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of the nursing home proprietors would not be satisfied, under present operations, with 5 or 6 percent return but theoretically it should be much greater than that.

Senator SMITH. Mr. Connelly, do you think that the nursing home field has developed reliable information on the actual costs of their services ?

Mr. CONNELLY. I think that the nursing home field has developed very reliable cost on the actual cost of their services. That is true today because every nursing home in Massachusetts must make such a reporting to the division of hospital costs and finances. What has not been done, however, is a cost analysis of what the public would consider to be the minimum adequate standard of care that ought to be provided for patients.

If this were done two things would follow. First, the nursing home could not be accused of failing to give proper care if rates paid were inadequate to permit it; and secondly the public, knowing through a State agency what the standard of care it is buying, would be able to exact adherance to such standard. There has not been enough work and study in this direction.

On this score may I say that in the hearing before the division of hospital costs and finances this year with respect to the nursing home rate, which was held in this room Monday of this week, an addition to a general presentation the Massachusetts Federation of Nursing Homes asked two other things. We asked that, through the division of hospital costs and finances, the appropriate State departments, which would include the department of public health and others, study a recreational therapy program for nursing homes and the cost of putting such a program in effect in a nursing home. Knowing the program

desired and what it would cost, the necessary moneys could be provided to nursing homes having an approved plan. Thus, we would know what we wanted, we would know what it would take in money to do it, and we could have programs where people who did put it into effect would receive the compensation for it.

Senator SMITH. Mr. Connelly, you speak of the realities of standards of care and the costs. In your opinion what standards would you recommend for the future?

Mr. CONNELLY. I cannot answer that question. I do not know in detail what the standard should be in the future, whether it should be a standard which would cost $7, $8, $9, $10 or $15 a day. I do not know because we have not had the facilities for such a study.

Senator Smith. That might be something that your association could look into and make recommendations.

Mr. CONNELLY. We would love to do it but of course we would need a great deal of money to do it. Secondly, we would prefer that it would be done by a disinterested group, maybe composed of members of the Federation of Nursing Homes but involving a lot of people in other professions in order that such a recommendation would have wider public acceptance.

Senator SMITH. Just one last question. Do you have any specific suggestions for Federal action to support the efforts at the State level, Mr. Connelly?

Mr. CONNELLY. Generally I would say that any aid and comfort, whether it be sympathetic words or grants or appropriations to the State, that would promote cooperative action at the State level would be a great step forward in the solution of problems. In my mind, working together at a level where people have got to be interested in practical performance is the best means of moving forward fast.

Senator SMITH. Thank you very much, Mr. Connelly, for this testimony.

Our next witness this morning will be Mrs. Eleanor Baird, accreditation chairman of the New England region and vice chairman of the National Accreditation Committee, American Nursing Home Association.



Mrs. BAIRD. Mr. Chairman and members of the committee, I am Eleanor B. Baird. I am a chairman for the New England region of the American Nursing Home Association accreditation program.

In 1948 the Second World War had been ended almost 3 years. The American political scene was geared to the high tension of a presidential election year. Many problems confronted the whole of mankind: Peaceful reconstruction, prosperity, poverty, starvation, disease, the problem of the aging. So it was then when the American Nursing Home Association was established in order to improve the kinds and quality of care rendered by nursing homes.

To those of us closely connected with this area of the aging problem it was an essential beginning, to others it went largely unnoticedthe attention of the public was not yet focused on the great increase in our older population and the problems arising, but this attention would come. "It did, culminating in the well-publicized White House Conference on Aging last January:

In the 13 years since its formation the American Nursing Home Association, as it should have done, fully aware of its responsibilities, fought for recognition of, acceptance of, and improvement of the spiraling problem of the aging by the public, other social and medical groups, and State, Federal, county, and municipal government. Much has been accomplished. Much more remains to be done.

What then is the American Nursing Home Association doing? The following remarks taken from the context of a report made by the U.S. Senate Subcommittee on Problems of the Aged and Aging from hearings held in 1959 are pertinent here:

Most proprietary nursing home operators do the best they can within the limits of their income. Some have done outstanding work. And in association with one another they attempt to improve conditions to meet better standards.

Much of the basic reasons for the present generally inadequate level of medical care and restorative services in nursing homes lies in the traditional attitude toward them.

These remarks are merely echoes of similar ones printed in newspapers, magazines, and other literature concerning nursing homes and related facilities all through the years.

The general impression of nursing homes is most often based on very little actual knowledge of fact, observation, or direct experience, but rather, on conjecture of “what everyone knows to be so.” Such conjective opinion is too often based on prejudice carried on, in a few instances, from long past experience, but most often from vague rumor or hearsay. Attitudes of this nature are both inaccurate and unfounded.

The performance and purpose of the American Nursing Home Association has been and will be progressive. Good standards in institutional practice cannot be brought about solely by means of legislation, nor good patient care assured through inspection and licensure. By the same token, a good public image cannot be secured by knowing and saying most nursing homes are doing a good job. More must be done, and by the nursing home profession itself, not only to improve, secure, and maintain high standards in nursing home practices and good patient care, but also to establish recognition by the public of the existence of that improved care, and a proper public attitude.

To this end, in 1959, the American Nursing Home Association adopted a national accreditation program. Copies of this projected program were to be attached to this report but unfortunately they are not. They will be mailed to you.

(The program referred to follows:)





To be composed of- •

A. 1. A chairman to be appointed by president of ANHA upon recommendation of ANHA National Accreditation Committee for a term of 1 year, who shall be an ANHA member in good standing and shall have a vote only in the event of a tie vote.

2. One representative from each of the eight regions of ANHA with one vote each, who shall be selected by the regional vice president with the approval of the ANHA Accreditation Committee. The original representative appointed from the first, fourth, and seventh regions shall be appointed for 1 year each, and the representative of the second, fifth, and eighth regions for 2 years each. Thereafter, the successive terms of the representative of the aforesaid regions and the original and successive terms of the third and sixth regions, shall be for 3 years each. These regional representatives shall be the regional chairmen and shall be in overall charge of development, implementing, and supervising the accreditation program within the States in their regions in accordance with the policy of the national accreditation committee.

3. One representative each from the American Medical Association, American Dental Association, American Hospital Association, and American Nurses Asso ciation with one vote each.

4. The president, coordinator, and general counsel of ANHA shall be ex officio members and shall have no vote.

B. The duties of the national accreditation committee shall be

1. The responsibility for the criteria, planning, and implementation of the national accreditation program.

2. To hear and determine appeals from denials of accreditation by the State accreditation board.

3. To issue certificates of full accreditation granted by it, the State board, or the executive committee of the board.

4. To adopt uniform survey report forms and to establish a reporting system for use of surveyors.

C. The duties of the chairman of the national accreditation committee shall be

1. To preside at all meetings of the committee. 2. To execute, develop, and implement the policy of the national committee.

3. To prepare an annual budget for consideration and approval by the committee and presentation to ANHA.

D. National coordinator.

1. A national coordinator shall be appointed by the national accreditation committee which coordinator shall receive and process all applications for accreditation by licensed nursing homes and related facilities (which have been in operation for 12 months or more). The coordinator shall establish a code system and such other procedure as is necessary with the approval of the national accreditation committee to be used in connection with all processing, surveys, accreditation, and appeals. After the survey team has completed its survey of an applicant, it shall forward its recommendations to the national coordinator who shall process the same in all successive appeals until a final determination is made by the national accreditation committee.


To be composed of

A. One representative each appointed by the following organizations (insofar as practicable) who shall have one vote each :

1. State medical society.
2. State hospital association.
3. State dental association.
4. State nurse association.
5. State league for nursing.
6. State practical nurses association.
7. State licensing agency.
8. State reimbursing agency.
9. Blue Cross-Blue Shield and/or Health Insurance Council.

10. Three active members of the State Nursing Home Association (insofar as possible there shall be one representative of each type of facility recognized by the applicable State law appointed).

11. A chairman (who shall also be chairman of the executive accreditation committee) shall be appointed by the president of the State Nursing Home Association for a term of 1 year. The chairman shall be a nursing home administrator and shall have one vote.

B. The duties of the State accreditation board shall be

1. To implement, develop, and execute the policy of the national accreditation committee on a State level.

2. To review the findings and orders of the executive accreditation committee on appeal from the grant, denial, or revocation of accreditation and to affirm, set aside, or modify such order.


A. There shall be an executive accreditation committee of the State board composed of the chairman, one other nursing home administrator, and three other members selected by and from the State accreditation board, no one of whom shall be a nursing home administrator.

B. The duties of the executive accreditation committee shall be

1. To consider applications for accreditation of nursing homes and related facilities in operation 12 or more months on the basis of a code system and as received from the national coordinator.

2. To use the basic accreditation program as established by the national accreditation committee. Any addition to the evaluating criteria made by the States must be approved by the national committee before it is implemented.

3. To review and consider the established standards of nursing home performance, including, but not limited to all administrative, professional, operational, and organizational aspects.

4. To establish survey teams and authorize surveys as requested by the national coordinator.

5. To review all survey reports and determine the status of the nursing home and transmit their findings and order to the State accreditation appeals board.

6. To recommend revocations of accreditation at any time for cause. 7. To grant or deny the transfer of accreditation from one licensee to another.


A. Accreditation shall be made in the name of the facility which shall be resurveyed within 3 years from the date of issuance of the certificate.

B. All records shall remain the property of ANHA National Committee and shall be considered classified unless released by the committee.

C. Accreditation shall be made only to a nursing home fully licensed in accordance with State and local statutes where the home is located.

D. The survey team may be composed of a nursing home administrator, one nurse, a registered professional or a licensed practical nurse who has had at least 2 years' nursing home experience, and one other qualified person such as a physician, dentist, public health officer, sanitarian, or social worker. The exact number shall be left to the discretion of the State, but no more than three shall survey a facility. However, in the event the survey team is composed of only one individual who is either an official of a public agency or a hired surveyor, his qualifications shall be cleared with the National Committee.


There shall be sufficient nursing personnel (or in the case of a supervised living care facility, a competent qualified individual) on duty at all times to assure safe nursing care.

A. Supervised living care facility.Personal care and service shall be provided by a competent, qualified individual.

B. Intermediate care facility.—Nursing service shall be under the supervision of a registered professional nurse or a licensed practical nurse.

C. Skilled nursing care facility.Nursing service shall be under the supervision of a registered professional nurse. At least one licensed practical nurse shall be on duty at all times.

D. Intensive care facility.Nursing service shall be under the supervision of a registered professional nurse and a registered professional nurse shall be on duty at all times. The equipment available for use shall be consistent with the standards in the profession for the condition of the patient under treatment or care. OCTOBER 1961.


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ADMINISTRATION A. Physical plant:

Yes 1. Compliance with individual State laws governing nursing homes for licensing-

( ) 2. Compliance with State rules and regulation for fire safety-- ( ) B. Administrator : 1. Qualifications and education: (a) 4 years of high school or its equivalent?

( )
(6) Is this training sufficient for proper discharge of his

( )
(c) Is his experience sufficient for proper discharge of
his duties?

( ) 2. Professional advancement:

(a) Does the administrator/owner belong to local, State,

National organization representing this profession ?--- ()
(6) Does the administrator/owner regularly attend

organized institutes, workshops, association meetings,

( ) C. Personnel policies :

1. Does the nursing home have written personnel policies?--- ( )
2. Are the personnel policies explained to employees when they
are hired? Are written copies readily available?-

( ) 3. Are schedules, plans, and duties posted in writing ?

( ) 4. Is an evacuation and distaster plan posted conspicuously?

Are employees trained in the execution of the evacuation
and disaster plan?-

( )
5. Is a preemployment and annual health examination, includ-
ing chest X-ray required for all personnel ?----

( ) 6. Is there any formal inservice training program (including

staff meetings) for personnel ?7. Are reference materials readily available to staff ?

( ) 8. Is a written employment application required for all personnel?

- ( )

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