During The Joint Commission (TJC) surveys, issues with informed consent and how psychiatric hospitals handle patient complaints are among the most common and serious problems found. These issues can lead to findings, increased regulatory scrutiny, and even threaten a psychiatric hospital’s accreditation status. They also violate CMS Conditions of Participation, which could result in fines and further penalties.
Knowing how to identify these issues, respond correctly, and prioritize improvements can help turn small fixes into lasting compliance and prevent bigger problems. Below, please see a Compliance Matrix for your use.
Compliance Matrix for Informed Consent and Complaint Resolution
JC Std / EP | CMS CoP / A-Tag | Common Findings | How to Assess | How to Respond |
Informed Consent – RI.01.03.01 | 482.13(b)(2) – A-0131 | 1. Consent forms signed despite being blank or incorrectly completed | Conduct a documentation audit of consent forms | Revise and clarify consent policies |
482.24(c)(4)(v) – A-0466 | 2. Use of white-out or altered consent forms | Review policies versus practice | Re-educate prescribers on consent requirements | |
482.51(b)(2) – A-0955 | 3. No documentation for consent for high-risk psychotropic medications | Interview prescribers in inpatient/outpatient settings | Reinforce policy adherence during onboarding and credentialing | |
4. Inconsistent adherence to hospital policies on psychiatric medication consent | Monitor medication records for evidence of verbal or written consent | Implement FPPE if providers are noncompliant | ||
5. Providers documenting consent in progress notes without formal consent forms | Perform monthly audits of medication consentsAdd hard stops in EHR |
JC Std / EP | CMS CoP / A-Tag | Common Findings | How to Assess | How to Respond |
Complaint and Grievance Process – RI.01.07.01 | 482.13(a)(2) – A-0118 & A-0119 | 1. Policies incorrectly defining complaints vs. grievances | Crosswalk policies with CMS regulations | Ensure a designated patient advocate or grievance coordinator |
2. Missing CMS timeframes for grievance resolution | Review closed complaints/grievance files | Redefine complaint vs. grievance categories | ||
3. Lack of clear tracking, documentation, and notification | Review mechanisms used for tracking documentation and notification | Establish and document specific resolution timeframes | ||
4. No aggregate analysis for improvement | Interview staff on handling patient concerns | Design or improve complaint tracking logs | ||
Ensure a designated patient advocate or grievance coordinator | Analyze grievance trends and integrate into PI | |||
Train staff on escalation protocols |
Applying the Findings to the Safer Matrix:
- The SAFER Matrix is a powerful tool used by The Joint Commission to assess both the Likelihood of Harm and the Scope of Noncompliance, helping leaders prioritize corrective actions.
- Informed Consent findings are often High Likelihood and Widespread Scope, which places them in the upper-right red zone of the matrix. This indicates an immediate corrective action is required. It’s also likely a follow-up will occur.
- Grievance Process deficiencies may also rank as High Harm Potential due to patient rights violations and regulatory implications, particularly if systemic and unresolved.
How to Use the Safer Matrix to Communicate to Staff:
- Plot findings on the matrix to guide prioritization.
- Allocate resources to red zone issues for rapid correction.
- Communicate SAFER Matrix outcomes to Governing Body, leadership and quality councils.
- Use the matrix to educate frontline staff on why specific standards matter.
Key Takeaways
- Joint Commission and CMS expect 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.
- Psychiatric hospitals 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.
Barrins & Associates – Can Help Ensure Your Psychiatric Hospital Is 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.”