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1
Application
Employment Interest
JOB DESCRIPTION
Skilled Nursing Checklist
Employment Verification Form
Non-Compete Agreement
DRUG SCREEN FORM
Confidentiality of Patient Information
RN/LPN Competency Exam
ELECTRIC MEDICAL RECORDS
New User Form
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Application
*Last Name
*First Name
Middle Initial
Other names by which you have been known (for date and reference verification)
*Social Security Number
*Permanent Address
*Driver’s License Number
*City
*State
*Zip Code
Country
Home Phone Number
Mobile Phone Number
*Email Address
Date of Application
*Are you either a U.S. Citizen or can you submit verification of your legal right to work in the U.S.?
Yes
No
*Are you under 18?
Yes
No
*Have you ever been convicted of an offense other than a minor traffic violation?
If yes, please attach a separate sheet with the date and nature of the offense(s). Convictions are evaluated for each position and are not necessarily disqualifying.
Yes
No
File Upload
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if yes, please indicate the date and nature of the offense(s). Convictions are evaluated for each position and not necessarily disqualifying.
Have you ever had your professional license or certification revoked, denied, suspended, reduced, limited, not renewed, voluntarily relinquished or place in probationary status?
(If yes, please attach a separate sheet with the date and nature of the offense(s).
Yes
No
File Upload
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if yes, please indicate the date and nature of the offense(s). Convictions are evaluated for each position and not necessarily disqualifying.
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Employment Interest
*Position Desired
Salary Desired ( NA for per diem )
Number of Years Experience
How many hours, on average, will you work per week?
Date Available
*Are you willing to work on weekends?
Yes
No
Will Consider
What shifts are you willing to work?
Day
Night
Any
Part-Time
*Do you have any transportation restrictions?
Yes
No
If yes, please specify:
What areas in the Chicagoland area can you cover?
Education and Training
Indicate last level completed:
*High School
Yrs
*College or University
Yrs
*Graduate School
Yrs
*Name, Address and Degree obtained from the School or College or the highest grade completed
Licensure, Certifications and Skills
License Type (Attach or Fax)
License picture upload
gif jpg jpeg png psd tif tiff
*License Number
*State/Province
Date
Certification (Attach or Fax)
Certification Type:
Certification Type:
Certification (Attach or Fax)
Exp Date
Exp Date
Certification (Attach or Fax)
Certification Type:
Certification Type:
Certification (Attach or Fax)
Exp Date
Exp Date
Attachment
doc docx mpg mpeg mp3 mp4 odt odp ods pdf ppt pptx txt xls xlsx jpg jpeg png psd tif tiff
Foreign Languages Read (indicate fluency)
References
*1. Name/Relationship
*2. Name/Relationship
3. Name/Relationship
Address
Address
Address
*Telephone Number
*Telephone Number
Telephone Number
Current Professional Information
Please list all full or part-time employment and military service for the past ten years. Begin with your present or most recent position.
*Are you employed now?
Yes
No
*If so, may we contact your present employer?
Yes
No
Do you have any exclusive contracts with other agencies that would restrict you from being employed by DirectMed Health Services?
Yes
No
Employment History
*Facility/Employer Name
Unit/Department
*City
*State/Province
Zip/Postal Code
Country
Date Employed, From
To
*Reason for leaving
Position Held
Discipline
Unit Specialty
Status
Full-time
Part-time
Per Diem
Temporary
Seasonal
Supervisor’s Name & Title
Base Rate of Pay
Per
Supervisor’s Phone
*Facility/Employer Name
*Unit/Department
*City
*State/Province
Zip/Postal Code
Country
Date Employed, From
To
*Reason for leaving
Position Held
Discipline
Unit Specialty
Status
Full-time
Part-time
Per Diem
Temporary
Seasonal
Supervisor’s Name & Title
Base Rate of Pay
Per
Supervisor’s Phone
Facility/Employer Name
Unit/Department
City
State/Province
Zip/Postal Code
Country
Date Employed, From
To
Reason for leaving
Position Held
Discipline
Unit Specialty
Status
Full-time
Part-time
Per Diem
Temporary
Seasonal
Supervisor’s Name & Title
Base Rate of Pay
Per
Supervisor’s Phone
Facility/Employer Name
Unit/Department
City
State/Province
Zip/Postal Code
Country
Date Employed, From
To
Reason for leaving
Position Held
Discipline
Unit Specialty
Status
Full-time
Part-time
Per Diem
Temporary
Seasonal
Supervisor’s Name & Title
Base Rate of Pay
Per
Supervisor’s Phone
Please document reasons for periods you were not employed. Supply an attachment if additional space is required
I attest that I am the applicant and the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from the program, and may be a violation of state law(s) that could result in civil penalties. The Company is authorized to obtain information from my current and previous employers, and to release information in support of my application (application references, background search results, etc.) to the Company’s client institutions. The Company may also share information regarding applicant’s employment with its affiliates and appropriate government or licensing entities, and send me employment opportunity-related information at fax numbers or email addresses that I provide. I understand that the Company, certain State’s and/or Client Institutions may require criminal background checks, and I consent to such checks. Prior to conduction any background checks that qualify as consumer or investigative consumer reports. I will be provided, and will return, separate disclosure and acknowledgement forms as required by the Company.
*Signature
Date
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Job Description
Title: Registered Nurse
Education/Qualifications:
• Registered Nurse currently licensed in the state of Illinois
• Graduate of NLN accredited nursing program
• Two years’ experience as a Registered Nurse is preferred
• One-year experience as a home health nurse is preferred
• Current CPR certification
• Excellent organizational and communication skills
Responsibilities:
Provide skilled nursing care in accordance with the plan or care approved and ordered by the patient’s physician or podiatrist.
• The Registered Nurse completes the initial evaluation visit including, but not limited to, completion of a comprehensive physical assessment, assessment of the patient and family knowledge about their medical condition.
• Develop a nursing diagnosis based on the patient’s medical challenges, identified knowledge deficits and on a completed medical assessment.”
• Provides services, treatments and instructions requiring substantial and specialized nursing skills.
• Initiates the plan of care per Physician or Podiatrist orders.
• Regularly re-evaluates the patients nursing needs and makes necessary revisions to plan of care after communication with the Physician, Clinical Manager and other treatment team members.
• Communicates all changes in plan to the patient/patient representative.
• Documents all patient care in the patient medical record by preparing clinical progress notes.
• Prepares a summary of patient’s progress and provides summary to Physician every 60 days.
• Counsels the patient and family regarding participation meeting clinical care goals.
• Initiates appropriate rehabilitative and preventive nursing procedures.
• Instructs the patient and family as appropriate on all aspects of their care and expected outcomes.
• Notifies the patient of expected visit by calling to schedule a date and time the day before the visit.
• Complies with all agency policies, procedures and protocols for providing quality patient care.
• Complies with all agency, state and federal policies and guidelines on patient confidentiality with regard to patient care and management of the patient medical record.
• Actively participates in all orientation and in-service programs.
Reporting Relationship:
• The Registered Nurse reports to the Director of Nursing/Designee
• She/He provides patient care supervision to the Licensed Practical Nurse and Home Health Aide.
• May be asked to participate in orientation of new staff.
Statement of Acceptance:
I have read and acknowledge the above job description and duties as listed. I understand the job requirements and agree to accept and carry out these responsibilities and other duties as assigned.
*Signature
Date
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Skilled Nursing Checklist
*Employee Name:
Check any
RN
LPN
Clinical Experience:
Please check the areas in which you have experience
Date
Plan Developed: OFFICE USE ONLY
Yes
No
Proficiency Level Key D = Daily; W = Weekly; O = Occasionally; N = Never
Experience Was Within 12 Months
Experience Was More Than 12 Months
Proficiency Level
Assessment Skills
Assessment Skills 12
Assessment Skills More then 12
Assessment Skills Proficiency level
Neurological
Neurological Within 12
Neurological More Than 12
Neurological Proficiency Level
Cardiovascular
Cardiovascular Within 12
Cardiovascular More Than 12
Cardiovascular Proficiency Level
Pulmonary
Pulmonary Within 12
Pulmonary More Than 12
Pulmonary Proficiency Level
Gastrointestinal
Gastrointestinal Within 12
Genitourinary More Than 12
Gastrointestinal Proficiency Level
Genitourinary
Genitourinary Within 12
Gastrointestinal More Than 12
Genitourinary Proficiency Level
Skin Care
Skin Care Within 12
Skin Care More Than 12
Skin Care Proficiency Level
Sterile Dressing Change
Sterile Dressing Change Within 12
Sterile Dressing Change More Than 12
Sterile Dressing Change Proficiency Level
Non-sterile Dressing Change
Non-sterile Dressing Change Within 12
Non-sterile Dressing Change More Than 12
Non-sterile Dressing Change Proficiency Level
Application of Skin Barriers
Application of Skin Barriers Within 12
Application of Skin Barriers More Than 12
Application of Skin Barriers Proficiency Level
Naso-Gastric Tube
Naso-Gastric Tube Within 12
Naso-Gastric Tube More Than 12
Naso-Gastric Tube Proficiency Level
Insertion
Insertion Within 12
Insertion More Than 12
Insertion Proficiency Level
Care
Care Within 12
Care More Than 12
Care Proficiency Level
Tracheostomy
Tracheostomy Within 12
Tracheostomy More Than 12
Tracheostomy Proficiency Level
Tube Change
Tube Change Within 12
Tube Change More Than 12
Tube Change Proficiency Level
Tube Care
Tube Care Within 12
Tube Care More Than 12
Tube Care Proficiency Level
Oxygen Therapy
Oxygen Therapy Within 12
Oxygen Therapy More Than 12
Oxygen Therapy Proficiency Level
Ventilator Care
Ventilator Care Within 12
Ventilator Care More Than 12
Ventilator Care Proficiency Level
Inhalation Treatments
Inhalation Treatments Within 12
Inhalation Treatments More Than 12
Inhalation Treatments Proficiency Level
Enteral Therapy
Enteral Therapy Within 12
Enteral Therapy More Than 12
Enteral Therapy Proficiency Level
Gastrostomy Tube Change
Gastrostomy Tube Change Within 12
Gastrostomy Tube Change More Than 12
Gastrostomy Tube Change Proficiency Level
Tube Care
Tube Care Within 12
Tube Care More Than 12
Tube Care Proficiency Level
Tube Feedings
Tube Feedings Within 12
Tube Feedings More Than 12
Tube Feedings Proficiency Level
Enema Administration
Enema Administration Within 12
Enema Administration More Than 12
Enema Administration Proficiency Level
Bowel Program
Bowel Program Within 12
Bowel Program More Than 12
Bowel Program Proficiency Level
Removal of Fecal Impaction
Removal of Fecal Impaction Within 12
Removal of Fecal Impaction More Than 12
Removal of Fecal Impaction Proficiency Level
Foley Catheter
Foley Catheter Within 12
Foley Catheter More Than 12
Foley Catheter Proficiency Level
Insertion
Insertion Within 12
Insertion More Than 12
Insertion Proficiency Level
Irrigation
Irrigation Within 12
Irrigation More Than 12
Irrigation Proficiency Level
Tube Care
Tube Care Within 12
Tube Care More Than 12
Tube Care Proficiency Level
Colostomy/Ileostomy Care
Colostomy/Ileostomy Care Within 12
Colostomy/Ileostomy Care More Than 12
Colostomy/Ileostomy Care Proficiency Level
Specimen Collection
Specimen Collection Within 12
Specimen Collection More Than 12
Specimen Collection Proficiency Level
Venipuncture
Venipuncture Within 12
Venipuncture More Than 12
Venipuncture Proficiency Level
Central Line Blood Sampling
Central Line Blood Sampling Within 12
Sputum More Than 12
Central Line Blood Sampling Proficiency Level
Sputum
Sputum Within 12
Sputum Within 12
Sputum Proficiency Level
Urine
Urine Within 12
Urine More Than 12
Urine Proficiency Level
Stool
Stool Within 12
Stool More Than 12
Stool Proficiency Level
Wound
Wound Within 12
Wound More Than 12
Wound Proficiency Level
Accucheck
Accucheck Within 12
Accucheck More Than 12
Accucheck Proficiency Level
IV Therapy
IV Therapy Within 12
IV Therapy More Than 12
IV Therapy Proficiency Level
IV Starts
IV Starts Within 12
IV Starts More Than 12
IV Starts Proficiency Level
Central Line Care
Central Line Care Within 12
Central Line Care More Than 12
Central Line Care Proficiency Level
Port-A-Cath
Port-A-Cath Within 12
Port-A-Cath More Than 12
Port-A-Cath Proficiency Level
Hickman
Hickman Within 12
Hickman More Than 12
Hickman Proficiency Level
Groshong
Groshong Within 12
Groshong More Than 12
Groshong Proficiency Level
Triple Lumen
Triple Lumen Within 12
Triple Lumen Proficiency Level
Triple Lumen More Than 12
Epidural Catheters
Epidural Catheters Within 12
Epidural Catheters More Than 12
Epidural Catheters Proficiency Level
TPN Administration
TPN Administration Within 12
TPN Administration More Than 12
TPN Administration Proficiency Level
Blood Transfusions
Blood Transfusions Within 12
Blood Transfusions More Than 12
Blood Transfusions Proficiency Level
Pain Management
Pain Management Within 12
Pain Management More Than 12
Pain Management Proficiency Level
Transfers
Transfers Within 12
Transfers More Than 12
Transfers More Than 12
Range of Motion Exercises
Range of Motion Exercises Within 12
Range of Motion Exercises More Than 12
Range of Motion Exercises Proficiency Level
Chemotherapy
Chemotherapy Within 12
Chemotherapy More Than 12
Chemotherapy Proficiency Level
Other Procedures/Skills
Other Procedures/Skills Within 12
Other Procedures/Skills More Than 12
Other Procedures/Skills Proficiency Level
Peritoneal Dialysis
Peritoneal Dialysis Within 12
Peritoneal Dialysis More Than 12
Peritoneal Dialysis Proficiency Level
Shunt Care
Shunt Care Within 12
Shunt Care More Than 12
Shunt Care Proficiency Level
Medication Set-ups
Medication Set-ups Within 12
Medication Set-ups More Than 12
Medication Set-ups More Than 12
Dietary Teaching
Dietary Teaching Within 12
Dietary Teaching More Than 12
Dietary Teaching Proficiency Level
Range of Motion Exercises
Range of Motion Exercises Within 12
Range of Motion Exercises More Than 12
Range of Motion Exercises Proficiency Level
Transfers
Transfers Within 12
Transfers More Than 12
THoyer Lifts Proficiency Level
Hoyer Lifts
Hoyer Lifts Within 12
Hoyer Lifts More Than 12
Hoyer Lifts More Than 12
Types of Clients
Types of Clients Within 12
Types of Clients More Than 12
Types of Clients Proficiency Level
Psychiatric
Pediatric More Than 12
Psychiatric More Than 12
Psychiatric Proficiency Level
Pediatric
Pediatric Within 12
Pediatric More Than 12
Pediatric Proficiency Level
Infants
Infants Within 12
Infants More Than 12
Infants Proficiency Level
Toddlers
Toddlers Within 12
Toddlers More Than 12
Toddlers Proficiency Level
School Age
School Age Within 12
School Age More Than 12
School Age Proficiency Level
Adolescent
AdolescentAge Within 12
Adolescent Age More Than 12
Adolescent Age More Than 12
Spinal Cord Injured
Spinal Cord Injured Within 12
Spinal Cord Injured More Than 12
Spinal Cord Injured Proficiency Level
Spinal Cord Injured
Spinal Cord Injured Within 12
Spinal Cord Injured More Than 12
Spinal Cord Injured Proficiency Level
Blind
Blind Within 12
Blind More Than 12
Blind Proficiency Level
Deaf
Deaf Within 12
Deaf Within 12
Deaf Proficiency Level
Aphasic
Aphasic Within 12
Hospice Proficiency Level
Aphasic Proficiency Level
Hospice
Hospice Within 12
Hospice Proficiency Level
Aphasic More Than 12
Immunosuppressed
Immunosuppressed Within 12
Immunosuppressed More Than 12
Immunosuppressed Proficiency Level
Transfers Proficiency Level
Medication Set-ups Proficiency Level
*Applicant Signature:
Date
Pre-Employment Employment Disclosure Authorization and Release
I understand that in connection with my application for employment, and/or continuous employment, DirectMed Health Services (“Employer”) IntelliCorp, their agents, assigns or any other authorized third parties (collectively, the “Investigators”) may be performing, requesting, obtaining or conducting a background check on me. This background check may include an inquiry into my employment history, education, general character or reputation, work experience, driving, criminal history and credit histories and such other information the (“Information”) as may be required.
I understand that employer may rely on any part or all of this Information in determining whether to extend an offer of employment to me. I further understand that if any adverse action is taken by employee, or if employer chooses not to extend an offer of employment to me based upon the Information, that I will be provided a copy of such information along with a summary of my rights under the Fair Credit Reporting Act.
I understand that the background check, which may be performed by Investigators, is being performed as part of the pre-employment process to evaluate me for employment, and is not conducted for any purpose other than in connection with my application for employment.
I have read this Pre-Employment Disclosure and, by signing below, hereby authorize Investigators to conduct a background check as described herein in conjunction with my application for employment. I hereby release any and all Investigators from any and all liability related to the procurement of disclosure of any information provided by me or obtained about me in connection with my Application with Employer. I further direct and authorize Investigators to conduct the background check and further authorize any third parties, who may be the custodians of or in possession of the requested Information, to disclose such Information to Investigators in connection with this background check.
*Signature
*Printed Name
*Date of Birth
*Date
*Social Security Number
Maiden Last Name (if applicable)
Current Address:
*Street
*City
*State
*Zip
Former Address:
*Street
*City
*State
*Zip
Adolescent Age Proficiency Level
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Employment Verification form 1
*Name
*Social Security Number
Job Title
*Employer
*City/State
*Employed from:
Address
Telephone Number
to:
I authorize DirectMed Health Services to verify the information I have provided. I release such persons from liability for providing such information.
*Signature
Date
Employment Verification form 2
*Name
*Social Security Number
Job Title
*Employer
*City/State
*Employed from:
Address
Telephone Number
to:
I authorize DirectMed Health Services to verify the information I have provided. I release such persons from liability for providing such information.
*Signature
Date
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Non-Compete Agreement
Date
*Employee Name
From: DirectMed Health Services
Subject: Employee Non-Compete Agreement
Employee Non-Compete Agreement
Effective Date:
Between DirectMed Health Services, LLC, hereinafter referred to as “[Company]” an Illinois Corporation located at 2600 South Michigan Avenue, Suite 410, Chicago, Illinois 60616
*and
Referred to "Employee" and illinois Resident
*Your physical address
Summary
Employee desires to give, and [Company] desires to receive from Employee, a covenant not to engage, either directly or indirectly, in competition with, or to solicit any customer, client, or account of [Company]. [Company] and Employee desire to set forth in writing the terms and conditions of their agreements and understandings. Employer or [Company], as used in this Agreement, shall include any corporation or entity which is at any time a parent or subsidiary of [Company].
NOW, THEREFORE, in consideration of the foregoing, of the mutual promises herein contained, and of other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto, intending legally to be bound, hereby agree as follows:
1. Covenants Against Competition
Employee acknowledges that the services to be rendered to [Company] have a significant and material value to [Company], the loss of which cannot adequately be compensated by damages alone. In view of the significant and material value to [Company] of the services of Employee for which [Company] has employed Employee; and the confidential information obtained by or disclosed to Employee as an employee of [Company]; and as a material inducement to [Company] to employ Employee and to pay to Employee compensation for such services to be rendered for [Company] by Employee (it is understood and agreed by the parties hereto that such non-competition shall also be paid for and received in consideration hereof as a result of Employees employment with [Company], Employee covenants and agrees as follows:
A. During Employee’s employment by [Company] and for a period of eighteen (18) months after Employee ceases to be employed by [Company], Employee shall not directly or indirectly, either for Employee’s own account or as a partner, shareholder (other than shares regularly traded in a recognized market), officer, employee, agent or otherwise, be employed by, connected with, participate in, consult or otherwise associate with any other business, enterprise or venture that would solicit or take [Company] patients. By way of example, and not as a limitation, the foregoing shall preclude Employee from soliciting business or sales from, or attempting to convert to other sellers or providers of the same or similar products or services as provided by [Company], any patient, customer, client or account of [Company] with which Employee has had any contact during the term of employment.
B. During employment and for a period of eighteen (18) months thereafter, Employee shall not, directly or indirectly, solicit for employment or employ any employee of [Company].
C. During employment, and thereafter [Confidentiality Period], Employee shall not disclose to anyone any Confidential Information. For the purposes of this Agreement, “Confidential Information” shall include any of [Company]’s confidential, proprietary or trade secret information that is disclosed to Employee or Employee otherwise learns in the course of employment such as, but not limited to, business plans, customer lists, financial statements, software diagrams, flow charts and product or treatment plans developed and/or marketed by [Company] including, but not limited to, its Dialysis Program. Confidential information shall also include patient information which is protected by law such as the Health Insurance Portability and Accessibility Act (HIPAA) for which must be complied with indefinitely. Confidential Information shall not include any information which; (i) is or becomes publicly available through no act of Employee, (ii) is rightfully received by Employee from a third party without restrictions; or (iii) is independently developed by Employee.
2. At-Will Employment
Employee acknowledges that Employee’s employment is “at will,” subject to applicable law, and that either [Company] or Employee may terminate employment at any time, with or without notice, for any reason or no reason whatsoever. Nothing in this Agreement shall constitute a promise of employment for any particular duration or rate of pay.
3. Accounting for Profits
Employee covenants and agrees that, if Employee shall violate any covenants or agreements in Section 1 hereof, [Company] shall be entitled to an accounting and repayment of all profits, compensation, commissions, remunerations or benefits which Employee directly or indirectly has realized and/or may realize as a result of, growing out of or in connection with any such violation; such remedy shall be in addition to and not in limitation of any injunctive relief or other rights or remedies to which [Company] is or may be entitled at law or in equity or under this Agreement.
4. Reasonableness of Restrictions
A. Employee has carefully read and considered the provisions of Section 1 hereof and, having done so, agrees that the restrictions set forth therein (including, but not limited to, the time period of restriction and the geographical areas of restriction) are fair and reasonable and are reasonably required for the protection of the interests of [Company], its officers, directors, shareholders and other employees.
B. In the event that, notwithstanding the foregoing, any part of the covenants set forth in Section 1 hereof shall be held to be invalid or unenforceable, the remaining parts thereof shall nevertheless continue to be valid and enforceable as though the invalid or unenforceable parts had not been included therein. In the event that any provision of Section 1 relating to time period and/or areas of restriction shall be declared by a court of competent jurisdiction to exceed the maximum time period or areas such court deems reasonable and enforceable, the agreed upon time period and/or areas of restriction shall be deemed to become and thereafter be the maximum time period and/or areas which such court deems reasonable and enforceable.
5. Burden & Benefit
This Agreement shall be binding upon, and shall insure to the benefit of, [Company] and Employee, and their respective heirs, personal and legal representatives, successors and assigns.
6. General Provisions
6.1 Non-Solicitation. Neither party shall solicit for employment or hire the other’s current or future employees, either directly or indirectly, during the Term of this Agreement, without obtaining the other’s prior written approval. Should an employee change employment from one party to the other, the new employer shall pay the old employer a fee equivalent to Twenty Percent (20%) of the employee’s new compensation, annualized for the first year.
6.2 Governing Law & Jurisdiction. This Agreement and the parties’ actions under this Agreement shall be governed by and construed under the laws of the State of Illinois, without reference to conflict of law principles. The parties hereby expressly consent to the jurisdiction and venue of the federal and state courts within the State of Illinois. Each party hereby irrevocably consents to the service of process in any such action or proceeding by the mailing of copies thereof by registered or certified mail, postage prepaid, to such party at its address set forth in the preamble of this Agreement, such service to become effective thirty (30) days after such mailing.
6.3 Entire Agreement. This Agreement, including the attached exhibits, if any, constitutes the entire Agreement between both parties concerning this transaction, and replaces all previous communications, representations, understandings, and Agreements, whether verbal or written between the parties to this Agreement or their representatives. No representations or statements of any kind made by either party, which are not expressly stated in the Agreement, shall be binding on such parties.
6.4 All Amendments in Writing. No waiver, amendment or modification of any provisions of this Agreement shall be effective unless in writing and signed by a duly authorized representative of the party against whom such waiver, amendment or modification is sought be to enforced. Furthermore, no provisions in either party’s purchase orders or in any other business forms employed by either party will supersede the terms and condition of this Agreement.
6.5 Notices. Any notice required or permitted by this Agreement shall be deemed given if sent by registered mail, postage prepaid with return receipt requested, addressed to the other party at the address set forth in the preamble of this Agreement or at such other address for which such party gives notice hereunder. Delivery shall be deemed effective three (3) days after deposit with postal authorities.
6.6 Costs of Legal Action. In the event any action is brought to enforce this Agreement, the prevailing party shall be entitled to recover its costs of enforcement including, without limitation, attorneys’ fees and court costs.
6.7 Inadequate Legal Remedy. Both parties understand and acknowledge that violation of their respective covenants and Agreements may cause the other irreparable harm and damage, that may not be recovered at law, and each agrees that the other’s remedies for breach may be in equity by way of injunctive relief, as well as for damages and any other relief available to the non-breaching party, whether in law or in equity.
6.8 Arbitration. Any dispute relating to the interpretation or performance of this Agreement shall be resolved at the request of either party through binding arbitration. Arbitration shall be conducted in Cook County, Illinois State in accordance with the then-existing rules of the American Arbitration Association. Judgment upon any award by the arbitrators may be entered by any state or federal court having jurisdiction. Both parties intend that this Agreement to arbitrate be irrevocable.
6.9 Delay is Not a Waiver. No failure or delay by either party in exercising any right, power or remedy under this Agreement, except as specifically provided in the Agreement, shall operate as a waiver of any such right, power or remedy.
6.10 Force Majeure. In the event that either party is unable to perform any of its obligations under this Agreement or to enjoy any of its benefits because of any Act of God, strike, fire, flood, governmental acts, orders or restrictions, Internet system unavailability, system malfunctions or any other reason where failure to perform is beyond the reasonable control and not caused by the negligence of the non-performing party (a “Force Majeure Event”), the party who has been so affected shall give notice immediately to the other party and shall use its reasonable best efforts to resume performance. Failure to meet due dates resulting from a Force Majeure Event shall extend such due dates for a reasonable period.
However, if the period of nonperformance exceeds sixty (60) days from the receipt of notice of the Force Majeure Event, the part whose ability to perform has not been affected may, by giving written notice, terminate this Agreement effective immediately upon such notice or at such later date as is therein specified. .
6.11 Non-Assignability & Binding Effect. Except as otherwise provided for within this Agreement, neither party may assign any of its rights or delegate any of its obligations under this Agreement to any third party without the express written permission of the other. Any such assignment is deemed null and void.
6.12 Severability. If any provisions of this Agreement are held by a court of competent jurisdiction to be invalid under any applicable statue or rule of law, they are to that extent to be deemed omitted and the remaining provisions of this Agreement shall remain in full force and effect.
6.13 Cumulative Rights. Any specific right or remedy provided in this Agreement will not be exclusive but will be cumulative upon all other rights and remedies described in this section and allowed under applicable law.
6.14 Headings. The titles and headings of the various sections and sections in this Agreement are intended solely for convenience of reference and are not intended for any other purpose whatsoever, or to explain, modify or place any construction upon or on any of the provisions of this Agreement.
6.15 Counterparts. This Agreement may be executed in multiple counterparts, any one of which will be considered an original, but all of which will constitute one and the same instrument.
6.16 Survival of Certain Provisions. The warranties and the indemnification and confidentiality obligations set forth in the Agreement shall survive the termination of the Agreement by either party for any reason.
Understood, Agreed & Approved
We have carefully reviewed this contract and agree to and accept all of its terms and conditions. We are executing this Agreement as of the Effective Date above.
Employee
*Signature
*Title:
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Quest Drug Screening Locations
Call 1-800-877-7484, Option 1 Available 24 hours per day,
7 days per week
Or
Log on to
www.questdiagnostics.com
Select “Find a Quest Diagnostic Location”
for drug screening locations, directions
and hours of operation
Hepatitis B Virus Vaccination Employee Options
*Employee:
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV) infection. I have been given the opportunity to receive the HBV vaccine series at no cost to myself.
I would like to receive the Hepatitis B vaccine series.
I decline the Hepatitis B vaccine series at this time.
Please Note:
Should you decline this vaccine, you continue to be at risk of acquiring Hepatitis B, a serious disease. If, in the future, you continue to have occupational exposure to blood or other infectious material, you may receive the vaccine at no cost.
The series consists of three (3) vaccinations. The initial vaccination, the second vaccine one month after the first, and the third vaccine five months later.
*Signature
Date
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Confidentiality of Patient Information
By accepting employment with DirectMed Health Services, I agree to carefully refrain from discussing any patient’s condition or personal affairs with anyone outside the agency, unless expressly authorized to do so. I will not share any medical information with other patients or visitors without written authorization provided to the agency by the patient and communicated to me by my immediate supervisor.
I acknowledge that all information seen or heard regarding patients, directly or indirectly, is completely confidential and is not to be discussed, even with my family or coworkers. My job as an employee requires that I govern myself by high ethical standards. Failure to recognize the importance of confidentiality is not only a breach of professional ethics, but can also involve an employee in legal proceedings. I will not share any information about patients or the agency with the media.
I acknowledge that I have been oriented to and understand the protection of Patient Identifying Information and protected health information as defined in the provisions of the Health Insurance Portability and Accountability Act of 1998 (HIPAA).
I have read and understand the above statement and agree to abide by these policies. I understand that a breach of policy my result in disciplinary action and possible dismissal from employment.
*Employee Signature
Date
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RN/LPN Competency Exam
1. Components of Standard Precautions would include all of the following except:
a. Wearing goggles to perform a daily bath
b. Wearing gloves to start a peripheral IV.
c. Wearing gloves and gown to clean up a patient with bloody diarrhea.
d. Disposing of used syringes without recapping needles.
2. Your bedridden patient has developed a right lower lobe pneumonia. She is on oral antibiotics for the infection. Which of the following nursing interventions is not appropriate?
a. Perform percussion and postural drainage as ordered.
b. Auscultate breath sounds during visit.
c. Administer expectorants as ordered.
d. Encourage low fluid intake to prevent fluid overload.
3. There is a small grease fire in the kitchen. You would do all of the following except:
a. Move your patient out of the home.
b. Call 911.
c. Pour water on the flames.
4. Your elderly patient tells you that her son is physically abusive to her. You notice bruises on her wrists and arms. All of the following actions are appropriate except:
a. Notify your supervisor.
b. Confront the son with the information.
c. Work with your supervisor to notify the physician, protective services, and social work, if appropriate.
d. Wait to see if the incident happens again.
e. B and D.
5. Your COPD patient is on 2LPM O2 via nasal canula. She complains of anxiety and feeling “air hungry.” Which of the following interventions is not appropriate?
a. Increase oxygen to 10 LPM
b. Elevate HOB to 90 degree.
c. Assist Patient to perform “pursed-lip” breathing.
d. Administer ordered IPPB treatment.
6. When assessing a patient’s lung sounds, the nurse should:
a. Only be concerned with listening at the front of the chest, below clavicles.
b. Auscultate at the apex and bases posterior by asking the patient to inhale deeply and exhale.
c. Have the patient cough to clear the upper airway passages. It isn’t necessary to auscultate with a stethoscope.
7. You are caring for a comatose patient. All medications are given via the G-tube. You notice the wife pouring medication directly from the bottle into the G-tube. As part of your family education, you would:
a. Explain to the wife to always check the tube for placement first. Otherwise she is doing fine.
b. Explain that you must check tube placement and measure the corret dosage of medication every time.
c. Explain that you must measure the correct medication dosage, but there is no need to check tube placement because you did that this morning.
d. Ignore the situation, as she is obviously doing her best in a difficult situation.
8. A common side effect of a narcotic pain medication is:
a. Diarrhea
b. Seizures
c. Constipation
9. Which of the following tests would be most specific for calculation of the daily dosage of anticoagulant?
a. Prothrombin time
b. Clotting time
c. Bleeding time
d. Sedimentation rate
10. Symptoms of hypoglycemia include:
a. Excessive sweating
b. Irritability, personality change
c. Faintness, not able to awaken
d. Hunger
e. Headache
f. Pounding of heart, trembling
g. Impaired vision
i. A, B, and C
ii. All except E
iii. All except G
iv. All of the above
11. A CHF patient has a 4lb. weight gain since your last visit. What actions should be taken?
a. Notify the physician.
b. Advise the patient to watch his carbohydrate intake.
c. Advise the patient to increase fluid intake.
d. Call 911.
12. The home health aide is responsible for all of the following except:
a. Light housekeeping.
b. Personal care of the patient.
c. Arranging ambulance transfer.
d. Participation in the plan of care.
13. A Hydrocolloid wound dressing (e.g., Duoderm) is used to:
a. Protect the skin.
b. Disinfect the wound.
c. Debride the wound.
14. Which of the following medications should not be crushes?
a. Morphine sulfate SR (MS Contin)
b. Acetaminophen (Tylenol)
c. Lasix
d. Warfarin (Coumadin)
15. An alginate wound dressing would be used for which of the following:
a. To treat a painful Stage II pressure ulcer.
b. To manage a highly draining Stage III pressure ulcer.
c. To treat an infected Stage IV pressure ulcer
d. All of the above.
Name
Signature
Date
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DirectMed Health Services
Electronic Document & Signature Authenticity Agreement
I understand that DirectMed Health Services staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents and other agency documents generated in the electronic system.
.
For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge the combined use of my Electronic Signature Passcode and Log in authentication password will serve as my legal signature. .
.
I understand that I will be required to update my password regularly for security purposes. I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of electronic signature, my documentation on the field-based or office computer. I understand that I am responsible for the security and accuracy of information entered into Axxess AgencyCore, and as such, I will: .
.
• Not share or otherwise compromise my electronic signature credentials (Log In authentication password or Electronic Signature Passcode).
• Exit the online application at the end of each working day or whenever the computer is not in my immediate possession.
• Not save my Log In password and Electronic Signature Passcode on the computer, but will enter them upon each access of the application.
• Review all of my documentation online prior to submitting to the agency server.
Employee Signature
Date
Electronic Signature Policy
Purpose:
To utilize current technology in the provision of patient care.
Policy:
DirectMed Health Services staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as authentication on patient record documents generated via Axxess AgencyCore.
Responsibility:
All personnel
Procedure:
1. DirectMed Health Services staff may create patient documentation via computer system.
2. For the purpose of the electronic medical record, and documents printed from the electronic medical record, the employee’s use of an Electronic Signature Passcode after authenticating with their system Log In password will serve as her/his legal signature.
3. The agency-based application administrator will issue each employee a system User Name and a temporary password. The user will create a new password upon initial log in to Agency Manager.
4. An Electronic Signature Passcode will be generated by the employee and will only be accessible to the employee.
5. Each user will be required to change their Log In authentication password for security reasons:
a. at the employee’s discretion
when there is reason to suspect a breach of secured access
6. If an Electronic Signature Passcode must be reset, only the user or the agency-based software administrator may reset the Electronic Signature Passcode by logging into the software.
7. After completion of a clinical document by the clinician her/his Electronic Signature Passcode must be entered to submit the clinical document to the case manager.
8. Each employee documenting electronically in the electronic medical record will be required to sign an Electronic Documentation & Signature Authenticity Agreement. This Agreement will require that he/she:
a. ensure the security of his/her Log In authentication password and Electronic Signature Passcode Information, which may not be shared with anyone,
b. all daily visits documentation to be completed and signed by the end of the day,
c. Oasis (SOC, ROC, Recerts, Discharges, Transfers) is to be completed with signature within 48 hours,
d. review all documentation prior to submission, and
e. exit the electronic medical record software at the end of each working day, when the computer will not be used for clinical documentation, and when the computer is out of her/his possession.
9. Each employee will review documentation and make necessary corrections per agency policy to documents returned by a case manager at which time the clinician will be required to re-enter the Electronic Signature Passcode to re-submit the documentation.
10. In the event of system downtime that results in the employee’s inability to use the electronic documentation system, the employee will complete records manually.
11. Each user must keep his/her Log In User Name, password, and Electronic Signature Passcode confidential.
12. Upon termination of employment, the administrator will immediately disable the employee user’s credentials to prevent access to the electronic medical record.
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New User Form
Email Address:
Name:
Address:
Phone Number:
Credential:
Title:
SSN:
User ID:
User Password:
Signature
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