Friendship Care Home Enterprises, LLC

Has applied for employment with our company. Please assist us in making a decision regarding employment that will best benefit this applicant and our organization by providing the requested information below.

I voluntarily give FRIENDSHIP CARE HOME, ENTERPRISES, LLC the right to investigate my past and/or present employment and release from all liability or responsibility by all persons, companies, or organizations supplying information.

have applied for employment or am employed with FRIENDSHIP CARE HOME ENTERPRISES, LLC and understand my duties involve direct contact with an agency consumer. I have informed the agency of all names (maiden, aliases) I have used in the past.

The agency will not employ a person if the agency determines, as a result of a criminal history check, a person has been convicted of an offense listed in this chapter that bars employment or that a conviction is a contraindication to employment with the consumers the facility serves, and if the applicant is a nurse aide, until the facility further verifies that the applicant is listed in the nurse aide registry and verifies that the applicant is listed is not designed in the registry as having a finding entered into the registry concerning abuse, neglect, or mistreatment of a consumer of a facility, or misappropriation of a consumer’s property.

I have not been convicted of the following offenses:

Sec. 250.006. CONVICTIONS BARRING EMPLOYEMENT.

A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:

Chapter 19, Penal Code (criminal homicide);
Chapter 20 Penal Code (kidnapping and unlawful restrain);
Section 21.02 (continuous sexual abuse of young child or children), or Section 21.11, Penal
Code (indecency with a child);
Section 22.011, Penal Code (sexual assault);
Section 22.02, Penal Code (aggravated assault);
Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual);
Section 22.041, Penal Code (abandoning or endangering a child);
Section 22.08, Penal Code (aiding suicide);
Section 25.031, Penal Code (agreement to abduct from custody);
Section 25.08, Penal Code (sale or purchase of a child);
Section 28.02, Penal Code (arson);
Section 29.02, Penal Code (robbery);
Section 29.03, Penal Code (aggravated robbery);
Section 21.08, Penal Code (indecent exposure);
Section 21.12, Penal Code (improper relationship between educator and student);
Section 21.15, Penal Code (improper photography or visual recording);
Section 22.05, Penal Code (deadly conduct);
Section 22.021, Penal Code (aggravated sexual assault);
Section 22.07, Penal Code (terroristic threat);
Section 33.021, Penal Code (online solicitation of a minor);
Section 34.02, Penal Code (money laundering);
Section 35A.02, Penal Code (Medicaid fraud);
Section 42.09, Penal Code (cruelty to animals); or

A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

A person may not be employed in a position the duties of which involve direct contact with a consumer in a facility before the fifth anniversary of the date the person is convicted of:

Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony; Section 30.02, Penal Code (burglary);
Chapter 31, Penal Code (theft), that is punishable as a felony;
Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony;
Section 32.46 Penal Code (securing execution of a document by deception), that is punishable as a Class A misdemeanor or a felony;
Section 37.12, Penal Code (false identification as a peace officer);
Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).

For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), article 42.12, Code of criminal procedure, is not considered convicted of the offense for which the person received on deferred adjudication community supervision.

The agency will review any criminal conviction listed on the DPS report to determine if the conviction(s) meets the criteria as an automatic bar for employment.

If the agency believes a conviction may bar a person from employment in the agency, the agency will notify the applicant or employee/contractor as applicable. The notification will include a statement informing the person he may contact DPS to request an opportunity to be heard concerning the accuracy of the criminal history record information.

A facility shall immediately discharge any employee who is designated in the nurse aide registry or the employee misconduct registry established under Chapter 253 as having committed an act of abuse, neglect, or mistreatment of a consumer of a facility, or misappropriation of a consumer’s property, or whose criminal history check reveals conviction of a crime that bars employment or that the facility determines is a contraindication to employment as provided by this chapter.

The agency may request a criminal history conviction check on unlicensed employees at any time the agency determines appropriate.

I understand the criminal history records and the information they contain will not be released or otherwise disclosed to any person or entity other than myself, except on court order or my written consent.

