Authorization Statement: 

I authorize IRIS HOME HEALTH, LLC to contact each former employer, firm or corporation. I authorize any of these persons to give all information concerning work-related items and I release all parties from liability for any damage that may result from furnishing same to you.

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 also understand that if accepted by IRIS HOME HEALTH, LLC my employment is voluntarily entered into and I am free to resign at any time. Similarly, IRIS HOME HEALTH, LLC is free to conclude my employment
at any time. I further recognize that this application is not a contract and cannot create a contract.

Criminal Offenses Addendum:

The Ohio Administrative Code O.C.G.A. 49-2-14.1et seq. requires that home health care companies ascertain from applicants for employment that they have not been convicted plead guilty of the offenses listed below. Your signature below indicates that you have not committed nor plead guilty of:

Aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, failing to provide for a functionally impaired person, aggravated menacing, patient abuse and neglect, kidnapping, abduction, criminal child enticement, rape, sexual battery, unlawful sexual conduct with a minor, gross sexual imposition, importuning, voyeurism, public indecency, compelling prostitution, promoting prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity, pandering obscenity involving a minor, pandering sexually oriented materials involving a minor, illegal use of a minor in nudityoriented material or performance, aggravated robbery, robbery, aggravated burglary, burglary, unlawful abortion, endangering children, contributing to the unruliness or delinquency of a child, domestic violence, carrying a concealed weapon, having weapons while under disability, improperly discharging a firearm at or into a habitation or school, corrupting others with drugs, trafficking in drugs, illegal manufacture of drugs or cultivation of marijuana, funding of drugs or marijuana trafficking, illegal administration or distribution of anabolic steroids, placing harmful objects in food or confection, child stealing, possession of drugs, felonious sexual penetration.

I have read the contents of this addendum to my application for employment with IRIS HOME HEALTH, LLC also understand that I am required by law to
notify IRIS HOME HEALTH, LLC within 14 (fourteen) days if I receive formal charges, convictions, or make a guilty plea to any one of the disqualifying offenses listed above.

A paraprofessional person who is specifically trained, competent and performs assigned functions of personal care
to the patient in their residence under the direction, instruction and supervision of the registered nurse (RN).

QUALIFICATIONS:
1. Must meet Medicare Conditions of Participation for Home Health Aide training program and competency.
2. Have a sympathetic attitude toward the care of the sick and elderly.
3. Ability to carry out directions, read and write.
4. Maturity and ability to deal effectively with the demands of the job.

RESPONSIBILITIES:
1. Understands and adheres to established agency policies and procedures.
2. Performs personal care and bath as ordered.
3. Completes appropriate visit records in a timely manner as per the agency policy.
4. Reports changes in the patient's condition and needs to the RN.
5. Performs household services essential to health care in the home as assigned.
6. Ambulates and exercises the patient as assigned.
7. Performs simple procedures as an extension of the therapy services, e.g., range of motion (ROM) exercises as
assigned.
8. Assists with medications that are ordinarily self-administered as assigned.
9. Attends inservice and continuing education programs as scheduled and necessary.
10. Attends patient care conferences as scheduled.

WORKING ENVIRONMENT:
Works indoors in the agency office and patient homes and travels to/from patient homes.

JOB RELATIONSHIPS:
1. Supervised by: Director of Clinical Services/Nursing Supervisor/RNs, PTs,
OTs, SLPs

RISK EXPOSURE:
High risk

LIFTING REQUIREMENTS:
Ability to perform the following tasks if necessary:
• Ability to participate in physical activity.
• Ability to work for extended period of time while standing and being involved in physical activity.
• Heavy lifting.
• Ability to do extensive bending, lifting and standing on a regular basis.

I have read the above job description and fully understand the conditions set forth therein, and if employed as a Home Health Aide, I will perform these duties to the best of my knowledge and ability

