Background: The Conditions for Coverage (CfC) for End-Stage Renal Disease Facilities require facilities to notify both the Network and the State Survey Agency of involuntary discharges and transfers. The Centers for Medicare and Medicaid Services (CMS) expects the Network and State Survey Agencies to work collaboratively to ensure facilties follow the requirements of the CfC and to protect the rights of Medicare beneficiaries. We frequently receive calls regarding procedure for involuntarily discharging a disruptive or abusive patient under the new CfC. Involuntary discharge should be an option of last resort. Discharged patients are at high risk for morbidity and mortality. This document and the attached checklist were created to assist providers in complying with requirements of the CfC and Survey Interpretive Guidance.
Prior to an involuntary discharge, the Network should be notified. This provides an opportunity for the facility staff to receive feedback on steps taken and planned, and to ensure consideration of other options that may exist. The Mid-Atlantic Renal Coalition (MARC) assists providers in handling challenging patient situations. Most challenging situations can be successfully managed through effective assessment, planning of care, interventions, and collaboration between providers and patients. Providers are encouraged to reference the DPC (Decreasing Dialysis Patient-Provider Conflict) materials, other related staff training modules, and to consult with MARC regarding challenging situations. These materials are available online at
www.esrdnet5.org/resources.asp. Facilities should train staff in conflict management techniques and work to remove any barriers that patients may be facing.
Frequently, when investigating grievances, the Network finds provider documentation severely lacking. It is
essential that the staff document and address any problematic behavior, no matter how insignificant it may seem. There should also be documentation of any meetings, interventions, and behavioral contracts that the staff and patients work on together. The CfC require that providers have a policy and procedure in place for involuntary discharges and that patients are made aware of these.
“The governing body must ensure that all staff follow the facility’s patient discharge and transfer policies and procedures. The Medical Director ensures that no patient is discharged or transferred from the facility unless-
(1) The patient or payer no longer reimburses the facility for the ordered services;
(2)The facility ceases to operate;
(3) The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented medical needs; or
(4) The facility reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired…
(5) In case of immediate severe threats to the health and safety of others, the facility may use an abbreviated involuntary discharge procedure.
(Reference: '494.180 (f) Standard: Involuntary discharge and transfer policies and procedures; Conditions for Coverage for End Stage Renal Disease Facilities).
Should a provider implement an involuntary discharge or transfer due to its inability to meet the patient’s medical needs, clear documentation should exist of the nature of the patient’s medical need and reasons why the provider can no longer meet the need. Should an abbreviated involuntary discharge procedure be implemented, the provider should have documentation regarding the exact nature of the immediate severe threat to the health and safety of others.
In the event of an involuntary discharge or transfer, the facility is required to notify the Network. MARC requests to receive notification by phone. Facilities may choose to follow up the phone notification either by fax or by mail. The person notifying the Network should be familiar with the situation and be prepared to provide the following information:
- Patient’s name and Social Security Number
- Anticipated date of last treatment
- Steps taken by the facility to resolve the problem
- Contributing factors to the discharge or transfer
We hope this letter and checklist help to clarify the involuntary discharge process. If you have any further questions, please contact the Network at 804-794-3757, and we will be happy to address your concerns
Adapted from Network 18 and adopted by MRB: February 19, 2009