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.
Day
Date
Month
Year
IN WITNESS WHEREOF the parties hereto have duly executed the within Agreement the day and year first above written.
Client Signature
*
PER, CLIENT OR GUARDIAN, POWER OF ATTORNEY, PUBLIC TRUSTEE
*
Client Information
Client Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Client Reference Number
Care Plan Table
CARE PLAN
*
Review Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature of Assessor
Signature of Client/Caregiver
*
Assessor name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Home Assessment
Number of People in Household
Description of Home
Number of Bathrooms
ENTRY - Front steps & walk in good repair
Yes
No
ENTRY - Kept free of debris, clutter, etc.
Yes
No
ENTRY - Outdoor lighting
Yes
No
ENTRY - Dead bolt on doors
Yes
No
ENTRY - Comments
ELECTRICAL - Extensive use of extension cords
Yes
No
ELECTRICAL - Cords stretched across walkways/high traffic areas
Yes
No
ELECTRICAL - Cords stretched under rugs/mats
Yes
No
ELECTRICAL - Damaged, old or frayed cords
Yes
No
ELECTRICAL - Any exposed wiring
Yes
No
ELECTRICAL - Comments
FLOORING - Loose rugs/runners/mats
Yes
No
FLOORING - Rugs/runners/mats secured to floor with double-faced tape
Yes
No
FLOORING - Rugs/runners/mats with curled up edges
Yes
No
FLOORING - Comments
TELEPHONE - Telephone Number
Please enter a valid phone number.
Format: (000) 000-0000.
TELEPHONE - Number of telephones
TELEPHONE - Where located
TELEPHONE - Emergency numbers written in large print near all phones
Yes
No
TELEPHONE - Cords stretched across floor that present a falling hazard
Yes
No
TELEPHONE - Phone located near the bedside
Yes
No
SMOKE ALARMS - Smoke Detectors in home
Yes
No
SMOKE ALARMS - Battery Operated
Yes
No
SMOKE ALARMS - Where located
SMOKE ALARMS - Hard wired to electrical system
Yes
No
SMOKE ALARMS - Number
SMOKE ALARMS - Battery checked
Yes
No
SMOKE ALARMS - Location
HEATING - Type of heat
Please Select
Kerosene
Space heater
Wood stove
Oil stove
Other
HEATING - Any auxiliary heat
Yes
No
HEATING - Heater(s) located at least 4 feet from combustible material
Yes
No
HEATING - Comments
STAIRWAYS - In good repair
Yes
No
STAIRWAYS - Well lit
Yes
No
STAIRWAYS - Light switch at top & bottom
Yes
No
STAIRWAYS - Solid handrails
Yes
No
STAIRWAYS - Runner mats/carpeting/treads well fastened
Yes
No
STAIRWAYS - Non-skid surface
Yes
No
STAIRWAYS - Clutter free
Yes
No
STAIRWAYS - Comments
BATHROOM - Grab bars
Yes
No
BATHROOM - Well fastened & properly placed
Yes
No
BATHROOM - Bath Seat
Yes
No
BATHROOM - Raised toilet seat
Yes
No
BATHROOM - Rubber bath mat or non-slip surface in tub/shower
Yes
No
BATHROOM - Night Light
Yes
No
BATHROOM - Comments
KITCHEN - Fire extinguisher
Yes
No
KITCHEN - Heavy items in lower cupboards
Yes
No
KITCHEN - Pots/pans/canned goods/staple foods easy to reach
Yes
No
KITCHEN - Appliances in good condition
Yes
No
KITCHEN - Stable step stool with handrail
Yes
No
KITCHEN - Comments
PETS - Dogs
Yes
No
PETS - If dogs, number
PETS - If dogs, breeds
PETS - Cats
Yes
No
PETS - If cats, number
PETS - Other pets
PETS - Is pet aggressive
Yes
No
PETS - Comments
GENERAL - Carbon monoxide detector
Yes
No
GENERAL - Alarm system
Yes
No
GENERAL - Emergency response system e.g. Lifeline
Yes
No
GENERAL - Night lights in convenient locations
Yes
No
GENERAL - Additional Information
Authorization & Signature
Authorization Text
Signed
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Month
Year
Submit
Submit
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