Employment Application (HHA/PCA)
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 in this application is complete and true. I understand that if employed, false statements will be a case
As an employee of 24/7 HomeCare 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.
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. 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.
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.
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.
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.
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 live-in 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.
Please complete the following:
For the plan year effective ( 2021-03-01 ) I am waiving coverage for:
☐ 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 coverage name of carrier:
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.
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:
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
☐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.
2414 Ralph Avenue Brooklyn, NY 11234 • T: 718-887-0782 • F: 718-874-2778 • Email: info(g)247nyhomecare.com
Hepatitis B Vaccination Form
I, (print your name)LISA THOMAS 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.
I, LISA THOMAS 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 been given the Complaint Form and contact information if I ever must file a complaint for sexual harassment.
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.
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
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
I LISA THOMAS 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:
I acknowledge that I have received the necessary information and instructions regarding Paid Family Leave benefits.
I LISA THOMAS 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, then 24/7 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 voicemail.
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.
I LISA THOMAS 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:
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.
I LISA THOMAS 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.
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 firstname.lastname@example.org
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.
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.
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 of a nurse, specifically sterile techniques.
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 AND OR EXPERIENCE
High school diploma or general education degree (OED) or equivalent, 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.
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.
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.
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.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.
(Signing this document acknowledges that the job description and responsibilities have been reviewed with me, the employee.)
24/7 HomeCare Agency of NY, Inc
Doing Business As(DBA) name(s) :
2414 Ralph Avenue
Brooklyn, NY 11234
2414 Ralph Avenue
Brooklyn. NY 11234
☐Before a change in pay rates (s), allowances claimed or payday
3.Employee's rate(s) of pay for each type of work or shift:
☐ Tips _________ per hour
☐ Meals _________ per meal
☐ Lodging _________
☐ Other _________
5.Regular payday: Friday
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.
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.
The employee must receive a signed copy of this form. The employer must keep the original for 6 years.
|Last Name||First Name||M.I.|
|Date of Birth (mm/dd/yyyy)||Mother’s Maiden Name||Alias: AKA|
|626 SUTTER AVENUE. APT 3A||BROOKLYN||NY||11207|
|Agency Name: 24/7 Home Care Agency||PFI/Operatinq License Number: 216ZLOO1|
|Print Name of Authorized Person:) LISA THOMAS||Title: PCA|
|Signature of Authorized Person:||Date 03-01-2021|
As an employee of 24/7 HomeCare Agency of NY, Inc, I, LISA THOMAS , 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.
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.
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.
TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.
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
► 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.
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):
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.")
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)
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.
Complete the worksheet on page 4 before making any entries
I certify that I am entitled to the number of withholding allowances claimed on this certificate
Job applicant: Fill in the lines below and check any boxes that apply. Complete only this side.
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.
Please circle the correct answer for the following questions:
Please circle the correct answer for the following questions:
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 Name||24/7 Homecare Agency|
|Address||2414 Ralph Ave|
|City/State/ZIP Code||Brooklyn, NY 11234|
|Name (First/Middle/Last)||LISA, E/ THOMAS|
|Address||626 SUTTER AVENUE, 3A|
|City/State/ZIP Code||BROOKLYN. NEW YORK, 11207|
|Date of Hire||03-01-2021|
I, LISA THOMAS , (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
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 email@example.com. contact 311 (212-NEWYORK outside NYC).
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):
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:
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.
How is the Arbitrator selected? All arbitrators must be licensed attorneys or retired judges selected from the ADR's regional Employment/Commercial Dispute Resolution Roster, or an equivalent list if such list is unavailable. Unless the parties agree otherwise, the arbitrator must be a retired or former Judge or a lawyer who has at least 5 years of experience with employment-related claims. No person may serve as an arbitrator unless that person has confirmed in writing that he or she is bound by and will adhere to the requirements of the FAIR Program.
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.
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.
|Rating:||NI=Needs Improvement||S = Satisfactory||VG=Very Good||E=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 :
|D = Direct Observation and/or Demonstration|
|0 = Oral Question and Answer|
|(Circle the appropriate method below)|
|Skills||Supervisor Assessment Method||Supervisor Evaluation Competency|
|Understand/Follow Plan of Care||D 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 respiration||D or O||☐ MET ☐ NOT MET|
|Universal Precautions (Standard Prec, Handwashing)||D or O||☐ MET ☐ NOT MET|
|PPE, TB, HEB B , HIV and Infection Control||D or O||☐ MET ☐ NOT MET|
|Follows HIPAA and HIV confidentiality||D or O||☐ MET ☐ NOT MET|
|Understands PT Rights and Adv. Directives||D or O||☐ MET ☐ NOT MET|
|Follows Emergency Procedures||D or O||☐ MET ☐ NOT MET|
|Assists with Medication||D or O||☐ MET ☐ NOT MET|
|Basic elements of body functions and changes in condition that must be reported||D or O||☐ MET ☐ NOT MET|
|Maintainig a clean,safe and health environment||D or O||☐ MET ☐ NOT MET|
|Ability to recognize emergency situations||D or O||☐ MET ☐ NOT MET|
|Ability to recognize physical and emotional needs and client and respect the pt's privacy and property||D or O||☐ MET ☐ NOT MET|
|Appropriate and safe techniques in personal hygiene and grooming:|
|Bed Bath||D or O||☐ MET ☐ NOT MET|
|Sponge Bath, Tub, Shower||D or O||☐ MET ☐ NOT MET|
|Shampoo (sink, tub or bed)||D or O||☐ MET ☐ NOT MET|
|Nail Care||D or O||☐ MET ☐ NOT MET|
|Skin Care||D or O||☐ MET ☐ NOT MET|
|Oral Hygiene||D or O||☐ MET ☐ NOT MET|
|Toileting and elimination (Bedpan, Diaper,Commode||D or O||☐ MET ☐ NOT MET|
|Safe transfer techniques||D or O||☐ MET ☐ NOT MET|
|Safe Ambulation (Wheelchair,Walker, Cane||D or O||☐ MET ☐ NOT MET|
|Ability to recognize adequate nutrition and intake||D or O||☐ MET ☐ NOT MET|
|Position/Prevent Bedsores||D or O||☐ MET ☐ NOT MET|
|Range of Motion||D or O||☐ MET ☐ NOT MET|
|Hoyer Lift||D or O||☐ MET ☐ NOT MET|
Welcome to 24/7 HomeCare Agency
|A||Tax Forms from TAXOA||YES||NO||N/A|
|B||1-9 Form, Wage form, W-4||☑||☐||☐|
|1.Employment Requirements and Agency Policies||☐||☐||☐|
|4.HIV Confidentiality Policy||☐||☐||☐|
|5.Infection Control. Universal Precaution||☐||☐||☐|
|7.Emergency Disaster Preparedness||☐||☐||☐|
|9.Required E V V, (clock in/out)||☐||☐||☐|
|11.Absences and Lateness Policy||☐||☐||☐|
|12.Patient Abandonment Policy||☐||☐||☐|
|13.No Call No Show Policy||☐||☐||☐|
|15.Cellular/Wireless Device Policy||☐||☐||☐|
|18.Equal Employment Opportunity Policy||☐||☐||☐|
|19. Pregnancy Accommodations||☐||☐||☐|
|20. Anti-Harassment Policy||☐||☐||☐|
|21.Sexual Harassment Policy||☐||☐||☐|
|22.Protection Against Retaliation||☐||☐||☐|
|D||Code of Conduct||☐||☐||☐|
|E||a. Fraud and Abuse||☐||☐||☐|
|b. Professional Standard||☐||☐||☐|
|F||HHA/PCA Activity -- DUTY CODES/Timesheets||☐||☐||☐|
|G||HHA Exchange App||☐||☐||☐|
|I||Missing 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.