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Appendix 10A

Employee Acknowledgement with Policies and Procedures

Active clinic: [Company]

This document describes the agreement between the employee and the Company regarding the organization's policies and procedures. Read each section carefully. Acknowledging each section confirms that you have read and understood the statement and agree to comply. A complete copy of the policies referenced will be provided upon hire.

1. Cellphone Use During Therapy Sessions

During therapy sessions and when providing direct services to recipients, therapists and analysts are strictly prohibited from using their personal cellphones or electronic devices for any purpose not directly associated with the CPT code or service being delivered.

2. Dress Code During Therapy Sessions

The Company maintains a professional dress code policy. Approved attire, grooming standards, and safety-related restrictions on jewelry, piercings, and tattoo coverage apply during all service delivery.

3. Session Documentation Requirements and Compliance

All employees must submit daily progress notes that are completed, signed, and reviewed in compliance with documentation standards. Notes must be finalized within 48 hours of service delivery and accurately reflect the CPT code billed, behaviors observed, interventions implemented, and any deviations from the treatment plan. Only finalized, reviewed, signed, and complete documentation will be billed.

4. Gifts and Gratuities Policy

As an employee of the Company, I acknowledge that I will not give or receive any money, reward, or other benefit exceeding ten dollars ($10) to or from the client, their parents, or any other person associated with the client. Violating this policy may result in disciplinary action, up to and including termination of employment.

5. Medication Administration Policy

As an employee of the Company, I acknowledge that I am not authorized to assist with the delivery, administration, or management of any medication. All medication-related matters must be handled directly by the client, their caregiver, or an authorized medical professional.

6. Non-Transportation Policy

The Company prohibits employees from transporting recipients or their relatives in personal vehicles. Transporting recipients is not an authorized work activity and is not reimbursable. Employees are expressly prohibited from transporting recipients in their personal vehicles.

7. Confidentiality

The Company strictly maintains the confidentiality of records. I am not authorized to disclose any information without prior written consent and explicit direction from the organization. Medical records may not be removed from the company unless a Release of Information form is completed and signed by the patient. I will comply fully with HIPAA regulations.

8. Crisis Management

The Behavior Support Plan (BSP) outlines crisis procedures. As the provider, if I am unable to safely manage the behavior, I will immediately contact 911 and notify relevant parties. I will regularly review the updated crisis plan within each recipient's treatment plan.

9. Overlapping of Behavior Analysis Services

Behavior analysis therapy services cannot be provided simultaneously with other services such as Personal Care Services, Speech Therapy, Occupational Therapy, or other services where the provider does not have direct engagement with the recipient. Exceptions may be granted by the Clinical Director when medical necessity is demonstrated.

10. Service Hour Limitations and Scheduling Requirements

As an employee, I will be assigned a schedule by the Company. I may work and bill a maximum of six consecutive days with one required rest day per week, a maximum of six hours daily per recipient, and a maximum of ten hours total per day across all clients. A single recipient may receive a maximum of eight hours per day across all providers, and no provider or combination of providers may exceed 40 hours per week per client. Standard hours are 8:00 AM to 8:00 PM; sessions outside this window require Clinical Director pre-approval. I am expected to be available on MLK Jr. Day, Presidents' Day, Good Friday, Columbus Day, and Veterans Day unless otherwise approved, and I will not be required on New Year's Day, Memorial Day, Independence Day, Labor Day, Thanksgiving Day, or Christmas Day unless agreed.

11. Drug-Free Workplace

The Company is committed to a safe, drug-free work environment. I acknowledge that random and specific drug testing may be requested at any time.

12. Sexual Harassment Policy

The Company operates a zero-tolerance policy for any form of sexual harassment. Any person found to have sexually harassed another will face disciplinary action, up to and including dismissal from employment. I have received a full copy of this policy.

13. Non-Exclusion from Medicaid and Medicare

I attest that I have not been excluded from participating in the Medicare or Medicaid programs in any state, and I will immediately notify the agency if I ever become excluded. The Company will verify this information with the Office of Inspector General (OIG).

14. Hepatitis B

Under federal OSHA 29 CFR § 1910.1030, I have been informed that due to occupational exposure to blood or other infectious materials, I may be at risk of acquiring Hepatitis B. I have been given the opportunity to receive the Hepatitis B vaccine at no charge, and I retain the option to request vaccination at no charge at any time.

15. Supervision Documentation and Expectations

Ongoing supervision is required to maintain BACB credentialing. RBTs are expected to make themselves available for supervision sessions in coordination with their analyst. Analysts are required to offer and provide supervision to assigned RBTs in accordance with BACB requirements and payer guidelines. RBTs out of compliance with supervision expectations will not be allowed to provide behavioral services.

16. Job Description

I attest that I have received and thoroughly reviewed my job description for my position as an RBT, BCBA, or Administrative staff. I understand the assignments and responsibilities outlined and agree to adhere to them. I have been given the opportunity to ask questions and seek clarification.

17. Reporting Abuse, Neglect, and Exploitation of Children and Vulnerable Adults

I attest that I have received detailed information and instructions on reporting abuse, neglect, and exploitation of children and vulnerable adults under Chapter 415, Florida Statutes. I have been informed how to recognize physical, behavioral, and environmental indicators and how to report suspected abuse to the Florida Abuse Hotline at 1-800-962-2873 or 1-800-96-ABUSE, and how to report life-threatening emergencies to 911.

18. Non-Solicitation Agreement

During my employment with the Company and for one (1) year thereafter, I shall not (a) persuade any patient, client, vendor, referral source, or business partner of the Company to cease or reduce their business with the Company; (b) employ or attempt to employ any person who is or was employed by or in a consulting relationship with the Company within one (1) year prior to my termination; (c) remove any property belonging to or within the possession of the Company; or (d) provide any healthcare or related services to any patient I served on behalf of the Company. I agree that breach would cause irreparable damage entitling the Company to injunctive relief in addition to other legal remedies, that I will pay all costs and expenses incurred by the Company in enforcing this Agreement, and that any action under this Agreement may be determined by a judge without a jury.

19. Acknowledgement of Understanding for Electronic Signature

I acknowledge that an electronic signature has the same legal force and effect as a handwritten signature. The signature below represents my official signature, and I commit to using this signature on all documents related to the service.

20. Communication and Meeting Participation Requirement

I am expected to actively participate in scheduled meetings and respond to written and phone communications within 6 hours as a condition for maintaining the employment relationship. Failure to meet these expectations may result in corrective action, up to and including termination of employment.

21. CAQH Profile Maintenance

I am responsible for maintaining and updating my CAQH (Council for Affordable Quality Healthcare) profile as required by payers. Failure to keep CAQH information up to date may result in delayed credentialing, reimbursement issues, or suspension from billing.

22. Incident Reporting Requirement

As a provider, I am required to submit a written incident report for any significant event occurring during a session. All incident reports must comply with reporting requirements outlined by the agency and funding sources.

Signature

I confirm that I have read, understood, and agree to the previous acknowledgments. I understand that this document is subject to change and that updates will be communicated via email.

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