One Stop Nursing Registry, LLC - Homemaker / Companion Application Packet - DRAFT

Organization: One Stop Nursing Registry, LLC | Address: 13319 SW 135th Ave, Miami, FL 33186 | AHCA License No. 30212618 | Phone: (786) 952-4767

By signing, you acknowledge falsified statements are grounds for dismissal, authorize investigation of statements, references, and employers, and that no representative can agree to employment for a specified period unless in writing signed by an authorized representative.

By signing, you acknowledge medical records privacy and HIPAA compliance, that patients belong to One Stop Nursing Registry, LLC, and that you will not lure patients away.

By signing, you acknowledge the Homemaker/Companion rules: Rule 59A-18.009, Sections 400.506, 408.809, 400.484, 400.462, 408.810(5), Rules 59A-18.018 and 59A-18.005.

ATTESTATION OF COMPLIANCE with Background Screening Requirements. Authority: This form may be used by all employees to comply with: the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury, to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse. This form must be maintained in the employee's personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application. Employee/Contractor Name: Health Care Provider/Employer Name: Address of Health Care Provider: I hereby attest to meeting the requirements for employment and that I have not been arrested for and been found guilty of, regardless of adjudication, or entered a plea of nolo contendere, or guilty to any offense, or have an arrest awaiting a final disposition prohibited under any of the following provisions of the Florida Statutes or under any similar statute of another jurisdiction: Criminal offenses found in section 435.04, F.S. (a) Section 39.205, relating to the failure to report child abuse, abandonment, or neglect. (b) Section 393.135, relating to sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct. (c) Section 394.4593, relating to sexual misconduct with certain mental health patients and reporting of such sexual misconduct. (d) Section 414.39, relating to fraud, if the offense was a felony. (e) Section 415.111, relating to adult abuse, neglect, or exploitation of aged persons or disabled adults. (f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection. (g) Section 782.04, relating to murder. (h) Section 782.07, relating to manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child. (i) Section 782.071, relating to vehicular homicide. (j) Section 782.09, relating to killing of an unborn quick child by injury to the mother. (k) Chapter 784, relating to assault, battery, and culpable negligence, if the offense was a felony. (l) Section 784.011, relating to assault, if the victim of the offense was a minor. (m) Section 784.03, relating to battery, if the victim of the offense was a minor. (n) Section 787.01, relating to kidnapping. (o) Section 787.02, relating to false imprisonment. (p) Section 787.025, relating to luring or enticing a child. (q) Section 787.04(2), relating to taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceedings. (r) Section 787.04(3), relating to carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person. (s) Section 787.06, relating to human trafficking. (t) Section 787.07, relating to human smuggling. (u) Section 790.115(1), relating to exhibiting firearms or weapons within 1,000 feet of a school. (v) Section 790.115(2)(b), relating to possessing an electric weapon or device, destructive device, or other weapon on school property. (w) Section 794.011, relating to sexual battery. (x) Former s. 794.041, relating to prohibited acts of persons in familial or custodial authority. (y) Section 794.05, relating to unlawful sexual activity with certain minors. (z) Chapter 796, relating to prostitution. (aa) Section 798.02, relating to lewd and lascivious behavior. (bb) Chapter 800, relating to lewdness and indecent exposure. (cc) Section 806.01, relating to arson. (dd) Section 810.02, relating to burglary. (ee) Section 810.14, relating to voyeurism, if the offense is a felony. (ff) Section 810.145, relating to video voyeurism, if the offense is a felony. (gg) Chapter 812, relating to theft, robbery, and related crimes, if the offense is a felony. (hh) Section 817.563, relating to fraudulent sale of controlled substances, only if the offense was a felony. (ii) Section 825.102, relating to abuse, aggravated abuse, or neglect of an elderly person or disabled adult. (jj) Section 825.1025, relating to lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult. (kk) Section 825.103, relating to exploitation of an elderly person or disabled adult, if the offense was a felony. (ll) Section 826.04, relating to incest. (mm) Section 827.03, relating to child abuse, aggravated child abuse, or neglect of a child. (nn) Section 827.04, relating to contributing to the delinquency or dependency of a child. (oo) Former s. 827.05, relating to negligent treatment of children. (pp) Section 827.071, relating to sexual performance by a child. (qq) Section 831.311, relating to the unlawful sale, manufacture, alteration, delivery, uttering, or possession of counterfeit-resistant prescription