MAJESTY CARE CLINIC

VOLUNTEER APPLICATION FOR

NON-INDEPENDENT PRACTITIONERS(RN, LDN, EMT etc.) 2015

Phone: 724.691.0216 Fax: 724.691.0416

Please type or print with black or blue ink. PRIVATE FOR OFFICE USE ONLY

Check One: _____ Physician _____ Certified Registered Nurse Practitioner _____ Physician Assistant _____ Other

Applicant Name ______

FirstMiddle Last

Mailing Address ______

Provide phone numbers: Cell ______Gender ______Male ______Female

Office ______Home ______

Email ______

Date of Birth ______SS# ______

Emergency Contact Person ______

Phone Number(s) ______

How did you hear about MCC? ______

Are you a U.S. citizen? _____ yes _____ no If no, do you have authorization to work in the US? _____ yes _____ no

Undergraduate Education

College(s) Attended ______

Address of College(s) ______

Year of Graduation ______Degree(s) ______

Professional School (if different from Undergraduate Education)

School Name ______

Address ______

Year of Graduation ______Degree/Specialty ______

Board Certified? _____ Yes _____ No Date of Expiration ______

Board Registration? _____ Yes _____ No Date of Expiration ______

License/Certificate/Registration PLEASE ATTACH A COPY OF YOUR CURRENT License, Certificate or Registration

Issue Date ______Expiration Date ______

License, Certificate, or Registration Number ______Identify & list other numbers related to your

License, certificate or registration______

Primary Hospital Affiliation if applicable is with ______

------

If you answer “YES” to any of the following, briefly explain the case and outcome on an additional sheet and attach it.

Any malpractice claims against you currently or in the past 10 years? _____ Yes _____ No

Do you have any claims that remain ongoing? _____ Yes _____ No

Has your license ever been revoked or suspended for any reason? _____ Yes _____ No

Have you ever been convicted of a crime? _____ Yes _____No

Are you currently using illegal substances or illegally using substances? _____ Yes _____ No

Employment History

Current Employer ______

Address ______

Employer’s Work Phone ______What date did you begin? ______

Previous EmployerTown/StateDates (from/to)

______/______

CPR_____ Yes _____ No I have a current CPR certification? Provide a copy of your certificate.

Immunization Status_____ Yes _____ No I have a current TB (PPD) Test.

If Yes, please include a copy of the test results which must be within 1 year. There is a

form to complete if you had a positive reaction or cannot take the test.

Photo IdPlease include a copy of your driver’s license or other government issued photo ID.

Background ClearancesAll volunteers are required to submit a Criminal Background Check.

_____ Yes, I have a current (within the last 2 yrs) criminal background check. Please include a

CHECK ONE: copy.

_____ No, I do not have a current criminal background check and authorize MCC or Excela

Health to obtain one.

MALPRACTICE INSURANCE

1. _____ Yes _____ NoI desire to volunteer at MCC and provide services to assess and/or treat patients.

2. _____Yes _____ NoMy malpractice insuranceDOES NOT insure me to volunteer and treat patients at Majesty Care

Clinic and I am requesting to be “deemed”by HRSA to acquire free malpractice insurance

through the FTCA and authorize MCC and or Excela Health to apply for me.

3. _____ Yes _____ NoI understand and agree that Excela Health will act as the CVO (Credential Verification

Organization) for MCC and as such they will verify the accuracy and correctness of my

credentials.

4. Check ONE:

_____I am affiliated with Excela Health and I authorize and give permission for Excela Health to

release my records pertaining to the information requested in this application and for the

purpose of volunteering at MCC.

OR

_____I am not affiliated with Excela Health. I agree to provide my credentialing information in order

that Excela Health may verify my credentials and certify their accuracy for MCC upon request.

**** Complete only if your malpractice insurance insures you to volunteer at MCC and you do not want the free malpractice

insurance through HRSA and the FTCA. Providers should not be insured by two carriers for work at MCC.

If malpractice is through a hospital, please provide the name. My malpractice insurance carrier is ______

My insurance carrier’s phone # is ______and my policy # is ______

Dates of Coverage: From _____/_____/_____ To _____/_____/_____ Contact Person ______

Who holds the Certificate of Insurance? _____ Self _____ Practice _____ Hospital _____ Other______

ADDITIONAL CONFIDENTIAL INFORAMTION

If you have any “yes” answers to any questions below, submit a separate sheet providing full details for each item.

Have any of the following at any time been, or are they currently in the process of being denied, revoked, not renewed, suspended, limited, restricted, placed on probation, or placed under other disciplinary action, either voluntarily or involuntarily in any jurisdiction? Answer whatever applies to you and put “NA” for those that do not apply.

YES NO

Medical or professional license______

DEA______

Hospital medical staff membership______

Clinical privileges or other rights on any hospital medical staff______

Employment by any hospital, institution, or the military______

Professional society memberships______

Participation in any private, federal, or state health insurance program______

Participation in an HMO, PPO, or any other managed care organization______

Academic Appointment______

Board Certification______

At any time have you ever been named as a defendant in a prosecution

whether convicted, acquitted or dismissed of:

Any felony______

Any misdemeanor______

Have you ever at any time or are you currently:

Under indictment for any crime______

The subject of an investigation by any private, federal or

state health insurance program______

The subject of any adverse action reports from the

National Practitioner Databank______

Have you ever either voluntarily or involuntarily:

Withdrawn your application for medical staff membership at a facility______

Withdrawn your request for any clinical privileges at any facility______

Had your privileges restricted or been suspended for any reason______

Relinquished, or made any agreement to avoid adverse action,

preclude investigation______

Please answer the following:

1. Are you able to safely and competently exercise the clinical privileges requested and perform the duties and responsibilities of appointment, including, but not limited to, emergency service coverage and committee service, either with or without reasonable accommodation? _____YES _____ NO

If you require reasonable accommodation to perform the duties and responsibilities of appointment please list any special accommodations that are required:

______

2. Are you currently using illegal substances or illegally using substances? _____ YES_____ NO

3. I agree that I do not have any communicable disease and further understand that if at any time I am considered to be infectious, I will notify the MCC Medical or Executive Director immediately. _____I AGREE _____ I DISAGREE

4. I agree that I will not release any information regarding patient’s diagnosis, finance, etc. unless authorized to do so. I will strictly adhere to patient confidentiality and privacy standards.

_____ I AGREE_____ I DISAGREE

STATEMENT OF APPLICANT (PLEASE READ CAREFULLY BEFORE SIGNING THE APPLICATION)

All information submitted by me in this application is true to the best of my knowledge and belief. I authorize MCC and Excela Health officials to consult with administrators and members of medical staffs of other hospitals or institutions with which I have been associated and with others, including past and present malpractice carriers, who may have information concerning my professional competence, character and clinical qualifications.

I authorize Excela Health and MCC representatives to release and exchange information to each other in order to evaluate his or her professional qualifications for appointment, privileging, and credentialing at MCC and with the federal government in relation to the FTCA application for deeming and free malpractice insurance to volunteer at MCC. To the fullest extent permitted by law, I release from all liability, extend absolute immunity to, and agree not to sue Excela Health, MCC, members of their respective Medical Staffs and/or Boards, authorized representatives, and third parties who provide information for any matter relating to appointment, reappointment, credentialing, and privileging to volunteer at MCC. This immunity covers actions, recommendations, reports, statements, communications, and/or disclosures involving me that are made, taken or received by Excela Health, MCC, their authorized agents, or third parties in the course of credentialing, privileging, and peer review activities.

In making this application, I acknowledge that I am familiar with the principles and standards of the Joint Commission and that I will abide by the Principles of Medical Ethics of the American Medical Association and/or the Code of Ethics of the American Dental Association as they are currently amended, whichever is applicable.

I understand that I have the responsibility to keep the information in this application current and will inform the MCC director of any changes. I agree to read the applicable Bylaws, Policies, Rules and Regulations for MCC and agree to be bound by the terms thereof. I have not requested privileges for any procedures for which I am not trained and clinically competent. I believe I am qualified to perform all procedures for which I have requested privileges.

By signing this application, I hereby certify that all information contained in this application is true, correct and complete in all respects and agree to promptly notify the “recipient” immediately if there are any changes in the information provided. I attest that I have obtained the required medical education as required by the Commonwealth of Pennsylvania for medical licensure. My signature on this application attests that I will comply with the above listed behavioral values.

I certify that the information included in this application is true and accurate.

I certify that I am healthy and fit to perform the work requested of me at MCC and the privileges I requested.

______

Applicant’s Signature Date

______

Printed Name

Complete all items on the application and attached pages, include all requested forms, and mail/give to:

Westmoreland Hospital

Attn: Office of Medical Affairs

532 West Pittsburgh St.

Greensburg, PA 15601

Please complete the following pages and submit along with this application. Contact the director if you need a different privilege request form other than those attached (RN and EMT). Other job description/privilege requests are available on an individual basis.

RELEASE, IMMUNITY, AND

EXCHANGE OF CONFIDENTIAL INFORMATION

[Part of the Majesty Care Clinic Application Form.]

I hereby authorize Excela Health (“Hospital”) and Majesty Care Clinic (“Clinic”) to release to each other Confidential Peer Review Information regarding my professional qualifications. For purposes of this authorization, “Confidential Peer Review Information” includes any and all information and/or documentation regarding my clinical competence and/or professional conduct that may be obtained or produced as part of the credentialing, quality assessment, or peer review processes at Hospital or Clinic.

I understand that any Confidential Peer Review Information that is released shall be used solely for credentialing, quality assessment, and peer review purposes. I further understand that Hospital and Clinic will maintain any Confidential Peer Review Information that they receive in strict confidence, in accordance with the protections and privileges afforded peer review information under Pennsylvania and/or federal law.

I hereby extend absolute immunity to, release from any and all liability, and agree not to sue Hospital, Clinic, or their employees, agents, or representatives for (1) releasing Confidential Peer Review Information to one another for credentialing, quality assessment, and peer review purposes, and (2) any action that may result from the release of Confidential Peer Review Information.

Signature of Practitioner

Printed or Typed Name of Practitioner

Date

MAJESTY CARE CLINIC

Volunteer Nurse Privilege Request and Job Description

Print Name ______Effective From ______/______/______

The Job Description and Privileges Requested represent the “core” privileges for nurses volunteering at MCC.

POSITION TITLE:

Volunteer Nurse (registered, certified, and/or licensed)

POSITION DESCRIPTION:

Plans, performs, directs, and documents delivery of patient care utilizing the nursing process in a community based clinic.

QUALIFICATIONS:

Graduate of an accredited nursing program with current licensure as a RN or LPN in Pennsylvania. Current CPR certification. Recent primary care nursing experience preferred. Evidences holistic philosophy and compassion for the poor.

RESPONSIBLE TO:

Physician in charge of clinic, Medical Director and Executive Director.

JOB SUMMARY/ESSENTIAL FUNCTIONS AND REQUIREMENTS:

  1. Provide coordinator a copy of licensure and insurance prior to starting at MCC and update annually.
  2. Assist the physician as needed in providing care and treatment to patients of MCC.
  3. Coordinate with other volunteers the care to be provided and treatments or procedures to be performed as ordered by the physician on duty, such as lab procedures, injections, wound care, etc.
  4. Provide clear documentation on daily clinic visit form of vital signs, weight, height, chief complaint, medications, and brief health history to be signed by person collecting data.
  5. Document all procedures such as injections, wound care, referrals on clinic visit form.
  6. Instruct clients as needed and as physician orders regarding patient education, referrals and/or treatments.
  7. Do not perform any procedure or task you do not feel clinically qualified to perform (venipuncture, EKG, etc.). Contact the Clinic Coordinator to determine how best to handle the situation.
  8. Clean work areas, discarding all garbage using approved disinfectant/cleaners.
  9. Other duties as assigned.

QUALIFICATIONS:

1.Current unrestricted license as a registered nurse in Pennsylvania.

2.Familiarity and appreciation for the mission of MCC.

3. Creativity, flexibility and openness to change.

4.Completion of volunteer application.

Nurse Core Essential Functions:

  1. Ensures that assessment of the patient and the direct and indirect patient care delivered are in accordance with the PA Nurse Practice Act, clinic policies, procedures, and protocols, and other professional standards of care.
  1. Collects patient health assessment data on admission and in an ongoing systematic manner, focusing on the physical, psychosocial, age, cultural and spiritual needs of the patient.
  2. Documents the initial nursing assessment on appropriate medical records within the established time frames utilizing the clinic’s Electronic Medical Record keeping system.
  3. Implements the individualized/psychiatriomedical plan of treatment, follows physician orders, evaluates and revises the established plan of care for each patient on an as-needed basis.
  4. Reassesses the patient’s condition and takes appropriate action as indicated by clinic-specific policy including follow-up to ensure medication, labs, and any ongoing treatment or testing are being done and followed as described in the treatment plan.
  5. Involves the patient/family and other healthcare providers when appropriate.
  6. Complies with completeness, accuracy and timeliness of documentation of all patient data.
  1. Develops an educational process for the provision and coordination of patient care activities that promote and maintain health, fosters self-care and improves outcomes.
  1. Participates in the interdisciplinary education to assess the patient’s readiness to learn, identify the patient’s educational barriers and tailor the educational processes to meet the needs of the patient/family.
  2. Ensures the process includes education about safely and effectively using medication, pain management, available resources, how to obtain further care and information about the patient’s responsibilities in their care.
  3. Acquires and distributes educational resources tailored to patient needs.
  4. Provides and reviews written discharge instructions that demonstrate an inter-relationship between education, discharge planning and continuity of care.
  1. Maintains a collaborative relationship with physicians and other health care providers to achieve desired patient outcomes and assure a continuous flow of patient care.
  1. Communicates relevant information for interdisciplinary patient care conferences.
  2. Takes action to proactively identify and resolve patient needs.
  1. Participates in clinic performance improvement activities designed to enhance the quality of patient care and customer services.
  1. Assists in data collection process as requested.
  2. Recommends modifications for performance improvement.
  1. Demonstrates leadership by utilizing the concepts inherent to the practice of the professional nurse.
  1. Demonstrates an ability to solve problems independently utilizing critical thinking skills and seeks assistance from immediate supervisor when appropriate.
  2. Delegates patient care appropriately.
  3. Maintains accountability for actions taken.
  4. Effectively functions as a resource person.
  5. Acts as a patient advocate to foster an appropriate goal.
  6. Performs effectively in the role of preceptor/mentor to new volunteers and/or students or interns.
  7. Assists in maintaining/decreasing organizations/department costs.
  1. Assists in the department’s compliance with state JCAHO, OSHA, and other regulatory agencies.
  1. Participates in continuous survey readiness for inspections and surveys.
  2. Adheres to the infection control processes, including standard precautions, to reduce the risk of acquiring or transmitting infections.
  1. Provides for patient safety in compliance with clinic policies.
  1. Utilizes two forms of patient identification before implementing any form of patient care.
  2. Involves the patient and/or family in patient safety standards and processes.
  3. Minimizes the use of patient restraints and, if patient’s condition warrants, monitors per individual assessed need and documents per policy.
  4. Responds effectively during emergency situations, including internal and external disasters.
  5. Assists in maintaining a safe and clean environment for patients, visitors and staff.
  6. Complies with all environmental, infection control, and safety procedures; properly uses safety equipment and devices; reports accidents, injuries and incidents as necessary.

Signed ______Date ______

Print Name ______

MAJESTY CARE CLINIC

Volunteer EMT Privilege Request and Job Description

Print Name ______Effective From ______/______/______

The Job Description and Privileges Requested represent the “core” privileges for EMTs volunteering at MCC.

POSITION TITLE:

Volunteer EMT (registered, certified, and/or licensed)

POSITION DESCRIPTION:

Plans, performs, directs, and documents delivery of patient care utilizing the nursing process in a community based clinic.

QUALIFICATIONS:

Graduate of an accredited EMT program with current licensure as an EMT in Pennsylvania. Recent primary care experience preferred. Evidences holistic philosophy and compassion for the poor.

RESPONSIBLE TO:

Physician in charge of clinic, Medical Director and Executive Director.

JOB SUMMARY/ESSENTIAL FUNCTIONS AND REQUIREMENTS:

  1. Provide coordinator a copy of licensure and insurance prior to starting at MCC and update annually.
  2. Assist the physician as needed in providing care and treatment to patients of MCC.
  3. Coordinate with other volunteers the care to be provided and treatments or procedures to be performed as ordered by the physician on duty, such as lab procedures, injections, wound care, etc.
  4. Provide clear documentation on daily clinic visit form of vital signs, weight, height, chief complaint, medications, and brief health history to be signed by person collecting data.
  5. Document all procedures such as injections, wound care, referrals on clinic visit form.
  6. Instruct clients as needed and as physician orders regarding patient education, referrals and/or treatments.
  7. Do not perform any procedure or task you do not feel clinically qualified to perform (venipuncture, EKG, etc.). Contact the Clinic Coordinator to determine how best to handle the situation.
  8. Clean work areas, discarding all garbage using approved disinfectant/cleaners.
  9. Other duties as assigned.

INTRODUCTION

ThefollowingisapositiondescriptionfortheEmergencyMedicalTechnician(EMT).Thisdocumentidentifiestheminimumqualifications,expectations,competenciesandtasksexpectedof the EMT.