Section 32.1-162; 9:1 of the Code of Virginia requires that any person desiring work at a licensed home care provider agency provide the hiring facility or center with a sworn disclosure statement or affirmation disclosing any criminal convictions or pending criminal charges, whether within or outside the Commonwealth of Virginia.
The law prohibits licensed assisted home care agency from hiring any individuals convicted of the following: murder or manslaughter, malicious wounding by mob, abduction, abduction for immoral purposes, assaults and bodily woundings, robbery, carjacking, threats of death or bodily injury, felony stalking, sexual assault, arson, drive by shooting, use of a machine gun in a crime of violence, aggressive use of a machine gun, use of a sawed-off shotgun in a crime of violence, pandering, crimes against nature involving children, incest, taking indecent liberties with children, abuse and neglect of children, failure to secure medical attention for an injured child, obscenity offenses, possession of child pornography, electronic facilitation of pornography, abuse and neglect of incapacitated adults, employing or permitting a minor to assist in an act constituting an obscenity or related offense, delivery of drugs to prisoners, escape from jail, felonies by prisoners; or an equivalent offense in another state. However, applicants convicted of one misdemeanor barrier crime not involving abuse or neglect may be hired if five years has elapsed since the conviction.
Any person making a false statement on this form regarding any criminal offense shall be guilty of a Class 1 misdemeanor. Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority or court as may be required to comply with an express requirement of law for such further dissemination.
I, Your Name* , authorize Alliance Home Care to:- Request my criminal background check from the Police Department.-Deduct $20.00 from my paycheck to cover the fees for the background check.
If yes, please complete the risk assessment and symptom checklist:
Provide personal care service to the client for which the client needs physical assistance.
Some examples of Personal care are listed below:
• Ambulation – physically assisting a patient who otherwise would be unable to move about independently
• Personal hygiene – which includes bathing the patient
• Dressing – physically applying a patient’s clothing to the patient’s body
• Toileting – assisting a patient to go to and from toileting facilities and in the activities of toileting.
• Eating – includes hand feeding a patient who is incapable of self-feeding
• Provide competent, state of the art care to its patients.
• Follow the Caregiver Service Plan (CSP) or the plan of care to perform the tasks agreed upon.
• For security reasons, the caregiver should not disclose or knowingly permit the disclosure of any information in a client record except to appropriate provider staff, the client, responsible party (if applicable), the client's physician or other health care provider, the regulatory department, other individuals authorized by the client in writing or by subpoena.
• In case of an emergency at a client's home, the caregiver must immediately contact the Client's emergency contact name (as stated in the client's file) and notify the Alliance Home Care office.
- The caregiver must notify the Alliance Home Care office and the Client's responsible party of any changes in the Client's condition.
- The caregiver is encouraged to report to the office any changes that may improve the quality of care a patient is receiving.
- Reports to Administrator.
I understand that the clients I will be working with are the clients of Alliance Home Care, LLC. I also understand that in the event the contract between Alliance Home Care LLC and the client(s) is terminated due to any reason, I cannot work with that client or their family for at least one year either independently or with another agency. Should this happen, Alliance Home Care, LLC will take full legal action.
Directions: For each task listed, please answer the two questions listed. Competence means "the ability to perform the procedures safely, correctly, effectively and professionally."
Scale: 1 – 4, where 1 means the least competency; and 4 means the highest competency.
Activities of Daily Living