Fill and Sign the Agreement to Provide in Home Personal Care Services Form

Agreement to Provide In-Home Care Services This Agreement is entered into by and between ______________________________ (Name of Client) , an individual residing at ___________________________________________ ______________________________________________________________________________ (street address, city, county, state, zip code) , hereinafter called the Client , and ______________ ________________________________________ (Name of Home Care Agency) , a corporation organized and existing under the laws of the state of ________________________, with its principal office located at _________________________________________________________ ______________________________________________________________________________ (street address, city, county, state, zip code) , referred to herein as HCA ; Whereas, Client desires to hire to provide an in-home caregiver under the terms and conditions provided herein and HCA desires, to provide such service; Now, therefore, for and in consideration of the mutual covenants contained in this agreement, and other good and valuable consideration, the receipt and sufficiency of which is hereby acknowledged, the parties agree as follows: 1. Services A. HCA shall provide an in-home caregiver ( Caregiver ) for the hours and days as specified based upon an hourly rate of $17.50 (day or night) on Monday through Saturday and an hourly rate of $18.50 (day or night) on Sunday. All fees are payable at the HCA offices located at __________________________________________________ ________________________________________________________________________ (street address, city, county, state, zip code) . Invoices will be sent every two weeks and payment is due within five (5) days of the receipt of the invoice. B. Caregiver shall prepare meals, perform light housekeeping, do laundry, and provide transportation and/or personal care of the Client when requested. C. Daytime service will be performed for a period of at least four (4) consecutive hours and for such other length as the parties agree. Overnight care will be provided for a period of at least eight (8) consecutive hours. D. If the Caregiver uses his/her car for transportation of the Client or errands for the Client in excess of five (5) miles per day, the Client will be charged $ 0.405 per mile. E. The Client may discontinue services for any reason with a minimum 2 week notice to HCA. A termination fee of $_______________ shall be paid if less than two weeks notice is given. 2. Term and Termination A. The initial term of this Agreement will be for a period of ____________________ (e.g., months) . At the expiration of this term , this Agreement will automatically be renewed for a period of one ________________________ (e.g., months) unless either party notifies the other of their intention to terminate the Agreement at least two weeks before the expiration date. B. HCA may terminate this Agreement immediately upon the occurrence of any of the following events, as determined by HCA in its sole and absolute discretion: 1. Client presents a threat to himself/herself and/or a HCA Caregiver; 2. Client requires personal care beyond the capability of the HCA Caregivers as determined in its sole discretion; 3. Any breach of this Agreement; 4. Client does not permit adequate or normal sleep for the HCA Caregiver; 5. Client fails to pay all monies owed within 10 days of invoice date; and 6. Client fails to provide a safe working environment for Caregiver. 3. Holidays If caregiver services are provided on New Year’s Day, Easter, Memorial Day, Fourth of July, Labor Day, Thanksgiving, Christmas, or Christmas Eve or New Year’s Eve, the hourly charge will be $24.00. 4. Overtime If a specific Caregiver is required to work more than forty (40) hours in a work week in order to meet client preferences or emergency client needs, the charge for each hour in excess of forty will be $24.00. 5. Duties not to be Performed Caregiver shall not be required to perform any of the following: A. Act as a representative payee nor attempt to manage personal financial affairs of the Client . At no time shall a Client give a Caregiver a check, credit card or bankcard (ATM, LINK, debit, etc.) for withdrawals or shopping. Any exceptions must have prior written approval of the Program’s Executive Director. B. Administer any prescription or non-prescription medications, perform professional nursing duties, ( e.g. blood pressure monitoring or glucose checking) or perform therapy activities which require special skill or training. Any exceptions must have prior written approval of the Executive Director as documented by the execution of the Medical Authorization and Release of Liability which is made as an addendum to this Agreement. C. Client transfers which require significant lifting, use of a lift device, or lifting a wheelchair into a vehicle unless an exception is made by the Executive Director. D. Perform home maintenance or repair activities such as cleaning gutters, gardening, auto cleaning or maintenance. E. Climb on ladders or chairs, move heavy furniture, or clean carpets. F. Sign any legal papers, receive process or appear in court on behalf of the Client served unless required by law. G. Perform any of the personal services described in the foregoing paragraphs for the family of the Client , including care of minor children. H. Purchase alcoholic beverages for a Client or family member. 6. Cleaning Supplies Client shall be responsible for providing the cleaning supplies and equipment needed by HCA Caregivers. If the Client cannot supply these, the HCA office will be notified by Client. 