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Involuntary Discharge (IVD)

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Network 7, on behalf of the Centers for Medicare & Medicaid Services (CMS), wants to make sure that all patients have access to dialysis care in an outpatient setting. No facility takes lightly the involuntary discharge of a patient. Challenging patient situations are often the result of unresolved issues involving both the patient and staff, where each has an expected responsibility.

In the unlikely event that your facility is faced with making a decision about involuntarily discharging a patient, you must abide by the parameters set forth in the Conditions for Coverage. You should also call your respective Network regarding the issuance of a 30-day notice or immediate involuntary discharge at:

  • Network 7 at 813.383.1530
  • Network 13 at 405.942.6000
  • Network 15 at 303.831.8818
  • Network 17 at 415.897.2400
  • Network 18 at 818.696.7040

All your efforts need to be documented in the patient’s medical record. 

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Anticipating Violent Behavior and De-Escalation Techniques
 (PDF)

Difficult Staff-Patient Situations: De-Escalation in the Dialysis Unit (30-minute presentation for dialysis facility staff training)(PDF)

This presentation can assist with teaching facility management and floor staff to:

  • Identify contributing factors and indicators significant in patients or caregivers who may become difficult or violent.
  • Use measures, techniques, and effective communication skills to decrease the likelihood of violent behavior from occurring and to de-escalate or defuse an explosive situation.
  • Improve staff knowledge and skill in communicating with and caring for the difficult and/or potentially violent patient or caregiver. 

The Safety is No Joking Matter poster highlights the importance of safety in your facility and that comments and actions are taken seriously. The poster is available in both English and Spanish.

Network 7

Network 17


Addressing Abusive Behaviors in the Dialysis Center

This document looks at some of the specific underlying causes of conflict that could possibly lead to abusive behaviors and methods for overcoming them.

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Agency for Health Care Administration (AHCA) Involuntary Discharge (IVD) Form

This form can be used by dialysis facilities to notify the Florida AHCA about the possible IVD or Involuntary Transfer (IVT) of a dialysis patient.

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Anticipating Violent Behavior and De-escalation Techniques (PDF)

This presentation can assist with teaching facility management and floor staff to:

  • Identify contributing factors and indicators significant in patients or caregivers who may become difficult or violent.
  • Use measures, techniques, and effective communication skills to decrease the likelihood of violent behavior from occurring and to de-escalate or defuse an explosive situation.
  • Improve staff knowledge and skill in communicating with and caring for the difficult and/or potentially violent patient or caregiver. 

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Behavioral Agreements - Things to Consider

This document outlines what a behavioral agreement is and items to consider when utilizing them in the dialysis facility.

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Can You Ever Be Discharged from Dialysis?

This document designed for use with patients outlines the situations in which a patient can be involuntarily discharged from his or her dialysis facility. Network 7—Can You Ever Be Discharged From Your Care? (PDF) (English/Spanish) Network 15—Can You Ever Be Discharged From Your...

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Conflict Resolution Tip Sheets

This sheet provides helpful tips for resolving patient-provider conflict in the dialysis facility. Network 7—Conflict Resolution Tips Sheet (PDF) Network 17—Conflict Resolution Tips Sheet (PDF)

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Decreasing Dialysis Patient-Provider Conflict Toolkit

The goal of the Decreasing Dialysis Patient-Provider Conflict (DPC) initiative is to provide the dialysis community with resources to manage and decrease conflict. The DPC Toolkit provides resources to help staff involved in the daily operations of the dialysis clinic to better understand, respond to, and decrease conflict.

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Dialysis Facility Compare

Find and compare Medicare-certified dialysis facilities and get information about chronic kidney disease, dialysis and transplants.

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Information and Recommendations for Challenging Dialysis Placements

This document provides information and recommendations related to placing dialysis patients who do not have an assigned dialysis facility. Network 7—Information and Recommendations for Challenging Dialysis Placements (PDF) Network 17—Information and Recommendations for Challenging...

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Involuntary Discharge (IVD) Guidelines and Checklist

Use these guidelines and IVD checklist when considering IVD for one of your patients. The checklist must be completed and returned to the Network within two business days of an IVD being completed. The Network frequently receives calls regarding the process of involuntarily discharging a patient....

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Involuntary Discharge (IVD): What Every Provider Needs to Know About Handling an IVD

This resource outlines the responsibilities of a facility and the process that must be followed before a patient can be involuntarily discharged (IVD) from a facility, as well as the Conditions for Coverage that specify the requirements and parameters for IVD.

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Involuntary Discharge of Patients - Network 13

Performance Guidance for Involuntarily Discharged Patients

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Involuntary Discharge: Alternative Strategies to Address Behaviors

This article discusses solutions providers can take to work more effectively with difficult and special needs patients while maintaining compliance with the ESRD Federal Regulations.

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IVDs: V-Tags and Interpretive Guidance - Network 17

This Network 17 document is an excerpt from the CMS ESRD Surveyor Training Interpretive Guidance (version 1.1) that highlights information regarding involuntary discharge.

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Managing Patients' Challenges at Dialysis

This presentation by Kristin Kuntz, Ph.D., Assistant Clinical Professor of Psychiatry at Ohio State University, provides an overview of the psychological challenges of dialysis and identifies interventions to support patients’ mental health. 

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Professionalism in the Dialysis Facility

This presentation, which is part of the 5-Diamond Patient Safety Program, helps providers to identify the characteristics and boundaries of proper professionalism, develop an understanding of how professionalism impacts conflict, and offers case scenarios of breaches in professionalism.

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Universal Behavioral Precautions: Techniques of Verbal De-Escalation

This PowerPoint presentation: Helps facilities to recognize situations that impact potential verbal and physical abuse by a patient or visitor toward staff. Provides tools to help facilities de-escalate potentially volatile situations. Network 7 presentation (PDF) Network 17 presentation (PDF)

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V-Tags and Interpretive Guidance on Patient IVD - Network 15

This Network 15 document provides information on v-tags and interpretive guidance regarding patient IVD excerpted from the CMS ESRD Surveyor Training Interpretive Guidance version 1.1.

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When Patients Don't Come to Dialysis

This document outlines some of the reasons a patient may miss their dialysis treatments, and suggested interventions to help combat these barriers. Netowrk 7—When Patients Don't Come to Dialysis (PDF) Network 17—When Patients Don't Come to Dialysis (PDF)

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Working Together to Address Challenging patient Behaviors and Prevent Involuntary Discharge

This presentation:

  • Reviews the End Stage Renal Disease (ESRD) Conditions for Coverage pertaining to involuntary discharge (IVD).
  • Increases awareness of risk factors that place patients at risk for IVD.
  • Identifies resources and approaches to manage challenging situations.

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