VIOLATION OF ANY OF THE FOLLOWING RULES MAY BE GROUNDS FOR IMMEDIATE TERMINATION

EMPLOYEE SHALL NOT:
1) Use client’s vehicle.
2) Consume client’s food and drink.
3) Use client’s phone for personal calls.
4) Discuss his/her personal problems, religious or political beliefs with client.
5) Accept gifts or tips from clients.
6) Bring friends or relatives into client’s home.
7) Consume alcoholic beverages, or illegal medication or drugs while on company time.
8) Smoke in client’s home, with or without client’s permission.
9) Breach client’s privacy or confidentiality of all records.
10) Eat food brought to client’s home without client consent.
11) Solicit clients for a donation or to purchase an item.
12) Fail to report any instances of suspected fraud or abuse.
13) Failure to report to immediate Team leader, at least 2 hours prior to the start of your shift, that you willbe
absent.
14) Fraudulently complete a time sheet or other legal document belonging to IRIS HOME HEALTH, LLC
CONSULTING SERVICES, (the agency will prosecute to the maximum amount allowed for this offense)
15) Borrow, purchase, or loan money or any other item to or from client.
16) Request client permission to leave before time there is complete.
17) Request client to sign time sheets before time furnished or several late time sheets.
18) Give client medical advice or dispense medication (prescribed or over the counter)
19) Discuss other clients or company business with a client, their family member or anyone outside ofthis
agency.
20) Remain in home if client is not present.
21) Breach any rules and company policies contained in employee handbook.
22) Perform additional duties for client on his/her personal time. All contact with client shall be only on
company scheduled time.
23) Fail to report immediately to your Team leader or appropriate person in charge:
a) Physical/Emotional changes
b) Changes in living arrangements
c) Absence of relatives that are to be there
d) Client cancels services
e) Client not at home

The Health Insurance Portability and Accountability Act of 1996 (HIPAA), is a federal law which, in part, protects the privacy of individually identifiable patient information and provides for the electronic and
physical security of health and patient medical information, and simplifies billing and other electronic transactions through the use of standard transactions and code sets (billing codes). HIPAA applies to all “covered entities” such as hospitals, physicians and other providers and health plans as well as their employees and other members of the covered entities’ workforce. Privacy and security are addressed separately in HIPAA under two distinct rules, the Privacy Rule and the Security Rule. The Privacy Rule sets the standards for how all protected health information should be controlled. Privacy standards define what information must be protected, who is authorized to access, use or disclose this information, what processes must be in place to control the access, use and disclosure of information, and to ensure patient privacy rights.
The Security Rule defines the standards that require covered entities to implement basic security safeguards to protect electronic protected health information (ePHI). Security is the ability to control access and protect electronic information from accidental or intentional disclosures to unauthorized
persons and from alteration, destruction, or loss. The standards include administrative, technical, and physical safeguards designed to protect the confidentiality, integrity, and availability of ePHI.

PRIVACY RULE
Purpose of Privacy Rule
To protect and enhance the rights of consumers by providing them access to their health information and controlling the inappropriate use of that information;
Highlights of Privacy Rule The Privacy Rule requires that access to protected health information (PHI), which includes electronic PHU (ePHI), by CHHS Board Members, professional employees, contractors be based on the general principle of “need to know” and “minimum necessary,” in which access is limited to the patient information needed to perform a job function. The HIPPA Privacy Rule also accords certain rights to patients, such as: Right to request access to their own health records, Right to request, and amendment of information in their records.
Right to receive an accounting of disclosure of their information
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HIPAA AGREEMENT (cont’d)
Potential Consequences of Violating the Privacy Rule
The Privacy Rule imposes penalties for non-compliance and for breaches of privacy which range from
$100 to $50,000 per violation, in addition to costs and attorney’s fees, depending on the type of
violation. Penalties include fines up to a maximum of $1,500,000 per event potential for civil lawsuits,
the potential for misdemeanor charges and reporting the violation to licensing boards for individuals.
Under state and federal laws and regulations governing a patient’s right to privacy, unlawful or
unauthorized access to, or use or disclosure of, patient’s confidential information may subject me to
disciplinary action up to and including immediate termination from my employment/professional
relationship with the agency.

I have read, understood and acknowledge all of the above STATEMENT OF PRIVACY RULE,
REGULATIONS AND THE AGENCY’s POLICY.

I will at all times keep the interests of the clients we serve as my foremost concern. I will not act to circumvent the
policies of my employer, and the agency. In particular, I will follow the established protocols concerning client
information, records, treatments, and inquiries.
I recognize that all client information is confidential and I will make every effort to uphold the privacy of client
information. I accept personal responsibility for any client information I disseminate contrary to the protocols of the
Company including, but not limited to, dissemination for personal gain.
I acknowledge that the agency is engaged, among other things, in the business of providing health care services.
Each of these services involves the use of propriety techniques and technology developed by the Company. At all
times during my employment and for a period of one hundred eighty (180) days after my employment terminates,
voluntary or involuntary, I agree to not directly or indirectly use, disclose or disseminate to any other person or
organization or entity all Company proprietary techniques and technology of which I have knowledge.
While employed by the agency. I will refrain from being an owner, agent or to have any financial interest, either
directly or indirectly, in any other business activity which covers services that are directly competitive with the agency
provided, however, that I may own shares in any publicly traded company.
Upon my termination of employment, I will return to the agency. All notes, records, files or documentation, whether
made or compiled by me, pertaining to propriety information of the agency.

