Is a Patient-Centered Dialysis Behavior Contract Possible?
Editor's note (October 29, 2026): This article has been reviewed and updated with additional resources and current information to help readers explore this topic further.
I have heard from social workers who ask for a template of a “behavior contract.” Social workers want to know how to motivate patients to behave differently. Some dialysis clinics ask patients who exhibit challenging behaviors to sign a contract to avoid consequences. Examples of challenging behaviors include, but are not limited to, swearing or yelling out, arguing with staff or patients, skipping or shortening in-center or home dialysis treatments, not attending home dialysis clinics as scheduled, and not providing home records as often as requested. Establishing a contract implies that both the clinic and the patient will get something of value—the clinic will see a behavior change or if the behavior doesn’t change, there will be consequences for the patient and the patient will get dialysis. Some clinics threaten discharge and others have discharged patients for infractions that are not allowed reasons for involuntary discharge under the ESRD regulations. If the clinic follows through on discharge, the patient may file a grievance with the ESRD Network and/or a complaint with the state survey agency, either of which could bring additional investigation of patient behaviors and clinic actions.
Staff need to understand that the Condition for Patients’ rights in the ESRD Conditions for Coverage (CfC) at 42 CFR 494.70(a) grants multiple rights. Among these are the right to participate as fully as desired in their care, to refuse or discontinue treatment, to be informed of ALL treatment options and settings, to receive services in their plan of care, to be informed of the clinic’s rules and expectations for behavior, and to file an internal and/or external grievance without fear of reprisal or denial of services. Dialysis staff should recognize how hard it is for patients to file a complaint or grievance out of fear of being labeled as a “difficult patient.” Instead of viewing a patient’s complaint or grievance negatively, it could be helpful to listen to patients’ complaints and viewing grievances as opportunities for improvement.
The ESRD CfC also requires patients to be informed about policies for routine or involuntary transfer/discharge and to receive a 30-day notice of involuntary discharge unless he/she presents an “immediate severe threat.” CMS’ State Operations Manual. Appendix H includes regulatory text and interpretive guidance, which provides more detail to help ESRD surveyors determine the dialysis facility’s compliance with the regulations and describes what behavior rises to that level.
The Condition for Governance at 42 CFR 494.180(f) provides only four reasons to involuntarily discharge a patient and requires that the medical director “ensures that no patient is discharged on transferred 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—
(i) Documents the reassessments, ongoing problems(s), and efforts made 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 or transfer 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 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.”
In most cases, the ESRD regulation above along with the American Medical Association’s Principles of Medical Ethics Section 1.1.5, effectively eliminate transfer or discharge as a consequence. Other consequences for challenging behaviors that dialysis clinics have used include shortening treatments, changing shift days or times, and requiring home patients to change from home to in-center dialysis. When these actions are taken without assessing contributing factors, it can lead to fractured patient-staff relationships, greater miscommunication, and worse outcomes.
Several social workers, like me, have reported that they believe behavioral contracts are not worth the paper they were written on. Some have suggested more patient-centered and less paternalistic punitive approaches to assuring both staff and patients follow rules. They believe developing an agreement that addresses goals and responsibilities helps make communication effective, respectful behavior possible, and desired outcomes achievable.
ESRD Networks have master’s-prepared social workers who are charged with helping to address challenging situations. The National Forum of ESRD Networks has posted resources to help clinics and patients including:
Decreasing Dialysis Patient-Provider Conflict conference reports, provider manual, and other resources funded by CMS and developed by a task force of stakeholders
Dialysis Patient Grievance Toolkit developed by the Forum’s Kidney Patient Advisory Council
The Role of ESRD Networks and How to Deal with Patient-Provider Conflict, a 58-minute webinar presented by Preethi Yarram, MD on April 9, 2026
Home Dialysis Central posted a Clinic Patient Agreement that dialysis clinics can download and use with new dialysis patients. We welcome your suggestions for improving this agreement, including when to share it with patients and how to introduce it in a way that encourages partnership and shared responsibility.
Comments
Amy Staples
Nov 10, 2017 3:16 PM
On my very last episode of sepsis, during the treatment wherein the nurse made the mistake of not following clean protocol, I complained during the treatment to the head nurse and FA, telling them I was highly suspect I would end up with Sepsis. This happened on a Monday and by Tuesday evening I'd spiked a 103 fever, fever chills, nausea, vomiting. Wed morning I called the clinic and spoke to the charge nurse telling her I wouldn't be at clinic for treatment as I was heading to the Hospital. Later when I requested my records they charted the day I'd called about going to the hospital that I had failed to report for treatment and that I had been educated on the importance of not missing treatments and the hazard it presented for my health. It was also charted that they spent at least 30 minutes being educated on the proper way to handle a catheter, and that as a patient I should never touch it and always have a nurse handle it. Funny right? I didn't even show up for any treatments at that clinic after that Monday and they never spoke to me about missing treatments or handling my catheter. How could they? I never had any contact with them except to inform them I was going to the hospital. As a consequence I ended up having 11 procedures done, in hospital for nearly 3 weeks, 4 transfusions and 7 catheters later I finally was able to get a bovine graft. How can any patient ever trust a clinic to chart the truth after incidents like this? Thank you so much for this. Blessings
Peter Laird
Aug 16, 2019 4:25 AM
Likewise, I was never given any of the prior warnings. In fact, I was asking for a transfer at the time I was discharged from HHD.
I believe if anyone should sign a behavioral contract, it is the staff at these clinics that routinely violate hygiene standards and medical record standards. It is time that the civil rights violations of these companies come to an end.
Beth Witten
Nov 10, 2017 9:18 PM
It's upsetting to me that from what you say your former dialysis clinic was not in compliance with the ESRD regulations. The ESRD Network should have thoroughly investigated your complaint. If the state agency surveyor investigated your complaint and found no evidence that your behavior warranted involuntary discharge and the clinic did not follow the steps to discharge you, I hope the surveyor cited the clinic. If so, the clinic would have been required to submit a plan of correction that the state would have had to approve. Hopefully having to do that would lead the clinic to act differently, which could protect someone else from facing the same fate as you. I don't know if the state could have required the clinic to readmit you, but I suspect that with all that happened to you, you wouldn't have wanted to return to that clinic.
So far as missing medical records, the only way to assure that your records are complete is to periodically ask to review them and keep copies. You have a right to inspect, review, and request a copy of your medical records. You also have the right to request a correction in your medical record if you find any errors. Here's the link to the HHS website describing this right. https://www.hhs.gov/hipaa/for-individuals/medical-records/index.html
Carla Hagood
Nov 10, 2017 3:38 AM
Beth Witten
Nov 10, 2017 9:44 PM
You can see a short video clip of Don Berwick expressing feelings that I suspect many of you (and the rest of us) have about being treated by a system in which care is far from patient-centered. I believe he was speaking to healthcare professionals so my hope is that things are changing. https://www.youtube.com/watch?v=5cpjsT1jd_s
Katherine Soto
Nov 10, 2017 3:22 AM
Beth Witten
Nov 10, 2017 9:56 PM