Massachusetts Department of Public HealthAcute Care Hospital Phase I Reopen Attestation

This attestation form is applicable to acute care hospitals and must be completed prior toperforming Phase I services and procedures as defined in Massachusetts Department ofPublic Health (DPH) Reopen Approach for Acute Care Hospitats guidance ("DPH HospitalReopening Guidance").

The form must be signed by the chief executive officer (CEO) of the hospital or the hospitalsystem and prominently posted on the hospital's website with a link to the Commonwealth'sReopening website. Hospitals must submit the attestation to DPH via its secure reporting web-based portal, the Health Care Facility Reporting System (HCFRS). Hospitals should upload thecompleted attestation as a new incident case, under the incident type "Phase I Attestation" andthen submit it. If the hospital no longer meets the criteria described in DPH Hospital ReopeningGuidance, the hospital should notifu DPH via a message in the notes section using the sameincident case in HCFRS.

Hospital Name or HospitalSystem Name:

Northeast Hospital Corporation dbo: Beverly Hospital

Date of Attestation: May 20,2020

Date to Begin Phase I Seruices: 5120120

CEO authorized to on orOflicer

the

Name: Philip M. Cormier

Phone Number: 978-8t6-2902

Phi lip.comier@lahelz.orgE-mail Address:

Hospital or Hospital 51stcrrr lnlirrrnation

In accordance with DPH Hospital Reopening Guidance, the undersigned certifies that:

Capacity CriteriaThe 7-day average of the hospital's or hospital system's available, staffed adultICU beds was at least25o/o of its total staffed adult ICU bed capacity (includingstaffed surge ICU beds) as of the date of attestation.

x

The 7-day average of the hospital's or hospital system's available, staffed adultinpatient beds was at least 25o/o of its total staffed adult inpatient bed capacity(including staffed surge ICU beds) as of the date of attestation.

x

Page I of I

Attcstation of Conr lllianccMurk cut'lr c'ritcrio willt un "X"

The hospital or hospital system has reopened and has the ability to staff allpediatric ICU beds and psychiatric/behavioral health beds consistent with pre-pandemic levels as described in DPH Hospital Reopening Guidance.

x

If the hospital's or hospital system's adult inpatient bed capacity falls below 20o%,

it must immediately give notice to DPH and promptly suspend the provision ofnon-emergent Phase 1 services.

x

Public Health and Safety Standards

The hospital or hospital system is in compliance with all Personal ProtectiveEquipment and Other Essential Supplies standards outlined in DPH HospitalReopening Guidance.

x

The hospital or hospital system is in compliance with all Workforce Safetystandards outlined in DPH Hospital Reopening Guidance.

x

The hospital or hospital system is in compliance with all Patient Safety standardsoutlined in DPH Hospital Reopening Guidance.

x

The hospital or hospital system is in compliance with all Infection Controlstandards outlined in DPH Hospital Reopening Guidance.

x

xThe hospital or hospital system maintains and regularly updates written policies orprocedures that meet or exceed all of the public health/safety standards outlined inDPH Hospital Reopening Guidance.

Ser"vices and Procedures Provided

The hospital will provide only those in-person procedures and services consistentwith DPH Hospital Reopening Guidance that based on the provider's clinicaljudgment, constitute: (1) high-priority preventative care such as pediatric care andchronic disease care for high-risk patients, (2) urgent procedures or services thatcannot be delivered remotely and would lead to high risk or significant worseningof the patient's condition if deferred, and (3) emergency procedures or services

x

xThe hospital is making clinical determinations about service provision in a mannerconsistent with DPH tal Guidance.

Compliance and Reporting

The hospital or hospital system has established a governance body that isresponsible for overseeing ongoing compliance with the criteria and standards forthe ho tal in DPH Guidance.

xS

The hospital or hospital system will maintain this attestation and documentation of

xcompliance, including all written policies and protocols that incorporate or exceedthe standards outlined in DPH Hospital Reopening Guidance for PPE and supplies,workforce safety, patient safety, and infection control, and will make suchdocuments available to DPH at time.The hospital or hospital system idirect care workers to the extent

s making reasonable efforts to recall furloughedxble

Certification and Attestation of Hospital Readiness

xOn behalf of the hospital or hospital spains and penalties of perjury that the

ystem indicated above, I certify under theabove certifications are true and accurate the

meets the Phase 1 criteria and standards in DPH

Page 2 of 2

this

. I understand that should the hospital become unable to meet any of theor standards in DPH Hospital Reopening Guidance and contained within

the hospital must immediately notify DPH and cease performing Phase Iuntil full is obtained.

Signature:

Date: May 1,2020

Name:

Page 3 of3

///L.---==--

Philip M. Cormier