Client Service Agreement

1. Parties and Agreement

This Client Service Agreement (“Agreement”) is between Harbor & Haven Home Care, LLC (“Harbor & Haven,” “Company,” “we,” “us,” or “our”) and the client identified below (“Client,” “you,” or “your”). If a legally authorized representative signs for the Client, that representative represents that they have authority to do so.

2. Nature of Services

Harbor & Haven provides non-medical home care and life management services within the scope of the services for which the Company is authorized and appropriately staffed. Services may include companionship, respite care, personal-care assistance where properly licensed, meal preparation, light housekeeping, wellness support, dementia companionship, veteran support, post-surgical non-skilled support, and concierge/life-management services.

Services will be limited to those listed in the Client’s service plan/care plan and agreed schedule. Harbor & Haven does not provide medical diagnosis, medical treatment, skilled nursing, therapy, prescribing, or other regulated professional services unless separately authorized, licensed, ordered, staffed, and contracted for those services.

3. Service Plan and Client Acceptance

Before services begin, Harbor & Haven will assess whether it can safely and adequately meet the Client’s needs. The service plan will identify the services, frequency, schedule, relevant safety instructions, and responsibilities of the parties. Virginia rules require the organization to accept a client only when it can adequately meet the client’s needs in the client’s residence.

Harbor & Haven may decline or defer services when the requested care is outside its scope, staffing, licensure, safety capability, or payer authorization.

4. Client Rights

• To be treated with courtesy, consideration, dignity, respect, and privacy.
• To receive confidential treatment of medical and financial records as provided by law.
• To be free from mental and physical abuse, neglect, exploitation, discrimination, and retaliation.
• To participate in planning services and refuse services.
• To receive services from appropriately trained and competent personnel.
• To voice complaints and grievances without retaliation.
• To receive fee, billing, payer-coverage, cancellation, and refund information before services begin.
• To receive advance-directive information before services begin when required.
• To receive written notice of termination as required by applicable Virginia law and regulations.

These rights do not waive any non-waivable rights under Virginia or federal law.

5. Client Responsibilities

• Provide accurate and complete information needed for safe service delivery.
• Notify Harbor & Haven of material changes in health status, residence, schedule, emergency contacts, or service needs.
• Maintain a reasonably safe environment for caregivers.
• Treat Harbor & Haven personnel with courtesy and respect.
• Follow the agreed payment and cancellation terms.
• Do not request services outside the caregiver’s scope of duties.
• Secure or disclose information concerning pets, weapons, hazardous conditions, infectious risks, or other safety concerns.
• Protect Company property, records, devices, keys, and access credentials.

6. Caregiver Conduct, Boundaries, and Prohibited Transactions

Caregivers are prohibited from borrowing money from clients, using client financial accounts or cards for personal purposes, accepting prohibited gifts, becoming beneficiaries of a client’s estate, entering private business arrangements with clients, or using client property except as authorized for service delivery. Caregivers may not purchase, sell, or trade personal goods with clients without written Company authorization.

Clients should not request or encourage caregivers to perform tasks outside their job description or professional scope. Concerns about caregiver conduct should be reported to Harbor & Haven immediately.

7. Theft, Property Loss, and Financial Responsibility

Harbor & Haven takes allegations of theft, financial exploitation, misuse of property, or unauthorized transactions seriously. However, Harbor & Haven is not an insurer or guarantor of a Client’s cash, jewelry, valuables, medications, documents, financial accounts, or personal property merely because a caregiver is present in the home.

The Company will not be responsible for loss caused by a caregiver or third party solely because the person had access to the home unless liability is established under applicable law. Nothing in this provision waives liability that cannot legally be waived or limits the Client’s right to report suspected theft or exploitation to law enforcement, Adult Protective Services, an insurer, or a regulatory authority.

Clients are strongly encouraged to secure cash, jewelry, sensitive documents, prescription medications, firearms, financial credentials, and other valuables before services begin. Allegations will be documented and investigated under Company policy.

8. Abuse, Neglect, and Exploitation

Harbor & Haven has zero tolerance for abuse, neglect, exploitation, harassment, or retaliation. Employees and other persons covered by Virginia law may have an independent duty to report suspected adult abuse, neglect, or exploitation to the appropriate authority. This Agreement does not restrict any legally required report.

9. Medication and Medical Services

Unless expressly included in a separately authorized service program, non-skilled Harbor & Haven caregivers do not administer medications. They may provide reminders or other permitted support consistent with the service plan and Company policy. Caregivers do not diagnose conditions, change prescriptions, provide medical advice, or perform skilled procedures outside their authorized scope.

10. Scheduling and Minimum Service

Services are scheduled in advance. The applicable service plan or rate sheet will identify the minimum visit length, hourly rate, premium rates, and other charges. Harbor & Haven may establish a minimum number of service hours per visit based on staffing and business requirements, provided applicable disclosures and contracts are followed.

11. Fees, Billing, and Payment

The Client agrees to pay the rates and charges stated in the attached Service Rate Schedule, estimate, or service plan. Where a third-party payer is involved, Harbor & Haven will identify known covered and non-covered services and the Client’s financial responsibility to the extent required by applicable law and payer contract.

• Payment methods may include approved card payment, ACH, invoice payment, or other Company-approved methods.
• Payment information must be submitted only through the Company’s approved secure payment process.
• Harbor & Haven will not request payment-card information through ordinary email.
• Returned payments, late balances, and collection costs may be charged only as disclosed in the applicable rate schedule and permitted by law.
• Billing errors identified by either party will be reviewed and corrected promptly.

12. Cancellation, Late Cancellation, and Missed-Visit Policy

Client cancellations or reductions in scheduled services must be provided in accordance with the notice period stated in the Service Rate Schedule. Unless a different written term is stated, Harbor & Haven’s standard private-pay policy is 24 hours’ notice.

Private-pay cancellations received less than 24 hours before the scheduled start time, or a missed visit/no-show, may result in a $45 non-refundable administrative/cancellation fee. The fee is intended to compensate for reserved scheduling capacity and administrative costs. The fee does not apply where prohibited by law or a controlling payer contract and may be waived at Harbor & Haven’s discretion for documented emergencies or other extraordinary circumstances.

Harbor & Haven will not apply a private-pay cancellation charge that conflicts with Medicaid, Medicare, managed-care, or other payer requirements. Payer-specific rules control where applicable.

13. Refund Policy

Payments for services not rendered will be reviewed under the applicable service agreement, rate schedule, payer contract, and law. The $45 administrative fee described above is non-refundable when lawfully charged. No refund policy provision will be interpreted to waive a non-waivable consumer protection right.

14. Insurance and Third-Party Coverage

Harbor & Haven may maintain general liability, professional liability, workers’ compensation, cyber, crime/fidelity, and other insurance appropriate to its operations. Insurance does not make Harbor & Haven an insurer of the Client’s personal property. Coverage, deductibles, exclusions, and policy limits are governed by the applicable insurance policies.

15. Confidentiality, HIPAA, and Non-Disclosure

Harbor & Haven will protect confidential client information in accordance with applicable federal and Virginia privacy requirements and the Company’s Notice of Privacy Practices. Where HIPAA applies, the Company will use and disclose protected health information as permitted or required by law.

The parties agree to maintain the confidentiality of non-public information obtained through the service relationship, including care plans, schedules, private contact information, financial information, business information, passwords, security information, and confidential communications. This confidentiality obligation does not prohibit disclosures required by law, court order, regulatory authority, law enforcement, mandated reporting, emergency response, payer requirements, or disclosures necessary to exercise or defend legal rights.

16. Privacy and Secure Communications

Clients should not send sensitive health information through ordinary, unsecured email or social-media messaging. Harbor & Haven will direct clients to its approved secure portal or other secure method for sensitive documents. Clients are responsible for protecting their own passwords and access credentials.

17. Intellectual Property and Copyright

Unless otherwise stated in writing, Harbor & Haven’s website, logo, name, service materials, forms, written content, graphics, training materials, policies, and original business materials are protected by applicable intellectual-property laws and may not be copied, reproduced, modified, distributed, published, or commercially reused without written authorization.

The Client agrees not to upload or provide copyrighted, confidential, proprietary, or third-party materials to Harbor & Haven without the right to do so. Nothing in this section prevents a Client from retaining copies of documents they are legally entitled to receive or from exercising statutory rights.

18. Marketing, Photography, and Testimonials

Harbor & Haven will not use a Client’s name, photograph, testimonial, or identifying information for marketing without appropriate written authorization. Refusal to provide marketing authorization will not affect eligibility for services.

19. Respectful Workplace and Discontinuation of Services

Harbor & Haven is committed to a respectful, safe workplace. Threats, violence, harassment, discriminatory conduct, intimidation, sexual harassment, repeated abusive or degrading conduct, deliberate property damage, or unsafe interference with caregivers may result in immediate safety measures and may result in suspension or termination of services.

Except where immediate termination is legally permitted or necessary to protect safety, Harbor & Haven will follow applicable Virginia notice requirements and its discharge/termination policy. Virginia’s home-care rules generally require at least five days’ written notice when the organization determines to terminate services, subject to applicable exceptions and the specific regulatory circumstances.

Harbor & Haven will not terminate services merely because a client makes a good-faith complaint, exercises a legal right, reports suspected abuse, or participates in a regulatory investigation.

20. Fraud, Misrepresentation, and False Claims

The Client must provide accurate information about identity, payer coverage, eligibility, service needs, authorized representative status, and other material information. Knowingly providing false information, falsifying service records, misrepresenting eligibility, directing staff to record services not provided, or submitting fraudulent documents may result in investigation, corrective action, termination, and referral to appropriate authorities when required.

Harbor & Haven will not knowingly submit false claims or misrepresent services, credentials, fees, payer coverage, or outcomes. Virginia regulations prohibit false, misleading, or deceptive advertising and misleading fee/payment disclosures.

21. Defamation, Reviews, and Good-Faith Complaints

Clients have the right to complain and provide truthful reviews or reports. Nothing in this Agreement prohibits lawful criticism, good-faith complaints, regulatory reports, or legally protected communications.

At the same time, the parties agree not to knowingly publish or communicate materially false statements of fact about the other party with the intent to cause unlawful harm. Concerns should, when practical, first be raised through Harbor & Haven’s complaint process so they can be investigated and addressed. Harbor & Haven reserves all rights available under applicable law concerning knowingly false statements.

22. Emergency and After-Hours Services

Harbor & Haven will provide or arrange on-call support consistent with its licensed service model and applicable Virginia requirements. Caregivers and clients must call 911 for medical or safety emergencies. The Company is not a substitute for 911, emergency departments, or licensed emergency medical providers.

23. Complaints and Grievances

Clients may submit complaints verbally or in writing without retaliation. Harbor & Haven will log, investigate, and resolve complaints according to its complaint policy. Virginia regulations require a complaint system and proposed resolution within 30 days of receipt.

Company complaint contact:

Virginia regulatory complaint information will be provided to the Client at admission as required by applicable regulations.

24. Discharge, Termination, and Transfer

Services may end when the Client requests termination, the goals/services are completed, the Client moves outside the service area, the Client’s needs exceed Harbor & Haven’s authorized capability, payment obligations are not satisfied after required notice, or other lawful termination criteria are met. Harbor & Haven will provide required notice and referrals/transition information when applicable.

25. Non-Discrimination

Harbor & Haven will provide services without unlawful discrimination and will comply with applicable federal, Virginia, and payer requirements. Reasonable accommodations will be considered as required by applicable law.

26. No Waiver of Non-Waivable Rights

No provision of this Agreement is intended to waive rights, remedies, reporting duties, privacy rights, consumer protections, or regulatory requirements that cannot lawfully be waived. If a provision is inconsistent with a controlling federal or Virginia law, regulation, Medicaid/Medicare rule, or payer contract, the controlling requirement will govern to the extent of the conflict.

27. Governing Law and Venue

This Agreement will be interpreted under the laws applicable in the Commonwealth of Virginia, subject to any controlling federal law, payer contract, or mandatory dispute-resolution provision. Nothing in this section prevents a party from exercising a right to file a regulatory, law-enforcement, administrative, or legally protected complaint.

28. Entire Agreement and Amendments

This Agreement, the attached Service Plan, Rate Schedule, Notice of Privacy Practices, and any signed addenda constitute the parties’ agreement concerning the services identified in those documents. Amendments must be in writing and accepted by authorized representatives, except for policy or fee changes that may be implemented with the notice required by applicable law or contract.

29. Electronic Communications and Signatures

The parties may use electronic communications and signatures where legally permitted. Each party is responsible for maintaining secure access to its email, portal, and electronic-signature credentials.

30. Acknowledgments

By signing below, the Client/authorized representative acknowledges that:

• I received an explanation of the services, frequency, fees, billing/payment method, cancellation requirements, and refund policy.
• I received or was offered the Client Rights information and complaint procedure.
• I understand that Harbor & Haven provides non-medical services unless a separately authorized service is identified in writing.
• I understand the medication restrictions applicable to non-skilled caregivers.
• I understand the $45 non-refundable late-cancellation/missed-visit fee applies only as permitted by law and payer contract.
• I understand that caregivers are not guarantors of my personal property and that valuables should be secured.
• I understand the confidentiality and lawful-disclosure provisions.
• I have had an opportunity to ask questions before signing.

Signature page

Harbor & Haven Home Care, LLC

Owner/CEO: Lakeisha Bradshaw-McIntosh

Stafford County, Virginia

Email: support@harborhavencare.org

Owner email: lakeisha@harborhavencare.org

Website: harborhavencare.org

Business phone: (202) 834-7910

Attachments / client admission checklist