Helping Hands SUPERIOR CARE LLC

Helping Hands SUPERIOR CARE LLC
WELCOME LETTER
Welcome to Helping Hands Superior Care ! We are honored to be a part of your care journey. Since 2016, we've been proudly serving families across the Tampa Bay area with heartfelt dedication and professional care. Founded by a healthcare professional with over 20 years of experience, our team understands the importance of trust, comfort, and reliability when it comes to supporting your loved ones.
At Helping Hands Superior Care LLC, we are more than just a home care agency we are a family committed to providing the very best care with respect, dignity, and compassion.

OUR MISSION

We are dedicated to providing compassionate, high-quality support to seniors and individuals with disabilities, ensuring they receive the care they need to thrive in a safe, familiar, and comfortable setting. Our goal is to enhance daily living, foster independence, and bring peace of mind to families.

OUR VISION

We envision a world where every person, regardless of age or ability, has access to high-quality, reliable care that enhances their well-being and promotes a fulfilling life at home.

OUR FOCUS

As a company, we focus on continuous improvement and innovation expanding our services to better meet diverse needs and ensure every client receives the best care possible.

If we're not the right fit, we'll help guide you to another agency that can provide the support you need.

Thank you for trusting Helping Hands Superior Care LLC. We look forward to supporting you and your family every step of the way.

Warmly,
The Helping Hands Superior Care Team
CLIENT CONSENT FOR SERVICES
Client Name
Date of Birth

MonthDayYear
Date
Start Date of Services

MonthDayYear
Date
CONSENT TO RECEIVE HOME CARE SERVICES

I, the undersigned client or legal representative, hereby consent to receive home care services provided by Helping Hands Superior Care LLC. I understand and agree to the following:
- Services will be rendered in accordance with my personalized care plan developed after assessment by a qualified healthcare professional.
- I retain the right to participate in planning and modifying my care at any time.
- I understand that services will be provided by trained, credentialed professionals including Caregivers, CNAs, HHAs, LPNs, or RNs, as appropriate to my needs.
- I acknowledge my right to refuse services at any time and understand that refusal may impact the outcome of my care.
- I understand that any personal health information shared with Helping Hands Superior Care LLC will be kept confidential and managed in compliance with HIPAA regulations.
- I understand that this consent remains valid unless revoked in writing. There is no contract, just a 30day notice to end services.
SIGNATURES
ClientLegal Representative Name Print
Signature of Client Legal Representative

Clear
Relationship to Client if applicable
Date

MonthDayYear
Date
Agency Representative Name
Signature of Agency Representative

Clear
Date

MonthDayYear
Date
CONSENT TO RELEASE CONFIDENTIAL INFORMATION
Client Name
Date of Birth

MonthDayYear
Date
I hereby authorize Helping Hands Superior Care LLC to release andor receive confidential information about me as described below
Information to be Released / Obtained

Medical RecordsService PlansCare AssessmentsEmergency Contact InformationMedical RecordsHospital or Provider ReportsOther
Purpose of Releases:

Continuity of CareEmergency ServicesInsurance or Medicaid BillingCoordination with Healthcare ProvidersLegal or Governmental RequirementsOther
Person(s) / Organization(s) Authorized to Receive / Provide Information:
1
2
3
Client Rights & Acknowledgments:
- I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken.
- I understand that signing this form is voluntary and will not affect my eligibility for care or services.
- This consent is valid for one (1) year from the date signed unless revoked earlier in writing.
ClientAuthorized Representative Signature

Clear
Printed Name
Date

MonthDayYear
Date
Relationship to Client if applicable
Witness Signature Agency Staff

Clear
Date

MonthDayYear
Date
Emergency Management Form
Client Information:
Client Name
Date of Birth

MonthDayYear
Date
Client ID
Primary Contact
Primary Contact Phone
Emergency Contact:
1. Name
1.1 Relationship
1.2 Phone Number
2. Name
2.1 Relationship
2.2 Phone Number
2.2 Phone Number
Medication Information
Primary Physician
Allergies
Current Medications
Preferred Hospital
Emergency Plan
Evacuation Plan: (Describe the steps for evacuation, including designated meeting points and transportation arrangements)
ShelterinPlace Plan Outline procedures for staying safe at home including emergency supplies and communication methods
Special Instructions Any specific needs or instructions for the client in case of an emergency
Emergency Contact and Resource
Local Emergency Services: 911
Poison Control
Utility Company
Home Care Agency Contact
Phone
Client Acknowledgment
I acknowledge that I have reviewed and understand the emergency management plan.
Client/Representative Signature:

Clear
Date

MonthDayYear
Date
ACKNOWLEDGMENT OF DO NOT RESUSCITATE (DNR) ORDER / POWER OF ATTORNEY (POA) / GUARDIANSHIP DOCUMENTS
Client Name
Date of Birth

MonthDayYear
Date
Date of Acknowledgment

MonthDayYear
Date
PLEASE CHECK ALL THAT APPLY:

I have a valid Do Not Resuscitate (DNR) order in place.I have assigned a Power of Attorney (POA) for healthcare decisions.I have a legal guardian appointed by the court.None of the above apply at this time.
IF APPLICABLE, PLEASE PROVIDE COPIES OF THE FOLLOWING DOCUMENTS:
- Do Not Resuscitate (DNR) Order
- Power of Attorney (POA) Documents
- Guardianship Papers
  
  These documents will be securely stored in the client's confidential file to ensure appropriate care and compliance with legal and medical directives.
ACKNOWLEDGMENT:
I understand that it is my responsibility, or that of my legal representative, to provide Helping Hands Superior Care LLC with accurate and up-to-date copies of any applicable DNR, POA, or guardianship documentation. I acknowledge that without such documentation, emergency medical services will proceed with full resuscitation efforts as per standard protocols
Client Legal Representative Name Print
Signature

Clear
Date

MonthDayYear
Date
Relationship to Client
Staff Name Print
Staff Signature

Clear
Date

MonthDayYear
Date
Policy Overview

At Helping Hands Superior Care LLC, we take all complaints and grievances seriously. We believe that every client and their family has the right to voice concerns without fear of retaliation or compromised services. This form is provided so that any individual whether a client, family member, caregiver, or community partner can formally report a concern regarding services, staff, care quality, safety, or any other issue. All complaints will be investigated in a timely, fair, and confidential manner. We aim to resolve all concerns within 7-10 business days. Follow-up communication will be made to the individual who submitted the complaint if contact information is provided.
COMPLAINTS/GRIEVANCES FORM
We are committed to providing high-quality, compassionate care. If you have experienced any issues or concerns, please complete this form so we can address and resolve the matter promptly.
Client Information
Client Name
Date of Birth

MonthDayYear
Date
Phone Number
Address
Person Reporting (if different from client)
Name
Relationship to Client
Phone Number
Details of Complaint or Grievance
Date of Incident

MonthDayYear
Date
Time of Incident if known
Location of Incident
Staff Involved if known
Please describe the issue or concern in detail
Have you reported this issue to anyone already?

YesNo
If yes to whom and when
Preferred Resolution or Outcome
Would you like to be contacted regarding this complaint?

YesNo
If yes best time to reach you
Signature

Clear
Received by
Date Received

MonthDayYear
Date
Followup Action Taken
Resolution Date

MonthDayYear
Date
Staff Signature

Clear
HIPPA COMPLIANCE PATIENT CONSENT FORM
Client Name
Date of Birth

MonthDayYear
Date
Our Notice of Privacy Practices explains how we may use or disclose your protected health information (PHI) for treatment, payment, and healthcare operations in compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA)

You have the right to review our Notice before signing this Consent. If our Notice changes, you may request an updated copy at any time.
The Patient Understands and Acknowledges the Following:
- PHI may be used or disclosed for treatment, payment, and healthcare operations.
- I have the right to request restrictions on how my PHI is used or disclosed. However, the practice is not required to agree to those restrictions.
- I may revoke this Consent in writing at any time. This will not affect disclosures already made based on prior consent.
- The practice has provided access to its Notice of Privacy Practices.
- The practice may change its Notice of Privacy Practices and I may request a current version at any time.
- The practice may condition treatment upon execution of this Consent.
Communication Preference:
May we contact you by phone, email, or text to confirm appointments?

YesNo
May we leave a voicemail or message on your answering machine or cell phone?

YesNo
May we discuss your medical condition with family members?

YesNo
If yes, list approved individuals:
1
Relationship
2
Relationship
HIPAA REGULATIONS ACKNOWLEDGMENT

By signing this document, I acknowledge and agree:
- I have received a copy (or had access to review) the agency's Notice of Privacy Practices.
- I understand how my health information may be used or disclosed.
- I understand my rights regarding my PHI, including the right to request restrictions or revoke this consent in writing.
- I understand this consent is valid until revoked in writing.
Signature and Consent
Patient Representative Name Printed
Signature

Clear
Date

MonthDayYear
Date
If signed by a Representative:
Relationship to Patient
Witness Name Printed
Witness Signature

Clear
Date

MonthDayYear
Date
WAIVER OF LIABILITY AND HOLD HARMLESS AGREEMENT FOR CLIENT TRANSPORTATION IN STAFF VEHICLE

This Waiver of Liability and Hold Harmless Agreement is made and entered into by and between Helping Hands Superior Care LLC ("Agency") and the undersigned individual or authorized representative of the individual receiving services ("Client") on the date written below.

Purpose:
Client acknowledges and understands that transportation services may be provided by Agency staff using their personal vehicles. This agreement outlines the responsibilities, risks, and reimbursement guidelines associated with such transportation.

1. Voluntary Participation

Client agrees that the use of transportation in a staff member's personal vehicle is voluntary and provided as a convenience.

2. Assumption of Risk

Client acknowledges that being transported in a personal vehicle carries inherent risks, including the possibility of injury or property damage. Client accepts and assumes full responsibility for any risks arising out of, or in connection with, transportation services.

3. Waiver of Release

To the fullest extent permitted by law, Client hereby waives, releases, and discharges Helping Hands Superior Care LLC, its owners, employees, contractors, and affiliates from any and all liability, claims, demands, causes of action, or damages arising out of transportation services provided by Agency staff in their personal vehicles.
4. Hold Harmless

Client agrees to indemnify and hold harmless Helping Hands Superior Care LLC and its staff from any claims, costs, or liabilities, including attorney fees, arising out of or related to transportation in a staff member's personal vehicle.

5. Mileage Reimbursement (For Internal Staff Use Only)

Staff who provide client transportation in their personal vehicles will be reimbursed for mileage at the standard rate for 2025, currently $0.67 per mile, or the rate in effect at the time of service. Mileage must be properly documented and submitted for approval per company reimbursement policy.

6. Insurance and Licensing

All staff providing transportation must maintain valid driver's licenses and insurance coverage as required by law. The Agency does not assume responsibility for any uninsured incidents or citations issued during transport.

7. Acknowledgment

By signing below, Client acknowledges that they have read, understood, and voluntarily agree to the terms and conditions of this Waiver of Liability and Hold Harmless Agreement.

Client Name: Date of Birth: Signature (Client or Legal Representative): Date:
Client Name
Date of Birth

MonthDayYear
Date
Signature Client or Legal Representative

Clear
Date

MonthDayYear
Date
Agency Representative Name
Date

MonthDayYear
Date
Signature

Clear
Assistance with Medications by Unlicensed Person
I,
(RN or LPN), have completed a thorough review of the medications that assistance will be provided with, ensuring that the CNA/Aide has the proper training and that assistance aligns with the medication prescription.
I,
(Client/Client Representative), or my surrogate, guardian, or power of attorney, acknowledge that I may receive assistance with the self- administration of medications from an individual who is not licensed to practice nursing, but who is under contract with the nurse registry and has received training to assist with medication self- administration in accordance with agency policy ("unlicensed person"
Note: Clients who are able to self-administer their own medications independently will be encouraged to do so.

Unlicensed persons may assist with medication in accordance with a dispensed prescription's label or the directions on over-the-counter medications, provided the client is medically stable and the medications are part of a routine, regular schedule intended for self-administration.

Permissible assistance includes:

(a) Retrieving the medication from its previously dispensed, properly labeled container, and delivering it to the client.

(b) Reading the label, opening the container, removing the prescribed dosage in the presence of the client, and returning the medication to its container.

(c) Placing the dosage in the client's hand or assisting by lifting the container to the client's mouth.

(d) Applying topical medications.

(e) Returning the medication to its proper storage location.

(f) Documenting each time the client receives medication assistance.
Client or Representative Printed Name
Client or Client Representative Signature

Clear
RN or LPN Printed Name
RN or LPN Signature

Clear
Date

MonthDayYear
Date
STAFF DOCUMENTATION & CLIENT ACKNOWLEDGMENT FORM
At Helping Hands Superior Care LLC, we are committed to ensuring the highest standards of care and professionalism in the services we provide. All caregivers we assign to clients have been thoroughly vetted through the following process:

- Level 2 Background Screening (FDLE/FBI)
- Active Certifications, including:
. CPR & First Aid Certification
. Caregiver, CNA, or HHA certification as applicable

Caregivers are required to use a GPS-monitored system to clock in and out at the beginning and end of their scheduled shifts. This helps us ensure services are delivered accurately and safely.

POLICY REMAINDER FOR CLIENTS:

1. No Private Contact:
Caregivers and clients are strictly prohibited from exchanging personal phone numbers or engaging in private communication. All communication should go through the Helping Hands Superior Care office.

2. Scheduled Hours Only:
Clients must not allow caregivers into their home outside of scheduled hours or visits not coordinated through the agency. We are not responsible for any actions, behaviors, or incidents that occur outside of the agency's scheduled visits.

3. No Private Hiring:
Clients are not permitted to hire Helping Hands caregivers privately. If a client chooses to do so, they agree to pay Helping Hands Superior Care a $5,000 liquidated damage fee, payable immediately upon demand.

4. No Direct Payments or Loans to Staff:
Clients may not provide caregivers with any direct payments, personal loans, gifts, gift cards, or cash advances. If you would like to gift something to your caregiver, please contact the office so we can distribute it appropriately and document it for your protection and ours.
5. Valuables Policy:
Clients agree to keep all cash, checks, jewelry, and other valuables in a secure and locked place during care visits. This helps protect both the client and the caregiver from misunderstandings.

6. Reporting Issues:
If there is any suspected theft, missing property, or misconduct, clients must immediately report the issue to the police and Helping Hands Superior Care LLC SO we can fully investigate and document the concern.

CLIENT AGREEMENT

By signing below, I acknowledge that I have read, understand, and agree to follow the policies outlined above. I understand that these policies are in place to protect both my household and the caregiver and to maintain the integrity of services provided by Helping Hands Superior Care
Client Name
Client Signature

Clear
Date

MonthDayYear
Date
Financially Responsible Party Signature if not client

Clear
CLIENT RIGHTS AND RESPONSIBILITIES & AGENCY POLICIES

Our Commitment to You:
As our client, you have the right to receive compassionate, respectful, and high-quality care in the comfort of your home. We are committed to protecting your dignity, privacy, and personal preferences while delivering professional services.

CLIENT RIGHTS
- To be treated with respect and courtesy at all times.
- To receive care free of discrimination, abuse, neglect, or exploitation.
- To have your information kept confidential.
- To participate in planning your care. To report any concerns without fear of retaliation.
CLIENT RESPONSIBILITIES
- To treat staff with respect and dignity.
- To maintain a safe environment for caregivers.
- To notify the agency of any changes in your care needs.
- To secure all firearms and weapons safely out of reach.
- To communicate any dissatisfaction or concerns with services promptly.
AGENCY POLICIES & HOUSEHOLD BOUNDARIES

Please review and acknowledge the following expectations for all clients:
- No sexual, suggestive, or inappropriate behavior toward staff is tolerated under any circumstance.
- Staff are only permitted to provide light housekeeping directly related to the client's care (e.g., tidying up after meals, laundry for the client)
- Staff are not responsible for caring for other family members, pets, or performing unrelated tasks.
- Staff are not allowed to bring their own children, pets, friends, or family members into your home while on duty.
- Please refrain from personal conversations that may lead to staff becoming personally attached or discussing personal matters.
- Avoid discussions involving politics or religion, which can create an uncomfortable environment.
- Immediately report to the agency if a caregiver is disrespectful, behaves inappropriately, or makes you feel uncomfortable in any way.
  
  We ask that you support a professional and safe working environment by honoring these policies. Your cooperation ensures the well-being and professionalism of everyone involved.
CLIENT ACKNOWLEDGEMENT

I have read, understand, and agree to follow the client responsibilities and agency policies outlined above.
Client Name Print
Client Signature

Clear
Date

MonthDayYear
Date
Agency Representative Signature

Clear
Date

MonthDayYear
Date
COVID-19 & FLU PRECAUTION AGREEMENT
Client Name
Date of Agreement

MonthDayYear
Date
At Helping Hands Superior Care, your health and safety as well as that of our staff is our top priority. In light of ongoing concerns regarding COVID-19 and flu viruses, we've implemented the following safety policy:

SERVICE PAUSE POLICY

If you (the client) report any symptoms of COVID-19 or the flu, such as:
- Fever or chills
- Cough
- Shortness of breath
- Sore throat
- Body aches or fatigue
- Loss of taste or smell
- Vomiting or diarrhea
We may need to temporarily pause in-home services until your symptoms have cleared or you've been medically cleared.

