Orientation Document Submission

Attestation Statement
I name* never have been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application.
Date

MonthDayYear
Employee Sign
Date

MonthDayYear
Supervisor Sign

ENFORCED RULES AND AWARENESS:

I understand that as part of the employment process any and all employees/contractors caught stealing/embezzlement from the department and /or client will be prosecuted. Theft includes turning in hours you did not work as well as forged client signatures.

I further understand that if I refused to sign this prevention and control of theft form, it will result in termination of the employment process.

My signature below is evidence that I have read and understand the content of this notice.
Prevention And Control Form

Or Internal Theft/ Employee/ Contractors
Date

MonthDayYear
Name of Applicant
Signature of Applicant
Signature of Hiring Official

Client's Rights And Responsibilities
Hope Private In-Home Care
Office Address: 2336 Wisteria Drive Suite 140. Snellville Ga 30078
Office Number. (770) 864-9398

The client has the right to...
1. Know his/her rights.
2. Choose the Home Care Agency that will provide his/her care.
3. Receive competent care without regard to race, creed, color, age, sex or national origin.
4. A personal and written care plan and participation in decisions affecting his/her care.
5. Be treated with respect, consideration, and kindness.
6. Be served by dependable and responsible caregivers.
7. Confidentiality regarding all medical and financial and personal information.
8. Not be abused physically, verbally, emotionally, or sexually by caregivers.
9. Request replacement of employees when necessary.
10. Contact the agency twenty-four hours a day, seven days a week at the office address and number.
11. Receive services as contracted and an explanation of all charges for services.
12. Voice complaints, have them reviewed and if possible, resolved without interruption in service. The name of the service supervisor is Oby Omesiete, who can be reached at the above number. You also have the right to receive the telephone number and address of the state licensing office (404) 657-1509. #2 Martin Luther King Jr Dr, SE, East Tower, 17th Floor, Atlanta, GA 30334.
13. To be informed of changes in the client's condition or events that would affect service plans.
14. To refuse treatment and service.
15. To privacy, modesty, and security.
16. To have his/her property respected.
17. To obtain a copy of the provider's licensing report.
18. To be informed promptly about any changes in services (before the change).
19. To be informed of complaint procedures.
Date

MonthDayYear
Signature of Applicant

Employee No Compete-No Circumvent Agreement
This agreement is made and entered into this .* day or Date*between Hope Private In-Home Care, LLC, a Limited Liability Company incorporated under the Jaw of the State of Georgia (hereinafter referred to as "HPC") and .* (hereinafter referred to as "Employee"), as follows:
Whereas HPC and Employee desire to enter into a no-compete, no-circumvent agreement maintains contractual relations and for other related purposes;

Now, therefore, in consideration of the mutual covenant and agreement contained herein the receipt and sufficiency of which are hereby acknowledged. It is mutually agreed and covenanted by and between HPC and Employee as follows;
1. Type of Work: Employee agrees to perform contracted home care management services to HPC client/customers, per the attached Job Description provided to the employee.
2. Employee's Duties: In connection with the activities listed in paragraph (1) above. Employee covenants and agrees to perform such duties as may be reasonably directed by HPC, Employee further covenants and agrees to observe all guidelines, policies, procedures, restrictions, rules, and regulations as may be reasonably imposed by HPC.
3. Covenant Not to Compete:
  A. Employee expressly covenants and agrees that during the term of this agreement and for a period of twelve (12) consecutive months immediately following the cancellation, expiration, revocation, or termination of this Agreement for whatever reason, he or she will not directly or indirectly market his or he own services if such services in any way conflict with services provided by HPC to its clients at any time during the most recent twelve (12) months in which this agreement was in effect.
  B. Employee also expressly covenants and agrees that during the term of this Agreement and for a period of twelve (12) months immediately following the Cancellation, expiration, revocation, discontinuance or termination of the Agreement for whatever reason, Employee will not solicit or accept payment for home care services from any of the clients or customers of HPC.
  C. HPC and Employee acknowledge and agree that any breach or invasion of these Covenants by Employee will result in immediate and irreparable injury to HPC's Order, as well as to other legal remedies to which HPC may be entitled.
4. Enforceable agreement: HPC and Employee agree and intend that the execution of this agreement imposes legal, blinding, and enforceable obligations on them in accordance with the terms stated herein.
Employee/ Date Signed
Hope Private Care

ACKNOWLEDGEMENT OF APPLICANT'S NON-CRIMINAL JUSTICE

PRIVACY RIGHTS AND CONSENT TO BE INCLUDED IN THE CAREGIVER PORTAL
- APPLICANT TYPE:
- PRINT FULL NAME
  
  First NameMiddle NameLast Name
- Date of Birth
  
  MonthDayYear
  Date
- Home Address
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Email Address
- Telephone No.
  Please enter a valid phone number.Format: (000) 000-0000.
- Name of Facility
- Street Address
- City
- State
- Zip Code
- I hereby authorlie the Georg la Department of Community Health (OCH), Office of Inspector General, to receive any criminal history record Information pertalnina to me which maybe In the files of any state or local crimfnaljustlce agency In Georgia. I understand a State and Federal fingerprint criminal background check will be conducted. By signing below, I am Indicating that I have read and understand the terms and conditions of the attached Non-Criminal Justice Applicant's Privacy Rights and Policy Act Statements.
- Applicant Signature
- Date
  
  MonthDayYear
  Date
- APPLICANT TYPE
- The Georgia Caregiver Portal only contains the eligibility status of applicants and employees who have successfully passed the background screening process. The Caregiver Portal does not contain the names of applicants and employees who are inelliglble. Family employees can access the Caregiver Portal to view a prospective applicant or current employee's eligibllity to determine their suitability for employment to provide personal care services to that employer's elderly family member or wards. All services are performed at locations not licensed by DCH.
  
  lndividuals should check one of the boxes below.
- Applicant Signature
- Date
  
  MonthDayYear
  Date

Job Description
Job Title
- Certified Nursing Assistant
- POSITION DESCRIPTION:
  A Certified Nursing assistant is a non-licensed member of the home health care team who assists the client with the tasks of daily living as outlined in a written care plan that is established by a Registered Nurse Supervisor and is kept in the client's home. Certified Nursing Assistant is supervised by the RN Supervisor at this agency and receives scheduling direction from the agency staffing Coordinator.
  
