New Jersey Administrative Code › Title 8 - HEALTH › Chapter 134 - PRE-PLACEMENT PROGRAM › Appendix - APPENDIX

Current through Register Vol. 56, No. 14, July 15, 2024
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)