Employment Application

Personnel File Management Checklist

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Employment Application


Applicant Information
Name
Address
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Are you a citizen of the United States?
If no, are you authorized to work in the U.S.?
Have you ever worked for this company?
Have you ever been convicted of a felony?

Education

Did you graduate?
Did you graduate?
Did you graduate?

Reference

Please list three professional references.

Previous Employment

May we contact your previous supervisor for a reference?
May we contact your previous supervisor for a reference?
May we contact your previous supervisor for a reference?
Military Services

Disclaimer and Signature

I certify that my answers are true and complete to the best of my Knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
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JOB DESCRIPTION

Personal Care Worker (PCW)

  JOB SUMMARY:  
A person who is specifically trained, competent and performs assigned Actions of personal care to the patient in their residence under the direction, institution and supervision of qualified Agency personnel.  
QUALIFICATIONS:
  1. Have a sympathetic attitude towed the care of the sick and elderly.
  2. Ability to carry out written and verbal directions read and site.
  3. Maturity and ability to deal effectively with the demands of the job.
  4. IS year's of age.
  5. High School Diploma or GED.
  LINE OF AUTHORITY: Reports to the Supervisor.
  RESPONSIBILITIES:
 
  1. Performs personal care services in accordance with the plan of cue and Agency policy,
  2. Understands and adheres to established Agency policies and procedures.
  3. Completes appropriate service notes completely, accurately and in a timely manner as per Agency policy.
  4. Reports changes in the patient's condition and needs to the supervisor.
  5. Performs household services essential to care in the home as assigned.
  6. Ambulates and exercises the patient as assigned.
  7. Provides medication reminder's as assigned.
  8. Understands and promotes patient rights.
  9. Participates in all required orientation, training, competency and in-service programs as scheduled and necessary her Agency policy.
  10. Is available for, and participates in, on-site supervisory visits her Agency direction, at a minimum of every 3 months.
  11. Participates in coordination of patient care, as required,
  12. Attends patient care conferences as scheduled.
 

WORKING ENVIRONMENT:

  Working indoors in Agency office and patient homes and travels to/from patient homes. The position may require the ability to travel in inclement weather in some cases. The position may require walking outdoors.  

JOB RELATIONSHIPS:


Supervised by: Supervisor.  

RISK EXPOSURE:


Low-Moderate risk  
LIFTING REQUIREMENTS:   Ability to perform the following tasks if necessary:
  • Ability to participate In physical activity.
  • Ability to world 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 Personal Care Worker, I will perform these duties to the best of my knowledge and ability.
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TITLE: Health Maintenance Ge Attendant
SUPERVISED BY: RN Supervisor
  JOB SUMMARY: Provide assistance to Agency clients who require help with skilled personal care and activities of daily living.  

QUALIFICATIONS:

  1. Be able to read, write, and understand English.
  2. Have ability to understand and follow written and verbal instructions.
  3. Have basic knowledge of propel food handling and appliances/equipment use found if client's home.
  4. Have knowledge of basic principles of cleanliness and safety.
  5. Demonstrate capacity for high level of tolerance to occasional, stressful situation.
  6. Demonstrate genuine interest in care-giver role through friendly, caring attitude
  7. Demonstrate a high degree of integrity and dependability in commitment to and in completion of work assignments.
  8. Must be at least 18 yrs. of age.
  9. Completion of at least twenty (20) hours training, or have passed a skills validation test, in the provision of unskilled personal care.
  10. Completion of a skills validation of aft Skills assigned to meet the consumers' needs.
  11. Maintain current Colorado driver‘s license, in goo4 standing: and necessary auto insurance as required by the state.
RESPONSIBILITIES: As a Attendant, it is necessary that you fulfil the following responsibilities to the best of your ability, in accordance with Agency policy and Procedure, and as de1ei‘irined by your Agency Assignment.
1.Function within your knowledge and experience, practicing safely and competently within HMA training and experience.
2.Demonstrate appropriate interpersonal communication with client, caregiver and employees
  • Perform And demonstrate competency with personal care assignments and tasks for which you have had training and experience and as assigned by the RN Supervisor.
  • Basic First Aide
  • Infection control measures
  • Proper body mechanics
  • Environmental cleanliness and safety
  • Meal preparation
  • Proper care and use of appliances/equipment
  • Follow established assignment
  • Accurate documentation of Services rendered

3. To notify your Services consultant or Director of changes in your client’s condition.
4. Comply with applicable regulations; including but not limited to proving accurate documentation of services provided to client and client activity, protect the client’s health care information and report potential fraud and abuse to the compliance officer.
5.Consistently use proper body mechanics and use proper infection control techniques to maintain environmental safety for you and your client(s)
6. To remain familiar with and respect the Agency Patients Bill of Rights and Responsibilities.
7. To inform Agency of your availability and desire for- work assignments and honour your commitment to work assignments that you accept.
8. To participate with staff meetings/in services as assigned.
9. To remain familiar with the Agency organizational structure and channels of communication
10. To comply with agency employee policies and procedures, including submitting timesheets according to assigned time lines.
11. To consistently function As a member of the care and services team and Agency employee in a positive manner.
12. To seek supervisory guidance whenever you have a question as to a specific task or responsibility.
13. Participate in continuing educational programs, as requested by the Agency.
14. To use your skills and individually to communicate to management areas where operations/patient care can be improved.
15. To perform other duties as assigned in accordance with your position and qualifications.
16. You must make the Agency aware of your allergy or‘ special needs.
17. Ensure client's safety and security by supervising the home environment.
18. All employees are expected to conduct themselves as a representative of this Agency . This means behaviour which may adversely impact company property, reputation, services or interferes with work will not be tolerated.
  By signing below, I agree I meet the above qualifications: and am wiling/able i ugly to perform the responsibilities as listed in the Stealth Maintenance Attendant position description and analysis.
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START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.
ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation

(Employees must complete and sign Section 1 of Form 1-9 no later than the first day of employment, but not before accepting a job offer.)
Name
Address
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I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):

Aliens authorized to work must provide only one of the following document numbers to complete Form 1-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
OR
OR
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I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
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Name
Address

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative most complete and sign Section 2 within 3 business days off the employee first day of employment. You must 'physically examine one document from List A OR a combination of one document from List B and one document from List C” as listed or the "Lists of Acceptable Documents.")
Name

List A

Identity and Employment Authorization
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List B

Identity
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List C

List C Employment Authorization
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Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.
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(See instructions for exemptions)
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Name of Employer or Authorized Representative
Employer's Business or Organization Address

Section 3. Reverification and Rehires

(To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
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C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
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I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.
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Step 1: Enter Personal Information

Name
Address

Step 2: Multiple job or spouse works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse Multiple Jobs also works. The correct amount of withholding depends on income earned from all of these jobs. or Spouse
Do only one of the following.

Step 3: Claim Dependents

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Step 4 (optional):

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.
(This form is not valid unless you sign it.)
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INDIVIDUAL'S INFORMATION

(To be completed by the individual being checked.)
Name
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(required for all licensed professionals)
You must provide at least one (1) personal phone number and one (1) email address.
All individuals are required to provide five (5) years of residential history, regardless of whether in the U.S. or abroad. If you lived outside the US in the past five (5) years, provide the international address(es), including the name of the city and country. If you have lived at your current address less than 5 years, please list your previous addresses for the past 5 years. Use another sheet of paper, if necessary.
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Current Address
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Previous Address
by my signature below, authorize the employer referenced above to request a CAPS check to determine if I have a substantiated finding as a perpetrator of mistreatment of an at-risk adult. I acknowledge that a substantiated finding rest/ting from such a check, unless the finding was expunged through a successful appeal, Shall be provided to the person directly involved in the employer's hiring process and may be used to inform their hiring decision of me. I acknowledge notification may occur through CAPS to this employer, for the duration of my employment or Volunteers assignment with them, of any future substantiated findings against me. I understand that wilfully providing false information on this form is a misdemeanour 1 penalty, punishable as outlined in é18-1.3-501, C.R.S. I declare under penalty of perjury under Colorado Low that this CAPS Check Request Form, including supporting documents, has been examined by me and IS true, correct, and complete.
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STANDARDS of CONDUCT AGREEMENT - Liberty Home Care

LEGALITIES

  Compliance
It is the responsibility of all members of the governing body, management and employees of the Agency to comply with federal, state and local laws, professional standards and the polices/ regulations of relevant federally funded health care programs in order that care provided to its clients and business interactions reflect integrity and ethical conduct.
Fraud
Employees shall not undertake any of the following fraudulent activities: 1. bill for services, which were not provided;
2. submit fraudulent claims to government or third-party payors including:
a. claims for services that were not provided;
b. claims billing for a service that varies from the service actually delivered;
c. claims for services that do not adhere with program/contract requirements;
d. make false representations to obtain a program's benefits or to remain eligible for a program's benefit; and,
e. make false representation to obtain payment for any service;
3. insert inaccurate information on medical claims; and/or,
4. compensate another individual for referring clients.
Concerns regarding fraud should be directed to the Compliance Officer/Designee.
Abuse
Abuse, involves practices that are not consistent with sound service delivery and economic practices. Such practices could, directly of indirectly, result in unnecessary program costs or in payment for services, which do not meet the standards of care or which are not medically necessary. Employees shall avoid all actual or perceived misconduct and shall report any noted non-compliances or risk potential disciplinary action, in accordance with the Agency's Disciplinary Action Policy for failure to report. Concerns regarding abuse should be directed to the Compliance Officer/Designee.
Reporting Fraud and/or Abuse
Fraud and Abuse laws apply to Medicare and Medicaid programs, Indian Health programs, maternal and child health care programs and Civilian Health and Medical Program of the Uniformed Services ( CHAMPUS). Allegations of Medicare or Medicaid fraud or abuse shall be reported to: Toll Free: 1-866-666-7590 Ext. 1320 or 877-247-5566 and/or
Kickbacks
The Agency is committed to following federal and state anti-kickback laws and regulations and thus prohibits members of its governing body, management and employees from accepting money or anything of value to:
1. refer Agency clients to other service providers; and/or,
2. to influence decisions pertinent to Agency operations.
The Agency shall consider unacceptable conduct to include, but not be limited to the following actions: falsifying personal education and/or experience information during the Job Application Process;
1. falsifying personal education and/or experience information during the job application process;
2. falsifying job and character references during the Job Application Process;
3. having a previous conviction or receiving a conviction for crimes committed;
4. falsifying data on clients' charts and other Agency records; falsifying information on billings for client services;
5. falsifying information on billing for client services.;
6. using codes which are in violation of federal rules and/or regulations;
7. destroying or altering Agency and client records without authorization;
8. exhibiting any behaviour that reflects poorly on the Agency;
9. using, possessing and/or being under the influence of alcohol and illegal substances while on the job;
10. being discourteous to clients, co-workers, health care professionals and members of the community-at-large;
11.possessing dangerous weapons or guns while on the job;
12. doing malicious damage to the Agency's or clients' property;
13. stealing from the Agency or clients;
14. conducting actions/activities, which are dishonest in any way;
15. disclosing clients' names, addresses, phone numbers and other personal information to non-Agency employees, without the clients' permission;
16. disclosing confidential information without authorization or legal direction to do so; 17. accepting inappropriate gifts or money from clients;
18. accepting appropriated gifts from clients without approval from the Compliance Officer/Designee;
19. engaging in financial transactions with the client other than those required for the performance of duties such as exchange of currency for purchasing items for clients;
20. bringing pets, children or any other unauthorized persons to clients' homes while performing job duties; and,
21. being absent without permission or without advising Supervisor, when able to do so.
  CONFLICT OF INTEREST
The Agency is committed to following and enforcing its Conflict of Interest Policy. All members of its governing body, management and employees should avoid potential or perceived conflicts of interest, which could develop when they:
1. have personal interests that compete with their employment with this Agency;
2. have positions of authority in this Agency, which conflict with their interests in another agency/organization; and/or, have conflicting responsibilities.
To ensure that the Agency's business relationships are void of inappropriate influences, members of the governing body, management and employees shall be required to disclose all possible conflicts of interest by completing and signing a Conflict of Interest statement.
  CONFIDENTIALITY
The Agency is committed to the appropriate protection of confidential information and enforces its Confidentiality and Privacy of Information Policy. A number of staff have access to various forms of sensitive, confidential, and medical information, which is maintained to serve clients, health care providers, the Agency and third-party payors, in accordance with legal, accrediting and regulatory requirements. Agency policy prohibits the unauthorized seeking, disclosing or giving of such information, including confidential inflammation contained in clients' records, except on a need-to-know basis, to consulting physicians, health care professionals and employees who may be providing client service and to third party payors to facilitate reimbursement. The operations, activities, business affairs and finances of the Agency shall also be kept confidential and shall only be discussed or made available to authorized persons.
  BUSINESS ETHICS
The Agency is committed to upholding the highest business ethics and integrity. Members of the governing body, management and employees are required to conduct themselves in a professional manner at all times.
—-They shall not:
1.falsely represent the Agency;
2. defraud individuals of money, property or candid services;
3. make false or misleading comments about the Agency's clients, employees, services, business contacts, competitors or competitor's services;
4. participate in any activity intendent to, inappropriately, obtain Agency services provide services to the Agency though payment, intimidation, or enticement;
5. engage in any corrupt business practice either directly or indirectly; or, +. provide compensation to another person for unlawful oi“ improper purposes.
  REPORTING and INVESTIGATING
Staff shall be held responsible for reporting any violations of laws, regulations or Agency policies, procedures and Standards of Conduct. Any violation of the aforementioned, which an employee either knows about or thinks he/she knows about another person/organization, associated with the Agency, has committed, is committing or may commit must be relayed to the Compliance Officer/Designee immediately. That employee shall be assured his/her anonymity will be protected.
The Compliance Officer/Designee shall investigate and document all allegations of misconduct or wrongdoing immediately by conducting an interview(s), reviewing relative documentation and evaluating !he facts and circumstances. Factors to be considered during an investigation include, but are not limited to:
1. the degree to which behaviour varied from the Standards of Conduct; 2. the seriousness of the behaviour,
3. the employee's work history; and,
4. other data and information deemed to be relevant.
  DISCRIMINATION and HARASSMENT
The Agency is committed to treating all persons equally without bias or prejudice, in part, through the enforcement of its policies on human rights, cultural diversity, equal opportunity and sexual harassment. It does not discriminate on the basis of race, colour, religion, sex, national or ethnic origin, age, disability, sexual orientation or military service. Members of the governing body, management and employees are required to promote and maintain a productive work environment that is free from harassment, discrimination and/or disruptive activity., No form of harassment or discrimination will be tolerated, Any or clients who experience harassment or discrimination on the basis of the aforementioned shall inform the Compliance Officer/Designee immediately.
The Agency prohibits retaliation against anyone who makes a complaint of harassing or discriminatory conduct.
  RETALIATION
The Agency is committed to disclosure of noncompliance concerns and for bids any action being taken against a member of the governing body, management or employees for making a report. Because employees have a responsibility to report actual or potential wrongdoings, the Agency shall not permit any consequential retaliative, revengeful or harassing actions/activities to be taken against the reporter. Anyone who is involved in retaliation measures shall be subject to disciplinary action, in accordance with the Agency’s Disciplinary Action Policy and/or as dictated by law. Should staff members report their own inappropriate or inadequate actions/activities, they shall still be subject to disciplinary action, in accordance with the Agency's Disciplinary Action Policy and/or in accordance with the law.
  COMPETITION
The Agency is committed to complying with state and federal antitrust (monopolies) laws and regulations. The Agency shall not establish charges in collusion with competitors and shall not share confidential information with competitors. Additionally, staff shall not share confidential information with competing service providers, such as salaries or charges for services rendered.
The Agency shall not take anticompetitive measures to reduce its competition ‹i rout first obtaining legaI counsel. Communication with competitors about matters that could be interpreted as an attempt to reduce competition or an attempt to fix prices, shall take place only after consultation with legal counsel.
INDUCEMENTS
The Agency does not allow members of the governing body, management and employees to offer any financial inducement, payoff, gift, bribe or kickback or to induce, influence or reward favourable decisions of any government personnel/representative, client, contractor, OF person who is in a position of being able to benefit the Agency/its staff. All activities must be carried out without such solicitation and other improper inducements. Staff are prohibited from accepting, offering or soliciting anything of value from anyone doing business with the Agency including clients, physicians, contractors or third-party payors. Small gifts and gratuities might be acceptable but only if the Supervisor gives authorization and if the acceptance meets the conditions delineated in the Agency's Acceptance of Gifts Policy
Employees shall notify the Agency's Compliance Officer/Designee, immediately, if anyone: 1. offers an inducement to the employee;
2. offers anything of value because of the employee's employment with the Agency; or,
3. has insinuated, solicited or requested compensation for referrals of business.
WORKPLACE SCRUTINY
Employees should not assume that any item or any part of their work/work-related areas is private and off limits to management. Any personal possessions or materials, which are private and/or confidential, should not be brought to the job site.
Agency Supervisors have been authorized to conduct unannounced and/or impromptu searches of the Agency office, property and equipment to: 1. promote a safe working environment for staff; 2. help enforce the Agency's Drug and Alcohol Policy; 3. help create an efficient, dependable and constructive staff pool to service its clients; and, 4. assist in the effective operation of the Compliance Program. In addition, Supervisors have been authorized to monitor and access computers, notebooks and other Agency-issued electronic devices to ensure that reasonable and responsible usage of such equipment, email and the Internet is being applied. FINANCIAL TRANSACTIONS The Agency is committed to charging, billing, aocumenting and submitting claims for reimbursement for services in the manner required by applicable laws, rules and regulations. All staff should know and carefully follow the applicable rules for submission of bills and claims for reimbursement on behalf of the Agency. Staff shall:
1. not possess, copy and/or distribute any Agency documentation, which they are not required to have “in-hand" for the performance of their duties;
2. issue financial reports only to individuals holding “need-to-know" positions and shall do so using protected distribution and retrieval methods;
3. create only those documents required by the Agency and/or the law necessary for the conduction of business;
4. ensure that claims to any payor, including, Medicaid, third-party payors, or clients correctly reflect the equipment, supplies or services actually received;
5. record all equipment, supplies and/or services provided to clients;
6. record all communications and billing information with third parties, including health care professionals;
7. accurately and definitively document accounting records, expense ac.‘ ,.ts, time sheets and other- documents; and,
8. support all cost reports with substantiated documentation.
Any suspicions or knowledge of incorrect, misleading or false records of claims shall be reported to the Compliance Officer/Designee immediately.
CREDIT BALANCES
The Agency shall comply with federal and state laws ano regulations governing credit balance reporting and shall refund all overpayments in a timely manner.
EXTERNAL AUDITS
The Agency is committed to cooperating with government investigators, as required by law. If an employee receives a subpoena, search warrant or other similar document, he/she shall immediately contact the Compliance Officer/Designee, Manager or Supervisor, before taking any action. The Compliance Officer/Designee, Manager and/or Supervisor are responsible for authorizing the release of, or the copying of, documents. If a government investigator, agent, or auditor comes to the Agency, the Compliance Officer/Designee, Manager or Supervisor should be contacted before an employee discusses any matters with such investigator, agent or auditor.
F-ALSE CLAIMS ACT
As a deterrent against the submission of fraudulent claims to the federal Government for programs such as Medicaid and to provide incentive to report such fraudulent claims, the Agency shall advise its employees —about the federal "False Clalms Act", which states that:
“Any person who knowingly.’
1. presents, or causes to be presented, to an officer or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claim for payment or approval;
2. makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claim paid or approved by the Government,
3. conspires to defraud the Government by getting a false or fraudulent claim paid or approved by the Government;
4. makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government; or,
5. submit, or cause another person or entity to submit, false claims for payment of government funds are liable for three times the government's damages plus civil penalties of 85,500 to $11, 000 per false claim.”
The terms "knowing" and "knowingly" mean that a person, with respect to information:
1. has actual knowledge of the information;
2. acts in deliberate ignorance of the truth or falsity the information; or,.
3. acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.”
"The False Claims Act contains “qui tam"" or whistle-blower, provisions. “Qui tam” is a unique mechanism in the law that allows citizens with evidence of fraud against government contracts and programs to sue, on behalf of ’he government, in order to recover the stolen funds. In compensation for the risk and effort of filing a “qui tarn" case, the citizen whistle-blower or "relator" may be awarded a portion of the funds recovered, typically between 15 and 25 percent.”
ASSETS USAGE
The Agency shall provide its staff with the necessary assets and equipment to perform their duties including office equipment such as photocopier, fax machine, computer/notebook and other electronic hardware such as cell phones and iPods, software, hardcopy/electronic record keeping supplies, office supplies and items for personal care services such as blood pressure monitoring tools, transfer belts, incontinence supplies, disposable gloves, masks etc.
Employees shall be prudent and efficient in their usage of Agency equipment, products and supplies. Agency property shall not be used for personal purposes or be removed from the Agency or from clients' homes without prior approval from the Supervisor.
COMPLIANCE TRAINING
The Agency is committed to providing training about compliance policies and procedures, applicable laws, rules and regulations. In addition, Managers and Supervisors shall advise employees that:
1. compliance with these policies and procedures is a condition of employment; and,
2. violation of policies and procedures could result in accordance with the Agency's Disciplinary Action Policy, up to and including termination of employment
Employees shall be given information on the Agency's Compliance Program during the Orientation process and shall receive regular compliance reviews and/or education at least annually. Subsequent training shall also be provided as new policies and procedures are developed and implemented. Staff are encouraged to Seek clarification and/or information from the Compliance Officer/Designee or Supervisor at any time. The Compliance Officer shall be proactive in presenting new or revised compliance information to staff as soon as such information is received.
Employee participation in compliance training shall be documented and shall include attendance and materials distributed at training. Attendance and participation in training programs shall be a condition of continued employment. Failure to comply with the training requirements may result in disciplinary action, in accordance with the Agency's Disciplinary Action Policy.
COMPETENCY
1. The Agency shall adhere to the standards and certifications for Home Care Services, which are: levied by:
a. the CDPHE; and, b. the state.
2. The Agency shall strive to hire Care Aides who can verify they meet CDPHE and/or State certification during the job application process.
3. The Agency shall maintain its training, competency, qualification, evaluation and related policies to ensure that competency standards are met and revised, as indicated.
4. Care Aide training shall include both theoretical and practical training and assessment to ensure these standards are being met. At a minimum, Care Aides shall receive 75 hours of training with at least 16 hours dedicated to classroom training prior to practical training and 16 hours of supervised practical training.
5. The practical portion of the training shall be under the general supervision of a Registered Nurse who possesses a minimum of 2 years nursing experience or at least 1 year of experience in the provision of home care. Other individuals may be used to provide instruction under the supervision of a qualified Registered Nurse.
6. The Agency shall ensure at* registered Nurse conducts performance views on each Care Aide at least every 12 months. These appraisals may be conducted while the care, ..be is providing care to a 7. The competency evaluations shall be documented, and the records shall be retained in the individual Care Aide's personnel file.
PERFORMANCE APPRAISALS
Compliance with the Standards of Conduct shall be an element in job performance assessments of all employees. Promoting adherence to the Standards of Conduct shall also be an element in evaluating the performances of managerial and supervisory staff. Their failure to adequately instruct subordinates or to detect violations of the compliance policies and applicable legal requirements may result in disciplinary action, in accordance with the Agency's Disciplinary Action Policy, if their reasonable attentiveness could have alerted them to such violations.
NON-COMPLIANCE CONSEQUENCES
All Agency staff shall:
1. perform their duties in a manner consistent with the Agency's policies; and,
2. report violations of local, state or federal laws, rules or regulations to the Compliance Officer or Supervisor, as required by law.
If an employee fails to report violations and is aware that not reporting violates a legal obligation, then that person could be subject to disciplinary action, in accordance with the Agency's Disciplinary Action Policy and/or could be terminated from employment. The Agency may also take disciplinary action if its investigation determines that a misconduct or wrongdoing has taken place, depending on the severity of the misdemeanour.
Disciplinary actions shall be in accordance with the Agency's Disciplinary Action Policy, which could consist of 4 stages:
1. verbal warning;
2. written warning;
3. work suspension; and,
4. termination of employment.
All Violations of the Standards of Conduct, compliance policies and federal, state and applicable local laws and regulations may be disciplined in a manner deemed appropriate by Manager and/or Supervisor in an attempt to prevent similar misdemeanours from taking place in the future. Disciplinary actions shall be applied consistently and fairly and shall not be influenced by the individual's position in the Agency. i.e. Employees and management personnel shall all be held accountable to the same extent and to the same degree.
The Compliance Officer/Designee shall not have any authority or responsibility for disciplinary measures. He/she will be responsible for investigating, evaluating and making recommendations consistent with the Agency's policies and procedures to the Supervisor and/or Manager. Any disciplinary action shall be determined and enforced by the Supervisor, Manager and/or governing body, in accordance with the Agency's Disciplinary Action Policy.
CONCLUSION The Agency shall constantly take measures to ensure that all its activities and actions, and those of its employees, comply with applicable laws and ethical standards. The purpose of these Standards of Conduct is a provide direction to employees to enable them to meet their responsibilities. Employees are expected to comply with all applicable laws, even if they are not dealt with in these Standards of Conduct.
RECEIPT AND ACKNOWLEDGMENT
All Agency staff shall be given a copy of the Agency's Standards of Conduct to read and sign attesting to the fact that they are responsible for knowing and adhering to these Standards of Conduct. The signed document shall be placed in their personnel file and a copy shall be issued to the staff member. In addition, each time new or revised Standards of Conduct are issued, employees shall be asked to sign a statement certifying that they have received, read, and understood the Standards of Conduct.
I have read these Standards of Conduct and have received a copy of them. I agree to comply with them and should I learn that there has been a violation of these standards, I shall contact the Compliance Officer/Designee, Manager and/or Supervisor immediately.
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Orientation Instruction Page Sign Off for All Employee

Liberty Home Care uses a unique method to orient its new employees so that we are assured that every employee receives ALL the information needed on your hiring date.
We ask that you have in front of you the complete hiring packet and the job description from your office manager.
As you go through, each document will be reviewed. You should have the document being reviewed in front of you and you should read through it as we proceed. As we finish each document you will sign and date each document and put it aside in the order we go though.
Use care on the document marked “Reference Request”. We require you to provide 2 written references in your file. Fill in the name of the company or person and their address that you would like us to send the reference request to (at the top of the document). If you don't know the addresses during oriental(on please find it out as soon as you leave today and call us before the day is over.
The section called “Orientation for All Employees” and the document called “Orientation for Direct Care Employees” are in a table format. As we complete each section, you will put today's date and your initials in the right-hand column indicating that you had that section reviewed with you.
Please inform us right away if you suspect that something negative will come back on your Criminal Background Check. Not all convictions will eliminate you from working in homecare but you must understand that we are responsible for assuring the safety of vulnerable Consumers (elderly and children). Speak to the Agency Director privately if you suspect a problem will be identified.
Many homecare employees work for more than one company at the same time. It is essential that you let us know if you are working for another agency. Remember that any Consumers you service for us are OUR Consumers. Should you ever decide to leave us for any reason, Consumers you are servicing for us MAY NEVER be encouraged to transfer to another company where you might be working. This is clearly a conflict of interest and will not be to1ei‘ated. Our legal department will be notified immediately should this occur.
Please have your documents ready for copy before Orientation begins: Driver's License, Car registration, Social Secui4ty Card, Legal migration documents (if applicable), Current Professional license, copy of professional liability insurance (if contractor), training certificates, TB test.
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Statement of Driving Status

