NC Caregivers Facility Participation Agreement

The purpose of this application is to:

Express interest for participating in the NCCaregivers Program. Only North Carolina Nursing Homes are eligible.
Provide information for the new NCCaregivers website that prospective employees will use to contact the nursing homes about employment.

If you have any questions, please contact:

Renee Batts, Project Leader, reneeb@futurecarenc.org , 252-292-3793

Eric Kivisto, erick@nchcfa.org, 919-782-3827

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* 1. Agreement

NC Nursing Homes participating in the NCCaregivers Program:

Agrees to attend or view the recorded video of the implementation webinar.

Agrees to reimburse the employee for approved Nurse Aide Training costs in accordance to 42 CFR 483.152 (c ) within one month of date of hire. (If the employee paid for the training his/herself.)

Agrees to pay eligible staff a $500 retention bonus if they work part-time or full-time for six consecutive months at your nursing home.

Agrees to input information into a secure on-line tracking system to include, but not limited to:

Date of hire

Date given the $500 retention bonus

Date separated or terminated if less than 6 months.

Agrees to allow all employees to complete three engagement/satisfaction surveys over the course of the project. The Facility also agrees to complete an on-line survey at the conclusion of the NCCaregivers program.

Agrees to participate in webinars related to employee engagement and satisfaction surveys, as well as leadership and improving workplace culture webinars.

I have read the "Agreement" and understand that this will be part of the requirements for participating.

Yes

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* 2. Please indicate the name of your nursing home.

Facility Name

City

Administrator Name

Administrator email address

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* 3. Please indicate the name and email address of your Medical Director.

Name

Email address

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* 4. Please indicate the name and email address of your Staff Development Coordinator.

Name

Email address

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* 5. Please indicate the name(s) and email address(es) of the staff responsible for the Family and Resident Councils.

Name

Email address

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* 6. The remaining questions relate to the information that will be shown on the NCCaregivers website regarding your nursing home. It is recommended to give a webpage link that is the most direct possible route to potential employees so they do not have barriers to participate. Ideally the nursing home would create a webpage related to employment and benefits.

Please include the email address that will be shown on the NCCaregivers webpage for the prospective employee to contact.

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* 7. Please include the nursing home website shown on the NCCaregivers website that the prospective employee will see.

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* 8. Please add any comments or questions.