Home Health Aide Application

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      I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL. I Authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

Royal Homehealth Care Services utilizes direct deposit payments to ensure timely payments. All information will be kept strictly confidential.

Royal Homehealth Care Services, LLC is hereby authorized to directly deposit my pay into the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

By execution of this document, I acknowledge that I have been informed by the Agency that a criminal history check will be performed on my name. I have informed that Agency of all names (for example, maiden name, aliases) that I have used in the past. I understand that I have been employed on a provisional basis and that my employment is temporary pending the results of the criminal history check. I also understand that it is the Agency’s not to hire an individual who has been convicted of the offenses enumerated below. I also understand that the Agency will search any Employee Misconduct Registry and Nurse Aide Registry (if applicable) to determine whether any acts of abuse, neglect or exploitation have occurred and whether my name is designated on either registry. If my name is designated on either registry I understand the Agency will deny me employment.

PART I: CONVICTION OF EITHER A FELONY OR MISDEMEANOR CHARGE FOR ANY OF THE OFFENSES LISTED BELOW:

CC2500 Criminal Homicide
CC2502A Murder I
CC2502B Murder II
CC2502C Murder III
CC2503 Voluntary Manslaughter
CC2504 Involuntary Manslaughter
CC2505 Causing or Aiding Suicide
CC2506 Drug Delivery Resulting in Death
CC2702 Aggravated Assault
CC2901 Kidnapping
CC2902 Unlawful Restraint
CC3121 Rape
CC3122.1 Statutory Sexual Assault
CC3123 Involuntary Deviate Sexual Intercourse
CC3124.1 Sexual Assault
CC3125 Aggravated Indecent Assault
CC3126 Indecent Assault
CC3127 Indecent Exposure
CC3301 Arson and Related Offenses
CC3502 Burglary
CC3701 Robbery
CC4101 Forgery
CC4114 Securing Execution of Documents by Deception
CC4302 Incest
CC4303 Concealing Death of a Child
CC4304 Endangering Welfare of a Child
CC4305 Dealing in Infant Children
CC4952 Intimidation of Witnesses or Victims
CC4953 Retaliation Against Witness or Victim
CC5903C Obscene or Other Sexual Materials to Minors
CC5903D Obscene or Other Sexual Materials
CC6301 Corruption of Minors
CC6312 Sexual Abuse of Children

CONVICTION OF A FELONY CHARGE FOR ANY OF THE OFFENSES BELOW:

CC5902B Promoting Prostitution
CS13A12 Acquisition of Controlled Substance by Fraud
CS13A14 Delivery by Practitioner
CS13A30 Possession with Intent to Deliver
CS13A35(i),(ii),(iii) Illegal Sale of Non-Controlled Substance
CS13A36 Designer Drugs Felony
CS13Axx* Any Other Felony Drug Conviction Appearing On PA Rap Sheet

PART III: CONVICTION OF EITHER ONE (1) FELONY CHARGE OR TWO (2) MISDEMEANOR CHARGES FOR ANY OF THE OFFENSES LISTED BELOW:

CC3901 Theft
CC3921 Theft By Unlawful Taking
CC3922 Theft By Deception
CC3923 Theft By Extortion
CC3924 Theft By Property Lost
CC3925 Receiving Stolen Property
CC3926 Theft of Services
CC3927 Theft By Failure to Deposit
CC3928 Unauthorized Use of a Motor Vehicle
CC3929 Retail Theft
CC3929.1 Library Theft
CC3929.2 Unlawful Possession of Retail or Library Theft Instruments
CC3929.3 Organized Retail Theft
CC3930 Theft of Trade Secrets
CC3931 Theft of Unpublished Dramas or Musicals
CC3932 Theft of Leased Properties
CC3933 Unlawful Use of a Computer
CC3934 Theft From a Motor Vehicle

I, the undersigned, do hereby confirm that I have not been convicted of any felony or misdemeanor listed in PART I above; that I have not been convicted of any felony listed in PART II or PART III above, and; that I have not been convicted of any two misdemeanors listed in PART III, above. I further confirm that there are no charges currently pending against me with respect to the above.

Home health aide services may also be provided by a CNA subject to the same supervision described below. If necessary, they may also be provided by an LPN or RN.

DUTIES

1. Provides personal care and related services in the home, under the direction, instruction, and supervision of the staff nurse and the Director of Nursing.

2.Tasks to be performed by an HHA must be assigned by and performed under the supervision of an RN who will be responsible for the patient care provided by the HHA.

3. Under no circumstances may an HHA be assigned to receive or reduce any intravenous procedures, or any other sterile or invasive procedures, including enemas.

RESPONSIBILITIES

1. Follows the plan of care to provide, safe, competent care to the patient.

2. Helps the patient to maintain good personal hygiene and assists in maintaining a healthful, safe environment.

3. Plans and prepares nutritious meals markets when instructed to do so by the nurse.

4. Assists the patient with ambulation as ordered by the physician and approved and supervised by the nurse.

5. Assists the therapy personnel as needed with rehabilitative processes.

6. Encourages the patient to become as independent as possible according to the nursing care plan.

7.Attempts to promote patient's mental alertness through involvement in activities of interest.

