Current through Register Vol. 54, No. 7, April 4, 2022
|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
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.
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
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.
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
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
PRE-PLACEMENT VISIT PROGRAM AGREEMENT
I, ____________________ , agree to accept
(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)
(Signature of Witness/Social Worker) (Date)