Step 1
Premier care
Your Care, Is what we care about
Please make sure that you sign and date each page where signature and date needed.
Completed application must be submitted with the following documentation:
  1. Driver's License or Stare issued I.D. Card
  2. Social Security Card
  3. GED/High School or beyond Diploma
  4. Current Auto Insurance
  5. Results from current T.B Test
  6. Stare License (if you are HHA or CNA)
  7. CPR Certification, if you have it
Make sure all copies are legible. DO NOT SEND ORIGINAL DOCUMENTS AS WE CANNOT BE RESPONSIBLE FOR RETURNING THEM TO YOU.
Completed application may be given to employee of Premier Care or may be mailed to:
Premier Care
32744 5 Mile RD Suite B
Livonia, MI 48154
32744 5 Mile RD Suite B
Livonia, MI 48154

Tel 844-200-8679
CHAP
Contractual Employee Files Checklist
1. PERSONNEL FILE RIGHT SIDE  
Employee Action Form Completed  
Application/Resume (resumes perferred for profesional & mgt. Candidates)  
Diploma /Evidence of Training (CHAP)  
Professional License/Certification Expiration Date
On - Line Verification of License /Certification  
Authorization for Criminal Check (Michigan Workforce Background)  
Notification of Arraignment or Conviction  
Criminal Background Check Results  
Driver's License Copy Expiration Date
Code of Ethics/Compliance  
Confidentiality Statement Date Signed
Emergency Contact Information  
Employee Handbook/At Will Acknowledgments Form  
Job Description signed by Employee  
Copy of SSN  
Auto Insurance Copy Expiration Date
Competency Checklist Completed  
I-9 Form  
TB Evaluation  
TB Test Results Expiration Date
Direct Deposit (Optional)  
CPR (Optional) Expiration Date
W-4  
1099  
Conditional Job Offer  
References  
Premier Care
Home Health Solutions, Inc.
Employee Action Form
Last Name: First Name , MI:
Street Address: City, State, Zip, Code:
Social Security: Job Title:
DOH: Date of Birth: Pay Rate:
 
Type: Effective Date: Deduction:
Type: Effective Date: Deduction:
Type: Effective Date: Deduction:
Type: Effective Date: Deduction:
 
Previous Position: New Position:
Effective Date: Current Pay Rate: New Pay Rate:
Previous Status: New Status:
 
Previous Name: New Name:
Previous Fed Taxes: New Fed Taxes: Effective Date:
Previous State Taxes: New State Taxes: Effective Date:
 
Vacation Sick Bereavement Jury Duty FMLA Educational
Millitary Medical Personal Floating Holidays Others:
Total # of Hours: Effective Date: Date of Return:
 
Resignation Discharge Laid Off Retirement Others:
Reason:
Effective Date: Property Return: Final Check Paid:
Comments:
 
Manager's Signature: Date:
Executive's Signature: Date:
Employee's Signature: Date:
Home Health Care
Employment Application
Personal Data
Legal Name (Last , First, M.I.) Social Security Position Applyig for
Is there any additional information relative to change of change of name, us of an assumed name, or nickname necessary to permit a background check of your work and educational records? Yes NO If yes, please provide any past name (s) and date (s) used so we may verify employment and education.
Name From To Name From To
Address (List all addresses from the past 7 years.)
Current Address Street City State Zipcode years At Address
Current Address Street City State Zipcode years At Address
Home Telephone No. Current Work Telephone No. (Calls Kept confidential) Cellular Telephone No.
Email Address Can you produce evidence of the right to work while in the U.S.? Are you at least 18 years of age?
Yes No Yes No
What type of work are you interested in ? When will you be available for work? Have you ever held a position with the company? Yes No
Full time Part Time contingent If Yes, When? What Position?
Education
School Name (City, State Required) Major/Minor Graduate Type of Degree Grade Point Average
High School

Yes No
GED

College

Yes
No

Other

Yes
No

Licenses, Certifications, (Include agency and / or state of issue if applicable.)
Employment (List all employment during the past 10 years. If you need more space use additional Paper.)
(1) Employer's Name Address Street City State Zipcode
Job Title Supervisor's Name /Title Supervisor's Telephone No. Dates of Employment (mm/ yy)
From To
Beginning Compensation Ending Compensation Base Salary / Wages Reason For Leaving:
(2) Employer's Name Address Street City State Zipcode
Job Title Supervisor's Name /Title Supervisor's Telephone No. Dates of Employment (mm/ yy)
From To
Beginning Compensation Ending Compensation Base Salary / Wages Reason For Leaving:
(3) Employer's Name Address Street City State Zipcode
Job Title Supervisor's Name /Title Supervisor's Telephone No. Dates of Employment (mm/ yy)
From To
Beginning Compensation Ending Compensation Base Salary / Wages Reason For Leaving:
Step - 2
U.S Military (Active Duty including Reserve or National Guard Service.)
Branch of Service Rank Type of Discharge Special Skills of Training Acquired in Service
Computer Skills
Typing List software packages with which you have experience.
wpm
Languages
Language Speak
Read
Write		 Language Speak
Read
Write 		Language Speak
Read
Write
Background Information
When completing this section, do not discuss information regarding convictions that have been judicially erased, sealed, expunged, impounded,or dismissed. Do not disclose information regarding juvenile court convictions or minor traffic violations. A conviction record does not automati cally ban you from employment. All of the job-related circumstances surrounding convictions will be considered.
1. Have you been convicted of , pled guilty or no contest to, been imprisoned, or no probation or parole for any felony?
2. Are you currently on probation ?
4. If you answered Yes to any of these questions above, please explain the number of convictions, how recent the offense(s), and sentence imposed :
Business References (provide two references other than relatives or employers)
Name Job Title Addresses Telephone No.
 
How Were You Referred To The Agency ?
Print Advertisement     Internet
Employee Referral (Name)     Other
PLEASE INDICATE YOUR SCHEDULE AVAILABILITY, TRAVEL AVAILABILITY AND SKILLS
Please circle days available per week M T W TH F SA SUN comments:
Please indicate times available per day:
Number of weekends available to work
per month:
What locations (area, cities) are you
willing to work?
Willing to drive
Agreement miles each way to work Clinical Experience: Home Care Hospital: ICU OTHER
GENERAL INFORMATION I understand making false statements or omitting facts on this application is sufficient cause for rejection of this application or dismissal form employment. I understand the issuance of this application does not in any way obligate the Company to hire me. If hired, In am willing to abide by all present and future rules and regulations of the company. I understand that my employment can be terminated with our without cause and with or without notice at any time at the option of either the Company or myself subject to applicable Laws. I also understand no representative has the authority to guarantee employment for any specified period of time or to make any agreement contrary to the foregoing (with exception of the company's President/CEO, in writing). I declare my answers to the questions on this application are true.RELEASE OF PERSONAL INFORMATION I hereby authorize the Company to collect, use, store, transfer, and purge my personal information. I understand that I can request additional information on the purpose, use, and choices relation to the personal information that I provide.RELEASE FOR REFERENCE CHECKS I authorize the company to contact my previous employers for work related references.RELEASE FOR REFERENCE CHECKS I authorize the Company to verify any information that I provide in connection with my employment. I release the company and its authorized representatives of all liability resulting from the use of background information about me for employment purposes.
Willing to drive
  Applicants Signature Date
Mc Guffey
Home Health Care L.L.C.
CANDIDATE EVALUATION
Please answer the following questions as they pertain to the requirements of the job:
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
Exceeds Requirements Meets Requirements Below Requirements  
Comments
 
 
 
 
MICHIGAN DEPARTMENT OF STATE POLICE
Central Records Division - Application Identification Team
7160 Harris Drive
Lansing, MI 4813
POLICE CHECK CONSENT FORM
As a prospective employee of Premier Home Health Care:

I understand that it is the Agency’s policy to secure conviction criminal history information as a part of their pre-employment screening process and it utilizes the requested information below

I understand the below information is required by the Central Records Division of the Michigan State police, Lansing, MI and I authorize Premier Home Health Care to utilize the information for the sole purpose of obtaining a conviction only Criminal History File Search.

Applicant Name:
  Last First Middle
 
Maiden Name(s) or Names previously used:
Date of Birth: Race: Sex:
Social Security Number:    
Driver's License Number:  
Premier Home Health Solutions, Inc.
1380 Coolidge Hwy , Suite 210
Troy, MI 48084
248-591-9200
Step - 3
State of Michigan
DEPARTMENT OF COMMUNITY HEALTH
DEPARTMENT OF HUMAN SERVICES
Lansing
        
Health Facility/ Agency:
Pursuant to Michigan Public Acts 27, 28, and 29 of 2006 (MCL 330. 1134a, MCL 333. 20173a and MCL 400. 734b), it is required that as a condition of continued employment in a health facility or agency (hereinafter defined as a nursing home, county medical care facility, hospice, hospital that provides bed services, home for the aged, or home health agency, psychiatric hospital, or ICF/MR) or adult foster care facility, each employee, independent contractor, or individual granted clinical privileges shall agree in writing that he or she will report to the health /adult foster care facility or agency immediately upon being arraigned on a felony charge and upon being convicted of one or more of the criminal offenses listed below. Reporting of an arraignment is not cause for termination or denial of employment.
a) Relevant Crime Described under 42 USC 1320a-7 is a statutory provision within the Federal Social Security Act Which describes a number of crimes for which a conviction will exclude an individual from participation in any federal health care program. The crimes include patient abuse, health care fraud, as well as any crimes related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
b) Felony - Any felony or an attempt or conspiracy to commit any felony, or any other state or federal crime that is similar to the felonies described below:
i.) A felony that involves the intent to cause death or serious impairment of a body function, that result in death or serious impairment of the body function that involves the use of force or violence, or that involves the threat or the use of force or violence.
ii.) A felony involving cruelty or torture.
iii.) A felony under chapter XXA of the Michigan Penal Code, 1931 PA 328, MCL 750. 145m to 750.145r. These statutory citations refer to crimes committed against “vulnerable adults,” i.e., individuals aged 18 and over who , because of age, developmental disability, mental illness, or physical disability, require supervision or personal care or lack the personal and social skills required to live independently.
iv.) A felony involving criminal sexual conduct.
v.) A felony involving abuse or neglect.
vi.) A felony involving the use of a fire arm or dangerous weapon.
vii.) A felony involving the diversion of adulteration of a prescription drug or other medications.
viii.) Any other felony.
c) Misdemeanor - Any misdemeanor, or a state or federal crime that is substantially similar to the misdemeanors described below:
i) A misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat of the use force or violence.
ii) A misdemeanor that involves vulnerable adult abuse under chapter XXA of the Michigan Penal Code, 1931 PA 328, MCL 750. 145m to 750.145r.
iii) A misdemeanor involving criminal sexual conduct.
iv) A misdemeanor involving cruelty or torture.
v) A misdemeanor involving abuse or neglect.
vi) A misdemeanor involving cruelty if committed by an individual who is less than 16 years of age.

DCH - 1373 (Revised 1/24/2007)
ivii) A misdemeanor involving home invasion.
viii) A misdemeanor involving embezzlement.
ix) A misdemeanor involving negligent homicide.
x) A misdemeanor involving larceny.
xi) A misdemeanor of retail fraud in the second degree.
xii) Any other misdemeanor involving assault, fraud, theft, or the possession or delivery or a controlled substance.
xiii) A misdemeanor for assault if there was no use a firearm or dangerous weapon and no intent to commit murder or inflict great bodily injury.
xiv) A misdemeanor of retail fraud in the third degree.
xv) A misdemeanor under part 74 of the Public health Code, 1978 PA 366, MCL 333. 7401 to 333.7461 involving the creation, delivery, or possession with intent to manufacture or deliver a controlled substance.
xvi) A misdemeanor under part 74 of the Public Health Code, 1978 PA 336, MCL 333. 7401 to 333.7461 involving the creation, delivery, or possession with intent to manufacture or deliver a controlled substance, if the individual, at the time of conviction, is under the age of 18.
xvii) A misdemeanor for larceny or retail fraud in the second or third degree if the individual , at the time of conviction, is under the age of 16.
I agree to report to the health/ adult foster care facility or agency immediately upon being arraigned on a felony charge and upon being convicted of one or more of the criminal offenses listed above.
I agree to immediately report If I become the subject of an order or disposition finding of not guilty by reason of insanity under Section 16b of Chapter IX of the Code of Criminal Procedures, 1927 PA 175, MCL 769.16b.
I also agree to immediately report upon becoming the subject of a substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuant to an investigation conducted in accordance with 42 USC 1395i-3 or 1396r. This statutory citation refers to violations of those provisions of the federal Social Security Act that set forth requirements for skilled nursing facilities and nursing facilities, respectively.
Further, I understand that the new background check requirements stipulate that within 24 months after the effective date of April 1,2006, all current employees, independent contractors, or individuals granted clinical privilege's shall provide the Michigan State police with a set of fingerprints for input into the automated fingerprint identification system database that would provide for an automatic notification if and when subsequent criminal arrest fingerprints matches a set of fingerprints previously submitted. I agree to provide same when requested by the employer.
 
Print Name    
 
Signature   Date
 
DCH - 1373 (Revised 1/04/2007)
STATE OF MICHIGAN
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS
DEPARTMENT OF HUMAN SERVICES
LONG TERM VARE WORKFORCE BACKGROUND
CHECK CONSENT AND DISCLOSURE
Part 1 - Consent
Part 2 - Applicant Information
Part 3 - Disclosure
Part 4 - Conditional Employment
Part 5 - Applicant Rights
MCL 333.20173a, MCL 333.1134a, and MCL 440.734b require that a heath facility/agency that is a:
  • psychiatric facility
  • hospital that provides swing bed services
  • ICF/MR
  • home for the aged
  • nursing home
  • home health agency
  • country medical care facility
  • hospice
  • adult foster care facility (AFC)
Shall not employ, independendtly contract with, or grant clinical privileges to an individual who regularly has Direct access to or provides direct services to patients or residents in the health facility/agency or AFC until The health facility/agency or ACF conducts a fingerprint-based criminal history check.
An individual who applics for employment either as an employee or an independent Contractor or for Clinical privileges with a health care facility / agency or AFC and has received a good faith offer of Employment, an independent contract, or clinical privileges shall give written consent at the time of Application for the health vare facility/agency or AFC to conduct a criminal history check, including a state And federal Bureau of Invertigation (FBI) fingerprint-based cheak, and shall give a written statement Disclosing that he or she has not been convicted of a crime that would prohibit employment.
NOTE: Throughout this form:
  • "Employmente" includes persons independenty contracted with and/or those granted clinical privilegeas
  • Clinical privileges do not apply to adult foster care facilities.
Health Facility or Agency
The health facility /agency or AFC:
a. May not Knowingly employ a worker, having direvt access to patients or resdents, who has been Convicted of a disqualifying crime or has been of a state or federal agency substantiated Finding of patient or resident neglect, abuse, or misappropriation of property.*"Direct access means regular access to a patient or resident, or to a patient's or resident's property, financial information,medical records, treatment information,or any other identifying information.
b. May terminate the background check or decide not to hire the individual at any stage of the proess.
c. Must ensure that any background check information provided will only be used the purpose of determining an individual's suitability for employment in a long - term vare setting.Must retain verification of compliance with background check requirments.
d. Will make the employment decision.

* This does not include a finding of abure, neglect, or misappropriation (financial exploitation) substantiated Under the Michigan Mental Health Code or Adult P rotective Servies Act.
BHCS-LTS-107(Rev.1/10)
Page 1 of 5
The Michigan Department of Licensing & Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age,national origin, colour marital status, disability. Or political beliefs. You may make your needs known to this Agency under the Americans with Disabilities Act if you need assistance with reading, writing,hearing.etc
Part 1 - Consent to Conduct Background and Criminal Record Checks
As a condition of being considered for employment :
a. I hereby consent to and authorize the health facility/agency or AFC to conduct a background check that Includes a search of state and federal abuse and neglect registries and databases, in addition to a Fingerprint-based search of state and federal criminal history records. I understand that this consent Extends to the release and sharing of such information with the Michigan Departments of Licensing and Regulatory Affairs, Human Services, and State Police

b. I further understand the Michigan State Police (MSP)and the Federal Bureau of Investigation(FBI) may also retain the submitted information and fingerprint as permitted by the Federal Privacy Act of 1974 (5 USC § 552a (b))for routine uses beyond the principal purpose listed adove. Routine uses include ,but Enforcement , counterintelligence, national security, or public safety.

c. I hereby authorize the release of any relevant information to the health facility/agency or AFC to be used To conduct the background check as required under MCL 333.20173a,MCL333.1134a, and MCL 440.73b.

d. I understand, except for a knowing or intentional release of false information, the health facility/agency Or AFC has no liability in connection with a background check conducted under MCL 333.20173a, MCL 333.1134a, and MCL 440.734b or the release of criminal record information for the Purposes of making an employment decision.

e. I understand that the health facility / agency or AFC will make the final employment determination. also understand that the health facility/agency or AFC may terminate the background check or decide not to hire me at any stage of the process.

 
Signature of Applicant   Date
 
BHCS-LTS-107(Rev.1/10)
Page 2 of 5
The Michigan Department of Licensing & Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, colour marital status, disability. Or political beliefs. You may make your needs known to this Agency under the Americans with Disabilities Act if you need assistance with reading, writing,hearing.etc.
Step - 4

Part 2 - This employment applicant information is required to process a complete and accurate Criminal record check.
First Name:      
Middle Name:      
Last Name:   Suffix:
First Name:      
Middle Name:      
Last Name:   Suffix:
Date of Birth:      Country of Citizenship:
Place of Birth(City, State/Province):       
Height: Weight: Hair Color: Eye Color: Gender: Female Male
Race: Asian Black Hispanic Native American Pacific Islander White All
Social Security Number:         
Street Address:
City: State Zip Code Country  
Job Title:     Conditional Hire:
Driver’s License or State/conadian ID:
State/Prov. 		   
License/ID Number
Has this employment applicant resided in Michigan continuously for the past 12 month?   Yes No
1. License/ Certification Number:  
2. License/ Certification Number:  
3. License/ Certification Number:  
BHCS-LTS-107(Rev.1/13)
Page 3 of 5
The Michigan Department of Licensing & Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color marital status, disability. Or political beliefs. You may make your needs known to this Agency under the Americans with Disabilities Act if you need assistance with reading, writing, hearing. etc.
Part 3 - Employment Applicant Disclosure Statements
The following conviction and/ or findings may disqualify you from working in a long –term Care facility/agency or AFC. ”Conviction” includes any plea of guilty or nolo contender (no contest), including cases that resulted In a deferred sentence or delayed sentence.
a. Relevant Crime Described under 42 USE 1320a-7- The crimes include patient abuse, health care fraud, and any crimes related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
b. Felony - Any felony, or an attempt or conspiracy to commit any felony.
c. Misdemeanor - Any state or federal crime that is substantially similar to the misdemeanors described below :
  • Any misdemeanor involving or the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat of the use of force or violence.
  • Any misdemeanor for assault if there was no use of a firearm or dangerous weapon and no intent to Commit murder or inflict great bodily injury.
  • Any misdemeanor involving home invasion.
  • Any misdemeanor involving embezzlement, larceny, fraud, theft or second or third degree retail fraud.
  • Any misdemeanor involving negligent homicide.
  • Any misdemeanor involving the possession, use or delivery of a controlled substance.
  • Any misdemeanor involving the creation, delivery, or possession with intent to manufacture or deliver a Controlled substance.
d. Any finding of Not Guilty by Reason of Insanity
e. A substantiated finding of patient or resident neglect, abuse, or misappropriation of property resulting from an investigation conducted in accordance with 42 USC 1395i or 1396r*
Listed below are all offenses that I have been convicted of, including all terms and conditions of sentencing, parole and Probation, and/or a substantiated finding of patient or resident neglect, abuse, or misappropriation of property. Listed below are also all PENDING FELONY change currently alleged against me.
Offense Date of
Conviction/Finding/
Charge (if pending)		 City State Sentence Date of Discharge
I certify that the above statements are correct and complete to the best of my Knowledge.
 
Signature of Applicant   Date
 
BHCS-LTS-107(Rev.1/13)
Page 4of 5
The Michigan Department of Licensing & Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age, national origin, color marital status, disability. Or political beliefs. You may make your needs known to this Agency under the Americans with Disabilities Act if you need assistance with reading, writing, hearing. etc.
Part 4 - Conditional Employment
If the health facility/agency or AFC determines it necessary to employ me pending the results of the state and federal criminal history background check, I understand following:
a. If the background check reveals disqualifying information my employment will be terminated for good cause, unless and until I successful prove that the disqualifying information is inaccurate, expunged orb set aside.
b. If I knowingly provided false information regarding my identity, criminal conviction, or substantiated findings of patient or resident neglect, abuse, or misappropriation of property, I may guilty of a misdemeanor punishable by imprisonment for not more than 93 days and/or a fine of not more than $500.00.
c. I understand that as a condition of continued employment, I am required to report in writing to the health facility/agency or AFC immediately upon being arraigned on a felony charge or convicted of one or more of the criminal offenses as described in MCL 333.20173a. MCL 330.1134a. and MCL 444.734b,or upon being the subject of an order or dispositional finding of “Not Guilty by Reason of Insanity”, or upon being the subject of a state or federal agency substantiated finding of patient or resident neglect, abuse, or misappropriation of property.*Reporting of an arraignment is not cause for termination or denial of employment.
 
Signature of Applicant   Date
 
Part 5 - Applicant Right
a. I understand that upon my request, the health facility/agency or AFC can provide a copy of any disqualifying record information found on any of the relevant registries or databases.
b. I understand that if I believe the results of any disqualifying information found on any relevant registry information
c. I understand that if I believe the results of the criminal history fingerprint record are inaccurate ,or if the conviction contained in the criminal history record is one that may be expunged or set aside, I may file an appeal with the Department of Licensing and Regulatory Affairs and /or Department of Human Services.
 
Signature of Applicant   Date
 
Part 6 - Disclaimer
The State of Michigan is not responsible for any additional information, requirements, or use of any substitute forms that the above named health facility/agency or AFC provides to the applicant.
BHCS-LTS-107(Rev.1/10)
Page 5 of 5
The Michigan Department of Licensing & Regulatory Affairs will not discriminate against any individual or group because of race, sex, religion, age,national origin, color marital status, disability. Or political beliefs. You may make your needs known to this Agency under the Americans with Disabilities Act if you need assistance with reading, writing, hearing. etc.
Personnel
  • The Agency shall provide employees with access to written personnel policies.
  • The Agency shall prove employees with an ongoing evaluation process.
  • The Agency shall be and equal opportunity employer and comply with all applicable laws, rules, and regulations and shall hire qualified staff and utilize them at the level of their competency.
  • The Agency shall provide supervision to all staff.
  • The Agency shall provide staff with continuing education and in-service training.
  • The Agency shall strive to maintain adequate staffing to meet specified needs of the patient.
  • The Agency shall provide employees with a mechanism to address ethical, cultural, or other personnel issues.
Employee Responsibilities:
  • To participate and contribute their talents to foster a dynamic, progressive organization from which everyone can benefit professionally.
  • To comply with all application laws, rules, and regulations.
  • To actively participate in continuing education and in-service training.
  • To refrain from paying or accepting and kickback.
  • To comply with all Federal HIPAA regulations regarding confidentiality of patient information. To sign a confidentiality Agreement.
  • To report any and all unethical business practices or unlawful actions by the Agency. Failure to do is considered misconduct warranting disciplinary action up to and including termination.
  • To abide by all Agency policies and procedures. The policies and procedures of the Agency reflect mutual cooperation among employees in attaining goals that assure quality care for patients and families.
Compliance Reporting
Employees are made aware of the Agency of the Agency’s compliance policy and procedure which allows employees to address external and internal issues or concerns including but not limited to patient right, patient/family responsibilities, Agency right, Agency responsibilities, Inter-agency relations. Agency marketing and public relations and personnel. Employees are instructed to contact the Compliance Officer by phone or in writing indicating their name and contact information. The designated representative will contact the employees as soon as possible. All information will be held in strict confidence.
I understand and agree to comply with the Agency’s Compliance and Code of Ethics policy.
   
Employee Signature     Date
 
Step - 5

Mc Guffey
Home Health Care L.L.C.
CONFIDENTIALITY STATEMENT

The Employee will perform services for Premier Home Health Solutions, Inc. Which may require it to disclose confidential Information and proprietary information (“Confidential any Information”) to the Employee. Confidential information is any Information of and kind, nature, or description concerning any matters affecting or relating to the Employee’s services for the Agency , the business or operations of the Agency , and/ or the services, plans, processes, or any other data of the Agency.

As a user of information at the Agency you may develop, use, or maintain patient information (for health care, quality improvement, peer review, education, billing, reimbursement, administration, or other purpose), personnel infomation (for employment, payroll, or other business purposes)or confidential business information of the Agency such as employees lists, client lists, financial information , marketing and sales processes. This information from any sources and in Any form, including, but not limited to paper record, oral/ written communication, audio recording, and electronic display is strictly confidential . Access to Confidential Information is permitted only on a need-to-Know basis and limited to the minimum amount of Confidential Information necessary to accomplish the intended purpose of the use, disclosure or request.

It is the policy of the Agency that employees will respect and preserve the privacy, confidentiality and security of Confidential Information. Violations of this statement include, but are not limited to:
  • Accessing information that is not within the scope of our duties.
  • Misusing, disclosing without proper authorization, or altering Confidential Information.
  • Disclosing to another persona your sing-on code and/or password for accessing electronic or Confidential Information or for physical access to restricted areas.
  • Using another person’s sign on code and/ or password for accessing electronic Confidential Information or for physical access to restricted areas.
  • Intentional or negligent mishandling or destruction of Confidential Information.
  • Attempting to access a restricted area without proper authorization or for purpose other than official Agency business.
Violations of this statement may constitute grounds for disciplinary action up to and including termination of employments Unauthorized use or release of confidential information may also subject the violator to personal, civil, and/ or criminal Liability and legal penalties.

The Employee will, upon the request or upon termination of his/her relationship with the Agency, deliver any notes, Documents, equipment, and materials received from the Agency or Originating from its activities for the Agency.

I have read and agree to comply with the terms of the Confidentiality statements and will read and comply with the Agency’s Privacy Confidentiality of Protected Health Information(PHI) policy as applicable, a copy of which will be Provided.
 
Employee Signature   Date
 
 
Printed Employee Name  
 
Premier care
Home Health Solutions, Inc.
CONFLICTS OF INTEREST AGREEMENT

In order to safeguard the activities and assets Premier Home Health Solutions, Inc. employees of the Agency should not have Interest in outside business which conflict or appear to conflict with their ability to act and make independent decision in the best interest of the Agency.

