{ IV. Issues to Consider Regarding Patient Discharge }

Transcription

1 We frequently receive calls regarding the process of involuntarily discharging a patient under the new Conditions for Coverage. Let us first emphasize that involuntary discharge should be the option of last resort. Discharged patients are at high risk for morbidity and mortality. Facilities should train staff in conflict management techniques and work to remove any barriers that patients may be facing. In the event that all options have been exhausted, the Network has several recommendations for the involuntary discharge process, some of which has already been covered. Notify the Network prior to an involuntary discharge: This provides an opportunity for the Patient Services Department to review the issues and interventions with facility staff and see if there are other options that can be explored. Train facility staff: The Network recommends that all staff receive training in conflict management techniques and that this training is documented. Staff should also become knowledgeable of financial assistance options and how to assist patients with any problems they might have with their medical insurance. Please refer to the Decreasing Patient-Provider Conflict Toolbox as well as Guidelines for Management of Disruptive and/or Abuse Patients (Both can be found at org). Documentation: It is essential that the staff document and address any problems, no matter how insignificant it may seem. This should include documentation of all meetings, interventions, and behavioral contracts that the staff and patients work on together. In addition note that V520 states, any patient considered at risk for involuntary discharge or transfer must be considered unstable. Also note that it requires patients at risk for involuntary discharge be reassessed monthly. Submit documentation to the Network within the time frame provided by the Patient Services Department: All facilities are given 10 calendar days from the date documentation is requested. It is essential that the documentation is forwarded by the due date to ensure that all documentation is accounted for. Should a facility submit the paperwork past the due date provided by the Network, the facility will be placed on an Improvement Plan. Have a policy and procedure in place for involuntary discharges: It is the Medical Director s responsibility to make sure 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; (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; or (5) Immediate severe threats to the health and safety of others. ( (f) Standard: Involuntary discharge and transfer policies and procedures; Conditions for Coverage for End Stage Renal Disease Facilities). Referral to the Department of Health Services: Please note that should a facility initiate an Involuntary Discharge and it is determined that the discharge was initiated prematurely or conducted in a manner that would not be supported by the Network, the case will be referred to the local DHS office for investigation. The major court cases (Payton v. Weaver and Brown v. Bower) regarding termination of dialysis services to extremely difficult or dangerous patients have found that physicians are not liable when all reasonable attempts have been made by the physician or facility to correct the situation. Page 17

2 ESRD Network 18 recommends that all threats or acts of violence be taken seriously and reported to the police. The intensity of the threat may require that the police or security guards be present during each treatment until transfer takes place. It is strongly recommended that legal counsel review any policy regarding disruptive/abusive patients before it is implemented. Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act (ADA), protect the disabled from discrimination. Within the context of this law, ESRD patients are considered disabled. When the decision is made to involuntarily discharge a patient for disruptive and/or abusive behavior, it is critical that the decision and the actions leading up to the decision are thoroughly documented. The documentation should show that facility actions were in response to the patient s behavior. Law enforcement should be contacted when physical aggression occurs, or severe threats of harm are made. Serious episodes where a patient behaves in a blatantly violent manner should not be tolerated. The Occupational Safety and Health Act of 1970 (OSHA) makes it the responsibility of the facility to ensure the safety of their staff and patients. Page 18

3 Involuntary Discharge Checklist If you have made the decision to Involuntarily Discharge (IVD) a patient make sure that you have covered the following, in accordance with the Conditions for Coverage (f): Be sure you do, or have done, the following: Document in the patient s medical record the ongoing problem. Document the impact of issue related to the reason for the IVD on other patients/staff/facility, if any. Document all steps the facility has taken to resolve the problem (including behavioral contracts, patient/staff meeting, letters of concern, billing statements, etc.). Document patient s response to each step taken and the reassessment of the situation. Once patient is a potential or an At-Risk for discharge the patient is considered unstable and comprehensive assessment is done monthly (v520). Notify the Network of the potential IVD. Contact another facility, attempt to place the patient when the 30-day notice has been given, and document your efforts. Obtain a written physician s order signed by both the medical director and the patient s attending physician agreeing with the patient discharge. In cases of immediate severe threats to the health and safety of others, the facility may use an abbreviated procedure. (Only one physician signature is required on the physician order, placement in another facility is not required, and follow the remaining guidelines.) Notify the State Survey Agency of the involuntary discharge (phone number at bottom of page) and document it in the medical record. Report the patient as an IVD (6c) in the monthly PAR. Those transferred out due to lack of payment should also be reported as a 6c. Provide the patient with a 30-Day notice of the planned discharge (If it is not an immediate discharge). Send the following documents to the Network Office within 10 days of request from the Network Send the progress notes of the issue and describing the facility attempts to solve the problem. Send copy of the physician discharge order. Send all letters, contracts and/or written communication with the patient and/or family regarding the issue. Send a copy of the incident report or police report if the IVD is due to Severe and Immediate Threat. Send documentation that State Agency was contacted. Send documentation that the patient was placed or placement attempts were made. Send verification that the patient received the discharge notice. Department of Health Services Offices Office Phone Number County Bakersfield District Office (866) Kern, Tulare Fresno DHS (800) Kings Los Angeles County DHS (800) Los Angeles Orange County DHS (800) Orange County Riverside DHS (888) Riverside San Bernardino DHS District Office (800) Inyo, Mono, San Bernardino San Diego DHS District Office North (800) (Parts of) Imperial, San Diego North San Diego DHS District Office South (800) Imperial, San Diego (cities south of Interstate 8) Ventura DHS (800) San Luis Obispo, Santa Barbara, Ventura If you have any further questions regarding this process, please contact ESRD Network 18 at (323) Page 19

4 CMS Conditions for Coverage for End Stage Renal Disease (ESRD) Facilities Interprative Guidance: V520 (2) At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. The criteria listed here are the minimum criteria for classifying patients as unstable. The IDT members have the flexibility to use their professional judgment to develop more stringent policies regarding the definition of unstable, based on their unique patient population and patient characteristics and to add other assessment criteria. Extended hospitalizations would include hospitalizations longer than 15 days, which was longer than the average length of stay nationally at the time these regulations were published. Frequent hospitalizations would include more than three hospitalizations in a month, which was more than the average number of hospitalizations annually at the time these regulations were published. The reason for hospitalization may also result in a patient being classified as unstable, for example, if the hospitalization results in amputation of a limb. V520 Marked deterioration in health status would be specifically identified and documented by the IDT. The following conditions have been suggested by representatives of the renal community: Change in ambulation severe enough to interfere with the patient s ability to follow aspects of the treatment plan; Hypotension, restlessness, pruritus or other symptoms severe enough to prevent completion of the majority of dialysis treatments; Sudden onset of recurrent cardiac arrhythmias; Recurrent infections (not recurring hospitalization); Chronic congestive heart failure with chronic hypotension; Advanced or metastatic cancer or other organ system disease which interferes with the patient s ability to follow aspects of the treatment plan; Chronic or recurrent peritonitis Significant change in psychosocial needs would include any event that interferes with the patient s ability to follow aspects of the treatment plan. Such events may include instability in one s own or immediate family member s employment, physical or emotional abuse, deterioration in mental or functional status, amputation, housing instability, death or major illness in the family, consideration of terminating treatment, and loss of emotional support. In addition, any patient considered at risk for involuntary discharge or transfer must be considered unstable. Note that V767 requires that patients at risk for involuntary discharge be reassessed. Page 20

5 Poor nutritional status would include failure to thrive symptoms, with loss of body weight and low serum albumin. Unmanaged anemia would include continued lab findings of hemoglobin/hematocrit values which are out of range as defined by community-accepted standards or Centers for Medicare and Medicaid Services (CMS) Clinical Performance Measures (CPMs). Refer to the Measures Assessment Tool (MAT) which lists the current professionally-accepted clinical standards and current CMS CPMs. Inadequate dialysis would include a trend of results for Kt/V or URR which do not meet minimum expectations as defined by community-accepted standards or CMS CPMs for a three month period of time. Refer to the MAT. Inadequate dialysis would also include symptoms related to fluid management such as volume overload or depletion; intradialytic symptoms such as syncope or congestive heart failure; hypertension; or the need for extra treatment(s) for fluid removal. Facilities must have a method for classifying patients as unstable. Documentation should be available of a monthly re-assessment and plan of care revision that addresses the issues related to the classification of the patient as unstable until the issues have been resolved or the IDT (including the patient if possible) determine that the condition is chronic and the active care plan adequately addresses the issues. Some changes leading to the patient classification of unstable are clearly within the purview of a specific member of the IDT. For example, while housing instability falls within the realm of the social worker, expect to see documentation of communication regarding a change in housing between the social worker and other members of the IDT who can determine the specific impact of that change on their specialty. The participation of some team members around some changes that do not impact their specialty may be limited. Page 21

