NAHQ CPHQ Practice Exam

A former patient emails an organization's chief executive officer complimenting the friendliness of the nurses while complaining that her pain was not well-managed. To comply with Centers for Medicare and Medicaid Services (CMS) Conditions of Participation, what actions are needed?

1. Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council

2. Interview staff involved, track performance over time, and report to the Quality Council

3. Investigate the complaint, write the patient, and report to the governing board

4. Review the medical record, put compliments and complaints in the appropriate staff personnel records, and report to the governing board

The correct answer is: Call the patient, put compliments in the nurses' personnel records, and report to the Quality Council

In this scenario, the correct answer is to call the patient, put compliments in the nurses' personnel records, and report to the Quality Council. This action addresses the patient's feedback by acknowledging the compliments received and also ensures that the positive feedback is appropriately documented in the nurses' personnel records. Additionally, reporting to the Quality Council allows for a systematic review of the patient feedback to identify any potential quality improvement opportunities. Options B and D focus more on documenting staff performance and feedback, but they do not specifically address the need to directly contact the patient to acknowledge their feedback. Option C does not emphasize the importance of recording the compliments in the appropriate personnel records or reporting to the Quality Council, which are essential steps in complying with CMS Conditions of Participation.