24/7 Home Care Agency of NY, INC

Employment Application (HHA/PCA)

Name First:
Andrew
Last:
Flinto
Middle:
W
Address:

City:
State:.
NY
Zip Code:
Home Phone Number:
Cell Number:
Emergency Contact Name:
Emergency Contact Phone Number:
Date of Birth:
Place of Birth:
Gender:
male
Social Security Number:
United States Citizen:
Yes
Education: Do you have a High School Diploma?:
Yes
Training: Do You have a PCA Certificate?:
No

                 Do you have a HHA Certificate?:
No
Please Provide Certificate Registry Number:
Name of Training Program:
Address:
City:
State:
NY
Zip Code:
Phone Number of Training Program:
Date of Completion:

Work History

1) Company Name:
Supervisor:
Address:
Job Title:
Date of Employment:
Phone Numer:
Reason for Leaving:
2) Company Name:
Supervisor:
Address:
Job Title:
Date of Employment:
Phone Numer:
Reason for Leaving:

24/7 Home Care Agency of Ny,inc does not discriminate because of age,sex,physical handicap,race,creed or national origin.
The agency is an equal opportunity employer.

I affirm that information inthis application is complete and true.I understand that if employed,false statements will be a case
for dismissal

Signature:
Date:
08-20-2020

Confidentiality/Conflict of Interest Statement

As an employee of 24/7 Home Care Agency of NY, Inc, and as a condition of my employment I agree to the following:

1. I understand that I am responsible for complying with the HIPAA policies, which were presented to me upon employment

2. I will not access or utilize patient information, unless needed to perform my job duties.

3. All information received during the course of employment with the agency, will be treated as privileged and confidential information.

4. I will not log onto any of the agency's computer systems, existing now or the future, using a password other than my own.

5. I will not email, fax or phone to transmit any patient information unless I am instructed to do so by the Administrator or Director of Nursing.

6. I will not take patient information from the premises in paper or electronic form without approval from the Administrator or Director of Nursing.

7. Upon termination of my employment, I agree to maintain confidentiality regarding any information learnt or gained while an employee of the agency and will return all keys, ID cards or any device that would provide continued access to agency or information within the agency.

8. I understand that all reports, accounting records, research reports, expense accounts, time sheets and other documents must accurately and clearly represent the relevant facts or the true nature of a transaction.

9. I understand I shall never offer any financial inducement, gift, payoff, kickback, or bribe intended to induce, influence or reward favorable decisions of any government personnel or representative, any customer, contractor or vendor in a commercial transaction or any person in a position to benefit the agency or the employee in any way.

To ensure no conflict of interest The Agency defines "conflict of interest" as those activities or actions which:

• Conflict with the mission, philosophy of objection of the Agency.

• Violate local, state or federal regulations.

• Place the Agency, personnel, clients or their families at risk ethically, financially or legally.

• To protect the Agency's assets, both material, concepts and publications, as well as to include:

• Confidentiality of patient diagnosis.

• Financial matters

• Staff salaries.

• Nursing or executive plans that can go to unauthorized agencies.

• Anything given to staff (e.g. forms, systems, and equipment) that goes to unauthorized people

By signing this document I understand that violation of this agreement will result in disciplinary action, up to and including, termination

Employee Name (Print Clearly)
Signature:
Date:
Personal Assistant Name:
Personal Assistant Signature
Date:
08-20-2020

24/7 Home Care Agency of NY, INC


ACKNOWLEDGMENT OF RECEIPT

The Employee Handbook/Code of Conduct/Compliance Program contain important information about the company, and I understand that I should consult the Administrator/Office Manager/General Manager regarding any questions not answered in these documents. I have entered into my employment relationship with the Company voluntarily, and understand that there is no specified length of employment. Accordingly, either the Company or I can terminate the relationship at will, at any time, with or without cause, and with or without advance notice.

Since the information, policies and benefits described herein are subject to change at any time, I acknowledge that revisions to the Handbook/Code of conduct may occur. All such changes will generally be communicated through official notices, and I understand that revised information may supersede, modify, or eliminate existing policies.

I have had an opportunity to read the handbook, Code of Conduct, and Compliance Program and I understand that I may ask my supervisor or any employee of the Human Resources Department any questions I might have concerning the handbook. I accept the terms of the documents described above. I also understand that it is my responsibility to comply with all the policies of 24/7 Home Care Agency of NY, Inc and any revisions made. I further agree that if I remain with the Company following any modifications to the handbook, I thereby accept and agree to such changes.

I have received a copy of the Company's Employee Handbook (Policies and Procedures), Code of Conduct, Compliance Program, Paid Family Leave and Notice of Employee Rights (regarding sick leave) on the date listed below. I understand that I am expected to read the entire handbooks. Additionally, I will sign the two copies of this Acknowledgement of Receipt, retain one copy for myself, and return one copy to the Company's representative listed below on the date specified. I understand that this form will be retained in my personnel file.

I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. 1 understand and agree that 1 am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, 1 agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in by myself or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding

I understand that I may be subject to discipline or other corrective action, up to and including termination of employment or termination of contract, if I violate the standards and requirements set fort in the Code of Conduct, any specific compliance policies or procedures, or any aspect of the 24/7 Home Care Agency of NY, Inc Compliance Program.

Employee's Name - Printed
Signature of Employee:
Date:
08-20-2020
Company Representative
Date:
08-20-2020

24/7 HomeCare Agency of NY, INC
2414 Ralph Avenue,
Brooklyn, NY 11234,
718-887-0782

HIPAA EMPLOYEE CONFIDENTIALITY AGREEMENT

I acknowledge that during the course of performing my assigned duties at 24/7 HomeCare Agency of NY, Inc. I may have access to, use or disclose confidential health information. I hereby agree to handle such information in a confidential manner at all times during and after my employment and commit to the following obligations:

A. I will use and disclose confidential health information only in connection with and for the purpose of performing my assigned duties

B. I will request, obtain or communicate confidential health information only as necessary to perform my assigned duties and shall refrain from requesting, obtaining or communicating more confidential health information than is necessary to accomplish my assigned duties

C. I understand that as an employee of 24/7 HomeCare Agency of NY, Inc. that is a health care provider, the use and disclosure of patient information is governed by the rules and regulations established under HIPAA, the Health Insurance Portability and Accountability Act of 1996, and related policies and procedures of 24/7 Home Care Agency of NY, Inc.

D. I will use and disclose confidential health information solely in accordance with the federal and 24/7 HomeCare Agency of NY, Inc policies and set forth above or elsewhere. I also agree to familiarize myself with any periodic updates or changes to such policies in a timely manner.

E. I will immediately report any unauthorized use or disclosure of confidential health information that I become aware of to the appropriate supervisor.

F. I also understand and agree that my failure to fulfill any of the obligations set forth in this agreement and/or my violation of any terms of this Agreement shall result in my being subject to appropriate disciplinary action, up to and including, termination of employment.

Applicant Printed Name:
Signature of Applicant:
Date:
08-20-2020
Signature of Broker
Date:
08-20-2020

Agreement between 24/7 HomeCare and HHA/PCA Live-In

1. All PCA/HHA assigned to live-in cases are to be present in the consumer home for 24 hours each working day.

2. During each live in day, based on a 13 hour day, HHA's/PCA's are to perform tasks in accordance with the verbal or written care plan., HHA's/PCA's may not work in excess of 13 hours in any day and no more than 5 Live in days per week

3. During each 24 hour day , HHA's/PCA's are to take eleven hours for personal time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times.

  • 8 hours of sleep time
  • 2 hours meal breaks
  • 1 hours of personal time- reading, watching television, etc.

4. If any , HHA's/PCA's finds it impossible to take the specified breaks from work duties because such times are constantly interrupted by the needs of the patient, she/he must call the administrator at 24/7 HomeCare Agency of NY, Inc immediately.

5. I understand and will abide by the agency's rules stated in this agreement regarding time worked on livein cases and I understand I will contact my coordinator if I believed I was paid improperly within 5 days. By simply accepting or continuing employment with 24/7 HomeCare Agency of Ny, Inc, you agree that you received proper reimbursement for all hours worked and you cannot bring forth any claim/dispute as a plaintiff.

6. I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, I agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in by myself or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.

7. My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 HomeCare's Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 HomeCare. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

Name:
Signature:
Date:
08-20-2020

24/7 HomeCare Agency of NY                              Tel:718-887-0782

Waiver of Group Health Benefits & Notice of Special Enrollment Rights

Employer Name:
24/7 Home Care Agency of NY, INC

Please complete the following:

Employee Name(First):
(Last):
(Ml):
Employee Social Security Number:

For the plan year effective ( 2020-08-20 ) I am waiving coverage for:

☑ Myself

☐ Spouse/Domestic Partner

☐ Dependent (s)- Please list names

I am waiving coverage due to:

☑ My preference not to have coverage


☐ Coverage under my spouse's/domestic partner's plan name of carrier:


☐ Other coveragename of carrier:

This other coverage is:
☑Individual ☐ COBRA ☐Medicare ☐TRICARE (formerly CHAMPUS)
Medicaid Employer-Sponsored Group Plan

Special Enrollment Notice and Certification - Please review and sign below if you wish to waive coverage

By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage.

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.

In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.


Signature:
Date of Signature:
08-20-2020

Declination of Influenza Vaccination


My employer, 24/7 HomeCare Agency of NY, Inc, has recommended that I receive the influenza vaccination to protect the patients I serve.

I acknowledge that I am aware of the following facts:

  • Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
  • Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and death.
  • If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
  • If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
  • I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time. This is why vaccination against influenza is recommended each year.
  • I understand that I cannot get influenza from the influenza vaccine.
  • The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including:
    • All patients in this healthcare facility
    • My Coworkers
    • My Family
    • My Community

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:

I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.

I also understand that I will need to wear a face mask during flu season while I am on a case with a patient.

I have read and fully understand the information on this declination form. I have also received a flu mask for this flu season

Name (print):
Signature
Date:
08-20-2020

Flu Vaccine Declination

☐I will NOT be getting the flu vaccine for the 2019-2020 Flu season. I will wear a surgical mask during any time spent with any patients.

☐I Received the Flu Vaccine for the 2019-2020 Flu Season.

I understand that failure to comply with these requirements will put me and the patient I care for at risk, and my employment with 24/7 HomeCare Agency of NY, Inc is conditional on meeting these requirements.

Name of Employee (print)
Signature of Employee:
Date:
08-20-2020

2414 Ralph Avenue Brooklyn, NY 11234 • T: 718-887-0782 • F: 718-874-2778 • Email: info(g)247nyhomecare.com

24/7 Home Care Agency of NY, INC

Hepatitis B Vaccination Form

I, (print your name) understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV Infection). I have been given the opportunity by 24/7 Home Care Agency of NY, Inc. to be vaccinated with HBV vaccine at no charge. If you would like to request the Hepatitis B Vaccination please do not sign below and fill out a request form.


PLEASE SIGN ONLY IF DECLINING HEPATITIS B

Declination of Hepatitis B Vaccination

I do not wish to be given the HBV vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. I am aware that I may request to be provided with the vaccination at a later date during my employment with the agency.

Signature:
Date:
08-20-2020

SEXUAL HARASSMENT POLICY ACKNOWLEDGMENT

I, certify that I have been trained on the NYS Sexual Harassment Policy. I understand that Sexual harassment is a form of workplace discrimination. 24/7 HomeCare Agency of NY, Inc has a zero-tolerance policy for any form of sexual harassment, and all employees are required to work in a manner that prevents sexual harassment in the workplace. I also understand that Sexual harassment is against the law and that I have the legal right to a workplace free from sexual harassment, and I can file a complaint internally with, 24/7 HomeCare Agency of NY, Inc or with a government agency or in court under federal, state or local anti-discrimination laws. This policy applies to all employees, paid or unpaid interns, and non-employees and all must follow and uphold this policy.

I have given the Complaint form and contact information if I ever must file a complaint for sexual harassment.

Employee's Signature
Date:
08-20-2020

Acknowledgement of Receipt of Paid Family Leave (PFL) Instructions

Under a new New York state law, working New Yorkers will be able to take time off to care for a loved one while still receiving a portion of their salary. The eligible employees will now be able to take up to 8 weeks of benefits and job-protected leave in any 52-week period at up to 50 percent of their salary.

Emplovee Eliaibility

Full-Time employees (Individuals working 30 or more hours a week): must work 20 or more hours per week for 26 or more consecutive weeks of employment.

Part Time employees (individuals working less than 30 hours a week): must work fewer than 20 hours per week for 175 days in a 52-consecutive week period.

The employee must provide advance notice of 30 days. If providing notice of less than 30 days an explanation must be given.

Types of Leave

  • 1. Care for a close relative with a serious health condition. A close relative could be your spouse, domestic partner, children, parents, parents' in-law, grandparents, and grandchildren.
  • 2. Maternity and paternity leave. Employees can take time to bond with their newborn, newly adopted, or a newly placed child, within the first 12 months after the child's birth, adoption, or placement of an adopted or foster child.
  • 3. Qualifying Exigency Leave: when an employee's spouse, child, domestic partner, or parent is on covered active duty or has been notified of an impending call or order to covered active duty; or to care for a service member with a serious injury or illness, if the employee is the service member's spouse, child, domestic partner, or parents.

Payroll Deductions to Fund Paid Family Leave Benefits

The maximum employee contribution is 0.126 percent of their weekly wage, not to exceed $1,305.92 as per NY DOL.

New York State has more information about the Paid Family Leave program at www.ny.gov/paidfamilyleave

All requests for Paid Family Leave must be made through the Human Resources Department. Please call Sharon at 718-887-0782

Print Employee's Name:
Employee's signature
Date:
08-20-2020

Acknowledgement of Receipt of the Paid Safe and Sick Leave Notice of Employee Rights


I have received the Notice of Employee Rights for the Paid Safe and Sick Leave Law. My questions regarding Paid Safe and Sick Leave have been answered.

I know I can contact 24/7 Home Care Agency of NY, Inc, at the above address or telephone number if I have any other questions regarding this notice.

I understand the following about the Paid Safe and Sick Leave:

  1. I must work 80 hours or more per calendar year (from January 1st to December 31st) in order to be covered by the Paid Sick Leave Law.
  2. I accrue 1 hour for every 30 hours worked, up to a maximum of 40 hours per calendar year.
  3. For new employees: I can use the accrued time after 120 days from my 1st workday.
  4. I am allowed to carry over any unused sick leave to the following year but can only use up to 40 hours of Paid Sick Leave per calendar year.
  5. I am required to provide 24/7 HomeCare with a health care provider's note if I use my sick leave time for four or more consecutive days, no specifics regarding my health is necessary.
  6. I may use Paid Sick Leave for sick leave ONLY and I must be scheduled in order to use sick leave. I must provide 24/7 HomeCare with 7 days of advance notice whenever possible; if I am presented with an unforeseeable situation, then I will provide a notice as soon as possible.
  7. understand that if I call out or sick the day before or the day after a holiday I am scheduled to work, I will not get paid sick time even if I have it available.

I acknowledge that I have received the necessary information and instructions regarding Paid Family Leave benefits.

Employee's signature
Date:
08-20-2020

Acknowledgement Of HHA Exchange Time and Attendance And Duty Codes Training and Responsibilities

I certify that I have been trained on 24/7 Home Care Agency of NY, Inc's automatic time and attendance and duty codes. I understand that my paycheck is generated by the call in and out through HHA Exchange automated telephone system, if I do not clock in and out correctly I will not be paid. When I clock out, it is my responsibility to dial in the duty codes that represent the duties I have performed for my patient that day. I must specify at least five duties performed. The Plan of Care should match the duties I put in. i must immediately inform my supervisor if the client's telephone is not working or if the client refuses the use their telephone..

I understand that my work day must be verified. If I fail to clock in and out correctly (because of circumstances out of my control, ex: telephone is not working) the visit must be verified by the submission of a signed and verified time sheet. If the visit is not verified, then24/7 Home Care Agency of NY, Inc will not be able to generate a pay check for that unverified work day.

I certify that I have been trained on 24/7 Home Care Agency of NY, Inc "on-call" policy and procedure. I understand that when the office is closed and there is an emergency or if I am unable to make it to work, it is my responsibility to follow the proper procedure. I must reach the answering service. I may not leave a voicemaii.

I may be subject to disciplinary actions/investigation and or termination for violation of the agency's policy and procedures, including but not limited to time and attendance.

Employee's Signature
Date:
08-20-2020
Instructor's Signature
Date:
08-20-2020

Acknowledgement of Mandatory Compliance
Regarding Time Sheets and Clock In and Out

I Home Health Aide / Personal Care Aide certify that I have been trained regarding mandatory compliance responsibilities of the agency with the Department of Health. I have been trained and understand the following:

  • Imesheets must be filled out according to the time that I serviced the patient. I understand to write down the time that I was with the patient, NOT the scheduled time.
  • I understand that I can not submit a timesheet if the patient is in care of a third party. Such as Hospital or Hospice or Dialysis Centers including any facilities that are considered 3rd Party.
  • I have been trained and shown how to fill out a timesheet correctly.
  • I understand that I must submit the time sheets by every week Monday the latest.
  • I understand that I may not schedule myself to work for two patients at the same time.
  • I understand that I must not give my clock-in ID # to anyone including the patient.
  • I imderstand that the patient or anyone else cannot clock me in or out.
  • I understand that I must not send anyone other than myself to work for me.
  • I understand that if the patient has a working phone, I MUST CLOCK IN AND OUT.
  • I understand that I will use the patient's telephone or cell phone, NOT MY CELL PHONE, to clock in and out.

I acknowledge that i am solely responsible for these requirements in order to continue my employment with 24/7 Home Care Agency of NY, Inc. Violations of these requirements are grounds for immediate termination. I acknowledge that for the safety of the patients whom i will service, i will abide by 24/7 HomeCare policy.

Print Name:
Signature
Date:
08-20-2020

Acknowledgement of Receipt of the
Personnel Policy and Privacy Notice

I have received 24/7 Home Care Agency of NY, Inc, Personnel Policy and Privacy Notice. My questions regarding the Personnel Policy and Privacy Notice have been answered.

I know I can contact 24/7 Home Care Agency of NY, Inc at the above address or telephone number if I have any other questions regarding this form.

I further understand that my employment is at will, and neither 24/7 Home Care Agency of NY, Inc nor I have entered a contract regarding the duration of my employment. Except as otherwise provided in a valid and enforceable collective bargaining agreement, I am free to terminate my employment with the 24/7 Home Care Agency of NY, Inc at any time, with or without reason and 24/7 Home Care Agency of NY, Inc has the right to terminate my employment, or otherwise discipline, transfer, or demote me at any time, with or without reason at the discretion of the Facility. No employee of24/7 Home Care Agency of NY, Inc can enter into an employment contract for a specified period of time or make any agreement contrary to this policy without the written approval of the Administrator.

Employee's Signature
Date:
08-20-2020

Compliance Program

Dear Staff Member:

24/7 HomeCare Agency of NY, Inc is dedicated to conducting its business honestly and ethically wherever 24/7 HomeCare Agency of NY, Inc operates. In order to meet this commitment, 24/7 HomeCare Agency of NY, Inc as set forth in this Code of Conduct the principles and rules to be followed by all personnel who work with 24/7 HomeCare Agency of NY, Inc.

The purpose of this Code of Conduct is to inform all personnel and interested third parties that 24/7 HomeCare Agency of NY, Inc is fully dedicated to approaching all of its activities, including compliance with laws and regulations, in an ethical manner. This Code of Conduct will familiarize new personnel with the ethical standards that guide our business and patient relationships in our highly regulated environment. For existing personnel, it will reaffirm our commitment to ethical behavior in all circumstances. Since everyone at 24/7 HomeCare Agency of NY, Inc has a personal stake in this important program, we strongly urge each of you to review this information thoroughly and refer to it whenever situations arise requiring you to exercise your judgment.

Compliance with laws, regulations and out policies require the full commitment of all 24/7 HomeCare Agency of NY, Inc personnel. Each of us is personally and professionally responsible for understanding and adhering to this Code of Conduct and the supporting policies and procedures, including those areas covering your specific job responsibilities. The purpose of this Code of Conduct is to provide you with guidance on ethical and compliance issues. However, this Code of Conduct cannot cover every issue you may encounter. If you have a question or encounter a situation which concerns you, you should ask for 24/7 HomeCare Agency of NY, Inc through your department supervisor, the Administrator and/or the Compliance Officer.

Compliance Hotline is 718-887-2922 or the email is info@247nvhomecare.com

Print Name:
Employee's Signature

J O B   D E S C R I P T I O N
Home Health Aide(HHA), Personal
Care Assistant (PCA)
REPORTSTO REGISTERED NURSE 1 DIRECTOR OF NURSING/REGISTERED NURSE DESIGNEE

SUMMARY

The Home Health Aide is a member of the home care team trained to provide personal care, other unskilled services, and companionship in the home setting, under the direction, instruction, and supervision of a Director of Nursing/Registered Nurse designee and the patient

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

  • Assists the patient in the Activities of Daily Living (ADL) including personal care, hygiene, baths, back rubs, shampoo, skin and nail care, eating, dressing, elimination, exercises, ambulation, and changin^making patient's bed. Plans and prepares meals.
  • Encourages the patient's family to participate in patient's care.
  • Provides companionship to the patient
  • Assists in the maintenance of a safe and healthy environment Uses equipment and supplies safely and properly.
  • Reminds the client to take, and assists client and/or family, with self-administered oral medications as ordered by the physician, in compliance with the laws in the state of operation.
  • Takes and records accurate patient vital signs when advised.
  • Follows the Home Health Plan as written, approved, and supervised by the Registered N urse or Physical Therapist
  • Gives emotional support to the patient and/or family
  • Informs Registered Nurse (RN)/Director of Nursing/Registered Nurse Designee of changes in patient's condition.
  • Documents activities and findings and submits documentation as required by company procedures.

This job description is not intended to be all-inclusive. The employee will be expected to perform other reasonable related duties as assigned by management

JOB LIMITATIONS
The Home Health Aide will not function in any manner viewed as the practice of nursing according to the State's Nurse Practice Act Specifically, the home health aide will not administer medications, take physician's orders or perform procedures requiring the mining, knowledge, and skill ofa nurse, specifically sterile techniques.

QUALIFICATIONS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION ANDJOR EXPERIENCE
High school diploma or general education degree (OED) orequivalent, and meets the training requirement in accordance with state and federal laws. (Effective 8J14/90, a person who has successfully completed a state established or other training program that meets the requirements ofCFR484.36(b), oracompetency evaluation program or state licensure program that meets the requirements of S 484.36(b).) At least one year of experience in home care, nursing, or hospital experience preferred.

LANGUAGE SKILLS
Ability to communicate effectively with patient/client, family members, clinical management, and staff. Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence.

REASONING ABILITY
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with simple problems in the home setting.

OTHER SKILLS AND ABILITIES
Nurse's Aide skills, observation skills, communication skills, knowledge ofhome health care. Good physical and mental health. Caring attitude, tact, patience, and good personal hygiene.

J O B   D E S C R I P T I O N
Home Health Aide(HHA)

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The work requires moderately heavy physical exertion on a regular and recurring basis such as: extensive driving, assisting patient in transfer activities (wheelchair, to bed, to tub, to commode) and providing substantial support to individuals in ambulation. While performing the duties ofthisjob, the employee is regularly required to use hands to finger, to handle or feel, and talk or hear. The employee frequently is required to stand; walk; reach with hands and arms' and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit. The employee must occasionally lift and/or move over 100 pounds. Specific vision abilities required by this job include close vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job

  • Patient home setting, exposure to infectious diseases, automobile.
Supervisor Signature
Date:
08-20-2020
Employee Signature
Date:
08-20-2020
Title:

(Signing this document acknowledges that the job description and responsibilities have been reviewed with me, the employee.)

Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Multiple Hourly Rate Employees

1.Employer Information

Name :
24/7 HomeCare Agency of NY, Inc

Doing Business As (DBA) name(s):

FEIN (optional):

Physical Address:
2414 Ralph Avenue
Brooklyn, NY 11234

Mailing Address:
2414 Ralph Avenue
Brooklyn. NY 11234

Phone:
718-887-0782


2.Notice given:

☑At hiring

☐Before a change in pay rate (s), allowances claimed or payday

3.Employee's rate(s) of pay for each type of work or shift:

  • $ 15 per hour for hourly cases
  • $ 15 per hour for 13 hrs on Live-in Cases
  • $ __ per hour for

4.Allowaces taken:
☑None
☐ Tips _________ per hour
☐ Meals _________ per meal
☐ Lodging _________
☐ Other _________

5.Regular payday: Friday

6.Pay is:
☐ Weekly
☑ Bi-weekly
☐ Other:_________________

7.Overtime Pay Rates(s) for each type of
work or shift:
1.5xReg Pay Rate

This must be at least 1 1/2 times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.

8.Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.

Check one:

☑I have been given this pay notice in English because it is my primary language.
☐My primary language is I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary lanuage.
Print Employee's Name
Employee's Signatue
Date
Preparer's Name and Title
24/7 HomeCare Agency of NY, Inc

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

DOH CHRC 102 (1/07)

NYS Department of Health
ACKNOWLEDGEMENT AND CONSENT FORM FOR FINGERPRINTING AND DISCLOSURE OF CRIMINAL
HISTORY RECORD INFORMATION
THIS FORM IS TO BE RETAINED BY THE AGENCY- DO NOT FORWARD TO THE DOH CHRC UNIT. chrc@health.state.ny.us

The purpose of this form is to obtain consent from the subject individual for fingerprints and criminal history record information pursuant to Article 28-E of the Public Health Law and Section 845-b of the Executive Law.

SECTION 1 – SUBJECT INDIVIDUAL INFORMATION

Last NameFirst NameM.I.
Date of Birth (mm/dd/yyyy)Mother’s Maiden NameAlias: AKA
Mailing Address (street)CityStateZip
NY

SECTION 2 - ATTESTATION

  1. I have applied to an agency to provide direct care or supervision to residents or patients. I understand that as part of the application process, the Public Health Law (PHL) Article 28-E requires that the New York State Department of Health perform a criminal history check on me with the New York State Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI).
  2. I acknowledge and consent to having my fingerprints taken for the purpose of a criminal history record check by the DCJS and the FBI.
  3. I have been advised that DOH is authorized by law to receive the results of the criminal history record check from DCJS and the FBI for the purpose of developing a criminal history record summary to be provided to the agency to which I applied for a position to provide direct care or supervision to residents or patients. I have been advised that the criminal history record summary will indicate whether I have a criminal history, as maintained by DCJS or the FBI, including convictions of a crime (felony or misdemeanor) or criminal charges which do not reflect a disposition. I have been advised that by law, DOH is authorized and may be required to provide the results of the criminal history record check through a criminal history record summary to the agency. The criminal history record summary prepared by DOH and sent to the agency will contain the results of the criminal history record check performed by DCJS. I have been advised that the information shall be confidential pursuant to applicable federal and state laws, rules and regulations and shall only be disclosed to persons authorized by law.
  4. I hereby consent to DOH sharing with any DCJS agency to which I applied for a position to provide direct care or supervision, any criminal history record check information provided to DOH by the FBI, including the specific crime(s) for which I was convicted or charged, the date of the arrest for such charge, and/or date of conviction, and the jurisdiction in which the arrest or conviction took place.
  5. I have been informed of the procedures and my rights to obtain, review and seek correction of my criminal history information pursuant to regulations and procedures established by the DCJS and the FBI.
  6. I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether an agency, DOH or I have reviewed my criminal history information.
  7. I certify to the best of my knowledge and belief that I (check as appropriate):
    ☐Have ☑Have not been convicted of a crime in New York State or any other jurisdiction
    ☐Do ☐Do not have a final finding of patient or resident abuse.
    If you have checked either “Have” and/or “Do”, please provide a brief explanation. (Optional)
  8. My current mailing or home address is indicated in Section 1 of this form.
  9. I have read this form and hereby consent to the request by the agency to use my fingerprints to obtain my criminal history record, if any, from the DCJS and the FBI. I hereby consent to the redisclosure of any convictions or open charges on my criminal history record, received by DOH from DCJS, to the requesting agency. I declare and affirm that the information I have provided on this consent form is true, complete and accurate and that the fingerprints to be submitted are my own (not applicable for Expedited Review submitted pursuant to CHRC Form 104).
Applicant Signature: 
Signature of Parent or Legal Guardian: (if subject individual is under 18 years of age)
Date:
08-20-2020
Date:
08-20-2020

SECTION 3 – AGENCY AUTHORIZED PERSON INFORMATION

Agency Name:PFI/Operating License Number:
Print Name of Authorized Pers:Title:
Signature of Authorized Person: Date: 08-20-2020

Acknowledgement of Receipt
Photo Identification

As an employee of 24/7 HomeCare Agency of NY, Inc, I, , acknowledge receipt of the agency issued photo identification badge. As required by regulation and agency policy, I agree to wear the ID when working where it is visible to the eye immediately by the patient, all the patient's family members and Supervising Nurse.

The identification badge is the property of 24/7 HomeCare Agency of NY, Inc and wiil be returned to the agency upon termination of employment.

I know I can contact 24/7 HomeCare Agency of NY, Inc at the above address or telephone number if i have any other questions regarding this form

HHA/PCA - Employee's Signature / Title
Date:
08-20-2020

Receipt of 24/7 HomeCare Agency of NY, Inc's
Cellular and Wireless Device In the
Workplace

Please read the policy carefully to ensure that you understand the policy before signing this document.

I certify that I have received a copy of 24/7 HomeCare Agency of NY, Inc's Cellular and Wireless Devices in the Workplace policies. I understand that it is my responsibility to read and comprehend the policy. I have read and understand the content, requirements and expectations of the policy and I agree to abide by the policy's guidelines. I understand that if at any time, I have questions regarding this policy, I will consult with my immediate supervisor or the Corporate Compliance Officer.

I agree to observe and follow this policy. I understand that failure to abide by the policy could result in disciplinary actions and possible termination.

Employee's Name:
Employee's Signature
Date:
08-20-2020
Form

W-4


Department of the Treasury
Internal Revenue Senrice

Employee's Withholding Certificate

► Complete Form W-4 so teat your employer can withhold the correct federal income tax from your pay.

► Give Form W-4 to your employer.

► Your witeholding is subject to review by the IRS.

OMB No. 1545-0074

2020

Step 1: Enter Personal Information

First name and middle initial
Last name
Your social security number
Address
City or town, stats, and ZIP code
► Does your name match tee name on your social security card? If not, to ensure you get credit for your earnings, contact SSA at 800-772-1213 or go to www.ssa.gov.
  • ☑ Single or Married filing separately
  • ☐ Married filling jointly(or Qualifying widow(er))
  • ☐ Head of household (Check only if you're unmarried artd pay more than half the costs of keefring up a home for yourself and a qualifying individual.)

Complete Steps 2-4 ONLY If they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2: Multiple Jobs 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 also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

  • (a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4); or
  • (b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
  • (c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld ►

TIP: To be accurate, submit a 2020 Form W-4 for ail other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps S-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job.)

Step 3: Claim Dependents

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

Multiply the number of qualifying children under age 17 by $2,000 ► $

Multiply the number of other dependents by $500 ► $

Add the amounts above and enter the total here

3$

Step 4(optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other Income you expect this year that won't have withholding, enter the amount of other income here. This may Include Interest, dividends, and retirement income

4(a)$

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

4(b)$

(c) Extra withholding. Enter any additional tax you want withheld each pay period

4(c)$

Step 5: Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, conrect, and complete.


Employee's signature (This fomri is not valid unless you sign it.)
08-20-2020

Date:

Employers Only

Employer's name and address
First date of employment
08-20-2020
Employer identification number (EIN)
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2020)

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

► 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 I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
NY
ZIP Code
Date of Birth (mm/dd/yyyy)
U.S. Social Security Number
Employee's E-mail Address
Employee's Telephone Number

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):

☑1. A citizen of the United States
☐2. A noncitizen national of the United States (See instructions)
☐3. A lawful permanent resident(Alien Registration Number/USCIS Number):
☐4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field.(See instructions)
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number

1. Alien Registration Number/USCIS Number:

         OR

2. Form I-94 Admission Number:

         OR

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1 Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
08-20-2020

Preparer and/or Translator Certification (check one):

☑I did not use a preparer or translator ☐ A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

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.

Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
08-20-2020
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
NY
ZIP Code
Employer Completes Next Page

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's 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 on the "Lists of Acceptable Documents.")

