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 aligns with the CMS Conditions of Participation as it addresses both the positive feedback received from the patient (acknowledging the friendly nurses) and the area of improvement identified (pain management). By documenting the compliments in the nurses' personnel records, the organization recognizes and reinforces positive behaviors. Additionally, reporting to the Quality Council allows for further evaluation and potential improvement in pain management protocols. Options B, C, and D are incorrect because they do not fully address both aspects of the feedback received from the former patient (compliments about the nurses and complaints about pain management) or may not align with CMS requirements regarding reporting and documentation.