Patient Information

To SHSHH Patients:
We are proud to have the opportunity to provide health services to you. The following information will assist you to understand our office schedule and our on-call system.

General Information

1. SHSHH – Office Hours – 9:00 a.m. – 5:00 p.m. – Monday through Friday
Telephone Number: 772-924-4431 to reach SHSHH personnel.

2. Emergency Situations: Call 911 for rescue, prior to notifying SHSHH.

3. 24 Hour On-Call: A nurse is available 7 days a week, including holidays. A staff member will screen the call and contact the Registered Nurse when appropriate.

Medical Information/Patient Confidentiality

Medical information is communicated to the patient’s doctor on an ongoing basis. No other information is released to any person or agency unless the patient or his/her representative has given written consent to release information. A copy of the written consent is retained in SHSHH’s files. Patients are requested to sign forms necessary to release medical information to their insurance carrier(s), physician(s), and appropriate health care providers at the start of SHSHH services.

Complaint Process

Concerns regarding the care provided by SHSHH may be voiced directly to SHSHH Administration withoutfear of recrimination or loss of services.

To express concerns to SHSHH Management call 772-924-4431 and ask to speak with the Administrator. Your complaint will be investigated in a confidential manner.

COMPANION/SITTER/HОМЕМAKER SERVICE PLAN

Medicaid Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him or herself or some other person. If includes any act that constitutes fraud under applicable federal or state law as it relates to Medicaid. The office of the Inspector General at the Agency for Health Care Administration accepts complaints regarding suspected fraud and abuse in the Florida Medicaid system by phone at 1-866-966- 7226 or on the Agency website at: http://ahca.myflorida.com/Executive/Inspector General/Medicaid.shtml

Acceptance of Patients or Clients Policy

The policies for acceptance of patients of SOLUX HEALTH SOLUTIONS HOME HEALTH LLC for services include the following conditions:

(1) No patient or client shall be refused service because of age, race, color, sex or national origin.

(2) When a patient or client is accepted for referrals of independent contractors, there shall be a reasonable expectation that the requested services can be provided adequately and safely in their residence. The responsibility of the registry is to refer independent contractors capable of delivering services as defined in a specific medical plan of treatment for a patient or services requested by a client, including all visits.

(3) When medical treatments or medications are administered, physician's, advanced practice registered nurse's, or physician assistant's orders in writing that are signed and dated shall be included in the clinical record;

(4) When services are to be terminated, the patient or client, or the person designated by the patient or client shall be notified of the date of termination and the reason for termination, and these shall be documented in the patient or client's record.

In the event of a violation of this chapter or a violation of any other law of this state by a referred registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide, or a deficiency in credentials which comes to the attention of the nurse registry, the nurse registry shall advise the patient to terminate the referred person's contract, providing the reason for the suggested termination; cease referring the person to other patients or facilities; and, if practice violations are involved, notify the licensing board. This section does not affect or negate any other obligations imposed on a nurse registry.

Records required to be filed under this chapter with the nurse registry as a repository of records must be kept in accordance with rules adopted by the agency. The nurse registry has no obligation to review or act upon such records except as specified above.

When a certified nursing assistant or home health aide is referred to a patient's home by a nurse registry, the nurse registry shall advise the patient, the patient's family, or any other person acting on behalf of the patient at the time the contract for services is made that registered nurses are available to make visits to the patient's home for an additional cost.

A registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide referred for contract by a nurse registry is deemed an independent contractor and not an employee of the nurse registry regardless of the obligations imposed on a nurse registry.

Upon referral of a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide for contract in a private residence or facility, the nurse registry shall advise the patient, the patient's family, or any other person acting on behalf of the patient, at the time of the contract for services, that the caregiver referred by the nurse registry is an independent contractor and that it is not the obligation of a nurse registry to monitor, supervise, manage, or train a caregiver referred for contract.

All persons referred for contract in private residences by a nurse registry must comply with the following requirements for a plan of treatment:

(a) When, in accordance with the privileges and restrictions imposed upon a nurse, the delivery of care to a patient is under the direction or supervision of a physician or when a physician is responsible for the medical care of the patient, a medical plan of treatment must be established for each patient receiving care or treatment provided by a licensed nurse in the home. The original medical plan of treatment must be timely signed by the physician, physician assistant, or advanced registered nurse practitioner, acting within his or her respective scope of practice, and reviewed in consultation with the licensed nurse at least every 2 months. Any additional order or change in orders must be obtained from the physician, physician assistant, or advanced registered nurse practitioner and reduced to writing and timely signed by the physician, physician assistant, or advanced registered nurse practitioner. The delivery of care under a medical plan of treatment must be substantiated by the appropriate nursing notes or documentation made by the nurse in compliance with nursing practices established.

(b) Whenever a medical plan of treatment is established for a patient, the initial medical plan of treatment, any amendment to the plan, additional order or change in orders, and copy of nursing notes must be filed in the office of the nurse registry.

It is not the obligation of a nurse registry to monitor, supervise, manage, or train a registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide referred for contract under this chapter. In the event of a violation of this chapter or a violation of any other law of this state by a referred registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide, or a deficiency in credentials which comes to the attention of the nurse registry, the nurse registry shall advise the patient to terminate the referred person's contract, providing the reason for the suggested termination; cease referring the person to other patients or facilities; and, if practice violations are involved, notify the licensing board. This section does not affect or negate any other obligations imposed on a nurse registry.

Records required to be filed under this chapter with the nurse registry as a repository of records must be kept in accordance with rules adopted by the agency. The nurse registry has no obligation to review or act upon such records except as specified above.

POLICY ADMINISTRATION OF DRUGS AND BIOLOGICALS

The nurse registry shall disseminate to its independent contractor nurses the procedures required by Chapter 464, F.S., and the rules of the Agency for Health Care Administration governing the administration of drugs and biologicals to patients.

PROCEDURES

The procedures shall include the following:

(a) An order for medications to be administered by the licensed nurse shall be dated and signed by the attending physician, physician assistant, or advanced registered nurse practitioner as required in Section 400.506(13), F.S.;

(b) An order for medications shall contain the name of the patient, the name of the drug, dosage, frequency, method or site of injection, and order from the physician, physician assistant, or advanced registered nurse practitioner if the patient or caregiver are to be taught to give the medication; and,

(c) A verbal order for medication or change in the medication orders from the physician, physician assistant, or advanced registered nurse practitioner shall be taken by a licensed registered nurse, reduced to writing, to include the patient's name, the date, time, order received, signature and title. The physician, physician assistant, or advanced registered nurse practitioner shall acknowledge the telephone order within 30 days by signing and dating the orders. A verbal order or change in medication order shall be on file in the clinical record at the nurse registry within 30 days.

When services are to be terminated, the patient or client, or the person designated by the patient or client shall be notified of the date of termination and the reason for termination, and these shall be documented in the patient or client's record.

Termination summary including:

(a) The date of the first and last visit;

(b) The reason for termination of services;

(c) An evaluation of established goals at time of termination;

(d) The condition of the patient at the time of termination of services; and,

(e) The referral for additional services when the patient requires continuing services.

In the event of a violation of this chapter or a violation of any other law of this state by a referred registered nurse, licensed practical nurse, certified nursing assistant, companion or homemaker, or home health aide, or a deficiency in credentials which comes to the attention of the nurse registry, the nurse registry shall advise the patient to terminate the referred person's contract, providing the reason for the suggested termination; cease referring the person to other patients or facilities; and, if practice violations are involved, notify the licensing board. This section does not affect or negate any other obligations imposed on a nurse registry.

Records required to be filed under this chapter with the nurse registry as a repository of records must be kept in accordance with rules adopted by the agency.

INFORMED CONSENT TО

ASSISTANCE WITH MEDICATION BY

UNLICENSED PERSONNEL

Under Florida law "Assistance with self-administered medication" means that trained, unlicensed staff can help a person to self-administer their medications by performing such tasks as bringing the resident's medication to the resident; reading a prescription label and removing a prescribed amount of medication from the container; placing the medication in the resident's hand or in another container and helping the resident to lift it to their mouth; applying topical medications; returning the medication to storage; and keeping a record of medications that the resident has self-administered.

"Assistance with self-administration" does not include calculating medication dosages; putting medications in a resident's mouth; preparing or administering injections; applying rectal, urethral, or vaginal preparations; administering medications by way of a tube inserted in a body cavity; administering parenteral preparations; conducting irrigations or using debriding agents for treating skin conditions; administering medications through intermittent positive pressure breathing machines or nebulizers; or performing any medication task which requires judgment or discretion. The unlicensed individual who will be providing "assistance" must have completed a 4-hour training course and has demonstrated their ability to assist you.

By SOLUX HEALTH SOLUTIONS HOME HEALTH LLC., and the undersigned client (the "Client") and personally guaranteed by the undersigned guarantor ("Guarantor"), if any.

SOLUX HEALTH SOLUTIONS HOME HEALTH LLC. provides in-home care to people who require assistance with their activities of daily living. Client desires to engage SOLUX HEALTH SOLUTIONS HOME HEALTH LLC. at the Client's location for such service type(s) and schedule (the "Schedule") as the parties hereto may in advance agree upon as indicated below:

Agreed Hourly Rate: $______ per hour

In consideration of the mutual promises and covenants contained herein and the Terms and Conditions attached hereto, the parties agree a set forth below:

Services Fees: The Client agrees to pay SOLUX HEALTH SOLUTIONS HOME HEALTH LLC time and one-half for any hours by SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor. Holidays for which time and one-half will be charged are as follows: After 3PM New Year's Eve, New Year's Day, Easter Sunday, Memorial Day, Independence Day, Labor Day, Thanksgiving, after 3PM Christmas Eve, Christmas Day. The weekend rate shall be $1 (one dollar) per hour more than the rate set forth above. SOLUX HEALTH SOLUTIONS HOME HEALTH LLC's fees and expenses are billed every 2 (two) weeks in arrears. Invoices are due immediately upon receipt. SOLUX HEALTH SOLUTIONS HOME HEALTH LLC reserves the right to modify the above referred fees for services.

2. Term: The term of this Agreement shall be from the date set forth above and shall continue, at will, until terminated by: (1) Client following one week advanced written notice to SOLUX HEALTH SOLUTIONS HOME HEALTH LLC or (2) SOLUX HEALTH SOLUTIONS HOME HEALTH LLC immediately and without the necessity of advanced notice. The Client's breach of this provision will result in the Client's forfeiture of the Client's deposit.

3. Deposit: A security deposit equal to (2) two weeks of service fees is due upon the execution of this agreement. The deposit will be fully refunded upon the Client's payment of all amounts due SOLUX HEALTH SOLUTIONS HOME HEALTH LLC.

4. Please Note: RN's are available to make visits at an additional cost.

IN WITNESS WHEREOF, the undersigned parties have executed this Agreement, which incorporates the attached Terms and Conditions as of the date set forth above.

Credit Card Authorization: I hereby authorize payment for all invoices to be applied to the credit card as indicated on this form and understand there is a 3% convenience fee for this service.

Availability of Caregivers: SOLUX HEALTH SOLUTIONS HOME HEALTH LLC will use reasonable efforts to provide the Client with qualified personnel from its available staff and to notify the Client in the event that it does not have the personnel resources to provide an Advanced Care Caregivers Contractor for the benefit of the Client. However, SOLUX HEALTH SOLUTIONS HOME HEALTH LLC makes no representation or warranties, expressed or implied, regarding the availability of a SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor at any given time. If SOLUX HEALTH SOLUTIONS HOME HEALTH LLC personnel do not arrive as scheduled, the Client agrees to promptly contact the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Office at 772-924-4431. Except in the case of an emergency, the cost of the shift will be due and payable for any scheduled shifts which are not cancelled at least forty-eight (48) hours prior to the scheduled shift.

Payment: Client agrees to pay one (1) week in advance for services ordered to secure their caregivers. Payment is due every Wednesday from the date of the 1st secured check. If payment is not received within ten (10) days from the date of the invoice, a late payment fee of the greater of $50.00 or 5% of the invoice amount will be applied to the following invoice. Interest on unpaid invoices or other amounts due hereunder shall be at the rate of 1.5% per month or the maximum amount permitted by law. No payment by the Client of a lesser amount than the amount set forth on the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC invoice shall be deemed to be a payment in full of the amount due, nor shall any endorsement or statement on any check or any letter accompanying any check or payment be deemed an accord and satisfaction, and SOLUX HEALTH SOLUTIONS HOME HEALTH LLC may accept such check or payment without prejudice to SOLUX HEALTH SOLUTIONS HOME HEALTH LLC right to recover the balance of such amount due or pursue any other remedy provided for herein. In the event of a bounced check, the client will be charged a bounced check fee of $30.00 as well as a late fee for that period. SOLUX HEALTH SOLUTIONS HOME HEALTH LLC reserves the right to no longer accept personal checks as a method of payment once the client bounces a check.

Supplies: SOLUX HEALTH SOLUTIONS HOME HEALTH LLC's caregivers are required to wear protective gloves while providing services, which gloves shall be supplied by the Client. If the Client fails to supply gloves for the caregiver, SOLUX HEALTH SOLUTIONS HOME HEALTH LLC will provide gloves to the caregiver, and the cost for the same shall be added to the Client's invoice.

Restrictive Covenants: The Client acknowledges that SOLUX HEALTH SOLUTIONS HOME HEALTH LLC has incurred significant expense for the recruitment, hiring, and training of its employees. Thus, during the term of this Agreement and for a period of twelve (12) months thereafter, the Client agrees not to (a) hire, solicit or contact, or attempt to hire, solicit or contact any SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor or (b) otherwise interfere with a SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor's employment relationship with Advanced Care, including, but not limited to requesting or inducing a SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor to provide services comparable to those provided through SOLUX HEALTH SOLUTIONS HOME HEALTH LLC through another entity. Notwithstanding the foregoing, if the Client desires to: 1) engage the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor directly or 2) cause the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Employee to provide services through another entity, the Client may request that SOLUX HEALTH SOLUTIONS HOME HEALTH LLC consent to the same. If SOLUX HEALTH SOLUTIONS HOME HEALTH LLC provides its consent, then the Client shall pay to SOLUX HEALTH SOLUTIONS HOME HEALTH LLC an administrative fee of $10,000.00.

Use of Automobile: Client hereby authorizes the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC caregiver to use Client's automobile for errands and to transport Client as needed. Client shall maintain insurance on Client's automobile during the term hereof. If the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor uses his/her own vehicle for Client errands or for Client transport, Client shall reimburse SOLUX HEALTH SOLUTIONS HOME HEALTH LLC at the rate of $.50 per mile. Notwithstanding the foregoing, all travel must be pre-approved by SOLUX HEALTH SOLUTIONS HOME HEALTH LLC.

Emergencies: In the event of an emergency, the caregiver's sole responsibility is to dial 911, wait for the paramedics and use reasonable efforts to contact the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Office and/or the Client's family.

Miscellaneous: In no event will SOLUX HEALTH SOLUTIONS HOME HEALTH LLC, its affiliates or any of its directors, officers, employees, or agents be liable for any indirect, punitive, special, incidental, and/or consequential damages in connection with the Services provided hereunder. SOLUX HEALTH SOLUTIONS HOME HEALTH LLC makes no representation or warranties, express or implied, to the Client with respect to the services to be provided. Client acknowledges that SOLUX HEALTH SOLUTIONS HOME HEALTH LLC does not provide insurance covering physical loss or damage to Client's vehicles, machinery, equipment, or materials that are in the care, control or custody of a SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractor, and that SOLUX HEALTH SOLUTIONS HOME HEALTH LLC is not responsible for any damage or physical loss related thereto. This Agreement shall be construed, interpreted and governed by the laws of the State of Florida without regard to its conflict of laws principles. The parties hereto acting for themselves and for their respective successors and assignees, without regard to domicile, citizenship or residence, hereby expressly and irrevocably consent to and subject themselves to the jurisdiction of the Florida courts and to venue in Palm Beach, Martin, St. Lucie, Indian River and Okeechobee counties as applicable. With respect to any matter arising under or in connection with this Agreement, SOLUX HEALTH SOLUTIONS HOME HEALTH LLC may, in addition to any other rights and remedies available hereunder, at law or otherwise, be entitled to have an injunction issued by any court of competent jurisdiction restraining the Client or the Guarantor from damages in this regard. This Agreement sets forth the entire understanding of the parties, and no oral agreements or written correspondence shall be held to affect the provisions hereof. This Agreement may be modified or amended by SOLUX HEALTH SOLUTIONS HOME HEALTH LLC upon advanced notice to the Client. Client may not sell, pledge, assign, or otherwise transfer any of its rights under this Agreement. Any notice required or permitted to be sent hereunder shall be in writing and shall be effective upon receipt of personal delivery, overnight courier service, facsimile as confirmed by transmission receipt, or delivery via U.S. Mail to the address of the respective party. All payment obligations and restrictive covenants contained herein shall survive the termination of this Agreement. SOLUX HEALTH SOLUTIONS HOME HEALTH LLC Contractors, agents, officers, managers, and/or members shall have no personal liability to the Client or to any person or entity claiming hereunder. In any action, claim, suit or demand brought under or pursuant to the terms of this Agreement or the Services provided hereunder, the Client's or any other party's maximum recourse shall be limited to the lesser of the value of the SOLUX HEALTH SOLUTIONS HOME HEALTH LLC's assets (or proceeds thereof) or the total amount of the fees received by SOLUX HEALTH SOLUTIONS HOME HEALTH LLC during the six (6) month period prior to such event creating liability. In the event that SOLUX HEALTH SOLUTIONS HOME HEALTH LLC seeks to enforce any provision of this Agreement, SOLUX HEALTH SOLUTIONS HOME HEALTH LLC shall be entitled to reimbursement of all of its costs and expenses, including attorneys' and expert witness fees and court costs, incurred in enforcing such provision.

Advance Payment: Solux Health Solutions Home Health, LLC collects an advance payment equal to one week of scheduled care. This payment is held by Solux Health Solutions Home Health, LLC until the end of services and applied to the last invoice. Any unused portion may be refunded, upon completion of services.