Employee Acknowledgement for Providing Care During The COVID-19 Pandemic
The safety and health of our employees and patients is always the top priority at Broadway Home Care (“the Agency”). We are committed to keeping you healthy, while continuing to provide essential health care services to our patients.

I, acknowledge that the Agency has set forth three required classes that must be completed on Mobile Health by a home health aide (“Aide”) prior to caring for any patient(s) during the novel coronavirus (COVID-19) pandemic. These three required classes include:
  1.  Infection Control;
  2. Disaster Planning/Emergency Preparedness;
  3. COVID-19 Program
  4. PPE and Contact/Droplet Isolation
I understand the purpose of the education provided by the Agency is to ensure that all Aides are trained to minimize the chances of COVID-19 infection, as well as transmission of COVID-19 to themselves, patients and those an Aide comes into contact with. This training also is to further ensure that all Aides are aware of, and can identify, the symptoms of COVID-19, as well as best practices for patient safety and screening. I will be notified and understand it is my choice to take a case with confirmed or suspected Covid-19.

I further acknowledge and understand that a failure to complete all of these classes will put myself, my patients and all those I come in contact with at risk. It may also jeopardize my employment with the Agency.  

I further acknowledge and understand that in addition to training, the Agency is taking certain precautions outlined by the Centers for Disease Control (“CDC”), Centers for Medicare and Medicaid Services (“CMS”), and the New York State Department of Health (“DOH”) for patient and Aide safety. Specifically, I acknowledge that the Agency is taking the following precautions and procedures, and that I am required to comply with the following, during the COVID-19 pandemic:
  1. I will answer the required health screening questions timely and accurately, on a daily basis, prior to arriving for work.
  2. I will self-monitor for fever by taking my temperature at least two times daily if directed by the Agency, and will remain alert for respiratory symptoms. I will record this information on a daily basis as directed, and will be able to provide my log to the Agency, if requested.
  3. I will screen all patients, as well as any other person who resides in or is present in the homecare setting for signs and symptoms of COVID-19, prior to providing services. If symptoms are noted, I will immediately inform my coordinator at the Agency before providing any further services.
  4. In the event that I exhibit a fever, respiratory and/or other COVID-19 symptoms, regardless of whether I have received a confirmed diagnosis. I will inform my coordinator at the Agency, follow any directives from my coordinator concerning providing further services and comply with the Agency’s referral to my medical doctor or another healthcare provider.
  5. I will communicate with my coordinator if I believe I need personal protective equipment (“PPE”). I understand that the following options are available to me for obtaining PPE during the COVID-19 crisis:  
    •  I may pick PPE up from the Agency’s local office;
    • I may have PPE delivered to my home; or
    • I may have PPE delivered to a patient’s home.
  6. I will report any COVID-19 symptoms exhibited by patients to the Agency immediately. I will also make the Agency aware of any instances where another individual in the household is exhibiting signs or symptoms of COVID-19, or if I have been exposed to possible or confirmed COVID-19, regardless of whether the individual has received a confirmed diagnosis.
  7. I understand that in the event that one of my patients is suspected or confirmed to have or been exposed to COVID-19, I will be required to take certain additional steps to reduce the risk of transmission while providing services in the patient’s home. I will follow directions to be provided by my coordinator
  8. I further agree to report any COVID-19 symptoms exhibited by other Aides and/or an Aide’s failure to comply with the requirements set forth in this document to the Agency immediately
  9. I understand that I have access to Agency staff 24 hours a day for guidance and reporting information, and I will seek clarification on questions I have from my coordinator as necessary
  10. I am aware that Agency office staff has received education, and that policies are being regularly updated due to the fluidity of the crisis. I understand that the Agency is working with the relevant local and state agencies to make sure our COVID-19 policies reflect the most current information to keep us all safe, and that the foregoing procedures may need to be revised or additional procedures added. I understand that I can ask my coordinator for additional guidance in the event I have questions about any precaution or procedure and any such changes will be communicated through official notices by the Agency.

By executing this document, I acknowledge that I understand the nature and risks of the COVID19 pandemic, the steps the Agency is taking to address such risks and prevent transmission, and have had the opportunity to ask and have questions answered. I understand that it is my responsibility to diligently follow the guidance provided by the Agency, as well as relevant CDC,CMS, and DOH guidance to protect myself, the Agency’s patients, the Agency and those with whom I come in contact.

I, certify that I have read the foregoing document and have had the opportunity to ask and have questions answered. I fully understand the requirements set forth herein and agree to comply with the requirements.

I further understand that failing to follow the precautions and procedures set forth in this document will be subject to immediate action and may result in disciplinary actions, including the possibility of termination of employment with the Agency.


Authorized Representative: 

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