8. Gives simple emotional and psychological support to the patient and other members of the household and establishes a relationship with the patient and family which transmits trust and confidentiality.

9. Reports any change in the patient's mental or physical condition or in the home situation to the staff nurse, or to the Aide supervisor.

10. Performs routine housekeeping tasks as related to a safe and comfortable environment for the patient, as instructed by the professional nurse.

11. Prepares a visit report promptly and incorporates same in the clinical record weekly

12. Confirms on a weekly basis, the scheduling of visits so that other necessary visits by staff members can be coordinated.

13. Works with personnel of other community agencies involved in the patient's care as directed by the nurse.

14. Attends in-service as required by regulation.

JOB CONDITIONS

1. The ability to drive and the ability to access patients’ homes which may not be routinely wheelchair accessible are required.

2. Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment of the patient's condition and to perform patient care.

3. On occasion, may be required to bend, stoop, reach and move the patient weight up to 250 pounds; lift and/or carry up to 30 pounds.

4. Must be able to communicate clearly, both verbally and in writing in English.

EQUIPMENT OPERATION

Use of BP cuff, thermometer, and stethoscope.  Hand washing materials

COMPANY INFORMATION

Has access to all patient medical records which may be discussed with the Registered Nurse and the Director of Nursing.

QUALIFICATIONS

1. Prefer a high school diploma or equivalent.

2. Successful completion of one of the following:

a. A minimum 75 hours training and competency evaluation program OR

b. A training program developed by the agency which meets the criteria set forth in PA Code 611.55. or

c. A competency evaluation program that meets the requirements of 42 CFR 484.80 (c); or

d. The nurse aid certification & training program sponsored by the PA Department of Education, meeting the requirements of 42 CFR 483.151 through 42 CFR 483.154, and is currently listed in good standing on the state nurse aide registry; If a Nurse Aide is certified by the state, the individual will meet the qualifications for a home health aide as hours of training will exceed the minimum required; or

e. The requirements of a state licensure program that meets the provisions of 42 CFR 484.80 (b) and (c)

3.Must be free from health problems that may be injurious to patient, self, and co-workers and must present appropriate evidence to substantiate this.

4. Must comprehend the basics of personal care, housekeeping, and meal preparation.

5. Must understand and respect patients including ethics and confidentiality of care.

6. Must have a complete criminal background check.

7. Must have a current CPR certification. Online certification is not accepted.

JOB ACCEPTANCE STATEMENT

I have read, understand, and agree to the terms specified in this job description for the position I presently hold. A copy of this job description has been given to me. I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.

 

It is both the Agency's and the employee's responsibility to ensure that every patient's health information is protected at all times. By signing below, you are indicating the acknowledgment of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire. I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated with the use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with the HIPAA Rule and Regulations. I agree to protect all Electronic Medical Records including passwords as outlined in the HIPAA policy.

There are specific guidelines to ensure patient's Protected Health Information is kept private.  I understand that my employment with the agency involves handling Protected Health Information.  I will ensure the patient's records are protected by enforcing the following measures:

·Patient Protected Health Information will be transported in a protected travel chart when traveling.

·When transmitting, and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area.

·Patient Protected Health Information will be returned to the agency upon acknowledgement of the patient being discharged.

I pledge to make every effort to keep patient's Protected Health Information protected at all times.

I understand that Agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as an authentication on patient record documents and other agency documents generated in the electronic system. For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge my use of the Signature Passcode and my Login authentication password will serve as my legal signature. I further understand that the Administrator issues employee passwords and the Signature Passcode’s are issued by the software application. Signature Passcodes and passwords will be changed on an as-needed basis if system security is breached. I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. (OASIS Comprehensive Assessments will not require electronic signature until the required information is obtained, which may be up to five days after the corresponding MO date i.e.: MOO30, MOO32, etc.) I understand that: I cannot divulge my login password or Signature Passcode. I must exit the computerized application at the end of each working day or whenever the computer is not in my immediate possession, I must type in (rather than save) the login password that allows me access to the agency computer network, and my Signature Passcode. I must review all of my documentation online prior to submitting it to the agency server.

For good consideration and as an inducement for Royal Homehealth Care Services, LLC, the undersigned Employee hereby agrees not to directly or indirectly use, manipulate or copy compete for any Protected Health Information (PHI), to include personal health information or personal contact information (address, phone, email address, etc.) with the business of the Agency and its successors and assigns during the period of employment.  Misuse of PHI or personal contact information will result in termination and report with action to HIPAA federal agencies.  Fines related to civil and criminal offenses for gross misconduct with the above information are the direct responsibility of the said employee. The Employee acknowledges that the Agency shall or may in reliance of this agreement provides Employee access to trade secrets, customers, and other confidential data and goodwill. Employee agrees to retain said information as confidential and not to use said information on his or her own behalf or disclose the same to any third party or for their own personal or monetary gain. The Employee agrees to not copy and to return all such Agency supplied Information immediately upon termination of employment. Further employee agrees not to solicit any of the customers or employees of employer for any purpose for a period of two years after termination. This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.

