I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above form all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.

To Whom it May Concern:

The applicant named below has submitted an application with our firm. Please verify employment and rate the performance for this candidate. This information will not be given to the employee.

Authorization Release: I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

To Whom it May Concern:

The applicant named below has submitted an application with our firm. Please verify employment and rate the performance for this candidate. This information will not be given to the employee.

Authorization Release: I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

To Whom it May Concern:

The applicant named below has submitted an application with our firm. Please verify employment and rate the performance for this candidate. This information will not be given to the employee.

Authorization Release: I hereby authorize the following information to be released for all previous employers listed. I release you and all persons and organizations from all claims and liabilities of any nature from any information given.

*Please notify Perfect Choice Home Care immediately if any of the emergency contact information changes.

TITLE OF IMMEDIATE SUPERVISOR: AGENCY MANAGER / SUPERVISOR
RISK OF EXPOSURE TO BLOODBORNE PATHOGENS – HIGH

POSITION RESPONSIBILITIES

I. Follows the plan of care to help the client to maintain good personal hygiene and maintain a healthful, safe environment, is to perform ONLY those functions specified for each individual client. Agrees to carry-out outcomes included in the clients service plan; II. Receives written instructions from the Office Manager/Supervisor regarding client’s service plan. III. Has knowledge of agency policies and procedures. Complies with agency in-service requirements. IV. Is oriented and trained in all aspects of care to be provided to client per client’s service plan. V. Ability to demonstrate competency in all areas of training for a direct care worker, including: 1. HIPPA and Confidentiality. 2. Consumer control and the independent living philosophy. 3. Basic infection control. 4. Universal precautions. 5. Handling of emergencies. 6. Recognizing and reporting abuse, neglect and exploitation. 7. Dealing with difficult behaviors. 8. Falls and accident prevention. VI. Personal Care Assistant (PCA) / Direct Care Workers (DCW) may assist clients with the following activities: a. Self-administration of medications for consumers who are competent to direct the care b. Housekeeping c. Personal care including grooming and dressing d. Meal preparation, eating and feeding e. Oral hygiene and denture care f. Toileting and toilet hygiene g. I ADL assistance h. Assistance with ambulation and transferring i. Administering emergency first aid j. Providing or arranging for social interaction k. Providing transportation assistance l. Specialized care – non-skilled services unique to the client’s care needs that facilitate the client’s health, safety and welfare, and ability to live independently VII. Documents observations and services in the individual client record day of visit using telephony system. VIII. Follows agency hand hygiene and Infection control policies. IX. Reports any change in the client’s mental or physical condition or in the home situation to his/her immediate supervisor or Agency Manager.

JOB CONDITIONS	• Able to drive or access public transportation along with the ability to access clients’ homes which may not be routinely wheelchair accessible is required. • Hearing, eyesight and physical dexterity must be sufficient to perform a physical assessment of the client’s condition and to perform client care/services. • On occasion, may be required to bend, stoop, reach and move client weight up to 250 pounds; lift and/or carry up to 30 pounds. • Must be able to communicate clearly, both verbally and in writing in English.
EQUIPMENT OPERATION	Hand washing materials. Able to manipulate medical assistive devices: walkers, wheelchairs, hospital beds.
COMPANY INFORMATION	Has access to client medical records which may be discussed with the Supervisor.
QUALIFICATIONS	PCA/DCW will be 18 years of age or older. Completion of at least the ninth grade; preferably a High School diploma or equivalent. Possess basic math, reading and writing skills. Completed one of the following: 1. Obtained a valid nurse's license in PA; or 2. Demonstrated competency by passing a competency exam developed by the home care agency which meets PA state regulation; or 3. Completed one of the following: a. A training program developed by a home care agency, home care registry, or other entity which meets the requirement of PA regulation for training. b. A home health aide training program meeting the requirements of 42 CFR 484.36 (relating to the conditions of participation; home health aide services). c. The nurse aide certification and training program sponsored by the PA Department of Education and located at this link. d. A training program meeting the training standards imposed on the agency or registry by virtue of the agency’s or registry’s participation as a provider in a Medicaid Waiver or other publicly funded program providing home and community based services to qualifying clients. e. Another program identified by the Department by subsequent publication in the Pennsylvania Bulletin or on the Department’s website.
	2. Must be free from health problems that may be injurious to client, self, and co-workers and must present appropriate evidence to substantiate per agency policy.
	3. Must comprehend the basics of personal care, housekeeping, meal preparation, and successfully complete the competencies.
	4. Must understand and respect client’s choices including ethics and confidentiality of care.
	5. Must pass a criminal background check and other checks as required by PA regulation.

