Mr. COHEN. That is correct.

Senator CLARK. And of these there are less than a dozen which are properly staffed and organized. Now, if I could ask you a question or two about that, of those 900 institutions, can you divide them between those publicly supported and privately supported?

Mr. COHEN. Yes, sir. There are roughly 480 proprietary institutions with approximately 10,000 beds.

Senator CLARK. When you say proprietary, you mean for profit! Mr. COHEN. For profit; that is correct.

There are 260 nonprofit, this would be the church and service club homes with a population or a bed capacity of approximately 14,000 beds.

Senator CLARK. Is there any significant difference in the care and custodial treatment between the proprietary and nonproprietary institutions, so far as your experience indicates?

Mr. COHEN. I would say that there is. While it is very hard to generalize, and there are a large number of domicilary-care institutions among the nonprofit group. In what we call often a home for the aged, I would say that in general the nonprofit institutions provide a higher level of care.

Senator CLARK. Now you have given the two categories of the private and perhaps the denominational and charitable institution, and the proprietary one. Is there a third one such as the public institution supported by tax funds?

Mr. COHEN. Yes, sir.

Senator CLARK. How many are there of those?

Mr. COHEN. There are 60 county institutions which have a bed capacity of approximately 15,000. We have 25,000-no, almost 30,000, in the nonprofit and public field and about 10,000-I am not coming out right, but about 10,000 or 11,000 in the proprietary field.

Senator CLARK. With respect to the public institutional field, can you give us any generalization from your experience as to the adequacies of the care provided, compared to the proprietary and the private charitable?

Mr. COHEN. The public institutions probably give you a better reflection of how the public feels, because they are tax supported, than either of the others. The range from one extreme, with the John Kane Hospital which I understand you will be visiting tomorrow, which provides a program that is the latest word as it were, on down to those homes which still have jail cells, in which old people are still kept in jail cells. They are almost medieval.

Senator CLARK. So you would say that the range of, let us say, not to use a very accurate words, efficiency, but I mean it in the broad sense, compassionate efficiency is from zero to a hundred.

Mr. COHEN. Yes, sir. But there is a trend and this is worthy of note. We are finding more and more of the county institutions prepared to move ahead and improve their programs. There are I would say probably no less than 25 percent of the 60 county homes that I mentioned that are making very significant advances in their thinking and in their organization and in the amount of money they are willing to put into county home organizations.

Senator CLARK. In other words, you look for a greater improvement in the public institutions in the immediate future than in either the

43350-60-pt. 3—6

proprietary or the charitable, private-charitable institution, or is that not fair?

Mr. COHEN. I am not certain I would want to make that kind of comparison but I will say this: I think that the public institution will change its character from the residual dumping ground into one of the more primary facilities. It will be a place where people will go for care and to have something done rather than for the primary purpose of being removed from the community.

Senator CLARK. Would you say that with respect to all three of these agencies, that the deficiencies which you mentioned are affected substantially by (1) lack of adequate trained personnel, and (2) a lack of funds?

Mr. COHEN. I would have to broaden that and say it is not merely training. It is a matter of attitude. This morning a question was raised about where we would get enough doctors, for example, to do the diagnostic evaluations. Well, every patient in a proprietary nursing home must be under the care of a private physician and yet the failure to make examinations, to do decent thorough examinations is appalling.

Senator CLARK. What you are saying is, is it not, that the law is not enforced?

Mr. COHEN. This is not a matter of the law, sir; it is a matter of what the medical profession is prepared to do, how they feel about doing the kind of job on the older people in the nursing homes. Too frequently the aged sick are referred to as the "crocks," the "old crocks," in the medical jargon. The opposition that we get out in the community when we ask physicians to present signed orders on medical orders is striking. I think it is worthy of note that in over 3 years I have yet to receive my first complaint from a physician on the kind of care being given in an institutional facility.

Now our complaints come in from families, they come in from patients. We do not get many from the social agencies or from the professionals who are in and out of these places. This is a deep factor at work and therefore I say it is not just a matter of having enough trained people. Certainly we need a huge number of trained people but the ones that we have are not really coming through for us. I am sure that the technical competence is there but there is something else that is missing.

