CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
1. True or False: According to The Joint Commission, the applicant's ability
to perform privileges requested must be evaluated and this evaluation must
be documented in the credentials file.: True
2. According to HFAP - information regarding ability to perform is
requested for each
a. Applicant
b. Applicant & Re-applicant
c. Re-applicant: Applicant & Reapplicant
3. True or False: According to HFAP for re-applicants, information
regarding ability to perform can come from peers familiar with their
practice or peer reviews only.: False - can also come from Credentials, MEC,
or Dept. Chair
4. What accrediting body requires a signed and dated attestation from
the applicant regarding the reasons for any inability to perform the
essential functions of the position, with or without accommodation, and
the lack of present drug use?
a. NCQA
b. URAC
c. CMS: NCQA
5. True or False: According to the Joint Commission the applicant must
submit a statement that no health problems exist that could affect the
exercise of clinical privileges: True
6. True or False: According to NCQA the attestation statement from the
appli- cant must be signed and dated: True
7. True or False: NCQA requires a current and signed attestation from the
applicant regarding reasons for inability to perform the essential functions
of the position with or without accommodation and lack of drug use: True
8. True or False: According to The Joint Commission the statement
submitted by the provider should be confirmed by a program director, chief
of services, or chief of staff from another hospital where the applicant holds
privileges, or and MD/DO approved by the medical staff: True
9. True or False: According to the Joint Commission, the medical staff can
require the applicant to undergo internal/external evaluation prior to
recom- mending privileges?: True
10. True or False: According to HFAP, peer references should include a
state- ment regarding the physician's physical and mental health in relation
to privileges requested: True
11. Although not specifically addressed in DNV standards (ability to perform)
Surveyor guidance instructs surveyors to
, CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
a. Ensure the hospital performs PSV
, CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
b. Validate the hospital's method for reviewing practitioner's surgical privi-
leges to determine if the process includes required verification of
practitioner training, experience, health status, and performance
c. Validate the hospital's method for reviewing practitioner performance re-
gardless of surgical privileges: Validate the hospital's method for reviewing
prac- titioner's surgical privileges to determine if the process includes required
verification of practitioner training, experience, health status, and performance
12. What accrediting body states that surgical privileges shall correspond
with the established competencies of each practitioner?
a. URAC
b. TJC
c. DNV: DNV
13. True or False: According to URAC, it is optional for the application to
include disclosure of any physical, mental, or substance abuse issues that
could without reasonable accommodation impede the practitioner's ability
to provide care.: False
14. This accrediting body uses the language "substance abuse" in their
stan- dard regarding ability to perform
a. NCQA
b. AAAHC
c. URAC: URAC
15. This accrediting body uses the language "chemical dependency" in
their standard regarding ability to perform
a. AAAHC
b. URAC
c. NCQA: AAAHC
16. At what time(s) does AAAHC consider ability to perform?
a. Initial and Reappointment
b. Reappointment
c. Initial Appointment: Initial and Reappointment
17. What accrediting body/regulatory agency does not specifically address
the ability to perform, but instructs surveyors to "Review the hospital's
method for reviewing the surgical privileges of practitioners. This method
should require a written assessment of the practitioner's training,
experience, health status, and performance."
a. DNV
b. TJC
c. CMS COPs: CMS COPs
, CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
18. True or False: The Joint Commission uses the term "allied health
profes- sional" in their standards: False
19. What accrediting body requires qualifications and competence of
non physician's to be assessed prior to providing care?
a. HFAP
b. The Joint Commission
c. URAC: The Joint Commission
20. True or False: According to the Joint Commission, non-employed
providers that provide care at the same frequency as employed providers
must be evaluated: True
21. True or False: According to the Joint Commission all LIP PA's and
APRNs who provide medical care must be credentialed through the medical
staff process.: True
22. True or False: According to the Joint Commission all LIP PA's and
APRNs who DO NOT provide medical care must be credentialed through the
medical staff process.: False
23. According to the Joint Commission, the equivalent medical staff
process for non-physicians must be approved by
a. Credentials Committee
b. Medical Executive Committee
c. Governing Board: Governing Board
24. True or False: According to NCQA non physician practitioners who have
an independent relationship with the organization and provide care under
the medical benefit must be credentialed: True
25. HFAP standards regarding Allied Health/Non Physicians are a direct
quote from what regulatory agency?
a. The Joint Commission
b. CMS Managed Care Manual
c. CMS COPs: CMS COPs
26. True or False: According to DNV standards, the medical staff is able to
be comprised soley of allied health professionals: False
27. True or False: According to DNV standards, the governing body does
not approve staff categories in accordance with state and scope of
practice laws: False
28. True or False: According to DNV standards, patients can only be under
the care of a member of the medical staff: False
29. True or False: According to DNV standards patients can be under the
care of a practitioner who is directly under the supervision of a member of
the medical staff: True
Rules+Practice Exams)
1. True or False: According to The Joint Commission, the applicant's ability
to perform privileges requested must be evaluated and this evaluation must
be documented in the credentials file.: True
2. According to HFAP - information regarding ability to perform is
requested for each
a. Applicant
b. Applicant & Re-applicant
c. Re-applicant: Applicant & Reapplicant
3. True or False: According to HFAP for re-applicants, information
regarding ability to perform can come from peers familiar with their
practice or peer reviews only.: False - can also come from Credentials, MEC,
or Dept. Chair
4. What accrediting body requires a signed and dated attestation from
the applicant regarding the reasons for any inability to perform the
essential functions of the position, with or without accommodation, and
the lack of present drug use?
a. NCQA
b. URAC
c. CMS: NCQA
5. True or False: According to the Joint Commission the applicant must
submit a statement that no health problems exist that could affect the
exercise of clinical privileges: True
6. True or False: According to NCQA the attestation statement from the
appli- cant must be signed and dated: True
7. True or False: NCQA requires a current and signed attestation from the
applicant regarding reasons for inability to perform the essential functions
of the position with or without accommodation and lack of drug use: True
8. True or False: According to The Joint Commission the statement
submitted by the provider should be confirmed by a program director, chief
of services, or chief of staff from another hospital where the applicant holds
privileges, or and MD/DO approved by the medical staff: True
9. True or False: According to the Joint Commission, the medical staff can
require the applicant to undergo internal/external evaluation prior to
recom- mending privileges?: True
10. True or False: According to HFAP, peer references should include a
state- ment regarding the physician's physical and mental health in relation
to privileges requested: True
11. Although not specifically addressed in DNV standards (ability to perform)
Surveyor guidance instructs surveyors to
, CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
a. Ensure the hospital performs PSV
, CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
b. Validate the hospital's method for reviewing practitioner's surgical privi-
leges to determine if the process includes required verification of
practitioner training, experience, health status, and performance
c. Validate the hospital's method for reviewing practitioner performance re-
gardless of surgical privileges: Validate the hospital's method for reviewing
prac- titioner's surgical privileges to determine if the process includes required
verification of practitioner training, experience, health status, and performance
12. What accrediting body states that surgical privileges shall correspond
with the established competencies of each practitioner?
a. URAC
b. TJC
c. DNV: DNV
13. True or False: According to URAC, it is optional for the application to
include disclosure of any physical, mental, or substance abuse issues that
could without reasonable accommodation impede the practitioner's ability
to provide care.: False
14. This accrediting body uses the language "substance abuse" in their
stan- dard regarding ability to perform
a. NCQA
b. AAAHC
c. URAC: URAC
15. This accrediting body uses the language "chemical dependency" in
their standard regarding ability to perform
a. AAAHC
b. URAC
c. NCQA: AAAHC
16. At what time(s) does AAAHC consider ability to perform?
a. Initial and Reappointment
b. Reappointment
c. Initial Appointment: Initial and Reappointment
17. What accrediting body/regulatory agency does not specifically address
the ability to perform, but instructs surveyors to "Review the hospital's
method for reviewing the surgical privileges of practitioners. This method
should require a written assessment of the practitioner's training,
experience, health status, and performance."
a. DNV
b. TJC
c. CMS COPs: CMS COPs
, CPCS 2022 Fall Study (Accred Grid+Roberts
Rules+Practice Exams)
18. True or False: The Joint Commission uses the term "allied health
profes- sional" in their standards: False
19. What accrediting body requires qualifications and competence of
non physician's to be assessed prior to providing care?
a. HFAP
b. The Joint Commission
c. URAC: The Joint Commission
20. True or False: According to the Joint Commission, non-employed
providers that provide care at the same frequency as employed providers
must be evaluated: True
21. True or False: According to the Joint Commission all LIP PA's and
APRNs who provide medical care must be credentialed through the medical
staff process.: True
22. True or False: According to the Joint Commission all LIP PA's and
APRNs who DO NOT provide medical care must be credentialed through the
medical staff process.: False
23. According to the Joint Commission, the equivalent medical staff
process for non-physicians must be approved by
a. Credentials Committee
b. Medical Executive Committee
c. Governing Board: Governing Board
24. True or False: According to NCQA non physician practitioners who have
an independent relationship with the organization and provide care under
the medical benefit must be credentialed: True
25. HFAP standards regarding Allied Health/Non Physicians are a direct
quote from what regulatory agency?
a. The Joint Commission
b. CMS Managed Care Manual
c. CMS COPs: CMS COPs
26. True or False: According to DNV standards, the medical staff is able to
be comprised soley of allied health professionals: False
27. True or False: According to DNV standards, the governing body does
not approve staff categories in accordance with state and scope of
practice laws: False
28. True or False: According to DNV standards, patients can only be under
the care of a member of the medical staff: False
29. True or False: According to DNV standards patients can be under the
care of a practitioner who is directly under the supervision of a member of
the medical staff: True
