Acknowledgement and Consent Related to Services During The COVID-19 Emergency
The safety and health of our patients and employees is always the top priority at Broadway Home Care (“the Agency”). We are committed to keeping you healthy and comfortable in your home during these challenging times. 

This acknowledgment and consent is being provided to all patients of the Agency, to provide education regarding our patients’ responsibilities and notice of the steps being taken by the Agency to ensure the safety of all parties—including patients, their loved ones, aides employed by the Agency (“Aides”), and the Agency—as related to home health services the Agency is providing or may provide during the novel coronavirus (COVID-19) pandemic.

I understand that the Agency is a primary, home health agency that is licensed to provide home health services under a Plan of Care authorized by my physician during the COVID-19 pandemic. I, or authorized representative, acknowledge the information below and knowingly and willingly consent to receive or to continue to receive home health services from the Agency. This consent is in addition to any prior consent provided.   

I further acknowledge and understand the Agency is providing or may provide home health services to patients who have a confirmed or suspected case of COVID-19 as well as other individuals during the period of the COVID-19 emergency declaration.  

I further acknowledge and understand that the Agency is taking actions to minimize my risk for exposure to COVID-19 by incorporating necessary 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 home health services, including: 
  • Screening: The Agency is screening Aides for symptoms or exposure to the disease, and requiring self-monitoring, prior to arriving to work. Aides are further screening all patients, as well as any other person who resides or is present in the homecare setting for signs and symptoms of COVID-19.
  • Self-Monitoring: Aides are being screened and self-monitoring for fever and other symptoms daily.
  • Reporting Symptoms: Aides are required to report any COVID-19 symptoms to the Agency immediately, including symptoms experienced by the aide, as well as their patient(s).
  • Medical Attention: The Agency will refer Aides to medical attention in the event that they exhibit a fever and/or respiratory symptoms.
  • Communication: Aides and patients have access to communication with Agency staff 24 hours a day.
  • Telehealth: A Registered Nurse (“RN”) will now complete assessments and Aide Plans of Care using telehealth (assessments over the phone or by video chat). Clinical telehealth consultations are available by an RN to help guide patient care during the COVID-19 pandemic.
  • Aide Education: Aides have been trained in minimizing the chances of their becoming infected with COVID-19 and transmitting infection to those they care for, as well as in identifying symptoms, and best practices for infection prevention, safety, and screening.
  • Office Staff Education: The Agency’s policies have been changed due to the fluidity of the crisis. We are working with the relevant local and state agencies to make sure our COVID19 policies reflect the most current information.
  • Personal Protective Equipment: Aides will have access to personal protective equipment (“PPE”), which will be accessed either by the aide picking up the PPE from the Agency’s local offices, delivering the PPE to the aide’s home, or delivering the PPE to a patient’s home. All supplies brought into, used, and removed from a patient’s home will be cleaned and disinfected in accordance with state and federal guidelines.
  • Access to E-visit by a Provider (including M.D., N.P., P.A.): If a patient’s current provider is not set up for telehealth, the Agency can assist the patient in accessing an e-visit by a provider.

I am aware that during times if/when isolation is warranted due to the nature of the disease process, and/or from further directives from regulatory authorities, the Agency’s the practices set forth above may be altered. Additionally, I understand the home health services I receive may need to be revised to decrease the risk of transmitting infection during the COVID-19 pandemic. In the event this is the case, the Agency will contact my ordering physician to discuss changes required.

In the event that I, or someone else in my home, has been tested and is confirmed to have COVID19, I understand that the Agency will work with the Local Health Department to continue providing necessary services to the extent possible. I also understand that in the event that I, or someone else in my home, is suspected or confirmed to have been exposed to COVID-19, I (and those in my home) may be asked to take certain steps to reduce the risk of transmission to others, and my Aide, while in my home.

I, or my authorized representative, , represent that I have an understanding of the nature of the risks resulting from the COVID-19 pandemic, the risks and benefits of the Agency’s services, have had the opportunity to ask and have questions answered and am/is legally competent to execute this document.


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