At the currently established rate of reimbursement for public assistance patients, it would not be practical to accept patients on public assistance for nursing home care and such groups would have to limit their activities to private patients, thereby defeating one of the primary purposes of this legislation; namely, to provide care for all patients including those on public assistance. This means, therefore, that the usual proprietary nursing home must care for the greatest bulk of nursing home patients, and for this we are extremely grateful to them.

It is hoped that in the future the U.S. Public Health Service will continue to support by additional funds both regulatory and educational programs for nursing homes. By these established mechanisms the U.S. Public Health Service is recognizing the fact that supervision of medical care facilities and activities, although a relatively new responsibility of public health departments, is a rapidly growing and tremendously important one. It is apparent that national and State legislatures and the medical and allied professions are gradually learning the lesson that better medical care, including better medical care for the aged, means, in the long run, better public health. Thank you, Senator.

Senator SMITH. Thank you very much, Dr. Rubenstein.

Now just a couple of questions here. Does the State have any special requirements for owners or operators in order to receive a license for running a nursing home?

Dr. RUBENSTEIN. According to our State law there is a requirement that the operator must be a suitable person and letters of recommendation must be submitted by persons who know the individual. However, there is no regular licensing program for administrators.

Senator SMITH. I see. Do you think this is adequately taken care of under the association setup that we have here now?

Dr. RUBENSTEIN. Yes. What we attempt to do is assure adequacy with respect to the nursing personnel who operate the home. In other words, we are interested more in the qualifications of the nursing personnel who run the nursing home.

Senator SMITH. Do State regulations require the homes to have certain medical supervision or is that left up to the

Dr. RUBENSTEIN. No; that is all included in our regulations. We have a pamphlet, which I will be glad to supply copies of, including about 20 pages of regulations.

Senator SMITH. If you could furnish that, we would like to make it a part of the record.

Dr. RUBENSTEIN. I would be glad to. Incidentally, these regulations have been revised three times, and each time of course there is considerable upgrading, so that I believe our regulations here in Massachusetts are very good. As a matter of fact, I am constantly sending them to health departments all over the country at their request.

Senator SMITH. Fine. That will be made a part of your testimony. Dr. RUBENSTEIN. Thank you.

(The documents referred to follow :)

RULES AND REGULATIONS FOR THE LICENSING OF

CONVALESCENT OR NURSING HOMES IN

MASSACHUSETTS

SECTION I

A. LEGAL AUTHORITY

1. General Laws, Chapter 111, Sections 71 to 73, inclusive, authorizes the Department of Public Health to issue, for a term of two years, a license, subject to revocation by it for cause, to any person whom it deems suitable and responsible, to establish or maintain a convalescent or nursing home which meets the requirements of the Department, established in accordance with its rules and regulations.

2. Convalescent or nursing homes conducted in accordance with the practice and principle of the body known as the Church of Christ, Scientist, shall be licensed and subject to the provisions for local board of health, fire, wire and zoning approval. The only inspection to be made in such homes by the Department of Public Health shall pertain to sanitation. The regular license fee is required.

3. In accordance with the authority granted by General Laws, Chapter 111, Sections 71 to 73, inclusive, the Department of Public Health herewith adopts the following rules and regulations for the conduct and supervision of convalescent or nursing homes.

4. Penalty for Establishing or Maintaining a Convalescent or Nursing Home without a License. Whoever establishes or maintains, or is concerned in establishing or maintaining a convalescent or nursing home, or is engaged in any such business, without a license granted under General Laws, Chapter 111, Section 71, shall for a first offense be punished by a fine of not more than five hundred dollars, and for a subsequent offense by a fine of not more than one thousand dollars or by imprisonment for not more than two years.

Penalty for Violation of Any Provision of Licensing Act (General Laws, Chapter 111, Sections 71 - 73 inclusive) or any of the rules and regulations made under Section 72. Whoever, being licensed under Section 71 of the General Laws, Chapter 111, violates any provision of Sections 71 to 73, inclusive, of Chapter 111 of the General Laws or any rule or regulation made under Section 72, shall for a first offense be punished by a fine of not more than five hundred dollars; and for a subsequent offense by a fine of not more than one thousand dollars or by imprisonment for not more than two years.

B. DEFINITIONS

1. A convalescent or nursing home is defined as any institution, however named, whether conducted for charity or for profit, which is advertised, announced or maintained for the express or implied purpose of caring for three or more persons admitted thereto for the purpose of nursing or convales

cent care.

2. A registered nurse is one who is currently registered by the Commonwealth of Massachusetts, Board of Registration in Nursing, to practice as a registered nurse.

3. A graduate nurse is one who has graduated from an approved school of nursing, or a school of nursing which was approved at the time the nurse was graduated.