blanks for controlled substances. (rr) Section 836.10, relating to written or electronic threats to kill, do bodily injury, or conduct a mass shooting or an act of terrorism. (ss) Section 843.01, relating to resisting arrest with violence. (tt) Section 843.025, relating to depriving a law enforcement, correctional, or correctional probation officer means of protection or communication. (uu) Section 843.12, relating to aiding in an escape. (vv) Section 843.13, relating to aiding in the escape of juvenile inmates in correctional institutions. (ww) Chapter 847, relating to obscene literature. (xx) Section 859.01, relating to poisoning food or water. (yy) Section 873.01, relating to the prohibition on the purchase or sale of human organs and tissue. (zz) Section 874.05(1), relating to encouraging or recruiting another to join a criminal gang. (aaa) Chapter 893, relating to drug abuse prevention and control, only if the offense was a felony or if any other person involved in the offense was a minor. (bbb) Section 916.1075, relating to sexual misconduct with certain forensic clients and reporting of such sexual misconduct. (ccc) Section 944.35(3), relating to inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm. (ddd) Section 944.40, relating to escape. (eee) Section 944.46, relating to harboring, concealing, or aiding an escaped prisoner. (fff) Section 944.47, relating to introduction of contraband into a correctional facility. (ggg) Section 985.701, relating to sexual misconduct in juvenile justice programs. (hhh) Section 985.711, relating to contraband introduced into detention facilities. (iii) Section 435.04(3), The security background investigations under this section must ensure that no person subject to this section has been found guilty of, regardless of adjudication, or entered a plea of nolo contendere or guilty to, any offense that constitutes domestic violence as defined in s. 741.28, whether such act was committed in this state or in another jurisdiction. Criminal offenses found in section 408.809(4), F.S. (a) Any authorizing statutes, if the offense was a felony. (b) This chapter, if the offense was a felony. (c) Section 409.920, relating to Medicaid provider fraud. (d) Section 409.9201, relating to Medicaid fraud. (e) Section 741.28, relating to domestic violence. (f) Section 777.04, relating to attempts, solicitation, and conspiracy to commit an offense listed in this subsection. (g) Section 817.034, relating to fraudulent acts through mail, wire, radio, electromagnetic, photoelectronic, or photooptical systems. (h) Section 817.234, relating to false and fraudulent insurance claims. (i) Section 817.481, relating to obtaining goods by using a false or expired credit card or other credit device, if the offense was a felony. (j) Section 817.50, relating to fraudulently obtaining goods or services from a health care provider. (k) Section 817.505, relating to patient brokering. (l) Section 817.568, relating to criminal use of personal identification information. (m) Section 817.60, relating to obtaining a credit card through fraudulent means. (n) Section 817.61, relating to fraudulent use of credit cards, if the offense was a felony. (o) Section 831.01, relating to forgery. (p) Section 831.02, relating to uttering forged instruments. (q) Section 831.07, relating to forging bank bills, checks, drafts, or promissory notes. (r) Section 831.09, relating to uttering forged bank bills, checks, drafts, or promissory notes. (s) Section 831.30, relating to fraud in obtaining medicinal drugs. (t) Section 831.31, relating to the sale, manufacture, delivery, or possession with the intent to sell, manufacture, or deliver any counterfeit controlled substance, if the offense was a felony. (u) Section 895.03, relating to racketeering and collection of unlawful debts. (v) Section 896.101, relating to the Florida Money Laundering Act. [] I have been granted an Exemption from Disqualification through the Agency for Health Care Administration (AHCA). Date of Decision: [] I have been granted an Exemption from Disqualification through the Florida Department of Health. Date of Decision: A copy of the Exemption from Disqualification decision letter must be attached. If you are also using this form to provide evidence of prior Level 2 screening (fingerprinting) in the last 5 years by the Department of Financial Services and have not been unemployed for more than 90 days, please provide the following information. A copy of the prior screening results must be attached. Purpose of Prior Screening: Attestation. Under penalty of perjury, I, ______, hereby swear or affirm that I meet the requirements for qualifying for employment in regards to the background screening standards set forth in Chapter 435 and section 408.809, F.S. In addition, I agree to immediately inform my employer if arrested or convicted of any of the disqualifying offenses while employed by any health care provider licensed pursuant to Chapter 408, Part II F.S. Employee/Contractor Signature Title Date. AHCA Form 3100-0008, July 2024 — Rule 59A-35.090, Florida Administrative Code — Form Available: https://ahca.myflorida.com/backgroundscreening

