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Trends in Long-Term Care Hearings TRENDS IN LONG-TERM CARE HEARINGS BEFORE THE SUBCOMMITTEE ON LONG-TERM CARE OF THE SPECIAL COMMITTEE ON AGING UNITED STATES SENATE NINETY-FIRST CONGRESS FIRST SESSION PART 1-WASHINGTON, D.C. JULY 30, 1969 Printed for the use of the Special Committee on Aging U.S. GOVERNMENT PRINTING OFFICE 41-304 WASHINGTON :1970 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C. 20402 -Price 60 cents SPECIAL COMMITTEE ON AGING HARRISON A. WILLIAMS, JR., New Jersey, Chairman ALAN BIBLE, Nevada EVERETT McKINLEY DIRKSEN, Illinois FRANK CHURCH, Idaho WINSTON L. PROUTY, Vermont JENNINGS RANDOLPH, West Virginia HIRAM L. FONG, Hawaii EDMUND S. MUSKIE, Maine JACK MILLER, Iowa FRANK E. MOSS, Utah CLIFFORD P. HANSEN, Wyoming EDWARD M. KENNEDY, Massachusetts GEORGE MURPHY, California RALPH YARBOROUGH, Texas PAUL J. FANNIN, Arizona STEPHEN M. YOUNG, Ohio EDWARD J. GURNEY, Florida WALTER F. MONDALE, Minnesota WILLIAM B. SAXBE, Ohio VANCE HARTKE, Indiana WILLIAM E. ORIOL, Staff Director JOHN GuY MILLER, Minority Staff Director SUBCOMMITTEE ON LONG-TERM CARE FRANK E. MOSS, Utah, Chairman HARRISON A. WILLIAMS, JR., New Jersey JACK MILLER, Iowa FRANK CHURCH, Idaho EVERETT McKINLEY DIRKSEN, Illinois EDMUND MUSKIE, Maine HIRAM L. FONG, Hawaii RALPH YARBOROUGH, Texas CLIFFORD P. HANSEN, Wyoming STEPHEN M. YOUN G, Ohio PAUL J. FANNIN, Arizona EDWARD M. KENNEDY, Massachusetts WILLIAM B. SAXBE, Ohio Part 2. Trends in Long-Term Care, St. Petersburg, Florida, January 9,1970 Part 3. Trends in Long-Term Care, Hartford, Conn., January 15, 1970 Part 4. Trends in Long-Term Care, Washington, D.C., February 9 &10, 1970 Part 5. Trends in Long-Term Care, San Francisco, Calif., February 12, 1970 Part 6. Trends in Long-Term Care, Salt Lake City, Utah, February 13,1970 (II) CONTENTS Page Opening statement of the chairman -1------- I CHRONOLOGICAL LIST OF WITNESSES Laughlin, Thomas, Deputy Commissioner, Medical Services Administra- tion, U.S. Department of Health, Education, and Welfare- 4 Hunt, Joseph, Commissioner, Rehabilitation Services Administration, U.S. Department of Health, Education, and Welfare - 15 Brinkley, Sterling B., M.D., chief medical officer, Rehabilitation Services Administration, U.S. Department of Health, Education, and Welfare 20 Martin, Hon. John B., Jr., Commissioner, Administration on Aging - 26 De Preaux, Paul, president, Connecticut Association of Nonprofit Homes and Hospitals for the Aged - -- 31 Hutton, William R., executive director, National Council of Senior Citizens.. 46 Salmon, Pierre, M.D., American Medical Association _ 52 Harrison, Bernard P., director, department of legislation, American Medical Association - 57 Shaughnessy, Miss Mary E., RN, M.S., member, ANA Commission on Nursing Services 61 Eggers, Rev. William T., president, American Association of Homes for the Aging -_--------------------------------------------- 71 Mason, Rev. John, director of services to aging, American Lutheran Church, Minneapolis, Minn., chairman, Committee on Title XIX-- 77 Baird, Mrs. Eleanor, vice president, region I, American Nursing Home Association _ -- 88 Schluter, A. L., national chairman, Skilled Nursing Home Conference 97 Smith, Harold -------------------------------------- 100 Bonin, Garland, commissioner of the Louisiana State Department of Public Welfare ---------------------- 102 Martin, Rose G., National Association for Practical Nurse Education and Service - 104 PREPARED STATEMENT Ambrosette, Sister Mvlary, O.S.F., administrator, St. Paul Home, KIau- kauna, Wis _ - - 81 APPENDIX Item 1. Material submitted by Paul De Preaux, president, Connecticut Association of Nonprofit Homes and Hospitals for the Aged - - 115 Exhibit A. Public Health Code of Connecticut: Regulations gov- erning the operation and maintenance of chronic and convales- cent nursing homes -115 Exhibit B. Connecticut State Department of Health Physical Standards -120 Exhibit C. Connecticut State Department of Health, Division of Hospital and Medical Care-Chronic and convalescent nursing home classification -130 (III) IV Item 2. Material submitted by William R. Hutton, executive director, Page National Council of Senior Citizens -135 Exhibit A. Washington Report on Medicine and Health, dated Jan- uary 27, 1969 -135 Exhibit B. News article from the Washington Daily News, dated February 14, 1969 ----------------------- 137 Exhibit C. News article from the Washington Post, dated February 16,1969 -------------------- 137 Exhibit D. Resolution on nursing home standards of the National Council of Seniors Citizens - 138 Exhibit E. Letter to Mary Switzer from William Hutton, re draft regulations for standards for payment for skilled nursing home care under title XIX of the Social Security Act -139 Item 3. Material Submitted by Mary E. Shaughnessy, member, American Nurses' Association -141 Exhibit A. Letter expressing objections of American Nurses' Association to interim policies and requirements pertaining to standards for payment for skilled nursing home care -141 Item 4. Material submitted by Rev. John Mason, director of services to aging, American Lutheran Church -142 Exhibit A. Statistics of 95 homes, December 31, 1968 -142 Exhibit B. Five-Year comparison-American Lutheran Church national program expense-Average per resident per day cost 143 Exhibit C. American Lutheran Church National average staff hours per bed per month -143 Exhibit D. Position of the American Lutheran Church on delivery of health -service to elderly people -144 TRENDS IN LONG-TERM CARE WEDNESDAY, JULY 30, 1969 U.S. SENATE, SUBCOMMITTEE ON LONG-TERM CARE, SPECIAL COMMITTEE ON AGING, Washington, D.C. The subcommittee met at 10:15 a.m., pursuant to call, in room 3110, New Senate Office Building, Senator Frank E. Moss (chairman of the subcommittee) presiding. Present: Senators Moss, Miller, and Fannin. Committee staff members present: William Oriol, staff director; John Guy Miller, minority staff director; and Margaret M{. Fink, assistant clerk. Senator Moss. The subcommittee will come to order. I am pleased to see so many here which indicates interest in this subject that we have to discuss this morning. I am grateful for your presence. OPENING STATEMENT OF THE CHAIRMAN I had expected to begin these hearings on "Trends in Long-Term Care" later in the year, but it has become obvious that this sub- committee cannot ignore a current crisis while considering future trends. That crisis is the recently issued interim regulations describing the standards for skilled nursing homes under medicaid issued by the Department of Health, Education, and Welfare. The new regulations provide that, by July 1, 1970, licensed practical nurses in charge of nursing activities on all shifts must be qualified by graduation from a State-approved school of practical nursing or have background equivalent to such training. But until then, nurses in charge on other than the day shift may be licensed practical nurses "waivered" by a State licensing agency. HEW's recent announcement also notes that the newrly published standards match those in the handbook of public assistance adminis- tration that regulated services until January 1 of this year, with the exception of the waiver granted for the employment of nurses who are not qualified by formal training. We are left, therefore, with regulations that say, in effect, that a single, untrained practical nurse on duty in a home with 200 or 300 patients or more constitutes "properly supervised nursing services" on the afternoon and night shifts. It is also questionable whether the provision for what HEW calls background equivalent to such training will in fact provide properly (1) 2 trained supervisory personnel. This language permits a State licensing authority to determine that an individual has "background con- sidered to be equivalent" to graduation from a State-approved school of practical nursing. I fear this may mean serious State-to-State differences in supervisory quality. I have become increasingly concerned with the reports on the quality of nursing care received in nursing homes across the country, whether the patient is a medicaid recipient, a private patient paying the fee out of his own pocket, or being cared for under medicare. Some of the reports have to do with the fact that many nursing homes do not accept medicaid recipients because, in their own words, "they cannot afford to-and still offer good care to these people." Of those homes who do accept medicaid patients, a number are reported to have separate "medicaid beds." The implications here are obvious: the medicaid patient does not receive the quality of care that the other patients receive. If the interim regulations are allowed to stand as they are, where will that place the medicaid patient who is on the low end of the pole as far as nursing services are concerned right now? "REALITY" AND STANDARDS Much has also been said about the necessity to bold down standards because of shortages of skilled nursing homes and of nurses. This is known as being "realistic." I would be very happy if we could introduce a little reality into these hearings in terms of factual information concerning the population of elderly persons residing in nursing homes today, the kind of care they are receiving, and the kind of care they should receive. We know that the nursing home population is made up of what are called the older aged; that is, individuals 75 years of age and older and that this age group consumes much of our health, hospital, and nursing costs. In addition, the nursing home population is a hetero- geneous group of individuals. Some patients need total care; some require help with medication only; others are terminal and have gone to the nursing home to die; while there are many who could be pre- pared for a return to the community or at least more independent living in a semiprotected environment. But there is one thing the nursing home population has in common-all of these individuals are sick; they need nursing services, medical services, and oftentimes they need psychiatric services. It is obvious that the problem will not be solved by calling facilities skilled nursing homes when they offer little or no nursing services and are not homes.
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