Senator SMITH. I see. So you make recommendations?
Mr. CURRAN. That is true.

Senator SMITH. Thank you very much, Mr. Curran, for this testi

mony.

At this time, ladies and gentlemen, I would like to remind you that the afternoon session, commencing at 2 p.m., will be open to suggestions and remarks from any of those people in the audience, who are not listed as speakers this morning, to give their opinions and their views on any of the problems that confront the aged. I will look forward to hearing from as many of you as possible.

Our next witness this morning will be Dr. A. Daniel Rubenstein, deputy commissioner of public health and director of the division of hospital facilities, Commonwealth of Massachusetts.

Dr. Rubenstein, it is a great pleasure to see you here this morning.

STATEMENT OF DR. A. DANIEL RUBENSTEIN, DEPUTY COMMISSIONER OF PUBLIC HEALTH AND DIRECTOR, DIVISION OF HOSPITAL FACILITIES, COMMONWEALTH OF MASSACHUSETTS

Dr. RUBENSTEIN. Thank you, Senator Smith; it is a pleasure to be here.

Senator Smith and members of the committee, I am Dr. Daniel Rubenstein, deputy commissioner of public health, and I am appearing here at the request of the commissioner of public health.

In Massachusetts the responsibility for the licensure of medical care facilities, including nursing homes and rest homes, is the function of the division of hospital facilities of the department of public health under sections 71-73 of chapter 111 of the General Laws. Prior to 1948 a program of hospital licensure by the department of public health had been in existence in the Commonwealth since 1941, and it was not until 1948 that this law was amended to establish a program for the licensure of nursing homes and to transfer the licensing of boarding homes for the aged, currently designated as rest homes, from the department of public welfare to the department of public health.

Since 1948 there has been a tremendous expansion in the number of nursing homes throughout the commonwealth. At the present time, there are 738 nursing homes with 21,915 beds and 510 rest homes with 7,731 beds. Standards in nursing homes in the Commonwealth have improved at a fairly constant rate in spite of insufficient inspectional personnel and also bearing in mind the financial limitation set by the rate of reimbursement for public assistance patients as established by statutory requirements.

When the department assumed responsibility for the licensing of nursing homes and rest homes it soon became apparent that this was to be no easy task. Although there were a number of good homes, many were obviously poor. Among the more pressing problems in such homes were shortages of personnel, poor sanitation, and patient accommodations, inadequate medical supervision, nursing care, nutrition, and equipment. There were those who felt that lack of adequate facilities for rehabilitation was a serious inadequacy in such homes. While this was true in general, it became apparent to the staff of the division that, since the average age of patients in nursing

homes and residents in rest homes was in the vicinity of 70 years, rehabilitation in the sense of physical restoration for job training and employment was an unrealistic goal; therefore, emphasis was directed toward promotion of self-help and prevention of further disability.

While there was an acute need for better recreational facilities and diversional activities in these homes, the most urgent need was to improve the environment and to provide a clean, comfortable home with adequate, nutritious, well-balanced diet, good medical supervision and nursing care, and a pleasant, happy, homelike environment. The achievement of this goal became the immediate objective of the staff of the division of hospital facilities.

When it was established by study that 60 percent of the persons in nursing homes and rest homes were cared for by public assistance and that many homes would accept but a small proportion of public assistance patients because of the low rates paid for their care, difficulties in this regard became apparent. If standards were to be pushed too rapidly by the department of public health, greater limitations on the number of public assistance patients would have been imposed by some homeowners.

