Medical Social Worker Application Form

Equal Employment Opportunity:

While many employers are required by federal law to have an Affirmative Action Program, all employers are required to provide equal employment opportunity and may ask your national origin, race and sex for planning and reporting purposes only. This information is optional and failure to provide it will have no effect on your application for employment.

We are an Equal Opportunity Employer and fully subscribe to the principles of Equal Employment Opportunity. Applicants and/or employees are considered for hire, promotion and job status, without regard to race, color, religion, creed, sex, marital status, national origin, and age, physical or mental disability.

Personal Information

Areas of Coverage

Education & Training

Skills and Qualifications

Professional Licenses:

Applicants applying for positions that require a Professional license must have a current Commonwealth of Virginia license, unless otherwise noted on position description. Please attach a copy with your application.

Nonprofessional Licenses or Certificates, including a valid Driver’s License (List below)

Employment History

Starting with your PRESENT or MOST RECENT EMPLOYER list in consecutive order ALL EMPLOYMENT for at least the past three employers.

Employment Reference Authorization and Release of Information

I authorize BeattyCare Home Health Services and/or its agents to contact any former employers, educational institutions, and certifying and/or licensing entities listed on this application for the purposes of employment and if hired, promotion.
I further agree to release this practice, and those previous employers or institutions which provide references regarding my work and academic practices, from all liability regarding this verification process.

A photocopy of this authorization and waiver shall be considered as legally valid as the original and may be sent to former employers as a statement of my intent to hold them harmless for the results of references given.

I certify that I have truthfully and accurately completed the employment application and that I have read and do understand this statement of authorization, release and waiver.

Emergency Contact

Fair Credit Reporting Act Disclosure and Authorization Statement

In connection with my application and or/continued employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance and experience, along with reason for termination with past employment. I understand that as directed by BeattyCare Home Health Services policy and consistent with the job described, you may be requesting information from public and private sources about my: COURT RECORDS, DRIVING RECORDS, WORKERS’ COMPENSATION INJURIES, EDUCATION, CREDENTIALS, CREDIT AND/OR REFERENCES.

Medical and Workers’ Compensation information will only be requested in compliance with the Federal Americans with Disabilities Act and /or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my perspective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the Source that provided the information.

I acknowledge that a facsimile or photographic copy shall be valid as the original. This release is valid for most federal, state and county agencies.

Your personal information is used and required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purpose. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by an agent of BeattyCare Home Health Services to furnish the information described. I hereby release BeattyCare Home Health Services, and all persons, agencies, and entities providing information or reports about me from all liability arising from the request for, or release of, any of the mentioned information or reports.

Non-Compete Statement

If hired, I agree not to accept employment (whether temporary or permanent, full-time or part-time) from or on behalf of any person who is or was a client of BeattyCare Home Health Services. This restriction shall apply only to employment for the provision of services like those offered by the Agency and shall be in effect for a period of one year following termination of employment. In the event of a breach of this restrictive covenant the employee shall pay to the Agency (or have his/her new employer pay on his/her behalf) liquidated damages in the nature of a placement fee in the amount of $2,500.

At-Will Employment Statement

Your employment with BeattyCare Home Health Services is a voluntary one and is subject to termination by you or BeattyCare Home Health Services at will, with or without cause, and with or without notice, at any time. Nothing in Beatty Care Home Health Services policies shall be interpreted to conflict with or to eliminate or modify in any way the employmentat-will status of BeattyCare Home Health Services employees. This policy of employment-at-will may not be modified by any officer or employee and shall not be modified in any publication or document. The only exception to this policy is a written employment agreement approved at the discretion of the President or the Board of Directors, whichever is applicable. These personnel policies are not intended to be a contract of employment or a legal document.

HIPAA Privacy Rule Employee Confidentiality Statement & Acknowledgement

I have read and understand BeattyCare Home Health Services policies regarding the privacy of individually identifiable protected health information (PHI), as mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the state of Virginia. In addition, I acknowledge that I have received training in policies concerning PHI use, disclosure, storage and destruction as required by HIPAA.

In consideration of my employment or compensation from, I hereby agree that I will not at any time – either during my employment or association with or after my employment or association ends – use, access or disclose PHI to any person or entity, internally or externally, except as is required and permitted in the course of my duties and responsibilities, as set forth in privacy policy and procedures or as permitted under HIPAA. I understand that this obligation extends to any PHI that I may require during the course of my employment or association with BeattyCare Home Health Services, whether in oral, written or electronic form and regardless of the manner in which access was obtained.

