Baseline Individual TB Risk Assessment

HCP should be considered at increased risk for TB if any of the following statements are marked ‘Yes”:

Employee Information

Early Detection of Tuberculosis: This questionnaire gives guidance in identifying individuals with suspected or confirmed TB so that appropriate controls can be promptly initiated.

AGENCY REP INSTRUCTIONS:

• Circle each answer provided by the employee and add your comments as the evaluator.
• Institute AMS exposure conbol measures outlined in AMS Exposure Control Plan, Respiratory Protection and lvfedical Surveillance Program and refer the individual for further evaluation if the individual has.-
  1. A persistent cough lasting 3 or more weeks and two or more symptoms of active TB.
  2. Had a positive TB test on mucous that he/she coughed up.
  3. Been told that he/she had TB and was treated, but never finished the medication.

TB HISTORY (Part 1)

I understand that due to my occupational exposure to blood or other potentially
infectious material, I may be at risk of acquiring the Hepatitis B (HBV) infection. I have been given the opportunity to be vaccinated with the vaccine, at no charge to me. The series consists of 3 doses: an initial IM dose, a 2nd dose 30 days after and a 3rd dose at 6 months.
PLEASE CHECK ONE OF THE FOLLOWING:

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me. OSHA [56 FR 64004, Dec. 06, 1991, as amended at 57 FR 12717, April 13, 1992; 57 FR. 29206, July 1, 1992; 61 FR 5507, Feb. 13, 1996]

I hereby consent to the administration of the Hepatitis B vaccine series and understand this will be at no charge to me. I know that I should not take this series if I am pregnant or nursing. I also understand that I should not take the vaccine if I have active infection present or have an allergy to the compound. I understand the risks and side effects of the injections and release the Agency from any liability that may arise from the effects of the vaccine.

Watching Over Us Home Care LLC complies with applicable Federal civil rights laws and does not discriminate in hiring or admissions, on the basis of race, color, national origin, age, disability, or sex. Our Agency does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Watching Over Us Home Care LLC:

Provides free aids and services to patients with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters. • Written information in other formats (large print, audio, accessible electronic formats, other formats).

Provides free language services to patients whose primary language is not English (LEP) such as: • Qualified interpreters. • Information written in other languages.

If you need these services, contact Loretta Folks.

If you believe that Watching Over Us Home Care LLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Agency Name: Watching Over Us Home Care LLC Agency Civil Rights Coordinator: Loretta Folks Agency Address: 2643 N. 3rd Street, Suite #2-223, Harrisburg, PA 17110 Agency Phone: (717) 210-3112

If you need help filing a grievance, Loretta Folks is available to assist you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building Phone: 1-800-368-1019 | TDD: 800-537-7697

*“**TIMESHEETS ARE DUE BY 12 NOON• THERE ARE NO EXCEPTIONS****

Timesheets are submitted in person or via email at timesheet@watchingoverus.org

Please submit timesheets that are CLEAR and LEGIBLE as Payroll must be able to verify your hours for

payment

• Your Name
• Clients Name
• Date/Time of Visit (Use comp lete dates i.e. May, 28, 2024 or 5/28/24)
• Total Hours worked

WHITEOUT IS NOT PERMITTED  NO SCRIBBLES or MARKS wilt be accepted on any timesheets.

If something needs to be changed you wilt be required to submit a NEW timesheet!

Timesheets are located outside of the office in the bfacK mailbox marked with the Watching Over Us Home Care logo for pickup anytime;.if it is empty please contact the office at 717-210-3112 and someone will assist you

If you work more than one shift with a client you must submit Mo timesheets as each shift will be invoiced.

PERSONAL CARE is required for ALL clients. You must have performed some form of PERSONAL CARE for the timesheet to be considered eligible for invoicing or payment.

Please use a check mark or“X”when marking timesheet. Lines drawn through with not be accepted.

If you are sending your timesheet via email, please check the quality of the submission as ANY timesheets considered illegible will be rejectea and you will not be paid for the hours until a clear and corrected timesheet is submitted.

If you submit a timesheet incorrectly or fraudutentty and payment is denied or recouped by the provider, you wifi be fiabLe and Watching Over Us Home Care will issue a deduction for the amount or possible take legal action to recover the payment.

I have read and understand this policy on protecting Consumers Health Information (PEI) and security. I an employee of Watching Over Us Home Care LLC understand that should any situation arise where I breach Consumers privacy I will be disciplined up to and including termination
I hereby agree to maintain Consumers confidentiality in the strictest manner possible, sharing or discussing Consumers information only with those designated care providers or supervisors who have "a need to know" and are actively involved in the care of services provided to the Consumers.
I further acknowledge that I have been trained in the provisions and laws related to HIPAA compliance during orientation and those Consumers must sign written permission to allow their health information (PEI) to be disclosed.
I further agree that I will protect PHI while driving in my vehicle servicing Consumers in their homes and will not allow any PHI to be visible inside my vehicle; I will not bring any PHI related to another Consumers into the homes/facilities of Consumers I am servicing.

INCIDENT/ACCIDENTS REPORTING ACKNOWLEDGEMENT

I have been thoroughly informed by the Agency that I MUST report ALL incidents/accidents and any medical, physical, or mental changes in my Consumers immediately to the Supervisor and/or Scheduling Coordinator.
I further understand that in the event that I become injured, even a minor injury, I am required to report fost incident to my office as soon as possible after an injury.

OUR AGENCY IS AVAILABLE BY PHONE 24 HOURS A DAY. THE ANSWERING SERVICE WILL RESPOND AFTER 5 PM WEEKDAYS AND ON WEEKENDS/HOLIDAYS
Acknowledgement and Understanding of Zero Tolerance Sexual Abuse Policy I acknowledge that I have received and read the sexual abuse policy and/or have had it explained 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 retaliating against any employee/volunteer exercising his or her rights under the policy.

This agreement is made between

and Watching Over Us Home Care LLC, (the “Employer”) on the

The Employee agrees to the terms of this Agreement.

1. As a condition of employment the employer requires that all new employees free to enter into this Confidentiality Agreement (the Agreement). The Employee acknowledges that employment with Employer is sufficient consideration for the Employee to entering into the Agreement.

2. The Employee acknowledges that, in the course of employment, the Employee will, and may in the future, come into possession of certain confidential information belonging to the Employer including but not limited to trade secrets, data, materials, products, technology, computer programs, specifications, manuals, business plans, software, marketing plans, financial information, and other information disclosed or submitted. This confidential information may be embodied in hand written notes by the Employee, computer disks, tapes, paper, or any other media.

3. The Employee hereby covenants and agrees that she or he will at no time, during or after the term of employment with the Employer, use for his or her own benefit or the benefit of others, or discloses or divulges to others, any such confidential information.

4. Upon termination of employment, the Employee will return, retaining no copies or notes, all documents relating to the Employer's business including, but not limited to, reports, lists, correspondence, information, computer files, computer disks, and all other material and all copies of such material, obtained by the Employee during employment nor will the employee attempt to contact or solicit any Consumers that the employee may have worked with during employment.

5. The Employee recognizes that the Employer may be irreparably damaged by breach of this Agreement and that the Employer shall be entitled to seek an injunction to prevent such competition or disclosure, and will entitle the Employer to other legal remedies, including attorney's fees and costs.

6. The obligations of Recipient herein shall be effective from the date the Owner last discloses any Confidential Information to Recipient pursuant to this Agreement.

7. If any part of this Agreement is adjudged invalid, illegal or unenforceable, the remaining parts shall not be affected and shall remain in full force and effect.

8. This instrument, including any attached exhibits and addenda, constitutes the entire Agreement of the parties. No representation or promises have been made except those that are set out in this Agreement. This Agreement may not be modified except in writing signed by all parties.

9. This agreement shall take effect as a sealed instrument and shall be construed, governed and enforced in accordance with the laws of the State of PA, without regards to its conflicts of law provisions.

10. The descriptive headings used herein are for convenience of reference only and they are not intended to have any effect whatsoever in determining the rights or obligations under this agreement.

We ask that you have in front of you the complete hiring packet and your job description prior to starting the exercise.
As you go through the packet, each document will be reviewed. You should have the document being reviewed in front of you and you should read through it as we proceed. As we finish each document you will sign and date each document and put it aside in the order we go through.
Use care on the document marked "Reference Request". We require you to provide 2 written references in your file. Fill in the name of the company or person and their address that you would like us to send the reference request to (at the top of the document). If you don't know the addresses during orientation please find it out as soon as you leave today and call us before the day is over.
The section called "Orientation for All Employees" and the document called "Orientation for Direct Care Employees are in a table format. As we complete each section, you will put today's date and your initials in the right hand column indicating that you had that section reviewed with you.
Please inform us right away if you suspect that something negative will come back on your Criminal Background Check. Not all convictions will eliminate you from working in homecare but you must understand that we are responsible for assuring the safety of vulnerable Consumers (elderly and children). Speak to the Agency Director privately if you suspect a problem will be identified.
Many homecare employees work for more than one company at the same time. It is essential that you let us know if you are working for another agency. Remember that any Consumers you service for us are OUR Consumers. Should you ever decide to leave us for any reason, Consumers you are servicing for 115 MAY NEVER be encouraged to transfer to another company where you might be working. This is clearly a conflict of interest and will not be tolerated. Our legal department will be notified immediately should this occur.
Please have your documents ready for copy before Orientation begins:
Drivers License, Car registration, Social Security Card, Legal Immigration documents (if applicable), Current Professional license, copy of professional liability insurance (if contractor), training certificates, TB test results.

Benefits are not currently offered as we are a startup agency. We will notify you immediately when we are prepared to begin offering a benefit package consult your employee handbook or the Agency Director for other benefit information.
Sincerely,

PROFESSIONAL BOUNDARIES definition:

Invisible, unspoken physical & emotional boundary that defines the nature of the caregiver relationship. Boundaries are what keeps the professional borders of the relationship in place. The professional home care provider/staff has the responsibility of defining and maintaining the consistency of these boundaries. Professional boundaries are guidelines for maintaining a positive and helpful relationship with our clients. Understanding boundaries helps caregivers avoid stress and misconduct, recognize boundary crossings and provide the best possible care/services.

TYPES OF BOUNDARY CROSSING | STAYING IN BOUNDS

Sharing Personal Information: It may be tempting to talk to your client about your personal life or problems. Doing so may cause the client to see you as a friend instead of seeing you as a home care professional. As a result, the client may take on your issues/burdens on top of their own.

☐ Use caution when talking to a client about your private life ☐ Remember that your relationship with the client must be professional, therapeutic, not social

Nicknames/Endearments: Calling a client 'sweetie' or 'honey' may be comforting to that client, or it might suggest a more personal interest than you intend. It might also indicate to some, that you favor one client over another. Some clients may find the use of nicknames or endearments offensive & disrespectful.

☐ Avoid saying honey and sweetie or the like ☐ Let the client determine how you will address them. Some may allow you to use their first name. Others might prefer a more formal approach: Mr., Mrs., Ms., or Miss- either is ok ☐ Remember the way you address clients indicates your level of professionalism

Touch: Touch can be healing and comforting to some or it can be confusing, harmful, or simply unwelcome. Touch should be used sparingly & thoughtfully.

☐ Ask the client if they is comfortable with touch ☐ Use only when it will serve a good purpose ☐ A client may respond differently than you intend ☐ If used, ensure it is serving client's needs and not your own

Unprofessional Demeanor: Demeanor includes appearance, tone and volume of voice, speech patterns, body language, etc. Professional demeanor affects how others perceive you. Personal and professional demeanor can be completely different.

☐ Clients may be afraid or confused by loud voices ☐ Good personal hygiene is a top priority ☐ Professional attire sends a positive message ☐ Off-color jokes, racial slurs, profanity, slang are never appropriate ☐ Body language and facial expressions are always picked up by clients

Gifts/Tips/Favors: Giving or receiving gifts, or doing special favors, can blur the line between a personal and a professional one. Accepting a gift from a client might be taken as friend or theft and is against agency policy.

☐ Follow the Agency policy on accepting gifts ☐ It's ok to tell clients that you are not allowed by agency policy to accept gifts, tips ☐ Report offers of unusual or large gifts to your supervisor

Over-Involvement: Signs may include spending inappropriate amounts of time with a client, visiting the client when off duty, making assignments to be with a client, thinking that you are the only caregiver who can meet the client's needs. Under involvement is the opposite of over-involvement and may include dishonesty and neglect.

☐ Don't confuse client needs with your needs ☐ Maintain a helpful relationship, treating each client with the same quality of care & attention, regardless of your emotional reaction to the client ☐ Ask yourself: Are you becoming overly involved with the client's personal life? If so, discuss your feelings with your supervisor

Job Summary: An individual who, under supervision, provides assistance with nutritional and environmental support, personal hygiene, feeding and dressing. Organizational Relationship: Reports to the designated supervisor. Risk Of Occupational Exposure To Blood Borne Pathogens: Limited exposure

Qualifications: Has successfully completed one of the following:

• Demonstrated competency by passing a competency exam developed by the Agency or other entity which meets the PA regulatory requirements.
• A training program developed by the Agency that meets all the PA state requirements.
• A training program meeting the training standards by virtue of the agency's participation as a provider in a Medicaid Waiver or other publically funded program providing home & community based services.
• Another program identified by the PA DOH by subsequent publication in the PA Bulletin or on the DOH website.
• Practices good hygiene and is neat in personal appearance.
• Speaks, reads, and writes English.
• Must have current CPR certification.
• Must have criminal background check.

Responsibilities:

Personal Services – assists with:

• Bath (tub, shower or bed)
• Oral hygiene
• Grooming and care of hair
• Ordinary care of nails
• Routine skin care/lotion massage
• Positioning and turning of patients that cannot assist self- in bed and chair
• Elimination
• Assist with eating, dressing walking and toileting
• Reminding Consumer to take self-administered medications

Homemaking – assists with:

• Meal planning and preparation in accordance with complex and modified diets
• Feeding
• Linen change (occupied and unoccupied)
• Laundry, Consumer's only
• Light housekeeping: washing dishes, clean kitchen, dust & vacuum, only those rooms the Consumer uses.
• List needed supplies and grocery shopping

CCW'S ARE REQUIRED TO:

• Follow universal precautions whenever giving any aspect of Consumer service.
• Maintain confidentiality.
• Perform ONLY those functions specified for each individual Consumer on the service plan.
• Respond to the physical, emotional and development needs of Consumers.
• Follow emergency procedures in the event of any incident e.g., accident, injury or significant change in Consumer's condition.

Essential Administrative Functions:

• Follow Consumer rights at all times.
• Record each activity performed on each case on a daily basis.
• Submit Daily Activity Sheets and record accurately on a timely basis (WEEKLY).
• Follow instructions, is punctual and is at work as scheduled.
• Follow all appropriate agency policies.
• Attend in-service education annually per agency policy.
• Provide all information required for the maintenance of his/her personnel record as per State regulations and Agency policy.
• Show interest, asks questions and seek help as indicated; is receptive to supervision.
• Develop relationships and is cooperative with Consumer, family and supervisor.
• Maintain appropriate appearance.
• Is productive and uses time efficiently.
• Follows instructions, is punctual and attendance is acceptable.
• Cooperates with supervisor and with Consumer/family.
• Is self-reliant and plans appropriately.
• Other duties as are reasonably assigned.

Functional Abilities:

• Is able to carry bundles upstairs weighing up to 10 pounds.
• Must be able to stoop and bend.
• Must be able to travel to prospective Consumer's place of residence.
• Must be able to hear and effectively communicate in English.

Review of Job description/duties/role

Agency Mission Statement/ History/Home Services industry info

Agency Organizational chart/Agency Services provided

Handling client complaints/grievances

Office communication (suggestion box, staff meetings, memos etc)

HIPAA (confidentiality)/quiz

Employee safety issues: OSHA/Hazardous materials

Working after hours/ office security/Employee injury/ Incident reporting/

Emergency Plan: Employee role in disasters

Fire safety plan/drills No smoking policy

Infection Control/Universal Precautions

Abuse Recognition and Reporting

Fraud/False Claims/Compliance program

Conflict of Interest

Name tag/ ID card/ ID # assigned

Cultural Awareness

Review Policy manuals

Review and sign/date job description

Review pay period, paydays and time sheets

Approved reimbursement expenses

Review HR policy/benefits

Performance evaluations

Disciplinary action (3 written then termination)

EEO /OSHA

Agency Organizational & Reporting Chart

Employee Handbook Review & Sign Off

Company policies: Dress Code, Office Hours, Reliability

Quality Assurance (QA) Program

Client Rights/responsibilities

Client communication barriers

Professional boundaries

Recordkeeping & reporting

Agency Compliance program

Conveying of changes for agency care/services (as applies)

Incident/variance reporting

Orientation to equipment (as applies)

Training for special populations served by our Agency (as applies)

Job specific training

2643 N. 3rd Street, Suite 2-219

Harrisburg, PA 17112

Phone: 717-210-3112

Website: www.watchingoverus.org

EMPLOYEE PAY RATE ADJUSTMENT & OVERTIME POLICY ACKNOWLEDGMENT

This document serves as tormal notice and acknowledgment of the following pay structure: Base Pay Rate (Up to 40 hours per workweek): $15.00 per hour

• Overtime Pay Structure (Any hours exceeding 40 hours per workweek):
  • Base rate tor overtime calculation: $11.50 per hour
  • Overtime rate (1.5x): $17.50 per hour

Watching Over Us Home Care must remain contractually compliant with the Pa State Regulations for consumers that participate in the Community Health Choices Waiver Program.

*“*Section 12006(a) of the 21st Century Cures Act (Cures Act), signed into law on December 13, 2016, added section 1903([) to the Social Security Act, 42 U.S.C. 91396(b)(I), which mandates that states require EW use for

• Medicaid-funded personal care services (PCS) for in-home and community* visits by a

provider,

• Medicaid-funded home heatth care services (HHCS) for in-home and community* visits

To remain in compliance with this federal and stated MANDATED law, we require our Direct Care Worker staff to acknowledge that they have received and understand the training on the EVV system. All Direct Care Workers providing service to CNC waiver consumers are required to use the HHA Exchange app and must have a functioning mobile device or be able to navigate the system through the consumer's phone. The EW system must be used for EVERY visit. Failure to use the EW system can and will result in disciplinary action up to pay holds, your ctient being disqualified for services and termination.

Watching Over Us Home Care requires that ALL Direct Care Workers acknow[eage receipt of training for their assigned consumer's plan of care (POC). The Plan of Care is established by the agency case manager and ONLY the care categories on the POC are to be completed. Direct Care Workers will find their consumers plan of care on the HHA Exchange app and will acknowledge care categories upon completion of their shift.

START HERE: Employers must ensure the form instructions are available to employees when completing this form. Employers are liable for failing to comply with the requirements for completing this form. See below and the Instructions.

ANTI-DISCRIMINATION NOTICE: All employees can choose which acceptable documentation to present for Form I-9. Employers cannot ask employees for documentation to verify information in Section 1, or specify which acceptable documentation employees must present for Section 2 or Supplement B, Reverification and Rehire. Treating employees differently based on their citizenship, immigration status, or national origin may be illegal.

Section 1. Employee Information and Attestation

Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.

I am aware that federal law provides for imprisonment and/or fines for false statements or the use of false documents, in connection with the completion of this form. I attest, under penalty of perjury, that this information, including my selection of the box attesting to my citizenship or immigration status, is true and correct.

Employers or their authorized representative must complete and sign Section 2 within three business days of the employee's first day of employment. Employers must physically examine, or examine consistent with an alternative procedure authorized by the Secretary of DHS, documentation from List A OR a combination of documentation from List B and List C. Enter any additional documentation in the Additional Information box; see instructions.

Certification: I attest, under penalty of perjury, that (1) I have examined the documentation presented by the above-named employee, (2) the above-listed documentation appears to be genuine and to relate to the employee named, and (3) to the best of my knowledge, the employee is authorized to work in the United States.

Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
Give Form W-4 to your employer.
Your withholding is subject to review by the IRS.
OMB No. 1545-0074 | 2025

TIP: Consider using the estimator at www.irs.gov/W4App to determine the most accurate withholding for the rest of the year if: you are completing this form after the beginning of the year; expect to work only part of the year; or have changes during the year in your marital status, number of jobs for you (and/or your spouse if married filing jointly), dependents, other income (not from jobs), deductions, or credits. Have your most recent pay stub(s) from this year available when using the estimator. At the beginning of next year, use the estimator again to recheck your withholding.

Complete Steps 2–4 ONLY if they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, and when to use the estimator at www.irs.gov/W4App.

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all these jobs.

Do only one of the following:

(a) Use the estimator at www.irs.gov/W4App for the most accurate withholding for this step (and Steps 3–4). If you or your spouse have self-employment income, use this option; or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below; or

(c) If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is generally more accurate than (b) if pay at the lower paying job is more than half of the pay at the higher paying job. Otherwise, (b) is more accurate.

If your total income will be $200,000 or less ($400,000 or less if married filing jointly):

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, correct, and complete.

POLICY:
No employee or member of the Governing Body or other individual, committee, or entity shall derive any profit or gain directly or indirectly by reason of their association with the agency, without the prior knowledge and approval of the Governing Body. All GB members and/or employees, at the discretion and specific request of the board, will be required to submit a disclosure statement annually.
If a matter arises in which a member of the board or employee has a conflict of interest, it shall be promptly disclosed to the Agency Director and Governing Body.
In matters involving a conflict of interest, a board member must disclose any known significant reasons why a transaction might not be in the best interest of the agency and a board member shall not
participate in discussions unless requested by the board nor vote on such transactions. The abstention and the reason for it shall be recorded in the minutes.
Field staff in any capacity understands that all Consumers are Consumers of the Agency not personal Consumers of the field staff. Consumers may never be serviced privately by an employee of Our Agency for the financial gain of the employee. Should an employee terminate employment with Watching Over Us Home Care LLC, the field staff understands that the Consumers may not be encouraged or otherwise moved from our Agency to another agency.

I understand that due to my occupational exposure to blood or other potentially infectious material, I may be at risk of acquiring Influenza infection. I have been given the opportunity to be vaccinated with the vaccine, at no charge to me. PLEASE CHECK ONE OF THE FOLLOWING:

I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Influenza infection. I have been given the opportunity to be vaccinated with the Influenza vaccine, at no charge to myself. However, I decline the Influenza vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Influenza, a serious disease.

I hereby consent to the administration of the Influenza vaccine and understand this will be at no charge to me. I know that I should not take this series if I am pregnant or nursing. I also understand that I should not take the vaccine if I have active infection present or have an allergy to the compound. I understand the risks and side effects of the injections and release the Agency from any liability that may arise from the effects of the vaccine.

BY SIGNING MY NAME BELOW, I AM STATING THAT I DO WISH TO HAVE THE INFLUENZA VACCINE. I UNDERSTAND THAT THIS IS ONE
INJECTION AND THAT I MUST RECEIVE ALL INJECTIONS TO BE CONSIDERED VACCINATED AGAINST INFLUENZA.

Listed are some pertinent references to employee policies from the Agency Employee Handbook. For more detailed information please refer to the Handbook. You may request to review any/all of the personnel policies pertinent to your employment at our Agency at any time.

1. Do wear scrubs to all your visits. However, if you do not have scrubs, you may wear business casual clothing. NO JEANS, scanty tops, see through clothing etc allowed.
2. Do wear your Agency Issued photo ID badge at all time when on agency business.
3. Do arrive on time for ALL assignments. Our Agency must be notified immediately if: a. An emergency or situation arises which causes you to be late by five or more minutes. b. You will be absent from your assignment.

Without calling the office, these situations are called NO CALL NO SHOW and are subject to termination.

4. Once you have been given an assignment, no more than 2 cancellations will be tolerated.
5. Don't use the client's phone. Cell phones are off during all visits.
6. Under No circumstances should you ever take property, money or "borrow" anything that belongs to a client or ever enter into any type of legal or financial agreement.
7. Don't discuss your rate of pay with your clients or any other employee of the Agency.
8. Do complete visit notes correctly and completely and have signed by the client AT THE TIME OF THE VISIT.
9. Do call our coordinator to inquire as to cases to be covered if you are not scheduled for work.
10. Do call the office immediately if any problem arises on your assignment.
11. Do call the office immediately if the client does not answer the door for a scheduled visit. Failure to notify the office may be considered abandonment, especially if the client has had a medical emergency and is in need of medical assistance. DON'T assume they aren't home. CALL THE OFFICE.
12. Don't leave any assignment early without first calling the scheduling coordinator/office immediately.
13. Do report any incident/accident or unusual occurrence involving a Watching Over Us Home Care LLC employee/client to our office immediately. If you are injured and unable to make the call have another person call us right away.
14. Do follow your schedule at all times WITHOUT MAKING ANY CHANGES.
15. Don't transport a client's in your car unless you have a signed consent/authorization.
16. Please know, at the present time our agency does not perform drug testing of staff but may do so at our discretion.
17. Cancellation Policy: A minimum of eight (8) hours cancellation notice must be given at all times, unless you are involved in an emergency. Sick call shall be made with a 2 hour notice. Should you decide an assigned client must be removed from your schedule, the office requires a minimum of one week's notice to arrange a change of worker. 2 weeks' notice is preferred.

My signature acknowledges that I have received and have read the Employee Handbook and agree to the Agency's Dos & Don'ts as listed above & in the Handbook.

I am available at the following days and/or hours:

PENNSYLVANIA CRIMINAL CHECK ATTESTATION

By signing this document, I acknowledge that I have been told by the Agency that a criminal history check will be performed on my name. I have informed that Agency of all alias used (maiden name, aliases). I understand that I have been employed on a provisional basis that is temporarily pending the results of the PA criminal history check. I also understand that it is the Agency's policy not to hire an individual who has been convicted of the offenses enumerated below. I also understand that the Agency will search any Employee Misconduct Registry and Nurse Aide Registry to determine whether any acts of abuse, neglect or exploitation have occurred and whether my name is designated on the registry. If my name is on the registries, I understand the Agency may deny me employment.

PART I: CONVICTION OF EITHER A FELONY OR MISDEMEANOR CHARGE FOR ANY OF THE OFFENSES LISTED BELOW

CC2500 — Criminal Homicide CC2502A — Murder I CC2502B — Murder II CC2502C — Murder III CC2503 — Voluntary Manslaughter CC2504 — Involuntary Manslaughter CC2505 — Causing or Aiding Suicide CC2506 — Drug Delivery Resulting in Death CC2702 — Aggravated Assault CC2901 — Kidnapping CC2902 — Unlawful Restraint CC3121 — Rape CC3122.1 — Statutory Sexual Assault CC3124.1 — Sexual Assault CC3123 — Involuntary Deviate Sexual Intercourse CC3126 — Indecent Assault CC3127 — Indecent Exposure CC3301 — Arson and Related Offenses CC3502 — Burglary CC3701 — Robbery CC4101 — Forgery CC4114 — Securing Execution of Documents by Deception CC4302 — Incest CC4303 — Concealing Death of a Child CC4304 — Endangering Welfare of a Child CC4305 — Dealing in Infant Children CC4952 — Intimidation of Witnesses or Victims CC4953 — Retaliation Against Witness or Victim CC5903C — Obscene or Other Sexual Materials to Minors CC5903D — Obscene or Other Sexual Materials CC6101 — Corruption of Minors

PART II: CONVICTION OF A FELONY CHARGE FOR ANY OF THE OFFENSES BELOW

CC5902B — Promoting Prostitution CS13A12 — Acquisition of Controlled Substance by Fraud CS13A14 — Delivery by Practitioner CS13A30 — Possession with Intent to Deliver CS 13A35(i),(ii),(iii) — Illegal Sale of Non-Controlled Substance CS 13A36 — Designer Drugs Felony CS 13Axx* — Any Other Felony Drug Conviction Appearing On PA Rap Sheet

PART III: CONVICTION OF EITHER ONE (1) FELONY CHARGE OR TWO (2) MISDEMEANORS CHARGES FOR ANY OF THE OFFENSES LISTED BELOW

CC3901 — Theft CC3921 — Theft By Unlawful Taking CC3922 — Theft By Deception CC3923 — Theft By Extortion CC3924 — Theft By Property Lost CC3925 — Receiving Stolen Property CC3926 — Theft of Services CC3927 — Theft By Failure to Deposit CC3928 — Unauthorized Use of a Motor Vehicle CC3929 — Retail Theft CC3929.1 — Library Theft CC3929.2 — Unlawful Possession of Retail or Library Theft Instruments CC3929.3 — Organized Retail Theft CC3930 — Theft of Trade Secrets CC3931 — Theft of Unpublished Dramas or Musicals CC3932 — Theft of Leased Properties CC3933 — Unlawful Use of a Computer CC3934 — Theft From a Motor Vehicle

Please provide a brief statement of your experience working with the special needs of the elderly, chronically ill and disabled population. Your statement should include any current certifications, years of experience and any specific knowledge of equipment related to care.:

AGENCY POLICY: We cannot hire individuals with convictions listed as unemployable by the state. Would anything be likely to show up on their Criminal History check to prevent us from hiring?

Question work history, explain structured environment and ask problem solver, open ended questions. (Document responses)

1. What would you do if you arrive at a Client's home and he/she refused to let you in?

2. What would you do if your Client fell and insists that you do not call for help and insists that they are ok?

3. How long do you think it is okay to hold onto paperwork for a Client?

4. How do you feel about scheduling an elderly Client's visit at 8 pm?

5. How would you respond if the supervisor gives you a written warning for something they have discovered happened?

Watching Over Us Home Care LLC is an equal opportunity employer. All applicants and employees are considered for employment, advancement, and development based upon their skills, performance and potential. No current or prospective employee will be discriminated against because of race, creed, color, gender, age, national origin, handicap or military status.

Most Recent Employment

By my signature below, I acknowledge/consent to a criminal check on my name.

The presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call any of my cited previous employers or reference candidate for information regarding my character, employment history or work ethics.

I-9 Form for ALL employees are filled all together, in a separate file folder.

Check all items that have been filed:

Check all items that have been filed:

**CONFIDENTIAL***
Filed separately from manila and red file.

Call in: Call HHA at 1-833-496-2307 Enter your Time and Attendance PIN:

Call out: Call HHA at 1-833-496-2307 Enter your Time and Attendance PIN:

Next type in your duty codes from the plan of care (Type the duty code then # to move on)

Plan of Care Codes

115 — Meal Prep 116 — Housework/Chores 118 — Managing medications 119 — Shopping 122 — Hygiene

Once codes are accepted you have successfully called out the system

Or exit with 000#

Please attach a voided check for each account here.