Please read and sign this form in the space provided below. Your written authorization is necessary for completion of the application process.
I, , hereby authorize Northbound Health to investigate my background and qualifications for the purpose of evaluating whether I am qualified for the position for which I am applying. I understand that Northbound Health will utilize an outside firm or firms to assist in checking such information, and I specifically authorize such an investigation by information services and outside entities of the company’s choice. I also understand that I may withhold my permission and that in such case no investigation will be completed and my application for employment will not be processed further.
I will be providing transportation, and I will submit my drivers documentation which includes the following:
1. my valid drivers license
2. my valid vehicle registration
3. my valid vehicle insurance
I will NOT at any time transport the member /client receiving services from Northbound Health, LLC. If I provide transportation , I may receive disciplinary action up to and may include termination.
If at any time my driving, or my non-driving status changes, I will immediately notify Northbound Health, LLC.
By signing this form, I affirm that I have been oriented on the HCBS member . I affirm that I have carefully read and assessed the members file, and I have a complete understanding of the members individualized health plan and specialized needs/supervision needs, and the members skills and abilities as per the PCSP plan. In addition, I have reviewed the members Behavioral Support Plan, as well as the members medication administration plan.
Current/Prospective Employee
I give permission to a representative of the following organization to access and retrieve my Direct Care Worker testing records from the AHCCCS online database. I understand that the organization’s purpose in accessing the records is to ensure that employees meet the testing standards required by AHCCCS.
I, , understand that upon employment. I am obligated and responsible for protecting and maintaining confidentiality regarding the individuals served by the Northbound Health, LLC/Division of Developmental Disabilities. As an employee, I realized I am prohibited from releasing records, correspondence, documents, information, etc. without proper authorization.
Confidentiality includes discussing individuals with family/friends/persons in the community who have no involvement with that person.
During a formal investigation of an incident (alleged rights violation , neglect , abuse , etc .), I understand than information I have knowledge of regarding the incident is confidential and will be discussed only with the person (s) conducting the investigation . Therefore , I cannot discuss it with family, friends, or co-workers.
Any breach of confidentiality as listed above will result in serious disciplinary action or termination. I understand this statement will be part of my permanent file.
By signing this form, I affirm that I have been fully orientated, and understood all documentation requirements for the appropriateness of services provided to a Member.
Documentation/Reporting Requirement and Template to be use
1. All incidents must be reported and followed by appropriate documentation.
2. All DDD incidents must follow DDD reporting format using form DD-191 for reporting. (Form DD-191 is attached).
3. Incident report must be objective and void of the writer's opinion. Just state what happened. Include names and job titles of persons who is involved in the incident or a witness to the incident.
4. Include demographic information (full name, date of birth, focus ID number) of member involved in the incident.
5. Write clearly and legibly the description of the incident and everything you know about the incident State who else was notified of the incident.
6. Attendant Care progress note reporting.
7. Report all NPS/GAPS to agency Program Manager.
8. All progress notes/report must be documented and submitted as required by Agency policy.
9. Documentation of goal tally sheets.
EMPLOYEE EMERGENCY CONTACT FORM
When arriving on shift at Member's home, please refrain from bringing personal items into member's homes. This includes personal packs, personal computers, tablets, and any other valuable items. The individuals we serve at Northbound Health, LLC, have developmental disabilities and behavioral challenges which may at times result in challenges that can pose circumstances which may result in property damage. Northbound Health, LLC holds no responsibility for a staff person's personal property damage. If you choose to bring a personal item to the Member's home, you do this at your own risk. Northbound Health, LLC will not be held responsible financially or otherwise for any personal property which belongs to the staff. However, employees can follow appropriate channels to report issues of property damage where applicable.
Please sign below that you understand and agree to abide by this notification.
Company’s goals and objectives
Our mission is to operate comprehensive and organized facilities on behalf of individuals with mental illness and developmental disabilities requiring locally based services and support. Northbound Health seeks to provide quality, professional, accessible, and effective services. We recognize the diversity of our community and seek to provide services to reflect those differences.
Our goal is to lead and support a community-based system that delivers and manages support services and treatment that advance the quality of community life for people with development disabilities. We provide essential in-home care centered on a warm and loving environment. Our employees are an integral part of our services and growth, maintaining a family atmosphere for children and adults with developmental disabilities.
Our vision involves mentoring and supporting children and adults in a community that is supportive of individuals with special needs by providing quality attention and care to enhance life in a manner that reflects the values, roles, and responsibilities of becoming well-adjusted citizens.
Northbound Health will service DDD members by providing a family structured stable living environment where they feel accepted, loved, and safe. Northbound Health extends care to adults, children, and their siblings, our promise is to provide our members with the solid foundation needed to reach life’s greatest achievements one milestone at a time.
Please, have my payroll check automatically deposited into the following account:
I authorize Northbound Health, LLC. and my bank to automatically deposit my payroll check into my account listed above. (This includes authorization to correct any entries made in error). This authorization remains in effect till a written notice of cancellation is given.
Summary of Responsibilities and Expectations:
This team Member position is a key and extremely important position within the Northbound Health agency.
The Team Member is responsible for assisting, supporting and teaching the skills necessary to enable consumers to achieve their activities of daily living in a residential situation.
Implement ISP, Training:
1.Provide teaching and support in accordance with individuals support, treatment plans and target behavior plans.
2.Assure all required documentation is complete, legible and written accordingly to policy and standards.
3.Complete assessment: and provide input into the development of services, goals and objectives.
4.Assist individuals with arranging medical and behavioral services.
5.Assist the resident in assuring training and daily activities are implemented and documented as scheduled.
6.Provide financial management assistance to consumers in the residence, as assigned.
7.Assist in arranging transportation to day programs, medical appointments and other community activities.
8.Assist consumers in maintaining contact with their families.
9.Assist consumers in accessing available community resources.
1.Assist consumers in developing their skills or by providing the assistance necessary to monitor health issues and maintain wellness.
2.Monitor and document health information concerns on a daily basis
3.Assist consumers in medication administration and provide training, when appropriate, in order to increase their medication knowledge.
4.Assist consumers in scheduling, attending, participating and following recommendations of medical and behavioral health providers.
5.Medication management to include medication inventory, pharmacy ordering and delivery.
1.Assure that consumers are free from abuse, neglect and/or exploitation.
2.Attend staff meetings, in-service and training activities as assigned.
3.Conduct and/or participate in fire drills as assigned.
4.Conduct and document all programming activities according to policy.
5.Assure home is clean, neat, safe and orderly as applicable according to ISP document.
6.Maintain confidentiality regarding all company, employee and consumer information, according to Northbound Health, LLC policies and procedures.
7.Follow all Northbound Health, LLC policies and procedures.
8.Other duties and responsibilities as assigned.
I have read and understand the duties of team Member and agree to abide by all policies and procedures set forth by Northbound Health, LLC. I agree that I am capable of performing the duties as outlined.