2023-03-03_akunnath_ClientConsentAgreement_Waterloo Blank.docx

CLIENT NAME:

CARE RECIPIENT(IF DIFFERENT THAN CLIENT):

This Client Consent Agreement (“Agreement”) is entered into on	(the “Effective Date”) by and between the aforementioned Client and/or on behalf of Care Recipient(s) (“Client”) and Home Care Assistance Waterloo (“Company”). The care services will be provided at the below mentioned address.

Address:

Street Name:

City:	Province:	Postal Code:

Home phone:

CONSENT TO RECEIVE SERVICES

Company will dispatch “Caregiver(s)” to the residence or other facility identified by the Client for the provision of companionship services. Company is hereby authorized to provide companionship services to the Client through the use of such Caregivers. Client understands that the Company is a non-medical agency that does not provide medical services or treatments. The Client acknowledges that the Client has authority of the Care Recipient to enter into this Agreement, and the Client waives any and all liability of the Company as it relates to medical services the Client may later allege that the Company should have provided, as the Company only provides non-medical services. A description of services to be performed is outlined as a part of the initial consultation. For more information on caregiver scope of work, refer to appendix A.

CAREGIVER AGREEMENT

The Client understands (and represents and warrants that the Care Recipient and all others with authority on behalf of the Care Recipient also agree, including family members, other substitute decision makers, executors and successors) that Company spends a significant amount of time, money and resources in the process of recruiting, screening, hiring and training its Caregivers and therefore, each Caregiver is a valuable asset to Company. Client further understands that each Caregiver working for Company is prohibited from accepting private employment with any Client or Care Recipient directly (or through another organization/agency) while the Caregiver is employed by Company, as well as for a period of three (3) years following the Caregiver’s termination of employment with Company. Accordingly, should Client or Care Recipient desire to employ any of Company’s Caregivers, such employment will be deemed in violation of these restrictions. In the case that Client wishes to employ any such Caregiver within a three (3) year period of Caregiver’s termination of employment with Company, Client agrees to pay Company a one-time placement fee of TEN THOUSAND DOLLARS ($10,000.00), which amount shall be due within 10 business days of employment of such Caregiver. Payment of such amount does not affect any liability or contractual obligations that the Caregiver may have toward the Company.

RATES

Until notice is given by the Company to the contrary, the rate for hourly care is $	per hour, with a minimum of 4 hours per Caregiver visit, and the rate for live-in care is   per day. Company will charge one and one-half times the normal rate for services rendered on statutory and civic holidays, Client can decline holiday service by notifying Company at least seventy-two (72) hours in advance.

MILEAGE & PARKING CHARGES

Client agrees to reimburse Company for the automobile traveling and parking expenses incurred by Caregivers in the performance of their duties. Duties include travel associated with Care Recipient appointments, running errands for the Care Recipient, etc. Traveling expenses do not include mileage to and from location of care. The Caregiver will abide by all legal requirements relating to owning and operating a vehicle. Company will invoice Client at the rate of 95 cents per kilometer.

In the event the Caregiver uses the Client’s vehicle or the Care Recipient’s vehicle,

No mileage will be charged for such services

It is the Client’s exclusive responsibility to ensure vehicle insurance is up to date and allows for third

parties to operate the vehicle. Furthermore, the Client warrants the vehicle is roadworthy.

CANCELLATIONS

Cancellations that are not received within the timeframes provided herein will be subject to a cancellation fee. Invoices are sent weekly and are due upon receipt. Client agrees to pay invoices on-time and understands late charges at the rate of 2% per month will apply for balances over 30 days.

Live-in Care - Should Client relieve a Caregiver of their duties or fail to cancel live-in services scheduled at least seventy two (72) hours before service is scheduled to commence, Client will pay a cancellation fee equivalent to one day of live-in service.

Hourly Care - In the case that Client relieves a Caregiver of their duties or fails to cancel hourly services scheduled at least seventy two (72) hours before service is scheduled to commence, Client will pay a cancellation fee equivalent to the hourly rate for the entire scheduled shift.

SECURITY OF CAREGIVER

Caregivers are instructed not to put themselves at risk of bodily harm or injury in the provision of companionship services. Thus, Client understands and acknowledges that, if a Caregiver is made to feel threatened and/or in physical danger while performing companionship services, the Caregiver is instructed to call the office for support and will follow directions from the office, which may result in the caregiver leaving Client’s premises without exposing the Caregiver and/or Company to any liability and the Client remains liable for the full payment of fees.

LIMITATION OF LIABILITY

In recognition of the relative risks and benefits of services provided by Company, Client agrees to the fullest extent of the law, to limit the liability of Company for any and all claims, losses, costs, damages of any nature whatsoever or expense from any cause or causes, including attorneys’ fees and costs, and costs of expert witness fees and costs, so that the total aggregate liability of Company to the Client shall not exceed the total fees payable to Company for services rendered. It is intended that this limitation apply to any and all liability or cause of action however alleged or arising, unless otherwise prohibited by law. Further, Client releases Company from any claims for liability which the Client may acquire by reason of damage, loss, injury and/or suffering which arises from the operation and/or use of a vehicle by a Caregiver, whether that may be owned by the Client or a vehicle provided by the Caregiver or Company. In the event that the Care Recipient or any other person acting with the authority of the Care Recipient makes any claim against the Company, the Company may plead this Agreement and this Section as a complete defense, and the Client shall be responsible for indemnifying the Company for any losses or

fees incurred. The Client also agrees not to hold Company liable for any intentional acts of Caregivers acting beyond the course and scope of their duties to provide companionship services, in which event a claim would be brought against the Caregiver directly.

FALL RISK

Client understands that even with the provision of twenty-four-hour, around-the-clock companionship services, Care Recipients may potentially experience a fall. Client understands that Care Recipients with dementia, Alzheimer’s or any condition that causes mental confusion are especially at high risk for experiencing falls, and other underlying medical conditions may also put a Care Recipient at a greater risk of experiencing a fall, but even Care Recipients without increased risk factors may be susceptible to falls. Client further understands that Company will do its best to minimize fall risks, and agrees to hold the Company, its employees, management, and corporation blameless in the event a Care Recipient experiences a fall.

CERTIFICATION OF AUTHORITY

If someone other than Care Recipient(s) (hereafter referred to as an “Authorized Agent”) signs this Agreement on behalf of Care Recipient( (s), said Authorized Agent hereby certifies that he/she has the authority and consent from all decision makers (including the Care Recipient or any legal substitute decision maker(s) of the Care Recipient) to enter into this Agreement on behalf of said Care Recipient(s) and is bound to the terms hereof as a principal party. Furthermore, said Authorized Agent is fully responsible for the payment of all fees incurred for services rendered to Care Recipient(s) pursuant to this Agreement, and for any expenses incurred by the Company if the Care Recipient or any substitute decision maker challenges the authority of the Authorized Agent and/or terminates or revokes this Agreement. The authorized agent will provide necessary documentation to support the decision-making privileges for the Care recipient. It is agreed that the Company will follow directions for care needs from the Authorized Agent as identified below. Authorized Agent of the Care Recipient has read and fully understands the contents of this Agreement and agrees to the terms contained herein.

Authorized Agent/Care Recipient Name:

Signature:	Date Signed:

Appendix A

Scope of caregiving duties

Assist Care Recipient with activities of daily living, which includes bathing, dressing, toileting, grooming and transferring.

Prepare meals following Care Recipient’s prescribed dietary restrictions and the Balanced Care Method.

Light housekeeping duties – the Client will provide in writing a list of housekeeping activities to be performed and agreed upon by the Company.

Conduct basic errands, such as grocery shopping.

Incorporate aspects of the Balanced Care Method into the Care Recipient’s care (e.g., go for a walk, visit the local

senior center, play a board game).

Provide or schedule transportation services e.g. Care Recipient’s appointments, errands etc.

Medication Reminders – Caregivers will provide medication that is already in blister packs and/or pill boxes. Caregivers will NOT dispense medication that is in prescription containers. - Medication delivery through IV, injections and all other treatments that require the supervision of a regulated health care professional will NOT be performed.

Assistance with exercises – All exercises will be directed and performed based on the written recommendation of a regulated health care professional or the Client and/or Power of Attorney for Health.

Mobility and Transfer Assistance - Assist Care Recipient with transfers (caregivers can ONLY assist with transfers that the Care Recipient is able to perform as approved by the occupational therapist). For any transferring assistance, the Care Recipient must be able to weight bear. If the Care Recipient is unable to weight bear, they must be assessed by an occupational therapist prior to transferring.

All modifications to Care Recipients care needs must be approved in writing by the Company. The Company will re-assess as needed and make recommendations. If the Client and Company agree upon the recommendations, such modifications will be implemented within 2 business days.

Authorized Agent/Care Recipient Name:

Signature:	Date Signed: