Here you have in brief the lessons we have learned, the strategy and tactics we have undertaken and the overall point of view.

Senator Moss. Thank you, Dr. Tayback. That was a very excellent statement and I commend you in being able to deliver it as you did without notes and certainly it was most informative.

I believe that you detailed many changes that have been made that certainly are encouraging as far as my view here is concerned.

This Director of Medical Services that you propose to have in the home, he would be an M.D., but he would have overall responsibility for the entire situation, even though a patient might have another doctor. Is that right?

Dr. TAYBACK. Yes. Dr. Schoenrich in 2 to 5 minutes could explain the functions of the medical director, if you would like.

Senator Moss. We would be glad to hear Dr. Schoenrich.

STATEMENT OF DR. EDYTH SCHOENRICH, DIRECTORATE OF SERVICES TO THE AGED AND CHRONICALLY ILL, STATE OF MARYLAND

Dr. SCHOENRICH. Our concept of the medical director, is, as Dr. Tayback said, one with aspects: First, this person will be directly responsible for the quality of all the professional activities in the nursing home rather than to have this delegated to administrative personnel; secondly, the medical director will have responsibility for the care of those patients who do not have their own physicians readily available, or who have no personal physician at all.

We envision a rather complex job for the medical director. We have worked closely with our medical society in designing this task and the society prepared the first draft of the duties of the proposed medical director.

The medical director is to be concerned with both patient care and employee health. We want to be certain that the employees are not suffering from communicable diseases or any other health problems that might be a danger to the patients.

The patient care aspects would include concern with the types of patients to be admitted to the institution, so that persons are not admitted who cannot be properly cared for by the resources of the institution; concern with an evaluation of the true status of the medical and nursing problems at the time of admission; concern that orders are properly written and reviewed; and concern that the appropriate plan for care and treatment of the patient is recorded and carried through.

We realize that there are perhaps unrealistic aspects of aiming as high as we are, because of the problem of funding medical directors. for our homes in Maryland. Also, as I am sure you realize, there is a shortage of physicians who are interested and knowlegeable in the fields of adult chronic illness and geriatric care.

We have thought of a possible plan for broadening the impact of the physicians able and interested in doing this work. One way of achieving this is to use physician assistants-either nurse physician assistants or especially trained ex-military corpsmen.

These physician assistants could make regular rounds two or three times a week on the patients in a nursing home, reporting back to a physician who then might be medical director of several homes.

Another point which in all honesty has to be made, is that not everyone will do an equally competent job, and we are not fooling ourselves about this. There are two ways we have thought of to increase surveillance of the kind of task that is performed. One is to involve the Medical Society in a type of peer review system, and the other is to use our own inspectors who regularly go to the homes checking on all aspects of nursing home functions for licensing and certification purposes.

So, that in essence is our plan for the medical director.

Senator Moss. Thank you Dr. Schoenrich.

Dr. Tayback, you said that since June 30, 24 homes have been audited by the State. Is that correct?

Dr. TAYBACK. I indicated that 24 extended care facilities as of this time have been audited.

Senator Moss. Medicare?

Dr. TAYBACK. This is Medicare. But you must understand, Mr. Chairman, that the same facility that is under Medicare also renders care under Medicaid. Under Medicare, the facility is known as an extended care facility. Under Medicaid, it is known as a skilled nursing facility.

Thus, if 24 have been audited under Medicare, that means that 24 facilities that are under Medicaid have also been field audited.

Senator Moss. Because they are the same institution?

Dr. TAYBACK. These same institutions will have participation both under Medicare and under Medicaid.

Consequently, if the audit was carried out for Medicare, there is the necessary spin-off of information to Medicaid.

I will tell you that there are 170 facilities involved in Medicaid-type care. There is another complication, namely, that skilled nursing facilities are under Title XIX and intermediate care facilities are under some other title.

This is another complication. But I would assure you that the Governor is well aware of this and he has also taken the position that he does not want dissipation of authority for this program in too many different hands.

So, the 175 facilities, which we have mentioned, constitute both the skilled nursing home and the intermediate care facilities.

When we carry out audits, the audits will have to include the 175. Senator Moss. In this report, "Examination into Certain Claimed Practices Relating to Nursing-Home Operations in the Baltimore, Maryland Area," by GAO, it says on page 19, "For example, during the 3-year period of fiscal years 1967 through 1969, Analysis Services made only two audits of nursing-home costs under the Medicaid program. These were made at the same nursing home in conjunction with audits under the Medicare program."

That is a 3-year period. Is what you are telling me now that this indicates the State is going to go forward in making annual audits or semiannual audits of all of them?

Dr. TAYBACK. In order to get the facts clear on this, I would appreciate it if I could have Mr. Rutherford Holmes, who is the director

of the Hospital Cost Analysis Services and represents the specific service with whom we contract to do this work.

Senator Moss. He might come forward, if he would, to answer that question for me.

STATEMENT OF RUTHERFORD HOLMES, DIRECTOR, HOSPITAL COST ANALYSIS SERVICES

Mr. HOLMES. Senator, we have an on-going program verifying the cost in the nursing homes, both under Medicare where the intermediary selected by the home is Maryland Blue Cross, where the Blue Cross plan in Maryland contracts with nursing homes for its patients and where the State of Maryland participates under the Medicaid program with the nursing home.

As Dr. Tayback said, this was given secondary priority in terms of the hospital verification program. But this is now going forward with all due effort that we can put to it.

Senator Moss. Do you have a program of annual auditing or are you going to audit annually these homes?

Mr. HOLMES. Each of the facilities submits an annual cost statement which is verified by us in our office and then in the field in actual visit to the actual institution.

Senator Moss. An actual on-the-scene visit and audit?

Mr. HOLMES. Yes, sir.

Senator Moss. Do you see any reason or necessity for having Federal inspection and audit of these homes?

Mr. HOLMES. Not in addition to the work that we do, sir.

Senator Moss. It would be duplicative of the work proposed to be done by the State?

Mr. HOLMES. Many of these homes also have audits by independent CPA's. Where that is done, we then rely to a large extent on their work, checking out work which they may not have paid as much attention to, which we feel is important.

Senator Moss. Thank you, Mr. Holmes.

Dr. Tayback, you detailed rather fully for us the fact that legally a physician isn't required to view the body of the person for whom he signs a certificate of death. And I believe you gave as your opinion, you didn't really feel that this was required since a doctor very often is familiar with the patient whose death occurs.

Why do you suppose we require it to be signed by a doctor if he doesn't have any firsthand knowledge of that certificate he signs?

Dr. TAYBACK. The firsthand knowledge that appears in documented form on the death certificate has to do with the certification of the cause of death. The certification of the cause of death is not predicated on what the physician may observe after death. It is predicated upon the prior medical history of the patient.

Certainly, in the instance of patients that a doctor has no knowledge of, it would be required that there be some observation, some study of the patient at death or even following death, but for a patient with which a physician has been associated for 30 or more days, the physician is fully familiar of the medical circumstances of the patient and consequently, on the basis of that information, he is able to certify

to the cause of death. And his signature is in connection with what he sets as the cause of death.

Senator Moss. Yes, but it is easy to think up a situation that wouldn't fit that. Suppose an elderly patient died because some negligent treatment was given him in the nursing home, or, like being scalded or something of the sort. The person who is responsible for that would want to cover his guilt. So, he would never report it. The doctor simply got the certificate to sign and he would say some reason that was because of the failing health of the patient and then we would never know what the real cause of death was.

Isn't that right?

Dr. TAYBACK. First of all, we go on the premise that the physician is generally familiar with the circumstances of the individual. If the individual was one who had no evidence leading the physician to believe that the individual was in terminal illness and the death constituted a sudden event in the history of that individual so far as the physician was concerned, the physician would not be likely to sign out that particular patient unless he learned more about the circumstances. But by and large, what we are dealing with, if not exclusively, are patients with a long history of decline known carefully and fully to the physician and a note if not a confirmed observation in the physician's mind that the patient is moving through the final days of life. Under those circumstances, when the word comes to the physician that the patient is dying, then this is what has been the expectation of the physician.

So, it really is not contrary, contradictory to good medical care for the physician under those circumstances to sign out the patient and give the causes of death.

The particular circumstance that you describe, certainly, is a possibility. We could have a patient, say, in terminal phases of illness and the patient could fall out of bed and that would constitute the final element in the patient's life, the patient already being in the terminal phases of illness. The fall could represent some element of significance and probably should be represented in the certification of the cause of death.

I would admit, under those circumstances, if the knowledge of the patient's fall from the bed was not given to the physician and if he didn't ask specifically, "What were the circumstances of death?", he would sign out the patient on the basis of his knowledge of the terminal illness.

Senator Moss. If this outbreak of salmonella had been discovered early, would the physicians actually have recorded on the death certificates the cause of death was illness that came from the food poisoning?

Dr. TAYBACK. I note, and Mr. Chairman, it is just this morning that I have your full report, most of my information has been from the newspapers as to what is transpiring-I would differ from the inference made in this report that had the physicians seen the bodies after death, the course of events would have been different.

I think in all fairness to all people concerned, one must say that that. is an absolutely false premise.

41-304-71-pt. 10- -3

I myself in trying to understand this event personally read through the 146 histories and I know from the histories what was the time sequence. We have with us today the epidemiologist, Dr. Garber, who has conducted a very careful study of this.

This event broke open in an explosive way on Monday following a Sunday evening meal. On Monday, by Monday night and by Tuesday, the circumstances of an outbreak were known to two or more physicians. The circumstances were known as an explosive outbreak to other personnel. Issues having to do with death and viewing the body after death are completely superfluous to the notion of how effectively to deal with an explosive outbreak of this type.

Senator Moss. What inspections are now being made of nursing homes? I am referring to the fact that Mr. Williar in the State hearing stated he knew of no nursing homes being closed during his 21year tenure with the State. Have any homes been closed since that time as a result of inspection?

Dr. TAYBACK. No homes have been closed since the time of the Gould incident. In all fairness, I cannot tell you the name, I have one home which is now under orders to be closed. I cannot tell you the name of the home because the individual owner has to be ordered in for a hearing before we are able to proceed any further.

The order to close has been made through recommendation of our Advisory Council on Hospital Licensing.

The concept that homes have not been closed is erroneous. I am told that within the past 10 years there have been as many as 100 homes that have closed affecting 1,500 beds. One must understand the nature of the closure of these institutions.

These institutions have not been closed by a direct order of the State Department. They have closed as a consequence of pressure placed upon them and then by the free will of the owner. But if you were to take a look at a list of nursing homes in the State of Maryland within the past 10 years, you will then note that during the 10-year period, approximately 100 nursing homes have ceased operation involving about 1,500 beds.

Senator Moss. Those are voluntary closures. They might have come from financial problems or otherwise. Is that correct?

Dr. TAYBACK. That is true, Mr. Chairman, but in many instances they came about as a result of pressure, even though there wasn't the conclusive order to close.

Senator Moss. You say there has been one notice already served that will have to be heard?

Dr. TAYBACK. That is right.

I might remind the chairman and the members of the committee of the unusual circumstances that attend to the issue of closing a nursing home, namely, that if you issue an order to close the nursing home and particularly if you are dealing with Medicaid patients, then you have got the obligation of finding other places for these Medicaid patients. This is a great difficulty, finding such places.

Nevertheless, the past pattern has been one where the public agency has frankly temporized because of the difficulty of finding other beds for the patients who would be closed out in a nuring home.

I can tell you that as a result of the work of your committee and various other circumstances that we now take the point of view that