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EMPLOYMENT

PLEASE FILL OUT AND SUBMIT ALL (4) FORMS

FORM 1

Hospice of Texarkana, Inc. - Application for Employment

It is Hospice of Texarkana, Inc.’s policy to provide equal employment opportunities without regard to age, race, color, religion, military status, gender preference, sex, marital status, national origin, or disability.

Are you at least 18 years old?

If you are not a U.S. Citizen, have you the legal right to remain permanently in the U.S?

Do you have adequate means of transportation to get to work on time each day and when called in on short notice during normal working hours?

Have you been convicted of a crime (excluding misdemeanors and traffic offenses) and/or released from confinement following a conviction for any criminal offense within the past 7 years?

Are you presently charged with any violation of the law other than traffic violation?

Educational History

Graduated

Last year attended

Graduated

Last year attended

Graduated

Last year attended

List professional licenses you possess.  Indicate type of license, number and state

List any memberships in professional organizations, honors or activities which you feel would enhance your application, excluding those that would indicate age, race, color, religion, military status, gender preference, sex, marital status, national origin or disability.

List languages spoken other than English:

List other skills applicable to the position for which you are applying, including computer experience, typing speed, etc:

In case of an emergency notify:

Out of State Contact, if possible:

Work History

Type of Business

OK to Contact Supervisor

Type of Business

OK to Contact Supervisor

Type of Business

OK to Contact Supervisor

PLEASE REVIEW, SIGN & SUBMIT

 

In making application for employment:

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I certify that the information in this application is true and complete for all practical purposes.  It may be verified by Hospice of Texarkana, Inc. or any affiliate.  Should a position be offered and later it is found that the information is significantly untrue, incomplete, or misrepresented, I understand and agree that Hospice of Texarkana, Inc. or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.

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I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable.  If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.

 

I understand and agree that if I am offered employment by Hospice of Texarkana, Inc., my employment will be for no definite term and that either I, or Hospice of Texarkana, Inc. will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice.  I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Executive Director of Hospice of Texarkana, Inc.

 

I understand, if I am an unlicensed person who has face-to-face patient/client contact, that Hospice of Texarkana, Inc. will perform a criminal history check per State Regulations as well as a check of the Nurse Aide Registry and Employee Misconduct Registry.  I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in DADS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Department of Aging and Disability Services (DADS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there’s a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All DADS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable.

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RELEASE:

 

I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals.  I also authorize any appropriate licensing board to release full information concerning my license status and my license history.

FORM 2

Hospice of Texarkana, Inc. - Arkansas & Texas Criminal History Search Consent

I give my consent for Hospice of Texarkana, Inc. to conduct a criminal record search on myself as it relates to my employment with this company.

 

This release shall remain in full force and effect for the next five (5) years, unless a formal withdrawal is filed by me.

Arkansas or Texas Driving Records Request

I give my consent for Hospice of Texarkana, Inc. to conduct a criminal record search on myself as it relates to my employment with this company.

 

This release shall remain in full force and effect for the next five (5) years, unless a formal withdrawal is filed by me.

FORM 3

Employee Acknowledgment

Confidentiality:  Hospice of Texarkana, Inc. maintains confidentiality of operations, activities, and business affairs of the agency and the clients according to 1996, Health Information Portability and Accountability Act (HIPAA).  Due to the nature of our work, each employee will gain, directly or indirectly, sensitive and confidential information on clients/patients and staff members.  The health care professional safeguards the client’s right to privacy by judiciously protecting information of a confidential nature including medical treatment information, diagnosis, medical records, personal patient information, etc.  This information should be shared only with those persons who, due to their position, have a need to know.  Sensitive or confidential information must never be used as the basis for social conversation or gossip.  If an employee is in doubt as to whether or not certain information may be shared, s/he should consult with  his/her supervisor.

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Drug Testing Policy:  Hospice of Texarkana, Inc. conducts “on hire and random/for cause” drug testing on its employees.  Hospice of Texarkana, Inc. maintains a drug free workplace policy with regard to the possession, use, distribution and sale of drugs or alcohol.  All employees are prohibited from the unlawful or unauthorized manufacture, distribution, dispensing, possession or use of a controlled substance or any alcoholic beverages while in the workplace or on Company paid time. Violation of this policy can result in disciplinary action, up to and including termination of employment.  I acknowledge I have received a copy of Hospice of Texarkana, Inc.’s policy on drug testing.

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Harassment Policy:  Hospice of Texarkana, Inc. is committed to providing a work environment, that is free from all forms of discrimination and unlawful harassment including sexual harassment.  This policy applies to all employees including management personnel.  Sexual harassment is any unwelcome sexual advances either explicit or implicit as a term or condition of employment.  Improper behavior may be verbal, visual, or physical in nature and/or the creation of a hostile environment.  Management will investigate complaints of sexual harassment promptly, impartially and without fear of retaliation to the employee.  An employee should report the alleged incident immediately and confidentially to the appropriate manager or Human Resources.

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Non Solicitation/Illegal Remuneration:  Hospice of Texarkana, Inc. does not reimburse or provide incentives to physicians, durable equipment providers, family or other referral entities for patient referrals for hospice services.  Employees may not solicit patients for Hospice of Texarkana, Inc.  Employees found in violation of this non-solicitation policy will be subject to discipline up to and including termination of employment.

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Non-Discrimination:  Hospice of Texarkana, Inc. does not discriminate against clients or employees based on age, race, color, religion, military status, gender preference, sex, marital status, national origin, disability or source of payment.

            

Abuse, Neglect, and Exploitation:  Hospice of Texarkana, Inc. employees will report suspected abuse, neglect and/or exploitation to the state departments of both the Texas Department of Family and Protective Services, the Department of Aging and Disability Services, and Hospice of Texarkana, Inc. management.  Hospice of Texarkana, Inc. employees suspected of abuse, neglect, or exploitation will be suspended immediately, an investigation will be conducted, and if the investigation validates the claim, the employee will be terminated.                    

 

Notice to New Employees Regarding Workers’ Compensation:  You may elect to retain your common law right of action if, no later than five days after you begin employment or within five days after receiving written notice from Hospice of Texarkana, Inc. that the employer has obtained coverage, you notify Hospice of Texarkana, Inc. in writing that you wish to retain your common law right to recover damages for personal injury.  If you elect to retain your common law right of action, you cannot obtain workers’ compensation income or medical benefits if you are injured.

 

Workers’ Compensation:  Hospice of Texarkana, Inc. is a subscriber to workers’ compensation insurance.  An employee who incurs an injury on the job that requires emergency medical treatment or is life threatening should proceed to the nearest emergency room.  Emergency medical treatment (non life threatening) or non-emergency treatment should be referred to Hospice of Texarkana, Inc.’s designated clinic.  Notify Hospice of Texarkana, Inc. of an injury within 24 hours to complete paperwork.  Medical expenses for injuries are covered with the exception of the following:  employee’s willful intent to hurt self or others, intoxication or drug use, horseplay, acts of  God, and/or acts of a third party.

 

Progressive Discipline Policy:  Hospice of Texarkana, Inc. utilizes a progressive discipline process in cases of misconduct or unacceptable performance.  This includes verbal warning, written warning and final warning.  Disciplinary action may begin at an advanced stage of the process or may result in immediate termination based upon the nature and severity of the offense, employee’s past record and other circumstances.

 

Hospice of Texarkana, Inc.  Policies:  I acknowledge that I have read, understand, and will comply with all applicable agency policies and guidelines.

FORM 4

Statement of Employability

By execution of this document, I acknowledge that I have been informed by Hospice of Texarkana, Inc. and agree that Hospice of Texarkana, Inc. may conduct a State of Texas criminal history check.  I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired.  I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency.  I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253; or if listed as unemployable in the Office of the Inspector General’s List of Excluded Individuals and Entities (LEIE) pursuant to sections 1128 and 1156 of the Social Security Act.

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Criminal History Check

I have informed Hospice of Texarkana, Inc. of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check, and that I may not have face-to-face patient contact or have access to patient records until results are returned. I will be notified of results.

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CONVICTIONS BARRING EMPLOYMENT

 

(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:

 

An offense under Chapter 19, Penal Code (criminal homicide);

An offense under Chapter 20, Penal Code (kidnapping and unlawful restraint);

An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);

An offense under Section 21.08, Penal Code (indecent exposure);

An offense under Section 21.11, Penal Code (indecency with a child);

An offense under Section 21.12, Penal Code (improper relationship between educator and student);

An offense under Section 21.15, Penal Code (improper photography or visual recording);

An offense under Section 22.011, Penal Code (sexual assault);

An offense under Section 22.02, Penal Code (aggravated assault);

An offense under Section 22.021, Penal Code (aggravated sexual assault);

An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual);

An offense under Section 22.041, Penal Code (abandoning or endangering a child);

An offense under Section 22.05, Penal Code (deadly conduct);

An offense under Section 22.07, Penal Code (terroristic threat);

An offense under Section 22.08, Penal Code (aiding suicide);

An offense under Section 25.031, Penal Code (agreement to abduct from custody);

An offense under Section 25.08, Penal Code (sale or purchase of a child);

An offense under Section 28.02, Penal Code (arson);

An offense under Section 29.02, Penal Code (robbery);

An offense under Section 29.03, Penal Code (aggravated robbery

An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual);

An offense under Section 33.021, Penal Code (online solicitation of a minor);

An offense under Section 34.02, Penal Code (money laundering);

An offense under Section 35A.02, Penal Code (Medicaid fraud);

An offense under Section 42.09, Penal Code (cruelty to animals);

An offense under Section 36.06, Penal Code (obstruction or retaliation);

An offense under Section 42.09, Penal Code (cruelty to livestock animals);

An offense under Section 42.092, Penal Code (cruelty to non-livestock animals); or

A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.

An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves.

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(B) A person may also be barred from employment the duties of which involve direct contact with a client in a facility if convicted of any of the following crimes within the past 5 years:

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An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or as a felony);

An offense under Section 30.02, Penal Code (burglary);

An offense under Chapter 31, Penal Code (theft that is punishable as a felony);

An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or

An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or a felony).

An offense under Section 37.12, Penal Code (false identification as peace officer); or

An offense under Section 42.01(a)(7), (8), or (9), Penal Code (disorderly conduct).

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(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:

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Of an offense under Section 30.02, Penal Code (burglary); or

Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.

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(D) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

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I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment.  I understand that all information obtained by Hospice of Texarkana, Inc. regarding any criminal history will remain confidential.

 

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

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