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       Before proceeding, please read the helpful instructions below on how to fill out the following forms:
AVAILABILITY FORM
     
Applicant’s Printed Name: *
*    
What is your primary language? *  
Which other languages do you speak?  
Do you have your own car? *  
Will you work in a home with a smoking patient? *  
Will you work in a home with Pets? *  
Do you have knowledge of a kosher kitchen?*  
     
Please fill in the chart below with the time you are available for each day. If you are not available, leave the box blank for that day.
Scroll over to view full week
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End Time: (AM/PM)
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Employment Eligibility Verification

Department of Homeland Security

U.S. Citizenship and Immigration Services

USCIS
Form I-9

OMB No. 1615-0047

Expires 10/31/2022

► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.
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.)
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I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):*
 

Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:
An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

OR

2. Form I-94 Admission Number:

OR

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1
Do Not Write In This Space

 

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Preparer and/or Translator Certification (check one):

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
 
 
Form I-9  10/21/2019 Page 1 of 3
Step 1: Enter Personal Information
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(c)
     
     

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, when to use the estimator at www.irs.gov/W4App, and privacy.
Step 2: Multiple Jobs or Spouse Works

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 of these jobs.

Do only one of the following.

(a) Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3–4); or

(b) Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; 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 accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld . . . . . ?

TIP: To be accurate, submit a 2022 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps 3–4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3–4(b) on the Form W-4 for the highest paying job.)
Step 3: Claim Dependents

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

Multiply the number of qualifying children under age 17 by $2,000 ? $

Multiply the number of other dependents by $500.......? $

Add the amounts above and enter the total here $

3 $
Step 4 (optional): Other Adjustments

(a) Other income (not from jobs). If you want tax withheld for other income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income

 4(a) $

(b) Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here

 4(b) $

(c) Extra withholding. Enter any additional tax you want withheld each pay period

 4(c) $
Step 5: Sign Here

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

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Employers Only
For Privacy Act and Paperwork Reduction Act Notice, see page 3. Cat. No. 10220Q Form W-4 (2022)
Step 2(b)—Multiple Jobs Worksheet (Keep for your records.)

If you choose the option in Step 2(b) on Form W-4, complete this worksheet (which calculates the total extra tax for all jobs) on only ONE Form W-4. Withholding will be most accurate if you complete the worksheet and enter the result on the Form W-4 for the highest paying job.

Note: If more than one job has annual wages of more than $120,000 or there are more than three jobs, see Pub. 505 for additional tables; or, you can use the online withholding estimator at www.irs.gov/W4App.
1 Two jobs. If you have two jobs or you’re married filing jointly and you and your spouse each have one job, find the amount from the appropriate table on page 4. Using the “Higher Paying Job” row and the “Lower Paying Job” column, find the value at the intersection of the two household salaries and enter that value on line 1. Then, skip to line 3... 1 $
2 Three jobs. . If you and/or your spouse have three jobs at the same time, complete lines 2a, 2b, and 2c below. Otherwise, skip to line 3.

a Find the amount from the appropriate table on page 4 using the annual wages from the highest paying job in the “Higher Paying Job” row and the annual wages for your next highest paying job in the “Lower Paying Job” column. Find the value at the intersection of the two household salaries and enter that value on line 2a...

b Add the annual wages of the two highest paying jobs from line 2a together and use the total as the wages in the “Higher Paying Job” row and use the annual wages for your third job in the “Lower Paying Job” column to find the amount from the appropriate table on page 4 and enter this amount on line 2b...

c Add the amounts from lines 2a and 2b and enter the result on line 2c...

2a

2b

2c

$

$

$

3 Enter the number of pay periods per year for the highest paying job. For example, if that job pays weekly, enter 52; if it pays every other week, enter 26; if it pays monthly, enter 12, etc... 3 $
4 Divide the annual amount on line 1 or line 2c by the number of pay periods on line 3. Enter this amount here and in Step 4(c) of Form W-4 for the highest paying job (along with any other additional amount you want withheld) 4 $
Step 4(b)—Deductions Worksheet (Keep for your records.)
1 Enter an estimate of your 2022 itemized deductions (from Schedule A (Form 1040)). Such deductions may include qualifying home mortgage interest, charitable contributions, state and local taxes (up to $10,000), and medical expenses in excess of 7.5% of your income ... 1 $
2

Enter:
- $25,900 if you’re married filing jointly or qualifying widow(er)
- $19,400 if you’re head of household
- $12,950 if you’re single or married filing separately }

 2 $
3 If line 1 is greater than line 2, subtract line 2 from line 1 and enter the result here. If line 2 is greater than line 1, enter "-0-"... 3 $
4 Enter an estimate of your student loan interest, deductible IRA contributions, and certain other adjustments (from Part II of Schedule 1 (Form 1040)). See Pub. 505 for more information... 4 $
5 Add lines 3 and 4. Enter the result here and in Step 4(b) of Form W-4... 5 $

Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Internal Revenue Code sections 3402(f)(2) and 6109 and their regulations require you to provide this information; your employer uses it to determine your federal income tax withholding. Failure to provide a properly completed form will result in your being treated as a single person with no other entries on the form; providing fraudulent information may subject you to penalties. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation; to cities, states, the District of Columbia, and U.S. commonwealths and possessions for use in administering their tax laws; and to the Department of Health and Human Services for use in the National Directory of New Hires. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism.

You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or its instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. Generally, tax returns and return information are confidential, as required by Code section 6103.

The average time and expenses required to complete and file this form will vary depending on individual circumstances. For estimated averages, see the instructions for your income tax return.

If you have suggestions for making this form simpler, we would be happy to hear from you. See the instructions for your income tax return.
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*

Note: If married but legally separated, mark an X in the Single or Head of household box.
Are you a resident of New York City? *
Are you a resident of Yonkers? *
Complete the worksheet on page 4 before making any entries

1 Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 19)...

2 Total number of allowances for New York City (from line 31)...

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.

3 New York State amount... $

4 New York City amount... $

5 Yonkers amount... $

I certify that I am entitled to the number of withholding allowances claimed on this certificate.

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Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.
Instructions

Important information

The 2021-2022 New York State budget was signed into law on April 19, 2021. Changes to New York State personal income tax have caused withholding tax changes for taxpayers with taxable income:

  • more than $2,155,350, and who are married filing jointly or a qualified widow(er);
  • more than $1,077,550, and who are single or married filing separately; or
  • more than $1,616,450, and who are head of household.

Accordingly, if you previously filed a Form IT-2104 and earn more than the amounts listed above, you should complete a new 2022 Form IT-2104 and give it to your employer.

Changes effective for 2022

Form IT-2104 has been revised for tax year 2022.The worksheet on page 4 and the charts beginning on page 5, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3, 4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2022 Form IT-2104 and give it to your employer.

Who should file this form

This certificate, Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee’s pay. The more allowances claimed, the lower the amount of tax withheld.

If the federal Form W-4 you most recently submitted to your employer was for tax year 2019 or earlier, and you did not file Form IT-2104, your employer may use the same number of allowances you claimed on your federal Form W-4. Due to differences in federal and New York State tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers

For tax years 2020 or later, withholding allowances are no longer reported on federal Form W-4. Therefore, if you submit a federal Form W-4 to your employer for tax year 2020 or later, and you do not file Form IT-2104, your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim is different from federal Form W-4 or

87 Washington St., (P.O. Box 148) Rensselaer, NY 12144
PH: 518-449-1142   FX: 518-449-1320

SEXUAL HARRASMENT POLICY

I have read and completely understand the sexual harassment policy effective on August 6, 2020. I acknowledge that I am in receipt of this policy and understand that I may call the agency if I have any further questions regarding the policy.

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DRUG FREE WORKPLACE POLICY

Purpose and Goal

Accu Care Home Health Services, Inc is committed to protecting the safety, health and well being of all employees and other individuals in our workplace. We recognize that alcohol abuse and drug use pose a significant threat to our goals. We have established a drug-free workplace program that balances our respect for individuals with the need to maintain an alcohol and drug-free environment

  • This organization encourages employees to voluntarily seek help with drug and alcohol problems.

Covered Workers

Any employee who provides direct client care, supervises clients and/or employees, or is conducting business on the organization's behalf is covered by our drug-free workplace policy. Our policy includes, but is not limited to supervisors, full-time and part-time employees.

Applicability

Our drug-free workplace policy is intended to apply whenever anyone is representing or conducting business for the organization. Therefore, this policy applies during all working hours.

Prohibited Behavior

It is a violation of our drug-free workplace policy to use, possess, sell, trade, and/or offer for sale alcohol, illegal drugs or intoxicants

Prescription and over-the-counter drugs are not prohibited when taken in standard dosage and/or according to a physician's prescription. Any employee taking prescribed or over-the-counter medications will be responsible for consulting the prescribing physician and/or pharmacist to ascertain whether the medication may interfere with safe performance of his/her job. If the use of a medication could compromise the safety of the employee, fellow employees or the public, it is the employee's responsibility to use appropriate personnel procedures (e.g., call in sick, request change of duty, notify supervisor) to avoid unsafe workplace practices.

The illegal or unauthorized use of prescription drugs is prohibited. It is a violation of our drugfree workplace policy to intentionally misuse and/or abuse prescription medications. Appropriate disciplinary action will be taken if job performance deterioration and/or other accidents occur.

Notification of Convictions

Any employee who is convicted of a criminal drug violation in the workplace must notify the organization in writing within five calendar days of the conviction.

Accu Care Home Health Services will take appropriate action which may include but not limited to notification of NYS Department of Health Registry or NYS Department of Education Division of Professional Licensing within 30 days of notification.

Consequences

One of the goals of our drug-free workplace program is to encourage employees to voluntarily seek help with alcohol and/or drug problems. If, however, an individual violates the policy, the consequences are serious

In the case of applicants, if he or she violates the drug-free workplace policy, the offer of employment can be withdrawn.

If an employee violates the policy, he or she will be terminated from employment

Assistance

Accu Care Home Health Services, Inc recognizes that alcohol and drug abuse and addiction are treatable illnesses. We also realize that early intervention and support improve the success of rehabilitation. To support our employees, our drug-free workplace policy:

  • Encourages employees to seek help if they are concerned that they may have a drug and/or alcohol problem.
  • Encourages employees to utilize the services of qualified professionals in the community to assess the seriousness of suspected drug or alcohol problems and identify appropriate sources of help.

Treatment for alcoholism and/or other drug use disorders may be covered by the employee’s health insurance plan. However, the ultimate financial responsibility for recommended treatment belongs to the employee.

Confidentiality

All information received by the organization through the drug-free workplace program is confidential communication. Access to this information is limited to those who have a legitimate need to know in compliance with relevant laws and management policies.

Shared Responsibility

A safe and productive drug-free workplace is achieved through cooperation and shared responsibility. Both employees and management have important roles to play.

All employees are required to not report to work or be subject to duty while their ability to perform job duties is impaired due to on- or off-duty use of alcohol or other drugs.

In addition, employees are encouraged to:

  • Be concerned about working in a safe environment.
  • Report dangerous behavior to their supervisor.

It is the supervisor's responsibility to:

  • Inform employees of the drug-free workplace policy.
  • Observe employee performance.
  • Investigate reports of dangerous practices.
  • Document negative changes and problems in performance.
  • Counsel employees as to expected performance improvement.
  • Clearly state consequences of policy violations.

Communication

Communicating our drug-free workplace policy to both supervisors and employees is critical to our success. To ensure all employees are aware of their role in supporting our drug-free workplace program:

  • All employees will receive a written copy of the policy.
  • The policy will be reviewed in orientation sessions with new employees.
  • The policy and assistance programs will be reviewed at Quality Assurance meetings.

DRUG FREE WORKPLACE POLICY

Accu Care Home Health Services establishes that it will make a good faith effort to maintain a drug free workplace.

As an employee of Accu Care Home Health Services, Inc. you agree to the following:

  • I will not participate in the unlawful manufacturing, distribution, dispensing, possession, or use of a controlled substance in the workplace including illegal or unauthorized use of prescription drugs.
  • I have received Accu Care Home Health Services policy on Drug Free Workplace and have been given the opportunity to ask questions.

87 Washington St., (P.O. Box 148) Rensselaer, NY 12144
PH: 518-449-1142   FX: 518-449-1320

EMPLOYEE RESTRICTIVE COVENANT OF EMPLOYMENT

Under the terms of this agreement, the employee agrees that he / she will not, during the term of employment or for a period of ninety (90) days following the completion of services rendered by this agency, become employed either directly or indirectly, by any client for whom the employee provided services as an employee of Accu Care Home Health Services, Inc.

In the event that the employee shall violate this condition of employment, the employee Agrees to pay upon demand to Accu Care Home Health Services, Inc., liquidated damages in the amount of three thousand dollars ($3,000.00).

This covenant shall inure to the benefit of Accu Care Home Health Services, Inc. its successors and assigns.

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87 Washington St., (P.O. Box 148) Rensselaer, NY 12144
PH: 518-449-1142   FX: 518-449-1320

EMPLOYEE CONFIDENTIALITY STATEMENT

Disclosure of confidential information gained through your employment by Accu Care Home Health Services, Inc. is stated as an act of prohibited conduct subject to formal disciplinary action. Any information concerning a patient / client’s illness, family, financial condition or personal peculiarities is strictly confidential. When a patient / client’s history or condition is reviewed, it must be done in privacy with only those persons involved with the care of the patient / client. Any other information coming to you in the course of your work concerning another person or employee is also considered confidential and may not become the topic of conversation with others.

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87 Washington St., (P.O. Box 148) Rensselaer, NY 12144
PH: 518-449-1142   FX: 518-449-1320

BENEFITS PACKAGE COVER LETTER

TO: Full Time Employees

RE: Health Insurance

As of January 1st, 2016, it is a federal mandate that everyone is covered by health insurance that is affordable. It may be through your employer, Medicaid, Medicare, or purchased on a governmental health exchange network.

Enclosed are the plans Accu Care is offering to full time employees. Accu Care Home Health Services, Inc. will be contributing to a portion of your health insurance to help with affordability.

To be eligible you must have been working as a full-time employee for 1 year. Full time hours are defined as working an average minimum of 30 hour per week.

Please review the plans, fill out the Health and Dental Election Form, and return to the office.

You must sign and return the Election Form even if you do not wish to participate in our health plan.

Health and Dental Benefits Election Form 2022

Accu Care Home Health Services is offering the following benefit plans this election period. Please make your selections below, then sign and return this form to Amanda Creedon. Attached is the summary of the plans we are offering

You must SIGN and RETURN the form electing a plan OR waiving your participation.

Health Insurance

Please choose one of the following plans:

Health Insurance OPTION 1: CDPHP Platinum 121 OPTION 2: CDPHP Gold 221 OPTION 3: CDPHP Bronze 421 OPTION 4: MVP Bronze 6
Single $563.46 $394.87 $205.06 $230.53
E + Spouse $1466.06 $1128.87 $749.24 $800.19
E + Child(ren) $1195.28 $908.67 $585.99 $629.29
Family $2233.26 $1752.77 $1211.80 $1284.40

*Accu Care is contributing $339.13 per month for full-time employees towards any plan.

**Amounts shown are calculated after Accu Care’s monthly contribution.

Dental Insurance – CDPHP Delta Dental

Please choose one of the following coverage categories:

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EMPLOYEE BENEFITS

Listed below are the benefits that are offered by Accu Care Home Health Services.

*Check the item(s) you may be interested in:

Health Insurance: We offer CDPHP and MVP. You must work 30 hrs or more per week and have worked for this agency for at least 90 days. Insurance becomes effective on the 91st day from your hire date. Notify us no later than 45 days after hire date if you are interested.

Dental Insurance: We offer Delta Dental Insurance. You must work at least30 hours a week and have worked for this agency for at least 90 days. Insurance becomes effective on the 91st day from your hire date. Notify us no later than 45 days after hire date if you are interested.

Flexible Spending Account (FSA): A pre-tax spending account for employees who want to set aside money each week to pay for out-of-pocket medical expenses. You must work at least 36 hours a week and have worked for this agency for at least 90 days. Notify us no later than 45 days after hire date if you are interested.

AFLAC Accident and Supplemental Insurance: This is supplemental insurance that is designed to cover the gaps that your regular health insurance may have due to deductibles and co-payments. This may cover additional expenses that your primary insurance doesn’t cover, such as lost income and living expenses. We offer 1) Personal Accident Expense, 2) Cancer Protection, 3) Personal Sickness Plan, 4) Short Term Disability. You need to have worked for this agency for at least 90 days to be eligible for this plan.

Simple IRA Retirement Savings Program: A pre-taxed savings where the employer matches 1-3% of the employee contribution. You must meet the following criteria: 1) be an employee for 2 years, 2) have made a salary of $5,000 per year for the past 2 years, and 3) expect to earn $5,000 in the upcoming year.

Direct Deposit: You can have your checks direct deposited. You can also have a portion or sum put into a savings account. And they offer so much more. Please send in a copy of a voided check.

Please complete this form and return to the office.

ACCU CARE MEDICAL PLAN
    2022 January Medical Renewals    
  Current Plan Current Plan Current Plan Current Plan
Benefits/Services CDPHP Platinum 121 CDPHP Embrace Health Gold 221 CDPHP HDEPO Bronze 421 MVP Bronze 6 HDHP
Network EPO EPO EPO EPO
Metal Level Platinum Gold Bronze Bronze
HSA Eligible No No Yes Yes
  In-Network Only In-Network Only In-Network Only In-Network Only
Deductible N/A $250 Single/$500 Family (Embedded) $6,900 Single/$13,800 Family (Aggregate) $6,900 Single/$13,800 Family (Embedded)
Coinsurance N/A N/A N/A N/A
Out-of-Pocket Maximum $7,350 Single/$14,700 Family (Embedded) $7,150 Single/$14,300 Family (Embedded) $6,900 Single/$13,800 Family (Embedded) $6,900 Single/$13,800 Family (Embedded)
Preventive Annual Visit Covered in Full Covered in Full Covered in Full Covered in Full
Primary Care Co-Pay $20 Deductible then $30 Deductible then Covered In Full Deductible then Covered In Full
Specialist Co-Pay $20 Deductible then $50 Deductible then Covered In Full Deductible then Covered In Full
Inpatient Co-Pay $750 Deductible then $1000 Deductible then Covered In Full Deductible then Covered In Full
Outpatient Surgery $50 Deductible then $100 Deductible then Covered In Full Deductible then Covered In Full
Emergency Room/Ambulance $100 Deductible then $100 Deductible then Covered In Full Deductible then Covered In Full
Urgent Care $50 Deductible then $70 Deductible then Covered In Full Deductible then Covered In Full
Telemedicine $20 Deductible then $30 Deductible then Covered In Full $0, not subject to deductible
Drug Benefit: Generic/Brand Name/Specialty $4/$30/$60 $10/$50/$80, not subject to deductible Deductible then Covered In Full, preventive drugs not subject to deductible Deductible then $0, preventive drugs not subject to deductible
Dependent Coverage To Age 26 To Age 26 To Age 26 To Age 26
Additional: If Applicable N/A $200 Bonus Account per subscriber N/A N/A
         
Renewal Rates Renewal Rates Renewal Rates Renewal Rates Renewal Rates
Single $902.59 $734.00 $544.19 $569.66
Employee & Spouse $1,805.19 $1,468.00 $1,088.37 $1,139.32
Employee & Child(ren) $1,534.41 $1,247.80 $925.12 $968.42
Family $2,572.39 $2,091.90 $1,550.93 $1,623.53
         
Monthly cost to Employee Admin Admin Admin Admin
Single $563.46 $394.87 $205.06 $230.53
Employee & Spouse $1,466.06 $1,128.87 $749.24 $800.19
Employee & Child(ren) $1,195.28 $908.67 $585.99 $629.29
Family $2,233.26 $1,752.77 $1,211.80 $1,284.40
Accu Care's contribution per month $339.13 $339.13 $339.13 $339.13

ACCU CARE DENTAL PLAN
2022 January Dental Renewal  
  Current Plan
Benefits/Services CDPHP Delta Dental
PPO + Premier Comprehensive Plan M
Diagnostic 100%
Preventive 100%
Basic Restorative 80%
Oral Surgery 80%
Endodontics 80%
Periodontics 80%
Major Restorative 50%
Prosthodontics 50%
Implants 50%
TMJ Coverage 50%
Orthodontics 50%
Annual Maximum $2,000
Ortho Maximum $1,000
Deductible per Person $50
Deductible per Family $150
Deductible waived for Diagnostic and Preventive Yes
Annual Maximum Waived for Diagnostic and Preventive Yes
   
Renewal Rates Renewal Rates
Single $42.44
Employee & Spouse $90.41
Employee & Child(ren) $87.68
Family $141.84
   
Accu Care Does Not Contribute Towards Dental  

EMPLOYEE SAFETY & OUR COMMITMENT

Accu Care Home Health Services, Inc. is committed to the safety and well-being of all our employees. Every employee is entitled to a safe work environment. It is our commitment that all employees will have a safe environment and be provided with the proper equipment and training to perform their job in a safe manner.

Accu Care Home Health Services, Inc. will comply with all Federal, State, and local safety and health regulations.

We recognize that in home care each environment our employees encounter is different. We welcome your input on the safety concerns you may encounter in these environments. By working together, we can make sure each work environment continues to be a safe one for both employees and clients.

Thank you for your commitment and assistance.

22353                                   22353_2

As an employee you are required to work in a safe manner and follow safety policies, as well as report any situations that you feel may be unsafe.

I have read the commitment to safety policy and agree to follow the guidelines.

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CORRECT FOR RULES FOR LIFTING

There are a few simple rules to remember when lifting any object which will keep the possibility of strained muscles, pulled tendons, or stretched ligaments to a minimum. Of course, the possibility always exists of pulling a muscle even when using the proper lifting technique if the object is too heavy. The incidence of pulling or straining muscles increases proportionately to the incorrect technique used.

Some simple rules for lifting are as follows:

  • Always keep the object you are lifting near the vertical axis of your body
  • Keep the object as near the center of your body’s gravity as possible
  • Use the greatest possible number of muscles to lift the object
  • Always use the large muscles of your body for lifting such as the leg, arm, and shoulder muscle
  • Always lift in a vertical direction
  • Avoid twisting your body when carrying an object; instead, turn your whole body using your feet
  • Never have your muscles extended when lifting.

I HAVE READ THE ABOVE AND FULLY UNDERSTAND THESE RULES FOR LIFTING.

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Employee Acknowledgement for Providing Care During The COVID-19 Pandemic

The safety and health of our employees and clients is always the top priority at the Agency. We are committed to keeping you healthy, while continuing to provide essential health care services to our patients.

I, * , acknowledge that the Agency has set forth four required classes that must be completed by a caregiver prior to caring for any client(s) during the novel coronavirus (COVID-19) pandemic. These four required classes include:

  1. Infection Control
  2. Disaster Planning/Emergency Preparedness
  3. COVID-19 Program
  4. Donning and Doffing PPE

I understand the purpose of the education provided by the Agency is to ensure that all caregivers are trained to minimize the chances of COVID-19 infection, as well as transmission of COVID-19 to themselves, clients and those a caregiver comes into contact with. This training also is to further ensure that all caregivers are aware of, and can identify, the symptoms of COVID-19, as well as best practices for patient safety and screening. I will be notified and understand it is my choice to take a case with confirmed or suspected Covid-19.

I further acknowledge and understand that a failure to complete all of this education will put myself, my clients and all those I come in contact with at risk. It may also jeopardize my employment with the Agency.

I further acknowledge and understand that in addition to training, the Agency is taking certain precautions outlined by the Centers for Disease Control (“CDC”), Centers for Medicare and Medicaid Services (“CMS”), and the New York State Department of Health (“DOH”) for client and caregiver safety. Specifically, I acknowledge that the Agency is taking the following precautions and procedures, and that I am required to comply with the following, during the COVID-19 pandemic:

  1. I will answer the required health screening questions timely and accurately, on a daily basis, prior to arriving for work.
  2. I will self-monitor for fever by taking my temperature at least two times daily and will remain alert for respiratory symptoms. I will record this information on a daily basis as directed and will be able to provide my log to the Agency, if requested.
  3. I will screen all clients, as well as any other person who resides in or is present in the homecare setting for signs and symptoms of COVID-19, prior to providing services. If symptoms are noted, I will immediately inform my coordinator at the Agency before providing any further services.
  4. In the event that I exhibit a fever, respiratory and/or other COVID-19 symptoms, regardless of whether I have received a confirmed diagnosis. I will immediately inform my coordinator at the Agency, follow any directives from my coordinator concerning providing further services and comply with the Agency’s referral to my medical doctor or another healthcare provider.
  5. I will communicate with my coordinator if I believe I need personal protective equipment (“PPE”). I understand that the following options are available to me for obtaining PPE during the COVID-19 crisis:
    1. I may pick PPE up from the Agency’s local office;
    2. I may have PPE delivered to my home; or
    3. I may have PPE delivered to a client’s home.
  6. I will report any COVID-19 symptoms exhibited by clients to the Agency immediately. I will also make the Agency aware of any instances where another individual in the household is exhibiting signs or symptoms of COVID-19, or if I have been exposed to possible or confirmed COVID-19, regardless of whether the individual has received a confirmed diagnosis.
  7. I understand that in the event that one of my clients is suspected or confirmed to have or been exposed to COVID-19, I will be required to take certain additional steps to reduce the risk of transmission while providing services in the patient’s home. I will follow directions to be provided by my coordinator.
  8. I further agree to report any COVID-19 symptoms exhibited by other caregivers and/or a caregiver’s failure to comply with the requirements set forth in this document to the Agency immediately following the existing reporting procedures of the Agency’s employee handbook.
  9. I understand that I have access and should call the Agency 24 hours a day 7 days a week for reporting and guidance as needed.
  10. I am aware that Agency office staff has received education, and that policies are being regularly updated due to the fluidity of the crisis. I understand that the Agency is working with the relevant local and state agencies to make sure our COVID-19 policies reflect the most current information to keep us all safe, and that the foregoing procedures may need to be revised or additional procedures added. I understand that I can ask my coordinator for additional guidance in the event I have questions about any precaution or procedure and any such changes will be communicated through official notices by the Agency.

