Stark vs anti-kickback, HPPD and staffing

A unit's census rises about 25% every winter and drops in the summer. Which staffing plan BEST manages this pattern at a reasonable cost?

1. Cover the winter surge with mandatory overtime for core staff
   Relying on mandatory overtime for a recurring, predictable surge raises premium pay and fatigue risk; a planned flexible pool is cheaper and safer.
2. Staff to the annual average census and hold that level all year
   A flat average leaves the unit short every winter and overstaffed every summer, because it ignores the known seasonal pattern.
3. Budget core FTEs to the winter peak census for the whole year
   Staffing to the peak pays for idle hours through the summer low; the core should match the baseline, not the high point.
4. Staff the core to baseline census and flex with float or PRN
   Core positions sized to the steady baseline avoid paying for idle summer hours, while float, PRN or seasonal staff absorb the predictable winter rise.

Last week a unit used 1,120 worked hours for 140 patient days against a target of 7.5 worked hours per patient day. If productivity is earned (target) hours divided by worked hours, what was the result and what does it mean?

1. 94%; more hours worked than the workload earned
   Earned hours are 7.5 × 140 = 1,050, and 1,050 ÷ 1,120 = 94%. A result below 100% means the unit used more hours than its workload justified.
2. 107%; the unit was understaffed for its workload
   This uses the inverted ratio and then misreads it; 8.0 actual hours per patient day against a 7.5 target means more staffing, not less.
3. 107%; more hours worked than the workload earned
   107% is the inverted ratio, worked ÷ earned (1,120 ÷ 1,050); under the formula in the question the result is 94%.
4. 94%; the unit was understaffed for its workload
   The number is right but the reading is reversed: a productivity index below 100% shows more hours than earned, which is overstaffing for the workload.

Which purchase belongs in the capital budget rather than the operating budget?

1. Paid staff education hours to train RNs on the monitors
   Paid education time is a personnel cost in the operating budget; training does not become capital because it relates to new equipment.
2. A one-year service contract for the monitoring system
   A service contract is a recurring annual expense of operations, even when it supports a capital asset.
3. A $300,000 patient monitoring system with a 7-year life
   Capital budgets hold long-lived assets above the organization's cost threshold; a monitoring system used for years is depreciated over its useful life.
4. A $40,000 bulk order of disposable ECG lead wires
   A large dollar amount does not make an item capital; disposables consumed within the year are supply expense in the operating budget.

A unit schedules 12 RNs, 4 LPNs and 4 unlicensed assistive personnel over 24 hours. What is the unit's RN skill mix?

1. 150%
   150% divides RNs by the non-RN staff (12 ÷ 8); skill mix puts all nursing care staff in the denominator.
2. 60%
   RN skill mix is RN staff as a share of all nursing care staff: 12 ÷ (12 + 4 + 4) = 12 ÷ 20 = 60%.
3. 75%
   75% divides RNs by licensed staff only (12 of 16), leaving the unlicensed assistive personnel out of the denominator.
4. 80%
   80% counts RNs and LPNs together (16 of 20), which is the licensed-staff share, not the RN skill mix.

A cardiologist refers Medicare patients for outpatient imaging to a center in which the cardiologist's spouse holds an ownership interest. Which law MOST directly governs this referral?

1. False Claims Act
   The FCA penalizes submitting false claims; it can follow a Stark violation but does not define which referrals are prohibited.
2. Anti-Kickback Statute
   The AKS targets offering or receiving anything of value to induce referrals and requires intent; a family ownership interest in the receiving entity is the Stark trigger.
3. EMTALA
   EMTALA governs emergency screening and stabilization, not physician referrals or financial relationships.
4. Stark Law
   Stark bars a physician from referring Medicare patients for designated health services, which include imaging, to an entity in which the physician or an immediate family member such as a spouse has a financial interest.

When building a unit's labor budget, which hours are classified as NONPRODUCTIVE?

1. Overtime hours worked on the unit
   Overtime raises the pay rate, not the category; overtime hours are worked and therefore productive.
2. Charge nurse hours without a patient load
   Charge hours are worked hours on the unit; a role without patients is still productive time, often budgeted as non-direct care.
3. Paid vacation and holiday hours not worked
   Nonproductive hours are paid hours in which no work is done, such as vacation, holidays and sick time.
4. Float pool hours worked on the unit
   Float hours are productive hours for the unit that uses them, whichever cost center pays the nurse.

Which nursing care delivery model assigns one registered nurse continuous accountability for a patient's plan of care throughout the hospital stay?

1. Team nursing
   Team nursing gives a group of patients to a mixed-skill team led by an RN for one shift; no single RN carries the plan across the stay.
2. Primary nursing
   In primary nursing one RN holds 24-hour accountability for a patient's plan of care from admission to discharge, with associate nurses carrying it out on other shifts.
3. Functional nursing
   Functional nursing divides the work by task, such as medications or treatments, so no single nurse owns the patient's plan.
4. Total patient care
   Total patient care assigns one nurse to all of a patient's care for a single shift; the accountability ends when the shift does.

A unit adds a second unit secretary position only when its average census exceeds 30 patients. How is this cost BEST classified?

1. Step-fixed cost
   A step-fixed cost stays flat across a range of volume and then jumps to a new level at a threshold, as when a second secretary is added above a census of 30.
2. Semi-variable cost
   A semi-variable cost has a fixed base plus a part that rises smoothly with each unit of volume; this cost does not rise gradually, it jumps once.
3. Indirect cost
   Indirect costs are shared overhead allocated to the unit; the secretary is a direct unit cost, and the question is how that cost behaves with volume.
4. Variable cost
   A variable cost changes in proportion to each patient day, like supplies; the secretary cost stays flat until the threshold.

A hospital reports $250 million in operating revenue and $240 million in operating expenses for the year. What is its operating margin?

1. 96.0%
   96% is the expense ratio, expenses ÷ revenue, not the margin left over.
2. 4.2%
   This divides the $10 million gain by expenses ($240 million) instead of revenue.
3. 0.4%
   The decimal is misplaced: 10 ÷ 250 is 0.04, which is 4.0%, not 0.4%.
4. 4.0%
   Operating margin is (operating revenue − operating expenses) ÷ operating revenue: $10 million ÷ $250 million = 4.0%.

An RN's base rate is $45 an hour, overtime is paid at 1.5 times base, and agency nurses cost $95 an hour. How much less does it cost to cover one 12-hour shift with overtime than with an agency nurse?

1. $810
   $810 is the full cost of the overtime shift, not how much less it costs than the agency shift.
2. $330
   Overtime is $45 × 1.5 = $67.50 an hour, or $810 for 12 hours; agency is $95 × 12 = $1,140; the difference is $1,140 − $810 = $330.
3. $27.50
   $27.50 is the hourly difference ($95 − $67.50); it has not been multiplied by the 12 hours of the shift.
4. $600
   This uses the $45 base rate instead of the overtime rate: ($95 − $45) × 12 = $600.

Two units have similar census and acuity, but Unit A's labor cost per patient day is 18% higher than Unit B's. Which analysis should the director perform FIRST?

1. Survey Unit A staff on perceived workload
   Perceived workload is context, but it does not explain a dollar gap; the cost data should first show where the gap sits.
2. Benchmark Unit A against national HPPD data
   Comparing hours alone misses the rate side of the gap, and Unit B with similar census and acuity is already the closer comparison.
3. Split the gap into hours and cost per hour
   Labor cost per patient day equals hours per patient day × cost per hour, so the first step is to see whether Unit A uses more hours, pays more per hour (overtime, agency, skill mix), or both.
4. Review Unit A's patient satisfaction trends
   Satisfaction is an outcome to watch if staffing changes, but it does not identify why labor cost per patient day is higher.

A unit's patient days are 50% Medicare paying $2,000 per day, 30% commercial paying $3,000 per day and 20% Medicaid paying $1,500 per day. What is the weighted average revenue per patient day?

1. $2,200
   Weight each rate by its share of patient days: 0.5 × $2,000 + 0.3 × $3,000 + 0.2 × $1,500 = $1,000 + $900 + $300 = $2,200.
2. $2,167
   $2,167 is the simple average of the three rates ($6,500 ÷ 3), which ignores how many patient days each payer contributes.
3. $2,000
   $2,000 is only the Medicare rate: the largest payer is treated as the whole mix.
4. $2,050
   This swaps the commercial and Medicaid shares (0.5 × $2,000 + 0.3 × $1,500 + 0.2 × $3,000), understating revenue from the higher-paying payer.

A unit's budget has been built for ten years by adding 3% to the previous year's amounts. What is the MAIN weakness of this approach?

1. It requires justifying every line from zero
   Justifying every line from zero describes zero-based budgeting, the method designed to correct this weakness.
2. It adjusts spending to actual patient volume
   Adjusting to actual volume describes a flexible budget; an incremental budget ignores changes in volume.
3. It cannot account for wage inflation
   A flat percentage increase is itself a crude allowance for inflation; the weakness is the unexamined base, not inflation.
4. It carries forward past inefficiencies
   Incremental budgeting starts from last year's base and adds a percentage, so spending that no longer serves the unit is never questioned.

A 30-bed unit recorded 810 patient days in a 30-day month. What was its occupancy rate?

1. 90%
   Occupancy = patient days ÷ (beds × days) = 810 ÷ (30 × 30) = 810 ÷ 900 = 90%.
2. 111%
   This inverts the ratio, bed days ÷ patient days (900 ÷ 810); occupancy cannot exceed 100% with these figures.
3. 81%
   This reads the 810 patient days as if they were out of 1,000 instead of the 900 available bed days.
4. 27%
   27 is the average daily census (810 ÷ 30 days), a count of patients, not a percentage of beds.

A unit that relies on travel nurses has had friction and two medication near misses involving travelers unfamiliar with unit routines. What should the nurse manager implement?

1. A skills checklist verified by the staffing agency
   Agency checklists confirm general competence, which is not the problem; the near misses came from not knowing this unit's routines.
2. Unit orientation with a staff resource buddy
   Travelers know nursing but not this unit's routines, equipment and escalation paths; a focused orientation with a named core-staff resource closes exactly that gap.
3. Assignment of travelers to the lowest-acuity patients
   Limiting acuity treats experienced nurses as a risk to hide and leaves the unfamiliarity with unit routines in place.
4. A requirement that travelers read the unit policy binder
   Reading policies passively does not teach workflows or where things are, and it does nothing for integration with staff.