1000 St. Albans Drive, Suite 270
Raleigh, NC 27609
P: 919.855.0882 F: 919.855.0753
Patient Toll Free Line: 800.524.7139
info@nw6.esrd.net
www.myskc.org
INVOLUNTARY DISCHARGE PACKET
(revised 10/14/2013)
Involuntarily discharging a patient is a last resort solution. Note that the Federal Conditions for Coverage
for ESRD facilities do not recognize “non-compliance” or “non-adherence” as an acceptable reason for
discharge. Non-compliant patients are at higher risk for morbidity and mortality. Prior to considering an
involuntary discharge, the interdisciplinary health team must conduct a thorough assessment of the
patient’s care and situation and exhaust other, more moderate solutions. The Southeastern Kidney
Council is available to assist facilities in identifying alternate strategies. In the case of the patient’s
immediate and severe threat to others, the Conditions for Coverage do provide for an abbreviated
discharge process.
This packet contains vital information pertaining to the Involuntary Discharge process. The
Centers for Medicare & Medicaid Services (CMS) End Stage Renal Disease (ESRD) Facilities
“Conditions for Coverage” explains the acceptable criteria for the involuntary discharge of an
ESRD patient to another outpatient dialysis facility.
A dialysis facility must:


Complete the entire packet for all involuntary discharges.
Submit the completed packet to Southeastern Kidney Council (SKC) / ESRD Network 6.

 In cases of “immediate and severe threat”, when your facility has decided to
discharge patient with minimal or no advance notice, submit the completed
packet within 24 hours of the incident/discharge.
 In cases of non-payment of fees, ongoing and disruptive behavior, facility ceases
to operate, and/or facility can no longer meet patient’s medical need, submit the
completed packet within the first two (2) business days after you have given (or
mailed) a patient your facility’s 30-day-notice of discharge letter. Example: If the
patient’s discharge letter has the date of May 15, you should submit the
completed packet to the Network within two (2) business days of May 15.
Retain a copy of the completed packet within the patient’s medical record.
CMS Conditions for Coverage:
http://esrdnetwork6.org/utils/pdf/Final%20Rule%20ESRD%20Conditions%20for%20Coverage.pdf
Interpretative Guidance regarding CMS Conditions for Coverage:
http://esrdnetwork6.org/utils/pdf/Interpretive%20Guidance%202008.pdf
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
§ 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 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 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 facility medical director
ensures that the patient’s interdisciplinary team:
(i) Documents the reassessments, ongoing problem(s), and efforts to resolve the
problem(s), and enters this documentation into the patient’s medical record;
(ii) Provides the patient and the local ESRD Network with a 30-day notice of the
planned discharge;
(iii) 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
from the facility;
(iv) Contacts another facility, attempts to place the patient there, and documents that
effort; and
(v) Notifies the State Survey Agency of the involuntary discharge or transfer.
(5) In the case of an immediate and severe threat to the health and safety of others, the facility
may utilize an abbreviated involuntary discharge.
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 2 of 8
Please remember to follow the time guidelines on page 1 when submitting your
involuntary discharge packet to the Network!
DEMOGRAPHIC INFORMATION
Patient Name: __________________________________________________________________
Patient Date of Birth: __________/__________/__________
Name and Title of Individual completing this form (please print):
______________________________________________________________________________
Facility Name: __________________________________________________________________
Facility Medicare Provider Number (6 digits): _________________________________________
Facility Address: ________________________________________________________________
Facility Phone: _________________________
Facility Fax: __________________________
Name of Facility Medical Director: __________________________________________________
Name of Attending Physician: _____________________________________________________
Name of Facility Administrator: ____________________________________________________
Name of Regional Manager/Director: _______________________________________________
INVOLUNTARY DISCHARGE INFORMATION
Please enter the appropriate dates:
_____/_____/_____
Facility notified Patient of discharge.
_____/_____/_____
Facility notified Network of discharge.
_____/_____/_____
Facility notified State Survey Agency of discharge.
_____/_____/_____
Facility’s anticipated date of discharge.
_____/_____/_____
Expected date of patient’s last treatment at your facility.
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 3 of 8
REASON FOR DISCHARGE
Please check one of the following and provide a brief description of the incident(s) that led to
your facility’s decision to pursue involuntary discharge (attach all supporting documentation):
o
o
o
o
o
o
Non-payment for services ordered/rendered (Conditions for Coverage)
Facility ceases to operate (Conditions for Coverage)
Unable to meet documented medical needs (Conditions for Coverage)
Ongoing disruptive and/or abusive behavior (Conditions for Coverage)
Immediate and severe threat to health and safety of others (Conditions for Coverage)
Physician’s termination of doctor-patient relationship (CMS Conditions for Coverage does not
allow patient discharge due to medical non-adherence. If the discharge is due to the physician
terminating the relationship with the patient, include documentation of the facility’s efforts to place the
patient with another physician and/or at another facility.)