By executing this document, I acknowledge that I understand the nature and risks of the COVID-19 pandemic, the steps the Agency is taking to address such risks, prevent transmission, and have had the opportunity to ask and have questions answered. I understand that it is my responsibility to diligently follow the guidance provided by the Agency, as well as relevant CDC, CMS, and DOH guidance to protect myself, the Agency’s clients, the Agency and those with whom I come in contact.

I * certify that I have read the foregoing document and have had the opportunity to ask and have questions answered. I fully understand the requirements set forth herein and agree to comply with the requirements.

I further understand that failing to follow the precautions and procedures set forth in this document will be subject to immediate action and may result in disciplinary actions, including the possibility of termination of employment with the Agency.
Employee signature : *

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PDN New Hire Orientation Verification

I, , have attended orientation today with Accu Care Home Health Service, PDN division. I hereby agree that as an employee with Community Home Health Care, I am responsible for understanding and abiding by the policies and procedures set forth in the orientation and in the provided employee handbook.

Provided to me was the following, but not limited to:

HUMAN RESOURCES

  • EMPLOYMENT ACCEPTANCE LETTER
  • Labor Law
  • Job Description
  • Employee Handbook
  • Employee Benefits
  • Tax Forms (W-2, NY IT2014)
  • I9 Forms and Documents
  • Photo for ID Badge
  • Corporate Compliance
  • Whistle Blower
  • NYS Sexual Harassment
  • Culture of Safety
  • Accu Care Policies and Procedures
    • Code of Ethics
    • Non-Discrimination
    • Workplace Violence
    • Incident & Accident Reporting
    • Grievances and Complaint Procedures
  • Employee Confidentiality
  • Employee Covenant

HIPPA TRAINING

  • HIPPA Training
  • HIPPA Quiz

OSHA AND INFECTION CONTROL

  • OSHA Orientation
  • HIV Orientation & HIV Confidentiality
  • PPE Orientation
  • Quiz
  • COVID

Emergency Preparedness

  • Emergency Preparedness
  • How to Spot a Meth Lab

NURSING DOCUMENTATION & MEDICATIONS ADMINISTRATION

  • Plan of Care
  • Physician Justification Orders
  • Interim Physician Orders
  • Medication Administration Record (MAR)
  • As Needed Medication Log (PRN)
  • Narcotic Log
  • Medication Errors
  • Treatment Administration Record (TAR)
  • Nurses Notes
  • Seizure Log
  • Vent Record
  • Communication Log
  • Medication Quiz

CHILD ABUSE AND MANDATORY REPORTING

  • Child Abuse
  • NYS Mandatory Reporting

CLIENT’S RIGHTS

  • Client’s Bill of Rights
  • Advanced Directives

NURSING SKILLS LAB

  • G-tube Care/Medication and Feeding Administration
  • Trach Care
  • Ventilator/BIPAP/CPAP

I have been in serviced on the above material that allows me to work as a nurse for Accu Care Home Health Services INC. I am in receipt of copies of said materials or aware of how to locate them electronically. I understand that if I have questions at any time regarding the agencies policies including transcribing physicians’ orders on appropriate forms and the completion of agency records, I will consult my immediate supervisor.
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ACKNOWLEDGMENT OF RECEIPT

I hereby acknowledge receiving a copy of the Agency’s Handbook. I have had the opportunity to ask questions about the policies. As a condition of my employment with the Agency, I agree to comply with all the rules and procedures of the Agency, as stated in this Handbook and any other document that may be issued to me during my employment, including the FAIR AGREEMENT.

I understand that the Agency has the maximum discretion permitted by law to interpret, administer, add to, change, or delete provisions in this Manual and Handbook at any time.

Additionally, I acknowledge that no promise of job security has heretofore been given to me and that there are no such promises contained in the Handbook since I am employed AT WILL and may resign at any time or be fired from my job at any time, with or without notice and with or without cause.

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