Work Experience/Skills

Certifications: Check all applicable certifications and enter expiration date:

Work Experience: List all of your work experience beginning with your most recent job. You will be asked to explain all gaps in employment. Attach additional sheet(s) if necessary.

Date Employed

Pay Rate/Salary

Date Employed

Pay Rate/Salary:

Date Employed

Pay Rate/Salary

The penalty for not wearing PPE is disciplinary action, up to and including termination.

ACKNOWLEDGMENT (Please read carefully and sign) In signing this application, I certify that I have read and fully understand the questions asked in this application and that all answers given by me are true, accurate, and complete. I also understand that the omission, concealment, or misrepresentation of any fact on this application or during any interview for employment may jeopardize my chances for employment and be cause for my immediate dismissal from employment. I give Elevate Healthcare Services permission to use any information in this application to enable it and its agents to verify the information contained in this application I also authorize present and former employers, educational institutions I have attended, credit agencies, all references, and any other persons to answer all questions asked by Elevate Healthcare Services with regard to y of the subjects covered by this application. I also understand that in connection with my application for employment or my .nployment, Elevate Healthcare Services may conduct a criminal background investigation and that my employment may be contingent on the results of such investigation. I release Elevate Healthcare Services, its agents, and all affiliated entities, as well as any person or situation that provides any information about me, from any and all liability whatsoever resulting from any such investigation or the disclosure of such information. In consideration of my employment and of my being considered for employment by Elevate Healthcare Services, I agree to abide by all rules and regulations, which I understand are subject to change at any time for any reason without prior notice. I also understand that if employed, I will be an employee at will and employed for no definite period of time. I understand that either Elevate Healthcare Services or I can terminate my employment at any time, with or without cause and with or without advance notice. I further understand that no communication, whether oral or written, by any representative of Elevate Healthcare Services, at any time, can constitute a contract of employment. No representative or agent of Elevate Healthcare Services, has the authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing. I am willing to submit to a physical examination, including the analysis for the detection of the use of unlawful drugs or substances in accordance with the applicable laws. If I receive an offer of employment I agree that my continued employment may be contingent on the results. I understand that Elevate Healthcare Services is not involved in the day-to-day supervision or decision concerning patient care or dentistry. This remains with the Professional as part of the Professional's practice. The Professional fully indemnifies Elevate Healthcare Services against any and all liability and responsibility associated with his or her professional duties. The Professional maintains his or her license as required by law, professional liability coverage and other responsibilities as found under state prime contract law. I HAVE READ THE ABOVE AND FULLY UNDERSTAND IT.

Thank you taking time to respond to my questions.

CONFIDENTIALITY AGREEMENT

It is the responsibility of all Healthcare workforce members, including employees, medical staff, and office staff to preserve and protect confidential patient, employee and business information. The Federal Health Insurance Portability Accountability Act (the "Privacy Rule"), govern the release of patient. identifiable information by home health agencies and other health care providers. These laws establish protections to preserve the confidentiality of various medical and personal information and specify that such information may not be disclosed except as authorized by law or the patient or individual.

Confidential Patient Care Information includes: Any individually identifiable information in possession or derived from a provider of health care regarding a patient's medical history, mental, or physical condition or treatment, as well as the patients and/or their family members records, test results, conversations, research records and financial information. (Note: this information is defined in the Privacy Rule as "protected health information.") Examples include, but are not limited to:

• Physical medical and psychiatric records including paper, photo, video, diagnostic and therapeutic reports, laboratory and pathology samples;
• Patient insurance and billing records;
• Computer and department based computerized patient data; and
• Visual observation of patients receiving medical care or accessing services; and
• Verbal information provided by or about a patient

Confidential Employee and Business Information includes, but is not limited to, the following:

• Employee home telephone number and address:
• Spouse or other relative names;
• Social Security number or income tax withholding records;
• Information related to evaluation of performance;
• Other such information obtained from the Agency records which if disclosed, would constitute unwarranted invasion of privacy; or
• Disclosure of Confidential business information that would cause harm to Elevate Healthcare Services.

I understand and acknowledge that:

1. I shall respect and maintain the confidentiality of all discussions, deliberations, patient care records and any other information generated in connection with individual patient care, risk management and/or peer review activities.
2. It is my legal and ethical responsibility to protect the privacy, confidentiality and security of all medical records, proprietary information and other confidential information relating to Elevate Healthcare Services and its affiliates, including business, employment and medical information relating to our patients, members, employees and health care providers.
3. I shall only access or disseminate patient care information in the performance of my assigned duties and where required by or permitted by law, and in a manner which is consistent with officially adopted policies of Elevate Healthcare Services, or where no officially adopted policy exists, only with the express approval of my supervisor or designee. I shall make no voluntary disclosure of any discussion, deliberations, patient care records or any other patient care, peer review or risk management information, except to persons authorized to receive it in the conduct of Elevate Healthcare Services affairs.
4. Elevate Healthcare Services Administration performs audits and reviews patient records in order to identify. inappropriate access
5. My user ID is recorded when I access electronic records and that I am the only one authorized to use my user ID. I will only access the minimum necessary information to satisfy my job role or the need of the request.
6. I agree to discuss confidential information only in the work place and only for job related purposes and to not discuss such information outside of the work place or within hearing of other people who do not have a need to know about the information.
7. I understand that any and all references to HIV testing, such as any clinical test or laboratory test used to identify HIV, a component of HIV, or antibodies or antigens to HIV, are specifically protected under law and unauthorized release of confidential information may make me subject to legal and/or disciplinary action.
8. My obligation to safeguard patient confidentiality continues after my termination of employment with the Elevate Healthcare Services.

I hereby acknowledge that I have read and understand the foregoing information and that my signature below signifies my agreement to comply with the above terms. In the event of a breach or threatened breach of the Confidentiality Agreement, I acknowledge that the Elevate Healthcare Services may, as applicable and as it deems appropriate, pursue disciplinary action up to and including my termination from the Elevate Healthcare Services.

SWORN DISCLOSURE STATEMENT

999 Waterside Dr, Suite 2525 Norfolk, VA 23510

(757) 779-4728

Section 32.1162.9:1 of the Code of Virginia requires that all applicants for employment in home care organizations provide a sworn disclosure statement or affirmation is completed for each employee.

Employment is prohibited if a person has been convicted of any offense specified below or has been the subject of a founded complaint of child abuse or neglect.

Convictions include adult convictions and juvenile convictions and adjudications of delinquency based on an offense that would have been at the time of conviction a felony conviction if committed by an adult within or outside the Commonwealth. Any person making a materially false statement regarding any such offense shall be guilty of a Class 1 misdemeanor. This statement must be provided to and maintained at the facility for prospective employees.

I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject to verification.

Position: Certified Nurse Aide/ Home Health Aide

Reports to: Case Manager/ RN

Revised: 11/19/2023

Job Summary: Provide supportive and personal services for the patients with consideration of dignity and privacy. Provide personal care and hygiene to home health patients.

Qualifications/Educational Requirements:

1. Graduate of an accredited High School or equivalent preferred
2. Ability read, write and follow directions
3. Must be a certified nursing assistant with proof of certification
4. Demonstrate compassion, responsibility, and cheerful attitude
5. A qualified home health aide is a person who has successfully completed:
   1. A training and competency evaluation program as specified in this job description; or
   2. A nurse aide training and competency evaluation program approved by the state as meeting the requirements of § 483.151 through § 483.154 of this chapter, and is currently listed in good standing on the state nurse aide registry; or
   3. The requirements of a state licensure program that meets the provisions of the training and competency requirements.

1. Training Requirement: Content and duration of home health aide classroom and supervised practical training.
   1. Home health aide training must include classroom and supervised practical training in a practicum laboratory or other setting in which the trainee demonstrates knowledge while providing services to an individual under the direct supervision of a registered nurse, or a licensed practical nurse who is under the supervision of a registered nurse. Classroom and supervised practical training must total at least 75 hours.
   2. A minimum of 16 hours of classroom training must precede a minimum of 16 hours of supervised practical training as part of the 75 hours.
   3. A home health aide training program must address each of the following subject areas:
      1. Communication skills, including the ability to read, write, and verbally report clinical information to patients, representatives, and caregivers, as well as to other HHA staff.
      2. Observation, reporting, and documentation of patient status and the care or service furnished.
      3. Reading and recording temperature, pulse, and respiration
      4. Basic infection prevention and control procedures
      5. Basic elements of body functioning and changes in body function that must be reported to an aide's supervisor.
      6. Maintenance of a clean, safe, and healthy environment.
      7. Recognizing emergencies and the knowledge of instituting emergency procedures and their application.
      8. The physical, emotional, and developmental needs of and ways to work with the populations served by the HHA, including the need for respect for the patient, his or her privacy, and his or her property.
      9. Appropriate and safe techniques in performing personal hygiene and grooming tasks that include-
         1. Bed bath;
         2. Sponge, tub, and shower bath
         3. Hair shampooing in sink, tub, and bed;
         4. Nail and skin care;
         5. Oral hygiene;
         6. Toileting and elimination;
      10. Safe transfer techniques and ambulation;
      11. Normal range of motion and positioning;
      12. Adequate nutrition and fluid intake;
      13. Recognizing and reporting changes in skin condition; and
      14. Any other task that the HHA may choose to have an aide perform as permitted under state law.
      15. The HHA is responsible for training home health aides, as needed, for skills not covered in the basic checklist, as described in paragraph (b)(3)(ix) of this section.
   4. HHA must maintain documentation that demonstrates that the requirements of this standard have been met.
2. Competency Requirement. An individual may furnish home health services on behalf of an HHA only after that individual has successfully completed a competency evaluation program as described in this section.
   1. The competency evaluation must address each of the subjects listed in paragraph (A)(3) of above. Subject areas specified under paragraphs (A)(3)(a), (c), (d), (e), and (f) of the above must be evaluated by observing an aide's performance of the task with a patient. The remaining subject areas may be evaluated through written examination, oral examination, or after observation of a home health aide with a patient.
   2. A home health aide competency evaluation program may be offered by any organization, except as specified in paragraph (f) of this section
   3. The competency evaluation must be performed by a registered nurse in consultation with other skilled professionals, as appropriate.
   4. A home health aide is not considered competent in any task for which he or she is evaluated as unsatisfactory. An aide must not perform that task without direct supervision by a registered nurse until after he or she has received training in the task for which he or she was evaluated as "unsatisfactory," and has successfully completed a subsequent evaluation. A home health aide is not considered to have successfully passed a competency evaluation if the aide has an "unsatisfactory" rating in more than one of the required areas.
   5. The HHA must maintain documentation which demonstrates that the requirements of this standard have been met.
3. A home health aide or nurse aide is not considered to have completed a program, as specified in paragraph (a)(1) of this section, if, since the individual's most recent completion of the program(s), there has been a continuous period of 24 consecutive months during which none of the services furnished by the individual as described in § 409.40 of this chapter were for compensation. If there has been a 24-month lapse in furnishing services for compensation, the individual must complete another program, as specified in paragraph (a)(1) of this section, before providing services.

Responsibilities/essential functions: The person in this position must be able to perform the following essential job functions with or without reasonable accommodations.

1. Provide only those services written in the plan of care and received as written instructions from the registered nurse supervisor as permitted under State law. May provide assistance with the following ADL's during each visit: mobility, transferring, walking, grooming, bathing, dressing or undressing, eating, or toileting. Some examples of assistance include:
   1. helping the patient with a bath, care of the mouth, skin and hair;
   2. helping the patient to the bathroom or in using a bedpan or urinal
   3. helping the patient to dress and/or undress;
   4. helping the patient in and out of bed, assisting with ambulation
   5. helping the patient with prescribed exercises which the patient and the health aide have been taught by appropriate personnel; and
   6. performing such incidental household services essential to the patient's health care at home that are necessary to prevent or postpone institutionalization;
2. May perform care assigned by a registered nurse if the delegation is in compliance with current standards of nursing practice
3. Shall complete a clinical note for each visit, which must be incorporated into record at least on a weekly basis.
4. Follow the instructions of the professional nurse/therapist in providing care.*
5. Perform and record accurate measurements (i.e. vital signs, or intake/output as instructed in the care plans). *
6. Observe and report any safety hazards found in the client's home or any significant observations regarding the client.
7. Attend staff meetings, attend/complete 12 hours of annual in-services, and participates in orientation of new employees.
8. Report patient complaints to the RN.
9. Maintain patient confidentiality/adheres to HIPAA requirements and agency policy and procedures manual.
10. Possess the ability to follow written and oral instructions
11. Report abnormal findings in patient's conditions as observed and per care plan to RN. *

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS The work environment and physical demands described here are representative of those required by an employee to perform to the essential functions of this job with or without reasonable accommodations. Physical Elements

• Sufficient clarity of speech and hearing or other communication capabilities, with or without reasonable accommodation, to enable the employee to communicate effectively;
• Sufficient vision or other powers of observation, with or without reasonable accommodation, to enable the employee to review a wide variety of materials in electronic or hard copy form;
• Sufficient manual dexterity, with or without reasonable accommodation, to enable the employee to operate a personal computer, telephone, and other related equipment;
• Sufficient personal mobility and physical reflexes, with or without reasonable accommodation, to enable the employee to safely lift, move, or maneuver whatever may be necessary to successfully perform the duties of their position;
• Sufficient personal mobility and physical reflexes, with or without reasonable accommodation, to enable the employee to efficiently function in a general office environment; and
• Sufficient personal mobility and physical reflexes, with or without reasonable accommodation, to enable the employee to efficiently function in a general office environment, with frequent travel to a variety of field sites.

Environmental Elements

Employee works in an office environment sometimes with moderate noise levels, controlled temperature conditions and sometimes travels to patients homes where they may have direct exposure to hazardous substances. Employees may interact with upset staff and/or public and private representatives in interpreting and enforcing departmental policies and procedures.

Employee will have to travel to a variety of patient homes and perform in conditions that vary greatly depending upon the client's home environment. Some homes will be clean, neat, and maintained at a comfortable temperature. Other homes may be cluttered, dirty, with an uncomfortable temperature.

The above list reflects the essential functions and other job functions considered necessary of the job identified, and shall not be construed as a detailed description of all work requirements that may be inherent in the job, or assigned by supervisory personnel. This job description is used as a guide only and not inclusive of responsibilities and job duties.

By my signature, I acknowledge that I have read and understand this job description and its requirement and that I am expected to complete all duties as assigned. I understand the job functions may be altered from time to time.