hereby acknowledge the orientation and review of the subject items listed below:

• Agency Mission, Vision and Plan & Organizational Chart.
• Advanced Directives.
• Types of Care Provided by the Agency including information provided to consumers regarding charges.
• Policies & Procedures; HIPAA; TB.
• Personnel Policies, Job Descriptions & Professional Boundaries of All Disciplines; completion of in-services required at orientation.
• Training specific to job descriptions and mandatory in-services.
• Cultural diversity.
• Consumer Rights and Grievance Policy.
• Ethics, Conflict of Interest & Confidentiality of Consumer Information.
• Supervision & Evaluation.
• Home Safety (including Bathroom, Electrical, Environment, Fire and Hazards)
• Safety Issues in the home (including security and guns in the home).
• Emergency Preparedness Plan / Actions to take in the event of a disaster.
• Action to take in unsafe situations.
• OSHA Requirements, Safety & Infection Control in the Home / Standard Precaution.
• Consumer Care Responsibilities including charges for service / care.
• Incidence and occurrence reporting.
• Understanding and coping with Alzheimer’s Disease and Dementia.
• Identifying and Reporting abuse, Neglect and Exploitation.
• Fraud / Abuse / Corporate Compliance, False Claims, False Statements, Whistle Blowing.
• Community Resources.
• Quality Assurance.
• Documentation – Record Keeping.
• Photo ID Issued.
• Medical Device / Hazards Reporting.
• Exposure Control Plan.

hereby acknowledge the orientation and review of the subject items listed below:

• Review of all Agency policies and procedures related to new job duties.
• Review of Federal, and State regulations.
• Review confidentiality of consumer information.
• Review contracts for all programs, agencies and individuals related to new job duties.
• Review employee benefits.
• Review infection control, safety and disaster programs.
• Consult with and observe other staff in the same job classification regarding consumer job issues.
• Review implementation of consumer goals and objectives.
• Ensuring safe and effective services to consumers and families.
• Establishing and maintaining effective lines of communication.
• Practicing staff development including orientation, in-service education, and continuing education.
• Following job description and performance of duties.
• Implementing and evaluating consumer care services related to new job.
• Participating in selective in-service programs related to new job.
• Encouraging staff participation and problem solving.
• Performing other duties as assigned by the Administrator.

I have read, understand and agree to the terms specified in this job description for the position I presently hold. A copy of this job description has been given to me.

I further understand that this job description may be reviewed at any time and that I will be provided with a revised copy.

The corporate compliance statement provided below is to be acknowledged and signed by every agency employee as well as every employee working for the agency on a contractual basis.

Acknowledgement of Receipt and Understanding.

As you know, our Home Care Agency and our Staff members have always been committed to providing exceptional health care and upholding ethical conduct standards and legal compliance.

Our policy formally and clearly states that there is a zero tolerance to any form of fraud or misconduct. This Agency believes that every employee or agent plays a key and active role in maintaining its image and reputation.

I hereby acknowledge that I have apprised of and agree to comply with the Agency’s Corporate Compliance Policy. I understand that in no way does this create an obligation or contract of employment and that I, as well as the Agency, have the right to end the employment relationship at any time.

It is both the Agency’s and the employee’s responsibility to ensure that every consumer’s health information is protected at all times. By signing below, you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency’s policy regarding consumer’s Protected Health Information will be provided to you upon hire.

I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated for use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations. I agree to protect all Electronic Medical Records including passwords as outlined in the HIPAA policy.

There are specific guidelines to ensure consumer’s Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure consumer’s records are protected by enforcing the following measures:

• Consumer Protected Health Information will be transported in a protected travel chart when traveling.
• When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area.
• Consumer Protected Health Information will be returned to the agency upon acknowledgement of the consumer being discharged.

I pledge to make every effort to keep consumer’s Protected Health Information protected at all times.

(Employee), the undersigned Employee hereby agrees not to directly or indirectly use, manipulate or copy compete any Protected Health Information (PHI), to include personal health information or personal contact information (address, phone, email address, etc.) with the business of the Agency and its successors and assigns during the period of employment. Misuse of PHI or personal contact information will result in termination and report with action to HIPAA federal agencies. Fines related to civil and criminal offences for gross misconduct with the above information are the direct responsibility of said employee.

The Employee acknowledges that the Agency shall or may in reliance of this agreement provide Employee access to trade secrets, customers and other confidential data and good will. Employee agrees to retain said information as confidential and not to use said information on his or her own behalf or disclose same to any third party or for their own personal or monetary gain.

The Employee agrees to not copy and to return all such Agency supplied Information immediately upon termination of employment. Further employee agrees not to solicit any of the customers or employees of employer for any purpose for a period of two years after termination.

This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.

This Agency requires adherence to the following Standards and Procedures:

1- All employees are expected to dress in a manner appropriate to the health care environment, or as directed by the consumer’s family. This includes personal hygiene, jewelry, hair and makeup.
2- Please do not smoke in the presence of a consumer.
3- Always wear your ID Badge.
4- You are expected to arrive on time to all assignment that you have accepted. However, if an emergency or any situation should cause you to be five minutes late, or more or to be totally absent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOUR CONSUMER DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION!
5- If you have any problem, incident or accident on the job, do not discuss it with the consumer, but call the Agency immediately.
6- If the consumer asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval.
7- Paraprofessional personnel (i.e. Aides) hereby acknowledge that they WILL NOT, UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION.
8- UNDER NO CIRCUMSTANCES are you to ask for, or accept any money from your consumer or take-home property that belongs to the consumer.
9- There shall not be any involvement with the consumer’s financial affairs (i.e. check writing).
10- You are expected to honor the confidentiality of any consumer information which is obtained in the regular course of your employment.
11- No personal telephone calls should be made or received by you while on assignment.
12- Please do not discuss your pay or any other personal affairs with the consumer family.
13- As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your consumer's family. If you are requested to do so, please have the consumer contact us.
14- It is imperative that all signed notes and documentation including Daily Log, be filled out properly and returned to the office as per our schedule. If the consumer is unable to sign your note, a family member or responsible party may sign.
15- During the course of employment, this Agency’s proprietary materials (i.e forms, medical records) will be used only in connection with employment and will not be disclosed to anyone without authorization from the Agency.

The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition.

The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, consumers and the Agency business.

The Employee will have access to information not generally made available to the public, such as identity of consumers, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency’s own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies. (During the course of employment and for a twelve month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any consumer or entity to discontinue any relationship with the Agency, solicit any consumer of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source.)

Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency’s property including keys, consumer records, forms, manual, beeper, etc. to the Agency and will not retain copies.

Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc. suffered by the Agency. Employee will be required to reimburse the Agency for all legal fees, cost and other expenses.

This agreement is in effect during the Employee’s employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy.

understand that copies of policy and procedure manuals are available and that it is my responsibility to read, understand and conform to all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions.

I have read the Agency’s Policy and Procedure on Abuse, Neglect and Exploitation and agree to Comply with and am bound by the Policy.

I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor it is an expression of my term of employment.

I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and that I am required to follow all Agency requirements and state and local laws,

I understand that only the Agency has the authority to admit consumers and will supervise with appropriate personnel all services provided.

As a caregiver, I will carry out the plan of treatment, submit time sheets, clinical and progress notes as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic consumer evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meeting and inservice training. Home health aides are required to have 12 hours of inservice training annually.

I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding consumer and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease: testing, results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under specific law. All information in connection with the examination, care or provision of services to any consumer will not be disclosed without the individual’s written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of consumer / employee confidentiality is subject to civil and criminal penalties.

If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will.

I understand a Personal Protective Equipment (PPE Kit) is available in the office and contains the following:

- Barrier Safety Goggles
- CPR Shield Face Barrier
- Fluid Resistant Gown
- Gloves
- Biohazard Bag
- Sharps Container
- 3M Respirator Mask (N95 or similar type)

I have been instructed in the use of this equipment, understand that I must comply with Policies and Procedures regarding use of personal protective equipment. I understand that I am responsible for contacting the agency for replacement of used equipment.

hereby attest that the state of my health is such that it will enable me to perform the duties of a health care professional. I further specifically attest that I am free of all potentially contagious diseases including, but not limited to those listed below:

AIDS	Anthrax	Chickenpox	Cholera
COVID 19	Diphtheria	Encephalitis	Hepatitis, Types A, B and C
Influenza / Flu	Leprosy (Hansen’s Disease)	Leptospirosis	Malaria
Measles (Rubeola)	Meningitis	Mononucleosis	Mumps
Plague	Poliomyelitis	Psittacosis (Ornithosis)	Rabies
Rocky Mountain Spotted Fever	Rubella (German Measles)	Shigellosis	Smallpox
Tetanus	Tularemia	Tuberculosis	Typhoid Fever
Whooping Cough