am currently licensed to drive a motor vehicle in the state of CO,
I carry auto insurance on my vehicle and I have supplied Liberty Home Care a current copy of my license and auto insurance.
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declare that I do not have a driver's license in the state of CO and therefore will find other forms of transportation to get to my scheduled visits (i.e. public transportation)
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Acknowledgement Employee Handbook Do's and Don'ts

liberty home Care


Listed are some pertinent references to employee policies from the Agency Employee Handbook. For more retailed information please refer to the Handbook. You may request to review any/all of the personnel policies pertinent to your employment at our Agency at any time.
1. Do wear scrubs to all your visits. However, if you do not have scrubs, you may wear business casual clothing. NO JEANS, scanty tops, see through clothing etc allowed.
2. Do wear your Agency Issued photo ID badge at all time when on agency business.
3. Do arrive on time for ALL assignments. Our Agency must be notified immediately if:
a. An emergency or situation arises which causes you to be late by five or more minutes.
b. You will be absent from your assignment.
Without calling the office, these situations are called NO CALL NO SHOW and are subject to termination.
4. Once you have been given an assignment, no more than 2 cancellations will be tolerated.
5. Don't use the client's phone. Cell phones are off during all visits.
6. Under No circumstances should you ever take property, money or “borrow” anything that belongs to a client or ever enter into any type of legal or financial agreement,
7. Don’t discuss your rate of pay with your clients or any other employee of the Agency.
8. Do complete visit notes correctly and completely and have signed by the client AT THE TIME OF THE VISIT
9. Do call our coordinator to inquire as to cases to be covered if you are not scheduled for work.
10. Do call the office immediately if any problem arises on your assignment.
11. Do call the office immediately if the client does not answer the door for a scheduled visit. Failure to notify the office may be considered abandonment, especially if the client has had a medical emergency and is in need of medical assistance. DON'T assume they aren't home. CALL THE OFFICE.
12. Don't leave any assignment early without first calling the scheduling coordinator/office immediately.
13. Do report any incident/accident or unusual occurrence involving an Liberty Home Care employee/client to our office immediately. If you are injured and unable to make the call have another person call us right away.
14. Do follow your schedule at all times WITHOUT MACING ANY CHANGES.
15. Don't transport a client's in your' car unless you have a signed consent/authorization. 16. Please how, at the present flue our agency does not perform drug testing of staff but may do so at our discretion.
17. Cancellation Policy: A minimum of eight (8) hours cancellation notice must be given at all times, unless you are involved in an emergency. Sick call shall be made with a 2-hour notice. Should you decide an assigned client must be removed from your schedule, the office requires a minimum of one week’s notice to arrange a change of worker. 2 weeks' notice is preferred.
My signature acknowledges that I have received and have read the Employee Handbook and agree to the Agency’s Dos & Don't as listed above & in the Handbook.
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Confidentiality Agreement

(the Employee) and Liberty Home Care (the Employer)
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The Employee agrees to the terms of this Agreement:
1.) As a condition of employment, the employer requires that all new employees agree to enter into this Confidentiality Agreement (the Agreement). The Employee acknowledges that employment with Employer is sufficient consideration for the Employee to entering into the Agreement.
2.) The Employee acknowledges that, in the course of employment, the Employee will, and may in the future, come into possession of certain confidential information belonging to the Employer including but not limited to trade secrets, data, materials, products, technology, computer programs, specifications, manuals, business plans, software, marketing plans, financial information, and other information disclosed or submitted. This confidential information may be embodied in hand written notes by the Employee, computer disks, tapes, paper, or any other media.
3.) The Employee hereby covenants and agrees that she or he will at no tune, during or after the term of employment with the Employer, use for his or her own benefit or the benefit of others, or discloses or divulge to others, any such confidential information.
4.) Upon termination of employment, the Employee will return, retaining no copies or notes, all documents relating to the Employee's business including, but not limited to, reports, lists, correspondence, information, computer files, computer disks, and all other material and all copies of such material, obtained by the Employee during employment nor will the employee attempt to contact or solicit any Consumers that the employee may have worked with during employment.
5.) The Employee recognizes that the Employer may be irreparably damaged by breach of this Agreement and that the Employer shall be entitled to seek an injunction to prevent such competition or disclosure, and will entitle the Employer to other legal remedies, including attorney’s fees and costs.
6) The obligations of Recipient herein shall be effective from the date the Owner last discloses any Confidential Information to Recipient pursuant to this Agreement.
7.) If any part of this Agreement is adjudged invalid, illegal or unenforceable, the remaining parts shall not be affected and shall remain in full force and effect.
8.) This instrument, including any attached exhibits and addenda, constitutes the entire Agreement of the parties. No representation or promises have been made except those that are set out in this Agreement. This Agreement may not be modified except in writing signed by all parties.
9.) This agreement shall take effect as a sealed instrument and shall be construed, governed and enforced in accordance with the laws of the State of CO, without regards to its conflicts of law provisions.
10.) The descriptive headings used herein are for convenience of reference only and they are not intended to have any effect whatsoever in determining the rights or obligations under this agreement.
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Employee Sign Off Regarding