Senator CLARK. Do you have any specific suggestions as to how you could bring these 900 institutions you are charged with supervising up to an acceptable level?

Mr. COHEN. First, there would have to be a ready acceptance by the community for the development of a network of services in the community so that we could properly utilize the institutions we have. Senator CLARK. This would cost money.

Mr. COHEN. Undoubtedly. But it might cost less money than what we are spending now. I am approached by the Hill-Burton people in your department who say, "What do you think we need in the way of new nursing-home beds?" My answer to them is, "I do not know that we need a single additional bed in Pennsylvania. Maybe we are using these 42,000 beds that we have in an altogether improper way." Senator CLARK. This turned out to be pretty true in connection with the mental-health program, did it not?

Mr. COHEN. That is correct. I believe that 8 or 10 years ago New York State floated a $300 million bond issue. This was in the face of all the new drugs and all the findings on what you could do if you put some money into treatment. The same thing is true here. Are we willing to start putting some money into homemaker service, caseworker service, home medical-care programs, decent clinic programs, preventive medicines, visiting-nurse society, so on and so forth?

This seems to me to underlie everything else we are going to do with this. Policing can only go a certain small way beyond the culture of the community.

Senator CLARK. Do you have any experience in comparing the status of these 900 institutions in Pennsylvania with comparable institutions in other States? Are we lagging behind? Are they all about as bad as this throughout the country or do you not know?

Mr. COHEN. I have just returned from a meeting with other licensing officials. My conclusion is that we are probably somewhere in the upper third or anyway in the upper half, something like that.

Senator CLARK. You are running in, say, third position but it is still the "Three I" league.

Mr. COHEN. That is correct. Undoubtedly there has to be some means of financing better care in the institutions when people are placed there. Our present public-assistance payments are at a maximum of $150 or $155 a month and it is pretty difficult to provide or find care at that level.

Senator CLARK. Do you have the power to close a nursing home that you think is being improperly operated?

LICENSING NURSING HOMES

Mr. COHEN. Yes; we have the power to revoke a license.
Senator CLARK. Have you ever done it?

Mr. COHEN. Yes, sir. We have. It is sometimes an extraordinarily difficult thing. We can wander through the courts which have a great concern for the property rights of the individual who is operating the home. We had one situation in Philadelphia where a woman had a record of convictions including abortion, operating a disorderly house, prostitution, fortune telling, and violation of the Dangerous Drug Act, and she kept on operating for something like 2 years after we brought our action before we finally got an injunction.

Senator CLARK. Do you remember the case some years ago of a nursing home in Philadelphia where they had a fire and a lot of people were burned to death because they were chained to their beds? As I recall, it took an interminable time to close that home. I do not know if it was ever closed. Maybe that was before your time. I see Mr. Block nodding.

Mr. COHEN. That is before my time, but I do not think we will find such restraint in Pennsylvania.

Senator CLARK. Let me ask you this: Could you estimate how much per patient per day it would cost to operate a nursing home which was organized and staffed and equipped in the way you think it should be?

Mr. COHEN. I think you could get a better answer from Mr. Waldman, if I might suggest it, from Mr. Waldman, who is going to testify this afternoon.

Senator CLARK. All right. Do you think we are going to have to continue to not only have but to encourage the establishment and organization of proprietary nursing homes in Pennsylvania for the foreseeable future?

Mr. COHEN. I am not certain that one works on encouraging the establishment of homes in terms of their ownership status. We have developed I think one of the most unique screening programs to try and make sure that only those who are going to operate properly are going to get into the field. We have a very lengthy procedure. This is by deliberate purpose. We insist that anybody who wants an application come to Harrisburg for group discussion meeting with other applicants where we carefully

Senator CLARK. To cut you short, because we are running short on time, do you think that the procedures preliminary to obtaining a license are pretty effective?

Mr. COHEN. I do.

Senator CLARK. With respect to the inspection of existing homes, is the regulatory legislation adequate?

Mr. COHEN. It is.

Senator CLARK. So it is an enforcement problem.

Mr. COHEN. That is correct, and it is a terrific problem of staff. We operate at about one-third the staff we need and have little of the consultant service which we should have necessary to help in the elevation of standards of operation.