Employee Info from Section 1
Last Name (Family Name)
First Name (Given Name)
M.I.
Citizenship/Immigration Status
List A
Identity and Employment Authorization
Or
List B
Identity
AND
List C
Employment Authorization
Document Title
Document Title
Document Title
issuing Authority
issuing Authority
issuing Authority
Document Number
Document Number
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Expiration Date (if any) (mm/dd/yyyy)
Expiration Date (if any) (mm/dd/yyyy)
Document Title
issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)

Additional Information
UK Code - Sections 2 & 3 Do Not Write in This Space

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.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
08-20-2020
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
NY
ZIP Code
Section 3. Reverification and Rehlres (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
B. Date of Rehire (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Date (mm/dd/yyyy)
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.
Document Title
Document Number
Expiration Date (if any) (mm/dd/yyyy)

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.

Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
08-20-2020
Title of Employer or Authorized Representative

Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
New York State • New York City • Yonkers

First name and middle initial
Last name
Your social security number
Permanent home address (number and street or rural route)
Apartment number
City, village, or post office
State
NY
ZIP code
Single or Head of household ☐
Married ☑
Married, but with hold at higher single rate ☐

Note: If married but legally separated, mark an X in the Single or Head of household box.

1. Are you a resident of New York City?       Yes ☑ No ☐
2. Are you a resident of Yonkers?                  Yes ☑ No ☐

Complete the worksheet on page 3 before making any entries

Total number of allowances you are claiming for New York State and Yonkers, if applicable (fmm line 20)1
Total number of allowances for New York City (fmm line 35)2

Use lines 3,4, and 5 below to have additional withholding per pay period under special agreement with your employer.

New York State amount3
New York City amount4
Yonkers amount5

I certify that I am entitled to the number of withholding allowances claimed on this certificate

Signature of Employee
Date
08-20-2020

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties

Employee: detach this page and give it to your employer; keep a copy for your records

Employer: Keep this certificate with your records.

Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):

A Employee claimed more than 14 exemption allowances for NYS ............ A ☐
B Employee is a new hire or a rehire ... B ☐
First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Are dependent health insurance benefits available for this employee? ............. ☐ Yes ☐ No

If Yes, enter the date the employee qualifies (mm-dd-yyyy):0

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)
Employer identification number
Instructions

Changes effective for 2020
Form IT-2104 has been revised for tax year 2020. The worksheet on page 4 and the charts beginning on page 5, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2018 Form IT-2104 and give it to your employer.

Who should file this form
This certificate, Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

If the federal Fonn W-4 you most recently submitted to your employer was for tax year 2019 or earlier, and you do not file Form IT-2104, your employer may use the same number of allowances you claimed on your federal Form W-4. Due to differences in tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

For tax years 2020 or later, withholding allowances are no longer reported on federal Form W-4. Therefore, If you submit a federal Form W-4 to your

employer for tax year 2020 or later, and you do not file Form IT-2104, your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim Is different from federal Fonn W-4 or has changed. Common reasons for completing a new Form IT-2104 each year Include the following:

You started a new Job.
You are no longer a dependent.
Your Individual drcumstances may have changed (for example, you were married or have an additional child).
You moved into or out of NYC or Yonkers.
You itemize your deductions on your personal income tax return.
You claim allowances for New York State credits.
You owed tax or received a large refund when you filed your personal income tax return for the past year.
Your wages have increased and you expect to earn $107,650 or more during the tax year.

Form

8850


(Rev. March 2016) Department of the Treasury
Internal Revenue Senrice

Pre-Screening Notice and Certification Request for the Work Opportunity Credit

► Information about Form 8850 and its separate instructions is at www.irs. Gov/form8850.

0MB No. 1545-1500

Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.

Your name:
Social security number:
Street address where you live:
City or town, state, and ZIP code:
County
Telephone number
If you are under age 40, enter your date of birth (month, day, year)
  1. ☐ Check here if you received a conditional certification from the state workforce agency (SWA) or a participating local agency for the work opportunity credit.
  2. ☐Check here if any of the following statements apply to you.
    • I am a member of a family that has received assistance from Temporary Assistance for Needy Families (TANF) for any 9 months during the past 18 months.
    • I am a veteran and a member of a family that received Supplemental Nutrition Assistance Program (SNAP) benefits (food stamps) for at least a 3-month period during the past 15 months.
    • I was referred here by a rehabilitation agency approved by the state, an employment network under the Ticket to Work program, or the Department of Veterans Affairs.
    • I am at least age 18 but not age 40 or older and I am a member of a family that:
      • Received SNAP benefits (food stamps) for the past 6 months; or
      • Received SNAP benefits (food stamps) for at least 3 of the past 5 months, but is no longer eligible to receive them.
    • During the past year, I was convicted of a felony or released from prison for a felony.
    • I received supplemental security income (SSI) benefits for any month ending during the past 60 days.
    • I am a veteran and I was unemployed for a period or periods totaling at least 4 weeks but less than 6 months during the past year.
  3. ☐ Check here if you are a veteran and you were unemployed for a period or periods totaling at least 6 months during the past year.
  4. ☐ Check here if you are a veteran entitled to compensation for a service-connected disability and you were discharged or released from active duty in the U.S. Armed Forces during the past year.
  5. ☐ Check here if you are a veteran entitled to compensation for a service-connected disability and you were unemployed for a period or periods totaling at least 6 months during the past year.
  6. ☐ Check here if you are a member of a family that:
    • Received TANF payments for at least the past 18 months; or
    • Received TANF payments for any 18 months beginning after August 5,1997, and the earliest 18-month period beginning after August 5,1997, ended during the past 2 years; or
    • Stopped being eligible for TANF payments during the past 2 years because federal or state law limited the maximum time those payments could be made.
  7. ☑ Check here if you are in a period of unemployment that is at least 27 consecutive weeks and for all or part of that period you received unemployment compensation.

Signature—All Applicants Must Sign

Under penalties of perjury, I declare that I gave the above information to the employer on or before the day I was offered a job, and it is, to the best of my knowledge, true, correct, and complete.


Job Applicant's Signature
08-20-2020

Date:
For Privacy Act and Paperwork Reduction Act Notice, see page 2.
Cat No. 22851L
Form 8850 (Rev. 3-2016)

U.S. Department Labor
Employment and Training Administration

0MB Control No. 1205-0371
Expiration Date: January 31,2020

LONG-TERM UNEMPLOYMENT RECIPIENT SELF-ATTESTATION FORM
Work Opportunity Tax Credit (WOTC) Program

Instructions: This Self-Attestation Form (SAF) is to be completed, signed, and dated by the new hire only.Employers or consultants submit this SAF to the State Workforce Agency with IRS Form 8850 or if filed separately, with ETA Form 9061 (or ETA Form 9062) for each certification request filed for the new target group.

Under penalties of perjury, I declare that this information is true and correct to the best of my knowledge.

New Hire's Signature :
Date:
08-20-2020

New Hire Name:
Social Security Number:
Employer Name:

Please check the statements below if they apply to you.

  1. ☑ I declare that I was In a period of unemployment that Is at least 27 consecutive weeks and for all or part of that period I received unemployment compensation.
  2. ☐I declare that I have been In a period of unemployment since 08-20-2020 (Enter start date)

Privacy Act Notice
The Internal Revenue Code of 1986, Section 51, as amended, and its enacting legislation, P.L. 104-188, specify South State Workforce Agendas are the "designated" agents responsible for administering the WOTC certification procedures of this program. The Information you provided completing this form will be disposed by your employer to the State Workforce Agency. Provision of this information Is voluntary; however the Information Is required to determine your employer's eligibility for the federal tax credit.

Public Burden Statement
Persons are not required to respond to this collection of Information unless it displays a currently valid OM B control number. Respondent's obligation to complete this form Is required to obtain or retain benefits (P.L. 111-5). Public reporting burden Is estimated to average 10 minutes per response, including the time for reviewing Instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of Information.


