Out on Pass Request

The resident was admitted to Cold Spring Hills for a skilled stay to be rehabilitated. Insurance has approved this rehabilitation as they feel it is necessary for the well-being of the resident. Short-term residents going out for social visits or other non-medical-related appointments are discouraged from going out. The particular insurance carrier may deem a social visit or non-medical outing as a reason to deny the claim for the rehabilitative services resulting in immediate discharge from Cold Spring Hills. 

If you are requesting clearance for a medical appointment, please reach out to the medical clinic for further instructions. They can be reached at 516-622-7735.

I, {accompaniedBy}, as a representative of {residentsName}, a resident of Cold Spring Hills Center for Nursing and Rehabilitation, would like to take the resident on a leave out of the facility. I understand that there are added risks and hazards by leaving the grounds of the facility. I accept full responsibility for the resident while off facility property and agree to hold harmless Cold Spring Hills Center for Nursing and Rehabilitation from any liability.

I understand that the resident's attending physician and the interdisciplinary team must consent to my request

Iagree to abide by all the policies, procedures, and facility rules for residents leaving escorted.

Specifically, I agree to:

1. Exit and enter only through the front door;

2.Obtain a signed pass whenever I would like to take the resident out of the facility, and notify the unit nurse when the resident returns;

3. Leave a copy of the signed Escorted Out On Pass form at the Reception Desk;

4. Follow all care plan instructions and education provided to me by the facility. Should I forget a step or need guidance while out of the facility, I will call the nursing supervisor for assistance;

5. Carry a cellphone at all times and provide that number to the facility, in cases of emergency;

6. In the event of an emergency, I will call 9-1-1 for immediate assistance to the resident and notify the facility of the incident. I will provide any and all information related to the incident to the facility in compliance with NYS DOH and other governing and legal bodies;

7. Refrain from purchasing and bringing back any illegal or hazardous items for the resident along with food, beverages, cigarettes, smoking paraphernalia (including lighters or matches), illegal, or hazardous items for other residents;

8. Maintain the resident in appropriate attire for current weather conditions, and have them wear sunblock when appropriate or advised to do so;

9.Abide by any restrictions not to leave the facility after there has been an advisory of inclement weather conditions and/or weather predictions. These include, but are not limited to:

     a. Temperature Extremes:

          1) For colder temperatures, wind chill readings and predictions will be taken into consideration

          2) For warmer temperatures, humidity and air quality readings and predictions will be taken into consideration

     b. Inclement weather: This includes weather conditions that pose added risk to my well-being, including, but not limited to: snow, ice, wind, rain, lightning/thunder, sleet and hail.

10. I take full responsibility for notifying the facility if I am not returning the resident back to the facility by the designated time. If I do not return the resident back to the facility by the designated time and have not called, I understand that I will be in violation of the out on pass privileges. This will constitute my wishes to discharge the resident and therefore consider this my consent for discharging the resident against medical advice;

11. I understand that passes will be issued for escorted out on pass between the designated hours, unless special arrangements have been made in advance; 

12. I understand that if I do not follow the above conditions, this agreement permitting escorted out on pass and corresponding physician's order allowing my leave of the facility unescorted will be rescinded pending further administrative and interdisciplinary team review.

With my signature below, I acknowledge that I understand the risks and hazards by taking the resident off the grounds of the facility and have had the opportunity to discuss these risks and hazards with the appropriate staff member. Therefore, I accept full responsibility for the resident while off facility property and agree to hold harmless Cold Spring Hills Center for Nursing and Rehabilitation from any liability. Further, I understand that should I fail to return the resident at the designated time without notifying the facility, that this constitutes my wish to discharge the resident against medical advice effective immediately.

 I, {residentsName}, a resident of Cold Spring Hills Center for Nursing and Rehabilitation, would like to leave the facility independently and unescorted. I understand that there are added risks and hazards by my leaving the grounds of the facility unescorted. I accept full responsibility for myself while off facility property and agree to hold harmless Cold Spring Hills Center for Nursing and Rehabilitation from any liability.

I understand that my attending physician and the interdisciplinary team must consent to my request to do so.

I agree to abide by all the policies, procedures, and facility rules for residents leaving unescorted.

Specifically, I agree to:

1. Exit and enter only through the front door;

2. Obtain a signed pass whenever I would like to go out unescorted, and notify the unit nurse whenI return;

3. Leave a copy of the signed Unescorted Out On Pass form at the Reception Desk;

4. Carry identification and a cellphone at all times, as well as a non-hospital DNR if I have one;

5. Refrain from purchasing and bringing back any illegal or hazardous items for myself along with food, beverages, cigarettes, smoking paraphernalia (including lighters or matches), illegal, or hazardous items for other residents;

6. Dress appropriately for current weather conditions, and wear sunblock when appropriate or advised to do so;

7. Abide by any restrictions not to leave the facility after I have been advised of inclement weather conditions and/or weather predictions. These include, but are not limited to:

     a. Temperature Extremes

          1) For colder temperatures, wind chill readings and predictions will be taken into consideration

          2) For warmer temperatures, humidity and air quality readings and predictions will be taken into consideration

     b. Inclement weather: This includes weather conditions that pose added risk to my well-being, including, but not limited to: snow, ice, wind, rain, lightning/thunder, sleet and hail.

8. I take full responsibility for notifying the facility if I am not back in the facility by the designated time. If I am not back in the facility by the designated time and have not called, I understand that I will be in violation of my out on pass privileges. This will constitute my wishes to be discharged and therefore consider this my consent for discharge against medical advice;

9. I understand that passes will be issued for unescorted out on pass between the designated hours, unless special arrangements have been made in advance; 

10. I understand that if I do not follow the above conditions, this agreement permitting unescorted out on pass and corresponding physician's order allowing my leave of the facility unescorted will be rescinded pending further administrative and interdisciplinary team review.

Please confirm the following details:

You are requesting for {residentsName} to have an {typeOf} pass starting on {dateTaking} with an expected return of {expectedReturn}.