Senator CLARK. Do you have any medical consultants?

Mr. COHEN. No; we do not.

Senator CLARK. I understood you to testify a little earlier that you were not entirely happy about the attitude of the medical profession toward this problem?

Mr. COHEN. That is correct. I should say that we have some very fine contacts with the medical society and I think that I should make the distinction here that we have received every cooperation from the medical society. They have reviewed our standards. They have been very helpful in that connection. Where our problem is is out at the local level with the practitioner so that I think that that distinction should be drawn.

Senator CLARK. Right.

Does that about clean up what you have to say?

Mr. COHEN. Just one other point, and that is that if I were to make one recommendation that I feel would represent the best possible investment, I would suggest the establishment of a grant-in-aid program along the lines of the Community Mental Health Act and the Children Welfare Service Act which provide funds to the States for the establishment of community service and for community education. And I would urge that these funds be granted through agencies which deal with the aged, not through chronic-disease programs, not through housing programs or heart programs and so on. There is some money that goes in on that basis now.

Senator CLARK. Let us make it more specific. You would, I take it, agree, that the Federal level should be supervised by the Department of Health, Education, and Welfare.

Mr. COHEN. That is correct.

Senator CLARK. Would you advocate setting up a bureau for the aged and aging comparable to the Children's Bureau?

Mr. COHEN. I really cannot answer that.

Senator CLARK. Would you think there would have to be a separate bureau or agency which dealt with the problem of the aged as such? Mr. COHEN. Yes. We find at this time we have nobody to relate to, the special staff on aging notwithstanding.

Senator CLARK. You said earlier you did not think there were very many agencies of this kind. Do you know how many agencies of your sort there are in State governments, or are you the only one? Mr. COHEN. Organized the way we are I believe we are the only one. Senator CLARK. Thank you, sir.

At this point, your formal statement will be made a part of the record.

(The prepared statement of Mr. Cohen follows:)

PREPARED STATEMENT OF ELIAS S. COHEN, COMMISSIONER, DEPARTMENT OF PUBLIC WELFARE COMMONWEALTH OF PENNSYLVANIA

My name is Elias S. Cohen, and I am commissioner for the aging in the Pennsylvania Department of Public Welfare, Office for the Aging. I am representing the Honorable Ruth Grigg Horting, secretary of public welfare, who unfortunately cannot be with you today. So that my testimony may fit into proper context, I would like to take a few minutes to describe the concern of my office and its place within the structure of the department of public welfare. The office for the aging, created in 1956, is one of six major units within the department. It has two principal lines of interest.

The first, community consultation and organization, is carried into action through the following activities:

(1) Provides regular, continuing consultative services to local groups and communities around the development of locally operated and sponsored programs for older people.

(2) Develops representative community groups to plan, develop, and implement local programs of services for the aging to meet local needs.

(3) Stimulates and aids in the initiation of services and studies to help formulate local programs, research, and demonstrations to develop new programs to meet the new and expanding needs of the aging.

(4) Provides a continuing program of education and motivation around the needs of the aging.

(5) Gathers data and material pertinent to the field for distribution and dissemination.

To attempt to do this, I have available three persons who can give their full time to serving local communities throughout Pennsylvania.

Second, the office for the aging has responsibility for the inspection, supervision, licensing, visitation, and development of all institutional facilities caring for the aged, including 460 proprietary nursing and convalescent homes, 260 nonprofit homes for the aged, 60 county institution district homes, and 105 commercial boarding homes for the aged, for a total of almost 900 facilities housing an aggregate of over 42,000 people.

Our objectives in regard to institutional care and supervision are the following:

(1) To provide a degree of supervision and education which will ultimately lead to a standard of care meeting the psychosocial and medical needs of older persons in accord with modern-day medical and nursing knowledge, the disciplines of physical therapy, occupational therapy, recreational therapy, and institutional administration.

(2) To establish educational programs in the field of institutional care so that all institutions will be given the opportunity for constant development. (3) To develop a planned approach for the location and utilization of the various types of facilities for the aged and aging,

(4) To develop a relationship between institutional care and community programs so that there will be a free flow of services between the community