The agency will maintain confidentiality and security of patient data that is entered into and stored on computer
systems.
I understand the need and responsibility to maintain a high level of security with computer access. I
will not allow anyone to use my computer key/password and accept full responsibility for the security
of my computer key/password.

 

 

I understand that due to my occupational exposure to blood or other potentially infectious
material, I am at risk of acquiring HBV (Hepatitis B Virus) infection. I have read the
Employee Information Sheet: Hepatitis B and Hepatitis B Vaccine and have had an
opportunity to ask questions and understand the risks and benefits of the HBV vaccine.
I have been given the opportunity to be vaccinated at no charge to myself.
Having been so informed, I decline to take the HBV vaccine at this time. I understand that by declining
the vaccine, I continue to be at risk of acquiring hepatitis. If in the future I continue to have
occupational exposure to blood or other potentially infectious materials and want to be vaccinated, I can
receive the vaccination series at no charge to me.

IRIS HOME HEALTH, LLC offers vaccination against influenza to licensed independent practitioners
and staff. The agency’s annual influenza program is not applicable to staff and licensed independent
practitioners that provide care, treatment, or services through telemedicine or telephone
consultation.
I understand that due to my occupational exposure to blood or other potentially infectious material, I
am at risk of acquiring Influenza.
I have been given the opportunity to be vaccinated at no charge to myself.
I understand that by declining this vaccine, I will continue to be at risk of becoming infected with Influenza.

My signature signifies my agreement to all of the above stipulations.

Ethical, Professional, Respectful and Legal Service Standards
Requirements for Providers to Become, and to Remain, Certified
OAC 173-39-02 (B)(8)
Updated 7/1/23
The provider shall not engage in any unethical, unprofessional, disrespectful, or illegal behavior
including the following:
(a) Consuming alcohol while providing services to the individual.
(b) Consuming medicine, drugs, or other chemical substances in a way that is illegal,
unprescribed, or impairs the provider from providing services to the individual.
(c) Accepting, obtaining, or attempting to obtain money, or anything of value, including gifts or
tips, from the individual or his or her household or family members.
(d) Engaging the individual in sexual conduct, or in conduct a reasonable person would interpret
as sexual in nature, even if the conduct is consensual.
(e) Leaving the individual's home when scheduled to provide a service for a purpose not related
to providing the service without notifying the agency supervisor, the individual's emergency
contact person, any identified caregiver, or ODA's designee.
(f) Failing to cooperate with or treating ODA or its designee respectfully.
(g) Engaging in any activity while providing a service that may distract the provider from
providing the service as authorized, including the following:
(i) Watching television, movies, videos, or playing games on computers, personal phones, or
other electronic devices whether owned by the individual, provider, or the provider's staff.
(ii) Non-care-related socialization with a person other than the individual (e.g., a visit from a
person who is not providing care to the individual; making or receiving a personal telephone call;
or, sending or receiving a personal text message, email, or video).
(iii) Providing care to a person other than the individual.
(iv) Smoking tobacco or any other material in any type of smoking equipment, including
cigarettes, electronic cigarettes, vaporizers, hookahs, cigars, or pipes.
(v) Sleeping.
(vi) Bringing a child, friend, relative, or anyone else, or a pet, to the individual's place of
residence.
(vii) Discussing religion or politics with the individual and others.
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(viii) Discussing personal issues with the individual or any other person.
(h) Engaging in behavior that causes, or may cause, physical, verbal, mental, or emotional
distress or abuse to the individual including publishing photos of the individual on social
media without the individual's written or electronic consent.
(i) Engaging in behavior a reasonable person would interpret as inappropriate involvement in
the individual's personal relationships.
(j) Making decisions, or being designated to make decisions, for the individual in any
capacity involving a declaration for mental health treatment, power of attorney, durable
power of attorney, guardianship, or authorized representative.
(k) Selling to, or purchasing from, the individual products or personal items, unless the
provider is the individual's family member who does so only when not providing services.
(l) Consuming the individual's food or drink, or using the individual's personal property
without his or her consent.
(m) Taking the individual to the provider's business site, unless the business site is an
ADS center, RCF, or (if the provider is a participant-directed provider) the individual's
home.
(n) Engaging in behavior constituting a conflict of interest, or taking advantage of, or
manipulating services resulting in an unintended advantage for personal gain that has
detrimental results to the individual, the individual's family or caregivers, or another provider.