  QUALIFICATIONS:
  1. A Certified Nursing assistant must have a minimum of one year of personal care experience which is Verifiable through references and must complete this agency's employment and certification process.
  2. Must be at least 18 years of age.
  3. Must be physically able to perform the duties of the position.
  4. Must exhibit mature responsible behavior, and understand the need for patient confidentiality.
  5. Must be able to read, write and speak English.
  6. Must be able to follow directions and accurately report to the RN Supervisor any changes in the client's condition.
  7. Must have available reliable transportation to and from assignments.
  DUTIES:
  The duties of a Certified Nursing assistant may include, but are not limited to the following:
  1. Recording pertinent information pertaining to the client's care.
  2. Reminding clients to take medication at the appropriate time.
  3. Planning and preparing meals according to specific dietary requirements of the client and if necessary feeding the client.
  4. Assisting the client with therapy exercises under the direction of a Registered Nurse.
  5. Assisting or performing personal care including hair care, oral hygiene, bathing, grooming, and dressing.
  6. Assisting with ambulation with or without mechanical aids.
  7. Assisting with routine bodily functions: Example, toileting.
  8. Maintaining a safe, clean and healthy environment through light housekeeping including changing bed linens, dusting and vacuuming cleaning kitchen and bathroom, and laundry.
  9. Providing companionship and stimulation for the client including reading walks, etc., and accompanying the client to doctors or other appointments.
  10. Grocery shopping or other errands when needed.
  11. Performing other housekeeping tasks as indicated in the care plan.
  12. Taking client's vital signs and recording input and output.
  13. Observing and reporting changes in client's condition to this agency's RN Supervisor.
  14. Accurately preparing daily records and submitting them to the office by the date due.
  15. Participating in in-service education programs.
  EMPLOYEE MAY NOT:
  1. Administer or pour medication as mandated by law.
  2. Cut the nails of any patient unless authorized by RN Supervisor.
  3. Perform any type of heavy housework such as cleaning stoves with oven cleaners, moving heavy furniture or appliances, etc.
- Date
  
  MonthDayYear
- Employee Signature
- Licensed Practical Nurse
- POSITION DESCRIPTION:
  A Licensed Practical Nurse/Licensed Vocational Nurse (LPN/LVN) is a professional member of the health care team whose primary responsibility is providing direct nursing care under the supervision of a physician and registered nurse in accordance with the Nurse Practice Act regulations of the State Board of Nursing. This position reports to the Nursing Supervisor. In an institutional setting, this position reports to the designated person.
  
  QUALIFICATIONS:
  1. Must possess a valid current license under the GA State Board of Nursing.
  2. Must be of mature and responsible character.
  3. Must possess general knowledge of the disease process and medication action.
  4. Must possess knowledge of necessary actions in emergency situations.
  5. Must be able to effectively communicate with the client, their significant others, and the Nursing Supervisor.
  6. Must be in good physical and mental health.
  7. Must complete this agency's employment process.
  DUTIES:
  The duties and responsibilities include, but are not limited to
  1. Provide direct nursing care of sub-acute, chronically ill, and convalescent clients.
  2. Administer medications and therapeutic treatments according to a prescribed regimen,
  3. Monitor client's condition including the effectiveness of treatments and medications.
  4. Notify supervisor of changes in client's condition.
  5. Teach the client appropriate self-care techniques.
  6. Document accurately and submit timely the nursing notes, according to agency standards.
  7. Work in cooperation with facility administration and personnel.
  8. Participate in continuing educational programs.
  PERFORMANCE:
  Performance is deemed competent when the LPN/LVN:
  1. Demonstrates ability to provide nursing care within the parameters of the State Nurse Practice Act and the policies and procedures of this agency.
  2. Demonstrates ability to implement a client's care plan.
  3. Demonstrates ability to accurately monitor a client's condition.
  4. Demonstrates effective communication skills.
  5. Demonstrates ability to document pertinent information and submit records in accordance with this agency policy.
- Date
  
  MonthDayYear
- Employee Signature

Please Upload your Certification
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LPN or OTHER CERTIFICATE

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Check Glucose Levels
Suprapubic Catheter
Condom Catheter
Foley Catheter
Spinai Cord Injury Clients
Diabetes
Parkinson's
Special Meal Prep
Feeding Tube
Gait Belts
Breathing Treatments
Gastronomy Tubes
Hospice Care
Amputation
Colostomy
Demenita
Hoyer Lift
Prosthetics
Suction Machine
Tracheostomy
Ventilator

Attestation Statement

Prevention And Control Form

Client's Rights And Responsibilities

Employee No Compete-No Circumvent Agreement

Medical Equipment-patient Experience

ACKNOWLEDGEMENT OF APPLICANT'S NON-CRIMINAL JUSTICE

Job Description

Please Upload your Certification