I certify the information on this form contains no willful misinterpretation and the information given is true and complete to the best of my knowledge.

I certify that the information on this application is correct and I understand that any misrepresentation or omission of any information will result in my disqualification from consideration for employment or, if employed, my dismissal. I understand that this is not a contract, offer, or promise of employment and that if hired I can be terminated at will, with or without cause, with or without notice, at any time and for any reason, at the option of either FRIENDSHIP CARE HOME, ENTERPRISES, LLC or myself. I further understand that no supervisor, manager, official of representative FRIENDSHIP CARE HOME, ENTERPRISES, LLC and its related entities has the authority to enter into an employment contract or make any agreement, orally or in writing, contrary to the forgiving.

FRIENDSHIP CARE HOME, ENTERPRISES, LLC in considering my application for employment may verify the information set forth on this application, related papers or oral interviews and obtains additional background information relating to my background. I authorize all persons, schools, companies, corporations, law enforcement agencies and doctors to supply any information concerning my background that they may have whether or not it’s on their records. I hereby release them and their company from all liability for divulging same. A photographic copy of this authorization shall be valid as the original. If any of my given information is found to be false or misleading, I understand that I will be subject to dismissal at any time during the period of my employment without liability for wages or salary except such as may have been earned at date of such termination and I agree to hold FRIENDSHIP CARE HOME, ENTERPRISES, LLC and persons named herein blameless in that event.

FRIENDSHIP CARE HOME, ENTERPRISES, LLC is an equal opportunity employer and does not discriminate in its recruiting, selecting and hiring procedures because of race, color, gender, religion, national origin, age, sexual orientation or disability status nor does it discriminate with regard to Veteran status.

PLEASE NOTE: REPLACEMENTS OF THE ABOVE ARE AVAILABLE AT THE AGENCY OFFICE. I HEREBY ACKNOWLEDGE RECEIPT OF THE ABOVE PERSONAL PROTECTIVE EQUIPMENT AND UNDERSTAND THAT IF I TERMINATE MY EMPLOYMENT OR IT IS TERMINATED THAT ALL UNUSED ITEMS MUST BE RETURNED TO THE AGENCY PRIOR TO THE ISSUANCE OF MY LAST PAYCHECK OR A FEE OF $20.00 WILL BE DEDUCTED FROM MY LAST PAYCHECK.

Hepatitis B infection is caused by the Hepatitis B virus, which causes death in 1% to 2% of patients. Most people with Hepatitis B recover completely, but approximately 5%to 10% become chronic carriers of the virus. Most of these people have no symptoms, but can continue to transmit the disease to others. The healthcare provider is at increased risk for acquiring this infection.

Hepatitis B vaccine is available and requires three injections for adequate response, although some persons may not develop immunity even after three doses. The duration of immunity is unknown at this time. The vaccine has been tested extensively for safety and efficiency in large-scale clinical trials with human subjects.

Engirex-B is a non-infectious recombinant DNA Hepatitis B vaccine. It contains purified surface antigen of the virus obtained by culturing a genetically engineered yeast cell, which carries the surface antigen gene of the hepatitis B virus. The product contains no more than a 5% yeast protein.

The vaccine side effects are very low. Tenderness and redness of the injection site and low grade fever may occur. Rash, nausea, joint pain and mild fatigue have also been reported. I should not take this vaccine if pregnant or nursing because effects at this time are unknown. I further understand that I should not take this vaccine if pregnant or nursing because effects at this time are unknown. I further understand that I should not take this vaccine if active infection is present, an allergy to this compound is known, or if hypersensitive to yeast.

To be completed by employee/ volunteer:

If the answer is yes, please answer the following:

Before the agency hires or rehires an unlicensed employee whose duties would or do involve face-to-face contact with a client, and on an annual basis thereafter, the agency must search the nurse aide registry (NAR) and the employees misconduct registry (EMR) by searching the DADS’ Employability Status Search Website to verify applicant is not listed with a finding concerning abuse, neglect, or exploitation or mistreatment of a client of an agency or a facility, or misappropriation of a client’s property as required by Texas Health and Safety Code §253.008.

A person listed in the EMR will not be offered employment at this agency.

As required by Texas Health and Safety Code§ 250.003. The agency shall immediately terminate a person’s employment if the agency becomes aware an employee is designated in the NAR or the EMR with:
• A finding concerning abuse, neglect, or exploitation or mistreatment of a client of an agency or a facility, or misappropriation of a client’s property; or
• Whose criminal history check reveals conviction of a crime that bars employment or that the agency determines is a contraindication to employment.

The NAR and EMR report was verified by using DAD’S Employability Status Search website.
Initial Search
Annual Search

1. I have read and agree to follow established agency safety procedures.
2. I agree to report any work-related accident or injury to my supervisor as soon as it occurs, but no later than the end of my duty shift or visit
3. If I need treatment for a work-related injury, I agree to notify my EMPLOYER of the need for the treatment.
4. If my job involves the handling of patients, I agree to enlist assistance, or use mechanical lifting devices for all patients whom I cannot safely handle by myself.
5. I agree to utilize available personal protective equipment (e.g., infection control equipment, biomedical waste disposal items, gait belts and lumbar belt).
6. I agree to maintain valid driver’s license and automobile insurance and to notify my supervisor if at any time the license becomes invalid.
7. I am able to physically and mentally perform my required job duties. If at any time, my situation changes and I am unable to physically or mentally perform my job duties, then I agree to notify my supervisor of this immediately.

Understand that in the performance of my duties, I may possess sensitive and confidential information about patients receiving services from the agency. In recognition of the sensitive nature of this information and the prevailing privacy laws, I agree to abide by the following:
1. If I have a fax machine in my home and receive patient information on the fax, I will place the fax machine in a private location and protect any PHI transmitted to me regarding patients in my care.
2. Upon discharge of a patient, I will return any patient information in my possession to the agency for destruction.
3. In transporting patient information to the patient’s home or to the agency, I understand that I must carry the information in a closed system and in a locked vehicle.

The Agency will respect the patient’s rights to confidentiality of personal and medical information in accordance with applicable state, federal, and HIPAA regulations. All employees will be provided with information during orientation regarding respect for the patient’s privacy and confidentiality of information obtained by the employee during the provision of services and through contact with the client’s medical record. Medical records will be secured at the agency’s office in file cabinets. In the event of agency closure, see Agency Closure policy. All medical records will be limited to the minimum amount necessary to accomplish the stated purpose according to professional judgement. Records will not be removed from the office. The patient’s or designated legal representative’s written consent will be required for the release of information as indicated in the HIPAA privacy guidelines.

A patient data sheet may be kept in the patient’s home for the purpose of communication between all health care providers and family and for quick reference on patient status. Example of items listed might include vital signs, glucose levels, and concerns or problems. The patient and/or authorized family members will be educated by the admitting agent upon admission re: the confidentiality of patient information and the need to protect it from loss or unauthorized use. To ensure confidentiality, any and all patient protected health information transported to and from patient’s homes must be safeguarded according to the agency’s policies, see Transporting of Notes and Other Protected Health Information Policy.

If a patient transfer to another home health agency or healthcare setting, a transfer form will be utilized per policy. Prior to beginning employment, personnel will be requested to sign an “Agreement of Confidentiality” attesting to their understanding of an agreement to maintenance of confidentiality of all protected health information and other privacy and security requirements required by HIPAA.

Understand that in the performance of my duties, I may have contact with sensitive and confidential information about patients’ receiving services from the agency. I will respect each patient’s right to privacy and will hold in confidence any private or medical information of which I may become knowledgeable of in carrying out my assigned duties.

I further understand that I should I fail to honor confidential information about patients, other employees, or the agency, such breach of confidentiality may be cause for my termination of employment with the agency and potentially, expose me to fines and other sanctions defined in the enforcement section of the HIPAA regulations.

This is to verify that today; I have been given training information regarding the Infection and Exposure Control Program.

1.The following policies and procedures, have been presented, reviewed and distributed:

a. Task Classifications
b. Personal Protective Services
c. Universal Precautions
d. Hand-washing
e. Management of Hazardous Materials
f. Management of supplies
g. Bag Procedure
h. Precautions to Protect Patients with Compromised Immunity
i. Respiratory Protection Plan
j. Employee or Contractor (as applicable) Health Requirements
k. Reporting of Employee or Contractor (as applicable) Infections
l. Employee or Contractor (as applicable) Blood borne Pathogens Exposure Evaluation and Post- Exposure Follow-up
m. Reporting and evaluating Patient Infections.
n. Patient Education

2. Information regarding the location of these written policies was provided.

3. I have been given the opportunity to ask questions about the safety guidelines aimed at protecting personnel from blood borne diseases and to have those questions answered.

4. I have received my personnel protective equipment and demonstrated appropriate use.

a. I have read and understand the above statements
b. I have declined because I already have PPE

Subject: ORIENTATION TO PERSONNEL POLICIES

AGENDA ITEMS FOR DISCUSSION:

1. Orientation of all personnel to the policies and objectives of the Agency
2. Periodic Evaluation of employee performance
3. Personnel Policies
4. Disciplinary actions and procedures
5. Job description for position
6. Safety/ Assignment
7. Change in client condition
8. Use of Forms and Documentation
9. Following Care Plan
10. Infection Control
11. HIPAA
12. Universal Precautions & Bio Hazardous Materials
13. Hepatitis B & Blood Pathogens

ACKNOWLEDGE THAT I AM RESPONSIBLE FOR FORMALLY LETTING MY CURRENT EMPLOYER (FRIENDSHIP CARE HOME ENTERPRISES LLC) KNOW TWO WEEKS IN ADVANCE BEFORE RESIGNING FROM THEIR COMPANY LOCATED AT 7457 HARWIN DR SUITE 303K HOUSTON TX 77036.

UNDERSTAND THAT FRIENDSHIP CARE HOME ENTERPRISES LLC DOES NOT PAY OVER-TIME. I ALSO UNDERSTAND THAT MY WAGES AND HOURS ARE STRICTLY STRAIGHT PAY. AGAIN NO OVER TIME WILL BE PAID TO ANY EMPLOYEE.

THIS IS TO NOTIFY YOU THAT OUR AGENCY DOES NOT PROVIDE WORKER’S COMPENSATION INSURANCE. PLEASE SIGN BELOW INDICATING THAT YOU HAVE READ THIS INFORMATION.

THANK YOU FOR YOUR COOPERATION.
ORDERED BY THE MANAGEMENT.

Please be aware that your appointment to provide care to any of our clients is temporary. In the event of loss of contract, Caregivers will be assigned to other clients, if there is an opening. If no client is available, the Caregiver will have to wait until there is an available client for re-assignment.

The PAS Attendant is responsible for providing personal assistance services to the client accordance with the established service plan to enable the client to function in the home and community.

QUALIFICATIONS
As of June 8th 2011 the agency shall employ an attendant who:
A. Is at least 18 years of age or if less than 18 years of age, will be a high school graduate or be enrolled in a vocational educational program.
B. Can NOT be spouse of clients.
C. Be neither legal nor foster parents of minor children who receive the service.
D. Free of communicable disease and open infections, wounds.

Duties and Responsibilities
A. Shall perform services as identified on the service plan.
B. Report to the supervisor on the day of awareness any significant changes in client’s condition.
C. Shall report emergency situations to the appropriate individuals in accordance with the policies immediately upon awareness.
D. Personal care workers shall complete 8 hours of in-service education annually. Homemaker/chore workers shall complete 4 hours of in-service education annually.

Physical/Mental/Essential Function of the Job:
A. Must be able to stand and walk throughout the majority of shift on various surfaces in the client’s homes.
B. Must be able to lift and carry items up to 30 pounds such as mop buckets – groceries and bags with trash.
C. Must be able to push/pull up to various weights while performing tasks such as pushing client wheelchair and transferring to client.
D. Must be able to climb stairs at various clients’ houses.
E. Must be able to bend, twist, and reach when performing various job functions such as cleaning throughout the shift.
F. Must be able to handle objects such as wheelchairs, brooms, mops, dishes and vacuum cleaner.
G. Must be able to communicate effectively with the client.
H. Overall environment: must be able to work in various degrees of temperature, depending upon client’s house setting. Position requires working with various cleaning solvents, fumes, dust and odors.
I. Must be sensitive to the needs of the aged, disabled, and conscientious about services and client’s needs.
J. Must not be short tempered and must be slow to anger and be able to respond in a calm way and be able to work in an often-stressful situation when dealing with patients who may be abusive.
K. Must be alert and be able to identify hazards, should one occur, in order to avoid them, by reporting immediately or in directed, to take corrective actions.
L. Performs duties listed on the patient’s authorization.

I received training on using the phone/ device for clocking in and out at the residence of consumer assigned to me.

To whom it may concern,
Friendship Care Home policy regarding gift acceptance from client,
Friendship Care Home will not condone any of its staff accepting gifts from any of its clients. Gifts such as: money, jewelries, furniture, electronics, food, books and etc.
In event of this occurrence, the individual staff involved will have his or her appointment terminated.

Also, providers are NOT allowed to drive the patients in the provider’s vehicle or the patient’s vehicle. If anything would to happen while provider is driving the patient e.g. car accident, tow, injury and/or traffic ticket, etc...Friendship Care Home/ HHSC will not be responsible for any damage or legal action.

Sincerely,
Administrator
M. Alaga

Friendship Care Home employees, volunteers and contractors are to ensure an environment that promotes health, safety and well-being for all clients. Each client has the right to live and receive services in a comfortable environment that promotes independent, open communication and prompt services delivery.

Any actual, alleged or potential threat of abuse, neglect or exploitation by an employee, volunteer or contractor of the agency is to be reported immediately (meaning within 24 hours) to the Department of Family and protective Services (DFPS) at 1-800-252-5400, or through the DFPS secure website at www.txabusehotline.org and the Texas Department of Aging and Disability Services at 1-800-458-9858, as well as the administrator. An incident report is to be completed by the administrator and the person reporting the abuse. The administrator is directly responsible for ensuring all policies regarding abuse, incidents and related disciplinary action are followed.

All employees, volunteers and contractors shall report suspected abuse, neglect and exploitation of a client to an agency supervisor and the appropriate state agency. Clients have been informed of this policy, verbally and in writing during the admission process.

Any employee, volunteer or contractor of the agency suspected of abuse, neglect or exploitation will be suspended from working with or having contact with the agency clients. An investigation will be conducted by the agency and the appropriate state agency. If the investigation validates the claim, the employee will be terminated and the incidents will be reported to appropriate state department, state licensing board or law enforcement official within the HIPAA guidelines.

All reports of suspected abuse, Neglect or exploitation by an employee, volunteer or contractor of the agency shall be documented by the agency and such documentation will be kept confidential by the agency to the extent required by the state law. Documentation shall report only observations and statements by the person involved. The reporter shall not document conclusions or opinions. Copies of reports filed with the state or local law enforcement will be tracked and kept by the agency.

PROCEDURE (CONT’D)
DEFINITIONS (Human Resources Code Chapter 48.401 and Texas Family Code 261.401):

“Abuse” means:

(A) The negligent or willful infliction of injury, unreasonable confinement, intimidation, or cruel punishment with resulting physical or emotional harm or pain to an elderly or disabled person by the person’s caretaker, family member, or other individual who has an ongoing relationship with the person; or

(B) Sexual abuse of an elderly or disabled person, including any involuntary or nonconsensual sexual conduct that would constitute an offense under Section 21.08, Penal Code (indecent exposure) or Chapter 22, Penal Code (assaultive offenses), committed by the person’s caretaker, family member, or other individual who has an ongoing relationship with the person.

“Exploitation” means illegal or improper act or process of caretaker, family member, or other individual who has an ongoing relationship with the elderly or disabled person using the resources of an elderly or disabled person for monetary or personal benefit, profit, or gain without the informed consent of the elderly or disabled person.

“Neglect” means the failure to provide for one’s self the goods or service, including medical services, which are necessary to avoid physical or emotional harm or pain or the failure of a caretaker to provide such goods or services.

Abuse, neglect, and exploitation of a child have the meanings assigned by the Texas Family Code, §261.401 as follows:

“Abuse” means an intentional, knowing, or reckless act or omission by an employee, volunteer, or other individual working under the auspices of a facility or program that causes or may cause emotional harm or physical injury to, or the death of, a child served by the facility or program as further described by rule or policy.

“Exploitation” means the illegal or improper use of a child or of the resources of a child for monetary or personal benefit, profit, or gain by an employee, volunteer, or other individual working under the auspices of a facility or program as further described by rule or policy.

“Neglect” means a negligent act or omission by an employee, volunteer, or other individual working the auspices of a facility or program, including failure to comply with an individual treatment plan, plan of care, or individualized service plan, that causes or may cause substantial emotional harm or physical injury to, or the death of, a child served by the facility or program as further described by rule or policy.

It is Agency’s policy to promptly document infections that are contracted by its clients including:

1. The date that the infection was disclosed to the agency employee
2. The client’s name
3. The treatment plan

This training is communicated to Staff via printed information or electronic communication by email, text, or within the record keeping software. A summary of infections is reported semi-annually in Quality Assurance Performance Improvements meetings.

Until the State of Texas Health and Human Services Commission and the Center for Disease Control say otherwise, each employee of the Agency will perform a self-screening prior to each shift and record in the record-keeping Software App. (Temperature, potential exposure, any symptoms of COVID-19)

Agency will provide all necessary PPE to staff. PPE includes gloves, surgical masks and hand sanitizer. If a client is COVID-19 positive under investigation for COVID-19, Agency will also provide disposable gowns and face shields to staff caring for said client. Agency will keep an adequate supply of PPE at Agency location at all times and will deliver or ship necessary PPE as needed. Staff will keep Agency informed of PPE supply in the client’s home.

All newly admitted clients, clients’ household members, and newly hired employees are screened for COVID-19 symptoms prior to interview, orientation, admission, and before each shift worked. Temperature, potential exposure, and any symptoms suspicious of COVID-19 such as shortness of breath, sore throat or cough are recorded in the Agency’s record-keeping software. Compliance will be measured during QAPI.

Upon determining that any employee has symptoms, potential exposure, or diagnosis of COVID-19, the employee will be ineligible to work for any client at least 3 days (72) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, at least 10 days have passed since symptoms first appeared; or if completely asymptomatic, 14 days after the confirmed exposure; or upon receiving negative COVID-19 test results. All clients who have been in contact with employee in the past 14 days, and all employees who work with those clients will be notified of potential exposure.

Upon determining that any client or member of client’s household has symptoms, potential exposure, or diagnosis of COVID-19, Agency instructs him/her to seek medical attention. Agency will evaluate the client’s requirement for ongoing services until a negative test has been presented or client has been asymptomatic for 14 days. Client/Household Member may be placed on 14-day quarantine away from Agency and all employees. If a COVID- 19 positive client requires continued assistance with activities of daily living that we are unable to provide, the Agency will ensure the client receives adequate care by a healthcare professional.

Agree to wear PPE provided to me by the Agency, such as masks and gloves, and to use universal precautions at all times to try to prevent the spread of COVID-19, I agree to follow Agency’s Infection Control Procedures and COVID-19 screening protocol.