I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of exposure or have been unknowingly exposed to the hepatitis B virus (HBV) as a result of my employment. I have read the information sheet concerning the disease, the vaccine, and possible adverse reactions to the infection. Additionally, I have asked questions which I may have had and they have been answered fully to my satisfaction. I hereby make the decision to:

o Provide written proof of immunity (attach positive documentation)
o Provide written proof of previous vaccination (attach supportive documentation)
o Provide written proof of medical contraindication (attach supportive documentation)

Perfect Choice Home Cares cell phone policy offers general guidelines for using personal and company cell phones during work hours. The purpose of this policy is to permit personal cell phone use while minimizing distractions, accidents, and frustrations improper cellphone use can cause. Our company expects employees to use their cellphones prudently during working hours.

This policy applies to all agency employees

Despite their benefits, personal cell phones may cause problems in the workplace. Employees who use their cellphones excessively may:

• Get distracted from their work.
• Disturb client by speaking on their phones.
• Cause security issues from inappropriate use
• Cause accidents when they are not paying attention to the client

Cell Phone Use Guidelines:

The following are Perfect Choice Home Cares basic guidelines for proper employee cell phone use during work hours. In general, cell phones should not be used when they could pose a security or safety risk, or when they distract from work tasks.

Agency follows all Federal, State and HIPAA regulations regarding cell phone use.

• Employees will be provided a secure individual password for the Telephony EVV/ Home Health Exchange system along with accessing applications to record assigned client care tasks. Password will not be shared with another individual.
• Do not use cell phones to record confidential client information.
• Client information and photos should not be stored locally on personal or work phone.
• Do not take photos of clients unless permission obtained from Office Manager and signed consent obtained from client or guardian.
• Secured messaging should be used for all texts sent to our agency regarding client information.
• Never use a cell phone while operating equipment.
• Avoid using work cell phones for personal tasks.
• Avoid using cell phones for personal calls, texting and social media apps in client care areas.
• Cell phones should be set to “silent” or “do not disturb” modes during client care Activities.
• Turn off or silence personal phone when asked by client.
• Do not use cell phones during meetings.
• Never use a cell phone while driving on company-related business.

Employees are permitted to use personal cell phones when:

• Work-related communication, such as signing into EVV software, signing into client care EMR to document client care tasks performed during visit, text messaging or emailing, in appropriate places and situations.
• For making or receiving work calls in the appropriate place and situation to do so.
• To schedule and keep track of client appointments.
• To keep track of work tasks or work contacts.
• To carry out work-related research.
• When Telemedecine visit is required.
• During break time, may surf the internet, text and talk on the phone only for a few minutes per day.

Improper use of cell phones may result in disciplinary action. Continued use of cellphones at inappropriate times or in ways that distract from work may lead to having cell phone privileges revoked.

Cell phone usage for illegal or dangerous activity, for purposes of harassment, or in ways that violate the company confidentiality policy may result in employee termination.

Reference Policies: HIPAA, Confidentiality, Telephony Electronic Visit Verification

Acknowledgement: Cell Phone use and Etiquette in the Workplace

By signing below, I acknowledge that I:
1. Have read the guideline and will not use my cell phone for personal use while providing client care.
2. Will be aware of using safe cell phone etiquette in clients home.

Telephony Electronic Visit Verification (EVV) system is used to accurately document time worked providing client's care, electronically verify visit occurred and to submit bills for payment of care.

PERFECT CHOICE HOME CARE uses an Electronic Visit Verification system to verify the caregiver has arrived at client’s location and record clock-in and clock-out. Visit time is reviewed to confirm time is approved and designated in clients care plan. Agency follows all HIPAA, Federal State and local home care regulations.

1. Caregivers will use personal cell phone or the client’s home telephone only to clock into EVV when arriving at the client’s home, which confirms caregivers GPS location, and to clock out upon scheduled shift time ending per hours designated in client’s care plan.
2. Caregivers should contact Office Manager immediately when unable to access EVV system.
3. Falsifying time records, clocking in late or consistently failing to record shift time will be cause for disciplinary action.
4. Employees should report to work no more than five minutes prior to their scheduled starting time and stay no more than five minutes after their scheduled stop time. Working past the scheduled ending time without prior authorization from their supervisor/ Office Manager is not permitted.
5. Employee must record the beginning and ending time of any split shift or departure from work for personal reasons.
6. Overtime work must always be approved by the Office Manager before it is performed. If a client dismisses the caregiver before the end of the shift, the caregiver should report to the office before leaving the client.
7. Altering, falsifying, tampering with time records, or recording time on another employee’s time record may result in disciplinary action, up to and including termination of employment.
8. Office Manager will review the time record before submitting for payroll processing.
9. Agency will not bill for services when client is ineligible to receive a service or authorization for care is terminated.

hereby give permission to Perfect Choice Home Care to obtain information relating to my criminal history record from the Pennsylvania access to criminal history website and or the FBI background check system. The criminal history record may include arrest and conviction data as well as plea bargains, deferred adjudications and delinquent conduct committed as juvenile. The criminal history also could contain information presumed to be expunged.

I understand that this information will be used, in part, to determine my eligibility for employment with this company. I understand that my employment will be considered provisional until the results of the background checks are returned satisfactory to Perfect Choice Home Care period. I agree to random monitoring of my work during my provisional hire. I also understand that, as long as I remain an employee here, the criminal history record check may be repeated at anytime.

I understand that, to the extent required by the federal fair credit reporting act, I will be informed, in writing, if an adverse action is taken in whole or in part based on the results of the criminal background check. I will be given an opportunity to review the criminal background check results upon request by me and submit an explanation and/or clarification if I dispute the record as received.

For applicants who have lived in the state of Pennsylvania for less than two years, an FBI background check with fingerprinting is required.

Note: criminal background reports received by Perfect Choice Home Care will be disclosed only to authorized employees who have a need to know in the performance of their job, or as may be required by law.

By signing this document below, I;
1. Attest that I am not currently excluded or disqualified by any governmental agency from being able to work as a direct care worker; and
2. do, for yourself, my errors, executors and administrators, hereby remiss, release and forever discharge and agree to identify Perfect Choice Home Care and each of their owners, officers, directors, employees and agents and hold them harmless from and against any and all cause of action, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever including claims for negligence, gross negligence and/or strict liability of Perfect Choice Home Care and any and all related attorney fees, court costs and other expenses resulting from the investigation of my background in connection with my application to become an employee or volunteer.

The organization prohibits and does not tolerate sexual abuse in the workplace or in any organization related activity. The organization provides procedures for employees, volunteers, family members, board members, patients, victims of sexual abuse, or others to report sexual abuse and disciplinary penalties for those who commit such acts. No employee, volunteer, patient or third party, no matter his or her title or position has the authority to commit or allow sexual abuse.

The organization has a Zero-Tolerance policy for any sexual abuse committed by an employee, volunteer, board member or third party. Upon completion of the investigation, disciplinary action up to and including termination of employment and criminal prosecution may ensue.

Sexual abuse is inappropriate sexual contact of criminal nature or interaction for gratification of the adult who is a caregiver and responsible for the patient or child’s care. Sexual abuse includes sexual molestation, sexual assault, sexual exploitation, or sexual injury, but does not include sexual harassment. Any incidents of sexual abuse reasonably believed to have occurred will be reportable to appropriate law enforcement agencies and regulatory agencies.

Physical and behavioral evidence or signs that someone is being sexually abused are listed below.

Physical evidence of abuse:

• Difficulty in walking
• Torn, stained or bloody underwear
• Pain or itching in genital area
• Bruises or bleeding of the external genitalia
• Sexually transmitted disease

Behavior signs of sexual abuse:

• Reluctance to be left alone with a particular person
• Wearing lots of clothing especially in bed
• Fear of touch
• Nightmares or fear of night
• Apprehension when sex is brought up

Reporting Procedure:

If you are aware of or suspect sexual abuse taking place, you must immediately report it to your President/CEO or another person you designate such as a human resource person. If the suspected abuse is to an adult, you should report the abuse to your local or state Adult Protective Services (APS) Agency. If it is a child who is the victim, then you should report the suspected abuse to your local or state Child Abuse Agency. If you do not know you state child abuse agency you can call the Child Help’s National Child Abuse Hotline, 1-800-422-4453, TDD 1-800-222-4453. Appropriate family members should be notified of alleged instances of sexual abuse. The organization should report the alleged sexual abuse incident to their insurance agent.