Likewise, if your assigned caregiver informs us that they are experiencing symptoms of the flu or COVID-19, we will pause their services immediately and reassign once they are cleared.

RETURN TO SERVICE PRECAUTIONS

Once services resume, we may recommend but not require that both clients and staff wear gloves and masks for a few days following a return from illness. This extra step is just a precaution to keep everyone safe and healthy.

We appreciate your understanding and cooperation as we continue to protect our community.

Client Acknowledgment:

I acknowledge that I have read, understand, and agree to the policy outlined above regarding flu and COVID-19 precautions.
Client Signature

Clear
Date

MonthDayYear
Date
Agency Representative Signature

Clear
Date

MonthDayYear
Date
TRANSFER / HOSPITAL VISIT / DISCHARGE FORM
Client Name
Date of Birth

MonthDayYear
Date
Start of Care Date

MonthDayYear
Date
Last Date of Services

MonthDayYear
Date
Diagnosis if known
REASON FOR TRANSFER / HOSPITAL VISIT / DISCHARGE
SERVICES PROVIDED BY AGENCY
GOALS OF SERVICE MET?

YesNo
If not explain
CLIENT'S CONDITION AT TIME OF TRANSFER/DISCHARGE
HOSPITAL OR FACILITY NAME IF APPLICABLE
Date of Transfer Hospital Visit

MonthDayYear
Date
Expected Duration of Hospital Stay if known
FOLLOW-UP / CONTINUITY OF CARE PLAN

Client agreeable with dischargePhysician notified of discharge or hospital visitClient referred to new provider or facilityRe-admission to Helping Hands services plannedEmergency transferClient to follow up with physicianOther
ADDITIONAL NOTES
Client Signature

Clear
Date

MonthDayYear
Date
Agency Representative Signature

Clear
Date

MonthDayYear
Date
COMMUNITY RESOURCES & SUPPORT CONTACT LIST

For the safety, well-being, and support of our clients and their families.
If you have questions, concerns, or need immediate support, please use the contacts below to reach the appropriate resources.

Resources	Phone Number
Helping Hands Superior Care Nurse Registry For any questions or concerns regarding your care, please contact our office.	866-521-7606
Abuse, Neglect or Exploitation Hotline To report suspected abuse, neglect, or exploitation.	1-800-962-2873
State of Florida Agency for Health Care Administration To file a complaint with the state about the services you receive.	1-888-419-3456 or 1-866-966-7226
Medicaid Fraud Reporting To report suspected Medicaid fraud or abuse.	1-888-419-3456 or 1-866-966-7226
Emergency Management - Pinellas County	727-464-3800
Emergency Management - Pasco County Special Needs Registry / Emergency Planning Resources	727-847-8137
Emergencies	911
Poison Control Pinellas & Pasco Counties (Florida Poison Information Center)	1-800-222-1222
211 Tampa Bay Cares (Community Assistance Line) For local services such as housing, food, mental health support and crisis resources.	211 or www.211trampabay.org

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Helping Hands SUPERIOR CARE LLC

WELCOME LETTER

CLIENT CONSENT FOR SERVICES

CONSENT TO RECEIVE HOME CARE SERVICES

SIGNATURES

CONSENT TO RELEASE CONFIDENTIAL INFORMATION

ACKNOWLEDGMENT OF DO NOT RESUSCITATE (DNR) ORDER / POWER OF ATTORNEY (POA) / GUARDIANSHIP DOCUMENTS

IF APPLICABLE, PLEASE PROVIDE COPIES OF THE FOLLOWING DOCUMENTS:

ACKNOWLEDGMENT:

COMPLAINTS/GRIEVANCES FORM

Client Information

The Patient Understands and Acknowledges the Following:

Communication Preference:

HIPAA REGULATIONS ACKNOWLEDGMENT

Signature and Consent

Assistance with Medications by Unlicensed Person

STAFF DOCUMENTATION & CLIENT ACKNOWLEDGMENT FORM

TRANSFER / HOSPITAL VISIT / DISCHARGE FORM

REASON FOR TRANSFER / HOSPITAL VISIT / DISCHARGE

COMMUNITY RESOURCES & SUPPORT CONTACT LIST