Pathway Home Care
Is an Equal Opportunity Employer
EMPLOYMENT APPLICATION
We do not discriminate on the basis of age over 40, race, sex, color, religion, national origin, disability, or any other applicable status
protected by state or local law. It is our intention that all qualified applicants be given equal opportunity and that selection decisions be
based on job-related factors.
Each question should be fully answered. No action can be taken on this application until all questions have been answered. Use blank
paper if you do not have enough room on this application. Please Print, except for signature on back of application. In reading and
answering questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non
job-related information
Job Applied for (PCP, RN, SECRETARY, CNA, etc.) ________________________ Todays Date __________/_______/________
Are you seeking- Full-time________ Part-time________ Temporary __________ employment? When can you start? _______
_________________________________________________________ _______________ ______________
Present street address
Are you 18 years of age or older? Yes ______ No _______
city
state____________
zip code

Phone:

Email:

Social Security # _____/_____/______ if hired will you furnish proof you are eligible to work in the U.S? yes ___ no ____
Have you ever applied here before? . . . . . . . . .yes _____ No _____
Were you ever employed here? . . . . . . . . . . . . yes _____ No _____
if yes, when? ___________________________________
if yes, when? ___________________________________
Have you ever been convicted of any law violation (except a minor traffic violation)? . . . . . . . . . . . . . . . . . . . . . . . .yes ___ no ____
If yes, give details ________________________________________________________________________________________
_______________________________________________________________________________________________________
Answering yes does not automatically disqualify you from employment, since the nature of the offense, date, and the job for which you
are applying will also be considered.
Are you now or do you expect to be engaged in any other business or employment? . . . . . . . . . . . . . . . . . . . . . . . yes ___ no ____
If yes, give details ________________________________________________________________________________________
Do you have a driver license? . . . . . . . . . . .. . . . . . . . . . . . . . yes____ no ____
Driver License Number _________________________ State of License ________ class of license ___________
Have you had your drivers license suspended or revoked in the last 3 years?………………………………………………….yes ___ no ____
If yes, please explain_____________________________________________________________________________________
REFERENCES, please list three professional references not related to you, with full name, address, phone number, and
relationship. If you don’t have three professional references, then list personal, unrelated references.
NAME
Address/City/State
Phone
Relationship___
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
QUALIFICATIONS
LIST AND NAMES OF SCHOOLS Please list any education or training you feel relates to the position applied for
that would help you perform the work, such as schools, colleges, degrees, vocational or technical programs, and military
training
School Name
Degree
Address/City/State_____________
_School__________________________________________________________________________________________
__School__________________________________________________________________________________________
__Other___________________________________________________________________________________________
SPECIAL SKILLS List any special skills or experience that you feel would help you in the position that you are
applying for (leadership, organizations/teams, etc.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
WORK HISTORY Start with your present or most recent employment and work back. Use separate sheet if
necessary. (INCLUDE PAID AND UNPAID POSITIONS)
Job title #1
Start Date (mo/day/yr)
___________ End Date (mo/day/yr)________________
Company Name______________________________________Supervisor’s Name_________________________________Phone Number_____________________
City________________________________________________State_____________________________________________Zip_______________________________
Duties_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Reason for leaving______________________________________________________Starting salary________________________Ending Salary________________
May we contact your present employer?
Job title #2
Yes ___
Start Date (mo/day/yr)
No ___ N/A ___
___________ End Date (mo/day/yr)________________
Company Name______________________________________Supervisor’s Name_________________________________Phone Number_____________________
City________________________________________________State_____________________________________________Zip_______________________________
Duties_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Reason for leaving______________________________________________________Starting salary________________________Ending Salary________________
Job title #3
Start Date (mo/day/yr)
___________ End Date (mo/day/yr)________________
Company Name______________________________________Supervisor’s Name_________________________________Phone Number_____________________
City________________________________________________State_____________________________________________Zip_______________________________
Duties_________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Reason for leaving______________________________________________________Starting salary________________________Ending Salary________________
I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I
understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize
the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any
liability. The employer may contact any listed references on this application. I acknowledge and understand that the
company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category employee) may
resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or
without cause, with or without notice to the other party.
________________________________________________
Applicant Signature
___________________
Date
Pathway Home Care
Is an Equal Opportunity Employer
Employee Availability
Please provide the following information on your availability to work for Pathway Home Care.
Type of Transportation you have / will use for home visits:
______________________________
Do you have any allergies that would affect your work at Pathway Home Care? □ No. □
Yes.
If yes, please list here: _________________________________________
Do you have a problem working with a client who smokes? □ No. □ Yes
How many hours are you willing to work per week? _______________________
EMPLOYMENT INFORMATION: To be completed by Applicant
Name of second Professional Reference to Be
Contacted__________________________________ Title____________________
Company Name_____________________________________________ Phone (_______)
________ – __________________
Reason for leaving this company:
___________________________________________________________________________
I authorize the company I worked for and/or the individual listed above to release information
about me Pathway Home Care Agency. LLC
_____________________________________________________________
______/______/___________
Applicant Signature____________________
Date__________
Employee Availability
Please Check (X) the Day and Time of Week You Are Available
SUN
MON TUE WED THUR FRI SAT
6:00 AM
7:00 AM
8:00 AM
9:00 AM
10:00 AM
11:00 AM
12:00 PM
1:00 PM
2:00 PM
3:00 PM
4:00 PM
5:00 PM
6:00 PM
7:00 PM
8:00 PM
9:00 PM
10:00 PM
Overnight
Pathway Home Care
Is an Equal Opportunity Employer
Acknowledgement & Receipt – Company’s Job Description
In-Home Aide
Description:
1.
2.
3.
Caregivers provide service to individuals in their own homes and communities, who need assistance
caring for themselves as a result of old age, sickness, disability and/or other inflictions. Services may
include assistance with the activities of daily living, housecleaning, laundry, meal preparation,
transportation, companionship and respite.
Caregivers are responsible for ensuring that service is delivered in a caring and respectful manner, in
accordance with relevant the local offices policies and industry standards.
Caregiver must:
a. not be a legal parent, foster parent, or spouse of the client who receives the service.
b. not be the spouse of the individual who receives the service, except for Family Care (FC) services; and
c. not be designated by a DADS case manager on DADS’ authorization for community care services form as
“Do not hire.
Responsibilities/Duties:
1. Assist clients with following a written, special diet plan and reinforcement of diet maintenance, which is
provided under the direction of a physician and as identified on the care plan.
2. Assist in maintaining all necessary supplies for client and facility needs, i.e., grooming supplies, household
cleaning supplies and office supplies
3. Attend orientation, in-service training sessions and staff meetings.
4. Carry out duties as assigned by the supervisor.
5. Communicate with Supervisor and co-workers.
6. Complete and maintain records of daily activities, observations, and direct hours of service.
7. Complete records as designated by policies and procedures such as, but not limited to; documentation of
training classes, progress /shift notes,
8. Contact appropriate administrative staff during evening and night hours as required.
9. Develop and maintain constructive and cooperative working relationships with others.
10. Ensure client’s safety and security by supervising the home environment.
11. Ensure service is delivered in accordance with all relevant policies, procedures and practices.
12. Escort clients to medical facilities, errands, shopping and outings as specified in the care plan.
13. Assist clients with communication by writing or typing correspondence for them or researching information
for them.
14. Follow the written care plan.
15. Monitor supplies and resources.
16. Must be physically able to perform the duties of the position, including, but not limited to; lifting/carrying at
least 50 lbs. (depending on assignment requirements), climbing stairs, bending, stooping, and
driving.
17. Observe clients and their environments and reports behavior, physical and/or cognitive changes and/or
changes in living arrangements to supervisor.
18. Observe clients and their environments and reports unsafe conditions to supervisor.
19. Participate on the Care Team by providing input and making suggestions.
20. Perform/assist with essential shopping/errands, which may include handling the client’s money in
accordance with the care plan and under the observation of the supervisor.
21. Performs any other duties as assigned by the Supervisor, and or/Administrator.
22. Provide companionship including social interactions, conversations, emotional reassurance and
encouragement of activities that stimulate the mind.
23. Provide first-aid assistance to clients and assist in the follow through on medical needs.
24. Provide respite care for families in accordance with care plans.
25. Report suspected abuse & neglect immediately (within one hour).
26. Safely provide transportation to residents (if applicable/approved in writing from Agency Administrator)
27. Provides non-medical, in-home caregiving and personal care to clients. This can include, but is not limited
to the following duties:
a. Companionship Care: Visiting and talking with the client, reading, listening to music, taking them on walks,
etc.
b. Errand Services, and Other Household Duties
c. Reviewing and Monitoring the Clients Care Plans
d. Assistance with Instrumental Activities of Daily Living (IADL)
e. Laundry
f.
Light Housekeeping: Cleaning floors, vacuuming carpet, surface cleaning of bathrooms and furniture,
vacuuming, taking out garbage, etc.
g. Managing Money
h. Medication Management: Taking prescribed medications
i.
Preparing Meals: Cooking a complete, nutritionally balanced meal for the client based on their individual
requirements, grocery shopping and assisting clients to adhere to medical meal plans.
j.
Shopping: For groceries and other necessities
k. Transportation: Driving the client to appointments, shopping for groceries or clothes, recreational or social
activities in the client’s or in the Caregiver’s automobile.
Note: If the Caregiver’s automobile is used, special arrangements may be made for mileage reimbursement.
28. Using communication devices: Including the computer or telephone
29. Assistance with the Activities of Daily Living (ADL), Including, But Not Limited To:
• Bathing and Showering: Bathing self completely, or requiring assistance with only one area of the body
including, hair and skin and oral care
• Dressing and Grooming: Including selecting appropriate clothes and outerwear and donning them
independently, including fasteners
• Eating and Self-Feeding (Not Meal Preparation): Moving food from plate to mouth or having the ability to
chew and swallow
• Exercising & General Mobility
• Functional Mobility: Including walking, positioning, ambulation/ transferring from one place to another,
specifically in and out of a bed or chair
• Toileting and Assistance with Incontinence Supplies
• Toileting: Including getting on/off the toilet and cleaning oneself
30. Other Requirements
• Ability to adapt to various living environments and locations
• Ability to communicate with clients in a friendly and congenial manner
• Ability to treat and care for clients and their property with dignity and respect
• Applicants must be able to successfully pass seven (7) year criminal background checks.
• Be at least 18 years or older
• If driving a client, must be able to provide proof of good driving record (copy of MVR record).
• Must be professional in appearance and demeanor, reliable and dependable in follow-through of job
duties, and be a compassionate, honest, and caring individual.
• Must satisfy all training requirements /Possess a high school diploma or GED
_____________________________________________
Printed Name
__________________________________________
Signature
______________________
Date
Pathway Home Care
Is an Equal Opportunity Employer

Client’s Rights Policy
I acknowledge receipt of a copy of the Client’s Right Policies of Pathway Home Care. I understand
that I am expected to always conform to these policies, and that part of an effective intervention with
clients is to keep them informed of the rights as a client of PHC.
I understand that I will be informed of any changes in client’s rights policies and will be expected to
conform to any new or additional client’s rights policies that come into effect.
I understand that failure to respect client’s rights is cause for termination.
Confidentiality Acknowledgement
I shall respect the privacy of the people we serve, and I shall hold in confidence all information
obtained in the course of professional service, whether that information is obtained through written
records or daily interaction with the person. Therefore, I will not disclose an individual’s confidences to
anyone, except as mandated by law to prevent a clear and immediate danger to a person or persons,
where I am compelled to do so by a court or pursuant to the rules of a court.
I shall store or dispose of professional records in ways that maintain confidentiality.
I shall possess a professional attitude which upholds confidentially toward the people we serve,
colleagues, applicants and any sensitive situations arising within the Agency.
I upon my termination, shall maintain client and co-worker confidentiality and I shall hold confidential
any information about sensitive situations within this Agency.
I understand that violence of the Agency’s confidentiality policies is grounds for immediate dismiss
No Smoking Policy
Pathway has a no smoking policy. Staff are prohibited from smoking in the homes of clients where
services are provided. If a staff member smokes in the home while providing care, client is to notify our
office so that proper disciplinary measures can be taken.
I have received a cop of the smoke free notification.

Employee Signature____________________________ _______________________ Date

Director Signature______________________________ _______________________ Date

Pathway Home Care
Is an Equal Opportunity Employer
Occupational Exposure to Bloodborne Pathogens
Hepatitis B Agreement/Declination Form
Universal Precautions
Blood has long been recognized as a potential source of pathogenic microorganisms that may present a
risk to individuals who are exposed during the performance of their duties. Universal precautions is the
method of control required by the Occupational Safety and Health Administration (OSHA) to protect
employees from exposure to all human blood and body fluids. Universal precautions refer to a concept of
bloodborne disease control, which requires that all human blood and certain human body fluids be treated
as if known to be infectious for HIV (the virus that causes AIDS), the Hepatitis B virus and other
bloodborne pathogens.
Protective barriers reduce the risk of exposure to blood, body fluids containing visible blood and other fluids
to which universal precautions apply. Examples of protective barriers include gloves, gowns, masks, and
protective eyewear. Universal precautions are intended to supplement rather than replace
recommendations for routine infection control, such as handwashing and using gloves to prevent gross
microbial contamination of hands. Universal precautions will be used during the provision of services as
applicable and appropriate.
Employee Initials: ________________ Date: ________________
Hepatitis B
Hepatitis B is a serious infection involving the liver. Hepatitis B virus (HBV) can cause lifelong infection,
cirrhosis (scarring) of the liver, liver cancer, liver failure and death. Hepatitis B is spread when blood or
body fluids from an infected person enters the body of a person who is not infected. HBV is a major
infectious occupational hazard for health care. Any health-care worker may be at risk for HBV exposure
depending on the tasks that he or she performs. Workers should be vaccinated if their tasks involve
contact with blood or blood-contaminated body fluids.
Employee Initials: ________________ Date: ________________
Hepatitis B Vaccination
OSHA standards effective June 4, 1992, require that employers make available the Hepatitis B vaccine
and vaccination series to all employees who have occupational exposure. The Hepatitis B vaccine is
available at no cost to the employee. The cost to provide vaccinations is an administrative expense to the
employer and is reimbursable to the employee.
The vaccine is administered in a prescribed series of three injections over a six-month period:
Dose 2 is administered 30 days after Dose 1.
Dose 3 is administered five months following Dose 2.
The employee is responsible for requesting from the healthcare provider administering the vaccination
additional
information specific to the efficiency, safety, benefits, method of administration and potential
side
effects of the Hepatitis B vaccination. The employee may elect to receive or decline the Hepatitis B
vaccination.
Employee Initials: ________________ Date: ________________
I have been provided with the Centers for Disease Control and prevention (CDC) Vaccine Information
Statement, Hepatitis B Vaccine Employee Initials: ________________ Date: ________________
Pathway Home Care
Is an Equal Opportunity Employer
Informed Choice Related to Hepatitis B Vaccination
Employment Statement – Check One statement below.
agree to receive the Hepatitis B vaccination and will be reimbursed by my employer within 30
days of presenting a paid receipt for each dose. I understand that I will only be reimbursed for
doses received while employed by the employer.

I agree to receive the Hepatitis B vaccination and the employer, and I have agreed to the following
arrangement(s) related to covering the cost of the vaccination:

I decline the Hepatitis B vaccination at this time because I have previously received the Hepatitis B
vaccination.

I decline the Hepatitis B vaccination.
* I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk
of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B
vaccine at this time. However, I decline the Hepatitis B vaccination at this time. I understand that by declining this
vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have
occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B
vaccine, I can receive the vaccination series at no charge to me.

Certification By Employee
I,_____________________________________________________________________________________, the
employee, acknowledge and certify that I have received information on occupational exposure to bloodborne
pathogens, universal precautions, Hepatitis B and Hepatitis B vaccination. I have been provided the opportunity to ask
questions and to seek additional information. I have made my choice (as documented above) related to the Hepatitis B
vaccination based on informed choice. * I may decide in the future to request and accept the vaccination at no charge
to me.

Employee: Employer:

Printed Name Printed Name

Signature Signature

Date Date

Pathway Home Care
Is an Equal Opportunity Employer

Bloodborne Pathogen Quiz 2022

1. There is currently no vaccination available for Hepatitis B.
True or False

2. Blood is the only bodily fluid that can carry pathogens.
True or False

3. It is important to understand and follow your employer’s policies regarding bloodborne pathogens.
True or False

4. The relative risk of exposure to bloodborne pathogens is great. However, once exposed the diseases are
not that serious.
True or False

5. AIDS is caused by which virus? HIV HBV HCV

6. Biological hazardous waste bags should be what color?
Green or Blue Red or Red-Orange Clear or Black

7. Personal protective equipment is an important line of defense against exposure to bloodborne
pathogens.
True or False

8. How often should Exposure Control Plans be reviewed and updated? Monthly Annually Once
each decade

9. Hepatitis B and Hepatitis C attack which organ:
Heart Lungs Liver Pancreas

10. Universal Precautions means treating bodily fluids as if they are known to be infectious. True or False

11. There are only 3 bloodborne diseases. True or False

12. The Hepatitis B Vaccination has been proven to prevent the disease in approximately what percentage of
those receiving the vaccine.
100% 95% 90% 70%

13. Disposable PPE can be reused if it is properly decontaminated.
True or False

14. All persons infected with a bloodborne pathogen will begin showing symptoms soon after infection.
True or False

15. PPE should be selected based upon the types of exposure that are reasonably anticipated. True or
False

16. It is the responsibility of the employees to provide PPE for themselves. True or False

17. Hand washing is an important part of disease prevention. True or False

18. Contaminated waste should immediately be placed in the nearest wastebasket. True or False

19. An incident report should only be completed if you do not know whose blood you were exposed to.
True or False

20. The Needlestick Safety and Prevention Act requires the use of safer needles and disposal containers.
True or False

I have read and understand the information contained in this booklet and have passed the quiz regarding
Bloodborne Pathogens.

____________________________________________________________________
Printed Name Signature

___________________
Date

Pathway Home Care
Is an Equal Opportunity Employer

COMPREHENSIVE EDUCATIONAL CEU
POST TEST 2022

1. You can be jailed or fined up to $10,000 for breaking HIPPA laws.
TRUE FALSE

2. Your patient, Mary Mermaid, has surgery tomorrow. Her neighbor sees you leaving her house and ask you
is Mary going in the hospital. Your response is, “No” This is a violation of HIPPA rules and regulations.
TRUE FALSE
3. As it relates to professional boundaries, borrowing and loaning money to your client is an ok practice if you
pay it back. TRUE FALSE

4. Poor vision, frayed chords and throw rugs account for falls in the elderly.
TRUE FALSE

5. When dealing with the elderly, asking multiple questions can cause disorientation and confusion.
TRUE FALSE

6. It is important to know that a patient that has heart failure should limit the amount of fluids and salt they
consume because this can cause swelling and fluid retention.
TRUE FALSE

7. You are caring for your diabetic patient and as you are washing her legs, you notice a large red scratch that
seems to be oozing. You also notice her feet are darker than they usually are. This is nothing to be alarmed
about because she is diabetic, and these things happen.
TRUE FALSE

8. Diabetes can cause damage to the heart, eyes, kidneys, and nerves in the body.
TRUE FALSE

9. COPD stands for Chronic Obstructive Pulmonary Disease and is a disease of the lungs that causes
narrowing of the airway. TRUE FALSE

10. The single most effective way to prevent the spread of infection is handwashing. TRUE FALSE
11. The most common bloodborne disease that you could be exposed to in the healthcare industry are HIV and
HBV.
TRUE FALSE
12. Symptoms of coughing, fever, loss of appetite and sweating should be ignored since this is common in
healthcare workers.
TRUE FALSE
13. When assisting a patient to stand, bend at your knees instead of twisting your waist. TRUE FALSE
14. Back support braces/belts prevent back injuries.
TRUE FALSE
15. Alzheimer’s disease is the most common form of dementia in the elderly population, TRUE FALSE
16. Dementia is an illness that affects the brain and eventually causes a person to lose the ability to perform
daily self-care. TRUE FALSE
17. Slowing down and engaging the client in the task may help reduce agitation, resistance, and combative
behavior. TRUE FALSE
18. A pressure ulcer can occur on any part of the body. TRUE FALSE
19. If your client smokes and has oxygen in the home, you should not report this to your supervisor because it
is none of your business what the client does in their home. TRUE FALSE
20. Safety for the client as well as safety for the worker is an important focus for Home Care Agencies. TRUE
FALSE
Signature
Print Name
Signature of Agency
Administrator
Print Name of Agency
Administrator
Pathway Home Care
Is an Equal Opportunity Employer
ACKNOWLEDGEMENT OF TEMPORARY POSITION
I__________________________________, understand that I
am accepting a temporary position with
Pathway Home Care Agency, I further understand that it is
my responsibility to contact Pathway Home Care at the
completion of my given assignment.
I understand that if I fail to contact the employer at the
completion of given assignment, I will be considered to have
voluntarily terminated my employment, and that this may
have an effect on the benefits for which might otherwise be
eligible.
Employee’s signature____________________________
Supervisor’s signature___________________________
Date_____________
Pathway Home Care
Is an Equal Opportunity Employer
Mailing Address, If different
Employee Contact Information
CONTACT INFORMATION
Employee Name _______________________________________________
Employee SSN _______________________________________________
Employee Address _______________________________________________
Employee City & ZIP Code _______________________________________________
Malting address, If different:________________________________________

Employee Home Phone
Employee Mobile Phone
Employee Email. _________________________________________________________

EMERGENCY INFORMATION
Please provide the name, phone number and address of the person we should contact In case of an
emergency, Also please advise this person, that you have given Pathway Home Care this instruction, to
contact in case of emergency
Contact Name
Relationship: (optional)
Phone #

Address:

Employee Signature_________________________Date _____________________
Pathway Home Care
Is an Equal Opportunity Employer
Employee Agreement
1. I am an employee of Pathway Home Care, and I am willing to work anywhere within my
assignment area.
2. I have read and received a description of my job.
3. I will appear in my client’s home dressed in neat, clean uniform.
4. I will contact the office with any changes in client’s health condition, admission to
hospital, or nursing home.
5. I understand that I must notify my supervisor if my client is out of the home during
Scheduled work hours.
6. I will contact the office if my client shows any sign of abuse or neglect.
7. I understand that it is not permissible to have family or friends visit or call me at my
client’s home.
8. I will never give out my client’s telephone number. Rather I will notify any persons who
may need to contact me at work, to call my supervisor and the office will reach me at my
client’s home to relay any messages.
9. I have been informed that I will not drink or eat my client’s property.
10. I will not accept or borrow money from my client.
11. I will not lend money to my client.
12. understand that I am not allowed to smoke inside of my client’s home. In the event that I
smoke, I will go outside for a period no longer than 5 minutes 3 times a day.
13. I will not use my client’s telephone for personal calls. Should I need to use the telephone
in an emergency, I will ask permission of my client.
14. I understand that if I am on fill in status, I will call my supervisor to receive my
assignment. I will be ready to leave immediately after receiving my assignment.
15. I understand that it is my responsibility to keep a record of the hours I have worked.
16. I understand that it is my responsibility to complete my task sheet daily. My client and I
will sign and date the task sheet at the end of each week.to submit my time log to the
office wither by fax, mail or personally.
17. If I am on a fill in assignment, I will have my client sign the time log prior to leaving the
home.
Employee signature_____________________ Date _________________
Pathway Home Care
Is an Equal Opportunity Employer
CONSENT RELEASE/DISCOLOSURE/RECIPROCAL EXCHANGE of INFORMATION
Social Security Number_________________________
Date of Birth_____________________
I hear by authorize and request that you make available to any duly authorized representative
of Pathway Home Care any information relevant to the items initialed below. I am signing this
waiver voluntarily, and request that you respond to this reference inquiry with full and complete
information.
Employment History ___________
Personal Character ___________
Background
Criminal History
____________
_________
Motor Vehicle Record _________
Educational History ____________
Candidate signature ____________________________________ Date ____________
Witness _____________________________________________ Date ____________
Pathway Home Care
Is an Equal Opportunity Employer
PROCEDURE FOR REPORTING ACCIDENTS AND INCIDENTS AT
An accident is an unplanned event that may result in injury, damage to property or some other loss. The law requires that certain work
related accidents/incidents are reported.
If an accident injury occurs while you are on duty at Pathway Home Care YOU MUST REPORT THE
INCIDENT WITHIN 24 HOURS of the occurrence to your immediate supervisor. ALL STAFF INVOLVED IN ACCIDENTS RESULTING IN
INJURY MUST COMPLETE A COMPANY PAID DRUG SCREEN WITHIN THE FIRST 24 HOURS OF INJURY.
Examples of Incidents for staff or patients include but are not limited to:
Slips
Falls
Scratches
Pulls/strains
Attacks/fight
Animals’ bites attacks
Damage to property
Burns
If medical attention is necessary, it will be rendered within a reasonable amount of time. Once the incident has been reported, an
incident form is filled out and a copy is forwarded to the Program Director for review. The form must be filled out in its entirety.
Specify all parties involved, time and date of incident, location, and nature of incident. Do not record opinions. Each incident
involving a PATIENT will be documented in the medical record at the time of occurrence or discovery. Documentation will include a
FACTUAL description of the incident, interventions, and name of physician (if notified),
For incident concerning an employee injury, the worksite supervisor/manager must complete a Supervisor’s Investigation, if it is
determined that corrective action is warranted, the supervisor will follow personnel policy and procedure, Pathway will collect,
maintain, and evaluate and respond to the data gathered from the incident to collaborate with the Director and Performance
Improvement Committee.
I have read and understand the procedure for reporting accidents/incidents while on duty at Pathway Home Care
Signature of employee _______________________________________________
Date ____________________
Pathway Home Care
Is an Equal Opportunity Employer
ABUSE
ABUSE—the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting
physical harm, pain or mental anguish.
ABUSE is never acceptable. Most abuse goes unreported or discovered because of fear of retaliation or worsening
abuse, 5 million seniors a year suffer some form of abuse.
Abuse falls into several categories:
(Cursing, yelling, threatening, belittling) Ex. c’ You better not wet this damn bed again or you
will be laying in it!”
(Pinching, slapping, squeezing, rough handling, pushing) Physical abuse remains the most
prevalent type of abuse, this involves the physical force that results in bodily injury or pain. Ex.
Shoving a patient over when trying to turn them when they refuse or resist care.
motion (intimidation, humiliation, belittling, harassment) Ex. “What kind of grown person
pisses on themselves. You should be ashamed of yourself!”
Ex. “Sign my timesheet or I’m not going to change you!”
sexual unwanted touching to violent assault such as rape, sodomy and forced nudity)
Ex. Fondling or rubbing a patient on their arm, breast, private.
Sadly enough, the abuser feels no remorse or regret. In NC a CNA or any healthcare worker that has substantiated
abuse on their record are not allowed to work in ANY healthcare facility. Any abuse that is reported and substantiated
will be placed on the healthcare personnel registry and will not be allowed to work in NC in the healthcare industry,
PLEASE SIGN AND DATE THAT YOU HAVE READ ANDUNDERSTAND THE ABOVE DOCUMENT. NO
EXCEPTIONS WILL BE GIVEN FOR NOT ABIDING BY THE NO TOLERANCE FOR ABUSE POLICY!!!!!
SIGNATURE _________________________________Date __________________
Pathway Home Care
Is an Equal Opportunity Employer
Required Personnel File Documents
1. Pre-employment Application, Resume
2. Copy of all active clinical license, registrations, or certifications & Verification of License
www.ncnar.org
3. Reference Checks
4. Copy of valid driver’s license
5. Copy of social security card
6.
Completed Forms
1-9 (required by law for Immigration Department)
NC—4 /
7. Signed Job Description
8. Completed and Signed Skills Check List
9. Health Questionnaire
10. Copy of the following medical documentation
• HEP-B vaccination records (HEP-B Declination Form
• Negative PPD or Chest X-ray results
11. Signed Pathway Homecare Exposure Control Plan (please include recent Exposure Control training
documentation from other health care organization)
Blood Borne Infection & Transmission
Exposure Control
• PPE & Work Practice Control
12. Signed Hand washing form
13. Signed Confidentiality and HIPPA agreement
14. Signed Criminal Background Check Authorization and Consent Form
15. Other signed forms: Signed Attendance & Telephone policy, Signed Drug free
workplace, signed smoking in the workplace and signed client’s rights policy
Employee’s Name. _______________________
Supervisor’s Signature: ____________________
Date: __________
Date: __________
Pathway Home Care
Is an Equal Opportunity Employer
CONFIDENTIALITY OF CLIENT INFORMATION
I understand that confidentiality means the client’s right to privacy. Therefore, any information learned by
me about a client should not be talked about to anyone except individuals who are directly involved with
the client’s case. Individuals who are considered “directly involved” are: the client’s Social Worker, the
client’s nurse, or the client’s family. Individuals who are not considered directly involved are: my family,
my friends, other clients, other aides, or anyone else not defined as directly involved.
All information about a client is considered confidential. Confidential information includes: a client’s
name, a client’s address, a client’s phone number, information about a client’s family, any information
given by the client about them and all other information relating to a client including the fact that a client
is receiving services from this agency.
Things to remember when working with a client in order to protect a client’s confidentiality:
a)
I will not give out a client ‘s phone number if there is someone who may needs to reach me in an
emergency. I will give them my supervisor ‘s number.
b)
I will not give out a client ‘s address except when someone is providing transportation for me to
get to an assigned client’s home. However, I understand that I am no to bring anyone else into a client’s
home.
c)
I will not say a client ‘s name to anyone not considered directly involved. The fact that a client is
receiving services is considered confidential.
d)
e)
f)
g)
h)
I will not repeat any information about the client even information volunteered by the client.
I will not talk about a client to another client.
I will not talk about a client to other aides whether they have worked for the client or not.
I will not talk about a client to family or friends.
I will no talk about a client ‘s physical or mental condition to anyone not directly involved with the
client ‘s case.
i)
I will not talk about a client ‘s family to anyone not directly involved with the client ‘s case.
All employee information must be kept in strict confidence and can only be shared with the individuals who have
the right to the information.
I understand that violating confidentiality of a client’s information is unethical and may be illegal and
punishable by law. I also understand that I can be terminated for violating current or former client’s
confidentiality.
In-Home aide Name ______________________________ Signature__________________________
Pathway Home Care
Is an Equal Opportunity Employer
SEXUAL HARRASSMENT POLICY ACKNOWLEDGEMENT
It is the policy of Pathway Home Care that no employee, Intern, or volunteer may engage in conduct that
falls under the definition of sexual harassment. Sexual harassment defined deliberate, unsolicited, and
tidally unwelcome verbal end/or physical conduct of sexual nature. With sexual Implications by
supervisor or co-worker which:
l. Has or may have direct employment consequences resulting from acceptance or rejection of such
conduct.
2. Creates an intimidating, offensive Working environment.
3. Interferes with an Individuals work performance,
No employment decisions Shall be made because of granting denial of sexual favors. All employees are
guaranteed the right to work in an environment free from sexual harassment, Violation of this policy
may result in disciplinary action, Including the possibility of immediate dismissal based on Inappropriate
personal conduct. An employee, Intern, or volunteer may report a complaints or allegation of sexual
harassment to the directors Pathway Home Care Agency, who will investigate all complaints and/or
allegations, An employee, intern, or volunteer? Who feels that they have been sexually harassed may file
a grievance? Complaints or allegations of sexual misconduct.
I acknowledge awareness of the Pathway Home Care sexual harassment policy. I understand that
violation of ho agency’s policy is grounds for disciplinary action up to and including Immediate dismissal.
EQUAL EMOLYMENT OPPORTUNITY ACKNOWLEDGEMENT
Is the policy of Pathway Home Care to promote equal employment opportunities Through a positive
continuing program. This means that Pathway Home Care will not discriminate, nor tolerate
discrimination against any applicant or employee because of race, color, religion, gender, sexual
orientation, national origin, age, disabled, or veteran status. Additionally, it is the policy of Pathway
Home Care Agency to provide an environment for each Pathway Home Care job applicant and employee
that is free from sexual harassment, as well as harassment and intimidation on account of an individual
race, color, religion, gender, sexual orientation, nation origin, age, disability, or veteran status.
I acknowledge awareness of the Pathway Home Care sexual harassment policy. I understand that
violation of ho agency’s policy is grounds for disciplinary action up to and including Immediate dismissal.
DRUG FREE WORKPLACE
Pathway Home Care has a zero-tolerance the policy regarding the use of illegal substances by its
employees. I acknowledge receipt of a copy of the rug-free workplace policy and have read and
understand the conditions of the policy. I consent to random drug testing per company policy, agree to
abide by the drug-free workplace policy, and understand that violation of the policy will result in
disciplinary action up to and including termination
I acknowledge awareness of the Pathway Home Care sexual harassment policy. I understand that
violation of ho agency’s policy is grounds for disciplinary action up to and including Immediate dismissal.
ETHICS POLICY ACKOWLEDGEMENT
I acknowledge receipt and awareness of the Pathway Home Care Ethics policy. I understand the violation
of the agency’s ethics policy is grounds for disciplinary action up to and including immediate dismissal.
________________________________
Employee Signature
_________________________________
Director Signature
_____________
Date
_____________
Date
Pathway Home Care
Is an Equal Opportunity Employer
Receipt and Acknowledgement of Employee Manual
Please read the following statements, sign below and return to your orientation manager.
I have received and read a copy of Pathway Home Care Manual. I understand that the
policies and benefits described in it are subject to change at the sole discretion of Pathway
Home Care Agency. LLC
At Will Employment
I further understand that my employment is at will, and neither Ultimate Home Care, nor I
have entered a contract regarding the duration of my employment. I am free to terminate
my employment with Pathway Home Care Agency. LLC at any time with or without
reason. However, failure to give a proper notice as outlined in this manual may make me
ineligible for rehire and some benefits.
Likewise, Pathway Home Care has the right to terminate my employment, or otherwise
discipline, demote me at any time, with or without reason, at the discretion of Pathway
Home Care. No employee of Pathway Home Care can enter into an employment contract
for a specified period of time or make agreement contrary to this policy without the written
approval from management.
Confidential Information
I am aware that during my employment confidential information will be made available to
me, for instance patient information, and medical information and facility information. I
understand that this information is proprietary and critical to the success of Pathway Home
Care premises or with non-Pathway Home Care employee. In the event of termination of
employment, whether voluntary or involuntary,
I hereby agree not to utilize, exploit, or disclose the information with any other individual
or company.
Employee Printed Name ___________________________
Date __________________
Pathway Home Care
Is an Equal Opportunity Employer
Skills Competency Check List for In-Home Aides
(Initial all that apply)
PERSONAL CARE SKILLS
_________ Assisting with Walking with cane, Walker, or Crutches
__________Assisting with Bath/Shower Assisting with Normal Skin Care
__________Assisting with Mouth/Dental Care
__________Assisting with Hair and Scalp Care
__________ Assisting with Finger/Toenail Care
__________ Assisting with Shaving
_________ Assisting with Dressing or Reinforcing Appropriate Dress
__________Assisting with Toileting and Incontinent Care
__________Assisting with Transfer (Bed to Chair to Toilet)
_________ Feeding Clients with Special Conditions
________ Observing, Recording, and Reporting Self- Administration of Medication or
Medication Reminder
_________Applying and Removing Prosthetic Devices
_________Assisting with Range of Motion (Passive/Active)
_________ Assisting with Exercise per PT/OT/SLP
_________Assisting with Ace (Elastic) Bandages, Elastic Stockings (Ted’s) or Binders
________Taking Temperature, Pulse, Respiration, Blood Pressure, and Weight
________Wound Care and Dressing Change
_______ Ostomy Care
_________ Position Change
HOME MANAGEMENT SKILLS
________Planning and preparing Balanced Meals
________Food Handling and Storage
________Light House Keeping: bedroom, bathroom, kitchen Bed Making and/or Linen Change
________Grocery Shopping Equipment Care, Community Resources
Employees Signature _____________________ Date _____________
Pathway Home Care
Is an Equal Opportunity Employer
TUBERCULIN TESTING FOR EMPLOYEES
In order to be in compliance with State and Federal regulations, it is mandatory that employees receive Mantoux testing
on hire and periodically during employment. The Mantoux test using PPD (Purified Protein Derivatives) will be used for
Tuberculin screening. If any of the following conditions exist, you should not receive the Mantoux test. Notify the
Agency Director immediately.
1. History of TB (provide documentation)
2. Anyone with rash or temperature elevation
3. Anyone with known positive reaction to the Mantoux (provide documentation)
4. Anyone who has receives the rubella vaccine within the last 30 days.
Employee Name ___________________________
Date: ___________
For employees 18 years of age or younger, parent or legal guardian must also read and sign this form.
Parent or Legal Guardian: ___________________________
Date: _____________
Relationship: _____________________________________________________________
The test must be read 48-72 hours after the injection. Please bring this form to the nurse who is authorized to read the test.
If this test is not read on time, it will have to be repeated.
First Dose:
Date and Time Given
Site
Lot. Number Nurse’s Signature
Date PPD Read
Results in MM Indurations
Nurse’s Signature
I have reviewed the contraindications for receiving the Mantoux test.
Employee Signature: _______________________________ Date _____________
Pathway Home Care
Is an Equal Opportunity Employer
HAND WASHING
Hand washing helps prevent personnel from transmitting pathogens to clients, family members, other health care
workers, and themselves. Handwashing remains the single most important means of preventing the spread
infection. All personnel providing direct client care will wash their hands before and after contact with client and
their environment. If soap and water are not available in a client’s home, employees are to use an antiseptic no
rinse gel or towelette.
EQUIPMENT:
Water, Liquid Soap, Paper Towels
PROCEDURE:
1. Use warm running water and liquid soap.
2. Lather hands and wrist.
3. Scrub vigorously, being sure to get hands, fingers and under nails.
4. Rinse thoroughly with hands pointing down, water flowing from Wrist to fingers.
5. Dry with paper towel.
6. Turn faucets off with paper towel.
7. Dispose of paper towels in waste container.
FREQUENCY:
l.
When entering or leaving home
2. Prior to accessing bag
3. Before putting on and after taking off gloves
4. Before and after patient contact
5. After touching blood, body fluids, secretions, excretions, or objects contaminated
With these; broken skin or mucous membranes, whether wearing gloves or not
6.
Between different procedures on same client
7. After covering a cough or sneeze, wiping nose
8. After using bathroom.
Signature_______________________________
Date_____________

Pathway Home Care
Is an Equal Opportunity Employer
PERFORMANCE REVIEW-Home Care Aide Evaluation

Goals/Plans for Improvement:
Evaluator Comments:
Employee Comments:
HR Comments:
I have reviewed this evaluation and discussed the contents with my supervisor My signature means that I
have been advised of my performance and have been given the opportunity to make comments, but does not
necessary Imply agreement With evaluation or the contents,
Employee Signature:Date:
Evaluator Signature: Date:

Pathway Home Care
Is an Equal Opportunity Employer
SKILLS CHECKOFF LIST
Name:_______________________________Date:___________ CNA or PCA (circle one)

TASK COMPETENT INCOMPETENT DATE EVALUATED INITIALS
Hand washing
Bed making
Bathing care
Mouth care
Skin care
ROM(range of motion)
Nail care (no
cutting/clipping)

Assisting with
ambulation

Turning & positioning
Transfer -bed to chair -onto commode

Elimination

Pathway Home Care
Is an Equal Opportunity Employer
HEALTH QUESTIONAIR
Name ____________________________________________ Sex ( ) Male ( ) Female
Last
First
MI
Have you had or do any of the following? (Circle yes or no for each question)
Disease
Cancer
Diabetes
Rheumatic Fever
Backaches/ Injury
Tuberculosis
Heart Problems
Stomach Problems
Hypertension
Fainting Spells
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Epilepsy Yes No
Asthma/ Sinus
Skin Disease
Hernia
Chest Pain
Boils or open Sores
Yes No
Yes No
Yes No
Yes No
Yes No
Arthritis
Hearing/Eye
Allergies
Yes No
Yes No
Yes No
Nervous Breakdown Yes No
Jaundice
Yes No
(Woman Only )
Abnormal Menstrual Periods Yes No___________________________________
Severe PMS
Yes No____________________________________
Please explain any other illness which might affect your abilities to perform the essential function
position_______________________________________________
I, the undersigned, certify the above answers to be true and give my primary physician permission to
submit a report to the agency if needed.
Applicant Signature_______________________________ Date _______________
Pathway Home Care
Is an Equal Opportunity Employer
Infection Control-Post-test
Name ______________________________
Date _______________
List Three signs and symptoms of an infection ________, ___________, ___________.
Which of the following are ways to break the chain of infection? Check all that apply.
a) Cover mouth when sneezing/coughing
b) Go to work 8ick but be sure to let the client know you are sick
c) wear gloves
d) do not cough or sneeze on the client
e) . Proper waste and trash disposal
f)
All of the above
Earlier an infection is found, the easier it may be to treat. (Check true or false)
TrueFalse
Individuals all respond the same to infections,
True
False
Examples of How to prevent the transmission of disease include. (Check all that apply).
a) wash your hands after using the bathroom
b) . wash raw fiuit3 and vegetables before eating or serving
c) . prepare and store food properly
d) use good housekeeping practices
e) . all of the above
The cycle of infection includes (Check all that apply):
a) pathogenic organism
b) reservoir of infection exits from reservoir of infection
c) method of transmission entrance into a new host
d) host
e) all of above
Gloves only need to be worn if you feel Like patient has an infection.
True False
There are certain factors such as poor munition and advanced age that contribute to a
client’s susceptibility to illness
True
False
Standard (universal) precautions is a method of infection control by which all human blood
and body fluids are treated as though they are infected with pathogens. True False
The___________ ___________ ___________ must be broken to prevent the transmission
of a pathogen from one host to another.
(Fill in the blanks)
Pathway Home Care
Is an Equal Opportunity Employer
PERFORMANCE REVIEW – IN-HOME CARE EVALUATION
Employee Name _____________________
Job Title: ___________________________
Hire Date: __________________________
Evaluation Date: ______________________
Exceptional (5)
• PRODUCTIVITY
Above Average (4)
Average (3)
Quantity accuracy and thoroughness of the work provided by employee are acceptable.
• FOLLOWS INSTRUCTIONS
Follows written patient care instructions as prepared by a licensed.
Needs Improvement (2)
• PATIENT CARE
Assists patients with personal care to promote good personal hygiene while maintaining a healthy,
safe environment
• RESPONSE TO SUPERVISON
Response positively and promptly to suggestions and criticism from supervisor.
Unacceptable (1)
• COMMUNICATION
Reports changes in patient’s condition to Supervisor or RN. Participates in case conference, as appropriate.
Documents coordinate of care as appropriate.
• RESPONSIBILITY
Demonstrates accuracy and thoroughness in all job responsibilities.
• PROCEDURES
Performs simple procedures as indicated per direction or delegation
• CONTINUOUS LEARNING
Takes advantage of the meets continuing education and other opportunities to learn, Attends in services as
Appropriate provides info to appropriate staff.
• POLICIES &PROCEDURES
Adhere to organization policies and procedures and code of ethics
• PERSONAL APPEARANCE
Dresses appropriately for position and is well groomed. Equipment utilization in patient care is within
acceptable condition
• TEAMWORK
Participate in patient care conferences to provide input requiring continuum of patient care
• INTERPERSONAL RELATIONS
Established and maintains good working relationship with the patient/family and co-workers
_______
_______
______
______
_______
_______
________
_______
_______
_______
_______
• DEPENDABILITY
Makes scheduled visits and participates in on-call rotation as required ________
• DOCUMENTATION
Maintains record of services performed and of apparent condition of patient. Documentation is complete
accurate and turned in according to agency policy. ________

Score__________
Employee Signature ___________________________________

RN Signature________________________________________

Date__________________

Pathway Home Care
Is an Equal Opportunity Employer
Handwashing Post Quiz
Name: ____________________________________ Date____________________
Score: ______________
It
1. Circle T for True and Circle F for False. Please fill the blanks where indicated.
2. T F
is not necessary to always rub hands thoroughly using friction.
3. T F
4. T F
5. T F
It
is not necessary to wash and rinse hands under running water.
Always fill sink bowl when washing hands.
It
is not necessary to clean under nails and between fingers.
6. Rub hands together while you count to ____________.
7. T F It is not necessary to dry hands thoroughly.
8. T F
Turn water off with your hands.
9. T F Only wash the top of your hands, do not be concern with using soap.
10. T
F
Rinse well under running water from the wrist area to the fingertips
Bonus question#
The first step to washing hands is __________________