By signing, you acknowledge the FDLE and FBI privacy policies for the Care Provider Background Screening Clearinghouse, including exchange, retention, and your right to challenge.

This agreement contains all 14 terms, including non-exclusive placement, independent contractor status, self-employment taxes, 1099 over $600 per year, weekly pay, and Florida law. Registry Representative Signature is office-completed after review, not applicant-completed. Registry: One Stop Nursing Registry, LLC, AHCA License No. 30212618.

This addendum contains all 9 sections, including assignment acceptance, conduct, scope, attendance, facility policies, confidentiality, and non-solicitation for 12 months after your last assignment. Registry Signature is office-completed after review.

Job Title/Position: Homemaker/Companion Health Aide

Reports To: RN

 

JOB DESCRIPTION SUMMARY

The Companion/Homemaker provides companionship to those individuals requiring socialization and/or minimum guidance to assure a protected environment and performs home management services within the client’s home.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Provides companionship by reading, conversation, and listening.

• Does household chores that include housekeeping, cooking, shopping assistance, laundry, and other routine household tasks.

• Assists patient/client in completing necessary phone calls, letter writing, etc.

• Maintains a safe home environment for the client.

• Accompanies patient/client on walks, community trips, doctor’s office, bank, etc.

• Reminds client to take self-administered medications.

• Informs staffing coordinator of any changes in assignment.

• Provides emotional support and promotes a sense of well-being.

 

This job description is not intended to be all-inclusive. The employee will be expected to perform other reasonable related duties as assigned by management.

 

POSITION QUALIFICATIONS

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

EDUCATION AND/OR EXPERIENCE

High school diploma or general education degree (GED) or equivalent preferred. Training in the topics related to human development and interpersonal relationships, nutrition, shopping, food storage, use of equipment and supplies, planning and organizing of household tasks and principals of cleanliness and safety.

 

LANGUAGE SKILLS

Ability to communicate effectively with patient/client, family members, clinical management, and staff. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

 

REASONING ABILITY

Ability to apply common sense understanding to carry out simple instructions. Ability to deal with simple problems in the home setting.

 

OTHER SKILLS AND ABILITIES

Communication skills, light housekeeping skills, cooking, cleaning, and shopping. Good physical and mental health. Caring attitude, tact, patience, and good personal hygiene.

 

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Patient home setting, exposure to infectious diseases, automobile.

 

SIGNATURE DATE

Form I-9 will be completed in the office at your in-person visit. Do not complete it online. The full I-9, employee Section 1 plus employer Section 2, current edition 01/20/25, expires 05/31/2027, is completed in person at the office visit, with Section 2 within 3 business days after the first day of employment after physically examining List A OR List B + List C.

Mark ONE path: decline now at no charge and you may accept later, OR previously vaccinated and you agree to provide your vaccination record and antibody testing. Never complete both a declination and a record for the same vaccine.

By declining, you acknowledge the influenza facts, are declining now, and may change your mind if vaccine is still available. If previously vaccinated, upload the record INSTEAD of the declination, never both.