Avenal Community Health Center Aria Community Health Center · 2015-08-24 · Avenal Community Health Center Aria Community Health Center Confidentiality Policy & Statement Avenal

ACHC New Employee Packet 1

Avenal Community Health Center

Aria Community Health Center New Employee Package

Name: _____________________________________

Position: _____________________________________

Start Date: _____________________________________

Check list:

1. _____ New Employee Data Record

2. _____ W-4 _____(I-9) Fillable pdf form available

3. INS FORM ID #1

_____ ID #1 ____________________

_____ ID #2 ____________________

4. Current License and Certification

_____ Profession ________________

_____ CPR

_____ ALS/BLS/ ________________

_____________________________________________

_____________________________________________

5. Health Examination Scheduled Date of Exam __________________

_____ Medical History (Employee Physical Form)

_____ Hepatitis B series, T.B., and Influenza (Vaccine Form)

_____ Please make copies of these 2 forms & give them to the Director of Operations

6. Position Documents Reviewed and Signed

_____ Job Description

_____ Evaluation Form

_____ Abuse Reporting

_____ Confidentiality Policy & Statement (HIPPA)

_____ 10 Step Quick Reference HIPAA Guide (HIPPA)

_____ Employee HIPAA Compliance Signature Form (HIPPA)

_____ Disaster Plan (Safety)

_____ HCSI Inc, (HIPPA, OSHA) Training Sign On

_____ Chain of Infection and Hand Washing Techniques (Infection Control)

_____ Blood Borne Pathogens and Flow chart of “How to Report Exposure”

_____ Policies & Procedures

_____ Employee Manual (Need signed acknowledgement page)


_____ Policy on Gossip, Rumors and Innuendo

7. Applications

_____ Health Plan

_____ Dental Plan

8. _____ Job Training (Two week process)

9. Other

_____ Badge

_____ Uniforms (Reimbursement Benefit)

_____ Keys ______________________________ Green Cup _____ Date: ___________

10. _____ Schedule

_____ Probationary Evaluation Date ____________________

_____ Health & Dental Start Date ____________________

_____ Vacation Start Date ____________________

11. _____ Agreed upon salary


Employee Data Record CONFIDENTIAL To Be Filed in Separate Medical File

Name Social Security # - -

Last First Middle

Please Complete this New Employee Data Record. It will supply us information needed for our payroll and benefits programs.

Present Address City State Zip Phone( )

Previous Address City State Zip Phone( )

How long at present address? How long at previous address?

In Case of Emergency Notify: (Please Print) 1. Name Phone (Day): ( )

Address Phone (Night): ( )

City State Zip

2. Name Phone (Day): ( )

Address Phone (Night): ( )

City State Zip

Personal Data

Date of Birth / / Sex: □ Male □ Female

Have you ever been employed here before? □ Yes □ No If yes, give dates: From / / To / /

List any friends or relatives working for us

Have you ever been bonded? □ Yes □ No

If yes Please Explain

Voluntary Information

Marital Status □ Single □ Married □ Separated □ Divorced □ Widowed

Name of Spouse Number of Dependents including yourself

Dependent Children:

Name Sex Age Name Sex Age

1. 3.

2. 4.

Physical

Are you requesting reasonable accommodation to assist you to perform the essential functions of the job? □ Yes □ No

If yes, what reasonable accommodation do you believe will assist you in performing the essential functions of the job?


Military

Were you in the U.S. Armed Forces? □ Yes □ No If yes, which branch?

Rank at time of discharge?

List duties and special training

Your Reserve Status? Your Draft Status?

Do you have a military obligation that would affect your work schedule? □ Yes □ No

General

List any foreign language(s) you know and check the boxes that describe your ability.

Speak Some Speak Fluently Read Write

□ □ □ □

□ □ □ □

□ □ □ □

List any professional, trade, business or civic associations and any offices held. (Exclude memberships which would reveal sex, race,

religion, national origin, age, color, disability or other protected status.)

Organization Offices Held

List special accomplishments, publications, awards and licenses, (Exclude information which would reveal sex, race, religion, national

origin, age, color, disability or other protected status.)

List hobbies and interests

Educational and Work Experience Educational: List your last three (3) schools attended, starting with the most recent.

Name and Location Years Completed Did you Graduate? Course of Study

Major Degree

Work Experience: List your last three (3) employers, starting with the most recent.

Company Name Address Phone Supervisor Pay Rate

( ) $_____.__ per __

( ) $_____.__ per __

( ) $_____.__ per __

Signed ____________________________________________________________ Date ___________________


Avenal Community

Health Center 1000 Skyline Boulevard ● Avenal, CA 93204-0700

Last Name First Name Date

Date of Birth mm/dd/yy Sex Phone

Employee Physical Allergies: ________________________________________

Reason for Visit: Current Medications Dose/Freq

Follow-up visit:

Vital Signs: HT- WT- BP- / TEMP- P- R- LMP-

Sp02%

History:

Physical: General Appearance

+ - Acute Distress

+ - HEENT

+ - Chest

+ - Heart

+ - Abdomen

+ - Extremities

+ - Neuro

+ - Skin

+ - Ortho

Assessment Dx. 1 Dx. 3

Plan: Dx. 2 Dx. 4

Follow-up Lab X-ray Other Medication # Inst.’s

Days

Weeks

Months

Has F/U

Instructions / Referrals

1

2

3

4

5

PA MD

BMI_____

_______%



1000 Skyline Blvd., P.O. Box 700

Avenal, CA 93204-0700

(559) 386-4500

Employee Name _____________________________________ Hire Date _____________________________

VACCINE FORM

Hepatitis B Series

Received (Dates) 1. 2. 3.

Declined (Signature & Dates)

Titer (Date, if indicated)

Tuberculosis

Test Date Read Date Titer or X-ray Results Comments

T / X + -

T / X + -

T / X + -

T / X + -

T / X + -

T / X + -

T / X + -

T / X + -

T / X + -

Influenza

Date Received Injection or Mist Declined (Date & Signature)

I / M

I / M

I / M

I / M

I / M


Example of Annual Job Performance Review Form (2 pgs)



Child Abuse Reporting Responsibilities With concern or the total well being of each patient, all employees of ACHC are directed to

report known or suspected incidences of child abuse in accordance with state law and district

regulations. Employees shall cooperate with the child protective agencies responsible for

reporting, investigating and prosecuting cases of child abuse.

All employees are considered Mandated Reporters of abuse or neglect.

Employees shall report known or suspected child abuse to a child protective agency by telephone

immediately or as soon as practically possible and in writing within thirty-six (36) hours. The

reporting duties are individual and cannot be delegated to another individual.

Definition

1. Child Abuse, as defined by law, includes the following:

a. Physical abuse resulting in a non-accidental physical injury.

b. Physical neglect, including both severe and general neglect, resulting in a negligent

treatment or maltreatment of a child.

c. Sexual abuse including both sexual assault and sexual exploitation

d. Emotional abuse and emotional deprivation including willful cruelty or unjustifiable

punishment

e. Severe corporal punishment

2. Mandated Reporters are those people defined by law as child custodians, medical

practitioners and non-medical practitioners and include virtually all school employees. The

following clinic personnel are required to report: doctors, nurses, medical assistants,

receptionists, and counselors.

3. Reasonable Suspicion means that it is objectively reasonable for a person to entertain such a

suspicion, based upon facts that could cause a reasonable person in a like position, drawing when

appropriate on his/her training and experience, to suspect child abuse (Penal Code 11166).

Reporting Procedures

To report known or suspected child abuse, employee shall report by telephone to the local child

protective agency:

Child Protective Services

1200 South Drive

Hanford, CA 93230

Phone 582-3211 or 582-3241

The telephone report must be made immediately, or as soon as practically possible, upon

suspicion. The verbal report will include: a) name of the person making the report, b) name of

the child, c) present location of the child, d) nature and extent of any injury, e) any other

information requested by the child protective agency, including the information that led the

mandated reporter to suspect child abuse.

___________

Initials


At the time the verbal report is made, the mandated reporter shall note the name of the official

contracted, the date and time contracted and any instructions or advice received. Within 36 hours

of the telephone report, the mandated reporter must complete the mail a written report to the

local child protective agency. The written report shall include completion of the required

standard Department of Justice Form (DOJ SS 8572) available in the nurses’ station.

Employees reporting child abuse to a child protective agency are encouraged, but not required, to

notify the site administrator or designee as soon as possible after the initial verbal report by

telephone. If requested by the mandated reporter, the site administrator may assist in the

completion and filing of forms necessary for reporting. If the mandated reporter chooses not to

disclose his/her identity, s/he shall provide a copy of the written report without his/her signature

or name.

Legal Responsibility and Liability

1. Mandated Reporters have absolute immunity. Employees required to report are not civilly or

criminally liable for filing a required or authorized report of known or suspected child abuse.

2. A mandated reporter who fails to report an instance of child abuse, which he/she knows to

exist or reasonable should know to exist, is guilty of a misdemeanor and is punishable by

confinement in jail for a term not to exceed six (6) months or by a fine of not more than one

thousand dollars ($1,000) or both. The mandated reporter may also be held civil liable for

damages for any injury to the child after a failure to report.

3. The duty to report child abuse is an individual duty and no supervisor or administrator may

impede or inhibit such reporting duties. Furthermore, no person making such a report shall be

subject to any sanction.

_________

Initials



Aria Community Health Center

Confidentiality Policy & Statement

Avenal Community Health Center is committed to the principal of fair and ethical business

practices and to ensuring confidentiality of records and related information for all patients,

employees and other clinic business.

Avenal Community Health Center gives full consideration to patients’ rights for privacy

concerning all aspects of their health care. All communications regarding their care will be

treated as confidential information. Access to any of the information is to be limited only to

individuals who have a legitimate purpose for the use of any given information.

All employees, volunteers and contracted providers who have access to information about

patients, employees or clinic operations which is of a confidential nature, will be prohibited from

discussing or revealing such information in any unauthorized manner.

Any breach of confidentiality (i.e. the unauthorized discussing or revealing of patient, employee

or clinic operating information), represents a failure to meet the professional and ethical

standards expected of all employees and constitutes a violation of this policy. If it is determined

that a breach of confidentiality has occurred, the employee may be subject to disciplinary action,

up to and including termination or employment.

This breach need not take the form of a deliberate attempt of breach of confidentiality, but will

include an unnecessary or unauthorized informal discussion of a confidential matter (i.e.

informal dialogue in the break room or hallways) for which the same rules will apply.

This policy and requirement to maintain confidentiality extends beyond the hours of work and

beyond the term of your employment at Avenal Community Health Center.

I hereby acknowledge receipt of this confidentiality policy, and I agree to be bound by such

policy, as stated above.

________________________________________________ ______________________

Signature Date

________________________________________________ ______________________

Witness Date


10 STEP QUICK REFERENCE HIPAA (PRIVACY) GUIDE (post in an accessible and prominent office location)

1. Use lowered voice for all verbal communication that might disclose personal

health information.

2. Never “call out” any information that might be considered as personal, e.g.

tests required or taken, test results, medications, devices used, etc.

3. Do not allow computer screens to be viewed, intentionally or

unintentionally, by unauthorized persons.

4. Exit all programs that might contain personal health information when

leaving a computer workstation for a period of time.

5. Be certain that “sign-in” sheets do not require “reason for visit” information.

6. All chart holders must effectively obscure patient information.

7. All email, written and faxed personal health information (PHI) must be

clearly marked “confidential” and contain a privacy warning.

8. Never leave files or folders open or unattended. Filing cabinets etc.

containing PHI must be secured and locked.

9. Do not share computer passwords. Change them regularly.

10. Take every precaution to control personal health information.

________

Initials


EMPLOYEE HIPPA COMPLIANCE SIGNATURE FORM

Employee: _____________________________________________

Date: _________________________

My Commitment to Compliance:

I have read and understand our office’s Employee HIPAA Compliance manual. I agree to do all I

can, within my area of responsibility to maintain up-to-date knowledge about federal and state

laws and program requirements. I will comply with these requirements to the best of my ability,

and to immediately let the Compliance Officer know if there is any where I feel our office is not

in Compliance with these laws and program requirements. Our policy is a simple, yet powerful

four-step process: Keep Up-to-date, educate comply, and audit/correct.

a. We seek to maintain up-to-date knowledge about federal and state law pertaining

to protection of our patients Protected Health Information.

b. We educate our employees and keep them up-to-date about federal and state law

as it applies to Protected Health Information.

c. Our policy is to comply with all federal and state law governing Protected Health

Information.

We desire that all our employees are particularly cognizant of the fact that protected health

information must be treated with utmost attention, accuracy, honesty, and integrity. We seek to

educate and carry out these policies with all our employees, managers, clinicians, and where

appropriate contractors and other agents.

I agree with our policy and will do all I can to comply with all regulatory laws pertaining to

personal health information. In understand that our office has an open door policy and I may

discuss any problems I feel may occur with PHI without worry of recourse with my supervisor or

other supervisors.

__________________________________ __________________________________

Signature of Employee Signature of Compliance Officer



Aria Community Health Center

Policy & Procedure

DISASTER PLAN

The Clinic has developed emergency plans to handle casualties in the event of an internal or local

disaster. Every employee within the Clinic must function according to the plan in time of disaster.

All employees are required to know the disaster plans, and to be able to implement it on a moment’s

notice.

For an internal disaster, all patients and employees will evacuate the building, and congregate in the

parking lot in the safest spot near the center island. The receptionist will bring the patient sign-

in/check-out sheet to verify that all patients are accounted for. The Administrator or other designated

person will take roll call of the employees.

All employees will be in serviced on the disaster plans and on appropriate skills needed during a

disaster (i.e., use of a fire extinguisher). Disaster drills will be conducted at least semi-annually. At

least one of those drills should mock an earthquake.

Review of the Disaster plan and compliance will occur annually. Evidence of such review shall

be the signed review of these policies and procedures.

_________

Initials


Avenal Community Health Center 1000 Skyline Boulevard • P.O. Box 700 • Avenal, CA 93204-0700 • Phone (559)386-4500 • (559)386-0550

Each of you will play an important part in preventing the spread of infection. Observe the following

infection control principles to protect yourself and others from infections. In order to know how to control

or prevent infections, you should first have a basic understanding of how infections are transmitted, or

passed from on person to another. The “Chain of Infection” illustrates this process, and your role is to

break the “Chain of Infection”.

In order for an infection to be passed to another al six of the links of the chain must be present.

Microorganism Carrier Way Out Travel Way In Susceptible

Person

1. A MICROORGANISM (virus, bacteria, fungus) that causes the infection.

2. A CARRIER is a patient or health-care worker, who carries the microorganism.

3. A WAY OUT of the carrier, such as coughing, sneezing, etc.

4. A METHOD OF TRAVELING such as though the air, through direct physical contact or through contaminated

hands, linens, towels, instruments, bandages, etc.

5. A WAY INTO ANOTHER PERSON, such as breathing, swallowing, or a break in the skin.

6. A SUSCEPTABLE PERSON who doesn’t have resistance and becomes infected.

INFECTION CONTROL MEASURES BREAK THE INFECTION CHAIN by reducing the number of

microorganisms, controlling travel, using barrier precautions to prevent entry into another person, and

immunizing susceptible employees against vaccine preventable illness.

HANDWASHING or USE OF ALCOHOL-BASED HAND RUBS is the single most

effective way to stop the spread of infection (break the chain of infection

Wash or gel your hands when:

You arrive at work

After using the restroom

Before eating, drinking or handling food

After patient contact

After touching blood, body fluids, secretions,

excretions, and contaminated items, whether or

not gloves are worn.

Immediately after gloves are removed

Note: Hands must be washed when they are

visibly soiled or exposed to blood or OPIM

(other potentially infectious materials).

How to wash your hands:

Wet your hands with warm running water.

Keeping hands lower than elbows, apply hand

washing agent.

Distribute hand washing agent thoroughly over

hands

Vigorously rub hands together for at least 10-15

seconds covering all surfaces of the

hands and fingers with particular attention to

-----the fingertips and nails

Rinse under running water.

Dry hands with a single use paper towel.

Use paper towels to turn off the faucet (this

helps keep your hands clean not touching the

dirty faucet).

How to gel your hands:

Apply to palm of one hand. Rub hand together covering all areas of

hands and fingers until hands are dry.

_____________ Initials


Bloodborne Patogens

Question and Answer

What is a Bloodborne Pathogen? Name two

Define Universal Precautions

Give at least 3 examples of workers who are at risk of exposure to bloodborne pathogens.

List three ways exposure to bloodborne pathogens commonly occurs.

Describe at least 5 key aspects of a bloodborne pathogen. Exposure Control Plan.


Name three PPEs

List three important steps to take if exposed to a bloodborne pathogen.

Print Name

Signature and Date



Aria Community Health Center Policy & Procedures

ACKNOWLEDGEMENT

I have reviewed the Policy and Procedures for Avenal Community Health Center, outlining both

my privileges and obligations as an employee. I understand that I am responsible for reading and

familiarizing myself with the material in the Policy and Procedures, which describes the policies

governing my employment. I further understand that the Clinic may, at its sole and absolute

discretion, with or without prior notice, supplement or rescind the rights and responsibilities

identified in the policy and procedure manuals.

No statement(s) in this Policy or in other statement(s) of policy, including statements made

during performance appraisals, are to be construed either as an expressed or implied promise of

continuing employment.

Employee Printed Name

Employee Signature Date

Within 30 days of hire, and annually thereafter, each employee will review the following:

1. Clinic Policy and Procedures

2. Disaster Plan

3. Infection Control Procedures

4. Safety Manual

5. Employee Handbook

This review is a prerequisite for continued employment. By signing below, the employee

acknowledges that they have reviewed the documents noted above.

Employee Printed Name

Employee Signature Date


Avenal Community Health Center 1000 Skyline Boulevard • P.O. Box 700 • Avenal, CA 93204-0700 • Phone (559)386-4500 • (559)386-0550

Memo: GOSSIP

Gossip can occur from misunderstandings or from someone who is intent on being destructive or

hurtful. The initiation or perpetuation of gossip is a waste of time and energy, and is completely

unacceptable!

Recent surveys show that gossip is one of the top three complaints found in the workplace.

When people feel betrayed by malicious or unfounded rumors and gossip, the entire clinic can

suffer. Low morale and contention can affect patient care. In addition, gossip outside the office

can put the practice at risk for unauthorized disclosure of protected health information, and are

destructive to the reputation of individuals and the organization.

Though the word ‘Gossip’ does not appear in our Employee Policy Manual, it would fall under

at least the ‘Harassment’ section on page 12, which starts with sentence ...’Our clinic prohibits

any form of harassment.’ Each and every person serving in our organization is required to

acknowledge that if you initiate or perpetuate gossip, rumor or innuendo, you may be

disciplined, up to and including immediate termination. Due to the nature of gossip, this will

apply whether you participate in gossip in the workplace or anywhere else.

Please feel free to ask questions or make comments to your supervisor or administrative

personnel.

I acknowledge I have read this memo, and understand that if I initiate or perpetuate

gossip, rumor or innuendo, I may be disciplined, up to and including immediate

termination.

Signature ____________________________ Date: ____________________

Print Name___________________________


Alphabewhat?

I. Put the following names in alphabetical order (use pencil)

Moron, Lorena Moreno, Edgar Morrillon, Luis Mora, Francisco

Morado, Emily Morfin, Leticia Morales, Maria

1.________________ 4. ________________ 6.________________

2. ________________ 5. ________________ 7. ________________

3. ________________

II. Number the following names from 1-6 in alphabetical order:

___Rodrigues, Jesus ___Rodriguez, Maria ___Rodriguez, Juan

___Rodriguez, Martha ___Rodrigues, Lourdes ___Rodriguez, Juana

III. Place in the correct order

Ana Ayala Rios, Rafael Angelica Dominguez

Teresa Calvillo Navarro, Leonardo Ferguson, Zachary

Diaz, Isabel Perez, Jose Lopez, Jose

Lopez, Jose Luis

1.__________________ 5. __________________ 8. __________________

2. __________________ 6. __________________ 9. __________________

3. __________________ 7. __________________ 10. _________________

4. __________________

IV. Number the following list of names. Make the first to come alphabetically #1:

___Chavez, Sebastian

___Chavez, Sebastian Jr.

___Chavez, Sebastian J.

___Chavez, Sebastian Sr.

___Chavez, Sebastian


Circle the names that are in the wrong place then write them in order in the column on the

right.

1. Ochoa, Humberto

2. Ochoa, Hector

3. Ochoa, Israel

4. Ochoa-Cantu, Nellie

5. Ochoa, Maria

6. Ochoa, Maria Teresa

7. Ochoa, Maria

8. Ochoa, Patricia

9. Ochoa, Olivia

10. Ochoa, Oliver

11. Ontiveros, Raquel

12. Ochoa-Rivera, Luis

13. Ochoa, Veronica

14. Ochoa, Victor

15. Ochoa, Victor Sr.

16. Olivera, Alicia

17. Olivera, Angela

18. Olivera, Angel

19. Oliva, Beatrice

20. Perry, Fred

21. Perry, Frances

22. Perez, Jose

23. Perez, Jose Luis

24. Perez, Jose Maria

25. Perez, Jose Angel

26. Pratt, Michael

27. Pratt, Michelle

28. Pratt, Melody

29. Ponce, Jesus

30. Ramierez, Mayra

31. Ramierez, Maria

32. Ramierez, Neida

33. Rivera-Ochoa, Pablo

34. Smith, Jesse

35. Smith, Gordan

36. Sanchez, Cristian

37. Sanchez, Christian

38. Solorio, Esteban

39. Solorio, Daniel

40. Soltero, David

1. __________________________

2. __________________________

3. __________________________

4. __________________________

5. __________________________

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40. __________________________