CHC PRACTICE QUESTIONS
(SCENARIOS) COMPLETE
QUESTIONS AND DETAILED
SOLUTIONS
A compliance professional has been working with a department director to implem
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ent a new policy regarding timely completion of medical records. Which of the follo
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wing should be completed by the department manager to promote compliance with
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the new policy?
ex ex ex
a. Statistically valid sampling audit
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b. Monitoring
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c. Discovery Audit
ex ex
d. Retrospective Audit - ANSWERS-b. Monitoring
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For monitoring activities, OIG uses the term regularly to describe the frequency of
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review. Which factors should an organization consider when establishing a frequen
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cy schedule for monitoring:
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a. Timing of staff job performance evaluations, how often compliance training is pr
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ovided, whenever computer upgrades occur, and how many new employees were
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hired in the target department.
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b. Size of organization, frequency of the activity being monitored, past incidences
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of misconduct, and current/future investigations.
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c. Whether organization used internal or external counsel, timing of the annual fina
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ncial audit, and number of hotline calls received. - ANSWERS-
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b. Size of organization, frequency of the activity being monitored, past incidences
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of misconduct, and current/future investigations.
ex ex ex ex
Ref. Healthcare Compliance Professional's Manual
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What is an important first step in creating a compliance team or improving the effe
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ctiveness of an existing one? ex ex ex ex ex
a) Making sure senior management has the time and other resources necessary to
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promote and carry out compliance improvements
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b) Give the CCO the authority to reconcile, standardize, and modify policies where
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appropriate.
x ex
c) Place the organization's CCO on the senior management team
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d) None of the above - ANSWERS-
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c) Place the organization's CCO on the senior management team.
ex ex ex ex ex ex ex ex ex
Explanation: This comes straight form Chapter 1 of the Auditing and Monitoring bo
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ok 2nd ed. Without being placed on the senior management team, the CCO is una
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ble to effectively carry out the duties and responsibilities of the office.
ex ex ex ex ex ex ex ex ex ex ex
,An employee has violated the non-
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retaliation policy, he has spread rumors about employee who reported him. The co
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mpliance professional's first action is to:
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a. Create formal hearing for the violator
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b. Pursue legal consequence against violator before pursuing work consequences
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c. Recommend disciplinary actions against the violator of the non-retaliation policy
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d. Dismiss both employees from work - ANSWERS-
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c. Recommend disciplinary actions against the violator of the non-retaliation policy
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There is no established template for documenting compliance risks. Each organizat
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ion should develop a Risk Assessment that fits its risk profile. The components tha
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t are commonly used throughout the industry are as follows EXCEPT:
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a. Risk Assessment
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b. Measuring key risk indicators
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c. Identifying key performance indicators
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d. Training the leadership of compliance regulation program - ANSWERS-
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d. Training the leadership of compliance regulation program
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Ref. ABA CRCM (certified regulatory compliance manager)
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After a compliance officer develops a base of knowledge, he/
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she must begin the art of applying regulations in a risk management environment.
ex ex ex ex ex ex ex ex ex ex ex ex ex
Which of the following is NOT out of a few things to be kept in mind when determi
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ning what to do FIRST?
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a. think practically about your role as an advisor, involve all department units in the
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decision process rather than making decisions from them
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b. calculate the organization's consolidated risk profile
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c. make sure you understand the level of risk that the organization will tolerate, so
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decisions do not exceed this limit ex ex ex ex ex
d. add value by analyzing regulatory requirements for the department units before
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you present proposed/final rules or solutions - ANSWERS-
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b. calculate the organization's consolidated risk profile (determine risk tolerance)
ex ex ex ex ex ex ex ex ex
Ref. ABA CRCM (certified regulatory compliance manager)
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To be effective, compliance risk management professionals must design a framew
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ork to ensure that management understands the risks and steps to take to mitigate
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them. The many roles compliance professionals fill incorporate risk management a
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spects including: ex
a. overseeing compliance training targeting higher risk areas
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b. tracking regulatory proposals or final rules to understand new risks
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c. both a and b - ANSWERS-c. both a and b
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Ref. ABA CRCM (certified regulatory compliance manager)
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After an investigation, it was discovered that the organization's reputation is at stak
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e. What should a Compliance Professional do next?
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A. Report the findings to the board
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B. Contact legal counsel
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C. Advise the CEO and recommend next steps
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, D. Self-disclose to the OIG - ANSWERS-B. Contact legal counsel
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The compliance officer has completed the non-
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retaliation policy and it's been officially implemented. The next steps should be:
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a. Investigate all reports of violations
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b. Post the information publicly in the internet
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c. Make the information available to hospital employees
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d. Revise it annually - ANSWERS-
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c. Make the information available to hospital employees
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If during the course of an internal investigation, the compliance officer believes the
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xintegrity of the investigation might be compromised by the continued presence of
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work force members who are the subject of the investigation. In the best interest of
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
exthe attorney-client privilege, which action would you take?
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a. Conduct employee background checks
ex ex ex ex
b. Counsel obtains employee's depositions
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c. Destroy documents and other evidence
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d. Re-assign employees to other responsibilities until the investigation is completed
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e. All of the above - ANSWERS-d. Re-
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assign employees to other responsibilities until the investigation is completed.
ex ex ex ex ex ex ex ex ex
Explanation: he/ ex
she should recommend that such individuals be temporarily removed from their cur
ex ex ex ex ex ex ex ex ex ex ex
rent responsibilities until the investigation is completed.
ex ex ex ex ex ex
Ref. Healthcare Compliance Professional's Manual
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The privacy officer for a hospital has updated the Notice of Privacy Practices/
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NPP to reflect a material change because the previous notice did not have a descr
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iption that individuals have the right to amend their PHI. The 3rd party review team
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
exidentified that the NPP did not have the required information to let individuals kno
ex ex ex ex ex ex ex ex ex ex ex ex ex
w of their right to amend PHI. What's the BEST course of action to correct deficien
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cy?
A. Make arrangements to mail the new NPP mailed to all patients seen within the l
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
ast year at the hospital
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B. Make arrangements to have the new NPP distributed to new patients that come
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xto the hospital
ex ex
C. Post a copy of the new NPP on the hospital's internal intranet so that all emplo
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
yees can see the updated version of the notice
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D. Meet with legal to discuss how to best self-
ex ex ex ex ex ex ex ex ex
disclose to OCR that the hospital was in violation of the NPP requirements and ha
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s since corrected the deficiency - ANSWERS-
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B. Make arrangements to have the new NPP distributed to new patients that come
ex ex ex ex ex ex ex ex ex ex ex ex ex e
xto the hospital
ex ex
The NPP must describe the following individual rights: https://
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www.law.cornell.edu/cfr/text/45/164.520
• The right to request restrictions on uses or disclosures of PHI for treatment, pay
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ment or healthcare operations; for use in a facility directory (if applicable); or to fa
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
mily members and others involved in the patient's care; however, the provider is n
ex ex ex ex ex ex ex ex ex ex ex ex ex
(SCENARIOS) COMPLETE
QUESTIONS AND DETAILED
SOLUTIONS
A compliance professional has been working with a department director to implem
ex ex ex ex ex ex ex ex ex ex ex
ent a new policy regarding timely completion of medical records. Which of the follo
ex ex ex ex ex ex ex ex ex ex ex ex ex
wing should be completed by the department manager to promote compliance with
ex ex ex ex ex ex ex ex ex ex ex
the new policy?
ex ex ex
a. Statistically valid sampling audit
ex ex ex ex
b. Monitoring
ex ex
c. Discovery Audit
ex ex
d. Retrospective Audit - ANSWERS-b. Monitoring
ex ex ex ex ex
For monitoring activities, OIG uses the term regularly to describe the frequency of
ex ex ex ex ex ex ex ex ex ex ex ex ex
review. Which factors should an organization consider when establishing a frequen
ex ex ex ex ex ex ex ex ex ex
cy schedule for monitoring:
ex ex ex
a. Timing of staff job performance evaluations, how often compliance training is pr
ex ex ex ex ex ex ex ex ex ex ex ex
ovided, whenever computer upgrades occur, and how many new employees were
ex ex ex ex ex ex ex ex ex ex ex
hired in the target department.
ex ex ex ex
b. Size of organization, frequency of the activity being monitored, past incidences
ex ex ex ex ex ex ex ex ex ex ex ex
of misconduct, and current/future investigations.
ex ex ex ex
c. Whether organization used internal or external counsel, timing of the annual fina
ex ex ex ex ex ex ex ex ex ex ex ex
ncial audit, and number of hotline calls received. - ANSWERS-
ex ex ex ex ex ex ex ex ex
b. Size of organization, frequency of the activity being monitored, past incidences
ex ex ex ex ex ex ex ex ex ex ex ex
of misconduct, and current/future investigations.