Anti-Retaliation:

The organization prohibits retaliation made against any employee, volunteer, board member or patient who reports a good faith complaint of sexual abuse or who participates in any related investigation. Making false accusations of sexual abuse in bad faith can have serious consequences for those who are wrongly accused. The organization prohibits making false and/or malicious sexual abuse allegations, as well as deliberately providing false information during an investigation. Anyone who violates this rule is subject to disciplinary action, up to and including termination.

Investigation & Follow Up:

The organization will take all allegations of sexual abuse seriously and will promptly and thoroughly investigate whether sexual abuse has taken place. The organization will use an outside third party to conduct an investigation. If the organization has a trained internal investigation team in place, the team will be used to investigate the incident. The organization will cooperate fully with any investigation conducted by law enforcement or other regulatory agencies. It is the organization’s objective to conduct a fair and impartial investigation. The organization provides notice that they have the option of placing the accused on a leave of absence or on reassignment to non-patient contact. The organization will make every reasonable effort to keep the matters involved in the allegation as confidential as possible while still allowing for a prompt and thorough investigation.

Acknowledging Receipt & Understanding of Sexual Abuse Policy:

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

Effective immediately, the following policy will apply to all employees of Perfect Choice Home Care Agency:
1. The effect of drugs and alcohol diminish one’s capacity to make sound decisions, which may lead to an on-the-job injury or effect the safety of other employees and the general public. In order to protect the general public as well as ensure a substance-free workplace, all employees who incur a work injury may be required to submit to a drug/alcohol screening as soon as practical following the injury.
2. The company may also test any individual whose performance could have contributed to the job-related injury. This determination shall be based on the best information available at the time of the accident/injury.
3. For purposes of this policy, an on-the-job injury will be considered any injury which requires medical treatment by a medical professional and will not apply for “report only” injuries. If medical treatment is required at a later date for a report only injury, testing will be required as soon as practical.
4. This policy will apply to injuries sustained as a result of vehicle accident or other reasonable suspicion instances where testing is warranted.
5. An employee who refuses to consent and submit to a test when requested, or who test positive, will be subject to disciplinary action up to and including termination of employment.
6. In no way is this post-accident test requirement intended to delay necessary medical treatment for injured people following an accident or to prohibit an employee from leaving the scene of an accident to obtain medical assistance for others or for personal medical assistance.
7. For new employees, this policy is a condition of employment, and the signature below indicates acknowledgement of the policy.

acknowledge that I have received, read and understand this policy.

understand that as an employee of Perfect Choice Home Care Agency that I am a mandatory reported. As so, I must report any proven or suspected abuse, neglect and exploitation.

Mandatory reporting means that I must report any and all signs of abuse, neglect or exploitation of a client that I see or hear. Reporting will be done by me within 24 hours of learning of the abuse. Neglect or exploitation to:

• Child Protective Services, for children under the 18 years of age.
• Adult Protective Services
• My supervisor at Perfect Choice Home Care Agency
• Local authorities, if there is suspected physical or sexual abuse or fear of imminent harm.

I further understand that I must report all allegations reported to me by a client or any observed signs of abuse, neglect or exploitation, whether I believe them to be true or not.

The signs of abuse, neglect and exploitation, as well as the procedure for making reports have been reviewed and explained to me during the orientation process and I understand my responsibilities as a mandatory reporter.

understand that, at my own discretion, I may use my motor vehicle while providing services for the care of Perfect Choice Home Care Agency clients.

I understand and agree that this is my primary responsibility to provide my own motor vehicle insurance, as required by the state law. I also understand and agree that until I provide Perfect Choice Home Care Agency with a valid proof of a current driver’s license and motor vehicle insurance, I am not, and will not be, authorized to use my own motor vehicle while providing services for any Perfect Choice Home Care Agency client or while on Perfect Choice Home Care Agency business.

I hereby agree to release Perfect Choice Home Care Agency from any and all responsibility for any accident or incident involving any use of motor vehicle, including damage to my motor vehicle, injury to myself or others.

VERIFICATION OF FACE TO FACE INTERVIEW:

RESIDENCE AFFIRMATION & RESIDENCE AUTHORIZATIONS

acknowledge that I have had a face to face in person interview with the representative of Perfect Choice Home Care agency. The type of services that I will be expected to provide, the working conditions, and position responsibilities have been explained to me.

I wish to proceed with my application and authorize the agency to call or write for information on me from the references and from my prior and current employer(s) as listed on my application.

FACE TO FACE INTERVIEW SUMMARY & HIRING STATUS