By execution of this document, I acknowledge that I have been informed by the
Agency and agree that the Agency may conduct a State of Texas criminal history
check. I agree to a search of the Nurse Aide Registry and the Employee
Misconduct Registry prior to employment and at least every 12 months if hired. I
understand that these checks will determine if I have a criminal conviction or
have committed certain conduct that will bar me from employment with this
Agency. I understand that I am unemployable if listed in the NAR or EMR per
TAC §93.3 and TxH&SC Chapter 253.
Criminal History Check: I have informed this agency of all names (i.e., maiden,
aliases) that I have used in the past. I understand that my employment is
pending the results of the criminal history check, and that I may not have face to
face patient contact until results are returned. I will be notified of results.
I acknowledge that if I am found to have been convicted of any other offense(s),
that these offenses may also bar my employment. I understand that all
information obtained by this agency regarding any criminal history will remain
confidential. I certify that the information on this form contains no willful
misrepresentation and that the information given is true and complete to the
best of my knowledge.
Confidentiality: Agency maintains confidentiality of operations, activities, and
business affairs of the Agency and the clients according to 1996, Health
Information Portability and Accountability Act (HIP AA). Due to the nature of our
work, each employee will gain~ directly or indirectly, sensitive and confidential
information on clients/patients and staff members. The health care professional
safeguards the client's right to privacy by judiciously protecting information of a
confidential nature including medical treatment information, diagnosis, medical
records, personal patient information, etc. This information should be shared
only with those persons who, due to their position, have a need to know.
Sensitive or confidential information must never be used as the basis for social
conversation or gossip. If an employee is in doubt as to whether or not certain
information may be shared, s/he should consult with his/her supervisor.
Drug Testing Policy: Agency conducts "on hire and random/for cause" drug
testing on its employees. Agency maintains a drug free workplace policy with
regard to the possession, use, distribution and sale of drugs or alcohol. All
employees are prohibited from the unlawful or unauthorized manufacture,
distribution, dispensing, possession or use of a controlled substance or any
alcoholic beverages while in the workplace or on Company paid time Violation of
this policy can result in disciplinary action, up to and including termination of
employment. I acknowledge I have received a copy of the agency's policy on
Harassment Policy: This agency is committed to providing a work environment
that is free from all forms of discrimination and unlawful harassment including
sexual harassment. This policy applies to all employees including management
personnel. Sexual harassment is any unwelcome sexual advances either explicit
or implicit as a term or condition of employment. Improper behavior may be
verbal, visual, or physical in nature and/or the creation of a hostile environment.
Management will investigate complaints of sexual harassment promptly,
impartially and without fear of retaliation to the employee. An employee should
report the alleged incident immediately and confidentially to the appropriate
manager or Human Resources.
Non Solicitation/Illegal Remuneration: Agency does not reimburse or provide
incentives to physicians, durable equipment providers, family or other referral
entities for patient referrals for home health services. Employees may not solicit
patients for the agency. Employees found in violation of this nonsolicitation
policy will be subject to discipline up to and including termination of
Agency does not discriminate against clients or volunteers
based on age, race, color, religion, military status, gender preference, sex, marital
status, national origin, disability, or source of payment.
Abuse, Neglect, and Exploitation: Agency employees will report suspected
abuse, neglect and/or exploitation to the state departments of both the Texas
Department of Family and Protective Services, the Department of Aging and
Disability Services, and Agency management. Agency employees suspected of
abuse, neglect or exploitation will be suspended immediately, an investigation
will be conducted, and if the investigation validates the claim, the employee will
Workers' Compensation: Agency is a subscriber to workers' compensation
insurance. An employee who incurs an injury on the job that requires emergency
medical treatment or is life threatening should proceed to the nearest emergency
room. Emergency medical treatment (nonlife
threatening) or nonemergency
treatment should be referred to the agency's designated clinic. Notify the agency
of an injury within 24 hours to complete paperwork. Medical expenses for
injuries are covered with the exception of the following: employee's willful intent
to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or
acts of a third party.
Progressive Discipline Policy: Agency utilizes a progressive discipline process in
cases of misconduct or unacceptable performance. This includes verbal
warning, written warning and final warning. Disciplinary action may begin at an
advanced stage of the process or may result in immediate termination based
upon the nature and severity of the offense, employee's past record and other
If you must leave your shift, for any reason, prior to your scheduled time, you
must first contact your office/recruiter, inform them of why you must leave your
shift and remain in the home until an alternative caregiver
is able to receive
report and continue care for your patient. If the parent or guardian of your client
is requesting you leave prior to your scheduled endofshift,
you must contact
the office/recruiter and report the parent’s request.
Pediatric Home Healthcare, LLC
hold each and every employee to a high
standard. If an employee agrees to work a shift with a patient,
Pediatric Home Healthcare, LLC
expects you to show up to the residence 15 minutes prior to start of shift to receive report
and fulfill your obligation to the patient. If an emergency occurs and you cannot
work, it is your responsibility to notify the office at least 6 hours prior to the start
of your shift. If you are ill and cannot work, please notify a recruiter immediately
and you may be asked to present a note from the Physician that treated you. If
you have a transportation problem that arises, notify a recruiter immediately and
we may be able to provide transportation for you. Continued/numerous
absenteeism or tardiness could result in disciplinary action up to and including
termination. A no call/no show for a shift that you have agreed to work will result
in immediate termination of employment with
Pediatric Home Healthcare, LLC .
Mycobacterium Tuberculosis is transmitted by air, carried in droplets that are
created when a person with respiratory TB coughs, sneezes or shouts. TB
Infection occurs when someone inhales the droplet particles containing the
Mycobacterium. A person may have no symptoms, but still have latent TB
infection (LTBI) and may develop TB disease at some point in their lives. TB skin
tests may become positive in 2 to 12 weeks after the exposure. The following
criteria is utilized to identify if an employee has potential TB. This criteria is also
utilized to determine if an employee needs another chest xray.
This information is also presented in training. Do you have any of the following Potential active
symptoms of TB which include but limited to: Persistent cough greater than 2
weeks duration, Bloody sputum, Hoarseness, Fatigue, Chest pain, Night sweats,
Weight loss, Anorexia, or Fever?
Do you consider yourself part of any of the following groups that have a higher
prevalence of TB infection? 1. Medically underserved populations 2. Homeless
individuals 3. Current or past prison inmates 4. Alcoholics 5. Injecting drug users
6. Elderly 7. Foreignborn
persons from Asia, Africa, the Caribbean and Latin
America 8. Contacts to individuals with TB 9. Groups with a greater risk to
progress from latent TB infection to active disease 10. Individuals with HIV
infection, silicosis, SIP gastrectomy or jejunoileal
bypass surgery, greater than 10 lb. Below normal body weight, chronic renal failure, diabetes mellitus,
immunosuppressed due to medication, and those with some malignancies. 11.
Individuals who have been infected within the past 2 years and individuals with
fibrotic lung disease on chest xray.
By initialing this box, I have reviewed the signs and symptoms of TB. I am not
experiencing symptoms of TB. I understand if I experience any of the above
symptoms I am to report to management immediately.