Heads up! The Joint Commission Rights standards have new requirements effective July 1, 2022. These new requirements are in both the Hospital and Behavioral Health Care & Human Services standards. So, they apply to both psychiatric hospitals and any programs TJC surveys under the Behavioral Health Care & Human Services standards.

Joint Commission Rights Standards: What are the Changes?

The first change relates to informed consent (RI.01.03.01 EP 1.) Specifically, you must now define in your policy who can conduct the informed consent discussion with patients.

First point:  It must be a licensed practitioner. Second, the designation of that LIP  must be consistent with applicable law and regulation in your state.

Along the same lines, your written policy must describe the “licensed practitioner permitted to conduct the informed consent discussion in accordance with law and regulation.” As a result, you’ll need to research your state laws and regulations to see if they have specific requirements regarding who can obtain informed consent.

The second change is TJC has removed EP 3 from RI.01.03.01.This required organizations to obtain patients’ informed consent prior to making and using recordings, films, or other images of patients.

They’ve replaced this with a broader requirement at Standard RI.01.01.01 EP 37. It states: “The hospital/organization considers patients’ privacy and complies with law and regulation when making and using recordings, films, or other images of patients. Note: The term “recordings, films, or other images” refers to photographic, video, digital, electronic, or audio media.”

This new EP requires health care organizations to comply with applicable laws and regulations (such as HIPAA) when making and using recordings, films, or other images of patients. On a related note, see the TJC FAQ Videotaping or Filming – Circumstances When Informed Consent is Required.

Informed Consent: What Hasn’t Changed?

Be aware: The rest of the informed consent standard (RI.01.03.01) contains the same requirements as in the past. First, you need a written policy on informed consent.

Next, your policy must include the following details:

• The specific care, treatment, and services that require informed consent
• Circumstances that would allow for exceptions to obtaining informed consent
• The process used to obtain informed consent
• How informed consent is documented in the patient record
• When a surrogate decision-maker may give informed consent

Informed Consent: Survey Challenges

TJC surveyors frequently  cite informed consent at psychiatric hospitals and behavioral health organizations. One common finding is the organization’s policy requires informed consent for a new psychotropic medication but staff haven’t documented that in the record.

Also, there’s sometimes confusion regarding where to document informed consent. For example, the organization’s policy may require a particular form for informed consent.

However, the provider has documented it in a progress note. Thus, this doesn’t conform to the organization’s policy. As a result, surveyors cite this issue.

An important note regarding informed consent: TJC doesn’t require a particular format for documentation of informed consent.

You can record it in a form, a progress note, or elsewhere in the record. However, be sure to include that detail in your policy. Moreover, audit your records to evaluate whether documentation of informed consent is consistent with your policy.

Examples of Recent Survey Findings

“In multiple records, staff documented informed consent for medications as “yes” or “no”.  There was no documentation of discussion of specific medications. Nor was there documentation as to how they had obtained consent (such as by signature, by patient verbalization of understanding, etc.)”

“The organization did not follow their Informed Consent policy regarding documentation of verbal consent.  The HCO’s policy #RR.007 titled “Informed Consent” states verbal or oral consent may be obtained; however, requires the witness and documentation from two (2) staff members.  There were multiple forms with verbal consent. However, each one had only one (1) witness signature.” 

“In 1 of 15 records, the consent for Prozac for this adolescent patient was not compliant with the organization’s Policy #8124358. Policy requires “the consent may be given over the telephone and witnessed by 2 licensed staff members.”  Consent was documented in the Psych Eval with a note that the mother consented to Prozac.”

New Joint Commission Rights Standards: What to Do Now

First, review your current informed consent policy. Second, research who in your state is qualified to obtain informed consent. Then, update your policy to include the new TJC requirements.

Next, educate your staff about your policy. Clarify who is responsible for obtaining informed consent. And where they should document it in the medical record.

Last, include informed consent documentation in your medical record review process. Review the results in your PI Committee and see if you need to make changes.

Barrins & Associates Consultation

As we conduct our Mock Surveys and Continuous Readiness Consultations we’re educating our clients on these new Joint Commission Rights Standards. As always, we’re committed to keeping you current on all TJC requirements and best practices for compliance.