New Employee Acknowledgements

Please complete the form below, Sign and Submit.

Employee Acknowledgement – Check each box*
- Confidentiality: The Agency maintains confidentiality of operations, activities, and business affairs of the Agency and the patients/clients according to 1996, Health Information Portability and Accountability Act (HIPAA). Due to the nature of our work, each employee will gain, directly or indirectly, sensitive and confidential information on patients/clients and staff members. The health care professional safeguards the patient’s/client’s right to privacy by judiciously protecting information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient/client information, etc. This information should be shared only with those persons who, due to their position, have a need to know. Sensitive or confidential information must never be used as the basis for social conversation or gossip. If an employee is in doubt as to whether or not certain information may be shared, s/he should consult with his/her supervisor.
- Drug Testing Policy: The Agency maintains a drug free workplace policy with regard to the possession, use, distribution and sale of drugs or alcohol. All employees are prohibited from the unlawful or unauthorized manufacture, distribution, dispensing, possession or use of a controlled substance or any alcoholic beverages while in the workplace or on Company paid time. Violation of this policy can result in disciplinary action, up to and including termination of employment. I acknowledge I have received a copy of the agency’s policy on drug testing.
- Harassment Policy: The Agency is committed to providing a work environment, that is free from all forms of discrimination and unlawful harassment including sexual harassment. This policy applies to all employees including management personnel. Sexual harassment is any unwelcome sexual advances either explicit or implicit as a term or condition of employment. Improper behavior may be verbal, visual, or physical in nature and/or the creation of a hostile environment. Management will investigate complaints of sexual harassment promptly, impartially and without fear of retaliation to the employee. An employee should report the alleged incident immediately and confidentially to the appropriate manager or Human Resources.
- Non Solicitation/Illegal Remuneration: The Agency does not reimburse or provide incentives to physicians, durable equipment providers, family or other referral entities for patient/client referrals for home health services. Employees may not solicit patients/clients for the agency. Employees found in violation of this non-solicitation policy will be subject to discipline up to and including termination of employment.
- Non Solicitation/Illegal Remuneration: The Agency does not reimburse or provide incentives to physicians, durable equipment providers, family or other referral entities for patient/client referrals for home health services. Employees may not solicit patients/clients for the agency. Employees found in violation of this non-solicitation policy will be subject to discipline up to and including termination of employment.
- Non-Discrimination: The Agency does not discriminate in patient/client provision of services with respect to race, color, national origin, age, sex, disability, marital status, religion, or source of payment according to Title VI of the Civil Rights Act.
- Abuse, Neglect, and Exploitation: Agency employees will report suspected abuse, neglect and/or exploitation to the Texas Department of Family and Protective Services, Texas Health and Human Services, and Agency management. Agency employees suspected of abuse, neglect, or exploitation will be suspended immediately, an investigation will be conducted, and if the investigation validates the claim, the employee will be terminated.
- Workers’ Compensation The Agency is a non-subscriber to workers’ compensation insurance. An employee who incurs an injury on the job that requires emergency medical treatment or is life threatening should proceed to the nearest emergency room. Emergency medical treatment (non life threatening) or non-emergency treatment should be referred to the agency’s designated clinic. Notify the agency of an injury within 24 hours to complete paperwork. Medical expenses for injuries are covered with the exception of the following: employee’s willful intent to hurt self or others, intoxication or drug use, horseplay, acts of God, and/or acts of a third party.
- Progressive Discipline Policy: Agency utilizes a progressive discipline process in cases of misconduct or unacceptable performance. This includes verbal warning, written warning and final warning. Disciplinary action may begin at an advanced stage of the process or may result in immediate termination based upon the nature and severity of the offense, employee’s past record and other circumstances.
- Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.
CONFIDENTIALITY OF PATIENT/CLIENT INFORMATION – Check each box.*
- I plan to utilize electronic documentation of patient care.
- I will ensure confidentiality and security of patient information by password protecting the device or program utilized.
- I agree to change the password at least quarterly or following a breach of security.
- I will not provide my password to anyone.
- I will use an electronic signature, if acceptable to payor source. Authentication will be available if requested by the Agency.
- I have been informed of the Agency’s Medical Record Information Confidentiality Policy and Safeguarding Medical Record Content Policy, and I agree to abide by these policies.
Emergency Preparedness Response Plan Inservice

To establish Agency programs that include policies and procedures for in-services of the Emergency Preparedness and Response Plan. Agency policy on Emergency Preparedness and Response plan reviewed. Topics include Definitions, Risk Analysis, Continuity of Operations plan, Patient Triage, Call Tree, Securing office building, IT Systems, plan of Utility disruptions, Off site location as well as employee responsibilities and Media/Information management through all phases.

In the event of an emergency, power outage, or utility disruption, report to:

Main Location: Approved – 965 Kerfoot Road, Gunter TX 75058 Phone Numbers: 972-658-4001, 972-658-0566, 214-453-0500, out of state: 408-981-8729 (if this location is unavailable due to disaster use back up location #1)

Back Up location #1: Approved – 10925 Estate Lane #303 Dallas TX 75238 Phone Numbers: 972-658-4001, 972-658-0566, 214-453-0500, out of state: 408-981-8729 (if this location is unavailable due to disaster use back up location #2)

Back Up Location #2: High Pointe Church – 3201 North Central Expwy, McKinney, TX 75071 Phone Numbers: 972-658-4001, 972-658-0566, 214-453-0500, out of state: 408-981-8729

I acknowledge Approved In Home Care has provided documentation and training on Emergency Preparedness and Response Plan. The instruction and documentation included but not limited to instruction during orientation by a staff member of Approved In Home Care, and documentation and policies on Emergency Preparedness and Response Plan has been provided to me to keep for my review and records. Additionally, I agree to continue yearly in-service training and education that may include Emergency Preparedness and Response Plan procedures.
Infection Control – Exposure Control – Hand Hygiene*
- To establish Agency programs that include policies and procedures for the protection of patients/clients. I acknowledge Approved In Home Care has provided documentation and training on Infection Control, Exposure Control and Hand Hygiene. The instruction and documentation included but not limited to instruction during orientation by a staff member of Approved In Home Care, and documentation and policies on Infection Control, Exposure Control and Hand Hygiene has been provided to me to keep for my review and records. Additionally, I agree to continue monthly in-service training modules education that may include Infection Control, Exposure Control and Hand Hygiene training.
NON-COMPETE AGREEMENT*
- I agree to not talk to Approved In Home Care, LLC’s clients about salary hourly rate, caregiver compensation or money concerning payment.
- I also agree to not talk to Approved In Home Care, LLC’s clients about schedule changes.
- I agree that anything concerning salary or schedules will be discussed with Approved In Home Care, LLC’s Administrator or Alternate Administrator directly.
- I agree not to offer caregiving services to Approved In Home Care, LLC’s clients aside from Approved In Home Care, LLC and understand that if it were not for Approved In Home Care, LLC employing me, I would not have this caregiving position, therefore I agree to not compete with Approved In Home Care, LLC.
- I also agree that should Approved In Home Care, LLC’s client offer me work aside from Approved In Home Care, LLC’s I shall not accept the client’s offer due to this “noncompete” agreement with Approved In Home Care, LLC.
- I understand that should I break this contract, Approved In Home Care, LLC, has the right to file a claim against me with the Texas State court and I agree to pay Approved In Home Care, LLC $7500.00 plus expenses and damages incurred.
Hand Hygiene Competency Checklist
- First Hand Hygiene with Soap and Water
- 1. Identifies and gathers the appropriate supplies
- 2. Wets hands with water using temperature that is comfortable
- 3. Applies an amount of product recommended by the manufacturer to hands, and rubs hands together vigorously for at least 20 seconds, covering all surfaces of hands, fingers and nail beds
- 4. Rinses thoroughly with water
- 5. With hands held upright, dries thoroughly with a clean paper towel
- 6. Turns the faucet off using a dry paper towel to touch the handle, protecting clean hands from the contaminated handle
- Verbalizes and/or Demonstrates When Hand Hygiene Indicated Using Soap and Water:
- 1. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids
- 2. Before eating and after using the restroom
- 3. After known or suspected exposure to clostridium difficile, infectious diarrhea during norovirus outbreaks, or if exposure to Bacillus anthracis is suspected or proven.
- Hand Hygiene with Alcohol-Based(60-95%) Hand Rub:
- 1. Applies product to palm of one hand (Follows the manufacturer’s recommendations regarding the volume of product to use)
- 2. Rubs hands together covering all surfaces of hands and fingers until hands are dry, this should take around 20 seconds
- Verbalizes and/or Demonstrates When Hand Hygiene Indicated:
- 1. Prior to initial entry into the supply bag
- 2. Before having direct contact with the patient
- 3. After direct contact with the patient
- 4. After contact with body fluids or excretions, mucus membranes, wound dressings and used supplies (PPE)
- 5. After known or suspected exposure to infections or infectious diseases
- 6. Before handling or preparing medication
- 7. Before moving from a contaminated-body site to a clean-body site on the same patient during patient care
- 8. After having contact with inanimate objects (including medical equipment) in the patient’s environment
- 9. Before contact with or the preparation of food items and beverages
- 10.After removing gloves
Personal Protective Equipment (PPE) Competency Checklist
- Identifies the proper PPE to gather and verbalizes that all appropriate PPE is available at point of use
- Verbalizes proper steps in examining PPE for defects
- Demonstrates the ability to follow the proper sequence for donning PPE in the following order:
- 1. Hand hygiene using hand sanitizer for 20 seconds cleansing all parts of hands, fingers and nail beds.
- 2. Dons gown: fully covering torso from neck to knees, arms, ends of wrists. Wrap around back. Tie/fasten in back of neck and waist.
- 3. Dons N95 respirator while ensuring air-tight fit.
- 4. Performs seal check.
- 5. Dons Face shield: Place over face and eyes, adjust to fit as needed.
- 6. Dons gloves covering wrist of gown.
- Demonstrates the ability to follow the proper sequence for doffing PPE in the following order:
- 1. Performs hand hygiene using hand sanitizer on gloves.
- 2. Doffs gloves: Grasp outside of glove with opposite gloved hand, peel off using glove in glove technique. Discards in appropriate waste container.
- 3. Doffs gown: Untie lower ties first and upper last without contamination using arm cross method. Pull away from neck and shoulders, touching inside of gown. Folds or rolls into bundle and discards in appropriate waste container.
- 4. Exits patient home.
- 5. Performs hand hygiene.
- 6. Doffs mask/face shield: Grasp bottom, untie lower ties first and upper last, pulling up and away from head. Avoid touching front of mask/respirator. Discards in appropriate waste container or stores mask for reuse per policy.
- 7. Performs Hand Hygiene.
Children in the Workplace – Family Members in the Workplace – Friends in the Workplace*
- The presence of children, family members or friends in the workplace with the employee parent during the employee’s workday is inappropriate and is NOT ALLOWED within company policy. Any violation of this policy will result in a loss of wage for the day and is considered grounds for termination of employment. This policy is established to avoid disruptions in job duties of the employee and co-workers, reduce property liability, and help maintain the company’s professional work environment and image.
Agency Policies: I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.
Name*
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Signature*
Email*
Date*
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