Pediatric Healthcare Connection - Annual Packet

Job Description - Step 1 of 10


Job Description: Private Duty Nurse


The PHC Private Duty Nursing (PDN) Staff provide the frontline services to PHC’s patient population. They deliver and document effective and efficient care. They also serve in the most fundamental role of establishing and maintaining positive working relationships with PHC leadership, staff, patients and families. Key activities may include:

  1. Follows the Plan of Care and notifies Clinical Supervisor of changes in orders.
  2. Delivers compassionate, accurate, quality care
  3. Produces clear, concise, and accurate documentation and submits within required time frames.
  4. Recognizes deviations in patient conditions and makes appropriate notifications
  5. Displays successful decision-making and problem solving skills, and coordinates with the Clinical Supervisor when appropriate
  6. Establishes and sustains a professional rapport with patients, families, co-workers, and PHC leadership
  7. Maintains effective communication and coordination between PHC staff, patients and families
  8. Exercises effective conflict avoidance and resolution skills
  9. Maintains current knowledge of work topics, including new diagnoses and medications
  10. Conforms with all PHC policies
  11. Minimizes call-outs
  12. Arrives on time to work and displays a strong work ethic
  13. Supports team-building efforts
  14. Displays strong organizational and time-management skills
  15. Continually strives for quality improvement

Essential Job Functions:

The PHC Private Duty Nurse divides time across clinical and administrative responsibilities. The allocation of time and effort will vary by patient and includes:

  • Clinical (95%)
    Direct patient care, accompany patient to physician visits, school, and therapy as needed; orders/re-orders medications, orders and organizes DME supplies
  • Clinical Administration (5%)
    Charting, Participate in training and Performance Evaluations

Job Qualifications:

  1. Education: Graduate of an accredited Diploma, Associate or Baccalaureate School of Nursing or a Certificate program recognized by the State of Texas Board of Nursing (BON)
  2. Preferred experience: One (1) year experience as a Registered Nurse (RN) or Licensed Vocational Nurse (LVN) obtained within the last 36 months; experience and knowledge of Trach/Vent, G-tube
  3. Licensures and certifications: Current Texas State license as an RN or LVN and current Texas Drivers License. Current CPR accredited by American Heart Association or American Red Cross or any other accredited sources approved by PHC; PDN to maintain their BON required 20 contact hours
  4. General Skills: Proven written and oral communication skills; proficient with computer use; excellent interpersonal and organizational skills; problem solving and conflict resolution skills
  5. References: Minimum of two professional references meeting PHC standards
  6. Transportation: Reliable transportation

Environmental and Working Conditions

Works the majority of time in the patient’s home with occasional shifts outside the home supporting family outings and hospital or clinic visits. Noise level may be moderately high, ability to work a flexible schedule and extended hours. Ability to travel locally and some exposure to inclement weather.

Physical and Mental Effort

Prolonged sitting and some standing required. Occasional need to lift, pull, carry and push items weighing up to fifty pounds. Frequent need to stoop, kneel and reach while providing patient care. Requires working under some stressful conditions to meet deadlines, resolve interpersonal conflicts, and address employer and employee needs. Requires hand-eye coordination and manual dexterity. Requires excellent interpersonal and problem solving skills.

Shift / Schedule

Shifts and schedules vary and are determined on an individual basis. Typical shifts are 12 hour day and/or 12 hour night shifts.

Job Description Acknowledgement

I have received, reviewed and fully understand the PDN job description. I further understand that I am responsible for carrying out the listed responsibilities and successfully executing the essential functions under the conditions as described.

Hepatitis B Vaccination - Step 2 of 10


Due to your occupational exposure to blood or other potentially infectious materials, you may be at risk for acquiring hepatitis B viral (HBV) infection. The vaccination series is available, at no cost, to you. Please indicate below your declination or acceptance to receive the vaccine.

Hepatitis B is a blood borne virus which can cause a range of symptoms from mild to serious, and possibly result in fatal liver damage to health care workers who become infected. The virus can be transmitted through contact with infectious fluids of a patient who has hepatitis B virus. You have been taught the concepts of Universal Precautions concerning safe patient care and the use of equipment to avoid unnecessary exposure.

Synthetic hepatitis B vaccine is derived from yeast cells. It is not composed of human blood or plasma. It is given as a series of three injections into the arm muscle at prescribed intervals (initial shot, one month later, and six months later). It has proven to be over 80-90% effective in protecting against the disease. There may be hypersensitivity to the vaccine, and there may be soreness and swelling of the injection arm. Other side effects may occur at an incidence of under 3% of injections.

The vaccine will not be given to persons with known sensitivity to aluminum hydroxide, thimerosal, yeast or hepatitis antigen and will only be given with your personal physician’s recommendations in the cases of pregnancy or presence of other infection of immunosuppressive state. The vaccine does not grant 100% assurance of immunity.


TB Fact Check - Step 3 of 10


The following criteria is utilized to identify if an employee has potential TB. This criteria is also utilized to determine if an employee needs another chest x-ray. This information is also presented in training.

Detection of employees who may have active TB are based on the following criteria:

Potential active symptoms:
  1. Persistent cough greater than 2 weeks duration
  2. Bloody sputum
  3. Night sweats
  4. Weight loss
  5. Anorexia
  6. Fever

Groups with a higher prevalence of TB infection:
  1. Medically underserved populations
  2. Homeless individuals
  3. Current or past prison inmates
  4. Alcoholics
  5. Injecting drug users
  6. Elderly
  7. Foreign-born persons from Asia, Africa, the Caribbean and Latin America
  8. Contacts to individuals with TB
  9. Groups with a greater risk to progress from latent TB infection to active disease
  10. Individuals with HIV infection, silicosis, S/P gastrectomy or jejuno-ileal bypass surgery, greater than 10lb. Below normal body weight, chronic renal failure, diabetes mellitus, immunosuppressed due to medication, and those with some malignancies.
  11. Individuals who have been infected within the past 2 years and individuals with fibrotic lung disease on chest x-ray

I have reviewed the signs and symptoms of TB. I am not experiencing symptoms of TB. I understand if I experience any of the above symptoms I am to report to management immediately.

Statement of Employability - Step 4 of 10


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. 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. 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 in the NAR or EMR per TAC §93.3 and TxH&SC Chapter 253.

Criminal History Check

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 contact until results are returned. I will be notified of results.


(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 and unlawful restraint);
  • An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
  • An offense under Section 21.08, Penal Code (indecent exposure);
  • An offense under Section 21.11, Penal Code (indecency with a child);
  • 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 22.011, Penal Code (sexual assault);
  • An offense under Section 22.02, Penal Code (aggravated assault);
  • An offense under Section 22.021, Penal Code (aggravated sexual assault);
  • An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual);
  • An offense under Section 22.041, Penal Code (abandoning or endangering a child);
  • An offense under Section 22.05, Penal Code (deadly conduct);
  • An offense under Section 22.07, Penal Code (terroristic threat);
  • 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 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 42.09, Penal Code (cruelty to animals);
  • An offense under Section 36.06, Penal Code (obstruction or retaliation);
  • An offense under Section 42.09, Penal Code (cruelty to livestock animals);
  • An offense 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 also be barred from employment the duties of which involve direct contract with a client in a facility if convicted of any of the following crimes within the past 5 years:

  • An offense under Section 22.01, Penal Code (assault 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 punishable as a Class A misdemeanor or a felony).
  • An offense under Section 37.12, Penal Code (false identification as a peace officer); 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) In addition to the prohibitions on employment prescribed by Subsections (A), (B) and (C), a nurse aide listed as unemployable per amendment to TAC 40, §94.10(l) and §94.11( c) (d) and is listed on the NAR or EMR stating a finding of abuse, neglect or misappropriation will not be recertified therefore, is unemployable.

(E) 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 Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

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.

Consent to Drug / Alcohol Testing - Step 5 of 10


I hereby agree, upon a request made under the drug/alcohol testing policy of Pediatric Healthcare Connection Inc., herby after to be referred to as PHC to submit to a drug or alcohol test and to furnish a sample of my urine, breath, and/or blood for analysis. I understand and agree that if I at any time refuse to submit to a drug or alcohol test under PHC policy, or if I otherwise fail to cooperate with the testing procedures, I will be subject to immediate termination. I further authorize and give full permission to have PHC and/or its company physician send the specimen or specimens so collected to a laboratory for a screening test for the presence of any prohibited substances under the policy, and for the laboratory or other testing facility to release any and all documentation relating to such test to PHC and/or to any governmental entity involved in a legal proceeding or investigation connected with the test. Finally, I authorize PHC to disclose any documentation relating to such test to any governmental entity involved in a legal proceeding or investigation connected with the test.

I understand that only duly-authorized PHC officers, employees, and agents will have access to information furnished or obtained in connection with the test; that they will maintain and protect the confidentiality of such information to the greatest extent possible; and that they will share such information only to the extent necessary to make employment decisions and to respond to inquiries or notices from government entities.

I will hold harmless PHC, its company physician, and any testing laboratory PHC might use, meaning that I will not sue or hold responsible such parties for any alleged harm to me that might result from such testing, including loss of employment or any other kind of adverse job action that might arise as a result of the drug or alcohol test, even if a PHC or laboratory representative makes an error in the administration or analysis of the test or the reporting of the results. I will further hold harmless PHC, its company physician, and any testing laboratory PHC might use for any alleged harm to me that might result from the release or use of information or documentation relating to the drug or alcohol test, as long as the release or use of the information is within the scope of this policy and the procedures as explained in the paragraph above.

This policy and authorization have been explained to me in a language I understand, and I have been told that if I have any questions about the test or the policy, they will be answered.

I understand that the PHC will require a drug screen and/or alcohol test under this policy whenever I am involved in an on-the-job accident or injury under circumstances that suggest possible involvement or influence of drugs or alcohol in the accident or injury event, and I agree to submit to any such test.

Emergency Disaster Receipt and Acknowledgement - Step 6 of 10


I hereby confirm that I have read Pediatric Healthcare Connection’s or PHC Emergency Disaster Plan and that it describes the content and behavior expected of me as an employee of Pediatric Healthcare Connection.

I also acknowledge that Tanya Howell is PHC’s Disaster Coordinator and that Steve Willingham is PHC’s Alternate Disaster Coordinator. They can both be reached at the numbers provided below:

Tanya Howell: Cell Phone: (512) 660-0207
Steve Willingham: Cell Phone: (512) 660-0508

ANE - Step 7 of 10

Acknowledgement of Responsibility for Reporting Abuse, Neglect, and Exploitation and Reasonable Suspicion of Crime

I acknowledge my responsibility as an employee to report abuse, neglect and exploitation. I understand that I should report any incident that I suspect may be abuse, neglect or exploitation even if I am not sure. I realize I may be criminally liable for failing to report abuse, neglect or exploitation.

Contact Hotline:

Texas Abuse/Neglect Hotline: (800) 252–5400 (24 hours a day, 7 days a week)

Texas Health and Human Services: (800) 458-9858

HIPAA Agreement - Step 8 of 10


Employee Acceptance of HIPAA Privacy Rules and Regulations

(Health Insurance Portability and Accountability Act of 1996)

I understand that while performing my jobs duties for Pediatric Healthcare Connection (PHC) at my workplace, I may have access to protected health information (PHI) about patients or residents of hospital or nursing homes and rehabilitation centers (hospital).

PHI means any information specifically relating to the past, present or future physical or mental health condition of an individual, the provision of healthcare to an individual or payment for healthcare to an individual, and is limited to information created or received by me from the hospital.

To insure confidentiality and privacy of PHI, I agree to:

  • Access, use or review PHI only as needed for the purpose of performing the job for which I was officially employed.
  • Never use PHI out of curiosity, or for personal interest or advantage, or in the presence of an unauthorized third party.
  • Never take with me any photocopies of documents from any patient or resident medical or personnel file when I end my daily shift or employments.
  • Report to the designated primary officer or my workplace, and to Pediatric Healthcare Connection, any use or disclosure of PHI by anyone else that is not permitted of which I may become aware within 24 hours of my discovery of such unauthorized use or disclosure.

OSHA Employment Agreement - Step 9 of 10


I have read and understand my job description and the policies set forth by Pediatric Healthcare Connection (PHC) and I agree to abide by them.

In addition, I have been advised of the “Right to Know” Law and have been instructed by my employer in the use and safest way to handle the chemical substance, which I use in my work. I understand it is my responsibility to take safety precautions when necessary.

Furthermore, I have received an inservice on Universal Blood and Body Fluid Precautions, from PHC. I am capable of following said Precautions as established by C.D.C. I have also been informed of the H.R.S. Guidelines pertaining to blood and body fluids.

Sign and Date - Step 10 of 10


Please sign and date below. If a PHC representative is not present you may click "Save/Omit" below the signature field.



Annual Packet Completed!


Thank you! All PHC Annual forms have been submitted.