Mandatory Client Signature Forms

• Welcome Letter introducing client's caregiver, and outlining what the caregiver can and cannot do
• Client Assessment outlining client's condition on admission
• Plan of Care outlining the care that will be provided to client by ATHHC
• Client Bill of Rights outlining client's rights and responsibilities as a client of ATHHC
• Grievance Procedure outlining the process to file a complaint
• Florida Abuse Hotline Document providing the number client or responsible party can call if I feel client is being exploited
• Privacy Policy outlining when and to whom client's records might be released
• Consent to Photograph giving the attending physician or other designated person permission to photograph the indicated parts of client's body to provide supporting documentation of medical conditions
• Fee Schedule outlining the financial agreement between client and ATHHC
• Service Agreement outlining the legal agreement between client and ATHHC
• Assignment of Benefit outlining ATHHC's policy on working with insurance companies
• Credit Card Authorization giving ATHHC permission to charge my credit card at the indicated frequency or in the event of non-payment by other means
• Self Medication Policy outlining that the Home Health Aide may not administer medications
• Medication Profile outlining the medications client is currently self-administering
• Advanced Directive Form outlining whether client has an existing Advanced Directive and explaining that ATHHC may assist client in preparing an Advanced Directive
• Release to Transport outlining ATHHC's transportation policy and releasing driver from liability
• Safety Assurance outlining the safety checks in client's home that I should be aware of
• Collier County Emergency Management Evacuation Form outlining client's evacuation plan in case of emergency

 

Once this packet is completed, all parties will receive an email with executed copies. If you prefer a printed copy, please notify us and one will be mailed to you.

Dear {clientName:first},

Thank you for choosing Always There Home Health Care as the team to help you remain in your home by assisting you with your activities of daily living. We would like to introduce our home health aide who has been assigned as your caregiver.

The home health aide is an important member of the Always There Home Health Care team and is trained to provide you with the best of care. The aide's primary function is to attend to your personal care needs. The duties and scheduels of the home heath aide have been determined according to the plan of care that was established with our case manager. The duties may include any or all of the following:

• Bath, shower or bed bath
• Temperature, pulse and respiration
• Back rub, skin care, foot soak
• Oral / mouth hygiene
• Hare care (excluding cutting)
• Nail care (excluding cutting)
• Shave male clients
• Feed and assist with fluids
• Assist with exercises when ordered
• Weigh and record weight
• Maintain a safe and clean bedside area
• Change bed linens
• Assist client on bedpan, bedside commode
• Assist client to bathroom
• Empty catheter bag
• Give catheter care
• Position the client
• Provide skin care

Please do not ask the home health aide to perform the following tasks as home health aides are not licensed by the State of Florida to perform these procedures and therefore are prohibited to render them:

• NO changing of sterile dressings
• NO application of heat or cold (any form)
• NO injections
• NO dispensing medication
• NO lifting entire weight of the client
• NO heavy house cleaning
• NO enema
• NO colostomy irrigations
• NO vaginal irrigations
• NO massage of a limb
• NO nail clippings

Please feel free to discuss any needs or concerns regarding the aide's performance the duties assigned. You can do this by calling Always There Home Health Care at 239-389-0170.

Thank you,

The Always There Home Health Care Team 

Client Name: {clientName}

Case Manager Name: {caseManager331}

Please Note: Client/Client Surrogate has been informed of the following policy:

• The client/client surrogate has the right to be informed of the plan of care
• The client/surrogate has the right to participate in the development of the plan of care
• The client/surrogate has the right to request a copy of the plan of care

Always There Home Health Care believes the patient has the right to be notified of their rights and responsibilities before services begin. Consistent with state laws, the patient's family or guardian may exercise the patient's rights when the patient is unable to do so. It is the policy of Always There Home Health Care that all patients will be treated with dignity and respect. Our policies will reflect required procedures of service. As a patient of Always There Home Health Care you have the following rights.

You have a right to...

1. Receive a timely response to your request for service upon receiving Doctor's orders
2. Be free from physical/mental abuse or neglect
3. Be given proper identification by name and title by all staff providing service
4. Receive a timely response to complaints made by you or your family regarding care or service
5. Call our staff for assistance at 239-389-0170
   
   TO REPORT SUSPECTED MEDICAID FRAUD which is any intentional deception or misrepresentation made by a person or provider with the knowledge that the deception could result in an unauthorized benefit to themselves or someone else. It includes giving false information, withholding information, billing for services not provided, or misusing Medicaid benefits.. This includes any fraudulent act defined under federal or state Medicaid laws. Complaints about Medicaid billing fraud can be filed with the Office of Medicaid Program Integrity at 1‑888‑419‑3456 or through their website online complaint form at https://myfloridalegal.com. 
   
   TO CONTACT THE AGENCY COMPLAINT HOTLINE PLEASE CALL 1-888-419-3456
   
   TO REPORT ABUSE, NEGLECT OR EXPLOITATION PLEASE CALL 1-800-962-2873
   

You have a right to...

1. Be advised of your rights and responsibilities prior to the start of service
2. Permit your designated agent to exercise your rights if you are unable to do so
3. Refuse all or part of care and to be informed of expected consequences of such action
4. Be given information about the care provided, including revisions to your Plan of Care
5. Be notified in advance of any changes prior to implementation of the change
6. Be given forthright information regarding home health care in general and Always There Home Health Care in particular

You have a right to...

1. Be advised of your rights and responsibilities prior to the start of service
2. Permit your designated agent to exercise your rights if you are unable to do so
3. Refuse all or part of care and to be informed of expected consequences of such action
4. Be given information about the care provided including revision of Plan of Care
5. Be notified in advance of any changes prior to implementation of the change
6. Be given forthright information regarding home healthcare in general and Always There Home Health Care in particular

You have a right to...

1. Have all information concerning care treated confidentially
2. Be given information if the care is terminated or transferred to another agency
3. Have our staff release information only as consistent with policy as authorized by patient
4. Confidentiality with regard to what take place in the home

You have a right to...

1. Be advised as to the extent of financial obligation due to the agency
2. Be informed that Always There Home Health Care is a privately owned corporation
3. Be informed of any benefit to Always There Home Health Care if it refers to another agency
4. Have access to all bills regardless of payment method or other part

You have a right to...

1. Appropriate and professional care without discrimination
2. Be provided information concerning aspects of your care that relates to the care provided
3. Be provided written information to formulate advanced directives
4. Be free from discrimination based on lack of an advanced directive
5. Be provided appropriate opportunity for you and your family to participate in ethical issues that arise from your case

You have a responsibility to...

1. Arrange and assure access of staff into their homes
2. Provide a safe atmosphere for the staff by restraining aggressive pets 
3. Be available for scheduled visits
4. Notify Always There Home Health Care when the patient will be unavailable for visits
5. Obtain medications and supplies as ordered by the client's physician

This notice describes how Medical Information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

UNDERSTANDING YOUR HEALTH CARE RECORD OR INFORMATION

Each time you visit or have contact with a hospital, physician or other healthcare provider (including this home care agency) documentation of the visit or contact is made. Normally, this documentation contains information regarding your health: symptoms, diagnosis, examination, treatment and an ongoing plan for your care and treatment. This information is often referred to as your health, medical or clinical record. It serves as a basis for planning your care and treatment and serves as a means of communication among the many health professionals who participate in your care. Understanding what is in your health records and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where and why others may access your health information and will also help you to make more informed decisions when asked for authorization to disclose this information to others.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

Unless otherwise required by law, your health care record is the physical property of the healthcare provider that compiled it, but the information belongs to you. You have the right to request a restriction on certain uses and disclosures of your information and request amendments to your health care record. This includes the rights to obtain a paper copy of the notice of information practices upon request, inspect and obtain a copy of your health record, obtain an accounting of disclosures of your health information, request communications of your health information by alternative means or at alternative locations, revoke your authorization to use or disclose health information except to the extent that action has already been taken.

RESPONSIBILITY OF ALWAYS THERE HOME HEALTH CARE

Always There Home Health Care is required to maintain the privacy of your health information. In addition, we are required to provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you. This agency must abide by the terms of this notice, notify you if we are unable to agree to a requested restriction, accommodate reasonable request you may have to communicate health information by alternative means or at alternative locations. We reserve the right to change our practices and to make the new provisions effective for all the protected health information we maintain. Should our information practices change, we will hand-deliver or mail a revised notice to the address you have supplied us. If we maintain a Web site that provides information about our customer services or benefits we will post our new notice on that Web site. We will not disclose your health information without your authorization, except as described in this notice.

EXAMPLES OF DISCLOSURE FOR TREATMENT, PAYMENT AND HEALTH OPERATIONS

The agency staff will utilize your health information for treatment. The health information you provide or the information that is obtained by the agency will be recorded in your clinical record. This information, which is compiled during the assessment, will be used to develop your Plan of Care. We will do this with your input and orders from your physician. The Plan of Care will include what kind of services you require i.e.aide, nursing, therapy, etc., how often, what the specific service is expected to do and what outcomes are expected from each service as well as your expected overall outcomes. Members of your health care team, i.e. aide, nurse or therapist, etc. will document the care they provide and their observations. For example, the physical therapist will document the exercise h/she id with you and how well you did. If you you practiced stair climbing, the document will show that stair climbing was done, how many stairs you were able to climb and if you had any problems such as shortness of breath while climbing the stairs. We will also provide each member of your health care team with the information needed in orderto care for you. For example, all members will be provided with information regarding your advance Directives if you have chosen to execute an advance directive. The physical therapist will also be provided with your history and information regarding your mobility and ability to get around.