I understand and acknowledge my responsibility to apply BeattyCare Home Health Services policies and procedures during my employment or association. I also understand that unauthorized use or disclosure of PHI will result in disciplinary action, up to and including termination of employment or association with BeattyCare Home Health Services and the imposition of civil penalties and criminal penalties under applicable federal and state law, as well as professional disciplinary action as appropriate.

I understand that this obligation will survive the termination of my employment or end of my association with BeattyCare Home Health Services, regardless of the reason of such termination.

CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION

It is both the Agency’s and the employee’s responsibility to ensure that every patient’s health information is protected at all times. By signing below, you are indicating the acknowledgment of HIPAA and understand that a thorough orientation of the agency’s policy regarding patient’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.

PROTECTION OF HEALTH INFORMATION

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

• Patient 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.
• Patient Protected Health Information will be returned to the agency upon acknowledgment of the patient being discharged.

I always pledge to make every effort to keep patient’s Protected Health Information protected.

Corporate Compliance Policy

Acknowledgment of Receipt and Understanding

As you know, our 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 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

Employee Policies & Procedures

I 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 is it 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 conductions 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 patients 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 planes of care, periodic patient 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 in-service training.

I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures required 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 patient 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 patient 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 statisti8cal or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of patient/ 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 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 tis discretion. I understand that this company is an “At Will” organization and may hire or fire at will.

Employee Policies & Procedures

I 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 is it 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 conductions 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 patients 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 planes of care, periodic patient 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 in-service training.

I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures required 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 patient 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 patient 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 statisti8cal or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of patient/ 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 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 tis discretion. I understand that this company is an “At Will” organization and may hire or fire at will.

Field Employee Standards & Procedures

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 patient/family. This included personal hygiene, jewelry, hair and makeup.
2. Please do not smoke in the presences of a patient.
3. Always wear you photo 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 assent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOU PATIENT 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 patient, but call the Agency immediately.
6. If the patient 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 patient or take home any property that belongs to the patient.
9. There shall not be any involvement with the patient’s financial affairs (i.e. check writing).
10. You are expected to honor the confidentiality of any patient 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 you pay or any other personal affairs with the patient/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 patient/family. If you are requested to do so, please have the patient contact us.
14. It is important that all signed notes and documentation including Daily Log, be filled out properly and returned to the office as per our schedule. If the patient is unable to sign your note, a family member or responsible party may sign.
15. During employment, this Agency’s proprietary materials (i.e. forms, medical records) will be used only in connection with patient employment and will not be disclosed to anyone without authorization from the Agency.

Personal Protective Equipment for Safety and Infection Control Acknowledgement

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 purchased from Ullin.com)


I have been instructed in the use of this equipment and understand that I must comply with Policies and Procedures regarding use of personal protective equipment.

Signature Attestation

The Signature Attestation statement identifies the author associated with initials or illegible signature.

The signature of physicians and staff who document on patient charts will then be able to be identified as per federal, state and accreditation requirements.

I do hereby attest that this information and below signature is mine, true, accurate, and complete

ELECTRONIC DOCUMENTATION AND SIGNATURE AUTHENTICITY AGREEMENT

I understand that Agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system.

For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge my use of the Signature Passcode and my Login authentication password will serve as my legal signature. I further understand that the Administrator issues employee passwords and the Signature Passcode’s are issued by the software application.

Signature Passcodes and passwords will be changed on an as needed basis if system security is breached. I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. (OASIS Comprehensive Assessments will not require electronic signature until required information is obtained, which may be up to five days after the corresponding MO date i.e.: MOO30, MOO32 etc.) I understand that: I cannot divulge my login password, Signature Passcode, I must exit the computerized application at the end of each working day or whenever the computer is not in my immediate possession, I must type in (rather than save) the login password that allows me access to the agency computer network, and my Signature Passcode. I must review all my documentation online prior to submitting to the agency server.

Applicant’s Acknowledgement

I certify that the facts set forth in this application for employment are true and complete to the best of my knowledge.
I understand that if I am employed, false statements may result in immediate termination. I authorize BeattyCare Home Health Services to conduct an investigation of any of the facts set forth in this application. I authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

I understand BeattyCare Home Health Services, is a Drug-Free Workplace. Should I be offered a position, I may be asked to submit to a drug test prior to, and during employment. A positive testing result now or in the future may disqualify me from employment.

I understand and agree to terms and information shown above.

Acknowledgement

I have received my job description. The Director of Nursing or his/her representative has reviewed and explained to BeattyCare Home Health Services policies and procedures. I further understand that if I need further information about the stated policies and procedures I, on my own time can review The Agency’s written policy and procedure manual.

I____________________________________ have read and understand BeattyCare Home Health Services policies and procedure. I fully understand and agree to all the terms of this agreement.

Coverage Areas and Availability Form

Areas of Coverage

SWORN DISCLOSURE STATEMENT OR AFFIRMATION

To the Applicant:

Sections 32.1-162.9:1 of the Code of Virginia require that any person desiring work at a licensed home care organization provide the Commissioner’s representative with a sworn disclosure or affirmation disclosing (1) whether the applicant has a criminal conviction or is the subject of any pending criminal charges within or outside The Commonwealth of Virginia, and (2) whether the applicant has been the subject of a founded complaint of child abuse or neglect within or outside the Commonwealth of Virginia.

Any person making a false statement on this form regarding any criminal offense shall be guilty upon conviction of a Class 1 misdemeanor.

Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.

I hereby affirm that the information provided on this form is true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part to any employment offered by this facility. I understand that all information on this form is subject to verification.

REFERENCE CHECK FORM

________________________________ has applied for employment with BeattyCare Home Health Services and has indicated that they have worked for you and you are willing to provide a reference for them. Please rate the following Performance areas by circling the number best describing their job performance

Agency Representative Verification completed by:

TB TARGETED MEDICAL QUESTIONNAIRE FORM

If the answer is YES, please answer the following:

HEPATITIS VACCINE REQUIRMENT

I,______________________________________ acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself. It is my decision to:

HEALTH STATEMENT

I, _________________________________________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 any and all potentially contagious diseases including, but not limited to those listed below:

Influenza Vaccination Employee Statement

I____________________________ am aware of BeattyCare Home Health Services influenza (flu) policy and have had a chance to have my questions answered about influenza vaccination. I understand the benefits and risks of the vaccine, and:

ACKNOWLEDGEMENT OF MANDATED REPORTER STATUS

(This is an optional form for employers of mandated reporters to document that their employees have been notified of their mandated reporter status. An acknowledgement form developed by the employer is also acceptable. If this form is used, page one should be retained by the employer. Page two listing indicators of adult abuse, neglect and exploitation should be retained by the employee).

I____________________________, understand that when I am employed as a ____________________________

I am a mandated reporter pursuant to §§ 63.2-1603 through 1610 of the Code of Virginia. This means that I am required to report or cause a report to be made to Virginia Adult Protective Services (APS) either by calling the APS Hotline (1- 888-83-ADULT) or the appropriate local department of social services whenever I have reason to suspect that an adult age 60 or over or an incapacitated adult age 18 and over and who is known to me in my professional or official capacity may be abused, neglected, or exploited. I understand that I must follow the reporting protocol, if any, of my employer, but my employer may not prohibit me from reporting directly to APS.

I understand that if I suspect a death of an adult age 60 or over or an incapacitated adult age 18 and over occurred due to abuse or neglect, I must report the death to the medical examiner and the law enforcement agency in the locality in which the death occurred.

I understand that I am immune from civil or criminal liability on account of any reports, information, testimony and records I release if the report is made in good faith and without malicious intent. My identity will be held confidential unless I authorize the disclosure or disclosure is ordered by the court.

I understand that if I fail to make a required report of suspected adult abuse, neglect, or exploitation, immediately upon suspicion, I may be subject to a civil money penalty imposed by the Commissioner of the Virginia Department of Social Services. If I am a law-enforcement officer, I understand the money penalty does not apply to me but that I will be referred to the court system for non-reporting of suspected adult abuse, neglect, or exploitation. If I am licensed, certified, or regulated by a health regulatory board, I may also be subject to administrative action or criminal investigation by the appropriate licensing, regulatory, or legal authority.

I understand that there is no charge when calling the Hotline number (1-888-83-ADULT or 1-888-832-3858) and that the Hotline operates 24-hours per day, 7 days per week, 365 days per year.

I affirm that I have read this statement and have knowledge and understanding of the reporting requirements, which apply to me pursuant to §§ 63.2-1603 through 1610 of the Code of Virginia.

Indicators of Adult Abuse, Neglect or Exploitation

Job Acceptance Statement

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.

Orientation Checklist

(Note: See Job-specific Competency Checklist for Skills)

INITIAL ON-SITE COMPETENCY CHECKLIST

Required Documents for hiring/orientation process