6 CMS Conditions for Coverage for End Stage Renal Disease (ESRD) Facilities Interpretive Guidance: V766 & V767 V766 (f) Standard: Involuntary discharge and transfer policies and procedures. 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 Involuntary discharge or transfer should be rare and preceded by demonstrated effort on the part of the interdisciplinary team to address the problem in a mutually beneficial way. The facility must have and follow written policies and procedures for involuntary discharge and transfer. If any patients have been involuntarily discharged or transferred since the latter of either the effective date of these rules (October 14, 2008) or the facility s last survey, surveyors will review those patients medical records to ensure compliance with these regulations and facility policy. See also requirements under Conditions for Patients rights at V468 and V469. The medical director must be informed of and approve any involuntary discharge or transfer of a patient. A facility may involuntarily discharge or transfer a patient only for those reasons listed here and at V767. The medical director must ensure that the reasons for any involuntary discharge or transfer are consistent with this requirement. If a facility involuntarily discharges or transfers a patient for nonpayment of fees, there must be evidence in the patient s medical record that the facility staff (e.g., billing personnel, financial counselor, social worker) made good faith efforts to help the patient resolve nonpayment issues. In the event a facility ceases to operate, the governing body must notify CMS, the State survey agency, and the applicable ESRD Network. The facility s interdisciplinary team must assist patients to obtain dialysis in other facilities. If the discharge or transfer is necessary for the patient s welfare, the patient s medical record must include documentation of the medical need and reasons why the facility can no longer meet that need. V767 (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 medical director ensures that the patient s interdisciplinary team (i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this Patients should not be discharged for failure to comply with facility policy unless the violation adversely affects clinic operations (e.g., violating facility rules for eating during dialysis should not warrant involuntary discharge). Patients should not be discharged for shortened or missed treatments unless this behavior has a significant adverse affect on other patients treatment schedules. A facility may evaluate the patient (who shortens or misses treatments) for any psychosocial factors that may contribute to shortening or missing treatments; for home dialysis; or, as a last resort to avoid inconveniencing other patients, may alter the patient s treatment schedule or shorten treatment times for patients who Page 22

7 persistently arrive late. Patients should not be discharged for failure to reach facility-set goals for clinical outcomes. Facilities are not penalized if a patient or patients do not reach the expected targets if the plan of care developed by the IDT is individualized, addresses barriers to meeting the targets, and has been implemented and revised as indicated. In the event facility staff members believe the patient may have to be involuntarily discharged, the interdisciplinary team must reassess the patient with an intent to identify any potential action or plan that could prevent the need to discharge or transfer the patient involuntarily. The reassessment must focus on identifying the root causes of the disruptive or abusive behavior and result in a plan of care aimed at addressing those causes and resolving unacceptable behavior. Evidence must be on file to substantiate that the patient received notification at least 30 days prior to involuntary discharge or transfer and that the ESRD Network was also notified at that time. While the early notice to the State agency is not required, facilities may choose to notify the patient, Network and the State agency at the same time. A 30-day notice is not required in the case of imminent severe threat to safety of other patients or staff. The State agency and Network would need to be notified immediately if the use of the abbreviated involuntary discharge procedure is necessary. There must be a written order in the patient s medical record, signed by the attending physician and the medical director for the facility to involuntarily discharge or transfer a patient. If the reason for discharge is the physician s determination to no longer care for a particular patient and there is no other physician on staff available or willing to accept the patient, generally the state practice boards for physicians require the patient be given some notice to avoid a charge of patient abandonment. The facility would need to follow this regulation as to reassessment, 30 day notice, attempts for placement, etc. during the physician s period of notice to the patient. Because the goal of contacting another dialysis facility is for continuity of care, the HIPAA privacy rule does not require patient consent to contact that other dialysis facility. However, it does limit sharing of protected health information to medical records requested by the other provider and prohibits sharing information obtained through hearsay. Good faith efforts should be made to find the closest facility to the patient s residence that will accept the patient in transfer. The applicable patient s medical record must include evidence of those placement efforts. Page 23

8 An immediate severe threat is considered to be a threat of physical harm. For example, if a patient has a gun or a knife or is making credible threats of physical harm, this would be considered an immediate severe threat. An angry verbal outburst or verbal abuse is not considered to be an immediate severe threat. In instances of an immediate severe threat, facility staff may utilize abbreviated involuntary discharge or transfer procedures. These abbreviated procedures may include taking immediate protective actions, such as calling 911 and asking for police assistance. In this scenario, there may not be time or opportunity for reassessment, intervention, or contact with another facility for possible transfer. After the emergency is addressed and staff and other patients are safe, staff must notify the patient s physician and the medical director of these events, notify the State agency and ESRD Network of the involuntary discharge, and document this contact and the exact nature of the immediate severe threat in the applicable patient s medical record. At the time of publication of these rules, each facility had received a copy of an interactive program developed by the ESRD Networks on Decreasing Dialysis Patient Provider Conflict (DPC) that addresses proactive techniques to resolve such issues before progression to involuntary discharge. Page 24