ex ex ex ex
Ref. Healthcare Compliance Professional's Manual
ex ex ex ex
What is an important first step in creating a compliance team or improving the effe
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
ctiveness of an existing one? ex ex ex ex ex
a) Making sure senior management has the time and other resources necessary to
ex ex ex ex ex ex ex ex ex ex ex ex
promote and carry out compliance improvements
ex ex ex ex ex ex
b) Give the CCO the authority to reconcile, standardize, and modify policies where
ex ex ex ex ex ex ex ex ex ex ex ex e
appropriate.
x ex
c) Place the organization's CCO on the senior management team
ex ex ex ex ex ex ex ex ex ex
d) None of the above - ANSWERS-
ex ex ex ex ex ex
c) Place the organization's CCO on the senior management team.
ex ex ex ex ex ex ex ex ex
Explanation: This comes straight form Chapter 1 of the Auditing and Monitoring bo
ex ex ex ex ex ex ex ex ex ex ex ex
ok 2nd ed. Without being placed on the senior management team, the CCO is una
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
ble to effectively carry out the duties and responsibilities of the office.
ex ex ex ex ex ex ex ex ex ex ex
,An employee has violated the non-
ex ex ex ex ex
retaliation policy, he has spread rumors about employee who reported him. The co
ex ex ex ex ex ex ex ex ex ex ex ex
mpliance professional's first action is to:
ex ex ex ex ex
a. Create formal hearing for the violator
ex ex ex ex ex ex
b. Pursue legal consequence against violator before pursuing work consequences
ex ex ex ex ex ex ex ex ex
c. Recommend disciplinary actions against the violator of the non-retaliation policy
ex ex ex ex ex ex ex ex ex ex
d. Dismiss both employees from work - ANSWERS-
ex ex ex ex ex ex ex
c. Recommend disciplinary actions against the violator of the non-retaliation policy
ex ex ex ex ex ex ex ex ex ex
There is no established template for documenting compliance risks. Each organizat
ex ex ex ex ex ex ex ex ex ex
ion should develop a Risk Assessment that fits its risk profile. The components tha
ex ex ex ex ex ex ex ex ex ex ex ex ex
t are commonly used throughout the industry are as follows EXCEPT:
ex ex ex ex ex ex ex ex ex ex
a. Risk Assessment
ex ex
b. Measuring key risk indicators
ex ex ex ex
c. Identifying key performance indicators
ex ex ex ex
d. Training the leadership of compliance regulation program - ANSWERS-
ex ex ex ex ex ex ex ex ex
d. Training the leadership of compliance regulation program
ex ex ex ex ex ex ex
Ref. ABA CRCM (certified regulatory compliance manager)
ex ex ex ex ex ex
After a compliance officer develops a base of knowledge, he/
ex ex ex ex ex ex ex ex ex
she must begin the art of applying regulations in a risk management environment.
ex ex ex ex ex ex ex ex ex ex ex ex ex
Which of the following is NOT out of a few things to be kept in mind when determi
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
ning what to do FIRST?
ex ex ex ex
a. think practically about your role as an advisor, involve all department units in the
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
decision process rather than making decisions from them
ex ex ex ex ex ex ex ex
b. calculate the organization's consolidated risk profile
ex ex ex ex ex ex
c. make sure you understand the level of risk that the organization will tolerate, so
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
decisions do not exceed this limit ex ex ex ex ex
d. add value by analyzing regulatory requirements for the department units before
ex ex ex ex ex ex ex ex ex ex ex ex
you present proposed/final rules or solutions - ANSWERS-
ex ex ex ex ex ex ex
b. calculate the organization's consolidated risk profile (determine risk tolerance)
ex ex ex ex ex ex ex ex ex
Ref. ABA CRCM (certified regulatory compliance manager)
ex ex ex ex ex ex
To be effective, compliance risk management professionals must design a framew
ex ex ex ex ex ex ex ex ex ex
ork to ensure that management understands the risks and steps to take to mitigate
ex ex ex ex ex ex ex ex ex ex ex ex ex
them. The many roles compliance professionals fill incorporate risk management a
ex ex ex ex ex ex ex ex ex ex ex
spects including: ex
a. overseeing compliance training targeting higher risk areas
ex ex ex ex ex ex ex
b. tracking regulatory proposals or final rules to understand new risks
ex ex ex ex ex ex ex ex ex ex
c. both a and b - ANSWERS-c. both a and b
ex ex ex ex ex ex ex ex ex ex
Ref. ABA CRCM (certified regulatory compliance manager)
ex ex ex ex ex ex
After an investigation, it was discovered that the organization's reputation is at stak
ex ex ex ex ex ex ex ex ex ex ex ex
e. What should a Compliance Professional do next?
ex ex ex ex ex ex ex
A. Report the findings to the board
ex ex ex ex ex ex
B. Contact legal counsel
ex ex ex
C. Advise the CEO and recommend next steps
ex ex ex ex ex ex ex
, D. Self-disclose to the OIG - ANSWERS-B. Contact legal counsel
ex ex ex ex ex ex ex ex ex
The compliance officer has completed the non-
ex ex ex ex ex ex
retaliation policy and it's been officially implemented. The next steps should be:
ex ex ex ex ex ex ex ex ex ex ex
a. Investigate all reports of violations
ex ex ex ex ex
b. Post the information publicly in the internet
ex ex ex ex ex ex ex
c. Make the information available to hospital employees
ex ex ex ex ex ex ex
d. Revise it annually - ANSWERS-
ex ex ex ex ex
c. Make the information available to hospital employees
ex ex ex ex ex ex ex
If during the course of an internal investigation, the compliance officer believes the
ex ex ex ex ex ex ex ex ex ex ex ex e
xintegrity of the investigation might be compromised by the continued presence of
ex ex ex ex ex ex ex ex ex ex ex ex
work force members who are the subject of the investigation. In the best interest of
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
exthe attorney-client privilege, which action would you take?
ex ex ex ex ex ex ex
a. Conduct employee background checks
ex ex ex ex
b. Counsel obtains employee's depositions
ex ex ex ex
c. Destroy documents and other evidence
ex ex ex ex ex
d. Re-assign employees to other responsibilities until the investigation is completed
ex ex ex ex ex ex ex ex ex ex
e. All of the above - ANSWERS-d. Re-
ex ex ex ex ex ex ex
assign employees to other responsibilities until the investigation is completed.
ex ex ex ex ex ex ex ex ex
Explanation: he/ ex
she should recommend that such individuals be temporarily removed from their cur
ex ex ex ex ex ex ex ex ex ex ex
rent responsibilities until the investigation is completed.
ex ex ex ex ex ex
Ref. Healthcare Compliance Professional's Manual
ex ex ex ex
The privacy officer for a hospital has updated the Notice of Privacy Practices/
ex ex ex ex ex ex ex ex ex ex ex ex
NPP to reflect a material change because the previous notice did not have a descr
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
iption that individuals have the right to amend their PHI. The 3rd party review team
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
exidentified that the NPP did not have the required information to let individuals kno
ex ex ex ex ex ex ex ex ex ex ex ex ex
w of their right to amend PHI. What's the BEST course of action to correct deficien
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
cy?
A. Make arrangements to mail the new NPP mailed to all patients seen within the l
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
ast year at the hospital
ex ex ex ex
B. Make arrangements to have the new NPP distributed to new patients that come
ex ex ex ex ex ex ex ex ex ex ex ex ex e
xto the hospital
ex ex
C. Post a copy of the new NPP on the hospital's internal intranet so that all emplo
ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex ex
yees can see the updated version of the notice
ex ex ex ex ex ex ex ex
D. Meet with legal to discuss how to best self-
ex ex ex ex ex ex ex ex ex
disclose to OCR that the hospital was in violation of the NPP requirements and ha
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
s since corrected the deficiency - ANSWERS-
ex ex ex ex ex ex
B. Make arrangements to have the new NPP distributed to new patients that come
ex ex ex ex ex ex ex ex ex ex ex ex ex e
xto the hospital
ex ex
The NPP must describe the following individual rights: https://
ex ex ex ex ex ex ex ex
www.law.cornell.edu/cfr/text/45/164.520
• The right to request restrictions on uses or disclosures of PHI for treatment, pay
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
ment or healthcare operations; for use in a facility directory (if applicable); or to fa
ex ex ex ex ex ex ex ex ex ex ex ex ex ex
mily members and others involved in the patient's care; however, the provider is n
ex ex ex ex ex ex ex ex ex ex ex ex ex
