EmailMeForm
TERMINATION & DEPARTURE/RESIGNATION FORM
termination.seniorcaremanhattan.com
Edit
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Past
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Resignation Form
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HISC Termination Guide
Date of this form:
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MM
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DD
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YYYY
HISC STAFF completing form
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Angie Dominguez
Rosa Dominguez
Sumaya Hossain
I. NATASHA'S RESPONSIBILITIES
Email
Name of Employee
Terminated/Departed:
Last carelog date Employee worked with HISC:
MM
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DD
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YYYY
Termination Date logged in HR Notes/ CC
MM
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DD
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YYYY
Labor review
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Please select
Was terminated by HISC
Voluntarily departed (resigned) from HISC
- Review the Unemployment Bible CMS made
- Go to strategies section and choose the best one.
Employee
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Please select
Was terminated by HISC
Voluntarily departed (resigned) from HISC
Resignation was
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Not applicable: CG no longer works for agency for reasons besides Resignation
Obtained via text, email or CC confirmation.
Obtained via emailmeform.
Not obtained: CG quit verbally and refused to fill out form.
Not obtained: HR confirmed verbal resignation noted on CC.
Communicated by HR after refusal of work or failure to communicate with the office.
Termination
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• Not Applicable, caregiver was not terminated
• NO CALL / NO SHOW
• Violation of Non-Solicitation provisions signed by Employee
• Abandonment of your shift in the middle of the shift without office permission.
• Failure to follow the Plan of Care.
• Failure to report observations on the client condition on a timely manner, as instructed in this handbook.
• Failure to follow standard PCA techniques and procedures.
• Failure to comply with any of the policies established in section 3. “Standards of Conduct”.
• Failure to comply with any of the policies established in section 4. “Standards of Care”.
• Failure to comply with any of the policies established in section 5. “Prohibited Activities”.
• Failure to follow the policies of section 6. “Timekeeping, Plan of Care Review and Attendance.
• Failure to communicate with the office as expected during the times you have made yourself available to work.
• Discussion of pay with the client.
• Failure to appear to your Annual Medical Examination as required by the NYS Department of Health or refusal to take a drug test according to HISC Drug Policy.
• Failure to attend a Counseling session when requested by the office administrative staff.
• Failure or refusal to take annual in-service or participate on an annual evaluation.
• Failure to wear a protective mask at work if you have refused to take the flu shot and the NYS Department of Health is declaring Influenza prevalent, thus requiring health workers to take the flu shot or wear a mask.
• Failure to come to office to discuss a critical HR Incident (numerous attempts were made to have employee come to office)
• Violation of Employee Drug Policy
Other (explain)
Termination
N/A
Employee was given the opportunity to discuss the reason for termination in person.
Other
Confirm that Employee was given the opportunity to discuss the reason for termination in person and refute the facts.
Send a letter stating that they were given the right to come in and discuss. Call CMS with advice to avoid losing UE based on CGs inability to have defended his/her case.
CC - deactivation
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Please select
Confirmation
Deactivated from CC
CC - HR Records - Summary about departure
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Please select
Confirmation
CC - HR Records
On HR Records write a summary reason of departure and any other important notes if applicable.
CC - Activity Note
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Please select
Confirmation
CC - Activity Note
1. Make a note using either tag (Termination or Departure)
2. Make it clear in the note why they were terminated or what the circumstances were for their departure (this will help when people call for references)
Obamacare. This employee had the following Obamacare status with HISC
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Please select
Declined our health care- Third Party Sponsored Insurance.
Declined our health care -Medicaid
HISC Sponsored MEC
HISC Sponsored MVP
Was Not Eligible at the time
Other (describe in notebox below)
II. ANGIE'S RESPONSIBILITIES (HR must make sure Angie does this WITHIN 10 BUSINESS DAYS OF TERMINATION)
Gmail Contacts
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Please select
All 3 things were done
1. Tag = Caregiver Termination
2. Description: copy and paste the information from the CC note and put in the notes section of Gmail contact.
3.In the last name of their profile add (TERMINATED/DEPARTED) after their last name so we can spot it any time they call and then research up on it
DOH Online database #1.
Employee was removed from HCR
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Please select
Employee was (i) removed from HISC roster in HCR and (ii) proof printed (iii) placed in DOH file
N/A - since was a companion, not a PCA case
N/A - since was an office personnel
DOH Online database #2.
Employee was removed from CHRC
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Please select
Employee was (i) removed from HISC roster in CHRC section (ii) proof printed (iii) placed in DOH file
N/A - since was a companion, not a PCA case
N/A - since was an office personnel
III. ROSA's RESPONSIBILITIES (HR must make sure Rosa does this)
Deactivate from (i) 401K (ii) PayPlus
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Please select
Done
Copy and paste to Rosa
(*) ADP - DEACTIVATE
Rosa, please note we are terminating [Name of CG], please deactivate from (i) 401K (ii) PayPlus
**** OTHER ******
NOTES - OTHER
IV. SUMAYA'S RESPONSIBILITIES
Step 1-
Add CG's name on this list
(HR & Patient Master)
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Please select
Done!
Not done, I will chat with CMS
(Filing cabinets)- Transfer file from regular active CG filing cabinet to Terminated discharged filing cabinet
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Please select
Done!
Not done, I will chat with CMS
V. COMMUNICATE WITH STAFF
Whatsapp/Email:
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Please select
Done!
Not done, I will chat with CMS
(*) COPY AND PASTE
[Name of CG] was just formally terminated because [reason]
