REQUEST FOR REFERENCES
EMPLOYEE EMERGENCY INFORMATION
HOME HEALTH AIDE SELF COMPETENCY CHECKLIST
Instructions: Use the following answer key to indicate the extent of your previous experience and personal rating of experience.
BACKGROUND CONSENT FORM
SWORN DISCLOSURE STATEMENT
Effective July 1992, section 63.1-19413, Code of Virginia and UNLIMITED CARE 4 CORPORATION require that persons desiring registering with our agency provide a sworn statement of affiliation disclosing any criminal convictions or pending or pending criminal charges, whether within or outside the Commonwealth of Virginia.
Individuals convicted of the following cannot be hired: murder, abduction for immoral purposes, assaults and bodily wounding, robbery, sexual assault, arson, pandering crimes against nature involving children, taking indecent liberties with children, abuse and neglect of children, failure to secure medical attention for an injured child, obscenity offenses or abuse or neglect of an incapacitated adult. However, applications of convicted of one misdemeanor crime not involving abuse of neglect or moral turpitude may be hired provided five years has elapsed since the conviction.
Any person taking a false statement on this form regarding any criminal offense shall be guilty upon convictions of Class I misdemeanor.
Further dissemination of the information provided on this form is prohibited other than to a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.
Please print the information required in section one.
This statement must be provided to and maintained by the property in the employee's personal file.
I, employed as a, RN/CNA/HHA or LPN, have agreed to carry out the duties and responsibilities listed on my job description. I have been given a copy of my job description.
I have read and agree to the terms specified in this job description for the position I presently hold. I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.
Both the employer (UNLIMITED CARE 4 CORPORATION) and I, will treat each other with
I understand that this job position may require a lot of flexibility and transportation on my part based on the needs of the clients that I may be assigned to work with.
I understand that my compensation for services with family healthcare services is based on hourly basis.
I acknowledged to have received a copy of my schedule and understand that this may change based on client’s needs.
It is my responsibility to notify UNLIMITED CARE 4 CORPORATION at least two weeks' in
advance if I chose to terminate this agreement. I also understand that UNLIMITED CARE 4
CORPORATION (employer) can terminate my services at any time with or without cause.
DRUG AND ALCOHOL POLICY AGREEMENT
It is the policy of UNLIMITED CARE 4 CORPORATION that all its employees be free of the influence of alcohol and drugs. All employees must be fit for the duty physically and mentally, as is necessary to perform work in a safe and competent manner.
Possession, trading, manufacture and sale of illegal drugs or alcohol on the job is therefore a violation of this policy.
Also, it is a violation of this policy to work under the influence of illegal drugs or alcohol. Violations of this policy are subject to disciplinary action up to and including termination.
JOB TITLE: Home Health Aide
REPORTS TO: Registered Nurse/Administrator
JOB SUMMARY: The Home Health Aide carries out supportive duties for the Nursing Department of a health care provider by performing specified non-skilled medically related skills under the direction and supervision of a Registered Professional Nurse, other agency designated health care professional and administrator.
Follows personal care activities documented in a written assignment by a health professional (RN or Therapist). Activities include assistance with personal care hygiene, activities of daily living.
Encourages client participation in activities to the extent to which client is able.
Assists with ambulation, eating, dressing, shaving and physical transfer.
Assists client to bed, commode, and/or chair
Turns and position bed bound client
Maintain appropriate documentation of all services as per agency policy and procedure
Changes bed linen
Maintains a clean, safe and healthy environment
May grocery shop for list often items or less
Informs supervisor of any changes in client's condition or home situation.
ACTIVITIES THE HOME HEAL TH AIDE MAY NOT PERFORM INCLUDE:
Administration of Medication
Irrigation of urinary catheters, colostomies, or wounds
Noso- gastric tube feeding or gastric irrigation
Applying heat by any method
Changing of sterile dressing
Any other services not included in the client's care package.
Any services requiring the skills of a licensed nurse and/or therapist.
Irrigate body cavities such as giving an enema
Providing care to a tracheotomy tube.
Must provide evidence of formal training and/or certification as a home health aide as required by state law and federal law. Must also provide evidence of competency training and evaluation as well as evidence of at least quarter attendance of in-service education programs. Must have a sympathetic attitude towards the care of the sick as well as have the ability to read, write and carry out job directions and the maturity and ability to deal effectively with the demands of the job. A minimum of one (1) year current experience and high school diploma is preferred.
By my signature, I acknowledge and accept the responsibilities of this position. I am qualified by education and/or experience to carry out these duties.
I understand that if I apply for a full-time position, I would be on an initial 90 days probationary
period after which an evaluation of my performance would made by my supervisor. Final offer for the position would then be made If I have met the satisfactory requirements for the job description.
An annual performance evaluation would be performed by the administrator/director as outlined in the agency's policies and procedures.
To maintain exclusive professional standards, UNLIMITED CARE 4 CORPORATION, prohibits any staff to solicit or transfer patients under their care to another agency/provider while employed as a staff or for 2 years after staffs employment is terminated. If I hired as an administrative staff, I would not establish/set-up or own a Home Health care Agency for two years from termination of my service with UNLIMITED CARE 4 CORPORATION.
EMPLOYMENT STATEMENT OF CONFIDENTIALITY
I, the undersigned, understand the importance of observing strict confidentiality policies. Therefore, I agree not to discuss / release any information obtained within the agency, any UNLIMITED CARE 4 CORPORATION client, their medical records, or any client's condition with any individual not directly associated with the client. I also agree that any information that is released regarding the client or the client's record will only be done with proper authorization and / or in accordance with established agency policy for the release of the information.
My signature on this document indicates that I understand and agree to abide by the aforementioned policies, and that any breach in the aforementioned policies will result in implementation of the Disciplinary procedure up to and including possible IMMEDIATE DISMISSAL from employment at UNLIMITED CARE 4 CORPORATION.
HEPATITUS B VACCINE DECLINATION FORM
I understand that due to the occupational exposure of blood or other potential infectious materials, I may be at risk of acquiring hepatitis B (HBV) infection. I have been informed about the importance of being vaccinated against hepatitis B. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B. If in the future I want to be vaccinated against hepatitis B, arrangements will be made for me to acquire the vaccine.
UNIVERSAL PRECAUTIONS QUIZ
Below is a set of 8 multiple choice and true/false questions. For multiple choice questions choose the one best answer. None of the questions are meant to be a trick question. Read each question carefully before choosing the correct answer.