When the general court enacted legislation requiring licensing of city and town infirmaries by the department of public health this soon constituted a considerable portion of the division's activites. Prior to 1953 the department of public welfare could only make recommendations to local welfare boards regarding these infirmaries. Rarely were this department's recommendations carried out. If the status of nursing and rest homes in 1948 were to be described as poor, then conditions with very few exceptions in city and town infirmaries in 1953 utilizing the same standards would have to be considered deplorable. It is difficult to put into words the sorry conditions found in many of these infirmaries. In one such institution erected early in the 19th century, bricks falling from a crumbling wall constituted a hazard not only to the residents of the home but to persons passing by in the neighborhood while falling ceilings were observed in the residents' rooms and wards. In some instances the department of public safety had refused to issue certificates of inspection indicating compliance with minimum standards in regard to fire and egress. In one community the local board of health had made violent protests to the welfare department in regard to the continued occupancy of the local infirmary by human beings. No attention had been paid to the pleas of the board of health because no licensing law was in effect. Life in many of these institutions may properly be described as a bare existence.

When the division became responsible for the licensing of these infirmaries many closed and, as time went on, 30 city and town infirmaries, or slightly more than 50 percent, ceased to operate either as a result of action instituted by the department of public health or by voluntary closure. Currently in operation are 27 infirmaries with 1,769 beds and 14 public medical institutions with 1,327 beds.

Improvement in all phases of nursing and resthome operation has become apparent during the past 12 years. This has been most marked in areas where the staff has been concentrating its activities; namely, in medical supervision, nursing care, dietary service, records, patient accommodations and equipment, housekeeping and general maintenance. It is expected that recent revisions of nursing home regulations will result in additional improvement in nursing home care, equipment, and facilities. Increases in the rate of payment for public assistance patients, as indicated by Mr. Curran, have been of considerable value in bettering conditions in many of these homes.

In general, the program of the division of hospital facilities has had two facets, one regulatory and the other educational. Examples of the kinds of educational activities carried on by the division are the following:

(1) Seminars at the annual meetings of the Massachusetts Federation of Nursing Homes, and at this point I would like to say the Massachusetts Federation of Nursing Homes has been very cooperative in this whole area.

(2) Institutes for nursing home personnel conducted in cooperation with universities, colleges, local hospitals and nursing homes throughout the State. We have just had an institute of that type at Northeastern University yesterday.

(3) Înstitutes and refresher courses in cooperation with schools of nursing and schools for practical nurses in Massachusetts.

(4) On a demonstration basis to improve rehabilitative and restorative services in a limited number of nursing homes in certain areas of the State.

Through the years, however, it has been extremely difficult to offer sufficient services in this area commensurate with the growth of the nursing home movement. The division's program has been very definitely limited by insufficient personnel, both professional and clerical. Since it has been the responsibility of the division of hospital facilities to carry out its legal mandate, first consideration had to be given, of necessity, to the regulatory phase of the program while maintaining as much activity as possible in the educational phase. It soon became apparent that nursing home administrators were extremely interested in all educational activities offered by the division. For example, one institute, 1 day a week for 10 weeks which was to be limited to 50 persons, finally, because of the great demand, was made available to 100 nursing home operators by scheduling a second session. Similar situations prevail when other institutes are arranged.

It is expected that as the immediate result of additional funds made available to the Department of Public Health by the U.S. Public Health Service for the improvement of nursing home care, the division's program aimed at raising standards in nursing homes will be considerably improved. With these additional funds one additional inspector and three clerks have been provided-this money having come from Federal grant-and greater attention will be given to the educational phase of our program. These additional personnel, together with our revised regulations, will raise even to a greater degree the level of nursing home care in the Commonwealth.

It must be emphasized at this point that nursing home licensure is a relatively new activity for most health departments. We in Massachusetts are fortunate that our program which has been in existence since 1948 has progressed more rapidly than in most other States. However, it wasn't until this year, actually 1961, that any Federal funds have been specially earmarked for nursing home programs. would like to emphasize this as a very important point, Senator. It is in this area that the States can use additional assistance from the Federal Government and the Public Health Service. Additional Federal funds are urgently needed to support the licensure program. As Mr. Curran mentioned, in cooperation with the Boston College School of Nursing a Federal grant has been assigned to the latter institution to study intensively standards of nursing care in nursing homes in Massachusetts. It is anticipated that when these standards have been defined it will be possible for an agency, definitely established for the purpose, and with broad representation of physicians, hospitals, nurses, and regulatory agencies to formulate a voluntary joint accreditation program for nursing homes similar in function to the Joint Commission on Hospital Accreditation. Such an accreditation program will supplement the activities of the State agency as well as that of the Massachusetts Federation of Nursing Homes.

It is my definite impression that standards of nursing home care and operation in Massachusetts, because of our long established program, have been many years ahead of similar programs in most other States. It is hoped that by the use of additional funds previously mentioned and increased professional and clerical staffs that the standard of nursing home care and operation will progress even more.

In Massachusetts the rate of reimbursement of care for public assistance patients is established by the division of hospital costs and finances in the commission on administration and finance in accordance with the statutory requirements. As standards are raised it follows, naturally, that costs of operation will rise proportionately. Similarly, it is to be expected that the rate of reimbursement will reflect the increased costs of operation.

As additional programs in rehabilitation and recreation become an integral part of nursing home care, nursing home operators will be entitled to additional reimbursement to compensate for the cost of such programs. Under the Kerr-Mills legislation which is being implemented in Massachusetts, the Federal Government will, of course, underwrite a substantial portion of this care. It is my opinion that within the next few years standards of care will rise as a result of the joint activity of State and Federal programs in the field of nursing home care and operation.

At this point, Senator Smith, I would like to clarify the misconception which arose as a result of the statement in connection with unacceptable beds in Massachusetts. Considerable confusion has arisen from material published in the State plan for the administration of the Hill-Burton program that there are more unacceptable beds in nursing homes in Massachusetts than in many other sections of the country. In setting up criteria for unacceptable beds in nursing homes the recommendation of the U.S. Public Health Service was

78681 0-62-pt. 4-2

adopted in this connection; namely, that all frame buildings be considered as unacceptable. Since most nursing homes in Massachusetts, as well as everywhere else in the country, were converted frame residences, it is obvious that the problem of unacceptable beds is no greater in Massachusetts than it is in other parts of the country.

However, it must be borne in mind that no nursing home license is issued or renewed in Massachusetts unless all required safeguards against fire hazards have been observed by nursing home operators. This includes proper certification by the State department of public safety, approval by local fire departments and local wire inspectors. In Massachusetts there is the additional safeguard required by law; namely, that each nursing home must be inspected and approved by the local fire department four times a year.

It is apparent from this that legislators in Massachusetts have supplied nursing homes with as many safeguards as possible in this important area of medical care activity. It is anticipated that within the next few years a statewide law will be enacted requiring sprinkler systems in nursing homes. Such safeguards are already enforced in several large cities of the Commonwealth as a result of local ordinances. It is apparent that Massachusetts is better off in this respect than most other States in the country.

Another problem in nursing home care has to do with placement of patients in medical care facilities by some welfare departments. A small number of medical care facilities have been classified by the department of public health as particularly suited for care of patients requiring more than average nursing care, and have been given the classification "chronic hospital." The division of hospital cost and finances has set a higher rate for public assistance patients admitted to these facilities. However, when physicians and social workers in general hospitals have designated certain patients for care in these institutions, some welfare departments have refused to pay the additional costs and have reclassified candidates for admission as typical nursing home patients at the usual rate of reimbursement, thereby defeating the primary purpose of our plan. Clarification of this problem is necessary, since under the medical assistance to the aged program the Federal Government could participate in the extra costs for care of such patients. This is a problem, Senator, at the State level rather than the Federal level.

There are two additional Federal programs which have an impact on nursing home care. One is the Wolverton portion of the hospital survey and construction program in which Federal funds are available for the construction of nursing homes operated by voluntary or governmental agencies. Thus far, the bulk of these funds in Massachusetts have been used by existing voluntary agencies engaged in nursing home operation. Many of these have been religious organizations.

Many voluntary groups have been slow in applying for grants under this program, primarily because of lack of funds. Such groups not having the advantage of accumulated reserves to assist in the operation do not find it practical to engage in nursing home activities, and this is a primary reason that hospitals have not gone into this field.