Brief description of incident(s)/issues leading to your discharge decision:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 4 of 8
BEHAVIORAL HEALTH ASSESSMENT
Please choose “yes” or “no” for each of the following items:
Mental health condition reported by patient
_____Yes
_____No
Mental health condition diagnosed/reported by
qualified mental health professional
_____Yes
_____No
Chemical dependency/abuse reported by patient
_____Yes
_____No
Chemical dependency/abuse diagnosed/reported by
qualified addictions professional
_____Yes
_____No
Cognitive impairment/deficit reported
_____Yes
_____No
If “yes” for any of the above items, please attach supporting medical documentation.
PATIENT DISPOSITION
Where did or where will Patient dialyze immediately after discharge?
_______Unknown / to be determined
_______Admitted to another outpatient facility: ______________________________________
(please provide the name of the facility to which patient has been admitted)
_______Patient admitted to correctional facility
_______Patient deceased
_______No outpatient facility will accept (please explain):
______________________________________________________________________________
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 5 of 8
REQUIRED DOCUMENTATION
o
Facility’s patient discharge letter/notice
(and, if applicable, nephrologist’s termination of doctor-patient
relationship notice that was given/sent to Patient)
o
Facility’s discharge & transfer policy/procedure
o
Facility’s patients’ rights/responsibilities document
(and patient’s signed acknowledgment)
o
Signature/Approval of discharge by Medical Director,
Attending Physician & Regional Manager/Director
(See “Required Signatures” on page 8 of this packet.)
o
Signed physician order for discharge
(to be signed by both Medical Director and Attending Physician
on facility’s physician order form and will include the reason for discharge)
o
Documentation of problem(s) leading to discharge & efforts to resolve
o
Documentation of efforts to relocate Patient
(copy of the list of dialysis facilities that was provided to patient and
facility progress notes indicating that your facility made contact with other facilities)
o
Documentation of facility’s notification of State Survey Agency
(copy of fax receipt/transmittal sheet or progress note w/date & time of call)
o
Facility’s financial policy & procedures
(if facility’s reason for discharge is non-payment of fees)
o
Documentation of facility’s inability to meet patient’s medical need
o
Copies of patient’s interdisciplinary reassessments and care plans
o
Police Report
o
Any other documentation that will assist the Network in evaluating the discharge
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 6 of 8
CROWNWeb ENTRY
When reporting an involuntary discharge in CROWNWeb, please remember to report the
“discharge reason” as “Involuntary.” Do not list the reason as “Discontinue”, “Other” or
“Transfer.” If you have submitted an involuntary discharge packet to the Network, you should
still report the discharge reason as “Involuntary” even if you know that a patient was accepted
at another dialysis facility.
STATE SURVEY CONTACT INFORMATION
GEORGIA
Healthcare Facility Regulation Division
GA Department of Community Health
Phone: (404) 657-5850
Fax: (404) 657-8934
NORTH CAROLINA
Health Service Regulation Division
NC Department of Health & Human Services
Phone: (919) 855-4620
Fax: (919) 715-3073
SOUTH CAROLINA
Bureau of Certification
SC Department of Health & Environmental Control
Phone: (800) 922-6735 or (803) 545-4300
Fax: (803) 545-4563
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 7 of 8
REQUIRED SIGNATURES
APPROVAL OF INVOLUNTARY DISCHARGE
We have reviewed and approved this document and all of the supporting documentation from
the patient’s medical record.
We concur with the involuntary discharge of ________________________________________.
(Patient’s Name)
PRINTED Name of Medical Director: ________________________________________________
Signature of Medical Director: _____________________________________________________
Date: _____/_____/__________
PRINTED Name of Attending Physician: _____________________________________________
Signature of Attending Physician: __________________________________________________
Date: _____/_____/__________
PRINTED Name of Regional Manager/Director (if your facility has one):
__________________________________________________________
Signature of Regional Manager/Director (if your facility has one):
__________________________________________________
Date: ____/____/________
FAX YOUR COMPLETED PACKET INCLUDING ALL REQUIRED SIGNATURES to:
ESRD NETWORK 6
ATTENTION: PATIENT SERVICES
FAX: (919) 855-0753
PHONE: (919) 855-0882
The mission of the Southeastern Kidney Council is to improve the lives of people
with or at risk for End Stage Renal Disease by promoting and advancing quality of care.
Page 8 of 8