4. A licensed practical nurse is one currently licensed by the Massachusetts State Board of Registration in Nursing to practice as a licensed practical nurse.

5. A graduate practical nurse is one who has satisfactorily completed the prescribed course of training in an approved school of nursing for practical nurses or a school of nursing for practical nurses currently approved or approved at the time the nurse was graduated, or in a hospital approved prior to July 1, 1956, by the Joint Commission on Hospital Accreditation or its predecessor, the American College of Surgeons. Proper credentials to certify the nurse as a graduate practical nurse shall be presented by the nurse.

6. An undergraduate nurse is one who has satisfactorily completed, in an approved school of nursing or a school of nursing which was approved at the time the nurse was in training, sufficient time

during which the nurse would have received theory and instruction comparable to that required for a graduate practical nurse. Proper credentials to certify the nurse as an undergraduate nurse shall be presented by the nurse.

7. The term "Department" as used in these regulations shall mean the Massachusetts Department of Public Health.

8. The term "Department of Public Safety" shall mean the Massachusetts Department of Public Safety.

9. The term "licensee" shall mean the individual or individuals, corporation, trust or governmental unit legally responsible for the conduct of the home.

10. The terms "local board of health," "local fire chief," "local wire inspector" and "local zoning authority" shall mean the individual or agency so designated in the city or town in which the convalescent or nursing home is located.

11. All adjectives and adverbs such as accessible, adequate, approved, attractively, clean, competent, good, proper, qualified, reasonable, reliable, reputable, responsible, safe, sanitary, satisfactory, sufficiently, and well, used in these rules and regulations to qualify a person, equipment or building shall be as determined by the Department.

C. PROCEDURE FOR LICENSURE OR LICENSE RENEWAL

1. Issuance of License or License Renewal

a. Request for an application shall be made in writing to the Department.

b. Application for a license or license renewal to establish or maintain a home shall be made in writing, and submitted to the Department upon the application forms secured from the Depart

ment.

Structural changes in a proposed or existing home shall not be undertaken until notification has been made to the Department and plans for said structural changes have been approved by the Departments of Public Health and Public Safety.

c. Two copies of the completed application shall be returned to the Department.

d. Written zoning approval on a form provided by the Department is a prerequisite for an original license.

e. Local board of health certification on a form provided by the Department that said convalescent or nursing home is suitable for this purpose is a prerequisite for licensure.

f. A certificate of inspection of the egresses, the means of preventing the spread of fire and the apparatus for extinguishing fire issued by an inspector of the Division of Inspection of the Department of Public Safety is a prerequisite for licensure.

g. The local wire inspector shall certify in writing on a form provided by the Department that, from his inspection of the premises, there is compliance with the local wiring codes; the corrected minor deficiencies shall be listed. In towns having no local wire inspector, the Department shall arrange with the state wire investigator for the same service and report. No license shall be issued or renewed without signed approval by the local wire inspector or state wire investigator.

h. A certificate of inspection issued by the head of the local fire department, certifying compliance with the local ordinances is a prerequisite for licensure.

i. A check or money order for the license fee payable to the Commonwealth of Massachusetts shall be forwarded to the Department when requested.

j. The applicant shall be a suitable and responsible person.

2. Name of Home

Every convalescent or nursing home shall be designated by a permanent and distinctive name which shall appear on the application for license, and which shall not be changed without first notifying the Department. The term "convalescent home" or "nursing home" shall appear in the name. The term "rest home" cannot be used.

3. Quota

a. Each license issued by the Department of Public Health shall specify the maximum allowable number of beds on each floor in the home, which number shall not be exceeded. The number of beds allowed on each floor shall be determined by the Department of Public Health and shall so appear on the license issued by said Department.

b. Requests for quota increase shall be made in writing to the Department. No increase will be granted without written approval of the Director or the Chief Hospital Inspector of the Division of Hospital Facilities of the Department and the building inspector of the Department of Public Safety.

4. Оссирапсу

a. Rooms below grade level shall not be used for patient occupancy.

b. Occupancy of rooms above the second floor shall be restricted to employees and members of the immediate family of the licensee.

c. Rooms without basement foundations shall not be used for patients unless there is proper heating and insulation.

D. POSTING OF THE DEPARTMENT LICENSE AND DEPARTMENT OF PUBLIC SAFETY CERTIFICATE OF INSPECTION

1. The license issued by the Department of Public Health and the inspection certificate issued by the Department of Public Safety shall be framed and posted conspicuously on the premises.

