I HAVE READ AND UNDERSTAND THE ABOVE AND WILL COMPLY WITH THIS AGREEMENT
Reporting to work with impaired abilities of the possession, consumption or distribution
of drugs or alcohol on company premises and/or worksites shall be grounds for
disciplinary action including discharge. A condition of employment includes willingness
on the part of the applicant or employee to agree to physical examination, polygraph
and/or substance testing if required by the company. We are committed to operating a
drug-free workplace. Violations of our drug and alcohol policy will result in dismissal
It is understood and agreed upon that any misrepresentation by me in this application
will be sufficient cause for cancellation of this application and/or separation from the
employer's service if I have been employed. Furthermore, I understand that just as am
free to resign anytime, the Employer reserves the right to terminate my employment at
any time. with or without cause and without prior notice I understand that no
representative of the Employer has the authority to make any assurances to the
contrary
I give my employer the right to investigate all police driving. and personal records and
reference: job-related. hereby release from liability the Employer and its representatives
for seeking such information and all other persons corporations or organizations for
furnishing such information.
The Employer is an Equal Opportunity Employer. The Employer does not discriminate in
employment aid no question on this application is used for the purpose of limiting or
excusing any applicant's consideration for employment on a basis prohibited by local
state or federal law
Any controversy of any kind arising between the parties under this agreement or
otherwise (or any agent. officer director or affiliate of any party, including but not limited
to common law, statutory, tort or contract claims, will be submitted to mediation and
falling settlement in mediation, to binding arbitration. Unless otherwise agreed,
mediation and arbitration designated by stat professionals will govern any mediation
and arbitration. The parties will select the mediator or arbitrator from the designated
company Panet of mediators are not the designated company, in writing, to initiate the
selection process. The arbitration will be subject to and governed by the provisions of
the Federal Arbitration Act 9 U.S.C Section 1-et seq. The parties hereto stipulate that
his agreement involves matters affecting interstate commerce.
This application is current for 60 days. At the conclusion of this time, if I have not heard
from the Employer and still wish to be considered for employment will be necessary to
fill out a new application
CONFIDENTIALITY OF INFORMATION AGREEMENT
Confidentiality of Information
All information designated confidential that is obtained or generated as a result
of any or all of the operations of the agency will be dealt with in a confidential
manner
All information that is gathered maintained or stored by the agency becomes the
agency's property and cannot be released without proper authorization from the
administration
Altering information is prohibited by the agency and by law Correction of any
identified erroneous information must be done according to the agency policy
WHAT WE CAN DO TO MAINTAIN CONFIDENTIALITY OF INFORMATION
In order to protect any individual from the invasion of privacy and to protect the
interest of the agency, arıy information gathered for patient care or operations will
be gathered maintained and stored in such a manner as to assure confidentiality
Access to information will be limited to a need to know basis to perform the
scope of one's duties and responsibilities
Dissemination of information will be handled according to agency policy, and staff
will be informed during orientation, will sign the confidentiality statement and it
will be placed in the employee's file
Proven violation of breech of the confidentiality agreement may be cause for
immediate termination
I understand that I’m responsible for following this CONFIDENTIALITY POLICY
AGREEMENT & THE GUIDELINES, both Written and Verbal.
CRIMINAL HISTORY SEARCH CONSENT FORM
I have had no prior convictions of an offence that would bar or potentially bar
employment as listed below
CRIMINAL HOMICIDE SOLICITATION OF A CHILD
INDECENCY WITH A CHILD ARSON
AGGRAVATED ROBBERY ASSAULTIVE OFFENSES
BURGLARY & CRIMINAL TRESPASS THEFT
WEAPONS
FRAUD
PUBLIC LEWDNESS INDECENT EXPOSURE
KIDNAPPING & FALSE IMPRISONMENT PUBLIC INDECENCY
AGREEMENT TO ABDUCT FROM CUSTODY A FELONY
VIOLATION OF A
STATUTE INTENDED TO CONTROL
THE POSSESSION OR
DISTRIBUTION OF
SALE OR PURCHASE OF A CHILD AN ILLEGAL SUBSTANCE
ROBBERY
I UNDERSTAND THAT THE HOME HEALTH AGENCY IS REQUIRED TO CONDUCT
A CRIMINAL HISTORY CHECK BEFORE OFFERING ME EMPLOYMENT. I, THE
UNDERSIGNED, HEREBY AUTHORIZE THIS AGENCY TO CONDUCT AND VERIFY
MY CRIMINAL HISTORY BY PERFORMING A CRIMINAL HISTORY
DRUG TESTING POLICY
Agency employees may not possess, distribute and or use alcoholic beverages or
controlled substances including inhalants while on premises of property controlled by
the Agency or while in the course of conducting company business or engaged in any
company-sponsored activity.
Patients or visitors may not possess, distribute and or use alcoholic beverages or
controlled substances while on the premises of the property controlled by the Agency
Any employee who has knowledge of a person or persons violating this policy must
report it to his/her supervisor immediately.
Based on reasonable cause the agency may condụct searches or inspections of an
employee's personal belongings and may be asked to take a drug test Refusal to
consent his result in termination
HEALTH & SAFETY AGREEMENT
I do understand the physical requirements of my job and understand proper wing and
moving techniques, which I am expected to use in moving and lifting objects and/or
patients,
I have been informed and do fully understand that any Injury claimed by me while on the
job must be reported immediately to my supervisor and documented on an Accident
incident Report form. I understand that unless an incident report is completed
immediately and signed by me, the agency may not consider a voluntary payment of
any medical bills or any other benefits as a result of my injury. I further understand that
the accident injury is proven to be a result of my failing to follow policy/procedure, the
agency may not be expected to cover medical payments.
I do fully understand that not encouraged to it or transfer any object or patent by MSN
unless I know that can safely lift or transfer alone. If I believe there is no one readily
available to assist me in moving patients or equipment while on duty, I am to wait until
can obtain the before moving or lifting
I have had the opportunity to review and have all question answered regarding
Health & Safety
FOLLOWING INFECTION CONTROL AGREEMENT
ABSOLUTE HOME HEALTH INC wants to improve patient outcomes by identifying and
reducing the risk of infection in patients and agency staff.
The agency will document infections that are acquired while the patient is receiving
services from the agency. The documentation will include at a minimum the date that
the infection was detected, the patient’s name or number, primary diagnosis,
signs/symptoms, type of infection, pathogens identified and treatment
The infection control program will include surveillance, identification, prevention, control,
and reporting Targeted surveillance of infections will focus on specific patient population
or procedures.
Infection Control Standards are established in compliance with the recommendations of
the National Center for Disease Control in Atlanta Georgia. All staff is educated on
these standards and they have practised consistently. Any incidents of infection related
to care and service are reported.
I recognize, and am fully aware of the fact that any patient may be contagious at
any time and that this may not always be a known fact while care is being
provided. I will follow all Infection Control and Universal Precautions Procedures
of the agency. I also state that currently I am in excellent health and have no
impairments that may alter my job performance
UNIVERSAL PRECAUTIONS
Training Document
LESSON 1- BLOODBORNE INFECTION
Definition of exposureV
Spread of HIV infection in the general populationV
Symptoms and effects of HIV infectionV
Spread of Hepatitis B, including the number of infections, hospitalization, SymptomsV
and effects of HBV infection and HBV vaccinationV
The hepatitis virus and the HIV virus can be transmitted in the workplaceV
It is estimated that there are 1 and % million HIV carriers in the USV
There may be as many as one million carriers of HBV
LESSON 2 - TRANSMISSION OF BLOODBORNE INFECTION
Sources of blood-borne infections in the workplace
Four primary ways of getting blood-borne infections outside the workplace
Three primary ways of getting blood-borne infections at work
Risky jobs tasks, and work practices
LESSON 3 - EXPOSURE CONTROL
The HBV Vaccine for all workers who come into contact with blood or other potentially
infectious body fluids on the job
The steps that should be taken after an exposure incident in order to prevent infection
Three primary ways of getting blood-borne infections at work
My rights in case of exposure and/or infection
I have the right to have HBV vaccinations provided to me free of charge. if am at risk for
infection if refuse it at this time, I have the right to be vacünaled free of charge at any
time in the future provided I am still at risk for infection
LESSON 4 -USING PERSONAL PROTECTIVE EQUIPMENT
Types of personal protective equipment (PPE) required for different tasks or situations
Key requirements for selecting providing using, and disposing of or cleaning PPE
Limitations of personal protective equipment
LESSON 5 - WORK PRACTICE CONTROLS
Disposing of used needles or other sharps
Working with lab materials
Decontaminating work areas, instruments, and equipment
Identifying and handling regulated waste
Handwashing and other personal hygiene and health practices
*I have received training covering all of the above topics and been informed of my
rights accordingly
REPORTING: ABUSE / NEGLECT / EXPLOITATION
REPORTING:
ABUSE
NEGLECT
● EXPLOITATION
All agency staff are required to report suspected abuse/neglect/exploitation and develop
a plan to minimize the risk of such. The home health employee is responsible for
reporting & documenting:
A child's susceptibility to abuse including self-abuse and neglect
Elderly individuals, as well as children, are susceptible to abuse as well
Physical components, such as impairments and the ability of patient-caregiver to
provide adequate care
Mental impairments, such as mental retardation, Alzheimer's disease, disorientation,
confusion, etc
Emotional status, such as positive personality, depression, etc
Physical environment, such as safety in or outside the home
The employee is responsible for reporting all incidents to DOPCs and/or Supervisor. A
written report may be forwarded to Social Services with the request for referral. The
Supervisor will review the situation and investigate to determine if this is a reportable
incident. If so it will be reported to the appropriate agency or Adult Child Protection
Agency by the DOPCS/Administrator of an appropriate designee
*I have read and understood the information above. As a home health employee,
it is my respo
EMPLOYEE DRESS CODE
ABSOLUTE HOME HEALTH, INC strives to present a professional and safe health care
image to patient's families, the community, and other Health Care professionals.
ABSOLUTE HOME HEALTH INC staff members adhere to the following standards in
their dress appearance.
All staff will wear an approved ABSOLUTE HOME HEALTH, INC name badge
when providing patient care.
Clothing shall be dean, neat and well maintained Allowed Clothing Loose
comfortable clothing, scrubs, walking shorts that are at least mid-thigh in length,
hemmed blue jeans, a plain T-shirt, and casual streetwear Appropriate
undergarments should be worn Not Allowed, mini skirt short shorts, tank tops:
halter-tops, midriff, cut-offs, frayed blue jeans, or T-shirts with any sayings on
them.
Shoes should be conservative and comfortable We encourage dosed toed shoes
for personal safety and infection control while providing patient care. No flip-flops
or thong sandals
When attending school with a nation, the employee will be provided with a copy
of the schools’ dress code and must adhere to it
Nurses should keep a clean lab coat available to wear over their clothes when
accompanying patients to any medical appointment. (These may be
unexpected).
ABSOLUTE HOME HEALTH INC employees will try to meet the request of
parents or primary caregivers within reason
Employees are expected to keep their hair dry neat, and clean Long hair must be
styled so it does not come in contact with the patient. Moustaches and beards
must be clean and trimmed
Perfume should be conservati
Jewellery represents a safety hazard, so it must be worn with discretion, ie.
wedding ring, rings without large mountings, small earrings or studs. Visible
piercing, except for earring, should be removed when providing patient care.
Both professionalism and safety should be considered when wearing jewellery.
Fingernails are to be kept clean, trimmed and moderately short for patient safety
*If an employee is sent home to change clothes due to inappropriate attire, the
employee will be sent home on his/her own time and may result in disciplinary action.
* Interpretation of compliance to this dress code policy is subject to the
discretion of the Administrator, DOPCS, or acting supervisor
DISCLAIMER AND WAIVER OF LIABILITY
I acknowledge and will adhere to the rules and regulations as set forth by the California
Department of Public Health Licensing and Certification Sacramento District Office and
Medicare and Medical understand that the falsification of documents particularly those
pertaining to the submission of visit notes where in fact no visit was made is considered
to be a fraud and is subject to the filing of a criminal grievance, civil and/or criminal
prosecution, and immediate termination. I, therefore, hold the home health care agency,
its shareholder’s directors and officers, harmless from any falsified documents.
I have read and understood the above information. I understand that the
falsification of documents, particularly those pertaining to the submission of visit
notes where in fact no visit was made, is considered to be a fraud and is subject
to the filing of a criminal grievance, civil and/or criminal prosecution, and
immediate termination.