• Welcome & Agreement

    Complete the client details, care plan entries, home assessment, and authorization, then sign and submit.
  • WELCOME

  • It is with great pleasure that I welcome you to our services and to our dedicated employees ready to provide you with the highest levels of service. And thank you for choosing Benevolent Hearts Home Care LLC as your partner in providing passionate home-based care. To us passion comes from the heart and is a combination of enthusiasm, interest, dedication and commitment. We are truly passionate about the caregiver and nursing services we provide! If you, your family or loved ones have any questions, suggestions or concerns regarding any aspect of our service please contact us at your earliest convenience.
  • ABOUT OUR EMPLOYEES

  • Our employees are screened and trained to provide the best in service. You can expect the following from our employees: 1. Adhere to the Company dress code 2. Display proper identification 3. Maintain strict confidentiality 4. Provide their own meals 5. Be punctual for all shifts
  • CLIENT RIGHTS

  • CONFIDENTIALITY — all matters concerning your medical and personal affairs are kept in the strictest confidence. RESPECT — your right to be treated as an individual with the dignity, respect and consideration deserved by all. Includes respect for your property and personal affairs. COMMUNICATION — we welcome your feedback, grievances and suggestions through any communication channel. FREEDOM FROM DISCRIMINATION — of any type including age, religion, handicap, ethnicity. EMPOWERMENT — to make choices, to have a voice, to be heard. SELF-SUFFICIENCY — we are not replacing you, we are assisting you to the best of our ability. RESPONSIBLE CARE — as provided by compassionate employees that have been screened and trained to deliver outstanding care.
  • COMPANY RIGHTS

  • The parties agree that Benevolent Hearts Home Care LLC shall have the right to: 1. Conduct a client assessment to determine the service requirements and determine the client needs. 2. Contact and/or consult and/or release information with the client's physician, other care providers assisting the client and other health or social care agencies involved in assisting the client in matters directly related to the care of the client. 3. Refuse or discontinue service immediately if a client poses a health or safety risk to the employee, is abusive or discriminatory, or refuses to allow the delivery of services. 4. To arrange at the client's expense emergency treatment or emergency transportation to a hospital. 5. To arrange additional care as deemed necessary by the assessment nurse.
  • DEFINITION OF SERVICE AND DUTIES

  • Home Service employees are not permitted to perform the following duties: 1. Administering medications of any kind or applying medicated substances of any kind. 2. Cutting of fingernails or toenails. 3. Transporting bodily fluids of any kind. 4. Picking up medications or prescriptions of any kind at any dispensary on behalf of or for the client. 5. Heavy lifting or duties beyond the scope of light household work. Health Service employees are not permitted to perform the following duties: 1. LPN/RPN's can only perform those duties to which they are trained and within their scope of practice. 2. Some LPN/RPN's have specialized training allowing them to perform duties that others with the same designation cannot. 3. RN's and other designated health professionals can only perform those duties which fall within their scope of practice.
  • CLIENTS AGREEMENT

  • The client agrees to the following: 1. Ensure a safe and healthy work environment including pet control and second hand smoke if the employee issues a concern. 2. Respect the employee's HUMAN RIGHTS and not discriminate against the employee for any reason as per the Human Rights Act. 3. All forms, charts and service plans left at the client's residence are the property of the Company and are to be made available to the employee. 4. All forms, charts and service plans are to be returned to the Company upon termination of service. 5. Provide all supplies required for personal living, medical requirements, meal preparation and housekeeping. 6. Not offer gifts, money, or property of any kind to the employee. 7. Not arrange or modify service with the employee without consent of the Company. 8. Notify the Company 48 HOURS prior to any shift change, cancellation, or termination of services. 9. Not employ an employee of the Company for a period of 1 year following termination of service. 10. Notify the Company of any employee or service concerns. 11. Benevolent Hearts Home Care LLC is committed to the schedule of care in place however, have an ALTERNATE PLAN OF CARE in case of snow storm, sudden illness or some reason beyond our control.
  • PAYMENT INFORMATION

  • The client agrees to the following payment terms: 1. Charges for services will be conveniently billed twice a month. (The 15th day, and the last day of each month.) 2. Charges for services provided by the employee are billed at the established rate plus any additional authorized expenses. 3. Payment is due upon receipt of the invoice. The client agrees to pay for the services promptly.
  • IN WITNESS WHEREOF the parties hereto have duly executed the within Agreement the day and year first above written.
  • Client Information

  • Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Care Plan Table

  • CARE PLAN*
  • Review Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time
  • Home Assessment

  • ENTRY - Front steps & walk in good repair
  • ENTRY - Kept free of debris, clutter, etc.
  • ENTRY - Outdoor lighting
  • ENTRY - Dead bolt on doors
  • ELECTRICAL - Extensive use of extension cords
  • ELECTRICAL - Cords stretched across walkways/high traffic areas
  • ELECTRICAL - Cords stretched under rugs/mats
  • ELECTRICAL - Damaged, old or frayed cords
  • ELECTRICAL - Any exposed wiring
  • FLOORING - Loose rugs/runners/mats
  • FLOORING - Rugs/runners/mats secured to floor with double-faced tape
  • FLOORING - Rugs/runners/mats with curled up edges
  • Format: (000) 000-0000.
  • TELEPHONE - Emergency numbers written in large print near all phones
  • TELEPHONE - Cords stretched across floor that present a falling hazard
  • TELEPHONE - Phone located near the bedside
  • SMOKE ALARMS - Smoke Detectors in home
  • SMOKE ALARMS - Battery Operated
  • SMOKE ALARMS - Hard wired to electrical system
  • SMOKE ALARMS - Battery checked
  • HEATING - Any auxiliary heat
  • HEATING - Heater(s) located at least 4 feet from combustible material
  • STAIRWAYS - In good repair
  • STAIRWAYS - Well lit
  • STAIRWAYS - Light switch at top & bottom
  • STAIRWAYS - Solid handrails
  • STAIRWAYS - Runner mats/carpeting/treads well fastened
  • STAIRWAYS - Non-skid surface
  • STAIRWAYS - Clutter free
  • BATHROOM - Grab bars
  • BATHROOM - Well fastened & properly placed
  • BATHROOM - Bath Seat
  • BATHROOM - Raised toilet seat
  • BATHROOM - Rubber bath mat or non-slip surface in tub/shower
  • BATHROOM - Night Light
  • KITCHEN - Fire extinguisher
  • KITCHEN - Heavy items in lower cupboards
  • KITCHEN - Pots/pans/canned goods/staple foods easy to reach
  • KITCHEN - Appliances in good condition
  • KITCHEN - Stable step stool with handrail
  • PETS - Dogs
  • PETS - Cats
  • PETS - Is pet aggressive
  • GENERAL - Carbon monoxide detector
  • GENERAL - Alarm system
  • GENERAL - Emergency response system e.g. Lifeline
  • GENERAL - Night lights in convenient locations
  • Authorization & Signature

  • Authorization Text
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: