For Office Use Only:
DATE OF HIRE:.....................................

Employment Application CDPAS

Last Name:
h
First Name:
Rajagiri Builders
Middle Name:
Address:
Apt #:

City:
State:
NY
Zip Code:
Home Phone Number:
Cell Phone Number:
Languages:
Country of Birth:
Ethnicity:

Emergency Contact:
Phone Number:
Relation:
CDPAS Patient Full Name:
CDPAS Patient Phone Number:
Citizenship:
Gender:
male

Education Training

Do you have a High School Diploma?

Yes ☑ No ☐

Do You have a PCA Certificate?

Yes ☐ No ☑

Do you have a HHA Certificate?

Yes ☐ No ☑


24/7 Home Care Agency of NY, Inc does not discriminate because of age, sex, physical handicap, race, creed, sexual orientation and any other protected classification, or national origin.
This agency is an equal employment opportunity employer.

I affirm that the information in this application is complete and true. I understand that if employed,
false statements will be a cause for dismissal.


Signature:

Date:
07-11-2023

EMERGENCY CONTACT FORM

Employee Name:

First Contact Information

Contact Name
Relationship to Employee:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:

Second Contact information

Contact Name
Relationship to Employee:
Emergency Contact Home Phone:
Emergency Contact Cell Phone:

Hepatitis B Vaccination / Declination Form

I, (print your name) Rajagiri Builders h understand that due to my occupational exposure to blood or other potential infectious materials, I may be at risk of acquiring the Hepatitis B Virus (HBV Infection). I have been given the opportunity by 24/7 Home Care Agency of NY, Inc. to be vaccinated with HBV vaccine at no charge. If you would like to request the Hepatitis B Vaccination please do not sign below and fill out a request form.

PLEASE SIGN ONLY IF DECLINING HEPATITIS B
Declination of Hepatitis B Vaccination

Declination of Hepatitis B Vaccination

I do not wish to be given the HBV vaccine at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B. I am aware that I may request to be provided with the vaccination at a later date during my employment with the agency.

Signature:

Date:
07-11-2023
Personal Assistant Name (Print Name):
Personal Assistant Signature

Date:
07-11-2023

Agreement between 24/7 HomeCare and Personal Assitant Live-In

  1. All Personal Assitant's (PA) assigned to live-in cases are to be present in the consumer home for 24 hours each working day.
  2. During each live in day, based on a 13 hour day, PA's are to perform tasks in accordance with the verbal or written care plan., PA's may not work in excess of 13 hours in any day and no more than 5 Live-In days per week.
  3. During each 24 hour day , PA's are to take eleven hours for personal time which will include hours of sleep, meal breaks and other personal time, remaining on premises at all such times.
    • 8 hours of sleep time
    • 2 hours meal breaks
    • 1 hours of personal time- reading, watching television, etc.
  4. If any , PA's finds it impossible to take the specified breaks from work duties because such times are constantly interrupted by the needs of the patient, she/he must call the administrator at 24/7 HomeCare Agency of NY, Inc immediately.
  5. I understand and will abide by the agency's rules stated in this agreement regarding time worked on live-in cases and I understand I will contact my coordinator if I believed I was paid improperly within 5 days. By simply accepting or continuing employment with 24/7 HomeCare Agency of NY, Inc, you agree that you received proper reimbursement for all hours worked and you cannot bring forth any claim/dispute as a plaintiff.
  6. I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, I agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in by myself or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.
  7. My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 Homecare Agency of NY's Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 Homecare Agency of NY to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 HomeCare. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

Name:
Rajagiri Builders h

Signature:

Date:
07-11-2023

THE PERSONAL ASSISTANT'S GUIDE TO THE CONSUMER DIRECTED
PERSONAL ASSISTANCE SERVICES PROGRAM

ACKNOWLEDGMENT OF RECEIPT

I have received the Personal Assistant’s guide and I have chosen to participate in the CDPAS as a Personal Assistant. I understand that 24/7 Home Care Agency of NY, Inc is the fiscal intermediary and I am hired, supervised, scheduled and trained by the consumer and/or designated representative. I have received, read and understand my role and responsibilities as Personal Assistant working for a Consumer or his/herDesignated Representative participating in the 24/7 HOMECARE AGENCY OF NY, INC. CDPAS Program.

I have had an opportunity to ask questions concerning my wage and benefit package.

  • I understand that is the Fiscal Intermediary and is responsible for processing on behalf of the Consumer the payroll and benefit administration for the PA.
  • I understand that I am hired, trained, supervised and receive my schedule by the Consumer and/or their Designated Representative.
  • I also understand it is the Consumer or Designated Representative who can terminate my services or dismiss me from working for them if they choose to do so.

I have received the copy of the CDPAS Handbook, Code of Conduct, Compliance Program, Paid Family Leave and Notice of Employee Rights (regarding sick leave). Equal Employment Opportunity Act, Wage Parity, Antisexual harassment notice and Fair Labor Standards Act (FLSA) on the date listed below 1 understand that this form will be retained in my personnel file.

I understand and agree that, in the event there is any dispute or claim arising out of or relating to this Agreement or the release of claims set forth above will be resolved exclusively through a final and binding arbitration on an individual basis only, and not in any form of class, collective, or private attorney general representative proceeding. I understand and agree that I am responsible to pay my own legal fees arising from these disputes. Further, to the fullest extent permitted by law, you agree that no class or collective actions can be asserted in arbitration or otherwise. All claims, whether in arbitration or otherwise, must be brought solely in your or the Company's individual capacity, and not as a plaintiff or class member in any purported class or collective proceeding.

My signature on this document acknowledges that I understand the above Arbitration Policy and agree to abide by its conditions. I further agree that, in accordance with 24/7 HomeCare’s Arbitration Policy, that I will submit any dispute arising under or involving my employment with 24/7 HomeCare to binding arbitration within 6 months from the date the dispute first arose. I agree that arbitration shall be the exclusive forum for resolving all disputes arising out of or involving my employment with 24/7 Homecare Agency of NY. I agree that I will be entitled to legal representation, at my own cost, during arbitration. I further understand that I will be responsible for half of the cost of the arbitrator and any incidental costs of arbitration.

Print Name
Rajagiri Builders h

Signature:

Date:
07-11-2023

ACKNOWLEDGMENT OF RECEIPT OF NOTICE PRIVACY PRACTICES

I acknowledge that I have been provided with a copy of an 24/7 Home Care Agency of NY, Inc Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.

Print Name:
Rajagiri Builders h

Signature:

Date:
07-11-2023

Personal Assistant Transportation

I will provide 24/7 Home Care Agency of NY, Inc with my driver’s license and insurance card in order to transport my patient in my car and/or the patient’s car.

OR

I will not be transporting my patient in my car and/or my patient’s car.

Personal Assistant Signature:

Date:
07-11-2023

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

► START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Last Name (Family Name)
h
First Name (Given Name)
Rajagiri Builders
Middle Initial
Other Last Names Used (if any)
Address (Street Number and Name)
Apt. Number
City or Town
State
NY
ZIP Code
Date of Birth (mm/dd/yyyy)
07-19-2023
U.S. Social Security Number
454-46-4665
Employee's E-mail Address
Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.
I attest, under penalty of perjury, that I am (check one of the following boxes):

☑ 1. A citizen of the United States
☐2. A noncitizen national of the United States (See instructions)
☐3. A lawful permanent resident(Alien Registration Number/USCIS Number):
☐ 4. An alien authorized to work until (expiration date, if applicable, mm/dd/yyyy):
Some aliens may write "N/A" in the expiration date field. (See instructions)
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1. Alien Registration Number/USCIS Number:

         OR

2. Form I-94 Admission Number:

         OR

3. Foreign Passport Number:

Country of Issuance:

QR Code - Section 1 Do Not Write In This Space
Signature of Employee
Today's Date (mm/dd/yyyy)
07-11-2023

Preparer and/or Translator Certification (check one):

☐I did not use a preparer or translator ☐ A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Signature of Preparer or Translator
Today's Date (mm/dd/yyyy)
07-11-2023
Last Name (Family Name)
First Name (Given Name)
Address (Street Number and Name)
City or Town
State
NY
ZIP Code
Employer Completes Next Page

Employment Eligibility Verification
Department of Homeland Security
U.S. Citizenship and Immigration Services

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Employee Info from Section 1
Last Name (Family Name)
First Name (Given Name)
M.I.
Citizenship/Immigration Status
List A
Identity and Employment Authorization
OR
List B
Identity
AND
List C
Employment Authorization
Document Title
Document Title
Document Title
Issuing Authority
Issuing Authority
Issuing Authority
Document Number
Document Number
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Expiration Date (if any) (mm/dd/yyyy)
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Document Title
Issuing Authority
Document Number
Expiration Date (if any) (mm/dd/yyyy)
Additional Information
Additional Information
UK Code - Sections 2 & 3 Do Not Write in This Space

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee, (2) the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee Is authorized to work In the United States.
The employee's first day of employment (mm/dd/yyyy): (See instructions for exemptions)

Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
07-11-2023
Title of Employer or Authorized Representative
Last Name of Employer or Authorized Representative
First Name of Employer or Authorized Representative
Employer's Business or Organization Name
24/7 Home Care Agency
Employer's Business or Organization Address (Street Number and Name)
City or Town
State
NY
ZIP Code
Section 3. Reverification and Rehlres (To be completed and signed by employer or authorized representative.)
A. New Name (if applicable)
B. Date of Rehire (if applicable)
Last Name (Family Name)
First Name (Given Name)
Middle Initial
Date (mm/dd/yyyy)
C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.
Document Title
Document Number
Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document's I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative
Today's Date (mm/dd/yyyy)
Title of Employer or Authorized Representative
Form

W-4


Department of the Treasury Internal Revenue Service

Employee's Withholding Certificate

► Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.
► Give Form W-4 to your employer.
► Your withholding is subject to review by the IRS.

0MB No. 1545-0074

2021

Step 1:
Enter Personal Information

(a) First name and middle initial
Rajagiri Builders
Last name
h
Address
City or town, state, and ZIP code
,NY,
(C)
☑ Single or Married filing separately
☐ Married filing jointly(or Qualifying widow(er))
☐ Head of household (Check only if you're unmarried and pay more than half the costs of keeping up a home for yourself and a qualifying individual.)
(b) Social security number
454-46-4665

► Complete Form W-4 so that your employer can withhold the correct federal income tax from your pay.

Complete Steps 2-4 ONLY If they apply to you; otherwise, skip to Step 5. See page 2 for more information on each step, who can claim exemption from withholding, when to use the online estimator, and privacy.

Step 2:
Multiple Jobs or Spouse Works

Complete this step if you (1) hold more than one job at a time, or (2) are married filing jointly and your spouse also works. The correct amount of withholding depends on income earned from all of these jobs.

Do only one of the following.

  • Use the estimator at www.irs.gov/W4App for most accurate withholding for this step (and Steps 3-4); or
  • Use the Multiple Jobs Worksheet on page 3 and enter the result in Step 4(c) below for roughly accurate withholding; or
  • If there are only two jobs total, you may check this box. Do the same on Form W-4 for the other job. This option is accurate for jobs with similar pay; otherwise, more tax than necessary may be withheld ► ☑

    • TIP: To be accurate, submit a 2020 Form W-4 for all other jobs. If you (or your spouse) have self-employment income, including as an independent contractor, use the estimator.

Complete Steps S-4(b) on Form W-4 for only ONE of these jobs. Leave those steps blank for the other jobs. (Your withholding will be most accurate if you complete Steps 3-4(b) on the Form W-4 for the highest paying job.)

Step 3:
Claim Dependents

If your income will be $200,000 or less ($400,000 or less if married filing jointly):

Multiply the number of qualifying children under age 17 by $2,000 ►

Multiply the number of other dependents by $500 ►

Add the amounts above and enter the total here

3




$

Step 4
(optional): Other Adjustments

  • Other income (not from jobs). If you want tax withheld for other Income you expect this year that won't have withholding, enter the amount of other income here. This may include interest, dividends, and retirement income.

4(a)
  • Deductions. If you expect to claim deductions other than the standard deduction and want to reduce your withholding, use the Deductions Worksheet on page 3 and enter the result here.

4(b)
  • Extra withholding. Enter any additional tax you want withheld each pay period.

4(c)

$

$

$

Step 5:
Sign Here

Under penalties of perjury, I declare that this certificate, to the best of my knowledge and belief, is true, conrect, and complete.

Employee Name (Signature) (This form Is not valid unless you sign It)
Date
07-11-2023

Employers Only

Employer's name and address
First date of employment
07-11-2023
Employer identification number (EIN)
47-3185512
For Privacy Act and Paperwork Reduction Act Notice, see page 3.
Cat. No. 10220Q
Form W-4 (2021)

Department of Taxation and Finance
Employee’s Withholding Allowance Certificate
New York State • New York City • Yonkers

First name and middle initial
Rajagiri Builders
Last name
h
Your social security number
454-46-4665
Permanent home address (number and street or rural route)
Apartment number
City, village, or post office
,NY,
State
NY
ZIP code
Single or Head of household ☑
Married ☐
Married, but with hold at higher single rate ☐

Note: If married but legally separated, mark an X in the Single or Head of household box.

1. Are you a resident of New York City?       Yes ☑ No ☐
2. Are you a resident of Yonkers?                  Yes ☑ No ☐

Complete the worksheet on page 4 before making any entries

Total number of allowances you are claiming for New York State and Yonkers, if applicable (from line 20) 1
Total number of allowances for New York City (from line 35) 2

Use lines 3, 4, and 5 below to have additional withholding per pay period under special agreement with your employer.
New York State amount 3
New York City amount 4
Yonkers amount 5

I certify that I am entitled to the number of withholding allowances claimed on this certificate

Employee’s signature
Date
07-11-2023

Penalty – A penalty of $500 may be imposed for any false statement you make that decreases the amount of money you have withheld from your wages. You may also be subject to criminal penalties.

Employee: detach this page and give it to your employer; keep a copy for your records.

Employer: Keep this certificate with your records.

Mark an X in box A and/or box B to indicate why you are sending a copy of this form to New York State (see instructions):

A Employee claimed more than 14 exemption allowances for NYS ............ A ☐
B Employee is a new hire or a rehire ... B☐
First date employee performed services for pay (mm-dd-yyyy) (see instr.):

Are dependent health insurance benefits available for this employee? ............. ☐Yes ☐No

If Yes, enter the date the employee qualifies (mm-dd-yyyy):

Employer’s name and address (Employer: complete this section only if you are sending a copy of this form to the NYS Tax Department.)
Employer identification number
47-3185512
Instructions

Changes effective for 2020
Form IT-2104 has been revised for tax year 2020. The worksheet onpage 4 and the charts beginning on page 5, used to compute withholding allowances or to enter an additional dollar amount on line(s) 3,4, or 5, have been revised. If you previously filed a Form IT-2104 and used the worksheet or charts, you should complete a new 2020 Form IT-2104 and give it to your employer.

Who should file this form
This certificate. Form IT-2104, is completed by an employee and given to the employer to instruct the employer how much New York State (and New York City and Yonkers) tax to withhold from the employee's pay. The more allowances claimed, the lower the amount of tax withheld.

If the federal Form W-4 you most recently submitted to your employer was for tax year 2019 or earlier, and you do not file Form IT-2104, your employer may use the same number of allowances you claimed on your federal Form W-4. Due to differences in tax law, this may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

For tax years 2020 or later, withholding allowances are no longer reported on federal Form W-4. Therefore, if you submit a federal Form W-4 to your

employer for tax year 2020 or later, and you do not file Form IT-2104, your employer may use zero as your number of allowances. This may result in the wrong amount of tax withheld for New York State, New York City, and Yonkers.

Complete Form IT-2104 each year and file it with your employer if the number of allowances you may claim is different from federal Fomn W-4 or has changed. Common reasons for completing a new Form IT-2104 each year include the following:

• You started a new job.
• You are no longer a dependent.
• Your individual circumstances may have changed (for example, you were married or have an additional child).
• You moved into or out of NYC or Yonkers.
• You itemize your deductions on your personal income tax return.
• You claim allowances for New York State credits.
• You owed tax or received a large refund when you filed your personal income tax return for the past year.
• Your wages have increased and you expect to earn $107,650 or more during the tax year.

24/7 HomeCare Agency of NY                              Tel:718-887-0782

Waiver of Group Health Benefits & Notice of Special Enrollment Rights

Employer Name
24/7 Home Care Agency of NY, INC

Please complete the following:

Employee Name
h
   
Rajagiri Builders
   

(Last)
(First)
              (MI)

Employee Social Security Number
454-46-4665

For the plan year effective(07-11-2023) I am waiving coverage for:

☑ Myself

☐ Spouse/Domestic Partner

☐ Dependent (s) Please list names:

I am waiving coverage due to:

☑ My preference not to have coverage


☐ Coverage under my spouse's/domestic partner's plan name of carrier:


☐ Other coverage name of carrier:

This other coverage is:
☑ Individual ☐ COBRA ☐ Medicare ☐TRICARE (formerly CHAMPUS)
☐ Medicaid ☐ Employer-Sponsored Group Plan

Special Enrollment Notice and Certification - Please review and sign below if you wish to waive coverage

By signing below, I certify that I have been given an opportunity to apply for coverage for myself and my eligible dependents, if any. I am declining enrollment as indicated above. I understand that I am declining enrollment for myself or my eligible dependents (including my spouse) because of other health insurance or group health plan coverage, I may be able to enroll myself and my eligible dependents in this plan if I lose, or my eligible dependents lose, eligibility for that other coverage.

I understand that I must request enrollment no more than 30 days after the date the other health plan coverage ends (or after the employer stops contributing toward the other coverage). If I do not do so, I will not be able to enroll until my employer's next annual open enrollment period.

In addition, I understand that if I have a newly eligible dependent as a result of marriage, birth, adoption, or placement for adoption, I may be able to enroll myself and my eligible dependent(s). However, I must request enrollment within 30 days after the marriage, birth, adoption, or placement for adoption.

I understand that in order to request special enrollment or obtain more information, I should contact my group administrator.


Signature of Employee
Date of Signature.
07-11-2023

Notice and Acknowledgement of Pay Rate and Payday
Under Section 195.1 of the New York State Labor Law
Notice for Multiple Hourly Rate Employees

1.Employer Information

Name :
24/7 HomeCare Agency of NY, Inc

Doing Business As(DBA) name(s) :

FEIN (optional):

Physical Address:
2414 Ralph Avenue
Brooklyn, NY 11234

Mailing Address:
2414 Ralph Avenue
Brooklyn. NY 11234

Phone:
718-887-0782


2.Notice Given:

☑At hiring

☐Before a change in pay rates (s), allowances claimed
or payday

3.Employee's rate(s) of pay for each type of work or shift:

  • $ 17 per hour for hourly cases
  • $ 17 per hour for 13 hrs on Live-in Cases
  • $ per hour for

4.Allowaces taken:
☑ None
☐ Tips _________ per hour
☐ Meals _________ per meal
☐ Lodging _________
☐ Other _________

5.Regular payday: Friday/p>

6.Pay is:
☑ Weekly
☐Bi-weekly
☐ Other:

7.Overtime Pay Rates(s) for each type of
work or shift: 1.5xReg Pay Rate

This must be at least 1 1/2 times the worker's weighted average of the multiple rates of pay for the week, with few exceptions. The weighted average is the total regular pay divided by the total hours worked in the week. The overtime rate may vary from week to week depending on how many hours you worked at each rate of pay. The overtime rate may vary from week to week.

8.Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate (if eligible), allowances, and designated payday on the date given below. I told my employer what my primary language is.

Check one:

☑I have been given this pay notice in English because it is my primary language.
☐My primary language is I have been given this pay notice in English only, because the Department of Labor does not yet offer a pay notice form in my primary lanuage.
Print Employee's Name
Rajagiri Builders h
Employee's Signature
Date
07-11-2023
Preparer's Name and Title
24/7 HomeCare Agency of NY, Inc

The employee must receive a signed copy of this form. The employer must keep the original for 6 years.

CORPORATE COMPLIANCE EDUCATION ACKNOWLEDGEMENT FORM

This is to certify that I am in receipt of Corporate Compliance Training and Educational Materials from my Consumer enrolled in 24/7 HOMECARE AGENCY OF NY, INC. CDPAP pertaining to the Federal False Claims Act, New York False Claim Act, Whistleblower Protection and Identifying Fraud and Abuse Law, as well as where to report these issue should they be suspected or uncovered.

Print Name
Rajagiri Builders h
Signature
Date
07-11-2023

HIPAA ACKNOWLEDGEMENT

I have been informed regarding HIPAA Privacy Rules by as provided to me by 24/7 HOMECARE AGENCY OF NY, INC and I acknowledge compliance with these rules as per NYS mandate.

I understand that the major goal of the privacy rules is to assure that all of our consumers health information is properly protected, while allowing the flow of vital healthcare/clinical information to all employees participating in providing patient care/services. As such, we can provide and promote high quality, safe and effective homehealth care.

24/7 HOMECARE AGENCY OF NY, INC also protects the public's health and their well-being by implementing disciplinary action upon notifications on any HIPAA violations by our employees.

Print Name
Rajagiri Builders h
Signature
Date
07-11-2023

The Personal Assistant (PA) agrees to:

  • Recognize the authority of the consumer as the Personal Assistant source of employment and supervisor.
  • Respect the Consumer’s health, wellbeing, privacy and property.
  • Authorize 24/7 HOMECARE AGENCY OF NY, INC. to collect and appropriately distribute employment related information.
  • Comply with the policies and practices of 24/7 HOMECARE AGENCY OF NY, INC. Consumer Directed Personal Assistant Program.

24/7 HOMECARE AGENCY OF NY, INC, Consumer Directed Personal Assistant Program Agrees to;

  • Monitor the Consumer’s or, if applicable the consumers designated representative, continuing ability to fulfill; the consumer’s responsibilities and appropriateness for continued participation in 24/7 HOMECARE AGENCY OF NY, INC.. Consumer Directed Personal Assistance Program, either directly or indirectly using all available information, or notifying the Consumers Medicaid Managed Care Plan Provider as needed..
  • Comply with Dept. of Health regulations contained in NYCRR 504.3
  • Maintain the information needed for payroll processing and benefit administration and process the Consumer’s payroll for each Personal Assistant.
  • Pay the Personal Assistant the prevailing wage in the industry for the hours of service indicated on the Consumer's time sheet or verification of hours worked utilizing a electronic time and attendance system.
  • Coordinate all matters, which relate to each Personal Assistants withheld taxes and benefits and comply with workers compensation, disability and unemployment insurance requirements.
  • Encourage the Consumer to provide equal employment opportunities to all prospective employees regardless of their race,creed, color, national origin, sex, disability, marital status, and sexual orientation, in all in all employment decisions.
  • Facilitate and monitor the completion of all Consumer and Personal Assistant documents that a required by Brooklyn, State orFederal Authorities either directly-or indirectly.
  • Maintain directly a personal record for each Personal Assistant that will include, at a minimum the enrollment forms, the annual worker's health status assessments prior to delivery of service pursuant to 10 NYCRR 766.11 (c) and (d) or any successor regulation.
  • Maintain a Consumer Record which includes authorizations from the consumers Medicaid Managed Care Plan Provider the Consumer Agreement, and all other documents required to monitor and maintain information required for participation in the CDPAP provided by the Consumers Medicaid Managed Care Plan.
  • Identify and Evaluate community resources that may be available to the Consumer to assist with Consumer for Recruitment Assistance Services.
  • Maintain a Consumer Advisory Committee and Grievance Committee.
  • Provide statistical and pertinent information to the various regulatory, legal and programmatic entities as required or requested.

PA Signature
Date
07-11-2023

Acknowledgement of Mandatory Compliance Regarding Time Sheets and Clock In and Out

I,Rajagiri Builders hPersonal Assistant certify that I have been trained regarding mandatory compliance responsibilities of the agency with the Department of Health. I have been trained and understand the following:

  • I understand that if the patient has a working phone, I MUST CLOCK IN AND OUT or the HHA App.
  • I understand that I will use the patient’s telephone or cell phone, NOT MY CELL PHONE, to clock in and out unless using the app.
  • Timesheets must be filled out according to the time that I serviced the patient. I understand to write down the time that I was with the patient, NOT the scheduled time. Timesheets are only given in emergency circumstances or pre-approved situations.
  • I understand that I can not submit a timesheet if the patient is in care of a third party. Such as Hospital or Hospice or Dialysis Centers including any facilities that are considered 3rd Party.
  • I have been trained and shown how to fill out a timesheet correctly.
  • I understand that I must submit the time sheets by every week Monday the latest.
  • I understand that I may not schedule myself to work for two patients at the same time.
  • I understand that I must not give my clock-in ID # to anyone including the patient.
  • I understand that the patient or anyone else cannot clock me in or out.
  • I understand that I must not send anyone other than myself to work for me.

I acknowledge that I am solely responsible for these requirements in order to continue working with my CDPAP consumer. Violations of these requirements are grounds for immediate termination. I acknowledge that for the safety of the patients whom I will service, I will abide by 24/7 HomeCare policy.

Print Name
Rajagiri Builders h
Signature
Date
07-11-2023

THE PERSONAL ASSISTANT'S GUIDE TO THE CONSUMER DIRECTEDPERSONAL ASSISTANCE PROGRAM ACKNOWLEDGEMENT OF RECIEPT

I have received the Personal Assistant's guide and I have chosen to participate in the CDPAP as a Personal Assistant. I understand that 24/7 Home Care Agency of NY, Inc. is the fiscal intermediary and I am hired, supervised, scheduled and trained by the consumer and/or designated representative.

I understand that failure to accurately complete the time slip or the automated time and leave call in system may be construed as fraudulent and may result In disciplinary action.

I understand that my timesllps and automated time and leave call in must reflect the exact hours worked and that the work I do is for the consumer only. I understand that I must report my patient's hospitalization to the agency Immediately and that I can not be paid if the consumer is In the hospital.

I understand it is my responsibility to report any act of fraud or abuse.

If you are aware of any fraudulent activity and do not report It, you could be punished. Whistleblower laws protect employees against retaliation for reporting. All reports will remain confidential and can be filed in person or writing or verbally over the phone with: Sharon Halfon RN, Corporate Compliance Officer @ 718-887-0782.

Print Name
Rajagiri Builders h
Signature
Date
07-11-2023

Acknowledgement of Receipt of the Paid Safe and Sick Leave Notice of Employee Rights


I Rajagiri Builders h have received the Notice of Employee Rights for the Paid Safe and Sick Leave Law. My questions regarding Paid Safe and Sick Leave have been answered.

I know I can contact 24/7 Home Care Agency of NY, Inc, at the above address or telephone number if I have any other questions regarding this notice.

I understand the following about the Paid Safe and Sick Leave:

  1. I must work 80 hours or more per calendar year (from January 1st to December 31st) In order to be covered by the Paid Sick Leave Law.
  2. I accrue 1 hour for every 30 hours worked, up to a maximum of 40 hours per calendar year.
  3. For new PA’s: I can use the accrued time after 120 days from my 1st workday.
  4. I am allowed to carry over any unused sick leave to the following year but can only use up to 40 hours of Paid Sick Leave per calendar year.
  5. I am required to provide 24/7 HomeCare with a health care provider's note if I use my sick leave time for four or more consecutive days, no specifics regarding my health is necessary.
  6. I may use Paid Sick Leave for sick leave ONLY and I must be scheduled in order to use sick leave. I must provide 24/7 HomeCare with 7 days of advance notice whenever possible; if I am presented with an unforeseeable situation, then I will provide a notice as soon as possible.
  7. I understand that if I call out or sick the day before or the day after a holiday I am scheduled to work, I will not get paid sick time even if I have it available.

I acknowledge that I have received the necessary information and instructions regarding Paid Family Leave benefits.

Personal Assistant Signature
Date
07-11-2023

I Rajagiri Builders h acknowledge that I will not be able to start working as a Personal Assistant for the CDPAS program until I am specifically informed by 24/7 Home Care Agency of NY,Inc that I am able to begin working on the case. Any allowance to work, that does not come directly from 24/7 Home Care Agency of NY, Inc, will be considered invalid. If I work under an invalid authorization I realize that I will not be able to be paid by 24/7 Home Care Agency of NY, Inc for the time that I worked. I understand that, generally, instructions to begin working as a Personal Assistant will be provided to me along with a caregiver code and an explanation of the process for clocking in and out.

Signature
Date
07-11-2023

Declination of Influenza Vaccination


My employer, 24/7 HomeCare Agency of NY, Inc, has recommended that I receive the influenza vaccination to protect the patients I serve.

I acknowledge that I am aware of the following facts:

  • Influenza is a serious respiratory disease that kills thousands of people in the United States each year.
  • Influenza vaccination is recommended for me and all other healthcare workers to protect this facility’s patients from influenza, its complications, and death.
  • If I contract influenza, I can shed the virus for 24 hours before influenza symptoms appear. My shedding the virus can spread influenza to patients in this facility.
  • If I become infected with influenza, even if my symptoms are mild or non-existent, I can spread it to others and they can become seriously ill.
  • I understand that the strains of virus that cause influenza infection change almost every year and, even if they don’t change, my immunity declines over time. This is why vaccination against influenza is recommended each year.
  • I understand that I cannot get influenza from the influenza vaccine.
  • The consequences of my refusing to be vaccinated could have life-threatening consequences to my health and the health of those with whom I have contact, including:
    • All patients in this healthcare facility
    • My Coworkers
    • My Family
    • My Community

Despite these facts, I am choosing to decline influenza vaccination right now for the following reasons:

I understand that I can change my mind at any time and accept influenza vaccination, if vaccine is still available.

I also understand that I will need to wear a face mask during flu season while I am on a case with a patient.

I have read and fully understand the information on this declination form. I have also received a flu mask for this flu season.

Name (print)
Rajagiri Builders h
Signature
Date
07-11-2023

Flu Vaccine Declination

☑I will NOT be getting the flu vaccine for the 2021-2022 Flu season. I will wear a surgical mask during any time spent with any patients.

☐I Received the Flu Vaccine for the 2021-2022 Flu Season.

I understand that failure to comply with these requirements will put me and the patient I care for at risk, and my employment with 24/7 HomeCare Agency of NY, Inc is conditional on meeting these requirements.

Name of Employee (print)
Rajagiri Builders h
Signature of Employee
Date
07-11-2023

2414 Ralph Avenue Brooklyn, NY 11234 • T: 718-887-0782 • F: 718-874-2778 • Email: info(g)247nyhomecare.com

SEXUAL HARASSMENT POLICY ACKNOWLEDGMENT

I, Rajagiri Builders h certify that I have been trained on the NYS Sexual Harassment Policy. I understand that Sexual harassment is a form of workplace discrimination. 24/7 HomeCare Agency of NY, Inc has a zero-tolerance policy for any form of sexual harassment, and all employees are required to work in a manner that prevents sexual harassment in the workplace. I also understand that Sexual harassment is against the law and that I have the legal right to a workplace free from sexual harassment, and I can file a complaint internally with, 24/7 HomeCare Agency of NY, Inc or with a government agency or in court under federal, state or local anti-discrimination laws. This policy applies to all employees, paid or unpaid interns, and non-employees and all must follow and uphold this policy.

I have been given the Complaint Form and contact information if I ever must file a complaint for sexual harassment.

Employee's Signature
Date
07-11-2023

Acknowledgement of Receipt of Paid Family Leave (PFL) Instructions

Under a new New York state law, working New Yorkers will be able to take time off to care for a loved one while still receiving a portion of their salary. The eligible employees will now be able to take up to 8 weeks of benefits and job-protected leave in any 52-week period at up to 50 percent of their salary.

Employee Eligibility

Full-Time employees (Individuals working 30 or more hours a week): must work 20 or more hours per week for 26 or more consecutive weeks of employment.

Part Time employees (individuals working less than 30 hours a week): must work fewer than 20 hours per week for 175 days in a 52-consecutive week period.

The employee must provide advance notice of 30 days. If providing notice of less than 30 days an explanation must be given.

Types of Leave

  • 1. Care for a close relative with a serious health condition. A close relative could be your spouse, domestic partner, children, parents, parents' in-law, grandparents, and grandchildren.
  • 2. Maternity and paternity leave. Employees can take time to bond with their newborn, newly adopted, or a newly placed child, within the first 12 months after the child's birth, adoption, or placement of an adopted or foster child.
  • 3. Qualifying Exigency Leave: when an employee's spouse, child, domestic partner, or parent is on covered active duty or has been notified of an impending call or order to covered active duty; or to care for a service member with a serious injury or illness, if the employee is the service member's spouse, child, domestic partner, or parents.

Payroll Deductions to Fund Paid Family Leave Benefits

The maximum employee contribution is 0.126 percent of their weekly wage, not to exceed $1,305.92 as per NY DOL.

New York State has more information about the Paid Family Leave program at www.ny.gov/paidfamilyleave

All requests for Paid Family Leave must be made through the Human Resources Department. Please call Sharon at 718-887-0782

Print Employee's Name:
Rajagiri Builders h
Employee's signature
Date:
07-11-2023

Acknowledgement of Receipt of the
Personnel Policy and Privacy Notice

I Rajagiri Builders h have received 24/7 Home Care Agency of NY, Inc, Personnel Policy and Privacy Notice. My questions regarding the Personnel Policy and Privacy Notice have been answered.

I know I can contact 24/7 Home Care Agency of NY, Inc at the above address or telephone number if I have any other questions regarding this form.

I further understand that my employment is at will, and neither 24/7 Home Care Agency of NY, Inc nor I have entered a contract regarding the duration of my employment. Except as otherwise provided in a valid and enforceable collective bargaining agreement, I am free to terminate my employment with the 24/7 Home Care Agency of NY, Inc at any time, with or without reason and 24/7 Home Care Agency of NY, Inc has the right to terminate my employment, or otherwise discipline, transfer, or demote me at any time, with or without reason at the discretion of the Facility. No employee of24/7 Home Care Agency of NY, Inc can enter into an employment contract for a specified period of time or make any agreement contrary to this policy without the written approval of the Administrator.

Employee's Signature
Date
07-11-2023

Compliance Program

Dear Staff Member:

24/7 HomeCare Agency of NY, Inc is dedicated to conducting its business honestly and ethically wherever 24/7 HomeCare Agency of NY, Inc operates. In order to meet this commitment, 24/7 HomeCare Agency of NY, Inc as set forth in this Code of Conduct the principles and rules to be followed by all personnel who work with 24/7 HomeCare Agency of NY, Inc.

The purpose of this Code of Conduct is to inform all personnel and interested third parties that 24/7 HomeCare Agency of NY, Inc is fully dedicated to approaching all of its activities, including compliance with laws and regulations, in an ethical manner. This Code of Conduct will familiarize new personnel with the ethical standards that guide our business and patient relationships in our highly regulated environment. For existing personnel, it will reaffirm our commitment to ethical behavior in all circumstances. Since everyone at 24/7 HomeCare Agency of NY, Inc has a personal stake in this important program, we strongly urge each of you to review this information thoroughly and refer to it whenever situations arise requiring you to exercise your judgment.

Compliance with laws, regulations and out policies require the full commitment of all 24/7 HomeCare Agency of NY, Inc personnel. Each of us is personally and professionally responsible for understanding and adhering to this Code of Conduct and the supporting policies and procedures, including those areas covering your specific job responsibilities. The purpose of this Code of Conduct is to provide you with guidance on ethical and compliance issues. However, this Code of Conduct cannot cover every issue you may encounter. If you have a question or encounter a situation which concerns you, you should ask for 24/7 HomeCare Agency of NY, Inc through your department supervisor, the Administrator and/or the Compliance Officer.

Compliance Hotline is 718-887-2922 or the email is info@247nyhomecare.com

Print Name
Rajagiri Builders h
Employee's Signature

ORIENTATION CHECKLIST

Name:
Rajagiri Builders h
SS#:
454-46-4665
TitIe:
HHA / PCA

Welcome to 24/7 HomeCare Agency

A Tax Forms from TAXOA YES NO N/A
B 1-9 Form, Wage form, W-4 ☑ ☐ ☐
C Employee Handbook ☑ ☐ ☐
1.Employment Requirements and Agency Policies ☑ ☐ ☐
2.Continuous Employment ☑ ☐ ☐
3.Job Description ☑ ☐ ☐
4.HIV Confidentiality Policy ☑ ☐ ☐
5.Infection Control. Universal Precaution ☑ ☐ ☐
6.TB Policy/Precautions ☑ ☐ ☐
7.Emergency Disaster Preparedness ☑ ☐ ☐
8.HIPAA/Privacy Rights ☑ ☐ ☐
9.Required E V V, (clock in/out) ☑ ☐ ☐
10.Case Acceptance ☑ ☐ ☐
11.Absences and Lateness Policy ☑ ☐ ☐
12.Patient Abandonment Policy ☑ ☐ ☐
13.No Call No Show Policy ☑ ☐ ☐
14.Dress Code ☑ ☐ ☐
15.Cellular/Wireless Device Policy ☑ ☐ ☐
16.Employee Counseling ☑ ☐ ☐
17.Grievances/Complaints ☑ ☐ ☐
18.Equal Employment Opportunity Policy ☑ ☐ ☐
19. Pregnancy Accommodations ☑ ☐ ☐
20. Anti-Harassment Policy ☑ ☐ ☐
21.Sexual Harassment Policy ☑ ☐ ☐
22.Protection Against Retaliation ☑ ☐ ☐
D Code of Conduct ☑ ☐ ☐
E a. Fraud and Abuse ☑ ☐ ☐
b. Professional Standard ☑ ☐ ☐
c. Confidentiality ☑ ☐ ☐
F HHA/PCA Activity -- DUTY CODES/Timesheets ☑ ☐ ☐
G HHA Exchange App ☑ ☐ ☐
H Picture IDs ☑ ☐ ☐
I Missing Documentation from Application Process ☑ ☐ ☐

I have read my job description and understand that I will be evaluated based on the performance criteria in my job description. I acknowledge having completed all of the orientation in service curriculum.

EMPLOYEES SIGNATURE
Date
07-11-2023
INSTRUCTOR'S SIGNATURE
Date
07-11-2023

CORPORATE COMPLIANCE / CONFLICT OF INTEREST
NON-SOLICITATION AND NONCIRCUMVENTION

As an employee of 24/7 Home Care Agency of NY, Inc I, Rajagiri Builders h ,understand that any attempt on my part to provide services to a patient without the knowledge of the agency would be harmful and damaging to the agency. I agree that during the term of my employment with the agency and for a period of ninety (90) days after the end of myemployment:

  1. I will not in any way, directly or indirectly, offer to provide services to any of the agenc/s patients without the agency's actual knowledge, authorization and consent.
  2. I will not in any way, directly or indirectly, accept a patient's offer to hire me directly without the agency's actual knowledge, authorization and consent.
  3. I will not in any way, directly or indirectly, actually provide services to any of the agency's patients without the agency's actual knowledge, authorization and consent.

I recognize that a breach of this agreement can result in harm to the agency and agree that in the event of such a breach, I will be liable to pay the agency a minimum of the full payment the agency would have earned had I not circumvented the agency, plus further damages to the extent allowed by law and that the agency shall be entitled to and may seek any and all additional remedies to the extent available by law.

Signature

Date:
07-11-2023

LS 62 Notice to Wage Parity Home Care Aides - (cont'd)
Benefit Portion of Minimum Rate of Home Care Aide Total Compensation

Hourly Rate Type of Supplement Name & Address of Provider Agreement/ Plan information
Supplement Number
$xxx
 (Pension, Welfare, or Other) Insert Name and Address of Company or Organization Providing Benefit Identify plan or agreement that creates the benefit, e.g., Union Local No. 1 Collective Bargaining Agreement or Insurance Company X Benefit Plan
Supplement Number 1
Health & Welfare Benefit & Risk Management Services P.O. Box 2140 Folsom, CA 95763 Summary Plan Description for the 2417 Home Care Agency of New York
Supplement Number 2
Annual Physical Compliance Mobile Health 229 W 36th St. #10, New York, NY 10018 MEC Employee Benefit Plan
Supplement Number 3
Employer Paid Reimbursement Card Ameriflex 2508 Highlander Way Carrollton, TX 75006 Amenflex Administrative Service Agreement
Supplement Number 4
JNS Benefit Management J.N. SavastaCorp. 1350 Broadway NY. NY 10018 J.N. Savasta Corp. Administrative Service Agreement

*If wage supplements are paid as a single payment awed to multiple Taft-Hartley multiemployer plans, list only the following: (1) the total paid for the supplement or benefit package; (2) the types of benefits included in the package, e.g., pension, health and welfare, or other; (3) the name and address of the entity to whom payment is sent; and (4) the relevant CBA or letter of assent as the agreement.

List any additional benefits and attach listing to this document.

Copies of the above listed agreements or summaries may be obtained by:

J.N. Savasta Corp.

Employee Acknowledgement:

On this day I have been notified of my pay rate, overtime rate, allowances, supplements/benefits, and designated payday provided on this form (LS 62) attached and this addendum on the date given below.

My primary language is English I have been given this notice in my primary language ☑ Yes ☐ No
Print Employee's Name
Rajagiri Builders h
Employee's Signatue
Date
07-11-2023
Preparer's Name and Title:

Note 1: Benefit eligibility and costs outlined on separate provided grid and can also be found at JN Savasta
Note 2: Amounts accrue weekly, but enrollment in benefits is based on total monthly accruals from a month prior.
For example, total accruals in January determine eligibility and enrollment for March benefits. Costs for benefits outlined in previously referenced grid

LS 62 (9/20)

RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have been provided with a copy of an 24/7 Home Care Agency of NY, Inc Notice of Privacy Practices that provides a description of protected information uses and disclosures, and that I have had an opportunity to ask questions about anything that I did not understand.

Member Name:
Rajagiri Builders h

Signature:

Date:
07-11-2023

Consumer Acknowledgement Form

I have completed the required training required by 24/7 HomeCare Agency of NY , Inc. I understand the responsibilities of all involved partied and agree to abide by them.

I have received training in:

  • Assessing my Needs
  • Recruiting and Hiring
  • Contents of advertisement
  • Screening Applicants
  • Conducting Interview
  • Checking References
  • Hiring
  • Back-up Assistants
  • Conflict Resolution
  • Personal and Property Safety
  • Training my Personal Assistant

I understand that I will meet and interview my employee’s according to guidelines provided by my training program. I also Understand that I am responsible for the completion of all requested paperwork.



Member Signatue
Date

CONSUMER DIRECTED PERSONAL ASSISTANCE PROGRAM (CDPAP) AGREEMENT BETWEEN 24/7 HOMECARE AND CONSUMER/DESIGNATED REPRESENTATIVE

Responsibilities of the Consumer/Designated Representative

The Consumer/Designated Representative should:

  • Understand the purpose of the CDPAP and the responsibilities of 24/7 HomeCare and consumer/designated representative.
  • Be responsible for recruiting, hiring, training, supervising, scheduling and terminating the qualified individual of their choosing in adequate numbers to meet their needs.
  • Maintain an appropriate home environment and provide training as necessary.
  • Review the plan of care with each personal assistant (PA) outlining their responsibilities and ensure that the PA only performs the tasks identified on the plan of care during authorized hours.
  • Comply with Labor Laws, providing equal employment opportunities as specified in the Consumer's agreement with the CDPAP 24/7 HomeCare
  • Inform the LDSS and 24/7 HomeCare of any change in status or condition, including but not limited to; hospitalizations, address and telephone number changes.
  • Assure the accurate and timely submission of the PA’s required paperwork to the CDPAP 24/7 HomeCare including time sheets, annual worker health assessments, and required employment documents.
  • Develop and maintain a contingency plan to assure adequate supports are available to meet needs.
  • Ensure that each PA has submitted timecards reflective of hours worked within the weekly authorized hours by signing timesheet.
  • Distribute paychecks to each PA, if applicable.
  • Cooperate with the LDSS and comply with Medicaid Program requirements to be available for the required reassessment.

I attest that I have received the Electronic Visit Verification (EVV) Fact sheet

BOTH PARTIES ACCEPT THE ROLES / RESPONSIBILITIES IN THE CDPAP AS EXPLAINED ABOVE.

Consumer/Designated Representative:

Date:
07-11-2023
Signatue
Fiscal Intermediary:
24/7 Home Care Agency of NY
Date: