APPLICATION FOR EMPLOYMENT: HOME HEALTH LICENSED VOCATIONAL NURSE (LVN)

Transcription

1 APPLICATION FOR EMPLOYMENT: HOME HEALTH LICENSED VOCATIONAL NURSE (LVN) First Name Last Name Date Address Unit Number City State Zip Code Home Phone Cell Can you, after employment, submit verification of your legal right to work in the U.S.? Yes No Have you ever been convicted of a felony? (Conviction is not an automatic disqualification from employment.) Yes No (You may exclude information regarding any conviction for which the record has been judicially ordered sealed, expunged or statutorily eradicated.) If your answer was YES, please explain EDUCATION High School Name City State College Name City State Degree Professional/Technical School Name City State Certification LICENSURE (if applicable) Type State Number Expiration Date Type State Number Expiration Date Years of relevant experience type of experience EMPLOYMENT INFORMATION How Did You Hear About Accredited? (List newspaper name, friend s name, etc.) Can you, with or without reasonable accommodation, fully and safely perform the essential duties of the position for which you have applied? Yes No EMPLOYMENT HISTORY (start with most current and account for past five years. Please include Supervisors Names.) TIME PERIOD EMPLOYER/ADDRESS/PHONE/SUPERVISOR POSITION HELD REASON LEFT From To From To From To If you do not want your present employer contacted, please sign here Accredited is committed to a policy of equal employment opportunity for all applicants and employees. Accredited prohibits discrimination against qualified applicants or employees because of race, color, religion, sex, gender identity, pregnancy, national origin, ancestry, citizenship, age, marital status, physical disability, mental disability, medical condition, genetic characteristics, sexual orientation, or any other characteristic protected by state or federal law, and any information furnished on this application will not be used for any purpose prohibited by law. LVN Application 1.5 (Rev. 9/22/2015) Page 1 of 6

2 ACCURACY OF INFORMATION/BACKGROUND CHECK I hereby certify that the information on this application is correct and complete to the best of my knowledge. I understand that falsification or omission of any material information on this application or in the interviewing process or in my resume may be sufficient cause for immediate termination if I have already received an offer of employment. I understand that this application will no longer be active or receive further consideration once the position for which I am applying has been filled, or if I am employed but do not actively work for the Company for a period of six months or more. I agree to have any of the statements herein as well as my background investigated by the Company or its agents. This authorization shall become effective immediately and shall remain in effect for a period of twelve months after the date of signing this authorization. I understand that the background investigation may include, but is not limited to, reviewing my education, employment history, any public records, and personal references, whether through a search of my social security number, name, or other identifying information. In consideration for reviewing my application and other related information, I hereby waive and release the Company, its employees and agents, and all other entities and persons, and their respective employees and agents, from any claims I might have, including defamation and invasion of privacy, arising out of any verbal or written inquiries and/or any verbal or written responses related to investigation of my background and/or the use or disclosure of such information. EMPLOYMENT AT WILL DECLARATION I agree that if employed, I will abide by all policies and procedures established by the Company. I acknowledge that the Company reserves the right to amend or modify any of its handbooks, policies and procedures at any time and without prior notice. I understand that my employment is at will, that I may resign at any time, that the Company may terminate my employment at any time, with or without cause, and that no employee or other representative of the Company has the authority to make an agreement contrary to the foregoing unless it is in writing and signed by the Company President. This constitutes my entire agreement with the Company with regard to the matters set forth in this paragraph. LIQUIDATED DAMAGES I understand that Accredited is not an employment agency and that the services it renders is made possible only by a substantial investment in the hiring process for a large staff. As a condition of employment, I agree not to solicit any client or patient for employment that I am assigned, from this date and for a period of 270 days from the last date employed by Accredited. In the event this agreement is violated, I acknowledge it would be difficult to ascertain the precise amount of damages that Accredited would suffer. Therefore, I agree that I will be obligated to pay Accredited $ in liquidated damages. CONFIDENTIALITY/ HIPAA AGREEMENT I agree to maintain confidentiality of all patient information including, but not limited to, names and addresses of clients and referral sources, patient medical condition and course of treatment, rates, etc.; and I understand that my failure to do so may result in disciplinary action up to and including discharge. I also agree to follow the rules and regulations set forth by the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH Act) which helps ensure that all medical records, medical billing, and patient accounts, both printed and electronic, meet certain consistent standards with regard to documentation, handling and privacy. MEDICAL PROVIDER NETWORK (MPN) California law requires us to provide medical treatment in the event you are injured at work. Accredited will provide this care by using a Medical Provider Network (MPN). I am aware that I must immediately notify Accredited should I require treatment. Additional information regarding the MPN is available on the employee website: AUTHORIZATION TO CORRECT FOR PAYROLL ERRORS Recognizing that payroll errors may occur for a number of reasons (e.g. illegible timecards, misidentification of employee name or number, keystroke errors), if I am employed, I authorize Accredited to withhold pay in order to correct for any payroll error that may have resulted in my overpayment. LVN Application 1.5 (Rev. 9/22/2015) Page 2 of 6

