KINGSLEY HOME CARE
EMPLOYMENT APPLICATION
It is Kingsley Home Care, In's policy to provide equal employment opportunity without regard to race, color, religion, political affiliation, national origin, disability, marital status, gender, or age.
I acknowledge that a criminal history check, registry check of the Employee Misconduct Registry, Nurse Aide Registry, as well as the state and federal Medicaid Exclusion List, may be performed as part of my application which may prohibit service delivery in compliance with THSC 250.006(a) or 250.006(b). Convictions do not necessarily disqualify applications from employment.
Application/ Employee
Information
Employment History
Personal Reference Must provide at least two personal reference who can attest to your character and personal qualifications
Applicant Statement
I, ,certify that the information in this application is true and complete for all practical purposes. It may be verified by the agency 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 Kingsley Home Care, 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.
Release: I authorize disclosure of all my employment information to verify information contained in my employment application and in the document and in the documents required in connection with my employment, either before employment or as part of its quality control program.
APPLICANT ACKNOWLEDGEMENT
(NOTE: Application will not be considered complete without the applicant’s signature)
Personal Attendant Services is a Medicaid funded program administered by Texas Health and Human Services (HHS). All personnel
who have direct contact with clients must sign a statement that they have read, understand, and will comply with all applicable policies.
Kingsley is an in-home care agency providing temporary employment to applicants seeking positions as attendants/caregivers. Such
employment is subject to the length and terms as determined by our clients and is not guaranteed for any period of time. For continued
employment, it is the responsibility of the employee to keep their personnel file current. This includes change of name, address, phone
number, email and/or evidence of current licensure/certification. Note: If an employee does not work for KHC in 6 months, employment
will be terminated. If performance has been satisfactory, the employee may be eligible for rehire when KHC’s needs and the employee’s
availability match. Because laws, regulations and policies are constantly evolving, employees should check the Employee Self Service
(ESS) portal www.paylocity.com to obtain the current policies, procedures, benefits, what employees can expect, and obligations.
The term “personal care services” or “attendant care” means those services that a client needs to have provided to him/her within
his/her home in order to achieve independent living within the community. Personal care services may include but are not limited to
helping a client with eating, dressing, meal preparation, toileting, bathing, grooming, transferring, and specific health maintenance
tasks, as well as some incidental housekeeping tasks that ensure Client’s health and safety, like grocery shopping and laundry. The
Supervisor will explain the attendants expected duties at the attendants time of hire.
Verification of Employability: Licensed long-term care employers in Texas are required under 40, TAC, Part 1, Chapter 93, to inform new
unlicensed employees about the Employee Misconduct Registry (EMR). The purpose of the EMR is to ensure that a person who
commits an act of abuse, neglect, or exploitation is prohibited from employment. A person is unemployable if he or she is listed on the:
● Criminal Conviction History Check obtained from DPS prior to employment performed on applicants and employees. A criminal
conviction outlined in 250.006 prohibits a person from employment in a health care setting in the state of Texas.
● Employee Misconduct Registry and the Nurse Aide Registry, obtained initially and annually; and
● initial and monthly screening of both the state and federal lists of excluded individuals and entities (LEIE).
Drug and Alcohol Testing. KHC has a Reasonable Suspicion Testing Policy of on the job drug or alcohol use. The drug screen analysis
is accomplished through urinalysis testing. Alcohol testing may be through breath and/or blood analysis testing. Employee consents to
a post employment drug screen as a condition of employment, if required. Additional reasons for testing may include, but not be limited
to: staff injury that is sustained in the performance of their duties; or client injury that occurs while under the care of the employee.
Service Provider Relationship: The applicant is not disqualified to be a paid service attendant for the client based on relationship status
to the client receiving services. Applicant is not the client’s legally authorized representative (LAR). That is, the client’s natural parent,
legal/adopted parent, stepparent or managing conservator if the client is under age 18 [a minor], or the court-appointed guardian of a
client of any age. The spouse* of the client. Spouse is defined as either a legal marriage or a marriage without formalities (common law
marriage) in accordance with the Texas Family Code.
Base Wage Requirement: Personal attendants provide attendant care services described and authorized in the Plan of Care at a
personal attendant base wage of at least $8.11 per hour as defined in 1 TAC §355.7051(a). Attendant will be paid only for those
authorized in the Plan of Care, and no others, and is not permitted to work in excess of the number of hours authorized during a given
week. Facilities and agencies that provide attendant services in community settings are required to comply with this requirement.
Method of payment. Attendant care programs are required by HHS Texas State Statute 531.024172 to utilize an Electronic Visit
Verification (EVV) timekeeping system to ensure oversight and enforcement efforts to deter fraud, waste and abuse and protect
vulnerable clients from harm by electronically verifying the services performed. This mandate ensures the attendant provides the
service; the client is receiving the service, and the date, time, and location of the service for Medicaid funded personal care services.
Liability Notice: KHC is not a subscriber of Texas Workers' Compensation through the Texas Department of Insurance, Division of
Workers' Compensation. It is important to report any illness, accident or injury immediately to your supervisor.
Contact with the Office: As a condition of continued employment, it is the employee's responsibility to contact the office for
assignments. Should an assignment end, it is the employee’s responsibility to request another assignment no later than the next
business day. Should he/she not do so or refuse assignments offered, it may jeopardize eligibility for unemployment entitlement.
Circumstances related to a discontinuance of service to a client and consequent end of assignment or reduction of hours may include,
but are not limited to: recovery by a rehabilitating client; completion of client contract; transfer of client to a facility (hospital, nursing
home, etc.); death of client; move of the client out of the service area; personality conflict between client and caregiver; lack of payment
from client; client’s change of service to another agency; or discontinuation of service.
I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR
GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL
OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE.
I have read, understand, and by my signature consent to these statements.
JOB DESCRIPTION: PERSONAL CARE ATTENDANT
The Personal Care Attendant is a member of the home care team trained to provide personal care, other unskilled services,
and companionship in the home setting, under the direction, instruction and supervision of a Supervisor/Care Coordinator.
ABILITIES NEEDED TO PERFORM THE JOB
1. Sensitivity to the needs of persons who are physically disabled, intellectually disabled and/or elderly.
2. Have reliable transportation to and from assignments and to run occasional errands.
3. Must be dependable, responsible, patient, and punctual.
Physical/Mental demands: Lift, push/pull objects including but not limited to household items, individuals, in order to implement
care plans and daily living activities. You may also be asked to lift a weight of 50 pounds or more.
Activities include: Standing, walking, bending, stooping, climb stairs, kneel, balance, squat, grasp, crouch, crawl,
repetitive hand movements and reaching. Good judgment is regularly required.
DUTIES AND RESPONSIBILITIES
Home Management ● light housekeeping ● laundering bed linens ● grocery shopping/errands
Personal Care ● bathing, sponge/bed bath ● dressing and undressing; ● skin care, excluding wound care
● standby assistance for safety ● teeth, mouth & hair care ● toileting, include use/care of bedpan
Transfer/Ambulation ● getting in and out of bed ● standby assistance ● simple transfer from bed to chair/wc
● adjusting/changing position ● range of motion exercises & reverse, incl walker/cane/crutches
Medication ● reminding re taking/timing ● opening med containers ● placing medication within reach
Meal preparation ● food purchasing ● meal serving ● assist with eating, if necessary
Accompany consumer to obtain medical diagnosis/treatment when: a) assistance of attendant is required for the individual to
access necessary services; and b) need for redirection/direct assistance, as indicated in the care plan
Tasks limited to: ● Light cleaning limited to the consumer’s bedroom, bathroom, and mobility and medical devices
● Light cleaning of the kitchen and entryway areas, in order to maintain a safe environment
● Shopping/errands for necessary tasks identified in the care plan & preparing non-communal meals
Promptly report any hazards, issues, or significant changes in the client’s condition to the Coordinator.
Report suspicions of abuse, whether physical or financial, to the proper authorities as indicated in KHC’s policy and
procedures on “Reporting Abuse”. All employees are mandated reporters for vulnerable adults.
Tasks not covered ● service to others in the home ● care of pets ● for the purpose of transportation
● Medical acts such as: wound care; suctioning; administering medications; and giving injections.
● When provided in any of certain settings, e.g.: hospitals, nursing homes, residential care facilities or
adult day programs. Providing attendant care is a duplication of services and is not allowed.
Interacting face-to-face to assist client in acquiring, retaining & improving self-help, socialization and daily living skills
necessary to reside successfully in home and community‐based setting.
Training & assisting clients in completing the above household chores (preparing grocery list, folding/sorting laundry)
Reach full potential in: ➢ household tasks ➢ money management ➢ personal decision making
➢ socialization & developing relationships ➢ reduction of challenging behaviors
➢ participate in leisure & recreational activities ➢ integrating into community activities
Reinforce ➢ professional therapies provided to the client ➢ socially valued behaviors
Conduct activities to Develop or improve skills that allow the client to live more independently
HABILITATION
This description is not intended to be all-inclusive. The employee will be expected to perform other reasonable related duties as assigned by supervisor. (Signing this document acknowledges that the job description and responsibilities have been reviewed with me, the employee.)
BACKGROUND CHECK AUTHORIZATION
Section I - To be completed by the applicant/employee: (Provide name as it appears on Social Security card)
Kingsley has an obligation to provide a safe environment for all members of the KHC community and to protect the property of KHC. For these reasons,
all job applicants must provide and certify any requirement to register as a sex offender and their complete criminal conviction record. This includes any
conviction and/or deferred adjudication where the final disposition is still pending (i.e. the original charge has not been judicially dismissed). Before an
applicant is hired, the severity, time since conviction, and direct job relatedness of his/her conviction(s) are compared to the functions of the position.
Based on that review, an applicant may not be hired. However, a criminal conviction does not necessarily disqualify an individual from being hired.
Gender
List the complete previous addresses, including counties, in which lived outside Texas any time during the past 5 years.