On-Call RN

By digitally signing below I certify that the information in this application is true and complete for all practical purposes. It may be verified by the facility 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 the facility or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse. I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, personal characteristics, and mode of living, whichever may be applicable. If such an investigative report is made, I understand that I will receive notice that such report has been requested, and that I will have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation. I understand and agree that if I am offered employment by the facility, my employment will be for no definite term and that either I, or the facility will have the right to terminate the employment relationship at any time, with or without cause, and with or without notice. I also understand that this status can only be altered by a written contract of employment which is specific as to all material terms and is signed by me and the Administrator of the facility. I understand, if I am an unlicensed person and if I have direct patient contact that the Agency will perform a background check, including criminal history check, OIG exclusion list check (if applicable), and any additional checks as required by accrediting body standards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform a check of the Nurse Aide Registry and Employee Misconduct Registry. I understand that: 1) the purpose of the Employee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect, exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-regulated facilities and agencies; 2) the State of Texas maintains a registry of all nurse aides who are certified to provide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and Human Services (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of resident property by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed on the registry; 3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registry and Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore, unemployable. *

By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency may conduct a State of Texas criminal history check per TXH&SC 250.006. I agree to a search of the Nurse Aide Registry and the Employee Misconduct Registry prior to employment and at least every 12 months if hired. As required, I agree to a search of the Texas Health and Human Services Commission’s OIG List of Excluded Individual/Entities, prior to being hired and monthly thereafter, the HHS - OIG Excluded Individuals/Entities Search Database and SAM Exclusion List. I understand that these checks will determine if I have a criminal conviction or have committed certain conduct that will bar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253.

I have informed this agency of all names (i.e., maiden, aliases) that I have used in the past. I understand that my employment is pending the results of the criminal history check and that I may not have face-to-face patient/client contact until results are returned. I will be notified of results. I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this Agency regarding any criminal history will remain confidential. I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.

(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection: An offense under Chapter 19, Penal Code (criminal homicide); An offense under Chapter 20, Penal Code (kidnaping, unlawful restraint, and smuggling of persons); An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children) or Section 21.11, Penal Code (indecency with a child); An offense under Section 22.011, Penal Code (sexual assault); An offense under Section 22.02, Penal Code (aggravated assault); An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or disabled individual); An offense under Section 22.041, Penal Code (abandoning or endangering a child); An offense under Section 22.08, Penal Code (aiding suicide); An offense under Section 25.031, Penal Code (agreement to abduct from custody); An offense under Section 25.08, Penal Code (sale or purchase of a child); An offense under Section 28.02, Penal Code (arson); An offense under Section 29.02, Penal Code (robbery); An offense under Section 29.03, Penal Code (aggravated robbery); An offense under Section 21.08, Penal Code (indecent exposure); An offense under Section 21.12, Penal Code (improper relationship between educator and student); An offense under Section 21.15, Penal Code (improper photography or visual recording); An offense under Section 22.05, Penal Code (deadly conduct); An offense under Section 22.021, Penal Code (aggravated sexual assault); An offense under Section 22.07, Penal Code (terroristic threat); An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual); An offense under Section 33.021, Penal Code (online solicitation of a minor); An offense under Section 34.02, Penal Code (money laundering); An offense under Section 35A.02, Penal Code (Medicaid fraud); An offense under Section 36.06, Penal Code (obstruction or retaliation); An offense under Section 42.09, Penal Code (cruelty to livestock animals), or under Section 42.092, Penal Code (cruelty to nonlivestock animals); or A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection. An offense the Agency determines to be contraindicated to employment with the consumers the Agency serves. (B) A person may not be employed in a position the duties of which involve direct contact with a patient/client in a facility or may not be employed by an individual employer before the fifth anniversary of the date the person is convicted of: An offense under Section 22.01, Penal Code (assault), that is punishable as a Class A misdemeanor or as a felony); An offense under Section 30.02, Penal Code (burglary); An offense under Chapter 31, Penal Code (theft) that is punishable as a felony); An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or An offense under Section 32.46, Penal Code (securing execution of a document by deception) that is punishable as a Class A misdemeanor or a felony. An offense under Section 37.12, Penal Code (false identification as a peace officer; misrepresentation of property); or An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct). (C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted: Of an offense under Section 30.02, Penal Code (burglary); or Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code. (D) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with, Article 42A.111 Code of Criminal Procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision. HCL / Statement of Employability Rvd. 050120 FAMILY FIRST HOME HEALTH, LLC - 1114471950