ETA Form 9175 (Rev. November 2016)

Home Health Aide/ PCA Acceptance Test

Please circle the correct answer for the following questions:

  1. Clients sometimes express religious beliefs with which the home health aide does not agree. In dealing with these situations, which of these understandings should the aide use as a guide?
    • ☑ A. Clients have a right to their own beliefs, which should be respected.
    • ☐B. Clients should be told not to discuss their beliefs with aides
    • ☐ C. Aides should explain their beliefs to the clients
    • ☐ D. Aides should pretend they have the same beliefs that the clients have.
  2. Mrs. Wayne, a home health aide, leaves the home of Mr. David, a terminally ill client. A neighbor stops her and says, "Mr. Davis is sick isn't he? I hear he is dying." What is the best response for the aide to answer?
    • ☑ A. "Yes, Mr. Davis is very ill."
    • ☐ B. "How do you know Mr. Davis is so sick?"
    • ☐ C. "I'm sorry, I can't discuss Mr. Davis"
    • ☐ D. "Mr. Davis is doing as well as can be expected"
  3. Miss Ferri, a home health aide, is assigned to care for Mr. Conway. Miss Ferri notices that she feels very angry when she is with the patient. What should Miss Ferris do because she feels this way?
    • ☑ A. Tell Mr. Conway how she is feeling.
    • ☐ B. Find out if other aides have felt this way.
    • ☐ C. Try to pretend Mr. Conway is someone she likes.
    • & ☐ D. Talk with the agency supervisor about the situation.
  4. A client accuses a home health aide of stealing five dollars. The aide has not taken the clients' money, but the client does not believe the aide. What should the aide do?
    • ☑ A. Ask the other aides who care for the client if they took the money.
    • ☐ B. Ask the client why the aide is being accused.
    • ☐ C. Offer to give the client five dollars.
    • ☐ D. Notify the agency supervisor.
  5. Which of these actions is the home health aide permitted to take in relation to drug administration?
    • ☑ A. Recording and reporting the client's reaction to the medication.
    • ☐ B. Giving nonprescription medications whenever the client asks for them.
    • ☐ C. Adjusting the dosage of the medication given to the client.
    • ☐ D. Adjusting the times medications are given to fit into the client's scheduled.
  6. The home health aide is helping Mrs. Elden with her bed bath. Mrs Elden requests to wash her genital and rectal areas herself. Which of these measures should the aide take?
    • ☑A. Have Mrs. Elden use cold water only in washing her genitals.
    • ☐ B. Have Mrs. Elden use no soap when washing her rectal area.
    • ☐ C. Remind Mrs. Elden to wash from the vaginal area toward the rectal area.
    • ☐ D. Tell Mrs. Elden she cannot wash herself.
  7. A patient who has been on bed rest is too weak to get up in a chair. The home health aide helps the client to sit on the edge of the bed. The client says "I am dizzy". What should the aide do?
    • ☑ A. Rub the client's feet.
    • ☐ B. Help the client to a standing position.
    • ☐ C. Put a cool compress on the clients head.
    • ☐ D. Support the client in sitting position and wait a minute or two to see if the dizziness goes away.

Home Health Aide/ PCA Acceptance Test

Please circle the correct answer for the following questions:

  1. Pressure ulcers are most likely to be prevented if:
    • ☑ A. The patient is turned on each side every 2 hours
    • ☐ B. Clients sleep all day
    • ☐ C. Clients eat well.
    • ☐ D. Clients shower frequently.
  2. An aide is taking care of a patient who becomes aggressive. The patient is cursing and yelling. What should the aide do?
    • ☑ A. Yell back at the patient.
    • ☐ B. Tell the patient to calm down.
    • ☐ C. Move away from the patient and give the patient a few minutes to calm down.
    • ☐ D. Leave the patient and go home.
  3. A fall risk patient asks the aide to go to the supermarket to buy some groceries. What should the patient do?
    • ☑ A. Leave the patient alone and go to the supermarket.
    • ☐; B. Tell the patient she cannot leave him alone and ask if he wants to go with her or order in delivery.
    • ☐ C. Put the patient to sleep and then go to the supermarket.
    • ☐ D. Tell the patient she doesn't want to go.

Commuter Benefits Participation Form

Under NYC's Commuter Benefits Law, certain employers must offer commuter benefits to existing full-time employees beginning January 1, 2016 or four weeks after an employee begins full-time work, whichever is later. For more information, please call 311 or visit nyc.gov/commuterbenefits to read Frequently Asked Questions about the Commuter Benefits Law.

Note to Employees:
Your employer is required by law to offer you a commuter benefits program; however, your participation is voluntary. You may decline to enroll in the program, or you may cancel your participation at any time. You may also choose to enroll in the program at a later date.

EMPLOYER INFORMATION
Employer Name
Address
City/State/ZIP Code
Phone Number
EMPLOYEE INFORMATION
Name (First/Middle/Last)
Address
City/State/ZIP Code
Phone Number
Email Address
Date of Hire

I, , (Employee’s printed name) ☐ Accept ☐; Decline my employer’s offer to use pre-tax income to pay for qualified transportation benefits to the extent permitted under federal law.

Employee Name (Signature):
    Date: 08-20-2020

If you have questions about your employer's obligations under NYC's Commuter Benefits Law or to report non-compliance, please contact the Department of Consumer Affairs (DCA) at nyc.gov/commuterbenefits. Email commuterbenefits@dca.nyc.gov. or contact 311 (212-NEWYORK outside NYC).

FACT-FINDING AND ISSUE RESOLUTION ("FAIR") PROGRAM

Purpose of the FAIR Program.
The Agency values each employee and looks forward to good relations with and among all of its employees. Occasionally, however, disagreements may arise between you and our agency or between employees in a context that involves the Agency We believe that the resolution of such disagreements will be best accomplished by internal dispute resolution and, where that fails, by external binding arbitration that is conducted by a neutral arbitrator. For these reasons, the Agency has adopted this Fact-Finding and Issue ResolutionProgram (the "FAIR Program"). The FAIR Program is effective immediately upon your execution of this document (the "Effective Date").

The FAIR Program is an essential element of Your employment and/or continued employment with the Agency.Although the FAIR Program Is a binding agreement between you and the Agency, It does not create a contract of employment for a specific term or otherwise affect the at-will nature of Your employment. You Indicate your agreement to be bound by the FAIR Program's terms and conditions by beginning or continuing your employment with the Agency.

What does the FAIR Program cover?
The FAIR Program applies to any and all Claims, regardless of when those claims arose or accrued or were first asserted, between You and the Agency (as these terms are defined below). For the avoidance of doubt, the FAIR Program applies to claims that accrued, arose, or were asserted before execution of this agreement and to claims that accrued, arose, or were asserted after execution of this agreement. The FAIR Program also applies to Claims that arise or are asserted after your employment with the Agency ends.

For purposes of the FAIR Program and this document, the following terms have the following meanings:

"The Agency" means 24/7 Homecare Agency of NY, Inc., each of its subsidiaries, affiliates, and successor entities, as well each of their partners, principals, owners, directors, agents, and employees against whom a Claim is asserted by You.

"You" and "your" refers to you and any other person who may assert your rights.

"Claim" includes any claim, dispute, allegation, controversy or action between you and The Agency that in any way arises from or relates to your employment with The Agency or the termination of your employment with The Agency, and that is based on a legally protected right (i.e., statutory, regulatory, contractual, or common-law rights). The term Claim includes, for example, any employment, labor, wage and hour, overtime, or compensation related claims. As further examples, the term Claim includes, without limitation, claims, disputes, demands or actions that may arise under the following laws (all as amended):

  • Title VII of the Civil Rights Act of 1964
  • The Civil Rights Act of 1991
  • The Age Discrimination in Employment Act of 1967
  • The Americans with Disabilities Act of 1990
  • The Fair Labor Standards Act of 1938 or any state wage and hour laws, such as the New York Labor Law and the Domestic Workers Bill of Rights
  • New York Public Health Law Section 3614- c, also known as the Wage Parity Law
  • Any other federal, state, or local wage parity, living wage, or prevailing wage law
  • The Equal Pay Act of 1963
  • The Rehabilitation Act of 1973
  • The Older Workers Benefit Protection Act employment, compensation, breach of contract, or defamation
  • Any common law theories, such as tort, contract, or quasi-contract, including, but not limited to, claims of breach of an expressed or implied contract, tortious interference with contract or prospective business advantage, breach of the covenant of good faith and fair dealing, unjust enrichment, promissory estoppel, detrimental reliance, retaliation.
  • The Family and Medical Leave Act of 1993
  • The Occupational Safety and Health Act of 1970
  • The Worker Adjustment and Retraining Notification Act of 1988
  • Any state anti-discrimination, anti-retaliation, or whistleblower laws (including, without limitation, the New York State Human Rights Law and the New York State Whistleblower Law)
  • Any other federal, state, or local statute, regulation, or common-law doctrine regarding employment, employment discrimination, harassment, terms and conditions of employment, termination of violation of public policy, invasion of privacy, nonphysical injuiy, personal injury or sickness or any other harm, wrongful or retaliatory discharge, fraud, defamation, slander, libel, false imprisonment, or negligent or intentional infliction of emotional distress
  • Disputes about the validity, enforceability, coverage or scope of the FAIR Program or any part thereof

FACT-FINDING AND ISSUE RESOLUTION ("FAIR") PROGRAM

The above list is not exclusive, and is only provided to illustrate examples of Claims. All Claims, whether listed above or not, must be resolved through the FAIR Program.

Are any Claims excluded from the FAIR Program?
Yes. The term "Claim" does not include the following, which are for a court or an agency and not an arbitrator to decide:

  • Controversies, claims or other disputes for injunctive relief for unfair competition or unauthorized use or disclosure of confidential information or trade secrets
  • Claims for workers' compensation (except that claims for interference with or retaliation for filing a workers' compensation claim will be considered a Claim subject to arbitration under the FAIR Program)
  • Claims for unemployment compensation benefits
  • Claims for employee welfare benefits (e.g., medical, health, dental)
  • Claims for retirement benefits under the Employee Retirement Income Security Act ("ERISA") (except that claims for interference with or retaliation for exercising protected rights under ERISA shall be considered Claims subject to arbitration under the FAIR Program)
  • Unfair labor practice charges under the National Labor Relations Act

The FAIR Program also does not prevent You from pursuing a claim based on alleged violations of any applicable collective bargaining agreement grievance procedure. Claims that are independent of rights under the CBA and/or that can be resolved without interpreting the collective bargaining agreement are not excluded from the FAIR Program. For instance, a claim alleging a violation of New York Labor Law, the Fair Labor Standards Act, or any other federal or state law is subject to the FAIR Program.

The FAIR Program also does not prevent You from filing a charge, testifying, assisting, or otherwise participating in any investigation or proceeding conducted by the equal employment opportunity commission, or another government agency to the extent You have a protected right to do so. But if You take such action in relation to a claim, controversy, or other dispute that would constitute a Claim and you have not fully pursued such dispute through the FAIR Program, The Agency may request the agency in question to defer its processing or investigation of such charge until the FAIR Program has been completed. Notwithstanding Your rights under this subsection. You agree that, to the maximum extent permitted by law. You may recover monetary relief with respect to a Claim only through the FAIR Program.

The FAIR Program does not require the Agency to begin arbitration proceedings or initiate any other procedure whatsoever before taking any action regarding your employment with which you might disagree, such as coaching, counseling, warning, reprimand, suspension, investigation, discipline, demotion, changing your days or hours of work, or termination.

Can a Claim be resolved in court? No. Under the FAIR Program, You and the Agency each waive your respective rights to have a Claim decided by a court, judge, jury and, where permitted by law, an administrative agency. Instead, You and the Agency agree that the internal dispute resolution (if any) and arbitration under the FAIR Program are the sole and exclusive methods for resolving Claims. If either You or the Agency files an action in court or another forum not contemplated by the FAIR Program asserting one or more Claims and the other party successfully stays such action andMr compels arbitration of such Claim, the arbitrator may assess reasonable costs and expenses, including an award of reasonable attorneys' fees, incurred in seeking such stay and/or order compelling arbitration against the party that filed the action in court or such other forum.

How should You Raise a Claim under the FAIR Program? If You believe You have a Claim against the Agency, You should first give the Agency a chance to investigate and resolve the Claim before You file a demand for arbitration (the arbitration process is explained further below). You do not need to use any specific form to submit a Claim. Simply write a letter explaining your Claim and the relief sought, and submit the letter to the Compliance Officer listed in your Compliance Training Module. As part of this process, a Agency representative might meet with you to discuss your Claim. Or, depending on the nature of the Claim, the Agency will investigate the Claim on its own, such as by reviewing its records. If You do not receive a satisfactory response from the Agency within 30 days of the date that you submitted Your letter or if you disagree with the response from the Agency, You must follow the arbitration procedure set forth below if you wish to pursue the Claim.

The Arbitration Process

How much time do You have to file a Claim? An arbitration proceeding under the FAIR Program must be commenced within the time period prescribed by the statute of limitations applicable to the Claim being asserted. For purposes of statute of limitations, an arbitration proceeding is deemed commenced when a demand for arbitration is filed with ADR Systems. Filing an internal Claim under the FAIR Program will not extend the time period within which You must file a demand for arbitration.

How does the Arbitration process begin? To start the arbitration process, the party wishing to file a Claim must file a written demand in accordance with the rules of ADR Systems ("ADR") for starting the arbitration process. More information about the ADR may be obtained at www.adrsystems.com or by calling 312-960-2260.

Can an attornev represent You? Yes. Any party may be represented by an attorney. If you need assistance finding an attorney, there may be resources available to you, such as the American Bar Association (www .amcricanbar.oru and 800-285-2221 or 202-662-1000) or the Legal Aid Society (www.legal-aide.org or 212- 577-3300 or 718-722-3100). Alternatively, You must represent Yourself.

When and where will Arbitration take place? The arbitration will be conducted by the arbitrator in whatever manner will most expeditiously permit full presentation of evidence and arguments of the parties. The arbitrator will set the time, date, and place of the hearing, notice of which must be given to the parties at least 30 calendar days in advance, unless the parties agree otherwise. In the event the hearing cannot be reasonably completed in one day, the arbitrator will schedule the hearing to be continued on a mutually convenient date. Any arbitration hearing will take place within the County of Kings, State of New York, unless the parties agree otherwise or the arbitrator, for the convenience of the parties, selects an alternative location.

What rules and law applv to the Arbitration? Arbitration under the FAIR Program will be conducted pursuant to the ADR's Employment/Commercial Arbitration Rules and Mediation Procedures. If there is any conflict between the FAIR Program and the ADR rules and procedures, the FAIR Program terms will govern unless application of such terms would cause the ADR to decline to provide its services, in which case the ADR rules and procedures will govern (except that under no circumstance will an arbitrator have the authority to hear or decide any Claim on a class, collective, or other group or representative basis). The arbitrator must apply the substantive law, including the applicable burdens of proof and persuasion, that would be applied by a court hearing the Claim in the venue of the arbitration. The arbitrator may grant relief that could be granted by a court hearing the Claim, including an award of attorneys' fees and costs, but will not have any authority to grant any other relief.

Can claims be heard or decided on a class, representative, or collective basis? No. Notwithstanding anything to the contrary, this is not permitted under any circumstance. Notwithstanding anything to the contrary: (a) no arbitrator is permitted to hear or decide any Claim on a class, collective, or other group or representative basis; (b) all Claims between You and the Agency must be decided individually; and (c) the ADR's Supplementary Rules for Class Action Arbitration (and any similar rules) will not have any applicability to any Claim. This means that if You have a Claim, neither You nor the Agency will have the right, with respect to that Claim, to do any of the following in court or before an arbitrator: (a) pursue or obtain any relief from a class, collective, or other group or representative action; (b) act as a private attorney general; or (c) join or consolidate a Claim with the Claim of any other person. Thus, the arbitrator shall have no authority or Jurisdiction to process, conduct, or rule upon any class, collective, private attorney general, or other representative or group proceeding under any circumstances. If there is more than one Claim between You and the Agency, those Claims may be heard in a single arbitration hearing.

Who pays for the arbitration? The party claiming to be aggrieved is responsible for paying the first $200.00 of any applicable filing fee in effect and established by the ADR at the time the demand for arbitration is made. The Agency will pay the remainder of any applicable filing fee and will pay any administrative or hearing fees and the arbitrator's fees (except postponement fees or additional hearing fees resulting from actions or inactions of the employee or employee's representative). Each party will be responsible for its own attorneys' fees, witness fees, expenses and costs, but the arbitrator may award either party reasonable attorneys' fees and costs, to the extent a court hearing such Claim would award attorneys' fees under applicable law. However, if the arbitrator finds that the employee's or the Agency's demand for arbitration is frivolous or vexatious, or was not filed in good faith, the arbitrator may require the offending party to reimburse the other party for the arbitrator's expenses and fees. Any amounts required to be paid by You under this paragraph may be adjusted or eliminated to the extent necessary for the FAIR Program to be enforceable.

Will there be discovery or deDositions? Yes. All discovery will be governed by the ADR's rules.

Can You have witnesses testify at the arbitration? Yes. At the hearing, the parties will have the right to present proof through testimony and documentary evidence, and to cross-examine witnesses who testify at the hearing. The arbitrator will require all witnesses to testify under oath. The arbitrator(s) will also have the authority to decide whether any person who is not a witness may attend the hearing.

The Arbitrator's Decision/Award. The Arbitrator will issue his or her award promptly after the arbitration hearing concludes or post-hearing briefs are received. The arbitrator's award will set forth the factual and legal basis for the award, including his or her legal reasoning, and contain a summary of the facts, the issues, the governing law applied, and the relief requested and awarded. It should also identify any other issues resolved and the disposition of any statutory claims. The arbitrator's award will be final and binding on the parties.

How Long Does the FAIR Program Apply to You? The FAIR Program will remain in effect and survive the cessation of Your employment relationship or affiliation with the Agency, regardless of the reason for such cessation.

Miscellaneous Provisions

Choice of Law. The FAIR Program and the terms of this document shall comply with and be governed by the provisions of the Federal Arbitration Act ("FAA") and not by any state law concerning arbitration. The parties acknowledge and agree that the FAIR Program evidences a transaction involving interstate commerce.

Severability. If any part or provision of the FAIR Program or this agreement is held to be invalid, illegal, or unenforceable, such holding will not affect the legality, validity, or enforceability of the remaining parts, and each provision of the FAIR Program and this agreement will be valid, legal, and enforceable to the fullest extent permitted by law. However, in the event the provision prohibiting class, collective, or representative actions is found to be unlawful or unenforceable, then the entire FAIR Program and this agreement will be considered null and void.

Notices. Any notice required to be given to You will be directed to Your last known address as reflected in the records of the Agency. Any notice required to be given to the Agency will be directed to the Agency's principal location in Brooklyn, New York.

Amendment. The Agency reserves the right to amend or terminate the FAIR Program. Such amendments may be made by providing notice to You, electronically or otherwise, of such amendment or termination. Your continuation of employment after receiving notice of any amendment to or termination of the FAIR Program will be deemed agreement to such amendment or termination.

Waiver. No waiver may be granted by either party, except in writing. No waiver of any provision of the FAIR Program will constitute a waiver of any other provision of the FAIR Program (whether or not similar), nor will such waiver constitute a continuing waiver unless otherwise expressly provided in such writing.

By signing below, You confirm that You have read and understand the terms and conditions of the FAIR Program, which require You to submit all Claims to binding arbitration on an individual basis.

PRINT EMPLOYEE NAME
EMPLOYEE SIGNATURE
Date:
08-20-2020

120 DAYS HHA PERFORMANCE REVIEW
BY: Staffing Coordinator ONLY

EmployeeLast Name
First Name
cc #
JOB TITLE:
HHA/PCA
Rating:NI=Needs ImprovementS = SatisfactoryVG=Very GoodE=Excellent
Longevity on assignments☐ NI☐ S☐ VG☐ E
Informs Staffing Coordinator of changes in schedule in a timely manner,
including client appointm ents or overtime."
☐ NI☐ S☐ VG☐ E
Accepts assignments to meet the needs of the program.☐ NI☐ S☐ VG☐ E
Uses HHA EXCHANGE for recording time appropriately.☐ NI☐ S☐ VG☐ E
Inputs tasks as required.☐ NI☐ S☐ VG☐ E
Reports incidents in a timely manner.☐ NI☐ S☐ VG☐ E
Calls for replacements in a timely manner.☐ NI☐ S☐ VG☐ E
Appearance is appropriate.☐ NI☐ S☐ VG☐ E
Demonstrates concern for assigned clients' well being.☐ NI☐ S☐ VG☐ E
Attends sched uled appointments including medical,in-service and competency."☐ NI☐ S☐ VG☐ E
Works alternate weekend.☐ NI☐ S☐ VG☐ E
Overall attendance (call outs/cancellations)☐ NI☐ S☐ VG☐ E
Punctuality☐ NI☐ S☐ VG☐ E
Works well with other staffing coordinators☐ NI☐ S☐ VG☐ E

Additional Comments :

Employee Comments :

Employee Signature
Date:
08-20-2020
Supervisor Signature
Date:
08-20-2020

HHA/ PCA Initial Competency

Home Health Aide Name:

Competency Assessment Method
D = Direct Observation and/or Demonstration
0 = Oral Question and Answer
(Circle the appropriate method below)
SkillsSupervisor Assessment MethodSupervisor Evaluation Competency
Understand/Follow Plan of CareD or O☐  MET   ☐  NOT MET
Observation, reporting and documentation of patient
status and the care of services provided
D or O☐  MET   ☐  NOT MET
Reading and recording temperature, pulse and respirationD or O☐  MET   ☐  NOT MET
Universal Precautions (Standard Prec, Handwashing)D or O☐  MET   ☐  NOT MET
PPE, TB, HEB B , HIV and Infection ControlD or O☐  MET   ☐  NOT MET
Follows HIPAA and HIV confidentialityD or O☐  MET   ☐  NOT MET
Understands PT Rights and Adv. DirectivesD or O☐  MET   ☐  NOT MET
Follows Emergency ProceduresD or O☐  MET   ☐  NOT MET
Assists with MedicationD or O☐  MET   ☐  NOT MET
Basic elements of body functions and changes in condition that must be reportedD or O☐  MET   ☐  NOT MET
Maintainig a clean,safe and health environmentD or O☐  MET   ☐  NOT MET
Ability to recognize emergency situationsD or O☐  MET   ☐  NOT MET
Ability to recognize physical and emotional needs and client and respect the pt's privacy and propertyD or O☐  MET   ☐  NOT MET
Appropriate and safe techniques in personal hygiene and grooming:
Bed BathD or O☐  MET   ☐  NOT MET
Sponge Bath, Tub, ShowerD or O☐  MET   ☐  NOT MET
Shampoo (sink, tub or bed)D or O☐  MET   ☐  NOT MET
Nail CareD or O☐  MET   ☐  NOT MET
Skin CareD or O☐  MET   ☐  NOT MET
Oral HygieneD or O☐  MET   ☐  NOT MET
Toileting and elimination (Bedpan, Diaper,CommodeD or O☐  MET   ☐  NOT MET
Safe transfer techniquesD or O☐  MET   ☐  NOT MET
Safe Ambulation (Wheelchair,Walker, CaneD or O☐  MET   ☐  NOT MET
Ability to recognize adequate nutrition and intakeD or O☐  MET   ☐  NOT MET
Position/Prevent BedsoresD or O☐  MET   ☐  NOT MET
Range of MotionD or O☐  MET   ☐  NOT MET
Hoyer LiftD or O☐  MET   ☐  NOT MET
Home Health Aide Signature
Date:
08-20-2020
Supervisor's Signature
Date:
08-20-2020

ORIENTATION CHECKLIST

Name:
Angrew
SS#:
wewew
TitIe:
we22323

Welcome to 24/7 HomeCare Agency

ATax Forms from TAXOAYESNON/A
B1-9 Form, Wage form, W-4
CEmployee Handbook
1.Employment Requirements and Agency Policies
2.Continuous Employment
3.Job Description
4.HIV Confidentiality Policy
5.Infection Control. Universal Precaution
6.TB Policy/Precautions
7.Emergency Disaster Preparedness
8.HIPAA/Privacy Rights
9.Required E V V, (clock in/out)
10.Case Acceptance
11.Absences and Lateness Policy
12.Patient Abandonment Policy
13.No Call No Show Policy
14.Dress Code
15.Cellular/Wireless Device Policy
16.Employee Counseling
17.Grievances/Complaints
18.Equal Employment Opportunity Policy
19. Pregnancy Accommodations
20. Anti-Harassment Policy
21.Sexual Harassment Policy
22.Protection Against Retaliation
DCode of Conduct
ea. Fraud and Abus
b. Professional Standard
c. Confidentiality
EHHA/PCA Activity -- DUTY CODES/Timesheets
FHHA Exchange App
GPicture IDs
HMissing Documentation from Application Process

I have read my job description and understand that I will be evaluated based on the performance criteria in my job description. I acknowledge having completed all of the orientation in service curriculum.

Home Health Aide Signature
Date:
08-20-2020
Supervisor's Signature
Date:
08-20-2020