above

2. How many days does an organization have to complete a thorough and credible root cause analysis in response to a sentinel event?

1. 30 days
2. 45 days
3. 90 days
4. 120 days
5. None of the above

3. Which of the following statements regarding the provision of informed consent is true?

1. Informed consent must be obtained prior to the performance of operative and complex invasive procedures.
2. Informed consent must include information regarding reasonable alternatives to the proposed care, treatment, and service
3. Informed consent is not required to be documented into the medical record
   
4. A and B only
5. A and C only

4. According to CMS, which of the following would be considered use of chemical restraint?

1. The medication is used within the pharmaceutical parameters approved by the Food and Drug Administration (FDA) and the manufacturer for the indications it is manufactured and labeled to address, including listed dosage parameters.
2. The use of the medication follows national practice standards established or recognized by the medical community and/or professional medical association or organization.
3. The use of the medication to treat a specific patient s clinical condition is based on that patient’s symptoms, overall clinical situation, and on the physician’s or other LIP’ knowledge of that patient’s expected and actual response to the medication
4. The use of PRN medications to limit a patient’s mobility and access to his or her body
5. None of the above

5. Which of the following statements regarding Joint Commission requirements for medication orders is false?

1. Preprinted order sheets must be reviewed and updated as needed to support clarity, accuracy, and safety
2. Blanket reinstatement of medication orders is permissible when transferring a patient to different level of care and no changes to the patient’s medications have been made.
3. The organization must define in writing when weight-based dosing for pediatric patients is required
4. The organization must define whether and when an indication for use is required as part of a medication order
5. None of the above

6. A hospital would be considered in compliance with Joint Commission standards regarding advance directives if they did all of the following except:

1. Ignore a patient’s wishes regarding organ donation since this is not an advance directive.
2. Help or refer the patient for assistance in formulating advance directives upon request
3. Assure that the existence or lack of an advance directive does not determine an individual’s access to care
4. Provide the patient with the option to review or revise their directive
5. Allow a patient to verbally provide an advance directive

7. Joint Commission requires environmental tour in areas where individuals are served:

1. Every six months
2. Every eight months
3. At least once a year
4. At least once in an accreditation cycle
5. None of the above

8. According to CMS, all entries into the medical record must be:

1. Signed, dated, and timed
2. Signed and dated only
3. Signed, dated, and only timed if timing is necessary to appropriately document the care provide.
4. Signed and only dated and timed if it is the first entry of the day
5. None of the above

9. Which of the following is not considered an unacceptable (prohibited) abbreviation by the Joint Commission?

1. U
2. QD
3. HS
4. MS
5. MGSO4

10. Which of the following statements regarding the focused professional practice evaluation of a physician is true?

1. There must be a period of focused evaluation for all newly granted privileges
2. There must be concurrent monitoring of physician practice regardless of the type of privilege requested
3. The medical staff must develop criteria that govern the length and type of focus review to be conducted
4. Both A & C
5. All of the above