This Agency requires adherence to the following Standards and Procedures:

1. All employees are expected to dress in a manner appropriate to the health care environment, or as directed by the patient/family. This includes personal hygiene, jewelry, hair, and makeup.

2. Please do not smoke in the presence of a patient.

3. Always wear your photo ID Badge. 

4. You are expected to arrive on time to all assignments that you have accepted.  However, if an emergency or any situation should cause you to be five minutes late, or more or to be totally absent from the assignment you must notify the Agency immediately.  PLEASE DO NOT CALL YOUR PATIENT DIRECTLY.  You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment.  A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION!

5. If you have any problem, incident, or accident on the job, do not discuss it with the patient but call the Agency immediately.

6. If the patient asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval.

7. Paraprofessional personnel (i.e. Aides) hereby acknowledge that they WILL NOT, UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION.

8. UNDER NO CIRCUMSTANCES are you to ask for or accept any money from your patient or take home any property that belongs to the patient.

9. There shall not be any involvement with the patient’s financial affairs (i.e. check writing).

10. You are expected to honor the confidentiality of any patient information which is obtained in the regular course of your employment.

11. No personal telephone calls should be made or received by you while on assignment.

12. Please do not discuss your pay or any other personal affairs with the patient/family.As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your patient/family.  If you are requested to do so, please have the patient contact us.

13. It is imperative that all signed notes and documentation including Daily Log, be filled out properly and returned to the office as per our schedule.  If the patient is unable to sign your note, a family member or responsible party may sign.

14. During the course of employment, this Agency’s proprietary materials (i.e. forms, medical records) will be used only in connection with patient employment and will not be disclosed to anyone without authorization from the Agency.

The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition. The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, patients, and the Agency business. The Employee will have access to information not generally made available to the public, such as the identity of patients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency's own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies. During the course of employment and for a twelve-month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any patient or entity to discontinue any relationship with the Agency, solicit any patient of the Agency (current and within the past twelve-month period), enter into competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source. Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency's property including keys, patient records, forms, manual, beeper, etc. to the Agency and will not retain copies. Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc. suffered by the Agency. Employees will be required to reimburse the Agency for all legal fees, costs, and other expenses. This agreement is in effect during the Employee's employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy.

I understand that copies of policy and procedure manuals are available and that it is my responsibility to read, understand, and conform to all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions. I have read the Agency’s Policy and Procedure on Abuse, Neglect, and Exploitation and agree to Comply with and am bound by the Policy. I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor is it an expression of my term of employment. I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and that I am required to follow all Agency requirements and state and local laws. I understand that only the Agency has the authority to admit patients and will supervise with appropriate personnel all services provided. As a caregiver, I will carry out the plan of treatment, submit timesheets, clinical and progress notes as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic patient evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meeting and inservice training. I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding patient and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing, results, or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under a specific law. All information in connection with the examination, care, or provision of services to any patient will not be disclosed without the individual's written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of patient/ employee confidentiality is subject to civil and criminal penalties. If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will

I, the undersigned applicant, hereby attest that the state of my health is such that it will enable me to perform the duties of a health care professional. I further specifically attest that I am free of any and all potentially contagious diseases including, but not limited to those listed below:

AIDS	Anthrax	Chicken Pox	Cholera
Diptheria	Leptospirosis	Malaria	Influenza
Leprosy (Hansen's Disease)	Mononucleosis	Hepatitis, Types A, B, and C	Rabies
Meningitis	Poliomyelitis	Mumps	Whooping Cough
Plague	Tularemia	Shigellosis	Small Pox
Rocky Mountian Spring Fever	Rubella (German Measles)	Psittacosis (Ornithosis)	Measles (Rubeola)
Tetanus	Tularemia	Tuberculosis	Typhoid Fever

I understand a Personal Protective Equipment (PPE Kit) is available in the office and contains the following: Barrier Safety Goggles, CPR Shield Face Barrier, Fluid Resistant Gown, Gloves, Biohazard Bag, Sharps Container, 3M Respirator Mask (N95 or similar purchased from Uline.com). I have been instructed in the use of this equipment and understand that I must comply with Policies and Procedures regarding the use of personal protective equipment.

The Corporate Compliance Statement provided below is to be acknowledged and signed by every Agency employee as well as every employee working for the Agency on a contractual basis. Our policy formally and clearly states that there is a zero-tolerance to any form of fraud or misconduct. This Agency believes that every employee or agent plays a key and active role in maintaining its image and reputation. I hereby acknowledge that I have apprised of and agree to comply with the Agency’s Corporate Compliance Policy. I understand that in no way does this create an obligation or contract of employment and that I, as well as the Agency, have the right to end the employment relationship at any time.