Forms

Acknowledgement of Employee Handbook

We are glad to have you as a member of our team. As a team member at Home Health and Hair LLC , you are an essential part of a team effort. We hope that you will find your position with the Company rewarding, challenging and productive. Every Employee has an important role in our operation, and we value the ability and experience you bring with you to the organization. You, and other Employees, are vital to the success. Our Employee Handbook provides guidance to our agency policies as follows.

I acknowledge that I have read, understand, agree with the Employee Handbook, agreeance with all privacy, HIPAA, field practice, compliance, policy, and procedure statements, and understand that I am responsible to read and adhere to all of its contents. I also understand that if I do not understand something that I will refer to the Handbook to seek guidance, as well as going to my direct supervisor or the agency Administrator for further information or clarification of all policies. MY SIGNATURE BELOW ATTESTS to the fact that I have read, understand, agree, and will adhere to the Agency’s Policies and Procedure Manuals.

Application for Employment

PERSONAL DATA

POSITION INFORMATION









EDUCATION

Please list any education or training you feel relates to the position applied for that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs.

REFERENCES

Please list 3 professional references not related to you. If you don’t have three professional references, then list personal, unrelated references.

WORK HISTORY

Job Title #2:

Job Title #3:

Agreement & Signature

I certify that all the information I have provided is true, complete, and correct.

The applicant, by signing the application, gives the employer consent to collect the information contained herein and use it for the purpose specified.

I authorize the employer to investigate all statements contained on this application and resume attached. I understand that any misrepresentation or omission of facts called for is the cause of immediate disqualification and/or if employed, immediate dismissal.

I understand that if I am hired, I will be required to provide a criminal background check, proof of identity and legal authority to work in Virginia, proof of certifications or educational qualifications, and a driver abstract (if applicable). This application does not in any way constitute an agreement or contract for employment.

Applicant Name:

Applicant Signature:

Date:

Job Title: Caregiver / Home Attendant / Personal Attendant

Reports to: Nursing Director / Care Supervisor / Care Manager

Purpose: To provide care services to clients in their homes. The Agency will follow regulations 12 VAC 5-381-360 in providing personal care services.

Description:

  • Provide companionship services and homemaker services to clients in their home.
  • Provide personal care services in support of the clients’ health and safety in their homes when related to independent living of the client and cannot be done by the client himself.

The Agency will designate a registered nurse (RN) responsible for the supervision of personal care services.

Personal Care Services Include:

  • Assistance with the activities of daily living.
  • Administration of normally self-administered drugs.
  • Taking and recording vital signs, if specified in the plan of service.
  • Recording and reporting changes regarding the client's condition, behavior, or appearance.
  • Documenting the services delivered in the client's record.

Personal care services may also include instrumental activities of daily living related to the client's needs.

Plan of Services:

  • Assessment of the client's needs
  • Functional limitations of the client
  • Activities permitted
  • Special dietary needs
  • Specific personal care services to be performed
  • Frequency of service

The plan will be retained in the client's record and reviewed with the home attendant before services begin.

Supervision:

Supervision of services will be provided as often as necessary, not to exceed 90 days, based on client needs and RN assessment.

Training Requirements:

Home attendants providing personal care services shall receive at least 12 hours annually of in-service training and education.

Qualifications:

  • Must have at least a high school diploma.
  • Must be able to speak, read, and write in English.
  • Must follow oral and written instructions in English.
  • Must have a valid Driver’s license and proof of car insurance.
  • Must have a current negative TB test.
  • Must pass a clear DOJ and DMV background check.
  • Must pass a Criminal Background check.
  • Must pass a Drug Test.
  • Ability to communicate effectively with clients and remain calm under stress.
  • Physical ability to lift and transfer clients.
  • Ability to perform repetitive tasks using hands, bending, stooping, and reaching.
  • Ability to safely drive a car.

Job Duties/Knowledge:

  1. Assist with household tasks necessary to the client’s health care needs.
  2. Assist with personal care activities including bathing, oral hygiene, grooming, toileting, etc.
  3. Use equipment and supplies safely, following safety programs and Universal Precautions.
  4. Assist in range of motion exercises and other procedures as instructed.
  5. Maintain a written log of daily activities and document care provided.
  6. Report any change in client’s condition to the Supervisor immediately.
  7. Perform other duties as requested.

Applicant Name:

Applicant Signature:

Date:

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