an employee of Liberty Home Care has read and understand is policy on protecting Consumers Health Information (PHI) and security. I understand that should any situation Use where I breach Consumers confidentiality I will be disciplined up to and including termination. I hereby agree to maintain Consumers confidentiality in the strictest manner possible, sharing or discussing Consumers information only with those designated care providers or supervisors who have “a need to know” and are actively involved in the care of services provided to the Consumes. I further acknowledge that I have been trained in the provisions and laws related to HIPAA compliance during orientation and those Consumers must sign written permission to allow their health information (PHI) to be disclosed. I further agree that I will protect PHI while driving in my vehicle servicing Consumers in their homes and will not allow any PHI to be visible inside my vehicle; I will not bring any PHI related to another Consumers into the homes/facilitates of consumers I am servicing
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INCIDENT/ACCIDENTS REPORTING ACKNOWLEDGEMENT

(print name) have been thoroughly informed by Liberty Home Care that I MUST report ALL incidents/accidents and any medical, physical, or mental changes in my Consumers immediately to the Supervisor and/or Scheduling Coordinator. further understand that in the event that I become injured, even a minor injury, I am required to report that incident to my office as soon as possible after an injury.
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OUR AGENCY IS AVAILABLE BY PHONE 24 HOURS A DAY. THE ANSWERING SERVICE WILL RESPOND AFTER 5 PM WEEKDAYS AND ON WEEIKNDS/HOLIDAYS

Acknowledgement and Understanding of Zero Tolerance Sexual Abuse Policy


I acknow1edge that I have received and read the sexual abuse policy and/or have had it explained to me. I understand that the organization will not tolerate any employee, volunteer, board member or third party who commits sexual abuse. Disciplinary actions will be taken against those who are found to have committed sexual abuse.
I understand that it is my responsibility to abide by all rules contained in the policy. I also understand how to report incidents of sexual abuse as set forth in the abuse policy, Including retaliating against any employee/ volunteer exercising his or her rights under the policy.
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Conflict of Interest


No employee or member of the Governing Body or other individual, committee, or‘ entity shall delve any profit or gain directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the Governing Body. All GB members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually.
If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Agency Director and Governing Body.
In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency and a board member shall not participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes.
Field staff in any capacity understands that all Consumers are Consumers of the Agency not personal Consumers of the field staff. Consumers may never be serviced privately by an employee of Our Agency for the financial gain of the employee. Should an employee terminate employment with Liberty Home Care, the field staff understands that the Consumers may not be encouraged or otherwise moved from our Agency to another agency.

INDIVIDUAL STATEMENT REGARDING CONFLICT OF INTEREST.

have read and am fully familiar with the agency's policy statement regarding conflict of interest. I am not presently involved in any transaction, investment, or other iatter in which I would profit or gain directly or indirectly as a result of my membership on the agency's Governing Body or its committees or my employment. Furthermore, I agree to disclose any such interest which may occur in accordance with the requirements of the policy and agree to abstain kom any vote or action regarding the agency's business that might result in any profit or gain directly or indirectly, for myself.
I also work for another homecare agency:
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CONFLICT of INTEREST STATEMENT

It is the responsibility of each employee to recognize and avoid any situation involving a business conflict of interest. Employees are expected to promptly disclose any known relationships or activities that may result in apparent conflicts of interest. This information is disclosed to your Supervisor and/or the Agency Manager, Hereby flowing issues to be worked before they develop into a problem. Through this action, an employee protects their own interests as well as those of the Agency. All employees must complete this Conflict of Interest Statement upon hire and update the Statement annually or whenever the status changes. Activities/situations that create a conflict of interest, or the appearance of one, must be declared on this Conflict of Interest Statement.
1. Do you have an outside job that may create a conflict of interest with your employment at this Agency?
2. Do you have any other conflict of interest with your employment with this Agency?
I understand that failure to observe and abide by these obligations may result in disciplinary action which may include dismissal and/or contract termination.
I also understand that in some cases, failure to observe and abide by these obligations may result in criminal or other legal actions.
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