E. RETURN OF LICENSE

1. The license issued by the Department of Public Health shall be returned immediately by registered mail to the Department on:

a. Receipt of renewal license

b. Revocation

c. Change of location

d. Change of ownership

e. Change of name

f. Change of quota

g. Voluntary closure of a home

h. Change of classification

i. Demise of licensee

F. CHANGE OF OWNERSHIP AND/OR LOCATION

The Department shall be notified immediately in writing of any proposed change in location, name or ownership of the home. A new application must be submitted at once in the instance of a change of location or ownership. A license cannot be transferred from one individual to another or from one location to another.

In the case of transfer of ownership, the application of the new home owner for a license to maintain a convalescent or nursing home shall have the effect of a license for a period of three months when acknowledged by the Department of Public Health. The quota granted to the former licensee shall not be exceeded until approved by the Director or Chief Hospital Inspector of the Division of Hospital Facilities of the Department and the building inspector of the Division of Inspection, Department of Public Safety, assigned to that district.

G. RESTRICTIONS

1. No home in which part of the premises is utilized for tenant occupancy or for business or professional purposes, including a commercial laboratory, shall be approved for licensure.

2. Office space is not permitted in the home for physicians, dentists or podiatrists or for physiotherapists or other paramedical persons.

3. Nursing services or medical treatment shall not be administered to non-residents.

4. Alterations and structural changes to the premises cannot be made until plans for proposed changes have been submitted to and approved by the Departments of Public Health and Public Safety.

H. RIGHT OF APPEAL

1. A licensee or an applicant aggrieved by the decision of the hospital inspector shall have the right of appeal to the Chief Hospital Inspector or the Director, Division of Hospital Facilities. 2. Any person aggrieved by the refusal of the local board of health to certify that the convalescent or nursing home is suitable for the purpose may, in writing, appeal to the Director, Division of

Hospital Facilities, Department of Public Health, for a public hearing. The Department shall hold said hearing and thereafter may modify, affirm or reverse the action of the local board of health.

3. Any applicant for an original license who is aggrieved by rejection of his application by the Department of Public Health on the basis of written disapproval, by the head of the local fire department or by the inspector of the Division of Inspection of the Department of Public Safety may, within thirty days, make an appeal in writing from such refusal to a board of review. The board shall, within twenty days of the receipt of such appeal, give the parties in interest an opportunity to be heard and shall, within thirty days after such hearing, render a decision, which shall be a matter of public record.

Within thirty days after action by the board of review, a person who is aggrieved by the refusal of said board to approve his application may bring a petition in the district court within the judicial district where the premises on which the application was based are located, addressed to the justice of the court, praying that the action of the board in refusing to approve his application may be reviewed, and after such notice as said court shall direct to all parties interested a hearing may be had before the court at an early and convenient time fixed by it; or the court may appoint three disinterested persons conversant with the subject matter of the controversy to examine the matter and hear the parties. The decisions of said court or the written decision under oath of a majority of those appointed by the court filed in the office of the clerk of courts in said county within ten days after such hearing may annul or affirm such refusal. Such decision, or a certified copy thereof, shall have the same authority, force and effect as an original refusal or approval by the board. If such decision results in the approval of an application for a license which the board has denied, the court shall order said license to be issued.

4. Upon written request by an applicant who is aggrieved by the refusal to renew such a license, or by a holder who is aggrieved by the revocation of such a license, as the case may be, the Commissioner of Public Health and the Public Health Council shall hold a public hearing after due notice and thereafter may modify, affirm or reverse the action of the Department.

I. REVOCATION OF LICENSE

A license to operate a convalescent or nursing home may be revoked by the Department in accordance with General Laws, Chapter 111, Sections 71 to 73, inclusive, as amended for any of the following

reasons:

1. Violation of the provisions of the licensing act or of the standards, rules or regulations of the Department adopted thereunder.

2. Permitting, aiding or abetting the commission of any illegal act in such home.

SECTION II

A. GENERAL REGULATIONS FOR CONVALESCENT OR NURSING HOMES

1. Fire Protection

a. Employees of the home shall be instructed by the head of the local fire department or his representative as to their duties in case of fire.

b. Fire extinguishers shall be recharged and so labeled at least once a year.

c. Where sprinkler systems are installed, the water pressure shall be checked weekly by the individual in charge of the home.

d. Lighting facilities shall be available in all common halls and inside and outside stairways.

e. Emergency lights shall be checked weekly by the individual in charge of the home.

f. All exits shall be clearly identified by exit signs, adequately lighted, and shall be free from obstruction.

g. Gas dryers shall be inspected by the proper authorities.

h. All fires involving patients, personnel or property shall be reported to the Department.

i. There shall be at least one telephone on each floor where patients or personnel reside. All telephones shall be available for use in any emergency, for both incoming and outgoing calls.