Comagine Health ESRD Network 16 Guidelines for Involuntary Discharge (IVD)


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 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 ESRD Network is available for consultation regarding challenging situations and should be contacted as a resource for technical assistance and education. This document is intended to assist dialysis facilities in complying with CMS and ESRD Network requirements related to IVDs. Actions the facility should take related to IVD, and a checklist of required documents to be sent to the Network are listed below.

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 in place 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 available on the Network website:
  • 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 checklist below provides the required steps in accordance with the Conditions for Coverage.

Facility Actions – When the decision has been made to involuntarily discharge a patient

  • Notify the Network and follow up with required records within 5 business days of patient notification of discharge.
  • Notify the State Survey Agency of the IVD: Fill out this online notification form, then print and fax it to the State (fax information for each State Survey office is provided below).
  • 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 Checklist: Send the following documents to the Network Patient Services Department by fax (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, 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 Involuntary Discharges

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 also has an Outpatient Medical Director toolkit that contains an excellent section on Dealing with Problem Patients in the Unit. The toolkit can be found here: Medical_Director_Toolkit_2020_0319_combined.pdf.

State Survey Agency ESRD Surveyor Phone and Fax Numbers

State Phone Number Fax Number
Alaska 907-334-9302 907-334-9302
Idaho 208-334-6626 208-364-1888
Montana 406-437-4672 406-444-3456
Oregon 971-673-3269 971-637-0556
Washington 360-236-4681 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.

Page updated May 7, 2021