The agency will utilize your health information for payment. For example, a bill may be sent to you, a third party or whoever is responsible to pay the bill for your care. The information on the bill may include information that identifies you, your diagnosis, the type and amount of service you received as well as any supplies or equipment. The agency will utilize your health information for health operations. For example, member of the quality improvement team may review your record as well as other client's records and utilize the information to assess the care and the outcomes from the care. This information will be utilized in an effort to continually improve the quality and effectiveness of the care and services the agency provides. There may be some services provided to our agency through contracts with Business Associates. Examples include consultants we use to audit clinical records, policies and procedures and our business operations to ensure compliance with Federal, State and Local Regulations and quality standards. Other examples of Business Associates include individuals or organizations that may provide the following services: legal, actuarial, accounting, management, administrative, accreditation, data aggregation or financial services. When we utilize these services we do so under contract with the individual or organization. We may disclose parts or all of your health information to the Business Associate so that they can do the task we asked them to do. In order to protect your health information, we include a clause in the contract about the need for the Business Associate to also safeguard your information.

We may also use or disclose information about you in order to notify a family member, caregiver, or a person responsible for your care, your location and your general condition. We may disclose information to researchers when you choose to participate in a research project. Disclosure will be made only after review of the research protocols to ensure that your health information will remain private. We may disclose your health information to a funeral director as required under law so that they can carry out their duties.

ORGAN PROCUREMENT ORGANIZATIONS

Consistent with your wishes and with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation or transplant.

We may contact you to provide appointment dates or information about treatment alternatives or other health related services that may be of interest to you. We may contact you as part of a fund-raising drive. As required by law, we may disclose your health information to the FDA if you should experience an adverse event with food, supplements, product and product defects or information that will enable product recalls, repairs or replacements. We may disclose your health information that is necessary to comply with laws related to workers' compensation or other similar programs established by law.

FOOD AND DRUG ADMINISTRATION (FDA)

We may disclose your health information, as required by law, to public health or legal authorities responsible for tracking births and deaths, as well as with preventing or controlling disease, injury or disability. If you are or become an inmate of a correctional institution, we may disclose your health information to the institution or to a representative of the institution. This health information is necessary for your health as well as the health and safety of others. An inmate does not have the right to the Notice of Privacy Practices.

As required by law, we may disclose health information for law enforcement purposes or in response to a valid subpoena. Federal law requires release of your health information to appropriate health oversight agencies, public health authority or attorney, if a staff member or Business Associate believes that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are potentially endangering one or more clients, workers or the public.

A hard copy of this privacy notice will be provided to you and all clients upon admission to the agency. It will also be prominently posted in the agency office at 317 North Collier Blvd, Suite #201, Marco Island, Florida 34145. If the Notice of Privacy is revised, you will receive a hard copy via mail at the address you have provided to us.

HIPAA PRIVACY NOTICE

The agency or its professional using their best judgment, may disclose to a family member, other relative, close personal friend or any other person you identify of your health information relevant to that person's involvement in your case or the payment related to your care.

By signing below, you acknowledge you have received, read and understand the Privacy Notice of Always There Home Health Care. 

TO REPORT A PROBLEM OR TO REQUEST FURTHER INFORMATION

If you would like additional information or if you feel your privacy rights have been violated you may contact Rosalind Minicozzi, Administrator at (239)-389-0170. You can also file a complaint with the Secretary of Health and Human Services at (800) 368-1019. There will be no retaliation for filing a complaint.

I, {clientName} (client), a current client of Always There Home Health Care (agency), hereby authorize the attending physician or other designated person(s) to take:

Hourly Rate	$35 per hour for up to 7 hours $33 per hour for 8 hours or more
Live-In Rate	$365 per day
Nursing Assessment	$60 (fee assessed if case lasts fewer than 2 weeks)
Medication Set-Up	$60 per visit
Last-Minute Cancellation Fee	$50 (if visit canceled fewer than 4 hours in advance)
Bath Service	$50 (maximum 1 hour)
Transportation Fee	$0.55 per mile, billed when caregiver uses own vehicle
Service on Federal Holidays*	Charged at time and one half

 

* Federal holidays include: New Year's Day, Easter Sunday, Memorial Day, Independence Day, Labor Day, Thanksgiving Day and Christmas Day.

Effective 01/01/2023

 

I acknowledge that I have read and agree to the above Fee Schedule

Definitions

Weekdays are defined as 7am Monday through 11pm on Friday.

Weekends are defined as 11pm on Friday through 7am on Monday.

Holiday and overtime (hours worked in the same clients' home over 40 hours a week at the client's request) will be billed at 1.5 times the regular time (time and one half).

Payment Responsibility

Medicare and Medicaid will not reimburse for the services requested, however, if there is a long-term home health care policy, the appropriate paperwork for the reimbursement will be provided by ATHHC so that it can be forwarded to the insurance company. Any payments not covered by the policy up to the entire amount will be the client responsiblity.

By my signature below, I acknowledge that I have read and fully understand the provisions of the Service Agreement. I understand that this representation is not a guarantee of payment by my insurance company. I understand that I am primarily responsible for all charges and that I will be held responsible for any applicable deductibles, co-insurance payment and non-covered services not paid after consideration of benefits by any and all payers, at time of verification or upon claims submission. ATHHC will be glad to provide you with the necessary paperwork for insurance submission.

I understand the charges, terms and conditions herein explained and that ATHHC may terminate any and all services for failure to pay the bill and if there is no compliance with payer requirements (i.e. pretreatment doctor's orders). I also understand that I may terminate any and all services for any reason upon reasonable notice to ATHHC.

Staffing Responsibility

Always There Home Health Care will do everything within its control to meet your individual staffing needs and requests. In the event we are unable to do so, you will be notified, and it will be the responsiblity of the family or guardian to secure an appropriate caregiver. Furthermore, it is the responsiblity of the family or guardian to make safeguard/care provisions before and after the assigned work time of the home health aide.

Non-Solicitation

I further understand that Always There Home Health Care is acting as the employer of the caregivers assigned to my care and that Always There Home Health Care has inherent cost in maintaining their employees, including advertising and administration cost.

I hereby agree that I, my significant other, family member(s), visitor(s) to our home, or any person or entity acting on my behalf, will not, either directly or indirectly, attempt to solicit for hire any caregiver assigned to my care, during the term of this Agreement and for a period of one (1) year immediately following the date the caregiver's employment is voluntarily or involuntarily terminated.

I acknowledge that the caregiver assigned to my care has executed an Agreement with ATHHC which contains a non-solicitation/non-servicing of clients and potential clients provision. I further acknowledge that this provision is effective during the term of the caregiver's employment with ATHHC and for a period of one (1) year immediately following the date the caregiver's employment is voluntarily or involuntarily terminated.

I acknowledge that a breach of the foregoing provision will result in immediate and irreparable harm to ATHHC entitling ATHHC to immediate injunctive relief. I further acknowledge that ATHHC's entitlement to such injunctive relief is in addition to all other remedies at law or in equity available to ATHHC.

Right to Recover Fees

I understand and agree that the prevailing party in any litigation involving the enforcement of this Agreement shall be entitled to recover from the non-prevailing party its cost and attorney's fees.

Severability

This agreement is severable and in the event that any one of the provisions hereof shall be deemed invalid, illegal or unenforcable in any respect, the validity and legality of the remaining provisions contained herein shall not in any way be affected or impaired thereby.

Signatures

This charge is for home health services.

Please complete and sign this form to authorize Always There Home Health Care to make credit card payments for the home health services that you receive.

A 3.5% convenience fee (minimum $3.00) will be assessed on all credit card transactions.

By signing below I authorize Always There Home Health Care to charge the credit card according to the terms indicated above. I certify that I am the authorized user of the card and that I will not dispute the charges with my credit card company so long as the transactions accurately correspond to the services I receive.

Always There Home Health Care is required under FS Refs 400.488 to inform the client or client's surrogate, guardian or attorney that the client may be receiving assistance with self administered medication from a person other than a licensed RN or LPN. Since only the RN and LPN are licensed and permitted under law to assist with self-medication, a written consent by the client or client's surrogate, guardian or attorney is required in the client's chart acknowledging that an unlicensed person will be assisting with medication.

Always There Home Health Care maintains the following policy for home health aides in the assistance with self-administered medications:

• Personal care activities contained in a written assignment by a health professional employee of the home health agency which include assisting the client with personal hygiene, ambulation, eating, dressing, shaving and physical transfer
• Other activities as taught by a health professional employee of the home health care agency for a specific client and are restricted to the following:
  • Assisting with the change of a colostomy bag, reinforcement of a dressing
  • Assisting with the use of devices for aid to daily living such as a wheelchair or walker
  • Assisting with prescribed range of motion exercises
  • Assisting with prescribed ice cap or collar
  • Doing simple urine tests for sugar, acetone or albumin
  • Measuring and preparing special diets
  • Measuring intake and output of fluids
• Keeping records of personal health care activities
• Observing appearance and gross behavioral changes in the client and reporting to the supervising registered nurse
• Supervision of self-administered medication in the home limited to the following:
  • Obtaining the medication container from the storage area (if applicable)
  • Preparing necessary items such as juice, water, cups or spoons to assist the client in the self-administration of medication
  • Reminding the client that it is time to take medication as prescribed
  • Observing the client self-administering the medication

The home health aide shall not:

• Change sterile dressings
• Irrigate body cavities
  • Give an enema
  • Irrigate a colostomy
  • Irrigate a wound
  • Perform a gastic irrigation
  • Perform enteral feeding
  • Catheterize
• Administer medication
• Apply heat by any method
• Care for a tracheotomy tube
• Provide any personal health service which is not included in the client's plan of care

Any further assistance with self-administration of medication by an unlicensed person is at the sole discretion of Always There Home Health Care and its training on an individual employee basis in addition to the minimum of two hours required per Refs 400.488 whcih will be documented in the employee's file.

By signing below I acknowledge I have read and understand the above terms which may and may not be carried out by a home health aide.

I, {clientName}, have been informed by {caseManager331}, a registered nurse employed by Always There Home Health Care, of the importance of planning ahead for my future health care decisions. Always There Home Health Care has informed me that if I would like to be provided with the forms to make these decisions and compile an Advanced Directive, they have the necessary form in their office and they will provide me with them immediately, if I so request.

I understand that: 

• I have the right to accept or refuse medical care
• I have the right to create an Advance Directive
• Always There Home Health Care will follow my Advance Directive to the extent required by Florida law
• My care will not be affected by whether or not I have an Advance Directive

Required Acknowledgement (per Florida 59-A.0245)**

Always There Home Health Care "the company" requires its employees to carry automobile insurance and furnish us with proof of insurance upon hire. However, in the event an employee is asked to transport the client then this request will be honored by the home health aide simply on a voluntary basis and is not part of the aide's usual and customary job responsibilities. In fact, transportation is not in the aide's job description. Therefore, the company cannot assume responsibility for the safe operating conditoin of the car or the driver. The client must accept full responsibility for any and all liability during the time that the client is being transported by the employee.

It is further understood that the client will be responsible for the cost of fuel, tolls and other out-of-pocket expenses associated with transportation.

In order for our personnel to transport the client it will be necessary for you to sign this release. If an employee is driving the client's car we will need to have the client's insurance information.

By signing this waiver of liability the client accepts full responsibility for any bodily injury they may incur while being transported by an Always There Home Health Care employee.

Pursuant to 59A-8.027 and 400.492 F.S. of the State of Florida, Always There Home Health Care is compiling information for the Collier County emergency and Safety Management Division having used the "Emergency Management Planning Criteria for Home Health Agencies" form number AHCA 3110-1006, February 2001. The Agency has requested all home care agencies to assist them during mandatory evacuation of the area. They have asked us to submit a list of those people who are presently being serviced by our caregivers.

Every year, the Collier County Emergency and Safety Management Division sends us new forms that will be filled out. We must dispose of the previous years forms and send new ones to the County. Our Case Manager will have you fill out a new form if the client is still receiving our service.

The following information will assist us during an emergency situation or a mandatory evacuation.

Consent for Services

I hereby authorize Always There Home Health Care (ATHHC) to provide services and supervise those services as outlined in the Service Agreement. I confirm that I have been informed of, and have participated in planning, the care and procedures to be carried out by ATHHC and I sign this consent willingly and voluntarily.

I further understand that this consent is valid beginning with the initial visit by an ATHHC employee. By signing this agreement I give my consent for the RN to make subsequent visits after the initial visit. I may withdraw my consent at any time by notifiying ATHHC and services will be discontinued.

Release of Information

I have been provided with a copy of the privacy act and the Client Bill of Rights. Therefore, I am aware that client's records and other pertinent information related to client's care may be released in order to obtain reimbursement from client's insurance company (if insurance is paying all or part of bill) or others who are outlined in the Health Insurance Portability Accountability Act of 1996 (HIPAA) Privacy Policy.

It has been explained to me that Always There Home Health Care is required by the licensing body of the State of Florida to comply with all necessary paperwork when providing home health services in the home. By signing this document I acknowledge that Always There Home Health Care's case manager has presented me with and reviewed the following: