Accreditation surveys frequently reveal gaps in informed consent procedures and complaint/grievance processes. Such deficiencies can result in citations and threaten the facility’s accredited status. Therefore, proactive assessments, staff training, and ongoing compliance efforts are essential.
Informed Consent and Complaint Resolution for Community Behavioral Health and Human Services Surveys
The following table outlines common areas of deficiency and action steps to ensure compliance.
Common Deficiencies, Explanations, and Responses
| Area | JC Standard/EP | Common Deficiencies | Explanation | Response |
|---|---|---|---|---|
| Informed Consent | RI.01.03.01 The organization obtains informed consent. |
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These issues demonstrate a failure to adequately inform patients of their treatment options and obtain proper consent, potentially violating patient rights and accreditation standards. This can stem from inadequate policies, lack of staff training, or insufficient monitoring of consent practices. |
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| Complaint and Grievance Process | RI.01.07.01 The organization addresses complaints and grievances. |
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These issues highlight a breakdown in the process of addressing patient concerns and using feedback to improve services. It can result from unclear policies, inadequate resources, or a culture that discourages open communication. |
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Informed Consent and Complaint Resolution Key Takeaways
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Differentiate between a Complaint vs a Grievance and clarify the actions to take for each. A complaint can be informal or a formal concern about specific services or interactions, needing prompt investigation and response. A grievance is a formal expression of dissatisfaction, often about policies or quality of care, requiring a documented resolution process.
- Joint Commission expects fully implemented, standardized, and monitored processes for informed consent and complaint resolution.
- Gaps in documentation, inconsistent provider practices, and weak policy alignment are red flags during deemed status surveys.
- Behavioral Health organizations must not only correct individual findings but embed preventive strategies into operations, policy, and provider accountability systems.
- The SAFER Matrix is your compass—use it to navigate risk and compliance prioritization.
Is Your Agency Ready?
Now is the time to assess your consent and grievance processes, train your teams, and safeguard your compliance. Let the Barrins & Associates team of accreditation and regulatory experts help your organization prepare, respond, and excel. Through expert-led mock surveys, policy reviews, and targeted education, our consultants specialize in behavioral health and deliver tailored solutions that align with accreditation standards, regulatory requirements, and leading practices. Contact us today to strengthen your compliance strategy and survey readiness.
Barrins & Associates: “Simplify, Deliver, and Thrive: Your Path to Compliance and Safe Care”