1.   Purpose

This Hospice Provider Agreement describes the conditions and procedures that apply to the cooperative relationship between the LaVigne Home for Compassionate Care. and hospice providers entering the home to service clients who need hospice services.

2.   Term of Agreement

The term of this agreement shall be from the date the Hospice Provider signs the agreement and will continue for as long as the provider serves clients at the LaVigne Home.

3.   Nature of Agreement

This agreement is not a joint venture or partnership agreement.  Neither party will have a right or obligation to share funding arising out of the efforts of the other party.  This agreement does not express or imply any commitment to purchase or sell goods or services.

4.   Provisions

As of the effective date of this agreement, the Hospice Provider agrees to:

4.1.  Acknowledge that the LaVigne Home is a free, no-cost, community-based, comfort care home. It is not a medical hospice facility and strictly provides food, shelter, and compassionate caregiving.

The LaVigne home does not provide skilled services.

4.2.  Collaborate with LaVigne Home staff as an extension of the family unit of care.

4.3.  Instruct all Hospice staff entering the LaVigne home, to the nature of the LaVigne Home model of care, and the limitations as outlined in this agreement.

4.4.  Provide and direct the hospice plan of care as the Case Manager to ensure that quality care and symptom management are achieved.

4.5. Acknowledge that the LaVigne Home provides short-term, end-of-life care. If a client’s prognosis changes significantly, the hospice agency will collaborate with the client and or family member to establish an alternative plan for care and living arrangements.

4.6.  Cooperate with the exchange of health information necessary for the provision of care at the LaVigne Home guests according to privacy standards.

4.7.  Provide, at the time of referral to LaVigne Home, the following information:

Demographic Record

If no patient advocate, next of kin

Current Nursing Assessment Including height and weight

History and Physical with defined terminal Hospice Diagnosis as per physician

Medication List

Advance Directives/DNR order

4.8.  Provide Nurse visits at the time of guest admission to communicate the plan of care, identify any additional DME or other supplies needed, and review medication regimen with LaVigne Home staff to adequately ensure a smooth transition of care without loss of comfort.

4.9.  Ensure that any Hospice staff members entering LaVigne Home will check in with staff upon arrival and provide a brief oral report to staff after the visit.

4.10.  Ensure that any changes to the plan of care, including medication changes are communicated verbally directly to LaVigne home staff, and reorder medications as needed to ensure the patient has adequate comfort meds when needed.

4.11.  Refrain from any type of solicitation activities on LaVigne Home premises or with guests and families.

4.12.  Coordinate, with guest/family, the transfer or relocation of a guest if guest care needs exceed the ability of LaVigne Home staff to provide those needs.

4.13.  Coordinate, with guest/family, the transfer or relocation of a guest if LaVigne Home staff determines a guest or guest’s family to be disruptive to the provision of quality care.

4.14.  Provide proof of professional liability and general liability coverage with limits of no less than $1 million.

4.15.  To the fullest extent permitted by law, LaVigne Home shall defend, indemnify, and hold harmless ___________________________________________including its owners, directors, officers, employees, agents, volunteers, and representatives, from and against all claims, damages, losses, and expenses, including, but not limited to reasonable attorney’s fees, arising out of or resulting from any act, conduct, omission, negligence, misconduct or unlawful act (or act contrary to any applicable governmental order or regulation) of LaVigne Home, its directors, officers, employees, agents, volunteers, or representatives in complying with this Agreement.

4.16.  To the fullest extent permitted by law,___________________________________________Shall defend, indemnify, and hold harmless LaVigne Home, including its directors, officers, employees, agents, volunteers, and representatives, from and against all claims, damages, losses, and expenses, including, but not limited to reasonable attorney’s fees, arising out of or resulting from any act, conduct, omission, negligence, misconduct or unlawful act (or act contrary to any applicable governmental order or regulation) of _______________________________________________, its directors, officers, employees, agents, volunteers, or representatives in complying with this Agreement.

4.17.  Authorize LaVigne Home to terminate this agreement if LaVigne Home determines that the Hospice Provider has violated the terms of the agreement.

5.   Entire Agreement

This is a Hospice Provider Agreement between _____________________, and LaVigne Home.  No oral modification or waiver of any of its provisions shall be binding on either party.  This agreement is for the benefit of and shall be binding upon both parties and their respective successors and assigns.

In witness whereof, the respective authorized representatives of the parties have executed this Agreement as of the Effective Date.