7. Cash Transactions If Caregiver is asked to purchase groceries or other items for the Client, a two-way cash receipt will be utilized. Upon completion of the transaction, one copy of the receipt will be provided to the Client and a second copy to the administrative office of HCA. 8. Direct Employment of HCA Caregiver by Client Client agrees not to solicit the employment of any of HCA Caregivers . Employment by Client of an HCA Caregivers will result in the termination of the Caregiver’s employment with HCA. All subsequent withholding, Social Security, unemployment tax, worker compensation insurance and other legal obligations of an employer may become the responsibility of Client. 9. Payments to Caregivers Client shall not directly pay any Caregiver employed by and provided by HCA. Payment of bonuses, tips, gifts, and granting of loans to an HCA employee is prohibited and may result in termination of the employee. HCA also prohibits any employee from accepting a bequest made by a Client pursuant to a Client’s last will and testament. An employee who accepts such a bequest be terminated as an employee. Acceptance of such a bequest could suggest that the HCA exerted undue influence on that Client . 10. Client Recognition of Caregiver If a Client (Participant) wishes to recognize outstanding effort of an HCA employee, HCA recommends the Client send a written acknowledgment to the Executive Director of HCA who will share it with the employee and include it in their personnel file. If it is important to the Client to give an employee a special occasion gift ( e.g., Christmas/birthday), the gift must be given through the employee’s immediate supervisor or the Executive Director. The Client may ask a supervisor to visit him/her for this purpose. Such gifts may not exceed $100 cash value per year. Failure to follow this policy may result in termination of the employee. 11. Cancellations If the Client cancels a scheduled shift for a Caregiver, HCA must be notified as soon as possible, but no less than 24 hours in advance. If the Client fails to give 24 hour notice for cancellation, the Client will be liable for payment for the four (4) hour minimum for day and evening shifts or the eight (8) hour minimum for overnight shifts. 12. Calls to HCA Business hours are 8:30 to 5:00 p.m. Monday through Friday. In emergencies when it is necessary to reach outside of normal business hours, call the main phone number (xxx-xxx- xxxx). You will hear a recording that you have reached our emergency beeper. Leave your name and the phone number where you can be reached and someone will call you back as soon as possible. Please leave your phone free so that we will not get a busy signal when we return your call. 13. Adherence to Schedule The Client agrees that the Caregiver shall not be expected to remain past the scheduled departure time of the scheduled shift. This is especially important in situations where the HCA Caregiver must await the return of a family caregiver. Repeated disregard of the Caregiver’s schedule may result in discontinuation of services. Any changes to the scheduled hours must be arranged through HCA’s office (not the Caregiver). HCA’s policies prohibit Caregivers from sharing their personal phone numbers with clients. 14. No Waiver The failure of either party to this Agreement to insist upon the performance of any of the terms and conditions of this Agreement, or the waiver of any breach of any of the terms and conditions of this Agreement, shall not be construed as subsequently waiving any such terms and conditions, but the same shall continue and remain in full force and effect as if no such forbearance or waiver had occurred. 15. Governing Law This Agreement shall be governed by, construed, and enforced in accordance with the laws of the State of ____________________. 16. Notices Any notice provided for or concerning this Agreement shall be in writing and shall be deemed sufficiently given when sent by certified mail to the respective address of each party as set forth at the beginning of this Agreement. 17. Mandatory Arbitration Any dispute under this Agreement shall be required to be resolved by binding arbitration of the parties hereto. If the parties cannot agree on an arbitrator, each party shall select one arbitrator and both arbitrators shall then select a third. The third arbitrator so selected shall arbitrate said dispute. The arbitration shall be governed by the rules of the American Arbitration Association then in force and effect. 18. Entire Agreement This Agreement shall constitute the entire agreement between the parties and any prior understanding or representation of any kind preceding the date of this Agreement shall not be binding upon either party except to the extent incorporated in this Agreement. 19. Modification of Agreement Any modification of this Agreement or additional obligation assumed by either party in connection with this Agreement shall be binding only if placed in writing and signed by each party or an authorized representative of each party. 20. Assignment of Rights The rights of each party under this Agreement are personal to that party and may not be assigned or transferred to any other person, firm, corporation, or other entity without the prior, express, and written consent of the other party. The undersigned _______________________________ (Name of Client) acknowledges that he/she has read the foregoing Agreement and acknowledges that he/she received a copy of HCA’s Notice of Privacy Information Practices. Witness our signatures this _____________________________ (Date) . _____________________________________ (Name of HCA) By: ______________________________ _________________________________ _________________________________ _________________________________ (P rinted or typed name) (P rinted or typed name of Client) __________________________________ __________________________________ (Name and Office in Corporation)