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Involuntary Transfers & Discharges



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.


It is advised that facilities contact the Network for assistance in managing difficult patient behaviors before they escalate to the point where patients are no longer welcome in the facility.


Considering IVD

1. Notify the Network prior to initiating an IVD. Call Phyllis Haas at 804-320-0004, Ext. 2704 to review the issues and explore possible interventions with the facility.

2. Adhere to the Conditions for Coverage 494.180 Condition: Governance (f) Standard: Involuntary Discharge and Transfer Policies and Procedures.

The governing body must ensure that all staff follows 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:

  • The patient or payer no longer reimburses the facility for the ordered services;
  • The facility ceases to operate;
  • The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented medical needs; or
  • The facility has 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, in which case the medical director ensures that the patient’s interdisciplinary team:
  1. Documents the reassessments, ongoing problem(s), and efforts to resolve the problem(s), and enters this documentation into the patient’s medical record;
  2. Provides the patient and ESRD Network 5 with a 30-day notice of the planned discharge;
  3. Obtains a written physician’s order that must be signed by both the medical director and the patient’s attending physician concurring with the patient’s discharge or transfer from the facility; Contacts another facility, attempts to place the patient there, and documents that effort; and
  4. Notifies the State survey agency of the involuntary transfer or discharge.
  • In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure.

3. Complete and submit an Involuntary Discharge Packet. Entire packet must be completed and faxed to the appropriate State Survey Agency and the Network at 804-320-5918 two weeks prior to discharge, within 48 hours of immediate and severe threats. Download IVD Packet.