*ALL APPLICANTS MUST BE REGISTERED ON THE FAMILY CARE SAFETY REGISTRY PRIOR TO SUBMITTING APPLICATION

*Valid Driver License, Social Security Card and active CPR/FA must be turned in prior to pre-hire testing

*Work history and education MUST be completed even if resume is submitted

DISCLAIMER OF LIABILITIES

1. If I am offered employment, I understand that I may be required to take a post-offer medical examination prior to client contact, in which case Deer Valley Home Health Services offer of employment will be conditioned upon my satisfactory completion of this examination. When post-offer medical examination is required, it will be required of all entering employees in the same job category and the information obtained in the course of the examination will be treated as a confidential medial record. I understand that I may be required to take a pre-employment drug test and understand that any offer of employment by Deer Valley Home Health Service will also depend on my satisfactory completion of this test. I consent to taking a pre-employment drug test if asked.

2. MANDATORY COVID VACCINATION POLICY AND ACKNOWLEDGEMENT…. The health and safety of our employees and their families is our top priority. Due to the ongoing nature of the COVID-19 pandemic and the fact that the Delta variant is extremely contagious, we have decided to require vaccination as a condition of employment. 

Deer Valley Home Health Services will make reasonable accommodations, when possible, for employees who are unable to be vaccinated because of a disability, pregnancy, or sincerely held religious belief. If you believe you qualify for an exception, please speak with Human Resources within 48 hours from the date you receive the policy and be prepared to provide documentation. Accommodations may include, but are not limited to, one or more of the following: regular testing and continued masking. Employees who are choosing to not be vaccinated without an exception approved by Human Resources will be required to turn in a weekly negative test no later than Monday of each week. Failure to vaccinate, without an approved exception, will result in termination.

3. If I am offered employment that requires driving as an essential function, I understand that the offer may be subject to proof of a good driving record, proof of insurance, current driver license and my ability to comply with all driving laws.

4. If I am offered employment, I understand that I may work for other companies. However, the time frame that I work for Deer Valley Home Health Services can not conflict with my other job.

5. The information contained in this application is true to the best of my knowledge. I understand that any misrepresentation of fact, as stated or implied, given in my application, interviews or any other employment form, may be sufficient reason not to hire me and may be for dismissal. I understand and agree that all information furnished in this application will be verified by Deer Valley Home Health Services or its authorized representative. I waive any right I may have to notice from any individuals and organizations named or referred to by in this application prior to the release of any employment information to Deer Valley Home Health Services. I authorize all individuals in organizations named or referred to in this application and any law enforcement organization to give Deer Valley Home Health Services all information relative to such verification and release such individuals, organizations and Deer Valley Home Health Services from any and all liability for any claim or damage resulting therefrom.

6. I understand that Deer Valley Home Health Services is not obligated to provide employment and that I am not obligated to accept employment. Nothing in the application, or in any prior or subsequent oral or written statement, is intended to create any contract of employment or to create any rights in the nature of a contract of employment. I understand that, if I am hired, nothing in this application shall restrict the right of Deer Valley Home Health Services to terminate my employment at any time.

7. All applicants must provide a current State ID and Social Security card at the time of submitting an application.  If you submit a print out verfying you Social Security number, you must bring in the actual card mailed from the Social Security Adminstration within 21 days from the date of your application. If you submit a print out of your State ID you must bring in the actual ID mailed from the Department of Revenue within 14 days from the date of your application. Failure to do so will result in suspension until documents are on file.

8. All Nurse and CNA applicants must provide the agency a copy of their certification card at the time of the application. If you do not have your certification card at the time of the application, you must submit your card within 7 days from the date of your application.

9. All applicants applying to work in the DMH program must have the following qualifications:  Valid drivers license, social security card, registration and clear background screen on the FCSR, copy of high school diploma or GED, CPR and First Aid card and a current TB Test.

10. All employees must have a clean background screen via the Family Care Safety Registry, must pass the EDL and OIG screening clearance in order to work for DVHH.  All screens must be completed prior to hire and are subjected to checked annually.  Employees who do not pass the annual safety checks will be suspended until proper documentation has been received for clearance.

11. All employees must have a current TB test and CPR card prior to accepting a client. Failure to provide a current TB test and CPR card will result in your application being placed on hold.  All Nurses must have a current physical on file prior to hire. Failure to provide a current physical will result in suspension until documents are on file.

12. All employees must complete references forms within 30 days from the date of hire. Failure to provide reference forms will result in suspension until documents are on file.

13. All employees with Deer Valley Home Health Services must adhere to the anti-kickback policy.  The anti-kickback statute makes it illegal for providers to knowingly and willfully accept bribes or other forms of remuneration in return for generating Medicare, Medicaid or other federal health care program business. The federal Anti-Kickback Statute is a criminal statute that prohibits the exchange (or offer to exchange), of anything of value, to induce (or reward) the referral of federal health care program business.  You must acknowledge that you will not participate nor accept any kickbacks for business exchanges whatsoever while in position as a DVHH employee.

Mandatory COVID-19 Vaccination Policy and Acknowledgment

The health and safety of our employees and their families is our top priority. Due to the ongoing nature of the COVID-19 pandemic and the fact that the Delta variant is extremely contagious, we have decided to require vaccination as a condition of employment.

The company will make reasonable accommodations, when possible, for employees who are unable to be vaccinated because of a disability, pregnancy, or sincerely held religious belief. If you believe you qualify for an exception, please speak with Human Resources within 48 hours and be prepared to provide documentation.

Accommodations may include, but are not limited to, one or more of the following: regular testing, and continued masking. Employees who are choosing to not be vaccinated without an exception approved by Human Resources will be required to turn in a weekly negative test no later than Monday of each week. Failure to vaccinate, without an approved exception, will result in termination.

Deadlines

Employees hired during this policy will be required to show proof of being fully vaccinated or of getting their first shot, if receiving the Pfizer or Moderna vaccines, within two weeks of hire.

Employees hired during this policy will be required to show proof of getting their second shot, if receiving the Pfizer or Moderna vaccines, within six weeks of hire.

Documentation

Employees will be required to show proof of vaccination, such as their CDC COVID-19 Vaccination Record Card or the vaccination record maintained by their health care provider. Employees who have lost their card may contact the Immunization Information System (IIS) in Missouri; the CDC provides links to state ISS pages. This documentation will be treated as confidential.

Acknowledgment

I have received and read a copy of the company’s Mandatory COVID-19 Vaccination Policy. I understand that failure to comply with this policy, or receive a management-approved exception, will result in termination.

Applicants are not required to give information prohibit by Federal, State/Provincial or Local Law.

Education and Training:

Work History: List most recent employer first, include part-time employment.

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The information I have provided is complete and accurate to the best of my knowledge. I also understand that providing the information may disqualify me from further consideration. I also authorize this agency to make any investigation(s) of my personal, financial, and/or credit background (including, but not limited to) obtaining a credit report (also known as a “consumer report” under the Fair Credit Reporting Act/Consumer Reporting Act) for the purpose of evaluating my qualifications for employment. This authorization extends for twelve months from today’s date.

Acknowledgement of Requirements of New Hire

I acknowledge my responsibility to attend CPR/FA Training and receive documentation of course being completed prior to hire.  I also acknowledge that I will receive TB testing prior to accepting a client.  The applicant is responsible for all costs associated with all testing requirements.  All nurses must provide documentation of having a physical prior to hire  If these documents are not on file with Human Resources within the given time frame, I understand that I will not be able to work with Deer Valley Home Health Services.

PPD/Test. Testing can be received at one of the seven Concentra locations of St. Louis City and/or county health clinics. If hired, you must get TB prior to taking a client.  Cost of TB testing is at applicant’s expense.  If test results are not received prior to hire, applicant will be able to take clients.

CPR/FA Training:  All applicants must provide certification of current and active CPR/First Aid prior to being invited for pre-hire testing. If attendant does not have certification, he/she will have not be able to take a client.  If no certification is provided, application will be voided.  

Physical- All nurses (LPN’s and RN’s), if hired, you must provide a current physical. Physical will have to be renewed yearly. 

It will be your responsibility to provide the agency with a current copy of your CPR/FA, Physical and TB results, within the recommended time frame.

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Background Screening

It is mandatory that all applicants be registered with the Missouri Department of Health and Senior Services’ Family Care Safety Registry. My signature below provides authorization for Deer Valley Home Health Services to conduct a background screening on me. If I am not registered, I will pay the fifteen dollars and twenty-five cent ($15.25) registration fee. Paying this fee does not guarantee employment.  If there are findings in my screening, and I want to become an employee, I agree to complete a “Good Cause Waiver” Application prior to being hired by Deer Valley Home Health Services. Once complete, Deer Valley Home Health Services will receive a report from the Family Registry indicating a Good Cause Waiver has been received and a case opened on my behalf.  The Department of Health and Senior Services may grant (approve) a “Good Cause Waiver” at their discretion.  Even with a “Good Cause Waiver”, it is still to the discretion of Deer Valley Home Health Services, if they choose to offer me employment.

FCSR/OIG/EDL

• The FCSR/OIG/EDL will be checked four times a year

E-Verify 

• Deer Valley Home Health Services is required by the Department of Homeland Security to verify employment eligibility for all newly hired employees regardless of citizenship. 

EDL

• The Employee Disqualification List (EDL) maintained by the Department of Health and Senior Services is a listing of individuals who have been determined to have:
• Abused or neglected a resident, patient, client, or consumer. 
• Misappropriated funds or property belonging to a resident, patient, client, or consumer; or 
• Falsified documentation verifying delivery of services to an in-home services client or consumer. 

No applicant can be employed by Deer Valley Home Health Services until they pass a screening of the Employee Disqualifications List (EDL) and until Deer Valley Home Health Services has obtained a background check on the applicant from the Family Care Safety Registry (FCSR). Anyone listed on the EDL, or OIG will not, under any circumstances, be employed by Deer Valley Home Health Services. If hired, the attendant will have a copy of the background check, OIG and EDL placed in their application file. If any new listings appear on either of these background checks, the attendant will no longer be able to be employed by Deer Valley Home Health.

I have read this policy and understand my employment is conditional pending the outcome of the Missouri Department of Health and Senior Services’ final decision and determination. I also grant permission for you to verify my employment eligibility through E-Verify, OIG and EDL.

Background Screening Application

Applicant Minimum Qualifications

Department of Health and Senior Services – Division 70 – Division of Missouri Health Net Chapter 91 – Personal Care Program – 13 CSR 70-91.030– Page 5-(3c) Page 6-(4)

Applicant must fulfill the following minimum requirements for hire as an in-home advanced personal care aide.

I acknowledge that I fulfill the following requirements:

All in-home advanced personal care workers employed by Deer Valley Home Health shall meet the following requirements: (Initial all that apply)

Hours of Availability & Location

In an effort to ensure we meet the needs of all clients, please complete the following indicating your availability.

Please indicate the hours you are available during the 24-hour period for each of the following days: