Landmark Medical Center

Pass Policy & Procedures

Counselor and patient giving each other fist bumps.

Policy

Passes with family/friends help assist our population to achieve the objective of improving and developing satisfactory personal relationships. Time away from a locked setting and socializing in a community setting helps the treatment team evaluate the readiness of the client for a lower level of care. Clients must earn passes by having behavior that complies with social norms and expectations of the resident, group attendance, and following medication routine. The available hours for a pass are: 10-hour pass Saturday OR Sunday; Every weekend.

Procedure

1) INFORM WHOEVER IS PICKING UP OUR CLIENT THAT THEY MUST ESCORT THE CLIENT BACK INTO THE BUILDING AFTER THE PASS IS COMPLETE.

2) THE PERSON WHO IS DROPPING OFF THE CLIENT MUST NOT DROP OFF CLIENT CURBSIDE. THE PERSON MUST WALK THE CLIENT TO THE LOBBY DOOR, RING THE BELL, WAIT FOR A STAFF MEMBER TO COME OUT, AND RECEIVE THE CLIENT.

3) WHEN THE PERSON COMES TO PICK UP THE CLIENT, PLEASE GIVE THEM THE PASS EVALUATION FORM.

4) WHEN THE PERSON COMES BACK FROM THE PASS, ASK FOR THE EVALUATION FORM.

5) FACILITY POLICY SUPERSEDES PASS REQUEST, FOR EXAMPLE:

  • A CLIENT GETS A 10-HOUR PASS BUT THE PERSON PICKING THEM UP SHOWS UP AT 4 PM. FACILITY POLICY STATES THAT A CLIENT MUST BE IN THE BUILDING BY 8 PM, SO THAT MEANS THE 10-HOUR PASS HAS BECOME A 4-HOUR PASS.
  • A CLIENT GETS A 10-HOUR PASS BUT THE PERSON PICKING THEM UP SHOWS UP AT 11:30 AM. FACILITY POLICY STATES THAT A CLIENT MUST BE IN THE BUILDING BY 8 PM, SO THAT MEANS THE 10-HOUR PASS HAS BECOME AN EIGHT-AND-A-HALF-HOUR PASS.
  • THE EARLIEST A CLIENT CAN BE PICKED UP IS 10 AM. IF THE PERSON WHO IS PICKING UP THE CLIENT ARRIVES AT 9:30 AM. THE PERSON MUST WAIT UNTIL 10 AM TO LEAVE WITH THE CLIENT. THE FRONT OFFICE ALWAYS INFORMS PEOPLE REQUESTING PASSES OF THESE POLICIES.

6) A 10-HOUR PASS INCLUDES TRAVEL TIME.

7) DRUG SCREEN WILL BE DONE UPON RETURN POSITIVE TEST RESULT WILL AFFECT FUTURE PASSES.

8) IF INAPPROPRIATE BEHAVIOR OCCURS AFTER THE COMMITTEE MEETS AND/OR AFTER HOURS THE CHARGE NURSE MAY CANCEL THE PASS. EVERY EFFORT WILL BE MADE TO CONTACT THE FAMILY/FRIEND ABOUT THE CHANGE BEFORE THE PERSON ARRIVES. IT IS RECOMMENDED THAT THE PERSON PICKING UP THE CLIENT CALL LANDMARK TO VERIFY THAT THE PASS IS STILL APPROVED.

9) The charge nurse may refuse re-entry to the unit if circumstances warrant, keeping the resident in the inner lobby with a staff member. IMMEDIATELY CALL THE D.O.N and ADMINISTRATOR!

10) If the resident is clearly intoxicated and the pass was with the conservator, the conservator will be required to take the resident to Pomona Valley Hospital Medical Center.

Administrative Procedure

A) All requests for passes are reviewed weekly by the pass committee. The committee consists of the Program Director and the Director of Nursing or their designee. Conservator must approve a pass if it is the first pass with the person requesting the pass.

B) A request must be called into the receptionist by Wednesday of the week being requested.

C) The person requesting a pass must call on Friday after 1 p.m. to get the results of the committee meeting.

D) Passes are only on the weekend, one weekend day, Saturday, or Sunday. This is so there is less interference with the weekday treatment program.

E) A client must be in the facility for at least 30 days before any pass is granted.

Criteria for Pass Denial

The following is a list of reasons, not all-inclusive, for which pass requests will be denied.

1) Missing four or more groups per week.

2) Being consistently late or refusing showers/baths, medications, or meals.

3) Breaking facility rules(resident may see the list on the unit bulletin board if they lose their copy).

4) Fighting or striking out at peers or staff.

5) Bringing contraband into the facility, in any manner.

6) Having matches or lighters on your person.

7) Smoking in non-designated smoking areas and times.

8) If physically ill.

9) Other behavior deemed inappropriate by the pass committee.

HELPFUL SUGGESTION FOR YOUR PASS

1. The person who is dropping off the client after the pass must NOT drop off the client curbside. The person must walk the client to the lobby door, ring the bell, and wait for a staff member to come out and receive the resident.

2. Never leave your loved one alone, they should always be supervised.

3. All residents going out on pass will be tested for substances such as drugs and alcohol upon return.

4. A positive test for substances will result in loss of passes and hinder discharge planning for your loved one.

5. If you have any problems with your loved one during the pass please return to the facility or call 911 if needed.

6. Report any issues or concerns you might have about your loved one’s behavior during your pass on PASS RECORD FORM AND STAFF UPON RETURN.

7. Give medications as prescribed and instructed.

8. Give any personal items you want your loved one to have to staff upon return so the item can be labeled and recorded.

9. Do not give or leave your loved one any form of cigarettes/cigars, food, or drink upon return to Landmark.