N.J. Admin. Code § Tit. 8, ch. 134, app APPENDIX
SAMPLE PPV AGREEMENT
____________________ PSYCHIATRIC HOSPITAL
PRE-PLACEMENT VISIT (PPV) PROGRAM
FACTS SHEET & PPV AGREEMENT
IMPORTANT INFORMATION ABOUT PPV's:
1. The purpose of a PPV is to give a client and a home provider time to get to know each other, and decide together whether the living arrangement is satisfactory. The provider will have the opportunity to review certain portions of the client's medical record (with the client's signed consent), with the understanding that this information is confidential. The client and provider will also have a face-to-face interview prior to the PPV.
2. A PPV may last for a maximum of 14 calendar days from the date the client is released from the hospital. During the PPV, the client is still on the census of the hospital, and has not been discharged.
3. To be eligible for PPV, the client must qualify for SSI and IAP, or have recurring income/benefits sufficient to sustain the community placement. If SSI/IAP eligible, the client and the provider will be asked to sign the IAP contract, MH-30, and SSI application upon the client's release to the PPV.
4. During the PPV, if the client does not have sufficient recurring income/benefits to pay the provider, the hospital will pay the client's room and board to the home provider and a Personal Needs Allowance to the client. If the client must return to the hospital, the provider will be paid for the days the client resided in the home.
5. The hospital will prescribe medications and continue Institutional Medicaid coverage for all clients while they are on PPV.
6. The client's hospital Treatment Team must be aware of the client's progress while on PPV, since the Team will decide whether the client may be discharged at the end of the PPV. It is important for both provider and client to communicate any problems or concerns as soon as possible.
7. A counselor from the client's Community Mental Health Center will be visiting during the PPV, and may even take the client to the Center for a program. This counselor should also be kept informed by both provider and client of how the PPV is going, since s/he is in frequent contact with hospital staff assisting the client with community adjustment.
8. If a problem or concern arises during regular business hours, the provider should contact __________________________ at (___)___-______. During evenings, weekends or holidays, the provider should call ____________________________ at (___)___-______. If it is necessary to return the patient, the hospital will arrange it. If a patient becomes missing, __________________ should be contacted immediately at (___)___-______.
9. At the conclusion of the PPV, if the client and provider have adjusted well to each other and wish to continue the arrangement, the client will be discharged with the Treatment Team's approval.
10. On the day of discharge, hospital-funded IAP will begin and continue until the SSI application is processed in accordance with the IAP program rules. If the client has his/her own sufficient funds and is not IAP eligible, s/he will continue to pay the provider.
11. If it appears that the client may be in need of immediate mental health intervention after s/he has been discharged from PPV status and the hospital, the home provider shall contact the local Screening Center for assistance.
PRE-PLACEMENT VISIT PROGRAM AGREEMENT
I, ______________________________, agree to accept _____________________________ into ___________________________________________
(Provider Name) (Patient Name) (Name and Address of Facility)
__________________________________ facility on a *_____-day PPV. I have been informed about the PPV program and agree to abide by its rules.
* The length of the PPV may be adjusted during the PPV considering input from the client and agreement between the Treatment Team and the housing provider.
(Signature of Provider) | (Date) | (Signature of Client) | (Date) |
Signature of Witness/Social Worker) | (Date) |
N.J. Admin. Code Tit. 8, ch. 134, app APPENDIX