HCS/430 Week 1: Sources of Health Law and Who Enforces Them, sample paper

Can the Clinic Discharge Him? Tracing a Dialysis Patient's Involuntary Discharge Through Statute, Federal Regulation, State Law and the Agencies That Enforce Each

[Student Name]

University of Phoenix

HCS/430: Legal Issues in Health Care: Regulation and Compliance

Week 1 Assignment

[Instructor Name]

[Date]

The clinic, patient and events are a composite written for a model paper.

A composite outpatient dialysis clinic treats 96 patients on a three-day-a-week schedule. One patient, a 58-year-old man with kidney failure, has shouted at staff several times over two months and, during his last treatment, threatened to hurt a technician who asked him to stay in his chair. The staff are frightened, and the clinic administrator wants to discharge him. But for this patient, losing his chair at the clinic could mean missing dialysis, which is life-threatening within days. The administrator's question sounded simple, but four different layers of law each had something to say about the answer. This paper traces those layers and the bodies that enforce them.

The Sources of Health Law

Law in the United States comes from constitutions, statutes passed by legislatures, regulations issued by executive agencies under authority from statutes and court decisions that interpret all of these and develop the common law (Pozgar, 2023). Health care organizations are also bound by the terms of their contracts with payers, and many choose to follow private accreditation standards. Each source has its own enforcer: agencies enforce regulations, courts decide lawsuits and prosecutors bring criminal cases.

Layer 1: Federal Statute

Most dialysis in the United States is paid for by Medicare. Congress extended Medicare coverage to people with kidney failure in 1972, and the Social Security Act § 1881 provides the statutory basis for the end-stage renal disease program, authorizing the Secretary of Health and Human Services to set requirements for facilities that are paid for dialysis. The statute itself does not say when a clinic may discharge a patient. It creates the authority for the agency to write detailed rules.

Another federal statute also applies. The Americans with Disabilities Act prohibits discrimination based on disability by public accommodations, which include health care providers. Kidney failure is a disability, and if the patient's behavior were related to a mental health condition, the clinic would need to consider whether reasonable modifications could address it before discharge. The Department of Justice and private lawsuits enforce the ADA.

Layer 2: Federal Regulation

Using its authority, the Centers for Medicare and Medicaid Services issued the Conditions for Coverage for End-Stage Renal Disease Facilities, which every dialysis facility must meet to be paid by Medicare. These rules directly address involuntary discharge. They limit the reasons a facility may discharge a patient against his wishes to a short list, including ongoing disruptive and abusive behavior that seriously impairs the facility's ability to care for him or other patients, and they set out a process the facility must follow. For disruptive behavior, the facility must reassess the patient, document the ongoing problems and its efforts to resolve them, give the patient and the regional ESRD Network 30 days' notice, obtain a written discharge order signed by both the medical director and the patient's attending physician, attempt to place him at another facility and notify the state survey agency. The rules allow an abbreviated process only when there is an immediate, severe threat to the health and safety of others.

Enforcement comes from CMS through state survey agencies, which inspect dialysis facilities and investigate complaints. A facility that discharges a patient without following the rules may be cited, required to submit a plan of correction and, in serious cases, lose its Medicare certification. The ESRD Networks, regional organizations under contract with CMS, handle patient grievances and help with placement.

Layer 3: State Law

The state licenses dialysis facilities through its health department, and its licensing rules may add requirements, such as notice to the state before a discharge. State law also governs staff licensure: the nurses and technicians who care for the patient are regulated by the state board of nursing and, in many states, a certification requirement for technicians. The state health department enforces facility licensure, and the licensing boards enforce professional licenses.

Layer 4: Common Law and the Courts

Courts have long recognized that a provider who has accepted a patient may not end the relationship in a way that leaves the patient without needed care; doing so can support a claim of abandonment. A dialysis clinic that discharged a patient abruptly, with no reasonable opportunity to find another facility, and the patient was harmed, could face a lawsuit decided under state common law (Pozgar, 2023). Courts enforce the common law through private lawsuits, and a jury may award damages.

The same common law also protects the staff. The clinic owes its employees a reasonably safe workplace, which is why it cannot simply ignore threats of violence.

Putting the Layers Together

Mapped this way, the answer to the administrator's question is yes, the clinic may discharge the patient, but only by following the federal process, meeting any state requirements and avoiding abandonment. Hall (2009) describes alternatives that dialysis facilities use before discharge, such as behavior agreements, involving social workers, adjusting the treatment schedule and involving family, and the federal rules require evidence that such efforts were tried.

The clinic's compliance sequence was as follows. The social worker and nurse manager met with the patient to discuss the incidents and learned he was struggling with a recent job loss and was sleeping poorly. They wrote a behavior agreement with clear expectations, referred him for counseling and moved his treatment to a quieter time. Each incident and intervention was documented. The clinic also installed a staff alert button and trained staff in de-escalation. If behavior continued despite these efforts, the clinic would give 30 days' written notice, obtain the two physician signatures, work with the ESRD Network to find another facility and notify the state survey agency.

Two months later, after one more incident, the behavior stopped, and discharge was not needed.

Conclusion

A single decision about a dialysis patient drew on a federal statute that created the program, federal regulations that set the discharge process, state licensure rules, the ADA and common law duties to patients and staff. Each source has its own enforcer: CMS through state survey agencies and ESRD Networks, the state health department and licensing boards, and the courts. Knowing which layer governs which question lets a health care administrator act lawfully and fairly when patient and staff safety seem to conflict.

References

Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq. (1990).

Conditions for Coverage for End-Stage Renal Disease Facilities, 42 C.F.R. pt. 494 (2024).

Hall, L. (2009). Involuntary discharge: Alternative strategies to address behaviors. Dialysis & Transplantation, 38(6), 221-223. https://doi.org/10.1002/dat.20329

Pozgar, G. D. (2023). Legal aspects of health care administration (14th ed.). Jones & Bartlett Learning.

Social Security Act § 1881, 42 U.S.C. § 1395rr (2018).