General Guidelines For Involuntary Patient Transfer and
Discharge
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