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Involuntary Discharge

The Conditions for Coverage for ESRD Facilities require notification to both the Network and the State Survey Agency of involuntary discharges and transfers. The Centers for Medicare & Medicaid Services (CMS) expects the Network and State Survey Agencies to work collaboratively to ensure facilities follow the ESRD regulatory requirements and to protect the rights of ESRD patients.

Involuntary discharge (IVD) should be the option of last resort. Discharged patients are at high risk for morbidity and mortality. Most challenging situations can be successfully managed through effective assessment, care planning, interventions, and collaboration between providers and patients.

The Network is available for consultation regarding challenging situations and should be contacted as a resource for technical assistance and education.

This webpage is intended to help dialysis facilities comply with CMS and ESRD Network requirements related to IVDs. It includes actions facilities should take and a checklist of the documents that must be sent to the Network.


Facility Actions — When Patients Are at Risk For IVD
  • Notify the Network prior to initiating an IVD. Call the Patient Services Department at 206-923-0714. Network staff will review the issues and explore possible interventions with the facility.
  • Follow your facility’s existing policy and procedure for IVD. It is the medical director’s responsibility to ensure that there is a clearly documented policy and procedure in place for IVDs.

    The ESRD federal regulations (see Interpretive Guidelines V766, V767 and V520) specify that no patient should be 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; 4) The facility has reassessed the patient and determined 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; or 5) The patient is an immediate severe threat to the health and safety of others. In cases of immediate severe threat to the health and safety of others, the facility may use an abbreviated procedure.

    See also Medical Director Responsibilities for Management of Involuntary Discharges.

  • Train facility staff. All staff should be trained on IVD policies and procedures and conflict management techniques. Training modules for decreasing patient-provider conflict are on our Decreasing Patient-Provider Conflict webpage.
  • Document all problems with patients. This includes all meetings, assessments, root cause analyses, interventions, patient grievances, written behavior agreements, etc. The regulations require that any patient considered at risk for involuntary discharge and transfer be considered unstable, and therefore reassessed monthly.
  • IVD should be the option of last resort. If all documented efforts to resolve the problem have failed, including consultation with the ESRD Network, then the facility, under direction of the medical director, can proceed with IVD. The Facility Actions checklist in the next section provides the required steps in accordance with the Conditions for Coverage.


Facility Actions — When the Decision Has Been Made to IVD a Patient
  • Notify the Network and follow up with required records within five business days of patient notification of discharge.
  • Notify the State Survey Agency of the IVD. Fill out the State Notification of Involuntary Discharge/Transfer form, then print and fax it to the state. State Survey office fax numbers are at the end of this page.
  • Document all actions related to the IVD in the patient’s medical record.
    • Description of problems and steps taken toward resolution
    • Reassessments
    • Root cause analysis
  • Required documents: Fax the following documents to the Network Patient Services Department at 206-923-0716.
    • Progress notes describing the problems and attempts toward resolution
    • Physician order to discharge the patient, signed by the attending nephrologist and the medical director
    • All letters, behavioral agreements and written communications regarding the issues
    • For immediate severe threat discharges, a copy of the incident report and/or police report
    • Documentation that the State Survey Agency was contacted
    • Documentation of attempts to place the patient in another outpatient dialysis facility
  • Report the patient as an IVD in EQRS upon the last day of treatment.


Medical Director Responsibilities for Management of IVDs

The medical director has specific responsibilities and accountability to the governing body for patient care and outcomes and is responsible for ensuring that the interdisciplinary team adheres to discharge and transfer policies. Code of Federal Regulations 42 CFR 494.180 (f) contains the reasons for involuntary discharge or transfer and the medical director’s responsibilities.

The Medical Advisory Council of the Forum of ESRD Networks’ Medical Director Toolkit contains an excellent section, “Dealing with Problem Patients in the Unit.”


State ESRD Surveyor Phone and Fax Numbers

Phone: 907-334-9302
Fax: 907-334-9302

Phone: 208-334-6626
Fax: 208-364-1888

Phone: 406-437-4672
Fax: 406-444-3456

Phone: 971-673-3269
Fax: 971-673-0556

Phone: 360-236-4681
Fax: 360-359-7958



ESRD Network 16 is under contract with the Centers for Medicare and Medicaid Services (CMS). The contents of this document do not necessarily reflect CMS policy.