Employees is considered to have an interest in an outside business if the Employee or any member of this his/her immediate Family holds and ownership in the business or its property; furnishes goods or services to the business’ is a creditor, employee, agent, officer, director, or consultant of the business. Outside businesses include any person, firm, corporation or government agency that sells or provides a services to, purchase from or competes with the Agency.

At the time of hire, and periodically as requested, all employees will be required to complete and Agreement concerning Ethical standard of conduct& conflict of interest. All Employees are expected to exercise good judgement and discretion Employee should discuss it with Premier Home Health Solutions, Inc..

The Agency expects its employees to observe the highest standards of business ethics. No employee should take any action On behalf of the Agency that they Know, or reasonably should Know, violates any applicable law or regulation. This obviously includes such activities of bribery, kickback, falsehoods, and misrepresentations.

The Agency prohibits all employees from accepting gift, gratuities, or entertainment from individuals or firms with whom the Agency conducts business or provides services. Its is also a violation to give gifts to individuals or firms whom the Agency conducts business. excluded from this prohibition is the exchange of normal business courtesies such as luncheons or dinners, when they are proper and consistent with regular business practice. Also excluded are advertising/ promotional material and holiday or other gift, of norminal value (less than $25,000).

Failure to comply with the aforementioned provisions may result in disciplinary action, up to and including termination of employment.
Do you or any member of your immediate family hold any “interest” in an “outside business” in such terms as defined above (check only one)?
YES NO
IF YES, please describe:

Do you have any relationship that might reasonably be regarded as creating a possible conflict of interest (check only one)?
YES NO
IF YES, please describe:
I certify that I have read, understand and will comply with all the Agency on Conflicts of Interest.
 
Signature   Date
 
Mc Guffey
Home Health Care L.L.C.
EMERGENCY CONTACT FORM

A. EMPLOYEE INFORMATION
NAME:
HOME ADDRESS:
PHONE NUMBER: HOME: CELL:
 
B. IN CASE OF EMERGENCY
DOCTOR: PHONE:
PRIMARY:
RELATIONSHIP:
ADDRESS:
PHONE
WORK: CELL: HOME:
SECONDARY CONTACT:
RELATIONSHIP:
ADDRESS:
PHONE
WORK: CELL: HOME:
 
 
Signature   Date
 
Mc Guffey
Home Health Care L.L.C.
Employee Handbook Acknowledgment Form

I acknowledge that I Have received a copy of the Employee Handbook, which describes important information about my employment at Premier Home health Solutions, Inc. and understand that I should consult my manager if have questions.

I have entered into employment with the Agency voluntarily and acknowledge that it is for no specified length of time. According, either I or the Agency may terminate the relationship at will, with or without cause, at any time, for any or no reason.

I understand that neither this Handbook nor any other Agency policy, practice or procedure is intended to Provide any contractual obligations related to continued employment, compensation or employment contract.

Since the information Policies and benefits described here are subject to change, I acknowledge that revisions to the Handbook May occur, except to the Agency’s policy of employment – at – will. I understand that the Agency may change, modify, suspend, interpret or cancel, in whole or part, any of the published or unpublished personnel policies or practices, with or without notice, at its sole discretion, without giving cause or justification to any employee. Such revised information may supersede, modify or eliminate existing policies.

The Agency’s [position] shall have sole authority to add, delete or adopt revisions to the policies in this Handbook. Any written or oral statement made by a supervisor or manager contrary to the personnel policy handbook is invalid and should not be relied upon by an employee.

I understand and agree that I will read and comply with the policies contained in the Handbook and any revisions, am bound by the provisions contained therein, and that my continued employment is contingent on following those policies.
 
Employee Signature   Date
 
 
Employee Name (printed)  
 
Step - 6

JOB DESCRIPTIONS
Home Health Aide
Reporting to : Staff Nurse/ Case Manager and/ or Clinical Coordinator
Status : Non – Exempt
Supervisors : None
GENERAL DESCRIPTION OF RESPONSIVILITIES
The home health aide is a non – professional employee, trained to provide personal care and related services in the home. She/he functions under the direction, instructions and supervision of the Staff Nurse/ Case Manager and/ or the Supervising Nurse.
DUTIES
By following the Home Health Aide Care Plan and/or assignment form, which has been completed by the Registered Nurse, the aide provides the following:

(1) Applies appropriate and safe techniques in helping the patient to maintain good personal hygiene.
(2) Assists in maintaining a healthful, safe environment.
(3) Plans and prepares nutritious meals. Markets when instructed to do so by the nurse.
(4) Assists the patient with ambulation. Uses safe transfer and ambulation techniques.
(5) Reading and recording temperature, blood pressure, pulse, and respiration.
(6) Maintains basic infection control procedures.
(7) Recognizes emergencies with knowledge of emergency procedures.
(8) Assists the therapy personnel as needed with rehabilitative process. Understand normal range of motion and positioning.
(9) Encourages the patient to become as independent as possible according to the nursing care plan.
(10) Attempts to promote patient’s mental alertness through involvement in activities of interest.
(11) Gives simple emotional and psychological support to the patient and other members of the household.
(12) Establishes a relationship with patient and family, which transmit trust and confidentiality.
(13) Prepares a report of her visit on the day it is performed and incorporates it in the clinical record weekly.
(14) Reports any change in body functions and/or mental status in the home situation and the care or service provided to her immediate supervisor, the staff nurse, or to the aide supervisor.
(15) Carries out his/her assignment as instructed by the nurse or the paramedical team and report to the nurse when he/she is unable to do so.
(16) Works with Personnel of other community agencies involved in the Patient’s care as directed by the staff nurse.
JOB DESCRIPTIONS
(17) Performs routine housekeeping tasks.
(18) Respect for patient’s rights, privacy, and property.
CRITICAL DEMANDS
(1) Visual/hearing ability sufficient to comprehend written/verbal communication.
(2) Ability to perform tasks involving physical activity, which may include heavy lifting and extensive, bending and standing.
(3) Must be able to meet the physical demands of providing patient care, ambulating patients, transferring patients, assisting with exercises, etc.
(4) Must be able to transfer patients, as needed, according to proper techniques of body mechanics.
(5) Ability to deal effectively with stress.
(6) Free from health problems that may be injurious to the patient and evidence of good personal health habits.
(7) Has emotional and mental maturity necessary for establishing and maintaining a good word relationship with the patient, patient’s family and Agency personnel.
QUALIFICATIONS
((1) High School Diploma or equivalent.
(2) Ability to read and write consistent with job requirements.
(3) Possession of certificate issued by Hospice and Homecare Foundation/National Association of Home Care OR
(4) Completion of Board approved Skills Demonstration and NLN written test.
(5) Current Michigan Driver’s License and/or reliable transportation with proof of automobile insurance of personal vehicle for business use.
(6) Good communication skills.
(7) Experience in – home health care or related health care field preferred.
AGREEMENT
COMPETENCY ASSESSMENT SKILLS CHECKLIST
HOME HEALTH AIDE
Name:
Date of Employment: Date Completed:
Evaluation Method Legends: P (patient or pseudo patient) W (written test)
 
Self - Assessment
Do you have experience
with this skill?		 Are you
Competent Performing
the following:		 Competency for the
Home Health Aide		 Proficiency Required Evaluation Method Competency
Validation
Indicated by
Preceptors
Initials and Date
Yes No Yes No P W
Demonstrates ability to process
Paperwork and associated functions
necessary to facilitate:
1. Temperature:
Oral (axillary/digital optional)
Digital Thermometers
2. Reading and Reporting Pulse
(radial)
3. Reading and Reporting
Respiration
4. Reading and Reporting Blood
Pressure
5. Bed Bath/Sponge Bath
6. Shower/Tub Bath
7. Nail Care
8. Skin care
9. Oral Care
10. Shampoo
11. Toileting/Elimination
a. Urinal
b. Bedpan
12. Transfer Techniques
a. Bed to Chair
b. Chair to Standing
c. Assist With Ambulation
13. Assists With Normal Range of Motion
14. Assistive Devices:
a. Walker
b. Cane
15. Positioning In Bed
16. Optional Skills
a. Dry Dressings
b. Ace Bandage Wrap
c. Medication Reminders
d. Urinary Catheter Care
e. Gastrostomy Site Care
f. Hoyer Lift
g. Enema
h. Other
17. Documentation Skills:
(legible, timely, accurate and complete)
a. Progress Notes, Flow Charts
b. Incident Reporting
18. Observation And Reporting To:
a. RN/Supervising Nurse
19. Adheres to Aide Assignment
a. Reviews Assignment Prior to Care
b. Performs Services as Ordered
c. Documents According to Assignment
20. Infection Control
a. Hand Washing
b. proper Bag Technique
c. protective Equipment
d. Exposure Plan
e. Equipment Care
21. Emergency Procedures
22. Patient Safety/ Falls Risk
23. Meal Preparation:
a. Feeding
b. Diabetic Diet
c. Low Sodium
d. Low Cholesterol/Fat
Light Housekeeping
24. Linen Change/Wash Clothing
25. Other
 
Comments:
Employee Signature: Date:
Supervisor Signature: Date:
 
Step - 7

  Employment Eligibility Verification
Department of Homeland Security
U.S Citizenship and Immigration Services 		  USCIS
Form I-9
OMB No.1615-0047
Expires 08/31/2019
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 1-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name) First Name (Given Name) Middle Initial Other Last Names Used (if any)
 
Address (Street Number and Name) Apt. Number City or Town State ZIP Code
 
Date of Birth (mm/dd/yyyy) U.S. Social Security Number Employee’s E-mail Address Employee’s Telephone Number
- -
 
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 ):
1. A citizen of the United States
2. A noncitizen national of the United States (See instructions)
3. A lawful permanent resident (Alien Registration Number/ USCIS Number):
4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy)
       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 1-9:

An Aliens Registration Number/USCIS Number OR Form 1-94 Admission Number OR Foreign Passport Number.

1. Aliens Registration Number/ USCIS Number:

OR

2. Form 1-94 Admission Number:

OR

3. Foreign Passport Number:

4. Country of Issuance:

QR Code – Section 1
Do Not Writhe In This Space













 
Signature of Employee Today’s Date (mm/dd/yyyy)
 
Preparer and/or Translator Certification (check one):
I did not use a preparer or translator. A preparer(s) and/or translator (s) assisted the employee in completing Section 1.

(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.
 
Signature of Preparer or Translator Today’s Date (mm/dd/yyyy)
 
Last Name (Family Name) First Name (Given Name)
 
Address Street Number and Name) City or Town State Zip Code
 
Section 2. Employer or Authorized Representative Review and Verification
(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee’s first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the “Lists of Acceptable Documents.”)
 
Employee Info from Section 1 Last Name (Family Name) First Name (Given Name) M.I. Citizenship/Immigration Status
 
List A OR List B AND List C
 
Identity and Employment Authorization Identity Employment Authorization
 
Document Title Document Title Document Title
Issuing Authority Issuing Authority Issuing Authority
Document Number Document Number Document Number
Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy) Expiration Date (if any)(mm/dd/yyyy)
Document Title
QR Code – Sections 2 & 3
Do Not Write In This Space


Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any)(mm/dd/yyyy)
 
Certification: I attest, under penalty of perjury. That (1) I have examined the document (s) presented by the above- named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United states.
(mm/dd/yyyy): (See instructions for exemptions)
 
Signature of Employer or Authorized Representative Today’s Date (mm/dd/yyyy) Title of Employer or Authorized Representative
 
Last Name of Employer or Authorized Representative First Name of Employer or Authorized Representative Employer’s Business or Organization Name
 
Employer’s Business or Organization Address (Street Number and Name) City or Town State ZIP Code
 
Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable) B. Date of Rehire (if applicable)
 
Last Name (Family Name) First Name (Given Name) Middle Initial Date (mm/dd/yyyy)
 
C. If the employee’s previous grant of employment authorization has expired. Provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
 
Document Title Document Number Expiration Date (if any ) (mm/dd/yyyy/)
 
I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document (s) , the document(s) I have examined appear to be genuine and to relate to the individual.
 
Signature of Employer or Authorized Representative Today’s Date (mm/dd/yyyy) Name of Employer or Authorized Representative
 
LISTS OF ACCEPTAVLE DOCUMENTS
ALL documents must be UNEXPIRED
Employees may present one selection from List A
Or a combination of one selection from B and one selection from List C.
LIST A
Documents that Establish
Both Identity and
Employment Authorization 		OR LIST B
Documents that Establish
Identity 		AND LIST C
Documents that Establish
Employment Authorization
1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien
Registration Receipt Card (Form I-5551)

3. Foreign Passport that contains a
temporary I-5551 stamp or temporary
I-555 printed notation on a
machine- readable immigrant visa

4. Employment Authorization Document
that contains a photograph (Form I-766)

5. For a nonimmigrant alien authorized to
work for a specific employer because of
his or her status:
a. Foreign passport; and
b. Form I-94 or Form I-94 A that has the
following:
(1) The same name as the passport; and
(2) An endorsement of the alien’s
nonimmigrant status as long as
that period of endorsement has
not yet expired and the proposed
employment is not in conflict with
any restrictions or limitations
identified on the form.

6. Passport from the Federated States of
Micronesia (FSM) or the Republic of the
Marshall Islands (RMI) with Form I-94 or
Form I-94A indicating nonimmigrant
Admission under the Compact of Free
Association Between the United States
and the FSM or RMI 		1. Driver’s license or ID card issued by
a State or outlying Possession of the
United States Provided it contains a
Photograph or information such as
name, date of birth, gender, height,
eye color, and address

2.ID card issued by federal, state or local
government agencies or entities,
provided it contains a photograph or
information such as name, date of birth,
gender, height, eye color, and address

3.School ID card with a Photograph

4.Voter’s registration card

5.U.S. Military card or draft record

6.Military dependent’s ID card

7.U.S. Coast Guard Merchant Mariner
Card

8.Native American tribal document

9.Driver’s license issued by a Canadian
government authority

For persons under age
18 who are unable to present
a document listed above:
10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record 		1. A Social Security Account Number
card, unless the card includes one of
the following restrictions:
(1) NOT VALID FOR EMPLOYMENT
(2) VALID FOR WORK ONLY WITH
INS AUTHORIZATION
(3) VALID FOR WORK ONLY WITH
DHS AUTHORIZATION

2.Certification of Birth Abroad issued by
the Department of State (Form FS-544)

3.Certification of Report of Birth issued
by the Department of State (Form
DS-1350)

4.Original or certified copy of birth
certificate issued by a State, county,
municipal authority, or territory of the
United States bearing an official seal

5.Native American tribal document

6. U.S Citizen ID Card (Form I-195)

7.Identification Card for Use of Resident
Citizen in the United States (Form I-179)

8.Employment authorization document
issued by the Department of Homeland
Security





Examples of many of these documents appear in part 8 of the Handbook for Employers (M-274).
Refer to the instructions for more information about acceptable receipts.
Mc GUFFEY
Home Health Care L.L.C.
1380 Coolidge Hwy Suite 210
Troy, MI 48084
248-591-9200
Tuberculosis Evaluation Form
Initial Annual Post Exposure Pre Employment
Last Name: First Name: Date of Birth:
Date of last PPD: Negative Positive
Have you ever been treated with INH? When?
Any recent exposure to Tuberculosis? If yes, When?
Date of last Chest X-ray specific to rule out Tuberculosis, if applicable:
Within the last year have you had any of the symptoms listed below?
Productive Cough Yes No
Coughing up Blood Yes No
Fever/Chills Yes No
Night Sweats Yes No
Fatigue Yes No
Weakness Yes No
Weight Loss Yes No
Loss of Appetite Yes No
If any questions marked yes must be evaluated at Physician’s office and return to work with a note from the Physician authorizing their ability to care for patient.
Comments:
Employee Signature:   Date:
 
Supervisor’s Signature:    
1/2011
 
Step - 8
AUTOMATIC DEPOSIT AUTHORIZATION FORM
Premier care is Pleased to offer direct deposit of employee Paychecks to the bank(s)
and account(s) of your choice. To arrange for direct deposit:
  • Complete the employee portion of this form.
  • Attach a voided personal check and/or personalized deposit slip to this from to verify your account number and bank routing number.
  • Return the completed form to the Payroll Coordinator.
  • Your direct deposit should being within two pay periods after we receive your completed form.

I hereby authorize Premier Home Health Solutions, Inc. to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my account(s) indicated below and the depository name(s) below, hereinafter called depository, to credit and/or debit the same:
NAME:       - -
(Please Print your name as it appears on your account)       (Social Security #)
ACCOUNT TYPE: Checking Savings       AMOUNT: $
BANK NAME:       PHONE#: ( ) -
ADDRESS:
ACCOUNT #       ROUTING #:
 
 
NAME:       - -
(Please Print your name as it appears on your account)       (Social Security #)
ACCOUNT TYPE: Checking Savings       AMOUNT: $
BANK NAME:       PHONE#: ( ) -
ADDRESS:
ACCOUNT #       ROUTING #:
(Use extra sheets for additional deposit distributions.)
The authority is to remain in full force and effect until the Agency has received written verification from me of its termination in such time and in such manner as to afford the Agency and depository a reasonable opportunity to act on it.
Premier care
Home Health Solutions, Inc.
Conditional Job Offer

This good faith offer is condition upon the organization’s ability to successfully establish eligibility for employment, to independently contract or grant clinical privileges on a timely basis. The eligibility determination is made at the sole discretion of Premier Home Health Solutions, Inc. and will be based not only on the organization’s policy on good moral character and reference but also the information obtained through the mandatory background check and fingerprinting requirements imposed by public Act 28 of 2006.

This conditional offer is also condition upon the applicant’s full cooperation to accurately complete all forms provided by Premier Home Health Solutions, Inc. , the production of acceptable persona identification, and obtainment of signed releases, consent forms, criminal history records, fingerprints and the obtainment of any other information required by Policy or low. Failure to produce acceptable personal identification, sign releases/consent forms, and fingerprints at the time of application will results in the automatic withdrawal of this offer.

This conditional offer will not change the will at nature of the applicant’s employment relationship whereby either the applicant or Premier Home Health Solutions, Inc. has the right to terminate the employment relationship at any time with or without good cause or reason without and prior notice.
   
Print Name    
 
Signature   Date
 
Premier care
Home Health Solutions, Inc..
Reference Request

Employer (Name):
Phone Number: , has applied for a position as a

 
Employer, please provide the following information to the best of your knowledge regarding the applicant named above.
 
Employment From: / / to / / Position:
EVALUATION CATEGORY EXCELLENT SATISFACTORY UNSATISFACTORY
Job Knowledge
Quality of Work
Quantity of Work
Initiative
Ability to Work With Others
Dependability
Acceptance of Supervision
Neatness * Word Appearance
Attendance & Punctuality
Overall Job Performance
If applicable, reason for termination:
Eligible for rehire?
Employer Signature
I hereby absolve my current and/or former employer(s) and/or reference sources of any liability in releasing and information regarding my past or present employment. I also waive Premier Home Health Solutions, Inc. of any liability and waive all rights to see or review comments that are furnished to the Agency by my past or present employers and other references.
 
Applicant Signature   Social Security Number
   
Date    
 
Premier Home Health Solutions,
1380 Coolidge Hwy, Ste: 210
Troy, Mi. 48084
Phone: 248-591-9200 Fax: 248-591-0623
HOW TO PROPERLY COMPLETE HHA FORMS
HHA FORMS must BE FILLED OUT WHILE YOU ARE ON YOUR SHIFT. This is the record of what you are doing while giving patient care. This form is how you get paid and will be forwarded to your client’s insurance company. Make sure that forms are filled out COMPLETELY and accurately. Please refer to the example given should you need a reference.

Time in/out is the actual time you work… not what you are scheduled. If you are scheduled to work 10am-10am and you arrive at 10:20 that is the time you write on the form. NO EXCEPTIONS.

Make sure your writing is neat and legible and that forms are filled out completely.

Paperwork may be submitted in any of the following ways and must be in NO LATER THAN 12 NOON ON TUSDAY.

1. Hand delivered to the office by you during the Business Hours of 9AM-5PM Monday – Friday. THIS IS THE BEST WAY.
2. Fax to 248-591-0623. When you use this method get the phone number of the fax machine that you are sending from as you will call the office to make sure that we got your paperwork and you will be ask for that phone number. Wait 10 minutes and call the office before you leave the place where you have faxed from to confirm that we have received your paperwork.
3. You may scan and e-mail documents to: info@premiercarehome.com. You must call office to confirm this method too.
IT IS YOUR RESPONSIBILTITY TO CALL THE OFFICE AND CONFIRM THAT WE HAVE RECEIVED YOUR DOCUMENTS. WE WILL NOT CALL YOU.
Always fill the forms out according to the example that has been given to you for reference.
Fill the forms out like your paycheck depends on it because it does. Documents that are not filled out completely MAY not be paid.
Step - 9
Premier Home Health Solutions,
1380 Coolidge Hwy, Ste.210, Troy, Mi . 48084
Phone:248-591-9200 Fax:248-591-0623
Email:info@premiercarehome.com
HHA PAPERWORK AGREEMENT
I, have read the Premier Home Health Solutions, Policy regarding completion of HHA forms and agree to follow the instructions when filing out all paperwork pertaining to client care.

I understand that part of my job requirement is that paperwork is filled out daily while on my Shift. I further acknowledge that it is MY responsibility to submit paperwork to the office in a Completed form not later than noon on Tuesday. Paper RECIVED in our office after the noon Cut off time WILL BE CHARGED A $25.00 LATE FEE THAT WILL BE DEDUCTED FROM MY CHECK.

IT IS MY RESPONSIBILITY TO CALL THE OFFICE @ 248-591-9200 TO CONFIRM RECEIP OF DOCUMENT BY THE OFFICE.

WHEN YOU CALL THE OFFICE YOU MUST HAVE THE PHONE NUMBER OF THE MACHINE THAT YOU FAXED PAPERWORKFROM FOR US TO CONFIRM RECEIPT. A confirmation from the Machine faxed from DOES NOT confirm that we received papaerwork…….it confirms that it Was sent by that machine.

I further agree that I will deliver all original paperwork from the previous month to office by the First Friday of the following month. IE January paperwork is due in too office by the 1stFriday of February and likewise for each month of the year. NO EXCEPTIONS!!!!

 
Caregiver Signature   Date
 
Witness Signature   Date
 
Premier care
Ph: (248) 591-9200 Fax : (248)591-0623
    DAILY PROGRESS NOTES
Patient Name Date Day Time In Time Out
VITAL SIGNS NOTES ACTIVITY   NOTES
Temp: Assist w/Ambulation:  
BP: Assist w/ Mobility:  
Pulse: ROM Active / passive :   
Respiration: Positioning - Encourage: Assist every Hours
Pain Rating: Exercise - per PT/OT/SPL:
BATH NOTES OTHER (specify):
Tub/shower: NUTRITION   NOTES
Bed Bath – Partial/ Complete: Meal preparation:  
Assist Bath- Chair: Assist w/Feeding :
Other (specify): Limit/Encourage Fluids:
HYGIENE/GROOMING NOTES Grocery shopping :
Personal Care: Other (specify):
Assist w/ Dressing: OTHER:
Hair Care(shampoo): Wash Cloths:
Skin Care: Light Housekeeping:  
Foot Care: Equipment Care:
Check Pressure Areas: Other (specify):
Nail Care: TBI ATTENDANT CARE INSTRUCTIONS
Oral Care (dentures): Maintain Stable Routine:
Other (specify): Encourage Personal Hygiene and Grooming:
PROCEDURES NOTES Prompt Memory and Awareness:
Assist w/ Elimination: Structure to Maximize Awareness:
Catheter Care: Supervision for Safety:
Ostomy Care: Focus Attention / Concentration:
Record Output: Assist w/problem Solving :
Inspect/ Reinforce Dressing: Prohibit Inappropriate Behaviors:
Medication Reminder: Encourage Discussions of Events and Activities:
Other (specify): Provide Emotional / psychological Support:
The patient is a brain injury victim and requires care throughout the day and night and oftentimes without
worning or predictability. The care Therefore ongoing and at time on call with constant observation because care
providers have to be able to intervene at all times. In addition to having to be available at all times,
the patient requires structure, support and supervision throughout the day. The goals include
progress and prevention as to cognitive, behavioral, emotional and functional deterioration
including The use of verbal encouragement and guidance, verbal cuing and observation, supervision
for safety, psychological support and the creation of a supportive living environment in a home
setting necessitated by the injuries sustained in this accident that
resulted in deficits which need to be attended to daily.
 Provide Physical Support:
Effectuate Physicians/ Therapist Instruction:
Arrange /Direct / provide Transportation Needs:
Restrict Elopement:
Discourage Isolation:
Other(specify):
Additional Comments/ Medical Appointments:
 
Patient Signature   Date
 
Caregiver Name parited   Signature
 
Hospice Aide Home Health Aide Homemaker   PROGRESS NOTES
Patient Name     Patient #ICR# Supervisor  
 
Date Day of Week Time Time Out Services Code (optional per eqency policy
VITAL SIGNS   NOTES SKIN CARE   NOTES
Temperature Moisture Skin
BP ACTIVITY   NOTES
Pulse Ambulation/ Mobility
Respiration Walk/ Wheelchair/ Cane
BATH   NOTES Chair /Bad
Tub Shower Dangle/Commode
Bed: Partial Complete Exercise PT/OT/LP/SLP
Assist Bath Chair Reposition Patient
Shampoo Hair Other
Comb Hair MEALS   NOTES
Mouth Care Prepare
Shave Electric Straight Feed
Assist with Dressing Setup
HAND/FOOT CARE   NOTES Offer Oral Supplement
Clean/File/Nails HOUSEKEEPING   NOTES
Sock Feet Change Bed Lineris
ELIMINATION   NOTES Make Bed
Perioeal Care Straighten Room
External Cath Care Laundry
Measure Cath Output Shopping
Empty Drainage bag OTHER   NOTES
      Fall precaution Maintained
Equirment ceaned:    
Changes in Condition /comments:    
Recirited To:
R/N Therapist Comments:
  RN/Therapist Signature Date
 
Name Patient Singnature    
Patient Singnature   Singnature   Date
   
White Clinical Record            Yellow Home Folder
 
Personal Mileage/ Medical Mileage
  MILEAGESHIP
 
Please Print Patients Name Employee Name
CLASSIE/CODE WEEK ENDING DATE
    MONTH DATE YEAR    
DATE STARTING
ODOMETER		 ENDING
ODOMETER		 MILES CLIENTENT EMPLOYEE VEHICLE LOCATION REASON FOR
TRANSPOTATION NEED
TOTAL MILES FOR THIS WEAK  
I Certify that the miles shown above represent my total L mile driven on assignment during the weeks, and that they were properly verified by theclient or by anAuthorized representative.
X X
EMPLOYEE SINGNATURE AUTHORIZED SIGNATURE