3 Authorization for Release of Information In connection with my application for employment/promotion/tenancy/care provider, including any contract for services, with you; I understand that a consumer report that may contain public information may be requested from TrustPointe, Inc. I authorize, without reservation, any party or agency by TrustPointe, Inc. or one of its agents to furnish above mentioned information. I have a right to make a request to TrustPointe, Inc., upon proper identification, of the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me, which TrustPointe, Inc. has previously furnished within the two-year periods preceding my request. Residents of California, Maryland, Minnesota, and Oklahoma only; you have the right to receive a copy of your consumer report. Please mark the appropriate box. I would like to receive a copy of my report? Yes No Full Signature Date: MM/DD/YY Applicant Verification Data In order to process your application; please provide the following information. Include your exact legal name and any other name(s) you may have used in the last seven (07) years. Please PRINT CLEARLY AND IN INK. Name: Current Address: First Middle Last Street Address Apt # City State Zip Code Social Security Number: - - Current Phone #: ( ) Area Code Date of Birth: / / Driver s License: State: Other Name(s) Used: From: / To: / Other Name(s) Used: From: / To: / Past Residence Data Applicants must provide city and state information for residence covering a period of seven (07) years. Begin with your most current address. If you are not sure of the address, include the city and zip. FROM: / TO: / CITY COUNTY STATE ZIP MM YY MM YY FROM: / TO: / CITY COUNTY STATE ZIP MM YY MM YY FROM: / TO: / CITY COUNTY STATE ZIP MM YY MM YY FROM: / TO: / CITY COUNTY STATE ZIP MM YY MM YY TrustPointe, Inc. P.O. Box 2020, Santa Maria, CA Voice: (800) Facsimile: (805) All Rights Reserved. Any Unauthorized Duplications Prohibited.

4 EMPLOYMENT REFERENCE Name of applicant Previous employer Employer address Phone City State Zip Code I have applied for employment with Accredited Home Health Services. I authorize them to collect any information concerning my qualifications and past performance. I also authorize and request that you provide answers to the questions below. I hereby release you from any and all liability in supplying any information regarding my previous employment. Date Signature of Applicant PREVIOUS EMPLOYER: PLEASE COMPLETE THIS SECTION The above-named individual has applied for employment with Accredited Home Health Services, a Medicare-certified and CHAPaccredited Licensed Home Health Agency, to provide nursing, restorative therapy or social work assistance to patients who require such intermittent clinical care due to advanced age, physical disability, mental deficiencies, or other health-related conditions. Applicant employed from to Position held Reason for separation Eligible for rehire? Yes No If No, please explain EVALUATION OF PERFORMANCE COMPETENCY SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE Initiative Technical Skills Client or Patient Care Cooperation Attendance Comments Feedback provided by Position Date Information obtained by Verbally Written/Faxed LVN Application 1.5 (Rev. 9/22/2015) Page 4 of 6

5 EMPLOYMENT REFERENCE Name of applicant Previous employer Employer address Phone City State Zip Code I have applied for employment with Accredited Home Health Services. I authorize them to collect any information concerning my qualifications and past performance. I also authorize and request that you provide answers to the questions below. I hereby release you from any and all liability in supplying any information regarding my previous employment. Date Signature of Applicant PREVIOUS EMPLOYER: PLEASE COMPLETE THIS SECTION The above-named individual has applied for employment with Accredited Home Health Services, a Medicare-certified and CHAPaccredited Licensed Home Health Agency, to provide nursing, restorative therapy or social work assistance to patients who require such intermittent clinical care due to advanced age, physical disability, mental deficiencies, or other health-related conditions. Applicant employed from to Position held Reason for separation Eligible for rehire? Yes No If No, please explain EVALUATION OF PERFORMANCE COMPETENCY SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE Initiative Technical Skills Client or Patient Care Cooperation Attendance Comments Feedback provided by Position Date Information obtained by Verbally Written/Faxed LVN Application 1.5 (Rev. 9/22/2015) Page 5 of 6

6 EMPLOYMENT REFERENCE Name of applicant Previous employer Employer address Phone City State Zip Code I have applied for employment with Accredited Home Health Services. I authorize them to collect any information concerning my qualifications and past performance. I also authorize and request that you provide answers to the questions below. I hereby release you from any and all liability in supplying any information regarding my previous employment. Date Signature of Applicant PREVIOUS EMPLOYER: PLEASE COMPLETE THIS SECTION The above-named individual has applied for employment with Accredited Home Health Services, a Medicare-certified and CHAPaccredited Licensed Home Health Agency, to provide nursing, restorative therapy or social work assistance to patients who require such intermittent clinical care due to advanced age, physical disability, mental deficiencies, or other health-related conditions. Applicant employed from to Position held Reason for separation Eligible for rehire? Yes No If No, please explain EVALUATION OF PERFORMANCE COMPETENCY SUPERIOR ABOVE AVERAGE AVERAGE BELOW AVERAGE Initiative Technical Skills Client or Patient Care Cooperation Attendance Comments Feedback provided by Position Date Information obtained by Verbally Written/Faxed LVN Application 1.5 (Rev. 9/22/2015) Page 6 of 6

7 INITIAL COMPETENCY ASSESSMENT SKILLS CHECKLIST LICENSED VOCATIONAL NURSE Name: Branch (circle): Wdld Hills West LA Pasadena Date of Hire: Date Completed: Self Assessment Experience with Skill? Self Assessment Competent Performing Skill? Competency Areas for the Licensed Vocational Nurse Proficiency Required A. Demonstrates ability to process paperwork and associated functions necessary to facilitate: 1. Assess patient response to treatment 2. Transfer of patient to Hospice/SNF 3. Attends Case Conference 4. Adheres to POC 5. Reports and documents key information to physician, D/C planned, Case Mgr, pharmacist, supervisor 6. Communicates/coordinates as appropriate with other team members 7. Coordinates community resources with Case Mgr 8. Documents according to POC a. Medicare guidelines for documentation b. Corrections to the clinical record c. Accidents/incident reports d. Clinical notes, flow charts e. DME requisition and management f. Supply requisition and management B. Review of Systems: Demonstrates ability to obtain and document appropriate age specific history /assessment for patients in the following categories: 1. Pulmonary System a. Pulmonary assessment b. Tracheostomy care c. Oxygen administration Evaluation Method Competency Validated by Preceptor Initials & Date LVN Comp Assmt 1.5 (Revised 9/23/2015) Page 1 of 5

8 d. Nasal/Pharyngeal suction e. Use of oral/nasal inhalers/nebulizer treatment/incentive spirometer f. Oxymeter g. CPCP/Pleurex catheter h. Oxygen mask equipment 2. Cardiovascular System a. Cardiovascular assessment b. Pulses (apical, radical, femoral, pedal) / Blood Pressure c. Edema assessment and management d. CHF energy conservation 3. Neurologic System a. Neurologic assessment / Seizure Precautions b. Head / Spinal Cord injuries care 4. Gastrointestinal System a. Gastrointestinal assessment b. NG / J and G tube care c. Enteral feedings d. Suction machine(s) e. Ostomy care (colostomy/ileostomy) f. Dysphasia precautions g. Impaction removal / enemas / bowel training 5. Genitourinary System a. GU assessment b. Urinary catheterization insertion and care (male & female) / removal / irrigation and obtaining specimens c. Care of supra-pubic catheter / insertion / removal h. Care of urostomy / nephrostomy a. Bladder training / incontinence care b. Knowledge of types of catheters and indications for use (straight, in-dwelling, condom) 6. Integumentary/Wounds/Dressings a. Assessment of skin and wounds (measuring, pictures, staging) b. Wound irrigation c. Wet to dry dressing(s) d. Decubitus care: e. i. Prevention LVN Comp Assmt 1.5 (Revised 9/23/2015) Page 2 of 5

9 f. ii. Various treatments (hydrocolloid, calcium alginate, transparent films) g. Ace wrap, cast care, compress / wound vacs h. All drains (i.e.: JP) i. Sterile dressing change j. Suture/staple removal 7. Musculoskeletal System a. Assessment b. Range of motion (ROM) c. TED hose d. Joint replacement care a. Assistive devices / beds / mattresses b. Transfers / ambulation c. Pain assessment and management 8. Metabolic a. Diabetic assessment and teaching i. Insulin types and teaching ii. Use care and teaching of glucose monitoring system iii. Diet, exercise and sick day teaching iv. Signs and symptoms of Hypo- Hyperglycemic reactions v. Foot and skin care 9. Behavioral Assessment a. Mental Status/ Psychosocial status/ Depression/Suicide precautions/ Psychotropic drugs/ Care of the demented patient 10. Miscellaneous Skills a. Vital signs b. Intake and output c. Caring for immuno-compromised patients d. Collection, labeling and delivering laboratory specimens (blood, urine, sputum, wound, stool) C. Medication Administration: Demonstrates ability to administer, monitor and document medications for patients 1. Medication Administration Techniques LVN Comp Assmt 1.5 (Revised 9/23/2015) Page 3 of 5

10 a. Oral, IM, IV, SQ b. Ear, eye, nose drops/irrigation c. Assessment for side effects, adverse reactions, therapeutic response D. Infection Control 1. Hand washing technique 2. Aseptic technique 3. Proper bag technique 4. Safe needle technique 5. Personal Protective Equipment 6. Exposure control plan 7. TB exposure control plan 8. Reporting of infections for patient and personnel 9. Standard precautions E. Equipment 1. Home Glucose Monitoring via Patient s Meter a. Verbalizes purpose of test b. Specimen collection c. Instrument calibration d. Quality control process e. Test correctly performed and interpreted 2. Coagcheck Meter F. Safety 1. Restraints, indications/policy 2. Fire extinguishers/smoke alarms 3. Emergency preparedness 4. Hazardous materials 5. Assessment of patient safety risks and home safety G. Patient Education 1. Determine patient and family learning needs 2. Sets measurable objectives 3. Develops/implements teaching plan 4. Evaluates effectiveness of teaching 5. Revises teaching plan based on patient needs 6. Documents response to teaching 7. Provides instruction in the following: a. Emergency care b. Diet and nutrition LVN Comp Assmt 1.5 (Revised 9/23/2015) Page 4 of 5

11 Comments: Employee Signature/Date Supervisor Signature/Date Preceptor Signature/Date Preceptor Signature/Date Preceptor Signature/Date LVN Comp Assmt 1.5 (Revised 9/23/2015) Page 5 of 5