In-Home Care Scope of Practice Acknowledgment

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Please review the document detailing the scope of provided in-home care services and limitations, then complete this form for acknowledgment prior to service start.

Client/Family Representative Full Name

Contact Phone Number

Date of Acknowledgment

YYYY

I understand that the provided in-home care is centered on delivering comfort, dignity, and peace of mind by focusing on discretion, reliability, and creating a supportive environment.

Yes, I understand and agree.

No, I require clarification.

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Please confirm your understanding of the detailed services offered (Select all that apply):

Full assistance with daily living activities (bathing, grooming, dressing, and hygiene) delivered with respect and professionalism

Mobility support, fall prevention, and safe transfers

Nutritious meal planning and preparation aligned with dietary needs and preferences

Medication reminders and attentive wellness monitoring

Transportation to appointments, errands, and social engagements with punctuality and care

Light housekeeping, organization, and maintaining a clean, comfortable living space

Engaging companionship that promotes emotional well-being and meaningful daily interaction

Assistance with physical exercise and/or physical and occupational therapies that have been prescribed by a licensed professional

Regarding supplies, I understand that the client must provide supplies for all services, with the exception of gloves.

Yes, I understand this supply requirement.

No, I have questions about supplies.

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I acknowledge the limitations on care provided. Please confirm your understanding of the services that *cannot* be provided (Select all that apply):

Wound care

Tube feedings

Medication administration and application of medicated substances

Stoma care and ostomy care

Bed sore treatment

Glucose readings and insulin shots

Monitoring vital signs

I understand that the care provider cannot administer medications or take personal debit or credit cards from clients to make purchases on their behalf.

Yes, I understand these specific limitations.

No, I need more details on these limitations.

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On a scale of 1 to 5, how clear is your understanding of the services provided and their limitations?

Not Clear

Extremely Clear

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Do you have any comments or questions regarding the Scope of Practice document before signing?

By submitting this form, I confirm that I have read and understand the 'Scope of Practice Understanding' document and agree to the terms outlined within it.

I acknowledge and agree to the Scope of Practice.

I do not agree at this time and require further discussion.

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