Anio Health Application Package 2022

Safe Resident Handling Training
Manual Title:
Centers’ Nursing Policies
Policy Title:
NSG234 Safe Resident Handling/Transfer Equipment
Application:
Genesis HealthCare Skilled Nursing Centers
POLICY
Staff may use Safe Resident Handling equipment, such as lifts or repositioning equipment, for patients when needed. Patients will be asssessed to determine the correct equipment to use. Staff will be training in the use of each type of equiptment. Slide boards are an approved method of transfer.

Due to the variety of lifts used in Centers, manufacturers’ instructions are not available in the center. All Registry Personnel must refer to a supervisor in the center for assistance.
PURPOSE
To provide safe, comfortable transfer, ambulation, and/or repositioning for patients who have a loss of functional abilities.

I have reviewed the Genesis HealthCare Safe Resident Handling Guidelines for Nurses training and have been informed by the Staffing Vendor of any general orientation information.
Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Agency Name
SAFE RESIDENT HANDLING PROGRAM
Score
Name

First NameLast Name
Date

MonthDayYear
Date
1. The Safe Resident Handling Program impacts which of the following
2. The sticker indicates the type of lift required, the type of sling and number of persons required to reposition patient in bed.
3. At least two staff are required at all times to operate a total lift
4. When a patient is on the floor, the total lift should be used to get the patient up after the nurse has assessed the patient and if they are unable to get up unassisted.
5. If the patient requires two staff to reposition in bed, a repositioning device does not need to be used.
NUR 212 Safe Resident Handling Program 1
6. Using a repositioning device for patients in bed reduces shearing force and helps to prevent skin breakdown.
7. A full body sling is ONLY used when a divided sling is not appropriate. Which of the following are examples of when a divided sling is not appropriate
8. A Sit-to-Stand lift is used for which of the following patients:
9. Employee injuries related to resident handling must be reported.
10. The Slide Board is used for patients who are able to independently transfer, and under the direction of rehabilitation services who will provide patient and/or caregiver training.
EMPLOYMENT APPLICATION
All information on this application will be kept confidential. Please print all information clearly.
Name

First NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address if different from above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number Cell
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number Home
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Date Of Birth

MonthDayYear
Do you have a Social Security Card
SSN
First 3 digits
SSN
Mid 2 Digits
SSN
Last 4 Digits
Do you have a valid driver’s license?
Driver's Lic. #
Can you show all evidence that you can work in USA?
Can you perform the duties of the job described in the attached job description with or without reasonable accommodation?
Are you open to block contracts in-State or out-of-State?
Describe any training or skills you have had in the area applied for
Education
Highest grade completed
GED
College
Name of College/University attended
Degree
Degree Awarded
Special Training
In Area applied for or others areas
Past Employment (please list your last three employers)
1 Employer’s Name
Date employment began

MonthDayYear
Start Date
Date employment ended

MonthDayYear
End Date
Supervisor’s Name
Reason: for leaving
Phone number of supervisor
Format: (000) 000-0000.
2 Employer’s Name
Date employment began

MonthDayYear
Start Date
Date employment ended

MonthDayYear
End Date
Supervisor’s name
Reason for leaving
Phone number of supervisor
Format: (000) 000-0000.
3 Employer’s name
Date employment began

MonthDayYear
Date
Date employment ended

MonthDayYear
Date
Supervisor’s name
Reason for leaving
Phone number of supervisor
Format: (000) 000-0000.
If there is a past employer that you do not wish to have contacted, please list here:
REFERENCE FORM
Employee Name

First NameLast Name
Title:
Position applying for
Please give two references other than relatives: (One Supervisor and a co-worker)
Name of Supervisor

First NameLast Name
Name of facility
Where you worked with the supervisor
Start Date at this facility

MonthDayYear
Date
End Date at this facility

MonthDayYear
Date
Address of facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Supervisor's Phone number
Format: (000) 000-0000.
Name of Co-worker

First NameLast Name
Name of Facility 2
Where you worked with co-worker
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Address of facility

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Co-worker's Phone number
Format: (000) 000-0000.
Have you been convicted of a crime other than minor traffic violation?
Applicant’s Signature
Date

MonthDayYear
Date
HEALTHCARE SERVICES
Staff Employment AGREEMENT
I

First NameLast Name
employed as RN/LPN/GNA/CNA have agreed to carry out the duties and responsibilities listed on my job description.

Both the employer (ANIO HEALTH CARE SERVICES, LLC and I will treat each other with mutual respect.

I understand that this job position may require a lot of flexibility based on the needs of the clients that I may be assigned to work with.

I understand that it is my responsibility to complete all my accepted assignments as scheduled.

In any event that my accepted assignment should be canceled, I must notify the employer at least TWO

HOURS before the start time of the assignment.

I understand that I may be charged the cost for a failure to notify the employer as stated above.

I understand that I shall not engage in any form of conflict of interest with any Client facility that I may be sent to by the employer. Should I resign my position with ANIO HEALTH CARE SERVICES, LLC. I shall not take up an employment with any of the employer's (ANIO HEALTH CARE SERVICES, LLC) Client facility within six (6) month of my official resignation.

I understand that my compensation for services with Anio Health Care Services, LLC is on an hourly basis

and as agreed and reflected on my pay stub. I understand that holidays and overtime with a genesis health care facility is not paid a time and half.

I acknowledge to have received a copy of my schedule and understand that this may change based on Client needs.

It is my responsibility to notify ANIO HEALTH CARE SERVICES, LLC. at least two weeks’ in advance if I chose to terminate this agreement. I also understand that ANIO HEALTH CARE SERVICES, LLC. (employer) can terminate my services at anytime with or without cause.
Employee Signature
Date

MonthDayYear
Date for employee
Anio Health Rep. Signature
Date

MonthDayYear
Date
HEPATITIS B VACCINE DECLINATION

I understand that, due to my occupational exposure to blood or other potentially infectious material, I

may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be

vaccinated with hepatitis B at this time. I understand that by declining this vaccine, I continue to be at

risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure

to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I

can receive the vaccination services series at no charge to me.
Name of Employee

First NameLast Name
Employee Signature
Date

MonthDayYear
Date
Administrator’s signature
Date

MonthDayYear
Date
STAFF LETTER OF ACKNOWLEDGEMENT
I (Employee Name)

First NameLast Name
, hereby acknowledge that the Policies andProcedures of Anio Health Care Services LLC.,

have been reviewed with me.
Employee Signature
Date

MonthDayYear
Date
Anio Health staff Signature
Date

MonthDayYear
Date
Consent to Drug, Alcohol Testing and Background Check
Date

MonthDayYear
Date
I, (Employee Name)

First NameLast Name
, understand that Anio Health Care Services LLC requires all applicants for employment to take a urine test for drug and/or alcohol use.

I hereby freely and voluntarily give my consent to such test, to be administered on

, having been fully informed of the test procedure involved, of what I am being tested for, and that a copy of the results will be forwarded to client facilities and placed in my record if I am ultimately hired. If not hired, I understand that the Company shall destroy all such records.

I also understand that, in the event of a positive test result, the Company will give me an opportunity to explain such a result.
Name

First NameLast Name
Applicant's Signature
Witness's Signature
AGENCY STAFF* FLU VACCINATION ACCEPTANCE/DECLINATION
*Agency Staff are those individuals who report to work at a Genesis Care Center location pursuant to an agreement between Genesis and the Individual’s employer.
ACCEPTANCEinformed and understand the risks of not receiving the vaccination. I further understand that by not receiving the vaccination, I may be at an increased risk of contracting the flu.

I understand that I may be at risk of being infected by and transmitting the influenza virus. I acknowledge that I have received and understand the information regarding the flu vaccination. I have had the opportunity to ask questions and have had my questions answered satisfactorily. I acknowledge that I have been informed and understand the risks of not receiving the vaccination. I further understand that by not receiving the vaccination, I may be at an increased risk of contracting the flu.
Based on the information I have received, I am making an informed decision to accept the inactivated influenza vaccine. In addition, I do not have a fever, have never had any severe (life-threatening) allergies, including a severe allergy to eggs. I have not had a serious allergic reaction to a prior dose of the influenza vaccine and have never had Guillain-Barre Syndrome. I acknowledge that I am not pregnant. I understand that if I were pregnant I would need authorization from my physician to receive the vaccination. I accept the inactivated influenza vaccine.
FLU VACCINE (TYPE OF INFLUENZA)
MANUFACTURER/Lot#
Expiration Date

MonthDayYear
Date
Site of Injection: LA
RA
Date

MonthDayYear
Date
Administering Clinician Name
Administering Clinician Signature
I DECLINE THE INFLUENZA VACCINE FOR THE FOLLOWING REASON(S) (CHECK ALL THAT APPLY):
Type a question
If your reason is Other; Enter your reason here.
Employee Name

First NameLast Name
Registrant’s Signature
Date

MonthDayYear
Date
Witness’ Name
Witness’ Signature
Date

MonthDayYear
Date
Last Name1167R
First Name1170R
Middle Initial
Other Names
Adress
Apt.#
City
State
Zip Code
DOB1190R

MonthDayYear
Date
SSN_1
First 3 digits
SSN_2
Mid. 2 digits
SSN_3
Employee E-mail
example@example.com
Cell Phone
CheckBox11198R
USCIS #
For Permanent Resident
Expiration Date1224R

MonthDayYear
Authorization to work
USCIS #1226R
Form I-94 Addmission #
Foreign Passport #
Country of Issuance
Employee Signature
Date1234R

MonthDayYear
Date
CheckBox51252R
Signature of Preparer/Translator
Date
Date
Last Name of Preparer
First name of Preparer
Address
City
State
Zip Code
Genesis HealthCare Mandatory PointClick Care ( PCC)
PointClickCare (PCC) Training Video: www.vitallearn.com/webapp/#/?course=6651933

Each Staffing Vendor is responsible for each Registry Personnel to complete the PointClickCare training video prior to working at any Genesis HealthCare facility. Failure to upload this document will result in inactivation of Registry Personnel.

The candidate’s log in information will be in this format: Username: first initial with full last name
- Example – John Smith
- jsmith
Password: Capital first initial, lower case last initial, last four of their SSN and the date of birth (MMDD) followed by #

o SSN: 123-45-6789 o DOB: 01/02/1990

I have viewed the Point Click Care training video required by Genesis HealthCare and have been informed by the Staffing Vendor of any general orientation information.
Employee Name

First NameLast Name
Employee Signature
Agency Name

MonthDayYear
Date
ANNUAL TB SCREENING QUESTIONNAIRE
This form is intended to be used for all employees and independent contractors, regardless of a negative skin test.
Have you EVER had a positive TB skin test? If "No," stop here; if "Yes", please complete the rest of this form
Have you EVER had a positive TB skin test? If "No," stop here; if "Yes", please complete the rest of this form
In the past 12 months, have you had any of the following symptoms:
A persistent productive cough for 3+ weeks?
Coughing up Blood?
Unexplained, excessive fatigue?
Unexplained, excessive sweating at Night?
Unexplained, recurrent fevers lasting more than three weeks?
Unexplained, weight loss?
Hoarseness lasting three weeks or more?
Have you ever been told by a Doctor or other health care provider that you had active TB?
Have you ever been told by a Doctor or otherhealth care provider that your immune system is not working right or that you cannot fight infection?
Have you had pneumonia in the past year?
Have you ever lived with or had close contact with someone who has/had active tuberculosis disease?
Have you ever been told that you have an abnormal chest x-ray?
Have you ever worked where patients with active tuberculosis disease receive care or services?
Have you ever worked, volunteered, or lived in any institution such as a jail, group home, or homeless shelter?
Have you ever traveled outside the United States? If Yes, identify city, country and approximate year.
year.
Were you born in the United States? If No, identify country you were born in.
Were you born in the United States? If No, identify country you were born in.
Should any of these symptoms develop during the year, please notify your supervisor and alert your regular physician of your positive skin test.
Name

First NameLast Name
Date

MonthDayYear
Date
(Employee Signature)
File Upload: Please attach all relevant documents; Resume, PPD, Covid 19 Card, Physical, Flu/Vaccine Records, CPR, Any Current Background check ETC. to amara@aniohealthcareservices.com
Not Required: Use the email to send documents
Should be Empty:

Safe Resident Handling Training

Manual Title:

Centers’ Nursing Policies

Policy Title:

NSG234 Safe Resident Handling/Transfer Equipment

Application:

Genesis HealthCare Skilled Nursing Centers

POLICY

PURPOSE

EMPLOYMENT APPLICATION

REFERENCE FORM

HEALTHCARE SERVICES

Consent to Drug, Alcohol Testing and Background Check

AGENCY STAFF* FLU VACCINATION ACCEPTANCE/DECLINATION

I DECLINE THE INFLUENZA VACCINE FOR THE FOLLOWING REASON(S) (CHECK ALL THAT APPLY):

ANNUAL TB SCREENING QUESTIONNAIRE